Rajiv Gandhi University of Health Sciences Karnataka, Bangalore s27

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the candidate and address BEARY RAHIMAT ABUBAKAR 203, SAS APARTMENT OPPOSITE KANKANADY MARKET KANKANADY MANGALORE - 575002

2. Name of the Institution CITY COLLEGE OF PHYSIOTHERAPY KADRI, MANGALORE

3. Course of study and subject MASTERS OF PHYSIOTHERAPY (MPT) 2 YEARS DEGREE COURSE “PT IN NEUROLOGY AND PSYCHOSOMATIC DISORDERS”

4. Date of admission to the course 01-06-2009

5. Title of the study: “EFFECTIVENESS OF LIMB ACTIVATION TRAINING AND TRUNK ROTATION ON UNILATERAL NEGLECT OF SUB ACUTE LEFT HEMIPLEGIC INDIVIDUALS”

1 6. BRIEF RESUME OF THE INTENDED WORK

Introduction

According to WHO, Stroke is rapidly developing clinical signs of focal disturbance of cerebral function, lasting more than 24hrs or leading to death with no apparent cause other than that of vascular origin1 .Two thirds of stroke occurs in people over age 65yrs.2 Clinical manifestations of stroke paresis of contra lateral face, arm, sensory impairment, motor speech disorder, perceptual problems, homonymous hemianopia etc.12 Perception is the mechanism by which the brain interprets sensory information received from the environment3.Perception is the ability to select those stimuli that require attention and action to integrate those stimuli with each other & with each other & with prior information finally to interpret them.4 These may include disorders of body scheme disorders or body image disorders, spatial relation disorders, agnosia, apraxia12.Body disorder/ body image include unilateral neglect, anosognosia , right left discrimination, finger agnosia12. The reported incidence of unilateral neglect(UN) varies widely from 10% to 82% following right hemisphere stroke & from 15% to 65% following left hemisphere stroke6.Neglect following right cerebral infarction occurs is 12-49% of patient.7 A typical clinical picture of UN is a patient with damage to the right parietal cortex who slouches to the left, fixates head & eye orientation to the right only dresses grooms, or protects the right side of the body , ignores people on the left eats food from only the right side of the plate & frequently collides with leftward obstacles8. There are different approaches to treat unilateral neglect, viz visual scanning training, limb activation training, prism adaptation, manipulation egocentric space, arousal neglect & trunk rotation9.Other such approaches are functional, remedial, sensory integration, adaptive, compensatory12. Limb activation training interacts to produce a coherent spatial reference system against which purposeful motor movements are calibrated and organized9. This study show that Limb activation training can produce an ending improvements in Unilateral neglect and in left sided motor impairment in Cardiovascular accident patient suffering from left unilateral neglect9. Trunk rotation has been effective method by which one’s egocentric reference frame can be displaced in normal or transiently realigned in neglect patients while performing various visuo-spatial tasks11.

So this study intends, that limb activation training and trunk rotation is a effective method treating unilateral neglect in sub acute hemiplegic, as it used to exploration of the neglected hemispace.

2 6.1 NEED FOR THE STUDY

Over the past several decades a growing amount of research has focused on the possibility of transiently reducing left neglect signs in right brain damaged patients by using vestibular and/ or visuo- proprioceptive stimulations. As, recently additional treatment strategies have focused on treating the representational aspects of brain functioning, these strategies include visual imaginary, manipulation of sensory input, manipulation or visual input etc. Hence, continued research will play a pivotal role in driving effective treatment strategies for patient with UN. In the above training the clients will be equally participating in the treatment and will be actively getting motivated by getting the feedback themselves by achieving the goal. As there is no clear study using both Limb activation training (LAT) and Trunk rotation (TR) together reducing Unilateral neglect (UN). Hence this study intend to prove the effectiveness of LAT and TR on Unilateral neglect and how it will help in improving quality of life.

Hypothesis

. Null Hypothesis

 H01 – Limb activation training & Trunk rotation is not effective is reducing Unilateral neglect in sub acute left hemiplegic.

 H02 – Limb activation training & Trunk rotation is not effective in improving the quality of life in sub acute left hemiplegic. . Experimental Hypothesis

 H11 – Limb activation training & Trunk rotation is effective in reducing Unilateral neglect in sub acute left hemiplegic.

 H 12 – Limb activation training & Trunk rotation is effective in improving the quality of life in sub acute left hemiplegic.

