DISSERTATION SYNOPSIS

SUBMITTED TO

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,

BANGALORE

TOWARD PARTIAL FULFILMENT OF

MASTER OF PHYSIOTHERAPY DEGREE COURSE

BY

TANYA FONDEKAR

UNDER THE GUIDANCE OF

V.S. SARAVANAN

VIKAS COLLEGE OF PHYSIOTHERAPY

AIRPORT ROAD, MARY HILL, KONCHADY,

MANGALORE-575008

2010-11

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the candidate and address

TANYA FONDEKAR

VIKAS COLLEGE OF PHYSIOTHERAPY,

AIRPORT ROAD, MARY HILL

KONCHADY POST, MANGALORE-575008

2. Name of the Institution

VIKAS COLLEGE OF PHYSIOTHERAPY.

MANGALORE

3. Course of study and subject

Master of Physiotherapy

NEUROLOGICAL AND PSYCHOSOMATIC

DISORDERS

4. Date of admission to Course

20.06.2011

5. Title of the Topic “RELATION BETWEEN MOTOR RECOVERY AND LEVEL OF STRESS IN STROKE SURVIVERS: A CORRELATION STUDY.”

6. Brief resume of intended work:

6.1  Need for the study

Stroke or brain attack is the sudden loss of neurological function caused by an interruption of the blood flow to the brain.

Stroke is defined by the WHO as a “rapidly developing syndrome with clinical signs of focal or global disturbance of cerebral function, with symptoms lasting for 24 hrs or longer or leading to death, with no apparent cause other than vascular origin”.

Patients with acute stroke are vulnerable to the development of various complications & the disability caused by the stroke.

The beginning of hemiplegia can compromise the normal biomechanical principle due to the loss of motor control & the development of abnormal movement patterns; secondarily, there can be soft tissues alterations. Recovery from stroke is extremely difficult to measure. In this study the motor recovery is to be measured by Fugl-Meyer scale.

The Fugl Meyer Assessment is considered to be one of the most comprehensive quantitative measures of motor impairement following stroke.2

The FM Scale is the 226–point multi-item Likert type scale developed as an evaluative measure of recovery from hemipegic stroke. It is divided into 5 domains- motor function, sensory function, balance, joint range of motion and joint pain. Each domains contain multiple items,each scored on 3-point ordinal scale (0=cannot perform,1=performs partially,2=performs fully).But ,in this study, only the motor domain items (upper extremity=66points, lower extremity=34points)are being measured.3

The FM Scale has aimed at incorporating all the relevant components in the stages of recovery described by Twitchell and Brunnstorm.4 It is also being studied that the motor domain of FM scale fulfills a high degree of sensibility.5

Stress refers to the perceived or actual threat on physical and/or psychological homeostasis of the human body1. Disrupted homeostasis elicits the so called “stress response”, meaning the activation of central and peripheral neuroendocrine mechanisms responsible for various adaptive responses and behaviors 1.

The other scale that is to be used in this study is the Percieved Stress Scale (PSS) with 10 items which evaluates the level of stress in stroke patients undergoing rehabilitation.

The PSS is the most widely used psychological instrument for measuring the perception of stress. It is the measure of the degree to which situations in one’s life are appraised as stressful. The questions in the PSS are of general nature thus relatively free of content specific to any subpopulation group.6

PSS was originally developed as a 14-item scale that assess the perception of stressful experiences by asking the respondent to rate the frequency of his/her feelings and thoughts related to events and situations that occurred over the previous month. There are also two product short forms, the PSS-4 and PSS-10 with 4 and 10 respectively selected items by the original PSS-14 form but in this study PSS-10 is to be used. High PSS scores have been correlated with higher biomarkers of stress, such as cortisol.7,8

Thus, this study is mainly intended to find out the relationship between level of stress and motor recovery in stroke survivors.

 6.2 Review of literature

1. Ruby Yu, Suzanne C. Ho et al (April 2010) did a study on 509 post-menopausal Chinese women selected from a community randomly and psychologically perceived stress was evaluated in this group. Principal component analysis of the PSS showed that the scale consisted of two factors which explained 52% of variance. Internal consistency was adequate (0.81) and the test-re-test reliability after an interval of 2 weeks was 0.86.Thus,PSS distinguished wee and in the expected manner between subgroups on the basis of age, work status, marital status, providing evidence of construct validity.9

2. Remor, Carrobles et al (2006) analyzed that the cultural adaptation of the European Spanish version of the PSS on the Mexicon samples. From there studies,

they found that PSS is an instrument with adequate psychometric properties (internal structure, reliability as internal consistency and convergent validity).10,11

3. F Angeleri, VA Angeleri, N Foschi, S Giaquinto and G Nolfe et al conducted a study on 180 consecutive patients affected by stroke who were hospitalized for the first time and discharged at least 1 year before the study. This study was designed to assess the quality of life after an active poststroke period of rehabilitation and to investigate the possibility of a return to a working environment for those still of working age. The results indicated that the patients were not happy after the aftermath of stroke because of depression, family stress or lessened social activity.12

