Study on Movement Time of Individual After Stroke

Study on Movement Time of Individual After Stroke Case scenario A 25 year old male Patient who was apparently well 1 year ago when he met with an accident and got severe head injury, diagnosed with right hemiplegia, was hospitalized for 1 month. Presently Patient complains of, difficulty in getting up from bed, and difficulty in walking. Patient has flexor synergy in Upper limb and extensor synergy is in lower limb, Rom and strength for right is decrease, tone for upper limb and lower limb is increased , grade3 on MAS , reflexes are exaggerated. Presently, Patient is able to sit but only with support and need assistance in toileting and mobility. INTRODUCTION Activities of daily living is refers to those â€Å"sensory motor skills necessary for the performance of usual daily activity† (1). These sensory – motor skills under lie the task of daily self care such as feeding, dressing, hygiene and physical mobility that are known as basic activities of daily living (1). Any problem in performing the ADL can affect personal social life (1),as well as community mobility. Stroke is the sudden loss of neurological function caused by an interruption of blood flow to the brain (1). Stroke can be caused by many reasons like traumatic, pathological etc. Post stroke patient deal with the variety of deficit like cognitive (1), sensory (3), motor (4), balance and coordination (5). All these components are necessary for the optimal performance of any ADL (6). In young population ADL can be affected because of several reasons, but now a days most common problem which young patient are facing is stroke(6) which affect their ADL in terms of transferring like sit to lie or lie to sits which is the basic activity in order to carry out any task. In this study time is measured for the individual to perform a particular activity. Time taken to perform any task measures several components like cognition (7), sensory (8), motor, balance and coordination (8). Any deficit in any one or all the components leads to increase in the time taken to perform any activity (7) (8) (9). Any deficit in cognition patient will have difficulty in interpreting the command given to patient which leads to increase in the time taken to perform the task. Any motor deficit and sensory deficit can cause difficulty in moving limbs and awareness about the orientation of the limbs. Balance and coordination deficit leads to decrease postural control, all these components will hinder the patient to perform the task at appropriate time (7) (8). Although there is no evidence or normative values are yet described which tells about the normal time taken by an individual to perform sit to lie and lie to sit activity. In order to rehabilitate the patient for sit to lie and lie to sit task, it is also necessary to see that at what degree of trunk flexion (0` or 45`) and with which side (dependent or non dependent) it is easy for the patient to perform task which is measured in terms of time taken by individuals to finish the task so that therapist can rehabilitate the patient with minimum difficulty. The normal timing taken by an individual to perform any task can be used both as a qualitative as well as quantitative. It helps to asses the various components of the deficit, and to rehabilitate the patients who have difficulty in performing ADL. Hence objective of this study is to measure the time taken to perform sit to lie and lie to sit activity at 0` and 45` of bed from dependent and non dependent side. This can be use to asses as well as rehabilitate the patient. NEED FOR STUDY Stroke in the young is particularly debilitating as the patient wants to get integrated into the society as early as possible. Also a unique requirement for stroke in the young is that the expectations and the society needs are different from the elderly when comparing community dwelling young adults vs. geriatric populations. There is no normative values are present in literature in order to find out the usual time taken by young individual to perform ADL. Sit to lie and lie to sit are basic bed mobility which patient with stroke generally encounter first. So in reference to these timing it is easy to asses as well as rehabilitate the patient in activities of daily living which is most important requirement of patients with stroke. LITERATURE REVIEW Lindmark B ,Hanrin E ,Tornquist K in 1920 conducted study on 207 stroke patient, they were tested after3 month and 1 year after the stroke, 183 survivors from the original population were assessed with standardized practical equipment which has 12 daily activities which is concerned with cognitive factor and coordination, hand function, mobility and balance . They did not find any significant difference, concluded that there is no difference in the performance of daily