RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS
FOR DISSERTATION
1
NAME OF THE
CANDIDATE AND
ADDRESS
Mr. AJOY KUMAR BISHAI
KUIKOTA(NEAR CHURCH) POST AND DIST WEST
MIDNAPORE, WEST BENGAL.
2
NAME OF THE
INSTITUTION
ACHARYA INSTITUTE OF HEALTH
SCIENCES&COLLEGE OF PHYSIOTHERAPY,
BANGALORE-32
3
COURSE OF STUDY
AND SUBJECT
MASTER OF PHYSIOTHERAPY IN NEUROLOGICAL
AND PSYCHOSOMATIC DISORDERS
4
DATE OF ADMISSION 10-07-2012
TO COURSE
5
TITLE OF THE TOPIC
SELF-EFFICACY AND BALANCE IN STROKE
SURVIVORS.
6.
BRIEF RESUME OF THE INTENDED WORK :
6.1
NEED FOR STUDY:
Balance is the condition in which all the force acting on the body are balanced such
that the centre of mass (COM) is within the stability limit, the boundaries of the base of support
(BOS)1. It is controlled by visual, vestibular and somatosensory system2. Stroke can affect the
way these systems work together, thus causing balance problems3. Several studies have revealed
the relationship between motor deficits, sensory problems and balance4,5,6,7.Therefore
rehabilitation efforts for persons with stroke primarily focus on enhancing physical function4,7,8,9
with less attention paid to mental function such as self- efficacy. Some literatures suggest that
there is low self- efficacy in stroke survivors10, which raises a question on its role11 in balance
performance in stroke survivors. There are literature which explore the association between selfefficacy and impairment, therapeutic intervention, in the fall risk, activity and
participation12,13,14,15. Unfortunately, studies dealing with self- efficacy and its association with
balance in stroke are limited as well as whose studies are basically done on acute stroke16,17.
Therefore, this study is intended to analyse the relation between self-efficacy and balance
performance, which may have implication in stroke rehabilitation.
REVIEW OF LITERATURE :
1.
Phillip A Gribble et al2: Objective of the study was to examine the effects of fatigue of the
lower extremity on postural control during single-leg stance. Fourteen healthy volunteers (age,
21-23 years) with no history of lower-extremity injury or neurologic deficits were included in
the study. Testing consisted of isokinetically fatiguing the sagittal plane movers of the ankle,
knee or hip with measures of static postural control. Postural control was associated with three
30-second trials during unilateral stance with eyes open. Outcome measures used were, centre of
pressure excursion velocity (COPV) in the frontal and sagittal planes. Results demonstrated
fatigue at the knee and hip which led to postural control impairment in the frontal plane,
whereas fatigue at the ankle did not. In the sagittal plane, fatigue at all 3 joints contributed to
postural control impairment. Authors concluded there is an effect of localized fatigue of the
sagittal plane movers of the lower extremity on COPV. It appears that fatigue about the hip and
knees had a greater adverse effect on COPV.
2.
JF Marsden et al3: Objective of the study was to examine vestibular control of balance in those
who recovered the ability to stand after middle cerebral artery (MCA) stroke. Sixteen patients
with MCA stroke were compared with 10 age matched controls. Vestibular evoked postural
responses were obtained using galvanic vestibular stimulation (GVS) while patients stood with
their eyes closed and head facing forwards, equally loading both legs. Results showed lateral
displacement and net lateral force following GVS were significantly larger after stroke. Authors
concluded MCA stroke may disrupt corticobulbar projections to brainstem output pathways
involved in vestibular control of balance.
3.
Lubetzky et al4: The review concluded that there was moderate evidence to suggest that balance
performance can be improved with balance training in the short term for post-stroke individuals
in the acute stage, but as both control and intervention groups improved the evidence should be
viewed with caution. There were data limitations and potential biases, but the author’s
conclusion s are suitably cautious and appropriate.
4.
