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“EFFECTIVENESS OF STRUCTURED SITTING TRAINING PROTOCOL ON SITTING ABILITY AND WEIGHT BEARING DURING STANDING UP BETWEEN THE DOMINANT

AND NON DOMINANT SIDE STROKE PATIENTS-A COMPARATIVE STUDY.”
Submitted By

PADMANABHAN SURESH BABU ROSHAN
Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore in partial fulfillment of the requirements for the degree of

MASTER OF PHYSIOTHERAPY
IN NEUROLOGICAL AND PSYCHOSOMATIC DISORDERS

Under the guidance of

Dr.SREEJESH.P
Assistant Professor

LAXMI MEMORIAL COLLEGE OF PHYSIOTHERAPY MANGALORE 2008-2010
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“EFFECTIVENESS OF STRUCTURED SITTING TRAINING PROTOCOL ON SITTING ABILITY AND WEIGHT BEARING DURING STANDING UP BETWEEN THE DOMINANT AND NON DOMINANT SIDE STROKE PATIENTS-A COMPARATIVE STUDY.”

Submitted By

PADMANABHAN SURESH BABU ROSHAN
Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore in partial fulfillment of the requirements for the degree of

MASTER OF PHYSIOTHERAPY
IN NEUROLOGICAL AND PSYCHOSOMATIC DISORDERS

                                                           

Under the guidance of

Dr. SREEJESH.P
Assistant Professor

LAXMI MEMORIAL COLLEGE OF PHYSIOTHERAPY MANGALORE
2008-2010

 

II

DECLARATION BY THE CANDIDATE
I hereby declare that the dissertation titled as “EFFECTIVENESS OF

STRUCTURED SITTING TRAINING PROTOCOL ON SITTING ABILITY AND WEIGHT BEARING DURING STANDING UP BETWEEN THE DOMINANT AND NON DOMINANT SIDE STROKE PATIENTS-A COMPARATIVE

STUDY.” is a bonafide and a genuine research work carried out by me under the guidance of Dr. SREEJESH.P

Date: Place: Mangalore

Signature of the candidate: PADMANABHAN SURESHBABU ROSHAN

© Rajiv Gandhi University of Health Sciences, Karnataka

 

III

”leted under my supervision. Date: Dr. SREEJESH. I am satisfied with the work presented with the work presented by the candidate towards the partial fulfillment of Masters of Physiotherapy in Neurological and Psychosomatic Disorders.P Assistant Professor Place: Mangalore Laxmi Memorial College of Physiotherapy.CERTIFICATE BY THE GUIDE This is to certify that this dissertation entitled   was “EFFECTIVENESS OF STRUCTURED SITTING TRAINING PROTOCOL ON SITTING ABILITY AND WEIGHT BEARING DURING STANDING UP BETWEEN THE DOMINANT AND NON DOMINANT SIDE STROKE PATIENTS-A COMPARATIVE STUDY. Mangalore   IV .

SREEJESH.ARUL DHANARAJ.” is a bonafide and a genuine research work carried out by PADAMANABHAN SURESH BABU ROSHAN under the guidance of Dr. Mangalore   V .P Date: Place: Mangalore Dr.ENDORSEMENT BY THE PRINCIPAL/ HEAD OF THE INSTITUTION This is to certify that this dissertation entitled “EFFECTIVENESS OF STRUCTURED SITTING TRAINING PROTOCOL ON SITTING ABILITY AND WEIGHT BEARING DURING STANDING UP BETWEEN THE DOMINANT AND NON DOMINANT SIDE STROKE PATIENTS-A COMPARATIVE STUDY. Professor & Principal Laxmi Memorial College of Physiotherapy. S.

KARNATAKA. shall have all the rights to preserve. use and disseminate the dissertation/ theses in print or electronic format for academic/ research purpose.COPYRIGHT DECLARATION BY THE CANDIDATE I hereby declare that RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES. Karnataka            VI . Date: Place: Mangalore Signature of the candidate: PADMANABHAN SURESH BABU ROSHAN © Rajiv Gandhi University of Health Sciences.

SREEJESH.P.CP.   VII . Mangalore.ARUL DHANARAJ.ACKNOWLEDGEMENT First and foremost I would like to thank God almighty.M. It is my pleasure and privilege to record my deep sense of gratitude to our respectable principal. Professor of L.C. A thesis in all its sense certainly can be accomplished only by the guidance and assistance of many people. constant encouragement and keen interest shown in this study without whom this work would not have been possible.SURESH BABU. . my mother Mrs.M.P. I take this opportunity to express my gratitude to all those who have helped me for completing this thesis successfully. Associate Professor and Principal of L. I wish to state my special thanks and credit to my respectable guide and teacher DR.. GEETHA SURESH and my brother PRIJIN who have made me what I am today with their blessings care and motivation. Mangalore.. DR. for his divine grace and blessing throughout my studies. for giving meticulous guidance and embodiment and there by molded and explored me in a right manner in the field of physiotherapy. for his valuable help and guidance. Asst. P. I owe to my loving parents my father Mr.

 SHWETHA  computer lab assistant for their timely technical help.   VIII .P. Neena our computer lecturer and MS. for always being accessible with his constant help and support throughout this study. I wish to express my thanks to Dr M. my seniors.I also wish to extend my sincere thanks to my co guide and assistant professor Dr. Saravana Hari Ganesh my PG coordinator for his valuable suggestion  I express my thanks to statistician MS.  library staff for their timely help in lending me books and journals for my reference all the time. Jignesh and Rasheiq they all deserve my gratitude.RESHMA for her timely help and guidance. I express my thanks to all the staff members in Laxmi Memorial College of Physiotherapy for their help and valuable suggestions. Renju.  I wish to express my thanks to Mrs.Magesh Gajapathy for helping me in selecting this topic and statistical analysis. My sincere thanks to all the contributors.V. I extend my sincere thanks to my teacher Dr. juniors and my classmates Sudha.ABHILASH.

