RESEARCH PROPOSAL
A STUDY TO DETERMINE THE FUNCTIONAL INDEPENDENCE AND COMMUNITY INTEGRATION OF SPINAL CORD INJURY PATIENTS IN AND AROUND MANGALORE
MPT (NEUROLOGICAL AND PSYCHOSOMATIC DISORDER)
MR. AJUMON MATHEW
DEPARTMENT OF PHYSIOTHERAPY
FR. MULLER MEDICAL COLLEGE
MANGALORE-575002
RajivGandhiUniversity of Health Science, Karnataka, Bangalore
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS: / AJUMON MATHEWDEPT. OF PHYSIOTHERAPY
FATHERMULLERMEDICALCOLLEGE
KANKANADY,
MANGALORE-575002
2. / NAME OF THE INSTITUTION / FATHERMULLERMEDICALCOLLEGE
3. / COURSE OF THE STUDY AND SUBJECT: / MASTER OF PHYSIOTHERAPY
(NEUROLOGICAL AND PSYCHOSOMATIC DISORDERS)
4. / DATE OF ADMISSION TO COURSE: / 01.06.2011
5. / TITLE OF THE TOPIC:
A STUDY TO DETERMINE THE FUNCTIONAL INDEPENDENCE AND COMMUNITY INTEGRATION OF SPINAL CORD INJURY PATEINTS IN AND AROUND MANGALORE
6.
7.
8. / 6.1) BRIEF RESUME OF INTENDED WORK
NEED OF THE STUDY
Spinal cord injury (SCI) often results in significant neurologic dysfunction and disability. The incidence of SCI varies but is estimated at 10 to 83 per million per year with most injured under the age of 25 years1,2. The peak incidence of SCI is among young adults, most commonly related to motor vehicle accidents and a second peak in older individuals, mostly due to unintentional falls2,3.
Spinal cord injury is a devastating condition that requires intensive and specialized clinical rehabilitation.The life expectancy of persons with SCI has increased in recent decades, although it is still lower than the life expectancy of the general population.4,5 Early rehabilitation treatment is crucial for patients with SCI in that it improves the patients motor function, ADL and functional independence after the injury.6
Within 72 hours to 1 month after a SCI, it is possible to predict with reasonable accuracy the magnitude of expected recovery based on physical examination. The impact of motor level on long term functional outcomes is also clear and has remained relatively unchanged for several decades.7
Rehabilitation should “add life to years” by facilitating people with SCI as much as possible to function independently and to create conditions for social reintegration.4,8 Restoring patients with spinal cord injury to their optimum level of functioning and participation and improving their quality of life are essential goals of a rehabilitation program.9,10 Independence in ADLs and fulfilling social roles are strongly related to health and well-being, and a high level of social activity leads to a better quality of life.9,11 Literature lists certain reasonable functional expectations, at various levels, for a young healthy patient with a complete lesion and unimpaired by secondary complication 12,13.
In a recent study in South India, the community integration and functional independence of SCI patients who has undergone inpatient rehabilitation for 3 months and having regular follow up is found to be good9. The ideal outcome may not always be achieved for each patient, because there is a significant amount of variability in individual outcomes despite similar levels of injury. Functional independence is dependent on the age of the individual and coexistent conditions and complications.13
Persons who are highly motivated and those who have good social support may exceed the expected functional outcome for their respective level13. The process by which a person with disability becomes an active, productive member of society and integrates into family and community is a complex phenomenon14, 15,16,17,18. Dijkers has eloquently defined community reintegration as “acquiring/ resuming age- gender- culture-appropriate roles/ statuses/activities, including independence/interdependence in decision making, and productive behaviours performed as part of multivariate relationships with family, friends, and others in natural community settings.” 9,19 There are several barriers to community reintegration of persons with SCI. Those with less severe neurologic injury and younger age at injury have achieved higher level of community participation.9,14
Community integration and functional independence of the SCI patients who underwent rehabilitation, in a rehabilitation centre and had regular follow up were found to be good as stated by Selvaraj et al9 and Marcel W.M et al.4 But here all patients are not receiving those kind of comprehensive rehabilitation facility and may not be able to complete the usual protocol of rehabilitation which may affect their functional status. So the functional outcome and community integration of SCI patients differs and identifying those factors may be an eye opener.
