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PROFORMA FOR REGISTRATION OF

SUBJECTS FOR DISSERTATION

DISSERTATION PROPOSAL

TOPIC

“A STUDY ON EFFICANCY OF CONSTRAINT INDUCED MOVEMENT THERAPY ON IMPROVING UPPER LIMB FUNCTION IN SUBJECTS WITH MCA- STROKE”

SUBMITTED BY

SINTHANAI CHELVI

1st YEAR MPT

SHRIDEVI COLLEGE OF PHYSIOTHERAPY

TUMKUR - 572106

2010-2011 BATCH.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGLORE - 41

ANNEXURE – II

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

| | | |

|1 |NAME OF THE CANDIDATE AND ADDRESS |SINTHANAI CHELVI R I st YR MPT |

| | |SHRIDEVI COLLEGE OF PHYSIOTHERAPY, LINGAPURA, SIRAROAD, |

| | |TUMKUR- 572106 |

| 2 | NAME | |

| |OF THE INSTITUTION |SHRIDEVI COLLEGE OF PHYSIOTHERAPY TUMKUR |

| 3 | COURSE OF| |

| |STUDY AND SUBJECT |MASTER OF PHYSIOTHERAPY(MPT) – IN [ NEUROLOGICAL & PSYCHOSOMATIC |

| | |DISORDERS ] |

| 4 | DATE| |

| |OF ADMISSION TO COURSE |20/05/2010 |

| | | |

| |TITLE OF THE STUDY |“ A STUDY ON EFFICACY OF CONSTRAINT INDUCED MOVEMENT THERAPY ON IMPROVING |

|5 | |UPPERLIMB FUNCTION IN SUBJECTS WITH – MCA STROKE” |

6. BRIEF FESUME OF INTENDED WORK

INTRODUCTION

“STROKE” or “BRAIN ATTACK” is the sudden loss of neurological function caused by an interruption of the blood flow of the brain. It is an acute onset of neurological dysfunction due to an abnormality in cerebral circulation with the resultant and signs and symptoms that corresponds to the involvement of focal areas of brain.1

The term “STROKE” indicates the sudden and surprising nature of symptomatic cerebrovascular disease and is preferred over the more scientific phrase “cerebrovascular accident” (CVA).2

The WHO defines “STROKE” as “rapidly developed clinical signs of focal or global disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin”.3

Stoke ranks foremost among all the disorders of central nervous system (CVS) and it is the third leading cause of death after heart diseases and cancer.4

Stoke could soon be the most common cause of death worldwide. The worldwide incidence has been quoted as 2/1000 population per annum out of which about 4/1000 are people between 45-84 years. A WHO study in 1990 quoted incidence of mortality due to stroke in India to be 73/100000 per year.5

Ischemic stroke is the most common type attacking about 85% of the individuals with stoke, which Haemorrhagic stroke occurs about 15%, when blood vessels rupture causing leakage of blood in or around brain.6

Stroke mortality is increased in individuals with age of 65 and older. The type of stroke is significant in determining the survival. Patients with intra cranial hemorrhagic accounts for the most number of deaths following an acute arachnoid hemorrhage (43%).6

Pathologic studies confirm that more than 2/3 of all strokes are fall within the distribution of middle cerebral artery (MCA) territory. The MCA is the second of the two main branches of the internal carotid artery and supplies the entire lateral aspect of the cerebral hemisphere and sub cortical structure including the Internal Capsule.7

Impaired function is the major problem of the stroke patients. The common functional impairments due to stroke affects mobility, speech and language, communication, cognition vision, swallowing, hand and arm function and motor planning.8

Stroke affects the survivor’s hand and arm function. Hand and arm function recovery may be slower than the lower extremity. It may take even months and years in the future.9

Hemi paresis and cortical sensory loss that is greater in the arm and face than in the leg along with aphasia or non dominant hemisphere dysfunction is the characteristic feature of MCA stroke.10

The ultimate goal of stroke rehabilitation should be safe, independent efficient, energetic and high quality functioning of the stroke survivors in the community.11

Achieving this goal requires addressing a verity of medical, functional and psycho social issues. Physical therapy plays a crucial role in the stroke rehabilitation. There are numerous neuro rehabilitation approaches existing in practice of physiotherapy including many conventional approaches, PNF techniques, NDT approaches, Roods approaches etc.,

Constraint Induced Movement Therapy, also known as “forced use therapy” is a modern concept and one among the selective rehabilitation technique concentrate mainly on the functional recovery that helps stroke and the CNS damage. Victims to regain the use of affected limbs very faster than the other techniques. 12

