Rajiv Gandhi University of Health Sciences, Karnataka

Bangalore

ANNEXURE II

1. / Name of the Candidate and Address (in block letters) / ANOOP VIKRAMAN NAIR
DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY
VIDYANAGAR
KULOOR,MANGALORE-575013
2. / Name of the Institution / DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY
3. / Course of Study and Subject / MASTER OF PHYSIOTHERAPY (MPT)
(NEUROLOGICAL AND PSYCHOSOMATIC DISORDER)
4. / Date of Admission to Course / 30TH JUNE’ 2010
5. / Title of the Topic / INFLUENCE OF SENSORY DEFICIT ON FUNCTIONAL BALANCE IN PATIENTS WITH STROKE: A CROSS-SECTIONAL STUDY.
6.
7.
8. / BRIEF RESUME OF THE INTENDED WORK:
6.1) Introduction and need of the study:
Despite improvements in health since the1950s stroke remains a major source of functional disabilities in the elderly because of their frequency and consequences.1
The postural performance of patients soon after a stroke has been found to be closely correlated with long term functional improvementi.2,3,4 Because it may help in establishing the severity and progress of stroke, the early assessment of balance in stroke survivors is an important part of clinical examination.5
Balance is a complex process involving the reception and integration of sensory inputs and planning and execution of movement to achieve a goal requiring upright posture .Balance emerges from a complex interaction of sensory (afferent) systems responsible for the detection of body position and motion ,motor (effector)systems responsible for the ,execution of motor responses and CNS integration processes.6
A motor task is practiced based on the sensory input organized and integrated by the Central Nervous System .The sensation and movement are inextricably linked as it guide the selection of motor responses for the effective interaction of the environment and to adapt movements and shape motor programs through feedback for corrective action7.
Previous research has examined the influence of various impairments on balance in people with stroke. Cognitive status have been found to correlate with BBS scores in people with chronic stroke.8,9 Strength difference has been proved to be a significant factor influencing functional balance9.Sensory organization has reported to associated with balance performance.10 Other factors such as age, hyper tonicity, aerobic fitness ,self-efficiency ,and sex have been shown to correlate with gait and balance.9,11,12,13,14
Need of the study:
There have been several studies which examined the relationship between prospectively selected measures of body function and structure and activity in people with stroke.9Sensory intervention studies have reported positive functional outcomes of postural sway and balance.15Evidence on the relationship between sensory deficit and functional balance in people with stroke is inconclusive.
A need was identified to estimate the relationship between somatosensory deficit associated with stroke and functional balance.
Research Question:
Is there any influence of sensory deficit on functional balance in patients with stroke?
Hypothesis:
Null hypothesis:
There will be no influence of sensory deficit on functional balance in patients with stroke.
Alternative hypothesis:
Sensory deficit has an influence on functional balance in patients with stroke.
6.2) REVIEW OF LITERATURE:
Louissette Mercier et al conducted a study to evaluate the relative impact of motor, cognitive and perceptual deficit on functional autonomy with 100 elderly victims of stroke and concluded that the confirmatory analysis show that motor ,cognitive ,and perceptual factors all make a significant contribution to the variation in functional autonomy.1
A study was performed on the relationship of sensory organization to balance function in patients with hemiplegia and concluded that the correlation between sensory organisation is related to functional status.10
A study was conducted to review sensory dysfunction following stroke and the available evidence on incidence, significance examination ,intervention and mechanism of injury.15
The relationship between prospectively selected measures of body function and structure(body mass index,muscle strength,senstion and cognition)and activity(gait speed,gait endurance,and functional balance)in people with stroke was examined by Patricia Kluding et al .Twenty six individuals with mean age of 57.6 and time after stroke45.4months participated and the result concluded that lower-extremity strength difference was a significant individual predictor for gait speed,gait endurance and functional balance.9