Hence this study aims to identify the extent of functional independence achieved by SCI patients and their community integration. Demographic variables such as age, educational status, duration of rehabilitation, and level of injurymay influence the functional independence and community integration of SCI patients. So this study also aims to analyse the influence of these variables in SCI patients functional independence and community integration.
The degree of disability of patients with a spinal cord injury can be roughly assessed by neurological examination, but it varies from patient to patient. Functional outcome of SCI patients can be measured using Functional Independence Measure (FIM) and these scales have shown excellent validity and reliability in studies done in SCI patients.4,20 The Craig Handicap Assessment and Reporting Technique (CHART) is one of the most commonly used measures to quantify community reintegration in SCI which is having good reliability and validity 9,21The rehabilitation challenges can be measured using the questionnaire, “The prevalence of barriers, their impact on the level of everyday physical activity and the importance of barriers”23
RESEARCH QUESTION:
Do the post discharge SCI patients in Mangalore achieve the expected functional outcome and community integration?
Are the SCI patient’scommunity integration and functional status, influenced by their demographic variables and do they face any rehabilitation challenges?
RESEARCH HYPOTHESIS:
H1: The post discharge SCI patients in Mangalore are not achieving expected functional outcome and community integration.
H2: The demographic variables influence the functional status and community integration of SCI patients.
H3: The SCI patients in Mangalore are facing rehabilitation challenges
NULL HYPOTHESIESIS:
H01: The post discharge SCI patients in Mangalore are achieving the expected functional outcome and community integration.
H02: The demographic variables does not influence the functional status and community integration of SCI patients.
H03 : The SCI patients in Mangalore are not facing any rehabilitation challenges.
6.2) REVIEW OF LITERATURE:
SCI brings changes within an individual's physical and psychosocial relationship with their environment. Some of these changes involve the loss of motor and sensory function, inability to control bladder or bowel function and vitiated sexual functioning. In respect to these changes, they are likely to have profound effects on an individual's social role and interpersonal relationships within their community24,25
Classification of SCI patients:
In a study done by Marcel W.M4 et al to determine the relation between the duration and functional outcome of the SCI patients in Netherlands, they classified the patients into four categories depending on the type of injury which are complete tetraplegia, incomplete tetraplegia, complete paraplegia, and incomplete paraplegia.
Functional independence at the time of discharge:
Marcel W. M4 et al has done a study in 157 patients from eight rehabilitation centers with a mean age 40.0 years. For 76.4% patients the cause was traumatic injuries, 39.8% had tetraplegia, and 69.9% had a motor complete SCI. Median motor Functional Independence Measure (FIM) scores at discharge were 37.3 for persons with complete tetraplegia and 69.7 for persons with complete paraplegia.
Functional independence after discharge:
Amathachaya.s26et al has done a study in 44 SCI patients to determine their functional ability using Spinal Cord Injury Independence Measure scale (SCIM) after 6 months of discharge. Their findings shows that after discharge the SCIM II scores of subjects showed a slight decrease in the mean value from 58.60(21.22) to 58.37(22.06). The significant decrement was illustrated in self-care and mobility scores of subjects with chronic motor incomplete SCI. They concluded that functional ability of subjects with SCI, particularly those with chronic motor complete SCI, significantly decreased after discharge.
Community integration after discharge and I year follow up in community:
Selvaraj Samuel.K.K9 et al have done a study to determine the community integration using CHART in 104 post discharge SCI patients after 1 year follow up. The mean scores for each CHART domain were, physical independence 98 (5), social Integration 96 (11), cognitive independence 92 (17), occupation 70 (34), mobility 65 (18), and economic self sufficiency 53 (40). They concluded that the SCI patients in south India who had a comprehensive rehabilitation and regular follow up had obtained a high level of community integration.
Relation between community integration and demographic data’s:
Selvaraj Samuel K.K9 et al, in their study, have compared demographic variables like age, gender, formal education, socioeconomic status, duration of rehabilitation, level of injury, and completeness of injury with the CHART domains. It showed no statistically significant difference with any of the CHART domains except for age and mobility, level of education, and social integration.
