Rajiv Gandhi University of Health Sciences, Karnataka,



Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

| | |NABARUN SAHA |

|1 |Name of the Candidate |NARENDRA NIBASH, CHIRUKANDI, N.H. BYPASS, SILCHAR, CACHAR, ASSAM PIN - 788003 |

| |& Address | |

| | |KRUPANIDHI COLLEGE OF PHYSIOTHERAPY, BANGALORE. |

|2 |Name of the Institution | |

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|3 |Course of study and subject |MASTERS IN PHYSIOTHERAPY |

| | |(NEUROLOGICAL AND PSYCHOSOMATIC DISORDERS) |

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|4 |Date of admission to course | |

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| |TITLE OF THE TOPIC: |

|5 | |

| |“Effect of Respiratory Muscle exercise to improve walking capacity on stroke subjects” |

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|6 |Brief resume of the intended work: |

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| |6.1 Introduction: |

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| |WHO defined stroke as ‘rapidly developed clinical sign of focal disturbance of cerebral function, lasting more than 24 hrs or leading to |

| |death, with no apparent cause other than vascular origin. The 24 hours threshold in the definition excludes Transient Ischemic Attacks (TIA).1|

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| |Stroke is caused either by ischaemia or haemorrhage and non-progressive in nature. There are several risk factors associated with stroke and |

| |can occur at any age more commonly in the elders. The interruption of blood flow to the brain to the brain leaves the patient with a focal |

| |loss of function of varying severity. The neurological deficit ranges from a temporary loss of function followed by complete recovery, to |

| |permanent life-altering impairment and disability, to death. The severity signs and symptoms are worse initially and declines with time and |

| |treatment intervention. |

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| |Therapeutic mobility and exercise training after stroke presents many challenges due to an asymmetrical gait pattern, decreased walking speed,|

| |and increased energy expenditure during activity. 2 |

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| |There is a need to improve cardiorespiratory fitness so that individuals participating in stroke rehabilitation can tolerate functional |

| |mobility training and activities. 3 |

| | |

| |Although not all patients after stroke have overt pulmonary disease4, respiration may be compromised as a direct result of the stroke itself |

| |(particularly brain stem stroke), associated complications (e.g., weakness of respiratory muscles, impaired breathing mechanics), |

| |comorbidities (e.g., chronic obstructive pulmonary disease, cardiovascular dysfunction), or lifestyle factors (e.g., physical inactivity high |

| |incidence of smoking). The excessive fatigue experienced by some people after stroke may be partly due to respiratory insufficiency. 5 |

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| |Need for the study: |

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| |Respiratory exercises when included in rehabilitation program in stroke patient may help in improving functional outcome and activities of |

| |daily living. Since there is limited study on outcome measure like walking capacity of the stroke patient in relation to respiratory exercises|

| |I intend to do the study on effect in respiratory exercise to improving walking capacity in stroke survivors. |

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| |Objectives of the study: |

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| |To find out the improvement in walking capacity in stroke patient with respiratory muscle training. |

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| |Hypothesis |

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| |Null Hypothesis: |

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| |There is no significant difference exists between Group I (experimental group) receiving both respiratory exercise and conventional exercise |

| |and Group II (control group) receiving only conventional exercise on walking capacity. |

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| | Alternate Hypothesis: |

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| |There is significant difference exists between Group I (experimental group) receiving both respiratory exercise and conventional and group II |

| |(control group) getting only conventional exercise on walking capacity. |

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| |Review of Literature: |

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| |Richard Zorowitz, et.al. (2004)6 stated that as stroke mortality has declined in the last few decades, the number of stroke survivors with |

| |impairments and disabilities has increased. There are 300,000 to 400,000 stroke survivors annually. 78% to 85% of stroke patients regain |

| |ability to walk (with or without assistive device). 48% to 58% regain independence with their self-care skills. 10% to 29% are admitted to |

| |nursing homes. |

| |Sandra Billinger (2010)7 stated that most individuals after stroke are deconditioned and have low levels of cardiorespiratory fitness. The |

| |goal should be to obtain the optimal cardiorespiratory fitness for people post-stroke that will also lead to important functional activity |

| |gains during rehabilitation. Cardiorespiratory fitness varies according to age, gender, physical activity levels, body composition, and the |

| |absence or presence of chronic disease or disability. In the poststroke population, the literature suggests that CR fitness is reduced by as |

| |much as 50% when compared to age-matched sedentary counterparts. The extent of deterioration is associated with several clinically relevant |

| |biological correlates which were the focus of this review. |

| |Sutbeyaz ST et.al.(2010)8 in a randomized control trial found that there is a significant short-term effects of the respiratory muscle |

| |training programme on respiratory muscle function, exercise capacity and quality of life were recorded in this study. |