4. K. C. A. Sneeuw, Ms et al; N. K. Aaronson et al, R. J. de Haan, RN et al, M. Limburg, MD et al did a study on 437 subjects who had suffered a stroke 6 months earlier. Quality of Life (QL) was assessed by means of the Sickness Impact Profile (SIP).Their results suggests that more QL impairments were found for patients with supratentorial cortical or subcortical infarctions and hemorrhages than for patients with lacunar infarctions and infratentorial strokes.13

5. Pamela W. Duncan et al; Henrik Stig Jorgensen et al, Derick T. Wade et al a systematic review of all published randomized studies of acute stroke drug intervention was undertaken, and the measures used were recorded. Fifty-one studies involving 57,214 subjects were identified. These studies used 14 different measures of impairment, 11 different measures of activity, 1 measure of "quality of life," and 8 miscellaneous other measures. It is recommended from these studies that further studies should include extended/instrumental activities and advanced mobility as components of the primary outcome measure, with outcome assessment being undertaken at 6 months.14

6. Michael S Clarke et al, Dennis S Smith et al examined the relative effects of depression and abnormal illness behaviour (AIB) on long-term rehabilitation outcome following stroke. Ninety-four twelve-month stroke survivors who had undergone an inpatient rehabilitation programme were selected. The result suggests that AIB was a better predictor of functional competence and performance than either age or stroke severity, at rehabilitation discharge and both six and twelve months later. Depression was not related to functional competence and performance at any assessment, but was strongly predictive of an inactive lifestyle at both six and twelve months.15

7. Reene D Goodwin et al, Devangere P. Devanand et al objective was to determine the association between stroke and depression, the co-occurrence of stroke and depression, and functional health outcomes among adults in the US population. Post-stroke adults of the age 24-75 years were selected. Results suggested that almost one third (29.2%) of adults with stroke in the past year also had depression

in the past year (odds ratio 3.5, 95% confidence interval 1.4, 8.9). The co-occurrence of stroke and depression was associated with significantly greater limitations in walking and climbing stairs and poorer general physical functioning than that associated with either without the other. There was evidence of interaction between depression and stroke in predicting limitations, specifically with a statistically significant effect in walking short distances (P =.045)16

8. David J Gladstone et al, Cynthia J. Danells et al, Sandra E. Black et al evaluated the measurement properties of the Fugl Meyer Assessment for stroke patients and concluded that it has an excellent inter-rated and intra-rated reliability and Fugl-Meyer motor scale is recommended highly as a clinical and research tool for evaluating changes in motor impairment following stroke.17

9. Sullivan KJ, Tilson JK, Cen SY, Rose DK, Hershberg J, Correa A, Gallichio J, McLeod M, Moore C, Wu SS, Duncan PW et al. analyzed the inter-rater and intra-rater reliability of the Fugl-Meyer Scale is assessed and concluded that it has high inter-rater reliability for the Fugl-Meyer motor and sensory assessments. Poststroke sensorimotor impairment severity can be reliably assessed for clinical practice or rehabilitation research with these methods.18

6.3 Objectives of the study

1. To evaluate the motor recovery in stroke survivors.

2. To evaluate the level of stress in stroke survivors.

3. To explore the relationship between the motor recovery and level of stress in

Stroke survivors.

MATERIALS AND METHODS

7.1 Source of data

Data will be collected from the government hospital of Mangalore and outpatient department of vikas college of physiotherapy.

7.2 Method of collection of data

HYPOTHESIS

ALTERNATE HYPOTHESIS (H1)

There will be a significant relationship between motor recovery and level of stress in stroke survivors.

NULL HYPOTHESIS (H0)

There will not be a significant relationship between motor recovery and level of stress in stroke survivors.

Research Design

Correlation study

Sampling method

Purposive sampling technique

All subjects will be diagnosed and referred by physician as hemiplegic stroke patients. 60 subjects of both sexes fulfilling criteria will be taken for the study. Informed consent will be obtained from each patient.

METHODOLOGY

Patients with acute stroke are selected and it includes both male and female patients of age group between 40-65years. To be eligible for the study the subjects should fulfill the following inclusion and exclusion criteria.

Inclusion Criteria

1. Acute stroke patients

2. Patients with both Hemorrhagic and Ischemic stroke

3. Age group between 40-65 years.

4. Patients who can understand the commands and also can respond

5. Both male and female patients.

Exclusion criteria

1. Unstable patients.

2. Patients with pacemaker and severe heart disease.

3. Patients with associated or with a history of any other neurological problems.

4. Patients with impaired cognition.

5. Patients with severe impairment of sensitivity and proprioception.

MATERIALS

The Fugl-Meyer Assessment (FMA) Motor test requires:Tennis ball ,A small spherical shaped container, A tool to administer reflex tests, A quiet room.

The Perceived Stress Scale (PSS) of 10 items requires: Scale form and pencil.

