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. |

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| |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 |

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| |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. |

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| |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|

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| |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 |

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| |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 |

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| |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 |

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| |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 |

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| |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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