Rajiv Gandhi University of Health Sciences
Karnataka, Bangalore
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / Name of the Candidate andAddress / Ms. NIVRUTI PANERI
NITTE INSTITUTE OF PHYSIOTHERAPY
MEDICAL SCIENCES COMPLEX
DERALAKATTE
MANGALORE - 575018
2 / Name of the Institution / NITTE INSTITUTE OF PHYSIOTHERAPY
MEDICAL SCIENCES COMPLEX
DERLAKATTE
MANGALORE-575018
3 / Course of Study and Subject / MASTER OF PHYSIOTHERAPY
PHYSIOTHERAPY IN NEUROLOGICAL AND
PSYCHOSOMATIC DISORDERS
4 / Date of admission to the course / JUNE 30th 2008
5 / Title of the topic:
“A COMPARATIVE STUDY ON TO FIND THE EFFECTIVENESS OF PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION TECHNIQUE VERSUS CONVENTIONAL TRUNK EXERCISES TO IMPROVE TRUNK CONTROL IN RECOVERY STAGE OF HEMIPLEGIC PATIENTS”.
6
7.
8. / Brief resume of the intended work
Introduction
According to World Health Organisation, stroke can be defined as “rapidly developed clinical signs of a focal disturbance of cerebral function of presumed vascular origin and of more than 24 hours duration.” 1 Motor deficit in stroke is characterized by paralysis (hemiplegia) or weakness (hemiparesis), typically on the side of body opposite to the side of lesion.2
Patients suffering from stroke may have many sensorymotor and cognitive impairments. Altered motor ability in stroke patients significantly impairs patient’s upper and lower extremity functional task, balance and trunk control, which diminishes patient’s ability to perform Activities of Daily Living independently. 3
Trunk control allows the body to remain upright, to adjust to weight shift, to control the movement against the constant pull of gravity, and to change & control the body position for balance and function. In hemiplegia altered trunk control affects postural control and ability to perform movement in sequence. Again the abnormal tone in the trunk leads to atypical alignment pattern in trunk and shoulder girdle and pelvic girdle, which create atypical starting position for functional movement and also affect the
balance. 4
In stroke rehabilitation, conventional therapeutic exercise to improve trunk control comprises of static and dynamic task oriented training activities, strengthing exercises to trunk muscles. 5,2
Proprioceptive Neuromuscular Facilitation is a method of facilitating the response of neuromuscular mechanism through the stimulation of proprioceptors. The basic procedures for facilitation include resistance (to increase strength), irradiation (spread of response to stimulus), manual contact, body position, verbal command, vision, traction or approximation, stretch, timing and pattern (mass movements, component of normal functional motion). These Proprioceptive Neuromuscular Facilitation procedures help the patients to gain efficient motor function in stroke. 6
Both the techniques were effective to improve the trunk activity but there will be difference between these interventions in improvement of trunk control. So this study aims to evaluate the comparative effect of conventional trunk exercise technique and Proprioceptive Neuromuscular Facilitation to improve trunk control of recovery stage hemiplegic patients.
6.1) Need for the study
In stroke rehabilitation program more importance is given to extremities and ambulation than trunk performance. Information regarding Proprioceptive Neuromuscular Facilitation techniques to improve trunk control is lacking. There is no enough literature comparing these two interventions in recovery stage stroke patients. So the need of the study arises to compare the effectiveness of Proprioceptive Neuromuscular Facilitation and conventional training in improving trunk control in recovery stage hemiplegic patients.
6.2) Objective Of Study
· To evaluate the effect of conventional trunk exercise program to improve trunk control in recovery stage stroke patient.
· To evaluate the effect of Proprioceptive Neuromuscular Facilitation techniques to improve trunk control in recovery stage stroke patient.
· To compare the effectiveness of conventional trunk exercise and Proprioceptive Neuromuscular Facilitation technique for trunk to improve trunk control in recovery stage stroke patients.
6.3) HYPOTHESIS
NULL HYPOTHESIS:
There will not be any significant difference between conventional trunk exercise program and PNF technique on improvement of trunk control in recovery stage hemiplegic patient.
EXPERIMENTAL HYPOTHESIS:
There will be a significant difference between conventional trunk exercise program and PNF technique on improvement of trunk control in recovery stage hemiplegic patients.