Clarissa B et al5: The aim of the study was to compare balance control in hemiparetic patients
during the first year post stroke and in age-matched neurologically normal subjects using the
Berg Balance Scale and Computerized Dynamic Posturography. Authors compared the Berg
Balance Scale Sensory Organization Test scores in 21 patients with hemiparesis after first-ever
ischemic stroke and in 21 age-matched, neurologically normal subjects. Results showed that
Berg Balance Scale scores were significantly lower in the patients than in the neurologically
normal subjects. Equilibrium scores were significantly lower in the patients than in the
neurologically normal subjects for those sensory organization test conditions that did not provide
appropriate somatosensory information and under conditions of sensory conflict. A history of
falls was more frequent in patients with lower equilibrium scores. Aythors concluded during the
first year after a stroke, defective sensory reweighting significantly impacts balance control in
hemiparetic patients.
5.
Louisette Mercier et al 6 :This study evaluates the relative impact of motor, cognitive and
perceptual deficits on functional autonomy with 100 elderly (aged 55-79 years) victims of stroke.
Authors incorporated two different approaches for measuring functional autonomy: Functunal
Autonomy Measurement System and the Assessment of Motor and Process skills (AMPS). The
results of the confirmatory factors analysis show that motor, cognitive and perceptual factors all
make a significant contribution to the variation in functional autonomy and confirm the accuracy.
Authors concluded the factors that make the greatest contribution in explaining the variance in
functional autonomy in order of importance, the motor factor, the perceptual factor and the
cognitive factor.
6.
Patricia Kluding et al7: This study was intended to examine the relationship between
prospectively selected measures of body function and structure (body mass index, muscle
strength, sensation and cognition) and Activity (gait speed, gait endurance and functional
balance) in people with chronic stroke. 26 individuals with mean age of 57.6(11) years and time
after stroke of 45.4(43) months participated. Four variables (body mass index, muscle strength
difference between the lower extremities, sensation difference between lower extremities and
Mini-Mental status exam score) were entered into linear regression models for gait speed, six
minute walk test distance and Berg Balance Score. Lower-extremity strength difference was a
significant individual predictor for gait speed, gait endurance and functional balance. Authors
concluded strength deficits in the hemiparetic lower extremity should be an important target for
clinical interventions to improve function in people with chronic stroke.
7.
Salbach et al8 : Conducted a study to evaluate the efficacy of a task oriented walking
intervention in improving balance self-efficacy in persons with stroke and to determine whether
effects were task specific. 91 individuals with a residual walking deficit within 1 year of a first or
recurrent stroke. Task-oriented interventions targeting walking or upper extremity function were
provided 3 times a week for 6 weeks. Measurements included Activities specific Balance
Confidence Scale, Six minute walk test, 5-m walk, Berg Balance Scale and Timed up and go
administered at baseline and post intervention. Results showed the walking intervention was
associated with a significantly greater average proportional change in balance self-efficacy that
the upper extremity intervention. Treatment effects were largest in persons with low self-efficacy
at baseline and activities relating to task practiced. In the walking group, change in balance selfefficacy co-related with change in functional walking capacity (co-relation co-efficient = 0.45,
95% C.I = 0.16- 0.68.). Authors concluded Task oriented walking retraining enhances balance
self-efficacy in community-dwelling individuals with chronic stroke.
8.
Weiss et al9: The objective of the study was to evaluate the effects of a progressive resistance
strength training program on changes in muscle strength, gait and balance in older individuals 1
yr after stroke. Seven individuals were recruited who were greater than 60 yr of age. Subjects
participated in a 12wk twice per week resistance program at 70% of one rep max. Results
showed 68% improvement in the lower limb strength on the effected side, motor performance
improved by 9% and static and dynamic balance(Berg Balance Scale) improved by 12%. Authors
concluded results support the concept that strength training is an appropriate intervention to
improve quality of physical function in older community dwelling stroke survivor.
9.