A study was conducted by Susan Ryerson to determine whether trunk position sense is impaired in people with post stroke hemiparesis.The study was done in 42 subjects.21 with chronic stroke and 21 non-neurological subjects and found that there were significant difference in absolute trunk reporting error between stroke and controlled groups in both sagittal and transverse plane.16
Sebestina A.Borbes performed a study to determine the effect of cognitive and perceptual deficits on sitting and standing following stroke and concluded that cognitive and perceptual deficits following stroke influence sitting and standing balance.17
A study performed by Pamela Ducon to determine whether standard, progressive, physiologically based programme for sub acute stroke produced gain greater than those attributable to spontaneous recovery and usual care and concluded that progressive exercise programme and therapeutic exercise in persons who had completed acute stroke rehabilitation produced gain in balance,endurance and mobility beyond these attributable to spontaneous recovery and usual care.18
6.3) OBJECTIVES OF STUDY :
(1)To estimate the influence of sensory deficit measured using Semmes-Weinstein monofilament on functional balance measured by using BBS in stroke patients.
MATERIALS AND METHODS :
7.1) Study Design:
Correlational Study.
7.2) Source of data:
Individual diagnosed with CVA referred by specialists for physiotherapy.
7.2(I) Definition of Study Subjects:
60 subjects above 40 years diagnosed with CVA.
7.2(II) Inclusion and Exclusion Criteria:
Inclusion Criteria:
1.Chronic stroke patients(at least 6 months prior to study).
2. Age above 40 years.
3.Patients able to walk 10mtrs without assistance.
4. Informed Consent.
Exclusion Criteria:
1.Unstable cardio vascular status.
2.Lower limb muscles co-morbidity interfering with the ability to stand upright.
3.Poor cognitive status(MMSE less than 20)
7.2(III) Study Sampling Design, Method and Size:
Sample design:
Purposive Sampling.
Sample size:
60 subjects fulfilling the inclusion and exclusion criteria.
7.2(IV) Follow Up:
Data forming the outcome measures would be obtained at recruitment of subjects. No further follow up is required.
7.2(V) Parameters used for comparison and statistical analysis used:
Spearman’s Rank Correlation.
7.2(VI) Duration of study:
Data will be collected over a period of 10-12 months.
7.2(VII) Methodology:
Subjects meeting the inclusion and exclusion criteria will be recruited for the study. Informed consent will be obtained from the patients. Sensory system would be evaluated using Semmes-Weinstein monofilament on the plantar surface of the feet. Functional balance using Berg Balance Scale would be performed in a single session for each subject,with rests provided during the testing as requested by the subjects.
BBS is a 14 item performance based instrument and it will be administered in a quiet area by the examiner. On the BBS,performance of each of 14 items,ranging in difficulty from sitting unsupported to standing on one foot is rated on a 4-point scale, for a maximum possible score of 56.19
A 5.07/10-g Semmes-Weinstein monofilament would be used in the assessment of sensation in both distal lower extremities. Each participant was positioned supine with shoes and shocks removed. A practise trial was given to the participant on the upper extremity of the less involved side to instruct the participant in the expected sensation. With eyes closed,the participant was intructed to respond “yes” when he or she felt the monofilament pressure on the plantar surface of the foot. Pressure was applied until the filament bent slightly for 2 seconds for a total of 10 repetitions on each foot,alternating between the least-calloused plantar aspect of the first and fifth metatarsals.The number of correct responses on each foot was recorded. The difference in sensation between the 2 sides also was calculated by subtracting the number of correct responses out of 10 for the more affected side from that of less affected side. A sensation difference score of 0 indicates no difference between the sides,and a larger number indicates a greater difference.20,21
7.3) Does the study require any investigations to be conducted on patients or other human or animal? If so, please describe briefly.
YES.
Clinical examination for all subjects included.
Somatosensation would be evaluated using Semmes-Weinstein monofilament.
Berg Balance Scale for measuring the functional balance.
7.4) Has ethical clearance been obtained from your institution in case of 7.3.
YES