METHOD OF APPLICATION

Motor recovery in stroke survivors is measured with Fugl-Meyer scaleof motor recovery after stroke. Motor domain contains multiple items,each scored on a 3-point ordinal scale (0 = cannot perform 1 =partially perform, 2 = performs fully). The motor domain includes items measuring movement, coordination, and reflex action about the shoulder, elbow, and forearm performs , wrist, hand, hip, knee, and ankle. The motor score ranges from 0 (hemiplegic) to a maximum of 100 points (normal motor performance),divided into 66 points for the upper extremity and34 points for the lower extremity .The FM assessment is best administered by a trained physical therapist on a one-to one basis with the patient. It takes approximately 20 minutes to administer.

Level of stress is assessed by Perceived stress scale. It is contains ten questions and 40 points (0 = Never 1 = Almost Never 2 = Sometimes 3 = Fairly Often 4 = Very Often).The questions in this scale will be asked to subjects about his feelings and thoughts during last one month and they have to indicate their feelings by circling on a scale paper.

OUTCOME MEASURES

1. The Fugl-Meyer Scale for assessing Motor recovery.

2. The Perceived Stress Scale of 10 items for assessing level of stress.

7.3 Statistical Analysis

Pearson product moment correlation (r) value will be used to find the relationship between motor recovery and level of stress.

P value <0.05 will be taken for statistical significance.

7.4 The study requires non-invasive investigations and interventions to be conducted on patients. The investigations to be conducted include physical examination of the patients on the basis of the Fugl-Meyer Assessment of Motor Recovery after Stroke and the Perceived Stress Scale.

List of References

1. Chrousos GP. Stressors, stress, and neuroendocrine integration of the adaptive response. The 1997 Hans Selye memorial lecture. Ann. N. Y. Acad. Sci. 1998; 851: 311–335.

2. Fugl-Meyer AR, Jaaskol, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. Scand J Rehabil Med 1975; 7: 13-31.

3. David J. Gladstone, Cynthia J.Danells and Sandra E. Black Neurorehabil Neural Repair 2002; 16: 232.

4. Bobath B. Adult hemiplegia: evaluation and treatment. London: William Heinemann Medical Books; 1970.

5. Feinstein AR. Clinimetrics. New Haren (CT): Yale University Press; 1987.6. Cohen S, Kamarck T, and Mermelstein R.(1983).A global measure of

perceived stress. Journal of Health and Social Behaviour, 24, 386-396.7. Malarkey WB, Pearl DK, Demers LM, Kiecolt-Glaser JK, Glaser R. Influence

of academic stress and season on 24- hour mean concentration of ACTH, Cortisol and beta endorphin.Psychoneuroendocrinology.1995; 20; 499-508.

8. Van Eck MM, Nicholson NA. Percieved stress and salivary cortisol in daily life.Am.Behav.Med.1994; 16: 221-227.

9. Ruby Yu, Suzane C.Ho.Journal of Psychology, April 2010:1-8.10. Remor E (2006).Psychometric properties of a European Spanish version of the

Percieved Stress Scale(PSS).The Spanish Journal of Psychology,9;86-93.11. Remor E, and Carrobles J. (2001). Version Espanola de la escala de estres

percibido (PSS-14): Estudio psicometrico en una muestra VIH.Ansiedad y Estress, 7, 195-201.

12. F. Angeleri, VA Angeleri, N. Foschi; S Giaquinto and G Nolfe. Institute , Italy, Stroke , Vol 24, 1478-1483.

13. K.C.A Sneeuw, M. S ; N. K. Aaronson, PhD; R.J.de Haan, RN, PhD ;M. Lindburg ;Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute ,Academic Medical Centre, Amsterdam, The Netherlands.

14. Pamela W, Dunean PhD, FAPTA; Henrik Stig Jorgensen, MD, DMSci; Derick T. Wade MD. University of Kansas Medical centre, Kanas City, Rivermead Rehabilitation Centre, Oxford , England, Department of Veterans Affairs Medical Centre, Kanas City.

15. Michael S Clarke; Rehabilitation and Ageing Studies Unit, Dennis S. Smith; Rehabilitation Centre, Sydney, Australia.

16. Renee D. Goodwin et al, Devangree P. Devanand et al; Dept of Epidemiology and Psychiatry, New York.

17. David J. Gladstone, Cynthia J. Danells, Sandra E. Black, Dept of Medicine, Canada.

18. Sullivan KJ, Tilson JK, Cen SY, Rose DK, Hershberg J, Correa A, Gallichio J, McLeod M, Moore C, Wu SS, Duncan PW. Dept of Neurology.

9. Signature of the candidate :

10. Remarks of the Guide

11. Name and Designation of

11.1 Guide :

11.2 Signature :

11.3 Co-Guide : -

11.4 Signature : -

11.5 Head of the Department :

11.6 Signature :

12. 12.1 Remarks of the Chairman and Principal

12.2 Signature :