Korperssoek C et al10: Conducted a systematic review to provide an overview of the literature
focusing on the influence of self-efficacy and self-efficacy enhancing intervention on mobility,
activities of daily living, depression and quality of life of patient’s with stroke. Studies were
retrieved from a systematic search of public studies over the period of 1996-2009, index in the
Cumulative index to nursing and allied health literature, Medline, Psychinfo and Embase and the
study focusing on stroke, thr influence of self-efficacy and self-efficacy enhancing intervention.
Their study found out that self-efficacy was positively associated with mobility, activities of
daily living and quality of life and negatively associated with depression. Authors concluded, it is
necessary to further emphasise the role of self-efficacy in the care for stroke patients.
10.
Marco YC Pang et al11: The purpose of the study was to determine the contribution of balance
self-efficacy to satisfaction with community re-integration in older adults with chronic stroke. 63
community dwelling older adults (50 yrs of age or older) with chronic stroke (onset of 1 year or
more) participated in this study. Satisfaction with community Re-integration was measured with
the Re-integration to normal living index (RNL) and balance self-efficacy was measured with the
Activity Specific Balance Scale. After adjusting for age, sex, depression and other impairments
after stroke, balance self-efficacy remained independently associated with the RNL index scores.
Researchers concluded from the study that balance self-efficacy is an independent predictor of
satisfaction with community reintegration in older adults with chronic stroke. Improving balance
self-efficacy may be instrumental in enhancing community reintegration in this population.
11.
Hollstrom K et al12: The objective of this prospective study, undertaken in elderly patients with
stroke undergoing rehabilitation was to determine to what extent fall related self-efficacy
changes overtime, its relationship to objectively assessed functions and activities, and the
predictive capacity of self-efficacy at discharge for activities of daily living 10 months after
stroke. The study comprises 37 patients, aged 66-89 years. Main outcome measurement
instruments were Falls self-efficacy scale (Swedish version), Berg Balance Scale and Functional
independence measure. Significant improvements occurred in all these measures from admission
to discharge, but patients with low self-efficacy at discharge showed less pronounce
improvements than those with high self-efficacy. Falls efficacy scale was closely associated with
all other measures and was a more powerful predictor of activities of daily living than the
observer-based measures of balance. To minimize dependence in activities of daily living
rehabilitation interventions should incorporate self-efficacy enhancement.
12.
Marigold DS et al13: Conducted a randomized controlled trial to determine, the effect of two
different community based group exercise program on functional balance, mobility, postural
reflexes and falls in older adults with chronic stroke. 61 community dwelling elder individuals
with chronic stroke were taken. Participants were randomly assigned to an agility (n=30) or
stretching/weight- shifting (n=31) exercise group. Both groups exercised 3 times a week for 10
weeks. Participants were assessed before, immediately after and 1 month after the intervention
for Berg Balance, Timed up and go, Step reaction time, Activities Specific Balance Confidence
and Nottingham Health Profile. Testing of standing postural reflexes and induced falls evoked by
a translating platform was also performed. In addition, falls in the community were tracked for 1
year from the start of the interventions. Although exercise leads to improvements in all clinical
outcome measures for both groups, the agility group demonstrated greater improvement in step
reaction time and paretic rectus femoris postural reflex onset latency than the stretching/weightshifting group. In addition, the agility group experienced fewer induced falls on the platform.
Group exercise programmes that induced agility or stretching/weight-shifting exercises improve
postural reflexes, functional balance, and mobility and may lead to reduce of falls in older adults
with stroke.
13.
Jocelyn E Harris et al14 : The purpose of this study was to estimate the strength of the
relationship of balance and mobility to falls. 99 participants, community-dwelling people with
chronic stroke were involved in the study. An interview was used to record fall history and
physical performance assessments were used to measure balance(Berg Balance Scale) and
mobility (gait speed). Results showed no differences between subjects who fell once and subjects
who did not fall or between subjects who fell more than once and subjects who did not fall.