Date: Place: Mangalore Signature Name: PADMANABHAN SURESHBABUROSHAN   IX . I thank all who have helped me all the while.Last but not the least I would like to thank all the subjects on my study without whom this task would not have been possible.

LIST OF ABBREVIATIONS USED CVA – Central Nervous System ADL – Activity Daily Living UE.Lower Extremity PVF.Upper Extremity LE.Peak Vertical Force CNS – Central nervous system MAS.Male F.Motor Assessment Scale SS.Female   X .Statistical Significance M.

OUTCOME MEASURES: Sitting Ability: was measured by reach distance and Standing up: was measured by peak vertical force STATISTICAL ANALYSIS: Paired‘t’ test was used to compare the mean difference of outcome scores before and after intervention within both the groups. P value < 0. OBJECTIVE: To compare the sitting ability and weight bearing during standing up before and after the sitting training protocol between the dominant and non dominant paretic side stroke patients. Hence this study is intended to compare sitting ability and standing up ability before and after the sitting training protocol between the dominant and non dominant side stroke patients.05 for statistical significance. Sitting training protocol was given for 2 weeks. Recovery of sitting after stroke is important for individuals because sitting skill is critical to independent living. Patients were again assessed for sitting ability and peak vertical force (PVF). Dominant side stroke patients were on group A and non dominant side stroke patients were on group B. Sitting training protocol was proved to be effective in stroke patients which improved sitting ability and quality. Averages of 3 attempts were taken. The reaching ability in sitting and peak vertical force transmission during standing was measured. Some studies on dominant and non dominant side in both normal and stroke subjects suggest that recovery is faster when impairment is on the dominant side. METHOD: 30 patients who had score 3 on 3rd item on MAS scale were included in study on voluntary.ABSTRACT BACKGROUND: Poor sitting ability is a common problem after stroke. Data’s was statistically analysed.   XI . Unpaired‘t’ test was used to compare the mean difference of outcome scores before and after intervention between both groups.

NON DOMINANT SIDE STROKE. Hence dominant side showed more recovery in sitting ability and weight bearing during standing up when compared to non dominant side. and average improvement in sitting ability in reach distance in non dominant side stroke patients was 0.    XII .RESULTS: Average improvement in sitting ability in reach distance in dominant side stroke patients was 0. SITTING TRAINING PROTOCOL. and average improvement in peak vertical force of non dominant side stroke patients was 12. PEAK VERTICAL FORCE. SITTING ABILITY.06. KEY WORDS: STROKE. CONCLUSION: More improvement was found in dominant side both in terms of sitting ability.10. Average improvement in peak vertical force of dominant side stroke patients was 19. and peak vertical force. DOMINANT SIDE STROKE.16. REACH DISTANCE.

Introduction Aims and Objectives Review of Literature Methodology Results Discussion Conclusion Summary Bibliography Annexure Topic Page No. 01. 02. 06. 04.TABLE OF CONTENTS S. 1-6 7-8 9-13 14-21 22-23 24-27 28 29 30-36 37-54   XIII .No. 03. 05. 08. 09. 10. 07.

reach distance in dominant side stroke patients Sitting ability. 03.LIST OF TABLES S. Topic Page No. 01.non dominant side stroke patients Comparison of sitting ability between dominant and non dominant side stroke patients Comparison of peak vertical force between dominant and non dominant side 46 47 48 49 06. Sitting ability. 04.dominant side stroke patients Peak vertical force. 51   XIV . 45 02.reach distance in non dominant side stroke patietns Peak vertical force. 05. No.

No Topic Materials used in the study Sitting training protocol.reaching beyond arm s length Measurement of reach distance Measurement of peak vertical force Page No 01 02 18 19 03 04 20 21   XV .LIST OF FIGURES S.

45 46 47 04 Peak vertical force.reach distance in non dominant side stroke patients Peak vertical force. No.in non dominant side stroke patients Comparison of sitting ability between dominant and non dominant side stroke patients Comparison of peak vertical force between dominant and non dominant side 48 05 50 06 52   XVI .GRAPHS S.reach distance in dominant side stroke patients Sitting ability. 01 02 03 Topic Sitting ability.dominant side stroke patients Page No.

depriving the brain of essential oxygen and nutrients. Stroke can result from a number of different vascular events that interrupt cerebral circulation and impair brain function. motor. These include cerebral thrombosis. To be classified as stroke. perceptual and language functions.INTRODUCTION Stroke is an acute onset of neurological dysfunction due to an abnormality in cerebral circulation with resultant sign and symtoms that correspond to involvement of focal areas of the brain. a variety of focal deficits are possible. The location and size of the ischemic process. and effectiveness of early emergency medical management all influence the symptomatology that evolves. affecting about 80 percent of individual with stroke. emboli. with diffuse problems affecting widespread areas of function. and results when a clot blocks or impairs blood flow. including changes in the level of consciousness and impairment of sensory.   1 . The term cerebrovascular accidents (CVA) are used interchangeably with stroke to refer to the cerebrovascular conditions that accompany either ischemic or hemorrhagic lesions. Rehabilitation programs for patients with stroke have been shown to improve functional outcomes and allow patients to regain independence Ischemic stroke is the most common type. Hemorrhagic stroke occurs when blood vessels rupture causing leakage of blood in or around the brain. focal neurological deficits must persists for at least 24 hours1. cognitive. For many patients stroke represents a major cause of disability. Clinically. the nature and functions of the structures involved. or hemorrhage. the availability of collateral blood flow.