(6.4). REVIEW OF LITERATURE
· Susan B. O’Sullivan et al (2001) has stated that coordinated movements can be promoted by using Proprioceptive Neuromascular Facilitation developed by Kabat and Knott, which reinforce and develop selective movement control while avoiding synergistic patterns.2
· Nick kofotolis, et al (2006) has concluded that static and dynamic Proprioceptive Neuromuscular Facilitation programme may be appropriate for improving trunk muscle endurance, flexibility, and functional performance in women with chronic low back pain. 7
· Wang Ry (1994) has concluded that in subjects with hemiplegia of short duration, gait speed and cadence improved immediately after session of Proprioceptive Neuromuscular Facilitation, and this improvement was further enhanced after 12 treatments. 8
· Gergory T Thielman, et al (2004) has concluded that task related training for severely impaired subjects appear most effective in promoting functional improvement in reaching albeit with compensatory trunk use, over Progressive Resisted Exercise for trunk motion. 5
· Verheyden G, et al (2004) has concluded that trunk impairment scale provides guidelines for treatment and level of quality of trunk activity can be derived from the assessment. 9
· F.P.Franchignori, et al (1997) has concluded that trunk control test showed a good sensitivity to change in assessing recovery of stroke patients 10
· De Seze, et al (2001) has concluded that Voluntary trunk control retraining during spatial exploration with the Bon Saint Come device appears to be a useful approach for rehabilitation of postural disorders in hemiplegic patients.11
· Ozdemir F, et al (2001) has concluded that cognitive evaluation by mini mental state examination is significant to predict functional out come in patients with acute stroke. 12
Materials and Method
7.1) Design:
Experimental study design.
7.2) Source of data:
Patients of K .S Hedge Charitable Hospital, Deralakatte, Mangalore.
7.2 a) Sampling procedures:
By using randomised sampling techniques to select 30 samples from the population for the
study.
7.3) Method of Collection of Data:
SUBJECT SELECTION CRITERIA
Inclusion criteria
· Ischemic right sided hemiplegic patients.
· 45-65 yrs of age
· Both male and female
· Trunk control scale score > 48
Exclusion Criteria
· Minimum mental score < 20
· Sensory deficit subjects
· Medically unstable patient
· Any previous musculoskeletal problems to trunk.
TOOL USED IN THIS STUDY
· Mini mental scale
· Trunk control test
· Trunk impairment scale
Procedure :
Well defined 30 patients will be selected by using simple randomized sampling technique after fulfilling the criteria from the population and then divide in to two groups. Each group consist of 15 patients and inform concern will be obtained. Both group patients will undergo regular physical therapy.
Group 1 will be given Proprioceptive Neuromascular Facilitation techniques for trunk for 45 min/day, 4days/week for the period of 4 weeks. Proprioceptive Neuromascular Facilitation is given to strengthen the trunk muscles, Proprioceptive Neuromascular Facilitation techniques for trunk are as follows :
· Bilateral upper extremity pattern for trunk by Chopping, Lifting.
· Bilateral lower extremity pattern for trunk.
· Trunk lateral flexion.
· Combination patterns for the trunk by Upper and lower trunk flexion, Upper trunk flexion with lower trunk extension, Upper and lower trunk extension, Upper trunk extension with lower trunk flexion. 6
The amount and intensity of the exercise at each session will be graded according to each subject functional level, with 2 minutes rest in between. Progression will be made by increasing the repetition and increasing the resistance according to the individual ability.
Group 2 will be receiving conventional trunk exercise program for 45 min/day, 4 days / week for the period of 4 weeks the intervention includes static and dynamic - task oriented trunk exercise and strengthing exercise to the trunk muscles with 2 minute rest in between the repetition of each set, Progression will be made by increasing the repetition and resistance according to individual ability. 2,5
Before and after the intervention for both the groups pre and post test score will be obtained for trunk control by using trunk impairment scale for the statistical analysis.
Statistical tools:
The data were analyzed for inter group comparison of group 1 (experimental) and group 2 (control) using unpaired t’ test.
The pre and post test score of both the group will be analyzed by paired ‘t’ test
7.4 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly
Yes, patients will undergo Proprioceptive Neuromascular Facilitation techniques for the trunk and conventional trunk exercises for the prescribed period of time.