LIST OF REFERENCES:

1 .Louisette Mercier,MA;Therese Audet,PhD,Rejean Hebert,MD,MP,Annie Rochette,Msc:Marc France Dubois,PhD.Impact of Motor,Cognitive and Perceptual Disorders on ability to perform Activities of Daily Living after stroke.Stroke.2001;32:2602-2608.
2. Felgin L,Sharon B,Czaczkes B,Rosin AJ.Sitting equilibrium 2 weeks after a stroke can predict the walking ability after 6 months.Gerontology.1996;42:348-353.
3. Jongbloed L.Prediction of function after stroke;a critical review.Stroke.1986;17:765-766.
4. Wade DT,Wood VA,Laangton Hewer K.Recovery after stroke;the first three months.J.NeurolNeurosurg Psychiatr.1985;48:7-13
5. Charles Benaim,MD;Dominique Alain Perennou,MD,PhD;Jacques Marc Rousseaux,MD,PhD,Jacques Yvon Pelissier,MD.Validation of a Standardised Assessment of Postural Stroke.The Postural Assessment Scale for Stroke patients(PASS).Stroke.1999;30:1862-1868.
6.Darcy A. Umphred.Neurological Rehabilitation.Fifth Edition.732-733.
7. Susan B’O Sullivan,Thomas J Schmitz.Physical Rehabilitaation.Fifth Edition.122.
8. Harris JE, Eng JJ,Marigold DS, et al.Relationship of balance and mobility to fall incidence in people with chronic stroke.Physical Therapy.2005;85:150-158.
9.Patricia Kluding,Byron Gajewski.Lower-Extremity strength differences predict activity limitations in people with chronic stroke.Physical Therapy.2009;89:73-81.
10. Richard P Dl Fablo,Mary Beth Badke.Relationship of Sensory Organization to Balance Function in Patients with Hemiplegia.Physical Theraapy 1990;70:542-548
11.Patterson SL,Forrester LW,Rodgers MM,et al.Determinants of walking function after stroke:differences by deficit severity.Arch Phys Med Rehabil.2007;88:115-119.
12.Eng JJ,Chu KS,Dawson AS,et al.Functional walk tests in individuals with stroke:relation to percieved exertio and myocardial exertion.Stroke.2002;33:756-761.
13.Pang MYC,Eng JJ,Dawson AS.Relationship between ambulatory capacity and cardiorespiratory fitness in chronic stroke:influence of stroke specific impairments.Chest.2005;127:495-501.
14.LeBrasseur N,Sayers S,Ouellette M,Fielding R.Muscle impairments and behavioral factors mediate functional limitations and disability after stroke.Physical Therapy. 2006;86:1342-1350
15.Jane E.Sullivan and Lois D. Hedman.Snsory Dysfunction Following Stroke.Incidence,Significance,Examinaation,and Intervention.Top Stroke Rehabilitaation 2008;15(3):200-217.
16.Susan Ryerson,Nancy N,David A Brown,Rita A Wing and Joseph M Hldler.Altered trunk position sense and its relation to balance functions in people with post stroke.JNDT.2008;32:14-20.
17.Sebestina A Borges,Ona A.A study adressing yhe impact of cognitive ans perceptual deficit on sitting and standing balance following cerebro vascular accident.The Indian Journal Of Occupational Therapy.2001
18.Pamela Duncan,Steven Gollub,Lone Richards,Sueminlai,Dean Reker,Subshan Pevers.Randomized clinical trial of therapeutic exercise in sub acute stroke.Stroke 2003;34:2173-2180.
19. Berg k,Wood-Dauphinee SL,Williams Jl.The Balance Scale:reliability assessment with elderly residents and patients with an acute stroke.Scand J Rehabil Med.1995;27:27-36.
20.Magnusson M,Johansson K,Johansson BB.Sensory stimulation promotes normalization of postural control after stroke.Stroke.1994;25:1176-1180.
21.William H.Herman MD,MPH,Lawrence Kennedy MD,RCP.Underdiagnosis of Peripheral Neuropathy in Type 2 diabetes.Diabetes Care.2001 Feb;24(2):251-256.

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