heart disease. 30 percent coronary heart disease. however poor balance and impaired gait can persist. the amount of collateral blood flow. but will regain walking ability and will be discharged home following hospitalization. In patients with ABI (atherothrombotic brain infarction). Hemipleagia is a major consequence of stroke and contributes significantly to the physical disability of stroke survivors. most people with stroke will regain walking ability. and early acute care management determine the severity of neurological deficits in an individual patient.2 Major risk factors for stroke are hypertension. Impairments may resolve spontaneously as brain swelling subsides (reversible ischemic neurological deficit). Residual neurological impairments are those that persist longer than 3weeks and may lead to permanent disability. Health care costs are also minimised when compared to long term placement in nursing homes. and diabetes.Motor deficits are characterized by paralysis (hemiplegia) or weakness (hemiparesis). typically on the side of the body opposite the site of the lesion.4 The majority of individuals with stroke will have some degree of residual impairment.3 People with stroke are at risk of falls. Although impairment is common. generally within 3 weeks. Stroke is the most common cause of chronic disability. 15 percent diabetes.   2 . The location and extent of brain injury. 70 percent have hypertension. Studies reported that patients with stroke three quarters fell in the first six months after their discharge from hospital. Only 17 percent require assistance in bowel and bladder care.

but other limiting factors include sensory loss. with 67 to 88 percent of patients demonstrating partial or complete dependence. with measurable neurological and functional recovery occurring in the first 1 to 3 months after stroke. Rates of improvement will vary across management categories: patients suffering minor stroke recover rapidly with few or no residual deficits whereas severely impaired individuals demonstrate more limited recovery. bathing.Functional mobility skills are typically impaired following stroke and vary considerably from individual to individual. Patients continue to make functional gains at a reduced rate for up to 6 months or longer after insult.7. Motor and perceptual impairments have the greatest impact on functional performance. especially in the areas of language and visuospatial function8. dressing and toileting are also compromised during acute stroke. Independence in ADL also improves with time with only 24 to 53 percent of survivors requiring partial or total assistance 6 months to one year later. Recovery from stroke is generally fastest in the first weeks after onset. with 70 to 80 percent of patients able to walk independently. The ability to perform functional task is influenced by a number of factors. Some patients may demonstrate prolonged recovery with improvements occurring over a period of years. During the acute stroke phase. and decreased cardiorespiratory endurance6. communication disorders.   3 . with or with out assistive devices5 . 70 to 80 percent of patients demonstrate mobility problems in ambulation while 6 months to one year later the figures are reversed. Basic ADL skills such as feeding. disorientation.

especially to the paretic side where deficits are expected. The patient’s ability to maintain a steady position as well as postural alignment and position within the base of support are assessed.An important finding is that recovery has been demonstrated even in patients with extensive CNS damage and advanced age. Control can be assessed in sitting and standing.11. The stimulation from active rehabilitation and an enriched environment plays an important part in brain repair and recovery. Sitting involves not only the ability to reach for a variety of objects located both within and beyond arms length 18 . The disability associated with poor   4 . In the presence of cell death functional reorganization of the CNS occurs. Poor sitting ability is a common problem after stroke19. The patient should be encouraged to shift weight in all directions.10. CNS plasticity is thought to account for continuing recovery. Both reactive postural control and anticipatory postural control should be documented16. and improved local circulation allows intact neurons that were previously inhibited to regain function.9. Recovery of sitting after stroke is important for individuals because sitting is a skill that is critical to independent living20.14 Early recovery is generally thought to be the result of resolution of local vascular and metabolic factors.17. Thus the reduction of edema.12. absorption of damaged tissue. Dynamic stability control can be assessed by having the patient move within a given posture without losing balance. Functional tasks that utilize moving from one posture to another can also be used to assess dynamic postural control.15 Postural control and balance are essential elements of a stroke assessment.13.

The therapist can aid the patient by ensuring proper spine and pelvic alignment. Weight shifts should incorporate moving forward . Typically patients with stroke will sit asymmetrically with weight borne more on sound side.spine straight. diagonally with upper trunk rotation. individuals after stroke are slower and do not load their affected foot or activate muscles of the affected leg sufficiently when reaching beyond arms length in sitting. A common problem with hemiplegia is the inability of the upper trunk to move independently of the lower trunk. Early sitting can be assisted by having the patient use the upper extremity for bilateral support. Gentle resistance can be applied to assist in holding.moving in the posture finally challenges to dynamic balance. In particular. Lateral weight shifts to the affected side typically are most   5 . it has been shown that in comparison to healthy individuals. Early training in sitting should focus on the development of a symmetrical posture. Intervention to train sitting is a common focus of rehabilitation after stroke. using techniques of alternating isometrics and rhythmic stabilization.sitting arises primarily because of muscle weakness and loss of dexterity and also because of the tendency to adapt behaviour to avoid threats to balance. Feet should be flat on the support surface. and upper trunk flexed. side to side. Trunk mobility in balanced flexion/extension. pelvis tilted posteriorly. The pelvis should be neutral. The therapist should manually guide the patient into the correct position. lateral flexion and rotation should therefore be stressed. Lateral flexion to the affected side is also common. backward. A progression that can be utilized includes first holding in the posture.

and moving in posture.   6 . Bridging activities should include assisted and independent assumption of the posture. If the affected lower extremity is unable to hold in a hooklying position. holding in posture. advanced limb control and stimulates early weight bearing on the foot. the therapist will need to assist by stabilizing the foot. It develops pelvic control. Hence this study is intended to compare sitting ability and standing up ability before and after the sitting training protocol between the dominant and non dominant side stroke patients. with an emphasis on symmetrical weight bearing and controlled responses of trunk Some studies on dominant and non dominant side in both normal and stroke subjects suggest that recovery is faster when impairment is on the dominant side. Manual contacts in the direction of the movements combined with gentle resistance can provide early learning cues. Upper extremity activities that encourage shoulder range of motion.difficult. The patient should also practice scooting in sitting to ensure mobility for dressing and sit to stand transitions. Bridging activities develop control in trunk and hip extensors for important functional tasks. Lifting the unaffected foot off the surface while maintaining the pelvis level significantly increases the difficulty and can be used to increase demand on the affected side. Sit to stand transitions should be practiced.

To compare the sitting ability and weightbearing during standing up before and after the sitting training protocol between the dominant and non dominant paretic side stroke patients   7 . 3. 2. To evaluate the sitting ability and weight bearing during standing up before and after the sitting training protocol in the dominant paretic side stroke patients. To evaluate the sitting ability and weight bearing during standing up before and after the sitting training protocol in non dominant paretic side stroke patients.OBJECTIVES OF THE STUDY 1.