Neither balance nor mobility was able to explain falls in people with chronic stroke. Authors
concluded clinicians should be cautious when using the BBS or gait speed to determine fall risk
in this population. Falls occurred frequently while walking; it may be necessary to focus on
reactive balance and environmental interaction when assessing individuals for risk of falls and
devising fall prevention programs for individuals with chronic stroke.
14.
Schimd A et al15 : the purpose of the study was to examine the relationship between multiple
posy stroke mobility variables(gait speed, walking activity, balance, balance self- efficacy ) and
activity and participation; and determine which post stroke variables are independently
associated with activity and participation. The study completed to understand the impact of
mobility on activity and participation in people with chronic stroke. 77 subjects with stroke
greater than 6 months were included in the study. They measured activity and participation with
the validated International Classification of Functioning, Disability and Health Measure of
Participation and Activities. Other variables included gait speed (10 meter walk), walking
capacity(6 min walk), balance (Berg Balance Scale), balance self-efficacy(Activities specific
balance confidence scale) and falls self- efficacy(Modified Falls Self-Efficacy Scale). Only
balance self-efficacy was found to be independently associated with post stroke activity.
15.
Engberg W et al16: the aim of the study was to analyse the correlation between how patients
estimate their perceived confidence in task performance without falling and the objective
assessment of balance made by physiotherapist, and whether the Falls Efficacy Scale FES(S) is
to be recommended for use in patients in acute phase of stroke. Sixty patients divided into two
groups assessed their belief to perform daily life activities without fear of falling using FES(S)
and were assessed by using Berg Balance Scale (BBS) and Timed up and go(TUG) by a
physiotherapist. The correlation between the FES(S) and TUG was moderate to good, but these
two scales consider different aspects and dimensions of balance, ability, and belief and therefore
not interchangeable.
16.
Karin Helstrom et al17: The general aim of this work was to evaluate the outcome of specialised
stroke rehabilitation and to examine the relation between both subjectively perceived and
objectively assessed balance and impairments and some activity limitations. 73 patients younger
than 70 years of age with a first stroke and walking ability were randomised into an intervention
group(walking on a treadmill with body weight support) and a control group(walking on the
ground). The patients in both groups improved their walking velocity, motor function, balance,
self-efficacy and ADL performance. Time points of assessments were: on admission for
rehabilitation, at discharge and 10 months after stroke. Walking training on a treadmill with body
weight support and walking training on the ground were found to be equally effective in the early
rehabilitation. The patients in both groups improved their walking velocity, motor function,
balance, self-efficacy and ADL performance. Authors concluded assessment and treatment of
self-efficacy seems relevant in stroke rehabilitation.
17.
Podsiadlo et al18: this study evaluated a modified, timed version of “Get Up and Go" test in 60
patients referred to a Geriatric Day Hospital (mean age 79.5 years). The patient is observed and
timed while he rises from an arm chair, walks 3 meters, turns, walks back and sits down again.
The results indicate that the time score is (1) reliable (inter-rater and intra-rater); (2) correlates
well with log-transformed scores on the Berg Balance Scale (r= -0.81), gait speed(r= -0.61) and
Barthel index of ADL (r= -0.78);and (3.) appears to predict the patients ability to go outside
alone safely. These data suggest that timed up and go test is reliable and valid test for quantifying
functional mobility.
18.
Steffen TM et al19: The purpose of this study was to provide data for 4 common clinical tests in
a sample of community dwelling older adults. 96 elderly people (61-89 years of age) with
independent functioning performed 4 clinical tests. Data were collected on six minute walk
test(6MW), Berg Balance Scale(BBS) and Timed Up and Go test(TUG) and during comfortable
and fast speed walking (CGS and FGS). Intra class correlation coefficients (ICCs) were used to
determine the test- retest reliability for 6MW, TUG, CGS and FGS measurements. Data were
analysed by gender and age (60-69,70-79 and 80-89 years) cohorts. The 6MW, TUG,CGS and
FGS measurements showed high test-retest reliability
19.