7.5 Has Ethical Clearance been obtained from your institution in case of 7.4?
Yes, Ethical Clearance has been obtained from K. S. Hegde Medical Academy.
List of references
1. Patrica A. Downie, Cash textbook of neurology for physiotherapist, (1993) fourth edition, publisher-Jaypee brothers, pg 241.
2. Susan B. O’ Sullivan and Thomas J. Schmiz, Physical Rehabilitation Assessment and Management, (2007) fifth edition, Publisher – Jaypee brothers, pg 520, 547-48,552-55.
3. Hamrin E Eklund et al. “Muscle strength and balance in post stroke patients. Ups J Med Sci,
1982:87:11-26
4. Darcy A. Umphred, Neurological Rehabilitation, fourth edition. Pg. 761-763
5. Gergory T Thielman MS, Catherine M Dean PhD, and A M Gentile Phd. “rehabilitation of
reaching after stroke, task related training vs progressive resisted exercise.” Archive of physical medicine and rehabilitation. Volume 85, pages 1613-1618.
6. Susan S. Adler, Dominiek Beckers, Math Buck. PNF in practice, second revised edition. Pg 3-17,227-249
7. Nick kofotolis, and Eleftherios Kellis (2006) “Efect of two four weeks Proprioceptive Neuromascular Facilitation program on muscle endurance, flexibility and functional performance in women with chronic low back pain” PHYS PHER, Vol.86, No.7, July2006, pp 1001-1012.
8. Wang Ry “effect of Proprioceptive Neuromascular Facilitation on the gait of patients with hemiplegia of long and short duration” Phy Ther. 1994 Dec; 74(12); 1108-15.
9. Verheyden G., Niewwboer A., Mertin J.,Preger R.,Kiekens C., Deweerdt W. (2004) “Trunk impairment scale, a new tool to measure motor impairment of the trunk after stroke.” Clin Rehabil, 2004 May, 18 (3); 326-34
10. F P Franchignori, L Tesio , C Ricupero, M T Martino “trunk control test as an early predictor of stroke rehabilitation out come.”STROKE 1997:28, 1382-1385. American heart association Inc.
11. De Seze, Laurent, Alain Bon-Saint-Come, Xavier et al (2001).”Rehabilitation of postural disturbances on hemiplegic patients by using trunk control retraining during exploratory exercise.” Arch Phys Med Rehabil, 2001, 82(6)793-800.
12. Ozdemir F, Birtune M, Ekuklu G, Kokino (2001) “Cognitive evaluation and functional out come after stroke.” AmJ Phys Med Rehabil, 2001 June: 80(6); 410-5
APPENDIX I
SUBJECT EVALUATION FORM
Sl No. :
Name: Age: Sex:
Date of assessment:
Referred by:
History: side affected-
Medical history-
Vital signs: respiratory rate- blood pressure- temperature-
Examination: Mini mental scale-
Sensory assessment-
Motor assessment-
Trunk control test-
Other systems-
Investigation: Treatment details
Pre test score / Post test scoreTrunk Impairment Scale
APPENDIX II
CONSENT FORM: I (FOR VOLUNTEERS)
I voluntarily accept to participate in the study entitled “A comparative study on to find the effectiveness of Proprioceptive Neuromascular Facilitation technique versus conventional trunk exercise to improve trunk control in recovery stage of hemiplegic patients.”
.
The nature and hazards involved in these studies have been fully explained to me. I understand that I may withdraw from this study at any time.
I consent to the data being collected and stored at the Department of Physiotherapy and for the data to be used for research purposes. I understand that I am assured of anonymity, and that the data will be treated as a confidential document.
I understand that I may also contact the KSHEMA Institutional Ethical Committee, if I feel I have been unfairly treated.
Date: Signature:
Name:
Witness: Signature
Name:
Investigator’s Statement:
I have carefully explained the nature of the above studies to the subjects.
Date: Name
Signature:
APPENDIX III
The Trunk Control Test for Motor Impairment After Stroke
Overview:
The Trunk Control Test can be used to assess the motor impairment in a patient who has had a stroke. It correlates with eventual walking ability.