ALTERNATE HYPOTHESIS(H1) : There will be a significant difference in the sitting ability and standing up before and after the sitting training protocol between the dominant and non dominant paretic side stroke patients.      8 .HYPOTHESIS NULL HYPOTHESIS (HO): There will be no significant difference in the sitting ability and standing up before and after the sitting training protocol between the dominant and non dominant paretic side stroke patients.

they patients can continue to make measurable functional gains generally at a reduced rate for months or years after insult.REVIEW OF LITERATURE A study. Herdricks et al found no significant difference in potential for motor recovery between type of stroke (hemorrhage Vs infarction) and location (brainstem Vs hemispheric infarction). in seated stroke subjects and healthy subjects by Nora hagstrom25. 70 to 80 percent of patients demonstrate mobility problems in ambulation while 6 months to 1 year later the figures are reversed. with 67 to 88 percent of patients demonstrating partial or complete dependence. on recovery of functional status after stroke showed that during the acute stroke phase. concluded that late recovery of function has been demonstrated for patients with chronic stroke (defined as greater than 1 year post stroke) who undergo extensive functional training. and weight transfer during reaching tasks. and toileting are also compromised during acute stage. dressing.21-23 In an extensive review of literature on motor recovery after stroke.25 Weight distribution in standing and sitting positions. with only 20 percent of patients needing help to walk independently. In a study on the effects of constrain induced movement therapy on patients with chronic motor deficits after stroke. Basic ADL skill such as feeding.26   9 .24. Taub E at al studied on technique to improve chronic motor deficits after stroke. bathing.

These initial data have positive implications for the rehabilitation of patients with hemiplegia who could be taught to overcome a reduced ability to use their impaired limb after stroke31 In a study Strength and Fatigability of the Dominant and Nondominant Hip Abductors(cale jcacobs)1990.27.28. Hip-abduction strength differences exist between the dominant and nondominant legs32.26.COP displacement patterns in stroke subjects deviate more than those of healthy subjects in seated reaching tasks. Measures of strength and fatigability were poorly related.29. The Functional Reach Test is a single item test developed as a quick screen for balance problems in adults. Stroke refers to patient who have had a ceribrovascular accident as the result of circulatory defects in which the symptoms have continued for more than 24 hours. clinicians may opt to assess hip strength and fatigability independent of each another.30 In a study(BRUNT 1991)The effect of foot placement on sit to stand in healthy young subjects and patients with hemiplegia . Muscle activity and GRF(Ground reaction force)can be influenced by altering the initial foot placement of the dominant or uninvolved limb during standing.   10 . therefore. The patient must be able to stand independently for at least 30 seconds without support. The deviating COP displacement patterns are discussed as a possible dysfunction in the ability to make postural adjustments and learn an efficient movement pattern. and be able to flex the shoulder to at least 90 degrees.

hemiplesgia is the paralysis of one side of the body and usually affects the arm. whichcan decrease the nondominant extremity’s ability to absorb large forces associated with athletic activities.9 The differences have been observed in both the frontal1 and transverse planes. Eggen et al10 reported that valgus movement ofthe   11 . the degree of involvement of the limbs and trunk33.2 The concept of limb dominance in the upper extremity has long been accepted.side strength differentials greater than 10%.7 have reported no significant sideto. Conversely.3.8 Leg dominance differences at the hip and knee have been revealed during functional tasks.9 Frontal-plane movement is of interest because of the potential for knee ligament injury from increased valgus motion38. Dominance-related strength differentials of the hip abductors may be partly responsible for the reported functional differences. leg.1–3 Both limbs can be negatively affected by this asymmetry. Authors1–6 have addressed34-37 The idea of leg dominance as it relates to both strength and function.1. Limb dominance has been defined as one limb demonstratingincreased dynamic control as a result of an imbalancein muscular strength and recruitment patterns. such as landing from a jump. Dependenceon the dominant limb can increase stress on the joints of that extremity. epidemiologic studies have shown not only that strength imbalances exist but that they may result in increased injury rates for athletes with sideto.side differences in isokinetic strength of the flexors and extensors of the hip and knee. yet researchers and clinicians often treat the 2 lower extremities as equal. and trunk. Hip-abductor endurance also plays a role in valgus knee movement. Overreliance on the dominant limbcan also result in weakness in the contralateral limb. Several groups4.

40 The MAS was developed by carr et al to examine functional mobility skills following stroke.99) with high concurrent validity with FMA 39 REF. Recovery of sitting after stroke is important for individuals because sitting is a skill that is critical to independent living (Dean et al 1998. sitting ability has been   12 . It includes 8 items of motor function including movement transition ( supine to side lying.knee increased after fatigue of the hip abductors. Therefore. Harleyet al 2006). supine to sit.It is a usefull clinical method of assessing standing weight distribution following stroke and in other patients with unilateral disturbances of lower limb weight bearing. Furthermore. The instrument has been shown to be highly reliable ( r = 0. our purpose was to examine the strength and fatigability of the hip abductors in the dominant and nondominant legs. In a study symmetry of weight distribution in normals and stroke patients using weigh scales. weighing machine is a reliable tool and can be measured for testing weighing machine 39.1999b). upper hand function. Morgan 1994. Dean et al 1999a. Poor sitting ability is a common problemafter stroke (Dean and Mackey 1992. balanced sitting . walking. but also the ability to reach for a variety of objects located both within and beyond arm’s length (Dean and Shepherd 1997). Sitting involves not only the ability to maintain the seated posture.89 to . sit to stand ). It uses a 6 point ordinal scale with description for each item score. Hip-abductor strength and endurance have yet to be determined in relation to leg dominance.

these individuals were able to increase the load taken through the affected foot and increased the consistency of activation of muscles in the affected leg. In addition.   13 . Carry over to standing up was also reported. Sandin and Smith 1990. Morgan 1994. it has been shown that in comparison to healthy individuals. Intervention to train sitting is a common focus of rehabilitation after stroke.shown to be a useful prognostic indicator of outcome for this population (Loewen and Anderson 1990. In particular. The disability associated with poor sitting arises primarily because of muscle weakness and loss of dexterity and also because of the tendency to adapt behavior to avoid threats to balance41. van de Port et al 2006). individuals after stroke are slower and do not load their affected foot or activate muscles of the affected leg sufficiently when reaching beyond arm’s length in sitting (Dean and Shepherd 1997). Previous work has demonstrated the efficacy of a sitting training protocol in individuals who had suffered a stroke 2–17 years previously (Deanand Shepherd 1997). Dean and Shepherd (1997) found that individuals who were trained specifically to improve their sitting by focusing on appropriate loading of the affected foot were able to reach further and faster42-45.

Patients who are able to maintain standing posture without support at least for 5seconds 6. 5.    14 . Patient in the age group of 40-70 years will be included in the study. Diagnosis of first stroke resulting in hemiplegia within three months. 3. Mangalore METHOD OF COLLECTION OF DATA Population: Patients diagnosed with stroke.J. Both sexes and both dominant and non dominant side affected stroke patients. Laxmi Memorial College of Physiotherapy OPD. A. SOURCE OF DATA: A total of 30 patients referred to physiotherapy department of 1. Ability to understand instructions. Study sample: 30 Gender: male/female (heterogeneous sampling) . A score of at least 3 on item 3(sitting balance) of motor assessment scale for stroke. Study design: experimental study Sampling technique: Purposive sampling technique. 4.Inclusion Criteria 1.METHODOLOGY. 2. 2. Mangalore. Hospital & Research centre.

Additional orthopaedic problem 4. Visual/ hearing problems. Lack of comprehension 2. Other neurological disorders 5. Materials used: 1.Exclusion Criteria 1. 3.  30 patients who had at least score 3 on item 3 (sitting balance) of on MAS were included for study after scrutinizing for other inclusion and exclusion criteria on voluntary basis. Measuring tape fixed card board. 3. 2. Motor assessment scales INTERVENTION: During the training period participants in both group received all regular physiotherapy intervention other than training to improve sitting. Chair 4. Based on side of stroke they were put into two experimental group Group A: Dominant side stroke patients Group B: non dominant side stroke patients. Two weighing machines.   15 . Severe cognitive and perceptual deficits.

The horizontal distance from tip of acromion process (on shoulder adjacent to wall) to inch tape was measured. Reach distance. patients were asked to reach to a object beyond arms length and it was focused on smooth co-ordinate movement of trunk and arm to get the hand to object. SITTING TRAINING PROTOCOL: Patients were seated in a chair.   16 . direction thigh support. ipsilateral (450 from the acromion away from the intact side). STANDING UP: was measured by peak vertical force which by placing weighing machine bilaterally. and across (450 from the intact acromion across the body toward the affected side). Patient was seated in chair. Outcome measure: SITTING ABILITY: It was measured by reach distance in inches. The average of 3 trial was calculated. seat height and task was varied systemically. Training was progressed over 2 weeks period time by increasing the reach distance and number of repetitions. Training program consist of ten sessions spread over a two week period with each session lasting approximately 30 mins. The patient was asked to stand up. and peak vertical transmission of force was noted.Participants in both groups received the sitting training protocol. an inch tape was placed parallel to patient on the wall. appropriate loading of affected foot and preventing use of maladaptive strategies such as widening the base of support. The patient was asked to reach in 3 direction forward.

CALCULATION OF ERROR: Patient weight was calculated initially by asking the patient to stand on weighing machine. thus error in reading was avoided. Unpaired‘t’ test was used to compare the mean difference of outcome scores before and after intervention between both the groups.05 for statistical significance. Then 2 weighing machine were kept under both the foot. STATISTICAL ANALYSIS: Paired ‘t’ test was used to compare the mean difference of the outcome scores before and after intervention within both the groups. STUDY DURATION: 2 WEEKS Patients were initially assessed for sitting ability and standing up ability before commencement of treatment which constituted the baseline data and they again assessed for same variables after 2 weeks. The sum of force transmission through two weighing machine was patients total body weight.   17 . P value was kept <0.

Figure 1:MATERIAL USED FOR THE STUDY                       18 .

  Figure 2: SITTING TRAINING PROTOCOL.   19 .REACHING BEYOND ARMS LENGTH.

Figure 3: MEASUREMENT OF REACH DISTANCE   20 .

Figure: 4 MEASUREMENT OF PEAK VERTICAL FORCE .   21 .

29 at p < 0.03. mangalore Dominant side stroke patients were in group A and nondominant side patients in group B.2± 0. Table 1 and Graph 1: Paired ‘t’ test was done to know the mean difference of the outcome score before treatment (baseline) to 2 weeks after treatment. The mean and SD for reach distance (sitting ability) before treatment for dominant side was 1.012: the Mean and SD for sitting ability (reach distance)after 2 weeks was 1. the ‘t’ was 8. Table 2 & Graph 2: The mean and SD for at baseline reach distance for nondominant side was 1. The Mean and SD for reach distance after 2 weeks was 1.09±0.J.RESULTS   30 patients participated in study from A.01.   22 . hospital.65 at p<0.044.26 ± 0.1± 0.05 which was statistically significant. Description of tables and graphs are follows. The ‘t’ value was 15.05 which was statistically significant.

05.433 at p<0.886 at p<0. the ‘t’ value was 4. the average improvement in sitting ability for dominant side stroke patient was 0.05 which was statistically significant.81. The average improvement in sitting ability for non dominant side stroke patient was 0. The average improvemet in PVF for nondominant side was 12.10 at p<0.699.250. The ‘t’ was 23.06. the ‘t’ value was 3. Table 5 and Graph 5: Un paired ‘t’test was used to compare the Mean difference of outcome scores of before and after interventions between the group.Table 3 and Graph 3: The mean and SD for dominant side peak vertical force at base line was 42±2. The ‘t’ was 10.05 which was statistically significant Table 4 and Graph 4: The mean and SD for nondominant side peak vertical force was at base line was 41.513 at p< 0.1040.23: the Mean and SD for dominant side peek vertical force after 2 weeks was 61± 3. Table 6 and graph 6: The average improvement in PVF for dominant side stroke patients was 19.16.   23 .05.93±2. The Mean and SD for nondominant side PVF after 2 weeks was 54± 2.