6.2 REVIEW OF LITERATURE

Harvey et al., 2003 The study shows effectiveness of rod lifting exercise on neglect patient. The study include 14 patients with right hemisphere stroke and USN to one of two groups. The experimental group reached and lifted rods on their right and left side (i.e. visuo-motor training), whereas the control group lifted rods on their right side only. These rod lifting exercises were administered for 1 hr/day x 3 consecutive days. Significant improvements were observed in the treatment group as compared to the control group after the 3-day practice as measured by

3 the Landmark Test. Eskes et al., 2003

The study include 10 non-randomized case studies examined the use of active voluntary movements of the upper extremity to promote scanning of the neglected left hemispace and found improvements in visual scanning when activation of the left upper extremity was executed as compared to right or bilateral activation Conclusion says there is level 2a evidence from two fair quality RCTs and ten non-randomized studies that limb activation can improve USN symptoms in sub-acute or chronic patients post-stroke.

Robertson et al. 2002

The study shows comparative result between two groups. 1st group with PT and 2 nd group with LAT+PT. They selected 40 patients with right hemisphere strokes were randomly allocated to perceptual training group (PT) or limb activation treatment (LAT) with PT (LAT+PT). Both groups received 12 sessions of 45 minutes duration over a 12-week period. Patients were assessed at intake, post-training and 3, 6 and 18 to 24 months post-training. Improvement up to 24 months in LAT+PT group with little change in PT group over time.

Kalra et al. 1997

The study was done to find the effectiveness of limb activation training in neglect. They selected 50 stroke patients with neglect, aimed to restoring normal tone, movement patterns and motor activity or to receive therapy aimed at integrating attentional and motor functions using the limb activation approach. Significant improvement was noted on body image and cancellation subtest of the (RPAB) Rivermead Perceptual Assessment Battery at 12 weeks in favour of the treatment group receiving spatial cueing via limb activation.

Weinberg et al. 1977

The study states the comparative result between two groups, one which were given testing and other which did not received testing.They selected 57 unilateral right brain damaged (RBD) patients due to stroke. Patients were randomly assigned to the experimental group receiving 20 hours of testing (1 hour/day for 4 weeks in reading, writing and calculation) or to the control group that received no testing between evaluations. The result says experimental group improved significantly more than the control group, especially patients within the experimental group with more severe deficits.

Wiart et al. 1997

The study states the comparative result between two groups, one with trunk rotation and other with traditional rehabilitation program. They selected 22 stroke patients with recent

4 stroke who exhibited severe unilateral neglect syndrome with line bisection > 11% of right deviation, line cancellation > 2% of right deviation . Patients were randomized to either and experimental or to a control group. Experimental group received 1 hour a day for 20 days of the trunk rotation to complete scanning tasks followed by 2 to 3 hours of traditional rehabilitation (1 to 2 hours of PT and 1 hour of OT). Control group received 3 to 4 hours of traditional rehabilitation.The result says Functional Independence Measure improved significantly more in the experimental group relative to the control group at 30 and 60 days.

Barat M.et al. (1997).

The study show the effectiveness of voluntary trunk rotation on FIM. They selected 22 consecutive acute patients with neglect resulting from stroke, they were randomly assigned to an Experimental Group (11 patients) or to a Control Group (11 patients). Group E followed the experimental program 1 hour a day for 1 month (20 hours) using a specific exercise that encourages visual scanning with voluntary trunk rotation. Controls followed usual neuro-rehabilitation during the same time. All USN test results (Line Bisection, Albert's Test and Bell's Test) and the Functional Independence Measure done at day 0, day 30, and day 60 improved significantly in the experimental versus control group.

Spinelli D et al. (1996)

The study shows importance of Trunk rotation in reducing neglect. They selected 4 patients with right-sided brain damage and neglect showed improved visual evoked potentials when their trunk was rotated towards the left neglected side. Such changes in the body-centered representation of space are thought to be caused by a shift of the perceived midline to the left.

North N et al. (1993).

The study was done by taking 1 patient with USN who practiced active and passive hand/leg showed significant improvements in active movements in the left space and scanning of that space as by measured the Letter Cancellation and tactile extinction test.

Boucheron M et al. (1986).

The study shows the importance of pointing exercise in neglect population. They selected 3 sub-acute patients with neglect practiced left and right active pointing in the left neglected space for 1 treatment session. Significant improvements in detection of visual stimuli were reported with left hand pointing only

5 OBJECTIVE:

 To find out effectiveness of Limb activation training & Trunk rotation on Unilateral neglect of sub acute left hemiplegic individuals.  To find out effectiveness of Limb activation training & Trunk rotation on quality of life of sub acute left hemiplegic individuals.