The result of a study done in 3835 SCI patients by Gale whiteneck14 et al shows that neurological classification, age, year post injury, gender, ethnicity, and education explains 29% of variance in physical independence, 29% variance in mobility, 28% of the variance in occupation, 9% of the variance in social integration and 18% of the variance in economic self-efficiency.
Rehabilitation challenges:
In a study done in Sri Lanka by Paul Chappell and Sheila Wirza24, shows that the extrinsic factors such as, individual self-esteem and lack of community support, could affect the life of patients with spinal cord injury . Barriers to community reintegration for persons with SCI have been identified in physical, social, psychological, and environmental domains by 9, 14, 27.
Reliability and validity of outcome measures:
The FIM has demonstrated reliability and validity in a number of different patient populations like multiple sclerosis, stroke, spinal cord injury, and traumatic brain injury.28The CHART is one of the most commonly used measures to quantify the community reintegration in SCI. CHART evaluates key domains of community reintegration like physical independence, cognitive independence, mobility, social integration, occupation, and economic self-sufficiency. A typical nondisabled person scores 100 on each domain, while the person with maximal handicap scores 0. It takes approximately 15 minutes to administer. It can be used with persons having a range of physical or cognitive impairments. There is quite adequate evidence for reliability and validity of the CHART.26,6 Maaike Vissers23 et al did a study using the questionnaire “The prevalence of barriers, their impact on the level of everyday physical activity and the importance of barriers” to determine the barriers and facilitators of everyday physical activity in post discharge SCI patients.
6.3) OBJECTIVE OF THE STUDY:
- To determine the functional independence and community integration of SCI patients in and around Mangalore.
- To determine the relationship of functional independence and community integration with the demographic data of SCI patients.
- To determine the rehabilitation challenges faced by the SCI patients.
7.1)Source of data
SCI patients in and around Mangalore
7.2) Method of data collection including sampling procedure:
Study Design:
A cross-sectional study.
SampleProcedure:
50 Samples will be evaluated usingPurposive sampling technique
Inclusion Criteria for the study :
- The SCI patients between the age of 18 and 60
- The patients with at least 3 months of duration after SCI
- The patients with SCI due to malignant tumour or other progressive diseases.
- The SCI patients with prior cardiovascular diseases and psychiatric problem.
- The patients with coexistent head injury and cognitive impairment.
The SCI patients in and around Mangalore who are meeting the inclusion criteria will be recruited for the study by a purposive sampling technique. The purpose and procedure of the study will be explained to the subjects and written consent will be obtained. Demographic data which includes name, age, gender, marital status, address, education, occupational status, family income, date of injury, aetiology of injury, historyof hospitalization, neurological level of injury, and details about rehabilitation and external appliances will be collected. The SCI patients will be classified into four categories depending on their type of injury as: Complete tetraplegia, incomplete tetraplegia, complete paraplegia, incomplete paraplegia. The FIM and CHART scores of each patient will be documented under above categories and will also be compared with the demographic data of the patient. The rehabilitation challenges faced by each patient will be determined using the questionnaire, “The prevalence of barriers, their impact on the level of everyday physical activity and the importance of barriers”, by Maaike Vissers et al in 2008. This questionnaire as well as the CHART will be executed through an interview method.
OUTCOME MEASURES AND TOOLS:
- The functional independence will be measured using Functional Independence measure(FIM)
- Community integration will be measured using The Craig Handicap Assessment and Reporting Technique (CHART)
- Rehabilitation challenges of the SCI patients will be identified using the questionnaire “The prevalence of barriers, their impact on the level of everyday physical activity and the importance of barriers.”
- Collective data will be analysed for Mean, Standard Deviation, Frequency, Chi-Square Test and‘t’ test.
No
7.4 Has ethical clearance been obtained from your institution in case of 7.3
Yes
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2)Wyndaele M, Wyndaele JJ, Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? Spinal cord 2006 sep;44(9):523-529
3)Furlan JC,Fehlings MG, Spinal Cord The Impact of Age on Mortality, Impairment, and Disability among Adults with Acute Traumatic Injury, J Neurotrauma. 2009; 10:1707–1717.