6.1 NEED FOR THE STUDY

Stroke is the third leading cause of death and the most common cause of death and disability among adults in Asia. It is the common life threatening neurological disease (Warlow, 1991)13

Approximately around 700 new or recurrent cases of stroke occur annually in the United State in which 28% of cause occurring in patients under the age of 65 years. The incidence of stroke increases dramatically with the age doubling every decade after 55 years of age.14

The prevalence of stroke survivors has doubled over past 25 years. The major contributor to the increased proportion of stroke survivors is reduced the mortality rate, as a result of better management and active rehabilitation care.15

Despite improvement in emergency and medical care for stroke, many survivors left with various functional disabilities. It has been estimated that 30% of stroke survivors requires assistance in [ADL ] Activity Of Daily Living and about 20% survivors requires assistance in overall. 16

Comprehensive physical therapy rehabilitation may improve functional abilities of stroke survivors and also decrease the long term patient care cost.17

Among the numerous methods of neuro-rehabilitation approaches, selecting the most comprehensive, cost effective, time saving and appropriate rationale for stroke is the uphill task for everyone involved in this process of rehabilitation.

Finding effective therapy for stroke survivors is a major goal for all who are very much concerned with this disease. This throws light upon many physical therapist to think and select an appropriate and specific approach for stroke to improve the function.

Constraint inducted movement therapy is relatively a newer concept and also positive result have been reported in animal models and also in studies with small groups of patients.

Thus, this study is very much needed to find out the efficiency of constraint inducted movement therapy on improving function of the MCA stroke victims compared to other conventional physical therapy approaches.

6.2 OBJECTIVES

1) To find out the efficiency of Constraint Induced movement therapy on improving upper limb function in subjects with MCA stroke.

2) To find out the efficiency of conventional physiotherapy approaches on improving upper limb function in subjects with MCA stroke.

3) To compare the efficiency of Constraint Induced Movement Therapy and conventional physiotherapy approaches on improving upper limb function in subjects with MCA stroke.

6.3 HYPOTHESIS

Null Hypothesis

There exists no significant improvement in upper limb function of MCA stroke victims due to the constraint induced movement therapy compared to other conventional physical therapy approaches.

Alternative Hypothesis

There exists significant improvement in upper limb function of MCA stroke victims due to the constraint induced movement therapy compared to other conventional physical therapy approaches.

6.4. REVIEW OF LITERATURE

1). Hacke W et al

A stroke is caused by the interruption of the blood supply to the brain, usually become a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage t the brain tissues18

2). Biller J et al.

Paralyses of an arm after a stroke makes arm movements such as reaching, grasping and manipulating an object difficult. In turn this causes many difficulties in activities of daily life.19

3). Mas J et al

The term stroke or cerebrovascular accident are used to describe neurological signs and symptoms, usually focal and acute, that result from diseases involving blood vessels. Disorder of blood vessels are among the most common serious neurological disorder.20

4). Coul BM et al

Most of the members of therapeutic team in stroke rehabilitation take effectiveness of physical treatment after stroke for granted. Yet published data show that the evidence is not so straight forward or easy to evaluate. The majority of hard evidence, however does imply that stroke patients benefit from rehabilitation with physiotherapy.21

5). Bander H et al

The constraint induced movement therapy found patients with upper extremity hemi paresis as a result of stroke and who were treated for a 2 week program experienced a 34% reduction in time to task completion and 26% improvement in the proportion of tasks they were able to complete with their affected arm vs subjects who received usual care. This proved to be relatively inexpensive rehabilitative approach to improve upper extremity function.22

CIMT forces the use of affected side limb by restraining the unaffected side. Then the patient uses his affected arm repetitively and intensively for two weeks.

6). Steven L et al

The wolf motor function test [WMFT] a new time based method of evaluate the upper extremity performance in chronic stroke population. While compared to the fugl meyer motor assessment (FMA) both showed the interracts reliability, constract validity and criterior validity.

7). Sharon E et al

A Volunteer sample of 22 participants with relative hemiplegia that revealed moderate disability in the more affected upper limb were participated in the study that aimed to reveal the efficacy of constraint induced movement therapy. After the 2 weeks intervention which included massed practice, shaping of the more affected upper limb, behavioral contents, all outcome measures like wolf motor function test, the fugl-Meye motor performance assessment were improved significantly as a result of the C.I.M.T. These preliminary results suggested that C.I.M.T may be effective for improving upper limb motor function following stroke.

8). Porter K et al

CIMT is a treatment that aims to improve upper limb function following storke. much of the litererture to date claims the substantial treatment effects. A convenient sample of 12 people with chronic stroke with persisting upper limb disability were selected and given CIMT for two phases of 14 days and 10 days. The motor assessment scale (MAS) was found to be the most responsive outcome measure. Paired-t-test demonstrated significant improvement in affected upper limb function.25

9). Mary H Bowman et al

CIMT is composed of three primary elements like repetitive, unilateral training, and constraint of the less affected hand. The evidence shows that CIMT improves functional use and occupational performance of the more affected upper extremity by reversing learned non use and facilitating use dependent brain plasticity.26

10. Wolfgang H .R Milther et al

Constraint Induced Movement Therapy (C.I Therapy) has previously been shown to produce large improvement in actual amount of use of a more affected upper extremity in the “real-world” . This study aimed to determine whether these result could be replicated in another laboratory. 15 chronic stroke patients were given C.I Therapy for 12 days 7 hours per day. Patients showed a significant and very large degree of improvement from before to after treatment.27

11. Jean E. Crago et al

Constraint Induced Movement Therapy is a neuro rehabilitation technique developed to improve the use of the more affected upper extremity after stroke. A number of studies have reported positive effects for this intervention. The study involved 15 chronic stroke patients were received constraint Induced Movement Therapy for 6 hours per day on 10 consecutive week days showed large to very large improvements in the functional use of their more affected arm in their daily lives28

7. MATERIAL AND METHODOLOGY

7.1 Source of Data

➢ Shridevi Hospital, Tumkur

➢ Government District Hospital, Tumkur

7.2. Methods of collection of data

1. Sample design: These samples are selected by purposive sampling technique.

2. Study design: Experimental study with the pre test and post test design.

3. Sample size: The sample size consists of 40 subjects with MCA stroke and be assigned as two groups.

a) Experimental Group:

Consists of 20 MCA stroke subjects to be treated with Constraint Induced Movement Therapy.

b) Control Group:

Consists of 20 MCA stroke subjects to be treated with conventional physiotherapy approaches.

7.3. Selection Criteria:

a) Inclusion Criteria:

➢ Both Genders

➢ MCA stroke Syndrome subjects

➢ Irrespective of sides

➢ Age group between 40 to 60 years

➢ Conscious patients who can able to obey commands

➢ Psychologically fit subjects

➢ Subjects with 6 months duration after stroke

➢ Ischemic stroke subjects

b) Exclusion Criteria

➢ Subject with above 60 years of age and below 40 years of age.

➢ Subjects with unstable medical condition

➢ Subjects with progressive metabolic disease

➢ Subjects with recent history of any orthopedic surgery

➢ Subjects with uncontrolled hypertension

➢ Mentally retarded unconscious subjects

➢ Subjects with the history of repeated stroke

➢ Hemorrhagic stroke subjects

2. Duration of Study

2 Weeks for each subject; 2 sessions per day, each session contains 3 hrs.

Measurement Tools

➢ Motor assessment scale

➢ Wolf Mayer function test

Procedure:

After checking the selection criteria, 40 subjects with MCA stroke to be selected purposively and assigned as two groups with 20 subjects each.

The experimental group consists of 20 subjects with MCA stroke to be treated with Constraint Induced Movement Therapy. The control group consists of 20 subjects with the MCA stroke, to be treated with conventional physiotherapy approaches.

After getting informed consent a brief introduction about the aim of the study and treatment procedures to be explained to all the subjects. Before starting the treatment procedure, both the groups to be evaluated for the upper limb function by means of Motor Assessment Scale and Wolf Mayers Function Test

I. Treatment procedure for experimental group

Constraint Induced Movement Therapy. (C.I. Therapy)

❖ C.I Therapy or Forced- use Therapy in patients following stroke that has demonstrated significant and large improvements of upper extremity function.

❖ Two factor are crucial to the successful outcomes achieved in their studies.

❖ The first is the concentrated and repetitive practice of the involved upper extremity.

❖ Training was intensive (averaging 6 hours/ day) and focused on practice of common functional tasks.

❖ Second, movement was restricted in the sound upper extremity through the use of mitts or splints and slings for up to 90% of walking hours.

❖ Behavioral shaping techniques were used in which the patients rewarded for improvement with Verbal reinforcement but not blamed for failure.

II. Treatment procedure for control group

Conventional physiotherapy approaches

➢ Passive movements

➢ Passive stretching exercise

➢ ROM exercise

➢ Cryo therapy

➢ Mat exercises etc.,

Statistical Test:-

Statistical Tests to be used are

❖ Mean.

❖ Standard deviation.

❖ Paired and impaired T- tests.

❖ Parametric / Non Parametric Tests

7.7. Does the study require any investigations or interventions to be conducted on patients or other human or animals? If, Yes, Please describe briefly.

Yes, this study requires interventions like Constraint Induced Movement Therapy and other conventional Physiotherapy approaches to be given to subjects with MCA- stroke subjects.