7 MATERIAL & METHODS

7.1 SOURCE OF DATA : 40 patients will be taken from hemiplegic individuals treatment will be given at City Hospital Mangalore.

STUDY DESIGN Pre & post without control, experimental design.

7.2. METHOD OF COLLECTION OF DATA

SAMPLING TECHNIQUE Purposive sampling technique

i. Definition of study subject 40 patients will be selected who have left sided Hemiplegic subjects with unilateral neglect.

ii. Group : Experimental group

Inclusion criteria

i. Age group between 50-65 yrs ii. Sub acute stage iii. Both sexes of individuals included iv. Subjects with good vision and hearing ability v. Subjects with better sitting balance

6 Exclusion criteria

i. Alcohol & drug abuse ii. Cancer iii. Severe mental illness iv. Communicable diseases iii. A) Study sampling design Non probability sampling will be used

B) Study sampling method Patients will be selected by purposive sampling technique

C) Study sample size. Total of 40 patients with left Unilateral neglect will be taken iv. Tools & Materials

a. Pictures b. Small Size Rods c. Posters with bold letter d. Peg boards e. Different shapes of objects with different colours

v. Study duration 9-12 months

vi. A) Methodology

The study includes 40 patients those who satisfied the inclusion & exclusion criteria. Informed written consents are to be obtained from all the patients. The subjects will be tested with line bisection test and cancellation test to identify unilateral neglect in hemiplegics population. The subject are assessed by Rivermead perceptual assessment battery and

7 Functional independence measure to find the severity of neglect and its effect on quality of life. The 4 wks training program included a period of 1 hr of Limb activation training(LAT) and Trunk rotation(TR).Pre and post training assessment compared and analysed. Evaluation will be taken on the day of assessment and at the end of 2 nd, 3rd, 4th weeks and analysed. Pre and post evaluation will be taken for all the subjects.

The LAT & TR progress included different exercises, given for 1 hr/day with different sets of exercise :

 Active movement Active movement are performed on the left side of the subject. The subject is made to see the movement throughout the session. And report about the direction of the limbs moving. The subject is made to write and do cancellation activity. The exercise is performed with 30 repetition for 15 min, with 4-5 sec breaks between very 10 repetition given 6 days a week.

 Passive movement The therapist will give passive movement to the left side limb and ask the patient about the position & the joint involved. Passive movement will help the patient to increase the kinaesthetic sensation. The exercise is given with 20 repetition for 10 mins with 2-3 mins break after 10 repetition given 5 days a week.

 Pointing exercise In the above exercise, the objects are placed around the subject and subject is asked to point out the objects with his fingers, in the direction of which the objects are kept, over head pointing exercises are also given. The duration 15 min for 5 days / week with 20 repetition, with 2 mins break after every 10 repetition.

 Left hand finger movement As the left hand is effected and as the patient is having neglect in the same direction. We used objects such as peg boards and other vestibular objects to help the patient to move his fingers of left hand. Even the patient can be encourage to do combing touched the thumb to all the fingers in opposition movement, calculation with the help of left hand fingers, etc. these exercise was given for 10 min with 15 repetitions. for 4 days a week

 Eye movement while reading exercise Posters of alphabets are kept round the wall as it starts from left hand corner of the wall to

8 right hand corner of wall. The patient is ask to read the alphabets from that posters dis will help is increasing the visual power and even reduce the negligence on either side. Exercise given for 15 min with 10 repitition for 3 days / week.

 Rod lifting exercise. Rod lifting exercise, encouraged by the patient to do it from their both hand, these are few rods kept on either side of the patient and the patient have to follow an alternative patterns of lifting the rods once from right hand followed by left hand. By rotating his trunk and turning himself to left to lift the rods with right hand which are kept on left hand side and lift the rods with left hands which are kept on right hand side. So that at the end of the session the patient gets the feedback that he is having equal number of rods is both his hands and attempt to work with his both hand equally. This exercise was given for 15 min with 15 repitition for 4 days a week.

OUTCOME MEASURES USED

a. Rivermead perceptual assessment battery b. Functional independence measure

STATISTICAL ANALYSIS

Collected data will be analyzed using Wilcoxon Rank Sum Test and by Paired’t’ test.

P value < 0.05 will be taken up for statistical significance

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.

YES: Patients will be assessed on base of the Rivermead perceptual assessment battery and Functional independence reassume.

7.4 Has ethical and clearance been obtained from your institution in case.

YES, Ethical clearance has been obtained.

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