4)Post MW,Dallmeijer AJ,Angenot EL,van Asbeck FW,van der Woude LH, Duration and functional outcome of spinal cord injury rehabilitation in the Netherland, JRRD 2005; 42:75-86
5)Devivo mj, Krause JS, Lammertse DP, Recent trends in mortality and causes of death among persons with spinal cord injury, Arch phys Med Rehabil 1999;80(11):1411-9
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9) Samuelkamaleshkumar S, Radhika S, Cherian B, Elango A, Winrose W, Suhany BT, Prakash MH. Community reintegration in rehabilitated South Indian persons with spinal cord injury. Arch Phys Med Rehabil 2010; 91:1117-21.
10)National Commission on Macroeconomics and Health. Burden of disease in India. New Delhi; Ministry of Family and Welfare, Government of India; 200511)Schonherr MC, Groothoff JW, Mulder GA, Eisma WH. Participation and satisfaction after spinal cord injury: results of a vocational and leisure outcome study. Spinal Cord 2005; 43:241-8.
12) O’Sullivan SB, Schmitz TJ, Physical Rehabilitation, 5th edition, Philadelphia, Jay Pee Brothers 2007.
13)Denise SK, Delisa CJA. Spinal cord Medicine, 1st edition, Philadelphia, Lippincott Williams and Wilkins 2002
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16) WHO, ICIDH-2 Beta 1 draft. Geneva: WHO; 1997
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18) Institute of medicine, Enabling America, assessing the role of rehabilitation science and engineering. Washington (DC): National academy press: 1997
19)Dijkers M. Community integration: conceptual issues and measurement approaches in rehabilitation research. Top Spinal Cord Inj Rehabil 1997; 4:1-17.
20) Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The reliability of the functional independence measure: a quantitative review. Arch Phys Med Rehabil 1996; 77(12):1226-32
21)Kennedy p,Lude P,Taylor N. Quality of life, social participation, appraisals and coping post spinal cord injury: a review of four community samples. Spinal cord 2006 44(2): 95-105
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23)Vissers M,van den Berg-Emons R,Sluis T,Bergen M,Stam H,Bussmann H.Barriers to and facilitators of everyday physical activity in persons with a spinal cord injury after discharge from the rehabilitation centre.J Rehabil Med 2008; 40: 461–467
24)Chapel P, Wirz S. Quality of life following spinal cord injury for 20-40 year old males living in srilanka. Asia pacific disability rehabilitation journal; 2003; 14:165-173
25)King C,Kennedy P. Coping effectiveness training for people with spinal cord injury: preliminary results of a controlled trial. Br J Clin Psychol.1999;38 ( Pt 1):5-14.
26)Amatachaya S,Wannapakhe J,Arrayawichanon P,Siritarathiwat W,Wattanapun P.Functional abilities, incidence of complications and falls of patients with spinal cord injury 6 months after discharge,SpinalCord.2011; 49(4):520-4.
27)Scelza WM,Kirshblum SC,WuermserLA,Ho CH,Priebe MM,Chiodo AE. Spinal cord injurymedicine. 4.Communityreintegrationafterspinal cord injury. Arch Phys Med Rehabil.2007 Mar;88(3 Suppl 1):S71-5
28) SaboeCA, Darrrah JM, Pain KS, Guthrie J. Early predictors of functional independence 2 years after spinal cord injury. Arch Phys Med Rehabil 1997;78:644-50
9. / SIGNATURE OF CANDIDATE
10. / REMARK OF THE GUIDE / Recommended
11. / NAME AND DESIGNATION OF
11.1 GUIDE / MR.JIDESH V.V
ASST.PROFESSOR
DEPT OF PHYSIOTHERAPY
11.2SIGNATURE
11.5 NAME OF THE HEAD OF THE DEPARTMENT / MR. NARASIMMAN.S
PROFESSOR
11.6 SIGNATURE
12. / 12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL
12.2SIGNATURE
CONSENT FORM
Mr. Ajumon Mathew Date-
MASTER OF PHYSIOTHERAPY IN NEUROLOGICAL AND PSYCHOSOMATIC DISORDERS (MPT-NPD)