| |Ada Tang (2006)9 in his study suggest that although the 6MWT may challenge the cardiorespiratory system in sub acute stroke survivors, it is |

| |representative of the ability for functional ambulation and is not an adequate measure of aerobic fitness alone. The findings demonstrate |

| |positive correlations between gait speeds obtained from various measures of walking function and, more importantly, highlight differences |

| |between them. |

| |Regine Bastin (1997)10 advocated that Incentive Spirometer can be used as a simple mean to follow lung function, especially Vital Capacity and|

| |Inspiratory Respiratory Volume, at the bedside in the postoperative period in patients breathing spontaneously. Incentive Spirometer is |

| |noninvasive and can be performed repeatedly at the bedside in the intensive care setting. Incentive spirometry has been shown to be at least |

| |as efficient as other methods (intermittent positive pressure breathing, deep breathing exercises). 5-7 It is used extensively because it |

| |encourages deep breathing and needs minimal supervision. |

| |Assunta Pizzi (2007)11, in his observational study stated that, the Wisconsin Gait Scale is a useful tool to rate qualitative gait alterations|

| |of post-stroke hemiplegic subjects and to assess changes over time during rehabilitation training. It may be used when a targeted and |

| |standardized characterization of hemiplegic gait is needed for tailoring rehabilitation and monitoring results. |

|7 | |

| |MATERIALS AND METHODS: |

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| |7.1 Source of data: |

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| |Population: Subjects with stroke in and around Bangalore who comes in inclusion criteria who comes for treatment. |

| |Sample Size: a total number of 30 subject of both gender |

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| |Material |

| |Record or data collection sheet. |

| |Stop watch. |

| |Measuring tape. |

| |Incentive Spirometer |

| |Methods |

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| |Sampling technique: |

| |Convenient sampling where 30 male and female subjects referred by physician after diagnosing stroke will be divided in to two groups of 15 |

| |each alternatively as per referral. |

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| |Group I : (Experimental group) Will receive Respiratory exercise and conventional stroke rehabilitation programme. |

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| |Group II : (Control group) Will receive conventional stroke rehabilitation programme. |

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| |Methodology |

| |Study design : |

| |Experimental study |

| |Inclusion criteria |

| |Subjects who have had stroke at least 6 months ago. |

| |Are able to walk at least 10m independently. |

| |Modified Ashworth Scale score more than 1 in their ankle plantar flexors |

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| |Exclusion criteria |

| |Unstable cardiopulmonary status |

| |Unstable or Uncontrolled hypertension |

| |COPD |

| |Painful Osteoarthritis of knee. |

| |Cognitive impairment. |

| |Hearing Impairment |

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| |Procedure |

| |A total of 30 subjects will be selected based on the inclusion and the exclusion criteria. An informed consent would be obtained from them to |

| |participate in the study. Having included them in the study, these patients will be randomly assigned to experimental and control group with |

| |15 patients in each group. A brief orientation about the study and the interventional procedure would be given to both the groups. The control|

| |group will receive conventional physiotherapy treatment thrice a week for a period of six weeks, with a single treatment sitting lasting for |

| |60 minutes. |

| |The experimental group will receive the same treatment as that of the control group, but additionally, they will be given Respiratory |

| |exercise. This additional training will be given at the end of the conventional treatment. Hence the overall treatment time for the |

| |experimental group will last for 90 mins, which will increase the treatment duration by 30 minutes. |

| |The procedure of the conventional treatment is as follows: |

| |Inhibition of tone for spastic group of muscle |

| |Facilitation for improving muscle performance out of synergic pattern. |

| |Active assisted exercises for lower limb |

| |Selective stretching exercises for both upper and lower limb |

| |Weight bearing exercises for the lower limb |

| |Strengthening exercises for the lower limb |

| |Walking around the bed or treatment table |

| |Procedure for Breathing exercise: |

| |Diaphragmatic Breathing exercise |

| |Chest expansion exercises |

| |Incentive Spirometer |

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| |Statistical analysis |

| |Parametric and non-parametric test will be used. |

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| |7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe |

| |briefly. |

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| |Yes, this study will be done on human’s and intervened with Physiotherapy protocol. |

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| |7.4 Has ethical clearance been obtained from your institution in case of 7.3. |

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| |Yes, the ethical clearance has been obtained from the institution. |