activities at 3 month and1 year after stroke and also found out that women had more difficulty in performing compare to men in performing mobility task (6). Podsiodlo D , Richardson S , in 1991 conducted study on 60 elderly patient(mean age 79.5 years) to find out TUG as test for basic functional activity, time is calculated for the patient to perform a rise from chair ,walk for 3 meters and then sit down again to perform a particular ADL, found out that TUG test is reliable and correlates well with berg balance scale and concluded that TUG test is reliable for evaluation of the ADL(10). Owsley C, Sloane M, Mc Gwin, Ball K. in 2001 conducted study on 173 older adults (65-90 yrs), which is large sample size in order to find out visual processing speed and correlation between memory and inductive reasoning with IADL ,time taken to perform the 5 IADL was calculated and found out that individual who have slow processing speed , takes more time to accomplish the task they concluded that cognition especially memory and reasoning are related to time taken to perform any ADL and it is useful in evaluating in cognition(8). Owsley, Cynthia, mcGWIN, Gerald Sloane, Michael E in 2001 conducted a study on 342 older adults who had visual impairment (58-86year) from eye clinic, to find out relation between visual function and time required to complete the IADL, under visual impairment –visual acuity, contrast sensitivity and useful field of view .17 IADL task which includes visual activity was evaluated with time taken. They concluded that visual function is necessary to achieve any ADL (9). Hsieh CL ,Shen CF,Hsueh IP, Wang CH in 2002 conducted a prospective study was on 169 stroke patient to find out relation between trunk control and ADL in early stage in stroke patient after6 month of stroke, postural assessment scale for stroke patient scale(PASS-TC) fugl meyer motor test and balance test was used to asses motor and balance respectively, patients were assessed at 14thday after stroke and 6 month. They concluded that trunk control is related to comprehensive ADL(11). Gregory T, Cullaghan A, Nettelback T ,Wilson C in 2009 conducted study on elderly people to examine whether early inspection time predict future problem in ADL , participant completed IT at baseline, 6 month,18 month and at 14 month after stroke, 2 group of 15 elderly with aged (74-88 years) are assessed for timed IADL, it shows that group with slower IT had poorer performance (took longer time to finish task)on more than half of the functional activity and concluded that slower IT shows difficulty in performing functional activity(12). Emma Barry, Rose Galvin, Claire Keogh, Frances Horgan and Tom Fahey in 2014 did a systemic review and metanalysis to find TUG is a predictor of risk of fall in older adult, a literature search of 25 in systemic review and 10 in metanalysis was done and TUG score> 13.5 sec was used to identify individual with high risk of falling and found out that TUG test has limited ability to predict to predict risk of fall in elderly (13). METHODOLOGY Study design: Cross- sectional study –a pilot study Sample size: n=30(50% male and 50% female) Type of sampling: convenience sampling Source of data collection: M.S. Ramaiah Medical College, Department of Physiotherapy. METHOD OF DATA COLLECTION: A cross- sectional study design was undertaken for the study. Young adult aged between 20 – 25 years fulfilling in M.S. Ramaiah medical college, department of physiotherapy were included in study. Convenience sampling was done and sample of 30 subjects were included in the study. Informed consent of all the 30 subjects are taken prior to undertaking the study and procedure was explained to them. Inclusion criteria: Mentioned conditions directly affect the time taken to perform a particular task. cognition is tested by checking memory reasoning and intelligence. 1. Aged between 20-25 years. 2. Subject should not have any pain, trauma, inflammation, fracture etc by history /reported. 3. Should not have any cognitive deficit. 4. Should have competed consent form. Exclusion criteria: Above mentioned condition can interfere in test and also affect the time taken to perform the  given task. Any reported trauma, inflammation, pain in lower back and lower limbs. History of Low back pain, knee pain. Intake of alcohol in last 24 hrs. Any history of hypotension while performing ADL. Any giddiness while performing IADL tasks Any cognitive or higher mental funti0n deficit. Materials used for the study: Stop watch Adjustable firm couch Height scale Weighing machine Test procedure: Demographic data of young adult was noted, including height, weight, gender etc. subjects to be tested was explained about the procedure of the test. Subjects are asked to sit at edge of bed. When start command was given, the subject had to lie down according to given instruction by using preferable speed to perform the activity, time taken for the subject to perform the sit to lie and lie to sit was noted down. Both these activities were performed at 0` and 45` of elevation of bed end, from dependent side as well as from independent side of elevation of bed end. Starting positions: Sitting Position: neck straight, head in midline, spine erect, Hands on a side, knee and hip at 90`, foot unsupported. Lying position: straight, head in midline, hands on sides, legs together, foot in a neutral position Task was observed from standing in front of patient. The same procedure was repeated and time is taken for 30 subjects, to find out normal value to perform sit to lie and lie to sit in young adult. Picture 1a: Firm and adjustable couch at 00. Picture1b: Firm and adjustable couch  at 450. PICTURE 2a: Starting position at 00 PICTURE 2b: Starting position at  00(side view). Picture 3: Starting position at 450 PICTURE 4a: Final position of sit to lie at 00 PICTURE 4b: Final position of lie to sit 45` Picture5: During test Data Analysis Statistical analysis: Microsoft word and Excel were used to generate data and graphs. Statistical Tests: mean, mode, median of time taken to perform the sit to lie and lie to sit activity was calculated for 30 subjects. Mean is taken to as average time taken to perform the task. t –test was done to compare the values of sit to lie and lie to sit from dependent and non dependent at 0` and 45`. RESULT A cross sectional study consisting of 30 normal healthy young adult is taken to find out the normal time taken by younger individual to perform sit to lie and lie to sit at 00and 450from dependent and non dependent side. This graph is showing average time taken to perform sit to lie and lie to sit. The values of sit to lie and lie to sit which are not showing any statistical significance depending on different side and angle of trunk flexion. Table2: t and p value of the average of time taken to perform sit to lie and lie to sit. t- scorep-score Sit to lieND(00) vs. ND(450)0.7040.483 D(00) vs. ND(450)1.0100.318 ND(00) vs. D(450)-1.0470.299 D(00) vs. D(450)1.3550.180 ND(0) vs. D(0)-0.4090.683 ND(45) vs. D(45)0.7040.483 Lie to sitND(00) vs. ND(450)1.6330.107 D(00) vs. ND(450)1.1700.246 ND(00) vs. D(450)1.5810.119 D(00) vs. D(450)1.1040.273 ND(00) vs. D(00)0.4880.626 ND(450) vs. D(450)-0.1160.907 Sit to lie vs. Lie to sitND(00) vs. ND(00)0.0270.978 D(00) vs. D(00)0.9330.354 ND(450) vs. ND(450)1.1600.250 D(450) vs. D(450)0.9470.347 Table2 the t value and p value are showed non of the data have p value Table 3: Comparison between 00 and 450 in sit to lie and lie to sit. 00450 Sit to lieND (3.497)ND(3.366) D(3.565)ND(3.366) ND(3.497)D(3.321) D(3.565)D(3.216) Lie to sitND(3.491)D(3.156) D(3.375)ND(3.136) D(3.345)D(3.156) ND(3.491)ND(3.156) Above table is showing the comparison between average time taken at 00 and 450. There is not significant difference between the time taken by subject in sit to lie and lie to sit from 00and 450. Figure2a: 00 vs. 450 from sit to lie Figure2b: 00 vs. 450 from lie to sit Given figure 2a is showing comparison of mean time taken to sit to lie from 00 and 450 which is not statistically significant(p Table 4: Comparison between the averages of time taken from dependent vs. non dependent side. Non Dependent Side (sec)Dependent (sec) Sit to lie 450(3.366)450(3.321) 00(3.497)450(3.321) 450(3.366)00(3.565) 00(3.497)00(3.565) Lie to Sit450(3.136)450(3.156) 00(3.491)450(3.156) 450(3.136)00(3.375) 00(3.491)00(3.375) This table presents the comparison between dependent vs. non dependent side from sit to lie and lie , average mean of the sit to lie and lie to sit are statistically not significant , P >0.05 , hence no suitable value can be concluded from this present data. Figure3a: Dependent vs. Non Dependent Figure3b: Dependent vs. Non Dependent from sit to lie. from lie to sit Given fig 3a is showing the comparison between dependent vs. non dependent from sit to lie and fig3b. From, the t scores of these data is not showing any statistical significance (p>0.05). Table 5: Comparison between average time taken in sit to lie vs. lie to sit. Sit to lie vs. lie to sitSit to lie in (sec)Lie to sit in (sec) Nondependent (00)3.4973.491 Dependent(00)3.5653.375 Nondependent(450)3.3663.136 Dependent(450)3.3213.156 This table presents the comparison between the average time taken from sit to lie vs. lie to sit. Statistically these values are not significant (p>0.05). Figure 4: comparison between time taken from sit to lie vs. lie to sit Figure 4: showing the comparison between the time taken from sit to lie vs. lie to sit which is statistically not significant hence is not showing any difference in time taken to perform both these activities. TABLE 6; Average of mean value for sit to lie and lie to sit from dependent and non dependent side at 00 and 450 Mean values Sit to lieNon Dependent(0)3.50 Dependent(0)3.57 Non Dependent(45)3.37 Dependent(45)3.32 Lie to sitNon Dependent(0)3.49 Dependent(0)3.37 Non Dependent(45)3.14 Dependent(45)3.16 Average3.36 In table6, the average of all mean time taken to perform sit to lie and lie to sit, as it is not any statistical significance ,so there is no difference in time taken to perform this task. DISCUSSION The time taken by young adult (20-25 years) to perform sit to lie and lie to sit from dependent and non dependent side at 00 and 450 of trunk flexion has done to find out the normal time taken by young adult to perform this particular activity. This activity is a basic mobility which the stroke patient encounter first and also find difficult to do. Timing of these activity measures cognition, sensory, motor, balance and coordination component of the patient which will help to find out the level of functional activity in reference to the time taken to accomplish the given activity. Activity was measured at different angle of trunk flexion (00 and 450) a well as from different side (dependent and non dependent). Before the study it was assumed that from dependent side it is easy to accomplish the task, as well as from 450 it is easy to lie down as well as get up as therefore should take less time to finish the task, as at 450 the length tension relationship is good and it provide extra leverage to come against gravity, in 450 as the muscle is in tension, muscle fiber recruitment is more. Getting up from dependent side was hypothesized to be easier as compare to nondependent. It was also assumed that as sit to lie and lie to sit are two different activities so time taken to perform both these activity will be different. In our study, on analyzing the result of table 2 ( t – test of the average of the time taken to perform the sit to lie and lie to sit at different plane) is observed that p-value of mean score of time taken to perform sit to lie and lie to sit is statistically not significant. Values at different plane is statistically not significant that may be because of the small sample size as well as population age. Good strength in muscles, balance and coordination in limbs helps to overcome the gravity easily. The t – score and p- value for the comparison of sit to lie and lie to sit is also statistically not significant. Since all comparisons were statistically insignificant, we averaged the mean for condition The average for the sit to lie and lie to sit was found to be 3.36 sec. In order to asses and rehabilitate the stroke patient timed ADL will asses several components in one time. In order to asses the patient who has difficulty in basic mobility like sit to lie or lie to sit can be assessed with respect to time taken to accomplish that activity , any increase in time taken to accomplish the particular activity may suggest need for intervention , and patient can be trained for the same activity for time taken. Time taken can evaluate contribution from different components such as cognition, strength, balance, coordination. Therefore assessing time may help the therapist to quantify these components and give direction to treatment. Thus concluded that sit to lie and lie to sit takes same time irrespective of dominant and non dominant side, and angle of trunk flexion (00 and 450). The average time to perform sit to lie or lie to sit for young adult is 3.36 sec. CONCLUSION From the present study we can conclude that the average time taken to perform the sit to lie and lie to sit activity is 3.36. The time taken to perform sit to lie and lie to sit from dependent and non dependent side at 00 and 450 was the same. It did not differ with the side as well as the angle of trunk flexion. à ¢Ã¢â€š ¬Ã†â€™ Limitation of the Study Video for the task is not taken which can help to evaluate the different components of task and may be helpful to explain the reason behind the variation in timing in different individual. Instruction to use a preferable speed may not reliable for every patient. The sample size is small and taken for only 20-25 year old young adult. Clinical Implication As the time taken to perform sit to lie or lie to sit is 3.36 sec, and in my case scenario patient is 25 year old and has difficulty in bed mobility we can take it (3.36 sec) as a baseline in order to asses and rehabilitate the patient . We can measure the time taken by a patient to complete sit to lie and can further retrain the patient to complete the tasks within 3.36 sec; this will help the patient to achieve the status of community functional mobility. It will help us to plan a treatment parameter such as time taken to complete and components of sit to lie as an outcome measure. So in this case summary we could set a goal of 3.36 sec as the time required to achieve functional mobility.