RESEARCH PROPOSAL

A STUDY TO FIND THE EFFECT OF MULTISENSORIAL TRAINING COMPARED TO CONVENTIONAL BALANCE TRAINING IN STROKE SURVIVORS.

MASTER OF PHYSIOTHERAPY IN NEUROLOGICAL AND PSYCHOSOMATIC DISORDERS

(MPT)

MS. DOSHI CHAARMEE RAMESHCHANDRA

DEPARTMENT OF PHYSIOTHERAPY

FR. MULLER MEDICAL COLLEGE

MANGALORE-5750

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / DOSHI CHAARMEE RAMESHCHANDRA
DEPARTMENT OF PHYSIOTHERAPY
FATHER MULLER MEDICAL COLLEGE
MANGALORE-575002
2. / NAME OF THE INSTITUTION / FATHER MULLER MEDICAL COLLEGE
MANGALORE
3. / COURSE OF THE STUDY / MASTER OF PHYSIOTHERAPY IN NEUROLOGICAL AND PSYCHOSOMATIC DISORDERS (MPT-NPD)
4. / DATE OF ADMISSION TO THE COURSE / 31-05-2010
5. / TITLE OF THE TOPIC / A STUDY TO FIND THE EFFECT OF MULTISENSORIAL TRAINING COMPARED TO CONVENTIONAL BALANCE TRAINING IN STROKE SURVIVORS.
6.
7.
8. / BRIEF RESUME OF THE INTENDED WORK.
6.1 NEED FOR THE STUDY:
WHO defined stroke as rapidly developed clinical signs of focal (or global) disturbances of cerebral function; lasting more than 24 hours leading to death, with no apparent cause other than vascular origin.1 The 24 hours threshold in the defination excludes transcient ischaemic attacks (TIA). Stroke also a leading cause of serious, long-term disabilities, including loss of motor, sensory, or cognitive functions.2
Balance is an essential part of sitting, sit-to-stand and walking activities. Impaired balance and increased risk of falling toward the paretic side is found to be significantly correlated with locomotor functional, functional abilities and length of stay in inpatient rehabilitation facilities.3 Stroke patients with balance problems appear to take longer to reach the same level of functional gain than patients without balance problems.4
Balance retraining programme is effective in reducing falls. Therefore, effective therapeutic interventions for improving balance function are suggested as an integral part of each person’s rehabilitation plan after stroke.4
A major focus of stoke rehabilitation programs, therefore, is to improve balance and optimize function and mobility.5
However, no general physiotherapy approach has proven to be superior for promoting balance recovery from stroke.4 The issue of evidence-based balance-improving interventions is of importance to physiotherapists engaged in the treatment of stroke patients in order to facilitate clinical decision-making, striving to use treatments founded on high-quality research. 6
A systematic review suggests that balance following stroke could be improved by a variety of physiotherapeutic interventions performed without the use of extensive technical equipment.6 Practical as well as economic issues may limit the access of technical equipment, whereas a standard approach is possible regardless of environment and equipment.
Balance in hemiplegic patients can be affected by various and mixed components.7 Balance is a complex motor skill requiring central processing of vestibular, visual and somatosensory information to activate the musculoskeletal system to produce coordinated eye movements, posture, stance and locomotion.6 A conservative, highly protective approach to physical therapy for patients with balance disorders may not provide the range of therapeutic challenges necessary to develop the strong balance reactions needed for active living.8 Since stroke subjects often present with somatosensory deficits the adaptation of regular exercises with the use of surface and vision manipulation to challenge balance could improve the process of somatosensory integration and have a positive effect on postural stability.9 Even though force platform training accomplishes sensory manipulation, there is no strong evidence for the functional usefulness of this.8 Jean-Francois et a l in 2006 had shown significant improvements in standing balance with altered sensory input in six months post stroke.9 Alain P. Yelnik et al in 2008 couldn’t establish the superiority of multisensorial approach in improving balance in stroke patients and suggested further studies of a multisensorial therapy approach in stroke patients who have less functional mobility and sooner after onset of stroke is required.8
There are limited studies which did sensory manipulation in acute stroke patients and have assessed the functional outcome of this approach. Hence this study aims to compare the effects of multisensory training approach with conventional balance training in improving balance and functional outcome in stroke patients.
OPERATIONAL DEFINITION:
CONVENTIONAL PHYSIOTHERAPY BALANCE TRAINING EXERCISE20
•  Weight shifting in sitting.
•  Reaching activities in sitting.
•  Rising from a chair with & without use of arms.
•  Performing tandem stance.
•  Stepping on stools.
•  Walking forward, backward and sideways.
MULTISENSORY BALANCE TRAINING9 – Physical rehabilitation based on the manipulation of the sensory information required to maintain balance, here improving static and dynamic balance by executing exercises while the proprioception of the feet and ankles and/or vision was manipulated
•  Performing double-legged stance for 10 s
•  Performing tandem stance for 10 s
•  Rising from a chair with and without the use of the arms
•  Walking forward and backward with a tandem walking pattern (toes of one foot touching the heel of the foot in front)
•  Performing single legged stance for 10 s
Exercise to be performed under following conditions:
(1) eyes open, firm surface; (2) eyes open, soft surface; (3) eyes closed, firm surface; and (4) eyes closed, soft surface.
RESEARCH QUESTION:
Is multisensory balance training more effective than conventional balance training in stroke survivors?
.
HYPOTHESIS:
Conventional balance exercises are as effective as multisensory balance training in improving the balance and functional out come in stroke survivors.
6.2 REVIEW OF LITERATURE:
Hammer A. et al. reviewed that stroke resulting in hemiparesis often affects balance demanding activities, limiting independence in activities of daily living. Balance is a complex motor skill requiring central processing of vestibular, visual and somatosensory information to activate the musculoskeletal system to produce coordinated eye movements, posture, stance and locomotion The rehabilitation process aims to restore function and the ability to participate socially in the community and to avoid secondary complications such as falls and contractures.6
A systematic review done by Hammer A. et al. review suggests that balance following stroke could be improved by a variety of physiotherapeutic interventions performed without the use of extensive technical equipment. There is limited evidence supporting the use of extensive technical equipment for improving function and balance post-stroke.6
Yavuzer G. et al. concluded that balance training using force platform biofeedback in addition to a conventional inpatient stroke rehabilitation programme is beneficial in improving postural control and weight-bearing on the paretic side while walking late after stroke.4
A study done by Shah S.B. & Jayavant S. concluded that training on stability trainer in various postures both static and dynamic at appropriate challenge levels helps to improve balance in ambulatory hemiplegics. Training on stability trainer can be generalized to functional activities such as staircase ascending and descending, going up and down ramp and walking on uneven surfaces.10
Robert Teasell, et al. concluded that evidenced based therapy approaches for balance training in stroke patients, including visual feedback, task-specific methods, platform training, additional strength training, and cycle training , have a similar significantly positive impact on outcomes.11
H. Gok et al. concluded that Kinaesthetic ability training in addition to a conventional rehabilitation programme is effective in improving balance late after stroke. However, this improvement is not reflected in individual functional status.12
Chen C. et al. found that dynamic balance function showed significant improvements in patients with visual feedback training when compared with those receiving conventional therapy only. Patients in the trained group also showed significant improvements in the self-care ability at 6 months of follow up. Further research is needed to confirm our results. The results showed that balance training was beneficial for patients after hemiplegic stroke.13
A Cochrane review, by Barclay-Goddard et al. showed the results of 7 randomized clinical trials and indicated that providing feedback from a force platform resulted in improved stance symmetry after stroke but did not improve balance during active functional activities, nor did it improve overall independence.14
A study done by Yelink AP et al. showed that when patients were given multisensorial approach based on higher intensity of balance tasks and exercises during visual deprivation showed significant improvement in balance and walking parameters, although it was not superior to NDT – based therapy that used a general approach for sensory motor rehabilitation.8
Bonen et al. stated that the balance is improved more after rehabilitation with visual deprivation than free vision after stroke. These findings also suggest that subjects improved their integration of somatosensory and vestibular imput and that the program enabled them to use the pertinent input (somatosensory, vestibular and visual) and to become less reliant on visual input. He also suggested that postural imbalance might be due to more to a higher level inability to select reliable sensory input than to elementary sensory impairment.21
A RCT done by Ibrahimi M et al concluded that sitting balance training under varied sensory input is more effective for improving balance and quality of life in stroke.22
Bayounk et al. concluded that task related training with altered sensory input is better than without altered sensory input for improving balance in stroke patients. More improvement in experimental group is due to somatosensory manipulation which could enhance multisensory interactions. This might resulted from sensory training which may have improved the sensory motor integration of postural stability of stroke patients.9
The Berg Balance Scale (BBS) developed by Berg and co-workers is an objective measiure of static and dynamic balance abilities. The scale is consists of 14 functional tasks commonly performed in everyday life. The Berg balance is sensitive, reliable and valid measure for low functioning elderly residents and acute stroke patients.15, 16.
Functional Independence Measurement (FIM) with stroke patients has been shown to have concurrent validity with Barthel Index. Gosman-Hedstrom and Svensson have shown strong contruct validity and reliability between items on Barthel And items on the FIM that measure the functional limitations. It is an 18 item measure of physical, psychological and social function.17, 18.
Modified Rivermead Mobility Index (MRMI) is a mobility scale represents a further development of the Rivermead Mobility Index (RMI). In its new form the scoring was adapted from a two-point to a six-point scale. The results showed that the modified RMI was responsive to change, stable when tested on two occasions, highly reliable between raters with high internal consistency.19
The motricity index, including three subscales (arm, leg and trunk control), is a measure of motor loss primarily developed for use after stroke. Validity and reliability have been proven find it has been found to be sensitive to change in recovery after stroke.29 – 32.
6.3 OBJECTIVES OF THE STUDY:
1. To study the effects of multisensory balance training on balance and functional outcome in stroke survivors.
2. To study the effects of conventional balance exercise on balance and functional outcome in stroke survivors.
3. To compare the effects of multisensory balance training and conventional balance exercise on balance and functional out come in stroke survivors.
MATERIALS AND METHODS:
7.1 SOURCE OF DATA :-
Stroke patients from Father Muller Medical College Hospital.
7.2 METHOD OF COLLECTION OF DATA :
STUDY DESIGN:-
Randomized controlled study.
SAMPLING TECHNIQUE AND SAMPLE SIZE:-
Purposive Sampling technique will be used for collecting a sample of 30 .
INCLUSION CRITERIA:
·  Age > 45 years.
·  First episode of unilateral stroke with hemiparesis.
·  Ability to understand and follow simple verbal instructions.
·  Ambulatory before stroke.
·  Stroke survivors within four months.
·  Able to stand for 1 minute with or without assistance.
·  No medical contraindications to walking.
·  Canadian neurological scale(CNS) with score of 4.0 to 7.0.
·  Mini mental scale examination(MMSE) with minimum score of 15.
EXCLUSION CRITERIA :
·  Impaired vision or conscious level.
·  Musculoskeletal conditions affecting lower limbs.
·  Unstable cardiovascular disease.
·  Severe cognitive or communicative disorders.
METHOD OF THE STUDY:
A total of 30 subjects diagnosed with unihemispheric and history of single stroke above the age of 45 years, both male and female will be chosen for the study. The purpose and procedure of the study will be explained to the subjects and informed consent will be obtained. Demographic data will be collected. Canadian neurological scale and Mini Mental Status examination will be done and stroke patients meeting the criteria will be randomly assigned to experimental group (receives multisensory balance training) and controlled group ( conventional balance exercise) based upon on random numbers obtained from www.randomization.com. Treatment duration for both the groups would be a total of 45 minutes which would include 15 minutes of conventional balance training in the control group and the experimental group would receive 15 minutes of multisensory balance training for a duration of 1 week. Outcome measures Modified Rivermead mobility Index(MRIM),Berg Balance Scale(BBS) Functional independence measure(FIM) will be used before and after the treatment sessions of 1 week to evaluate the effect of the treatment.
TOOLS :
·  Modified Rivermead Mobility Index(MRIM)
·  Berg Balance Scale(BBS)
·  Functional Independence Measure(FIM)
STATISTICAL ANALYSIS :
Collected data will be analysed by Mann Whiteny and Wilcoxon Rank tests.
7.3 Does the study require any investigation or intervention to be conducted on patients or animals?
Yes
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes
LIST OF REFERENCES :
1. K. Park. Park’s textbook of Preventive And Social Medicine. 19th Edition. Bhanot Publishers.
2. Hajek VE, Gagnon S, Ruderman JE. Cognitive and functional assessment of stroke patients: an analysis of their relation. Arch Phys Med Rehabilitation 1997;78:1331-7.
3. Eser F, Yavuzer G, Karakus D, Karaoglan B. The effect of balance training on motor recovery and ambulation after stroke: a randomized controlled trial. Eur J Phys Rehabil Med. 2008; 44(1):19-25.
4. Yavuzer G, Eser F, Karakus D, Karaoglan B, Stam HJ. The effects of balance training on gait late after stroke: a randomized controlled trial. Clin Rehabil. 2006; 20(11):960-969.
5. Walker C, Brouwer BJ, Culham EG. Use of visual feedback in retraining balance following acute stroke. Phys Ther. 2000;80:886–895.
6. Hammer A, Nilsagarad Y, Wallquist M. Balance training in stroke patients-a systematic review of randomized, controlled trials. Adv Physiother. 2008; 10(4):163-172.