Testing done by patient lying on bed:
(1) roll to weak side
(2) roll to strong side
(3) balance in sitting position on the edge of the bed with the feet off the ground for at least 30 seconds
(4) sit up from lying down
Scoring Each Test / Pointsunable to do without assistance / 0
able to do so using nonmuscular help or in an abnormal style; uses arms to steady self when sitting / 12
able to complete task normally / 25
• Minimum score: 0
• Maximum score: 100
• If the test is done at 6 weeks after stroke a score >= 50 predicts recovery of the ability to walk by 18 weeks.
References:
Collin C Wade D. Assessing motor impairment after stroke: a pilot reliability study. J Neurology Neurosurg Psychiatry. 1990; 53: 576-
APPENDIX IV
TRUNK IMPAIREMENT SCALE
static
Starting position for all items; sitting, thighs horizontal and feet flat on support, knees 90 degree flexed, no back support, hands and fore arm resting on the thighs. The subjects get 3 attempts for each item. The best performance is stored. The observer may give feedback between the tests. Instruction can be verbal or non verbal.
ITEM / TASK DESCRIPTION / SCORE DESCRIPTION / SCORE / REMARKSSTATIC SITTING BALANCE
1. / Keep starting position for 10 sec / -Falls or needs arm support.
-Maintains position for 10 sec / 0
2 / If 0, total TIS score is 0
2. / Therapist crosses strongest leg over weakest leg. Keep position for ten sec. / -Falls or need arm support.
-Maintain position for 10 sec. / 0
2
3. / Patient crosses strongest leg over weakest leg. / -Falls
-Needs arm support -Displaces trunk for more than ten sec or assist with arm -Moves without trunk or arm compensation / 0
1
2
3
7
DYNAMIC SITTING BALANCE
1. / Touch seat with right elbow, return to starting position(task achieved or not) / -Does not reach seat or uses arm
-touches seat without help / 0
1 / If 0 , items 2+3 are also 0
2. / Repeat item 1(evaluate trunk movement) / - no appropriate trunk movement
- appropriate trunk movement (shorting right side , lengthening left side) / 0
1 / If 0 , item 3 is also 0
3. / Repeat item1(compensation strategies used or not) / - compensation used (arm, hip, knee, foot) -no compensatory strategies used / 0
1
4. / Touch seat with left elbow return to starting position(task achieved or not) / -does not reach seat , falls or uses arm
-touches seat without help / 0
1 / If 0 , item5+ 6 are also 0
5. / Repeat item 4(evaluate for trunk movement) / - no appropriate trunk movement
- appropriate trunk movement (shorting left side , lengthening right side) / 0
1 / If 0, item 6 is also 0.
6. / Repeat item 4 (compensation strategies used or not) / - compensation used (arm, hip, knee, foot) -no compensatory strategies used / 0
1
7. / Lift right side of pelvis from seat return to starting posture(evaluate the trunk movement) / - no appropriate trunk movement - appropriate trunk movement (shorting right side , lengthening left side) / 0
1 / If 0, than item 8 is also 0.
8. / Repeat item 7 (compensation strategies used or not) / - compensation used (arm, hip, knee, foot) -no compensatory strategies used / 0
1
9. / Lift left side of pelvis from seat, return to starting position(evaluate trunk movement) / - no appropriate trunk movement
-appropriate trunk movement (shorting left side , lengthening right side) / 0
1 / If 0, item 10 is also 0
10. / Repeat item 9(compensation strategies used or not) / - compensation used (arm, hip, knee, foot) -no compensatory strategies used / 0
1
10
COORDINATION
1. / Rotate shoulder girdle 6 times(move each shoulder 3times forward) / -does not move right side 3 items -asymmetric rotation
-symmetric rotation / 0
1
2
/ If 0, item 2 is also 0
2. / Repeat item 1 perform within 6 sec / -asymmetric rotation
-symmetric rotation / 0
1
3. / Rotate pelvic girdle 6 times(move each knee 3times forward) / -does not move right side 3 items -asymmetric rotation
-symmetric rotation / 0
1
2 / If 0, item 4 is also 0
4. / Repeat item 3 perform within 6 sec / -asymmetric rotation
-symmetric rotation / 0
1
6
TOTAL TRUNK IMPAIREMENT SCALE 23