Rajiv Gandhi University of Health Sciences, Karnataka.
SYNOPSIS
For Registration of Subjects for Dissertation.
1 / Name of the Candidate and Address / MS.ANURADHA.K1st, year M.Sc Nursing
Diana College of Nursing,
Bangalore.
2 / Name of the Institution / Diana College of Nursing,
No.68, Chokkanhalli,
Jakkur post,
Bangalore - 560064
3 / Course of the Study and Subject / M.Sc Nursing,
Medical Surgical Nursing
4 / Date of Admission / 10-06-2009
5 / Title of the Study / A STUDY TO ASSESS THE EFFECTIVENESS OF MENTAL IMAGERY (MI) ON TASK PERFORMANCE AMONG PATIENTS WITH CEREBROVASCULAR ACCIDENT (CVA) IN SELECTED HOSPITALS, BANGALORE.
6. Brief Resume of the Intended work:
Introduction:
“CVA patients may be the victims of fate;
But let not be victims of our neglect”.
A chronic illness isn't the name of just one illness. It's a word used to describe a group of health conditions that last a long time. In fact, the root word of chronic is "chronos," which refers to time. Most chronic illnesses are not contagious - you usually don't catch them from someone else. But chronic illnesses can be genetic, meaning that parents can pass the tendency to get them on to their children before they are born through genes. If a person has a chronic illness, he needs to take care of his condition for months or years.1
CVA is one such illness which is chronic. Once when it attacks the human because the person`s abilities and personal appearance changes, and there is sudden alteration in activities of daily living, the quality of life for survivors of CVA is severely deteriorated.1
Stroke is the third leading cause of death in the United States and the leading cause of disability. In India per year about 3million people are affected. Two-thirds of strokes occur in people over age 65. Strokes affect men more often than women, although women are more likely to die from a stroke.2
Disabilities due to stroke will happen sudden. To an extent it depends on which area of the brain is damaged, it causes weakness, loss of speech, loss of vision, hemiplegia, difficulty in swallowing, alteration in gait, inability to fulfill the activities of daily living.2
Methods are used to improve the performance as rehabilitation. Individuals who experience a stroke may require a variety of rehabilitation services including physical therapy, occupational therapy, speech therapy, and orthotic management. Individuals discharged to a rehabilitation hospital or skilled nursing unit should have several hours of therapy daily.The focus of occupational therapy is to regain the individual's ability to perform activities of daily living. Orthotic management may also be required for individuals to regain function.Occupational therapy, physical therapy, speech therapy are given along with Mental Imagery.3
Mental imagery involves memory retrieval, and the generation and maintenance of images. It is believed that generating the image, ‘seeing the performance of the behavior with the mind’s eye’, prior to performance of the task, activates neural substrates that are subsequently involved in the actual performance of the task. This effect is thought to facilitate the planning and execution of the task, thereby increasing the level of independent task performance.4
One of the major goals in rehabilitation for survivors of central nervous system (CNS) trauma is the return to independence in activities of daily living. The extent to which skills learned in the hospital environment are generalized to the home environment contributes to the success with which the person reintegrates into the community and is able to lead a normal life.5
This study aims to investigate the benefits of an MI intervention to enhance performance of tasks in patients with stroke.
6.1. Need for the study
“The inlet of man`s mind is what he learns”,
The outlet is what he accomplishes.