Lynda Elayne et al20: This study provides a replication of falls efficacy scale (FES) and a headto-head comparison with the Activities-specific Balance Confidence (ABC) scale designed to
include a wider continuum of activity difficulty and more detailed item descriptors. Items to the
newly developed 16-item ABC Scale were generated by 15 clinicians and 12 elderly outpatients.
Psychometric testing involved 60 community seniors (aged 65-95) self- classified as either high
or low in mobility confidence according to their perceive need for a walking aid and personal
assistance to ambulate outdoors. Both the FES and ABC scale were found to be internally
consistent and demonstrated good test retest reliability, convergent and criterion validity. While
both scale were able to discriminate between two mobility groups, the ABC scale was a more
efficient discriminator and yielded a wider range of response. Author concluded ABC scale is
more suitable to detect loss of balancing confidence in more highly functioning seniors.
6.3
OBJECTIVE OF THE STUDY:
•
6.4
To analyse the correlation between self-efficacy and balance performance in stroke
survivors.
HYPOTHESIS OF STUDY:
NULL HYPOTHESIS:
•
There is no correlation between self-efficacy and balance performance in stroke survivors.
ALTERNATE HYPOTHESIS:
•
There is correlation between self-efficacy and balance performance in stroke survivors.
7.
MATERIALS AND METHOD :
7.1
SOURCE OF DATA:
Stroke survivors in and around Bangalore .
7.2
METHOD OF COLLECTION OF DATA:
STUDY DESIGN:
Cross-sectional study design.
SAMPLE SIZE :
30 subjects
SAMPLE DESIGN:
Convenient sampling.
MATERIAL USED :
•
Armchair.
•
Stop watch.
•
Measuring tape.
•
3m walkway.
•
Activities specific balance confidence questionnaire.
INCLUSION CRITERIA :
•
•
•
•
•
•
•
•
Gender: both male and female.
Clinical diagnosis of first or recurrent stroke.
Either side of hemiplegia.
Duration of stroke more than 6 months.
Subjects who are able to walk with or without aid.
MMSE score>17. Subjects scoring below 17 on this exam due to presence of dysphasia
were admitted to the study if they expressed an interest in participation.
Subject willing to sign informed consent.
Subject who can comprehend the test procedure.
EXCLUSION CRITERIA :


Neurologic deficit other than stroke.
Any other illness which prevents safe participation of individual in test procedure.
DURATION OF THE STUDY :
•
6 months
7.3
INTERVENTION OF THE STUDY :
Not applicable
OUT COME MEASURES:
30 subjects will be selected on the basis of inclusion, exclusion criteria and MMSE score>17.
All the selected subjects will be assessed for balance self-efficacy using Activities-Specific
Balance confidence (ABC) scale and balance will be tested using Timed up and Go test.
MINI MENTAL STATE EXAMINATON (MMSE):



Individual will respond to a questionnaire comprising of 30 points.
The responses to the question contained in questionnaire will be recorded.
Scores below 17 indicates cognitive impairment.
ACTIVITIES SPECIFIC BALANCE CONFIDENCE SCALE:



Subjects are instructed to rate their level of confidence on an 11 point scale that ranges
from 0% (no confidence) to 100% (complete confidence) in performing 16 different
activities without losing their balance or becoming unsteady.
Each activity involves position change or walking.
A total score out of 100 is computed by taking the average of item scores.
TIMED UP AND GO TEST:


Subjects are instructed to stand up from an armchair, walk 3m,turn and return back to
seated position.
Time taken to complete the task is recorded.
DATA ANALYSIS:
Data collected from Timed up and go test and Activities Specific Balance Confidence Scale
will be used to find out correlation between balance and self-efficacy using Spearman’s corelation test.
ETHICAL CLEARANCE :
Ethical clearance for the study has been obtained from the ethical committee of
Acharya institute of health sciences.
8.
REFERENCES :
1.
Physical rehabilitation Susan B O’Sullivan fifth edition.