DISCUSSION Hemiplegia or stroke is paralysis of one side of body is the classic sign of neurovascular disease of brain and its number one cause of disability in adults. The recovery following stroke takes place in two stages. impairments in cognition. GROUP A with dominant   24 . the amount of collateral blood flow and early acute care management determine the severity of neurological deficits48. sensation. balance and functional performance. Based on side of stroke they were divided into two experimental groups. In the present study 30 patients who had score 3 on 3rd item on MASS scale along with other inclusion criteria were taken for study on voluntary basis.46. Stroke can be defined as a condition with rapidly developing clinical signs of focal loss of cerebral function with symptoms lasting more than 24 hours or leading to death with no apparent cause other that vascular origin. initially there is resolution of diaschiasis or neuronal shock and recruitment of previously silent synopsis which brings about some amount of recovery. But clinically a variety of focal deficits are possible following the stroke including changes in the level of consciousness. The location and extent of brain injury. Second stage of recovery is due to motor learning which occurs with practicing of relatively novel task49.47 The term Hemiplegia refers to motor deficits that are characterized by paralysis or weakness on one the side of body opposite to the site of lesion.

Both the groups improved considerably in standing up ability with the sitting training protocol. During the study duration of 2 weeks both groups underwent sitting training protocol with regular physiotherapy. After two weeks significant improvement was found in both the groups but when compared the scores were higher for dominant side stroke patients. The assessment was done on baseline and after 2 weeks of treatment.16 which was higher when compared to average improvement in sitting ability for non dominant side which was 0. As during sitting training subjects practiced moving their trunk forward rapidly over their center of mass whilst loading their legs. Each session lasted approximately for 30 mins. The average improvement sitting in sitting ability was 0. But when the scores were compared the average improvement in transmission of peak vertical force was higher in dominant side stroke patients when compared to non dominant side stroke   25 . Training was progressed over the two week period by increasing the reach distance in number representations. Reach distance for sitting ability and peak vertical force for standing up ability. which increased their ability to transmit force through affected extremity.side stroke and GROUP B with non dominant side stroke. the data was statistically analyzed. The sitting training protocol was designed to improve sitting ability and standing up while focusing on smooth coordinated motion of trunk and arm.10 may be because of the fact that reaction time of neutrally and cortical representation of dominant more.50 Training program consisted of 10 session spread over a two week.

which has more areas of cortical representation. This study results are similar to study done by dean and shepherd stating lateralization influences the recovery.patients51. This may be because of the reason that non dominant side may not spontaneously take on load when compared to dominant side. Thus our study results suggest that there is significant difference in sitting ability and standing up before and after the sitting training protocol between the dominant and non dominant paretic side stroke patients   26 .

Follow up after 2 weeks was not done. 2. Age group included in this study was 40 to 70. Dynamic balance and gait characteristic can be evaluated. Further studies can be done by doing follow up studies foe 3 months 2.   27 .Limitations 1. young stroke bellow 40 and geriatric population above 80 were not included in this study 3. Sensory influence on balance was not considered Suggestions for further research 1.

  28 .CONCLUSION More improvement was found in dominant side both in terms of sitting ability. and peak vertical force. Hence dominant side showed more recovery in sitting ability and weight bearing during standing up when compared to non dominant side and alternative hypothesis was proved.

Reach distance during sitting ability and peak vertical force transmission during standing up was the outcome measures. Group A with dominant side side stroke patients and group B with nondominant side stroke patients. Results revealed both group improved significantly with sitting training protocol but still when scores were compared the dominant side stroke patients improved.sitting training protocol was given for both the groups for 2 weeks. This may may be due to increased cortical representation of dominant side and lateralization on brain. after   29 . the datas were statistically analysed. Patients were assessed before treatment which was baseline data and after 2 weeks of treatment. 30 patients were included in the study screening for inclution and exclution criteria and was sorted into two groups.SUMMARY The purpose of this study was to compare the sitting ability and weight bearing during standing up before and after the sitting training protocol between the dominant and nondominant paretic side patient.

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Arch Phys Ned Rehabil. 1995. 51. Paretic upper limb strength best explains arm activity in people with stroke. Jocelyn E Harris. 20 (3). Stein J. 380-89. Geriatrics. 48.Nielsen T. Wilsgaard T. 47. Does it matter? Changes in bone mineral density within first 12 months after stroke.108. 1977. Walking after stroke. Jorgensen L. Magus JH. 32: 101. 76: 840.     36 . Osteoporos int. Jacobson BK. Viramontes BE. Janice J. Neurorehab and Neural Repair 2006. A longitudinal study. Wanger. Catherine E. Dorothy F. Lang. Falls by hospitalized eldery patients: causes.387. 444-54. 2007. Recovery of grasp versus reach in people with hemiparesis post stroke. Joanne M. 50. Shirley A. 87.46.843. 49. Kerrigan DC. Harris JE. Individuals with the dominant hand affected following stroke demonstrate less impairment than those with the non dominant hand affected. 11: 381. Eng. 20 (4). Eng JJ. prevention. 2000. Edwards. Neurorehabil Neural Repair 2006 Sep. Sehested P. Serverin. Fall related injuries in anticoagulated stroke patients during inpatient rehabilitation. Sahrmann. Phys Ther Jan.

Subject is fit/unfit for the study: _______________________.___________________________________________________________________ ___ voluntarily declare to participate in the research study “EFFECTIVENESS OF STRUCTURED SITTING TRAINING PROTOCOL ON SITTING ABILITY AND WEIGHT BEARING DURING STANDING UP BETWEEN THE DOMINANT AND NON DOMINANT SIDE STROKE PATIENTS-A COMPARATIVE STUDY. Signature of the researcher: __________________________. Guide: _____________________ Date: ___________________________ Co-guide:___________________   37 . risks and benefits of participation and has answered all my questions and queries regarding the study to my satisfaction. Signature of participant: ____________________________..”The researcher has explained me about the study. Signature of the witness: ____________________________.  ANNEXURE I CONSENT FORM I.