If his mind is not fed by a continued supply of new ideas
Which he puts to work with purpose and
If there is no outlet of in action his mind become stagnant,
Such mind is danger to the individual and is useless to the community also
- Jirminiah.w.Jerks
CVA is chronic illness as referred as stroke and it needs medical emergency requiring immediate treatment. Prompt treatment improves the chances of survival and increases the degree of recovery that may be expected.4
Annually, 15 million persons worldwide suffer a stroke: of these, 5 million die and 5 million are left permanently disabled, placing a burden on the family and community. Improved medical treatment of all types of stroke has resulted in a dramatic decline in death rates in recent decades. In 1950, nine in ten died from stroke, compared to slightly less than one in three today.4
After a CVA, both the CVA survivor and the family often are uneasy about being on their own at home. They have many apprehensions and anxieties for what the future holds. They fear that another CVA incident might happen again. They worry that the CVA survivor may be unable to accept the disabilities or that the survivor might be placed in a nursing home. They have concerns that the caregiver may not be prepared to face the responsibility of caring for the CVA survivor. There are also fears that friends and family will abandon the CVA survivor.5
It is very difficult for many CVA patients to come to terms with the change in their abilities and personal appearance. Their intellect is lowered. They can no longer go to the bathroom by themselves. They have problems controlling their bladder and bowel movements. They have difficulty swallowing foods and have trouble speaking due to slurred speech. They also face sexual dysfunction which leads to feelings of inadequacy. Because of the devastating change and sudden loss of skills that were once second nature to them, the quality of life for survivors of CVA is severely deteriorated. Naturally, this together with certain physical disabilities and communication difficulties can lead to irritability, anxiety, frustration, and sometimes deep sadness. A typical manifestation seen with CVA survivors is depression. They suffer from intense feelings of hopelessness and helplessness.6
Rehabilitation actually starts in the hospital as soon as possible after the CVA. In patients who are stable, rehabilitation may begin within two days after the CVA has occurred, and should be continued as necessary after release from the hospital.7
Rehabilitation consists of physical therapy, occupational therapy, and speech and language pathology. For the CVA patient, the physical therapist's aim is to get back as much movement as possible by means of a range of exercises, and to prevent complications arising as a result of the way in which limbs are positioned. Occupational therapy, speech therapy, physical therapy are used along with mental imagery which helps the patient to relearn the lost activities. 8
Mental imagery is the umbrella term for the active process of reliving sensations with or without external stimuli. This is facilitated by the use of images brought about by combinations of the different modalities,i.e. visual, auditory, tactile, kinesthetic, olfactory, gustatory. When a movement of an action of a person or object is imaged, this is referred to as movement imagery. Specifically when it is the human body that is imaged by the internal reactivation of the action within working memory without overt motor output, it is called motor imagery.9
Images generated could vary from a person seeing themselves or another do the action using a third person perspective, as if watching a movie, called visual imagery. Or, it could be facilitated through a first person perspective where the individual internalizes the sensations that accompany the imagined movement. This is referred to as kinesthetic imagery.10
MI being a non-invasive rehabilitation technique may be used by nurses for the patients with CVA, as nurses stay with the patient for 24 hours.
The study was conducted to investigate the benefits of an MI intervention to enhance performance of tasks in patients with stroke. The study emphasized the importance of engaging in motor or physical practice of tasks for as much time as possible during rehabilitation programs. After practice sessions are usually confined to few hours of therapy in the clinic per day and possibility of ensuring fatigue and staff availability further limits practice sessions. Thus MI may serve as an avenue for patients to continue their skills training even when they are already physically exhausted, or when supervised therapy sessions have finished.11
With the growing number of studies on this intervention for the stroke population, there is the need to consolidate this evidence to determine the potential use of mental practice with motor imagery in neurological rehabilitation particularly for stroke patients.12
Considering the significance of the mental imagery used for the task performance, the investigator felt a strong need to undertake the present study.
6.2. REVIEW OF LITERATURE:
Review of the literature is the key step of research process and it helps as a guide. It is essential step in development of research project.