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|8 |List of References: |

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| |Srikanth V, Read SJ, Thrift AG et al. Poverty and stroke in India. A time to act. Stroke. 2007;38: 3063-3069. |

| |Macko RF, DeSouza CA, Tretter LD, et al. Treadmill aerobic exercise training reduces the energy expenditure and cardiovascular demands of |

| |hemiparetic gait in chronic stroke patients. A preliminary report. Stroke.1997;28:326-330. |

| |Billinger, Sandra., Cardiovascular Regulation after Stroke: Evidence of Impairment, Trainability, and Implications for Rehabilitation. Cardio |

| |Phy Th Journal 2010; 21-24. |

| |S. T. Sutbeyaz, F. Koseoglu, L. Inan, and O. Coskun, “Respiratory muscle training improves cardiopulmonary function and exercise tolerance in |

| |subjects with subacute stroke: a randomized controlled trial,” Clin Rehab, 2010,24: 240–250. |

| |F. Vingerhoets and J. Bogousslavsky, “Respiratory dysfunction in stroke,” Clin Chest. Med., 1994; 15: 729–737. |

| |Richard Zorowitz, M.D., Edgardo Baerga, M.D., and Sara Cuccurullo, M.D. Stroke Rehabilitation , Physical Medicine and Rehabilitation Board |

| |Review. New York: Demos Medical Publishing; 2004. Available from |

| |Sandra Billinger, Cardiovascular Regulation after Stroke: Evidence of Impairment, Trainability, and Implications for Rehabilitation. |

| |Cardiopulm Phys Ther J. 2010; 21: 22–24 |

| | |

| |Sutbeyaz ST, Koseoglu F, Inan L, Coskun O., Respiratory muscle training improves cardiopulmonary function and exercise tolerance in subjects |

| |with subacute stroke: a randomized controlled trial. Clin Rehabil. 2010;24:240-50. |

| |Ada Tang, Kathryn M Sibley, Mark T Bayley, William E McIlroy and Dina Brooks, Do functional walk tests reflect cardiorespiratory fitness in |

| |sub-acute stroke? J. of NeuroEngg and Rehab, 2006, 3:23. Available from |

| | |

| |Re´gine Bastin, Jean-Jacques Moraine, Gizella Bardocsky, Robert-Jean Kahn, and Christian Me´lot, Incentive Spirometry Performance A Reliable |

| |Indicator of Pulmonary Function in the Early Postoperative Period After Lobectomy? CHEST 1997; 111:559-63 |

| |Assunta Pizzi, Giovanna Carlucci, Catuscia Falsini, Francesco Lunghi, Sonia Verdesca and Antonello Grippo Gait in Hemiplegia: Evaluation of |

| |clinical features with the Wisconsin Gait Scale, J Rehabil Med. 2007;39:170-174. |

| |Marco Y.C.Pang, Janice J. Eng, and Andrew S.D., Relationship Between Ambulatory Capacity and Cardiorespiratory Fitness in Chronic Stroke |

| |Influence of Stroke-Specific Impairments CHEST 2005;127:495–501. |

| |Janice J. Eng, Kelly S. Chu, Andrew S. Dawson, C.Maria Kim and Katherine E. Hepburn Functional Walk Tests in Individuals With Stroke: Relation|

| |to Perceived Exertion and Myocardial Exertion, Stroke. 2002;33:756-761. |

| |Rodriquez AA, Black PO, Kile KA, Sherman J, Stellberg B, McCormick J, Roszkowski J, Swiggum E. Gait training efficacy using a home based |

| |practice model in chronic hemiplegia. Arch Phys Med Rehb 1996;77: 801-805. |

| |Rubertone JA, Balwin K, Bucknum J, Elias S, Mitchell D, Sukenick J. Reliability analysis of the Wisconsin Gait Scale for novice evaluators. |

| |The Annual Conference and Exposition of the American Physical Therapy Associatio; Indianapolis, Available from |

| |display/citfd322229 |

| |Wellmon R, Campbell SL, Rubertone JA, Ellison M, King R, Meduri C, et al. The interrater and intrarater reliability of the Wisconsin Gait |

| |Scale when administered by physical therapists to individuals post-stroke. Proceedings of the American Physical Therapy Association Combined |

| |Sections meetings. Tampa, Florida, 2003. |

| |Lewis C. On balance: Using the Wisconsin Gait Scale. Geriatric Function 2007; 18:8. Available from |

| | On-Balance-Using-the-Wisconsin-Gait-Scale.aspx |

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|9 |Signature of Candidate |(Nabarun Saha) |

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|10 |Remarks of the Guide | |

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|11 |Name and Designation (in block letters) | |

| |11.1 Guide | |

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| |11.2 Signature | |

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| |11.3 Co-Guide ( if any ) | |

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| |11.4 Signature | |

| | |Mr. MASIH MUHAMMAD KHAN MPT |

| |11.5 Head of Department | |

| | |(MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY) |

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| |11.6 Signature | |

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|12 |12.1 Remarks of the Chairman & Principal | |

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| |12.2Signature : | |

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