Rajiv Gandhi University of Health Sciences
|6 |Brief resume of the intended work: |
| |6.1 Need for the study: |
| |Stroke is often referred to as a cerebrovascular accident (CVA). It is defined as a sudden, non-convulsive loss of neurologic |
| |function due to an ischemic or hemorrhagic intracranial vascular event 1 |
| |Fatigue is a common problem among people after stroke 2,3that may hamper full participation in a rehabilitation program.4 The |
| |prevalence of fatigue following stroke and Transient Ischemic Attack (TIA) is disputed, with prevalence ranging from 30% to 72% |
| |reported.5 Fatigue has been defined as a feeling of early exhaustion, weariness, lack of energy, and aversion to effort. 2 A high |
| |incidence of fatigue has been reported in people with poststroke.2, 3,6,7,8 |
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| |In 1989 Funk and colleagues proposed a neurophysiological model in an attempt to explain fatigue in terms of central and peripheral |
| |nervous system components.9 Impairment of central component leads to decreased motivation and transmission of messages from the |
| |brain and spinal cord. It also leads to exhaustion of brain cells in the hypothalamic region. Impairment of the peripheral component |
| |can change complex biochemical interactions between nerve and muscle that generate the force to movement.9 |
| |Glader et al suggest that survivors of stroke with fatigue have a higher fatality rate 3 years after stroke possibly associated with |
| |sedentary lifestyle.7 In survivors of stroke, decreased aerobic capacity,10-13 decreased endurance,14 and increased energy |
| |expenditure associated with impaired motor movements11,15 may be related to fatigue and can further affect daily functions such as |
| |walking16 and further rehabilitation. Survivors of stroke may experience increased energy expenditure during gait due to the |
| |inability to activate normal motorpatterns;11 such limitation may cause poor biomechanical efficiency and promote an earlier onset of|
| |fatigue. Physical impairment, therefore, is an important contributing factor to fatigue in people post-stroke.3,8,17,18 There appear|
| |to be multiple contributors of fatigue including depression, chronic pain, sleep disorder, immobility, and lack of exercise.19 |
| |Fatigue also impacts on performance of daily activities, especially those requiring physical effort.4 Researchers have recently |
| |begun to explore the negative impact of fatigue on stroke rehabilitation.1,2,8 |
| |As stroke is more common in the elderly, fatigue is an important issue due to its association with deterioration of various aspects |
| |of everyday life. The combination of stroke, fatigue, and sedentary lifestyle can create a morbid downward-spiral in terms of quality|
| |of life and functions. Therefore, it is essential to better understand the nature of fatigue. If more contributing factors of fatigue|
| |could be identified, clinicians will be able to modify therapeutic treatment accordingly for post-stroke rehabilitation. 20 |
| |The treatment of the patient will also vary according to severity of fatigue as patient with elevated fatigue severity has poorer |
| |falls efficacy in stroke,17 so it is essential to better understand the nature of fatigue. |
| |Hypothesis : |
| |Null hypothesis: There will be no significant difference in fatigue among stroke individuals with lesions in different hemispheres |
| |and locations. |
| |Alternate hypothesis: There will be a significant difference in fatigue among stroke individuals with lesions in different |
| |hemispheres and locations. |
| | |
| |6.2 Review of literature: |
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| |Thomas John Chestnut (2010) conducted a study to investigate the experience of fatigue in two main causes of ischemic stroke: |
| |small-vessel (SVD) and large-vessel disease (LVD) Fatigue is common amongst ischemic stroke rehabilitation participants with 85% of |
| |the combined sample experiencing fatigues which demonstrate a trend towards LVD participants experiencing greater fatigue. 21 |
| |Benjamin Y. Tseng, Byron J. Gajewski, and PatriciaM. Kluding (2010) conducted a study to evaluate the reliability, responsiveness, |
| |and validity of the VAFS and concluded that it has good reliability (0.84-0.88) responsiveness, and validity of the VAFS to assess |
| |exertion fatigue in people post-stroke. 22 |
| |Benjamin Y. Tseng, PhD, Patricia Kluding, PT, PhD (2009) conducted a study To explore the relationship between fatigue, aerobic |
| |fitness, and motor control in people with chronic stroke. And concluded that motor control capability may be a good predictor of |
| |fatigue in people post-stroke. Fatigue is a complex phenomenon; a quantifiable measure that is sensitive to multiple components is |
| |needed in order to distinguish the nature of fatigue and its contributing factors. 20 |
| |Park, Ji Young MD; Chun,et al (2009) conducted a study to evaluate the influence of fatigue on functional outcomes after stroke and |
| |concluded that Post stroke fatigue was not closely associated with motor function, activity of daily living, or cognitive function, |
| |but showed significant correlation with depression and sleeping problems. These findings emphasize the need for careful clinical |
| |screening of both fatigue and depression in individuals after stroke. 23 |
| |Tyson S, Connell L.(2009) conducted a study To identify psychometrically robust and clinically feasible measures of six-minute walk|
| |test in walking and mobility in people with neurological conditions and concluded that it is psychometrically robust measures of |
| |walking and mobility and are feasible for use in clinical practice with ICC = 0.97. 24 |
| |Gillian Mead, MD; Joanna Lynch, MA; Carolyn Greig, PhD; Archie Young, MD; Susan Lewis, PhD; Michael Sharpe, MD(2007) conducted a |
| |study to identify which currently available fatigue scale is most valid, feasible, and reliable in stroke patients .among the |
| |vitality subscale of the SF-36v2, the fatigue subscale of the Profile of Mood States (POMS-fatigue), the Fatigue Assessment Scale |
| |(FAS), the general subscale of the Multidimensional Fatigue Symptom Inventory (MFSI-general), and the Brief Fatigue Inventory (BFI) |
| |and concluded that All four scales were valid and feasible to administer to stroke patients. The Fatigue Assessment Scale had the |
| |best test-retest reliability but the poorest internal consistency. 25 |
| |Van de Port IG, Kwakkel G, Schepers VP, Heinemans CT, Lindeman E.(2006) conducted a study To determine the longitudinal association|
| |of post stroke fatigue with activities of daily living (ADL), instrumental ADL (IADL) and perceived health-related quality of life |
| |(HRQoL) and to establish whether this relationship is confounded by other determinants. And concluded that fatigue is longitudinally|
| |spuriously associated with IADL and independently with HRQoL and suggest that in examining the impact of post stroke fatigue on |
| |outcome, one should control for confounders such as depression. 18 |
| |Choi-Kwon S, Han SW, Kwon SU, Kim JS(2005) conducted a study to elucidate the characteristics of and the factors associated with |
| |Post stroke fatigue( PoSF) and concluded that fatigue is a fairly common sequela of stroke patients, exerting an impact on their |
| |daily activities, especially physical ones. PrSF is the most important factor related to PoSF, followed by high MRS and post stroke |
| |depression (PSD). Nevertheless, the causes of PoSF appear multifactorial. Strategies to improve the PoSF should be individualized |
| |according to the causative factors. 8 |
| | |
| |Chia-Ling Chen, MD, Fuk-Tan Tang, MD, Hsieh-Ching Chen, PhD, Chia-Ying Chung, MD,May-Kuen Wong, MD(2000) conducted a study To |
| |investigate effects of brain lesion profiles that combined sizes and locations on motor recovery and functional outcome after stroke |
| |in hemiplegic patients. And concluded that motor and functional outcomes after stroke correlate with brain lesion profiles (a |
| |combination of delimiting sizes and primary locations) more than with absolute or relative lesion sizes only. Delimiting sizes in |
| |determining final outcomes varied markedly according to the primary lesion locations. 26 |
| |Ingles JL, Eskes GA, Phillips SJ. (1999) conducted a study to determine the frequency and outcome of fatigue, its impact on |
| |functioning, and its relationship with depression in patients 3 to 13 months post stroke and concluded that Fatigue can contribute to|
| |functional impairment up to 13 months after stroke, and its recognition and treatment are important for maximizing recovery. 2 |
| |Macko RF, DeSouza CA, Tretter LD, Silver KH, Smith GV, Anderson PA, Tomoyasu N, Gorman P, Dengel DR.(1997) conducted a study to |
| |investigate the effects of 6 months of treadmill aerobic exercise training on the energy expenditure and cardiovascular demands of |
| |sub maximal effort ambulation in stroke patients with chronic hemiparetic gait. And concluded that Six months of low-intensity |
| |treadmill endurance training produces substantial and progressive reductions in the energy expenditure and cardiovascular demands of |
| |walking in older patients with chronic hemiparetic stroke. This suggests that task-oriented aerobic exercise may improve functional |
| |mobility and the cardiovascular fitness profile in this population. 10 |
| |Objective of the study: |
| |To investigate the difference in fatigue among stroke individuals with lesions in different hemispheres and locations. |
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|7 |Materials and Methods: |
| |7.1 Source of data |
| |K.C.G Hospital, Malleshwaram, Bangalore |
| |E.S.I. Hospital, Rajajinagar, Bangalore |
| |Padmashree Physiotherapy clinic, Bangalore. |
| |Ravi Kirloskar Memorial hospital, Bangalore |
| |7.2 Method of collection of data: |
| |Population- Subjects with stroke |
| |Sample design- Convenience Sampling |
| |Study Design- Cross sectional study design |
| |Sample size- 30 |
| |Duration of the study-6 months. |
| |Inclusion Criteria: |
| |Subjects diagnosed by a neurophysician with stroke that confirmed by a MRI or CT |
| |A single stroke at least 6 months prior confirmed by clinical assessment |
| |Subjects scoring 5 each in ‘walking’ & ‘sit to stand’ subgroups of motor assessment scale(MAS) 27 |
| |Subjects with Mini-Mental-Status-Exam (MMSE) 28,29 score of 25 or more, which indicated the ability understand instructions and |
| |communicate verbally. |
| |Subjects of age between 45-60 yrs. |
| |Subjects of Both genders. |
| |Subjects scoring 0-10 in Beck depression inventory(BDI) 30 scale |
| |Exclusion Criteria: |
| |Subjects with any musculoskeletal condition that could potentially affect the ability to perform the motor tasks of the study. |
| |Subjects with significant cardiac arryhthmia, hypertrophic cardiomyopathy, severe aortic stenosis, or pulmonary embolus. |
| |Subjects with recent symptoms of chest discomfort. |
| |BMI more than 24.31 |
| |Materials Required: |
| |Pen and paper |
| |Chair |
| |Area where one can ambulate freely(30m length,100ft hallway) |
| |Stopwatch |
| |Measuring tape |
| |Sphygmomanometer |
| |Methodology: |
| |Subjects who fulfill inclusion and exclusion criteria will be included in the study. Informed consent will be taken from the |
| |subjects. |
| |All the subjects will be given a fatigue questionnaire (FAS) 25 sheet to fill up. The procedure to be performed will be instructed to|
| |the subjects. |
| |Subjects in the group will be asked to perform Six-Minute-Walk Test (6MWT) 32 used to induce fatigue prior to assessing the level of |
| |fatigue. The 6MWT will be performed on a 100-feet walkway and Subjects will be informed that the goal of the test is to cover as much|
| |distance as possible during 6 minutes and then the distance covered & fatigue level will be measured by using Fatigue Index (VAFS) 21|
| |where fatigue is measured using a 10-point verbal analogue scale where 0 indicates “very alert” and 10 “extremely fatigued. |
| |So based on the availability of subject, they will be categorized according to their lesion of location as cortex, corona radiata |
| |(CR), internal capsule (IC), putamen, and thalamus26. |
| |All data will be recorded and statistically analyzed. |
| | |
| |Outcome measures: |
| |Fatigue assessment scale(FAS) |
| |Fatigue index by visual analogue fatigue scale(VAFS) |
| |6MWT-Distance covered |
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| |Statistics: |
| |Statistical analysis will be performed by using SPSS software for windows(version 17).alpha value will be set as .05 |
| |Descriptive statistics will be done to analyze the different group. |
| |Mann-Whitney U test will be used to compare the FAS&VAFS between the right &left side hemisphere lesion and also between ischemic & |
| |hemorrhagic stroke. |
| |Kruskal-wallis test will be used to compare FAS&VAFS between different lesion locations. |
| |If it becomes significant, Post hoc analysis will be done. |
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| |7.3 Ethical clearance: |
| |As my study includes human subjects, ethical clearance for the study has been obtained from the institutional ethical committee, |
| |Padmashree Institute of Physiotherapy, Nagarbhavi, Bangalore, as per the ethical guidelines for biomedical research on human |
| |subjects, 2000.ICMR, New Delhi. |
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|8. |List of references: |
| |World Health Organization (WHO). Cerebrovascular accident, stroke. 2007 |
| |Ingles JL, Eskes GA, Phillips SJ. Fatigue after stroke. Arch Phys Med Rehabil. 1999;80:173-178 |
| |Van der Werf SP, van den Broek HL, Anten HW, Bleijenberg G. Experience of severe fatigue long after stroke and its relation to |
| |depressive symptoms and disease characteristics. Eur Neurol. 2001; 45:28-33. |
| |Michael K. Fatigue and stroke. Rehabil Nurs. 2002; 27:89-94, 103. |
| |Falconer M, Walsh S, Harbison JA Estimated prevalence of fatigue following stroke and transient ischemic attack is dependent on |
| |terminology used and patient gender. J Stroke Cerebrovasc Dis. 2010 Nov-Dec; 19(6):431-4. Epub 2010 May 15. |
| |Staub F, Bogousslavsky J. Fatigue after stroke: a major but neglected issue. Cerebrovasc Dis. 2001 Aug; 12(2):75-81. |
| |Glader EL, Stegmayr B, Asplund K. Poststroke fatigue: A 2-year follow-up study of stroke patients in sweden. Stroke. 2002; |
| |33:1327-1333. |
| |Choi-Kwon S, Han SW, Kwon SU, Kim JS. Poststrokefatigue: Characteristics and related factors. Cerebrovasc Dis.2005; 19:84-90. |
| |Funk S. Key aspects of comfort: Management of pain, fatigue, and nausea. New York, NY: Springer; 1989. |
| |Macko RF, DeSouza CA, Tretter LD, et al. Treadmill aerobic exercise training reduces the energy expenditure and cardiovascular |
| |demands of hemiparetic gait in chronicstroke patients. A preliminary report. Stroke. 1997; 28:326-330. |
| |Macko RF, Smith GV, Dobrovolny CL, Sorkin JD, Goldberg AP, Silver KH. Treadmill training improves fitness reserve in chronic stroke |
| |patients. Arch Phys Med Rehabil. 2001; 82:879-884. |
| |Eng JJ, Dawson AS, Chu KS. Submaximal exercise in persons with stroke: Test-retest reliability and concurrent validity with maximal |
| |oxygen consumption. Arch Phys Med Rehabil. 2004; 85:113-118. |
| |Pang MY, Eng JJ, Dawson AS. Relationship between ambulatory capacity and cardiorespiratory fitness in chronic stroke: Influence of |
| |stroke-specific impairments. Chest. 2005; 127:1473-1474. |
| |Walker GC, Cardenas DD, Guthrie MR, McLean AJ, Brooke MM. Fatigue and depression in brain-injured patients correlated with quadriceps|
| |strength and endurance. Arch Phys Med Rehabil. 1991; 72:469-472. |
| |Richerson RL, Richerson ME. Energy expenditure in simulated tasks: Comparison Walker GC, Cardenas DD, Guthrie MR, McLean AJ, Brooke |
| |MM. Fatigue and depression in brain-injured patients correlated with quadriceps strength and endurance. Arch Phys Med Rehabil. 1991; |
| |72:469-472between subjects with brain ninjury and able-bodied persons. Arch Phys Med Rehabil. 1981;62:212-214 |
| |Kelly JO, Kilbreath SL, Davis GM, Zeman B, Raymond J. Cardiorespiratory fitness and walking ability in subacute stroke patients. Arch|
| |Phys Med Rehabil. 2003;84:1780- 1785. |
| |Michael KM, Allen JK, Macko RF. Fatigue after stroke: Relationship to mobility, fitness, ambulatory activity, social support, and |
| |falls efficacy. Rehabil Nurs. 2006; 31:210- 217. |
| |Van de Port IG, Kwakkel G, Schepers VP, Heinemans CT, Lindeman E. Is fatigue an independent factor associated with activities of |
| |daily living, instrumental activities of daily living and health-related quality of life in chronic stroke? Cerebrovasc Dis. 2006; |
| |23:40-45. |
| |Piper B. Fatigue. In: Carrieri-Kohlman V, Lindsay A, West C, eds. Pathophysiological Phenonmena in Nursing: Human Responses to |
| |Illness. Philadelphia, PA: Saunders; 1993:279- 302. |
| |Benjamin Y. Tseng, PhD, Patricia Kluding, PT, PhD. The Relationship Between Fatigue Aerobic Fitness, and Motor Control in People With|
| |Chronic Stroke: A Pilot Study. Journal of Geriatric Physical Therapy.2009 Vol. 32;3 |
| |Thomas John Chestnu. Fatigue in stroke rehabilitation patients: a pilot study 18 May 2010 |
| | |
| |Benjamin Y. Tseng, Byron J. Gajewski, 2and PatriciaM. Kluding. Reliability, Responsiveness, and Validity of the Visual Analog |
| |Fatigue Scale to Measure Exertion Fatigue in People with Chronic Stroke: A Preliminary Study. Stroke Research and Treatment Volume |
| |2010, Articl412964,7pagesdoi: 10.4061/2010/ 412964 |
| |Park, Ji Young MD; Chun, Min Ho MD; Kang, Si Hyun MD; Lee, Jin A. MD; Kim, Bo Ryun MD; Shin, Mi Jung OT. Functional Outcome in Post |
| |stroke Patients With Or Without Fatigue American Journal of Physical Medicine & Rehabilitation: July 2009-Volume 88 - Issue 7 - pp |
| |554-558 |
| |Tyson S, Connell L. The psychometric properties and clinical utility of measures of Walking and mobility in neurological conditions:|
| |a systemic review. Clinical Rehabilitation. 2009; 23: 1018-1033 |
| |Gillian Mead, MD; Joanna Lynch, MA; Carolyn Greig, PhD; Archie Young, MD; Susan Lewis, PhD; Michael Sharpe, MD Evaluation of Fatigue|
| |Scales in Stroke Patients Stroke. 2007; 38:2090-2095. |
| |Chia-Ling Chen, MD, Fuk-Tan Tang, MD, Hsieh-Ching Chen, PhD, Chia-Ying Chung, MD,May-Kuen Wong, MD: Brain Lesion Size and Location: |
| |Effects on Motor Recovery and Functional Outcome in Stroke Patients Arch Phys Med Rehabil 2000; 81:447-52. |
| |Poole JL, Whitney SL Motor assessment scale for stroke patients:concurrent validity.An interrater reliability.Arch Phys Med |
| |Rehabil.1988 Mar;69(3 Pt 1):195-7 |
| |Michael N. Lopez, Richard A. Charter,Beeta Mostafavi, Lorraine P. Nibut, Whitney E.Smith Psychometric Properties of the Folstein |
| |Mini-Mental State Examination.sage Journals. Assessment June 2005 vol. 12 no. 2137 |
| |Atilla H. Elhan, Sehim Kutlay, Ayse A. Kucukdeveci, Cigdem Cotuk, Gulsah Ozturk Luigi Tesio et al.Psychometric properties of the mini|
| |mental status examination in Patients with acquired brain injury. J Rehabil Med 2005; 37: 306–311. |
| |Aaron T. Beck, Robert A. Steer, and Gregory K. Brown Beck Depression |
| |Inventory,secondEdition(BDI-II):ThePsychologicalCorporation ,1996 |
| |Prentice AM and Jebb SA. Beyond Body Mass Index. Obesity Reviews. 2001 August; 2(3): 141–7. |
| |ATS statement: guidelines for the six-minute walk test. ATS Committee on Proficiency Standards for Clinical Pulmonary Function |
| |Laboratories. Am J Respir Crit Care Med. 2002; 166 |
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