7.8. Ethical clearance

The study will be conducted at the approval of research committee of the college. Permission will be obtained from the head of the institution. The purpose and details of the study will be explained to the study subjects and assurance will be given regarding confidentiality of the data collected.

LIST OF REFERENCES

1. Adams HP Jr ; “Guidelines for the early management of adults with stroke : Guideline from AHA. Stroke. 38 (5) : 1655-1711 (2007).

2. Fung TT. Prospective study of major dietary patterns and stroke risk. Stroke, 35 : 2014-2019(2004)

3. Wassertheil. S ; “Heart diseases and stroke”;JAMA, 289(20) :2367-2384.(2003)

4. Lee CD ;” Physical activity and storke risk : A metaanalysis.” Storke,34 (10): 2475-81(2003).

5. Yadav Js; High risk storke patients”; New England Journal of medicine, 351(15): 1493-1501

.

6. O’ Regan C; “storke prevetion “-Ametaanalysis involving 121,000 Patients, American of medicine, 121(1) :24-33.

7. Mayer SA ,”Subarachnoid hemorrhagic merritt’s Neurology. 11th ed. Pp 328-338 philadelphia: Lippincot willons and wilkins .

8. Adams RJ,” Coronary risk evaluation in patients with transient ischemic attach and ischemic stroke A Scientific statement ; American stroke Association. Circulation, 108(10); 1278-1290.

9. Gami A ; “Secondary prevention of ischemic Cardiac events”.; Clinical evidence (15):1-31(2006).

10. Goldskein LB ; Primary prevention of ischemic stroke”; stroke, 37(6) : 1583-1633.

11. Cohen J ; “Approaches in treatment for Physical Rehabilitation”;Rehab Psychol. 1998; 43 :157-170

12. Morris DN, Crago E; “Constraint Induced Movement Therapy for motor recovery after stroke”. Neuro rehab. 1997; 9 :29-43.

13. StrausnSE; “New evidence for stroke prevention : Scientific Review” ; JAMA,288(11) :1388-1395.

14. Albers GV, Easton JD ; “Stroke”;American College of chest physicians – Evidence based practice (8th Ed). Chest. 2008 june; 133 (6 suppl) : 630-699.

15. Donnan GA, Fisher M , “Stroke” Lancet.2008 may 10; 371(9624) :1612-23.

16. Libby P ; Borow RO ; “Prevention and management of stroke” Braunwald’s heart disease: A Text Book of Cardiovascular Medicine.8th Ed, Saunders ;2007 chap-58

17. Lipest J, Sommer M ; “ Stroke Rehabilitation.”; Top Stroke Rehab.1997; 3:38-61

18. Hacke W; “Acute Ischemic Stroke”; New England Journal of Medicine; 457(13):1315-1346(2005).

19. Biller J ; “Stroke Prevention Guide American Stroke Association ; 97(5).

20. Mar J : “Stroke Rehabilitation”;Stroke 33(7): 1934-1942.

21. Coul BM ; “Stroke outcome-Evidence based practice” ; American Stroke Association ; Vol-21(1081-1981) (2004) Abstract.

22. Bauder H : Fellis JC; “Effect of CI Therapy on movement related brain potentials;” Psychophysiology.1993;36:531.

23. Shrout PE ; Steven L ; Interclass correlation : uses in assessing rater reliability. Motor function Test “; Psychol Bull. 1979; 86 : 420-428.

24. Sharon E ; David m morris : “C.I. therapy for recovery of upper limb function following stroke ; JRRD;Vol-42, No:6:769-788(2005).

25. porter K; Lord S ; “C.I Therapy for people following stroke-out patient setting ; N.Z.journal of Physical Therapy; 32(3) : 111-119(2004)

26. Mary H Bowman, Vicor W, Marle : “CI Therapy for restoration of upper limb function”;Interventional Handbook of Occupational Therapy Intervention –Part III ;Vol-4: 301-308[2009]

27. Wolfgang H.R.Miltres ; Monika sommer; “Effects of C.I Therapy on patients with chronic motor defects after stroke. 1999 ; 30 : 586-592

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|9 | | |

| |SIGNATURE OF THE CANDIDATE | |

|10 | | |

| |REMARK OF THE GUIDE | |

|11 | |

| |NAME AND DESIGNATION (in block letter) |

| |11.1 Guide | |

| |11.2 Signature | |

| |11.3. Co- guide (if any ) | |

| |11.4. Signature | |

| |11.5. Head of the Department. | |

| |11.6. Signature | |

|12 |12.1. Remarks of the Chairman and Principal |

| |12.2. Signature |

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