ANNEXURE II EVALUATION OF THE PATIENT   Name Age Sex Date of assessment Occupation Address Time since stroke Side of paresis Any associated disorders Medication Perceptual problem if any Any visual problems Patient selected for study : : : : : : : : : : : : yes/ no : yes/ no   38 .

Actively moves impaired leg across body to roll but leaves impaired arm behind. 2. Pt may be assisted to side-lying & is assisted to sitting but has head control throughout. 3. 6. Uses intact arm to pull body toward intact side. Actively moves impaired arm and leg rolling to intact side but overbalances. Supine to Sitting over side of bed 1. 5. The rest of the body moves as a block. Supine to Side-lying onto intact side (starting position: supine with knees straight) 1. Pt may be assisted to side-lying but is able to sit up without help. 4. Pt may be assisted to side-lying & is assisted with lowering LEs off bed to assume sitting. 2. 4. Pt assisted to the side-lying position: Patient lifts head sideways but can’t sit up. Impaired arm is lifted across body with other arm. There are 9 sections in all. Uses intact leg to hook impaired leg to pull it over. Rolls to intact side in 3 seconds without use of hands. 3.   39 .ANNEXURE III MOTOR ASSESSMENT SCALE Date: _____________ Patient Name: ______________ Therapist: _________________ If the patient cannot complete any part of a section score a zero (0) for that section. Actively moves impaired arm across body. Impaired leg moves actively & body follows as a block.

Sits on stool unsupported with feet on the floor. Pt is assisted to sitting and needs support to remain sitting. The patient’s weight is evenly distributed but hips and knees are flexed – No use of hands for support.   40 . 2. 4. Pt sits unsupported for 10 seconds with arms folded. Without allowing the legs or feet to move & without holding on the patient must reach forward to touch the floor (10 cm or 4 inches in front of them) The affected arm may be supported if necessary. Balance Sitting 1. The patient’s weight is unevenly distributed & may use hands for support. Hands resting on thighs. 3.5. Sits unsupported with feet together on the floor. Head and thoracic spine extended. Sits unsupported with feet together on the floor. Pt reaches sideways without moving the legs or holding on and returns to sitting position. knees and feet together & feet on the floor. 6. Pt able to move from supine to sitting without help in 10 seconds. Pt assisted to standing. Pt assisted to standing – any method. Pt stands up. 5. Pt able to move from supine to sitting without help. 3. Support affected arm if needed. 6. 2. Sitting to Standing 1. Without moving the legs the patient turns the head and trunk to look behind the right and left shoulders. Pt sits unsupported with weight shifted forward and evenly distributed over both hips / legs.

4. The patient must maintain the position for 2 seconds with some external rotation and with the elbow in at least 20 degrees of full extension. With assistance the patient stands on affected leg with the affected weight bearing hip extended and steps forward with the intact leg. The patient protracts the affected shoulder actively. Walks 10 feet or 3 meters without assistance but with an assistive device. Supine: Therapist places affected arm in above position. 5. Supine: Therapist places affected arm in 90 degrees shoulder flexion and holds elbow in extension – hand toward ceiling. Walks 33 feet or 10 meters without assistance or a device. Remains standing for 5 seconds with hips and knees extended with weight evenly distributed. Upper Arm Function 1. Pt stands up. Pt stands up and sits down again 3 x in 10 seconds with hips & knees extended & weight evenly distributed Walking 1. 6. 5. Walks with the assistance of one person. 2. Pt stands up and sits down again. 2. Walks 16 feet or 5 meters without a device or assistance in 15 seconds. Walks up and down 4 steps with or without a device but without holding on to a rail 3 x in 35 seconds. Is able to pick up a small object from the floor with either hands and walk back in 25 seconds.   41 . 3. When standing hips & knees are extended with weight evenly distributed 6. 4.

2. Patient asked to lift object off table by extending the wrist – no elbow flexion allowed.3. Sitting at a table (Radial Deviation of Wrist): Therapist should place forearm with ulnar side on table in mid-pronation /supination position.   42 . 4.holds it there for 10 seconds and then lowers it with some Shoulder external rotation and forearm supination. Hand Movements 1. Patient must maintain arm position while turning body toward the wall. Patient is asked to lift hand off table. Fingers around cylindrical object. 3. Sitting (Pronation / Supination): Affected arm on table with elbow unsupported at side. Patient asked to supinate and pronate forearm (¾ range acceptable). (Flexion & extension of elbow) Therapist may assist with supination of forearm. No excessive shoulder elevation or pronation. Sitting: Patient lifts affected arm to 90 degrees forward flexion . Sitting at a table (Wrist Extension): Affected forearm resting on table. Thumb in line with forearm and wrist in extension. Supine: Patient assumes above position and brings hand to forehead and extends the arm again. 5. Standing: Have patient’s affected arm abducted to 90 degrees with palm flat against wall. 6. Patient must hold the affected arm in position for 2 seconds with some shoulder external rotation and forearm supination. No pronation. Sitting: Therapist places affected arm in 90 degrees of forward flexion. Place cylindrical object in palm of patient’s hand. No wrist flexion or extension.

Place another teacup an arms length away on the intact side. wrist in neutral or extended. Continuous opposition of thumb to each finger 14 x in 10 seconds. 2. in a teacup an arms length away on the affected side. Place 8 jellybeans. (beans). Have the patient pick up one jellybean with their affected hand and place the jellybean in the cup on the intact side. Have the patient reach forward to pick up the top of a pen with their affected hand. Have the patient pick up a polystyrene cup with their affected hand and put it on the table on the other side of their body without any alteration to the cup. starting with the index finger. Have the patient pick up a pen/pencil with their affected hand. 4. 6. Have the patient reach forward with shoulders protracted. Advanced Hand Activities 1. Do not allow thumb to slide from one finger to the other or go backwards.   43 . bring the affected arm back to their side and put the pen cap down in front of them. elbows extended. Have the patient draw horizontal lines to touch the vertical line. 3. and position it without assistance and make rapid consecutive dots (not strokes) on a sheet of paper. 5. Draw a vertical line on a piece of paper.4. Each finger in turn taps the thumb. The goal is 10 lines in 20 seconds with at least 5 lines stopping at the vertical. pick up the ball with both hands and put it back down in the same spot. hold the pen as for writing. Goal: at least 2 dots a second for 5 seconds. Place a 5 inch ball on the table so that the patient has to reach forward with arms extended to reach it.

sometimes flaccid. sometimes good tone.5. sometimes hypertonic. no resistance when body parts are handled. ____Variable. The test looks at a patient’s ability to move with low tone or in a synergistic pattern and finally move actively out of that pattern into normal movement. Have the patient take a dessert spoon of liquid to their mouth with their affected hand without lowering the head toward the spoon or spilling. 6. High Score: 54 Low Score: 0   44 . limb. The higher the score – the higher functioning the patient is on the affected side. General Tonus (check one – add “6” to score if tone on affected side is normal) ____Flaccid. forearm in supination. Have the patient hold a comb and comb the back of their head with the affected arm in abduction and external rotation. ____Some resistance felt as body parts are moved. ____Hypertonic 50% of the time ____Hypertonic all of the time 6 = Consistently normal response This test is designed to assess the return of function following a stroke or other neurological impairment.

ANNEXURE IV Table 1: SITTING ABILITY-REACH DISTANCE-DOMINANT SIDE STROKE PATIENTS Sitting Ability Reach Distance Dominant side mean Baseline Week2 SD t-value p-value 0.000 result P<0.05 sig 1.1 0.289 1.26 0.033594 GRAPH 1: SITTING ABILITY-REACH DISTANCE-DOMINANT SIDE STROKE PATIENT     45 .014639 15.

NON DOMINANT SIDE STROKE PATIENT   46 .TABEL 2:SITTING ABILITY-REACH DISTANCE-NON DOMINANT SIDE STROKE PATIENT Sitting Ability Reach Distance Non Dominant side mean Baseline Week2 SD t-value p-value 0.000 result P<0.650 1.012984 8.044881 GRAPH 2: SITTING ABILITY-REACH DISTANCE.05 sig 1.096 0.2 0.

817254   Graph 3: PEAK VERTICAL FORCE-DOMINANT SIDE STROKE   47 .106 61 3.236068 23.Table 3:PEAK VERTICAL FORCE-DOMINANT SIDE STROKE Peak Vertical Force Dominant side mean Baseline Week2 SD t-value p-value 0.05 sig 42 2.000 result P<0.

Table 4-PEAK VERTICAL FORCE-NON DOMINANT SIDE STROKE PATIENT Peak Vertical Force -Non Dominant side mean Baseline Week2 SD t-value p-value 0.250926 10.000 Result P<0.699206   Graph 4: PEAK VERTICAL FORCE-NON DOMINANT SIDE STROKE PATIENT   48 .433 54 2.05 sig 41.93333 2.

05 sig   49 .513 0.16 Average improvement in Sitting Ability Reach Distance non Dominant side t-value p-value Result 0.002 P<0.Table 5:COMPARISON OF SITTING ABILITY BETWEEN DOMINANT SIDE STROKE PATIENT Average improvement in Sitting Ability Reach Distance Dominant side 0.1040 3.

Graph 5: COMPARISON OF SITTING ABILITY BETWEEN DOMINANT SIDE STROKE PATIENTS   50 .

TABLE 6:COMPARISON OF PEAK VERTICAL FORCE BETWEEN DOMINANTAND NON DOMINANT SIDE Average improvement Peak Vertical Force Dominant side 19 Average t-value improvement Peak Vertical Force -Non Dominant side 12.05 sig   51 .06 4.886 p-value result 0.000 P<0.

Graph 6: COMPARISON OF PEAK VERTICAL FORCE BETWEEN DOMINANT AND NON DOMINANT SIDE STROKE PATIENTS   52 .

17 0.3 1.09 1.15 0.25 1.08 1.1 42 40 44 38 46 41 43 42 42 40 44 39 45 43 41 61 58 64 62 60 58 64 61 61 56 66 54 68 58 64 19 18 20 24 14 17 21 19 19 16 22 15 23 15 23   53 .26 1.11 1.22 1.19 0.24 1. Sitting ability reach distance.1 1.02 0.ANNEXURE V MASTER CHART 1 DOMINANT SIDE NO.25 1.08 1.12 0.1 1.31 1.1 1.28 1.18 0.09 1.17 0.11 1.08 1.22 1.12 1.11 0.2 0.22 0.12 1.21 1.22 0.09 1.16 0.3 1.13 1.11 1. Base line After 2 weeks Difference PVF base line PVF after 2 weeks Difference 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1.27 1.2 0.27 1.14 0.12 1.09 0.

16 0.1 1.15 1.08 1.11 0.1 1.14 0.08 1.09 1.14 0.09 1.2 1.18 1.11 1.MASTER CHART 2 NON DOMINANT SIDE NO Sitting ability reach distance(inch) Base line After two weeks Difference Standing up PVF.08 1.09 1.1 1.18 1.26 1.08 1.1 0.04 0.2 1.12 0.25 1.2 1.12 1.1 1.26 1.09 0.1 0.11 1.22 1. Base line After two weeks Difference 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1.11 1.03 0.07 0.18 0.14 1.17 0.14 1.13 0.06 41 42 40 44 39 45 43 41 40 44 38 46 41 43 42 54 50 58 52 56 55 53 51 57 50 58 52 56 53 55 13 8 18 8 17 10 10 10 17 6 20 6 15 10 13   54 .26 1.06 0.22 1.

                                                                                                                                           55 .