Review of literature is followed under tree main steps:
1. Literature related to patients with CVA and their task inadequacy
2. Literature related to mental imagery
3. Literature related to mental imagery on task performance
1. Literature related to patients with stroke and their task inadequacy
In a study conducted on patients who had CVA high rate of disabilities in their task performances were revealed. They also demonstrated a great ability of retain their skills by relearning. The researchers conclude that through rehabilitation program there is a effect of relearning appears to help patients to retain and generalize the skills and tasks.13
In a study conducted in CVA patients, it was observed increased rate of disabilities to certain task and decreased quality of affected arm in patients with CVA. It seems that the motor activity log is very useful tool since the separate interview of care givers from the patients may in fact be an objective measure of not using the affected hand of patients in their homes.14
A study was conducted and assessed the CVA patients where they adopted the randomized control design. Selected sample of 54 patients they were age group over 60 years. After stroke 34 patients had loss of speech and motor activity and 17 patients had loss of motor activity only. Depending on brain where stroke occurred the disabilities will result. Study provides the evidence of sensory and motor impairment after stroke which leads in their task inadequacy.15
2. Literature related to Mental Imagery
This study was undertaken to explore the use of a mental imagery training of a vocational task. An outline of a mental imagery assessment method is provided along with a description of the training procedures that were used in the study. Mental imagery was taught and rehearsed by means of a PowerPoint TM computer presentation. Trainers and participants worked collaboratively to complete a task analysis and to take photos of each person performing the operations correctly. Through the use of self-modeling and feed forward, participants were able to learn from observing their own actions and, in particular, to learn from ‘successes’ that they have not yet had. On the basis of this pilot study, it is proposed that mental imagery training is an important new approach for collaborative training, especially for individuals whose language systems are not well developed. There is a need, however, for further investigation into the role of mental imagery as this relates to memory, self-regulation and metacognition.16
In a study Mental Imagery appears to be effective at enhancing the task relearning of subjects after brain injury. Further research should conduct clinical controlled trials to gather evidence on its efficacy at randomized, controlled, observer masked prospective trial will be conducted with adult stroke patients in the (sub) acute phase of stroke recovery. Over a six weeks intervention period the control group will receive multi professional therapy as usual. Patients in the experimental group will be instructed how to perform mental practice, and will receive care as usual in which mental practice is embedded in physical, occupation and speech therapy sessions. Outcome will be assessed at six weeks and six months. The primary outcome measure is the patient-perceived effect on performance of daily activities as assessed by an 11-point Likert Scale. Secondary outcomes are: Motricity Index, Nine Hole Peg Test, Barthel Index, Timed up and Go, 10 metres walking test, Rivermead Mobility Index. A sample size of the patients group and all therapists will be interviewed on their opinion of the experimental program to assess feasibility. All patients are asked to keep a log to determine unguided training intensity. 17
In this study assessing effectiveness and enjoyment have used a quantitative approach, employing questionnaires as the primary measurement tool. A qualitative methodology overcomes some of these concerns by allowing participants to respond using their "own written or spoken words and observable behaviours. It provides extensive, descriptive data that is not possible to obtain when using quantitative methods. For these reasons, the present study chose to employ a qualitative methodology in order to gain a more comprehensive understanding of imagery effectiveness and enjoyment.18
In a study which examined the influence of mental practice on sports skills. They selected 78 subjects and classified them as novice or experienced trampolinists. She also classified the subjects as either high or low imagers based on initial skill level. Both groups were trained in three skills over a six week period. The experimental group physically practiced the skill for 2-1/2 minutes, which was then followed by 5 minutes of mental practice. Lastly, an additional 2-1/2 minutes of physical practicefollowed the mental practice. Meanwhile, the control group physically worked on the skill for 2-1/2 minutes, which was then followed by 5 minutes of a session trying a mental task of an abstract nature, such as math problems, puzzles, and deleting vowels. Then, 2-1/2 more minutes were spent physically working on the skill again. The outcome of the experiment was as followed: there existed a significant difference in the improvement of the high and low imagers. In both novice and experimental groups where the initial skill ability was similar, the high imagery groups showed significantly more improvement than the low imagery group. Furthermore, there was a significant difference between the experimenter and control groups. This study posits that despite the level of skill visual imagery proves effective.19