2.
Gribble; Hertel (2004). “Effect of Lower-Extremity Fatique on Postural Control”. Archives of
Physical Medicine and Rehabilitation (85): 589-592.
3.
JF Marsden et al: The vestibular control of balance after stroke. J of Neurology Psychiatry.
2005; 76:670-678.
4.
Lubetzki-Vinai, A., & Kartin, D. (2010). “ The effect of balance training on balance
performance in individuals post stroke: a systematic review”. Journal of neurological physical
therapy 34 (3): 127-137.
5.
Clarissa B et al: Abnormal sensory integration affects balance control in hemi-paretic patients
within the first year after stroke. Clinics (SaoPaulo). 2011 December; 66 (12): 2043-2048.
6.
Lousette Mercier et al: impact of motor, Cognitive, and Perceptual Disorders on ability to
perform activities of daily living after stroke. Gerontology and Geriatrics research centre. Sept
2003; 23(4): 567-573.
7.
Patricia Kluding et al: lower- extremity strength difference predict activity limitations in
people with chronic stroke. Dept of physical therapy and rehabilitation science.2006;
45(9):674-80.
8.
Salbach M et al: the effect of a task oriented walking intervention on improving balance selfefficacy post stroke. J AM Geriatric society. 2005;53:576-82.
9.
Weiss et al: High intensity strength training improves strength and functional performance
after stroke. American Journal of physical Medicine and Rehabilitation. July 2000; 79:369376.
10.
Korpersjoek C et al: Self –efficacy and its influence on recovery of patients with stroke: a
systematic review. Journal of Adv Nursing. 2011 Sep; 67(9): 1876-94.
11.
Marco YC Pang et al: Determinants of satisfaction with community reintegration in older
adults with chronic stroke: Role of balance self-efficacy. Dept of rehab sciences.march
12.
Hellstrom K et al: Self efficacy in relation to impairments and activities of daily living
disability in elder persons with stroke.J of Rehab Med.2003;35:202-7.
13.
Marigold DS et al: Exercise leads to faster postural reflexes, improved balance and mobility
and fewer falls in older persons with chronic stroke.J AM Geriatric Society. 2005; 53: 416-23.
14.
Joycelin E Harris et al: Relationship of balance and Mobility to fall incidence in people with
chronic stroke.GF strong rehab centre, Rehab Research Lab.2005; 56(7): 234-39.
15.
Schmid et al. Balance and balance self-efficacy are associated with activity and participation
after stroke: a cross sectional study in people with chronic stroke. Arch Phys Med Rehabil.
2012 jun;93(6); 1101-7
16.
Balance related efficacy compared with balance function in patients with acute stroke.
Physiother Theory Pract.2008 Mar-Apr; 24(20: 105-11. Doi: 10.1080/09593980701389576.
17.
Hellstrom, K. 2002. On self-efficacy and balance after stroke. Acta Universities Upsaliensis.
18.
Podsialda et al: timed Up and Go, a test of basic functional mobility for frail elderly person J
Am Geriatr Soc. 1991 Feb; 39 (2): 142-8.
19.
Steffen tm et al age and gender-related test performance in community dwelling elderly
people: Six-minute walk test, Berg Balance Scale, Timed Up & Go test, and gait speeds. Phys
Ther.2002 Feb;82 (2):128-37
20.
Lynda Elaine et al: Activities specific balance confidence scale. Journal of Gerontology. 1995;
50(A); 1:28-34.
9.
SIGNATURE OF THE CANDIDATE:
10.
REMARKS OF THE GUIDE:
11.
NAME AND DESIGNATION OF :
11.1
GUIDE:
11.2
SIGNATURE:
11.3
CO-GUIDE:(IF ANY):
11.4
SIGNATURE:
11.5
HEAD OF DEPARTMENT:
11.6
SIGNATURE:
12.
REMARKS OF THE CHAIRMAN &PRINCIPAL:
12.2
SIGNATURE: