FCPS Dissertation Research Protocol

Protocol No. (To be

provided by BCPS)

1. Date of

submission

2. Discipline: Physical Medicine and Rehabilitation

3. Name of the

examinee:

D R . M D . N U R U L H O Q U E M I A H

4. Address Registrar, Department of Physical Medicine and Rehabilitation

Chittagong Medical College Hospital ,Chittagong.

Email: nhoquepmr@gmail.com Cell phone # 01712612162

5. Title of the

Dissertation:

“Disability assessment of Hemiplegic patients within 3 weeks of stroke”.

6. Summary: It is a cross-sectional study, will be performed in the Department of Physical

Medicine and Rehabilitation, Chittagong Medical College Hospital (CMCH),

Chittagong on 78 patients. Study period is 6 months. The primary purpose of

this study will be to assess the disability of Hemiplegic patients within 3 weeks

of stroke. All hemiplegic patients attending the outpatient department (OPD)

referred from the different wards of CMCH and from general practitioners

outside the hospital will be the population of this study. Participants will be

selected by consecutive sampling who meets the selection criteria. Proper

history will be taken. Impairments and risk factors will be assessed. The

relation of stroke with age, gender, occupation, educational level will be

assessed. Disability will be assessed by using the Barthel index (BI) and

compared between hemorrhagic and ischemic stroke patients.

Key words: Cross-sectional study, Hemiplegic, Impairments,. Disability,

Barthel index

7. Place of

study:

Department of Physical Medicine and Rehabilitation,

Chittagong Medical College Hospital (CMCH), Chittagong.

8. Study period: 1st October 2012 to 31st March 2013.

9. Study design: Cross-sectional study.

10. Introduction: Stroke is defined by the World Health Organization as a clinical syndrome

2

consisting of ‘rapidly developing clinical signs of focal (at times global)

disturbance of cerebral function, lasting more than 24 hours or leading to death

with no apparent cause other than that of vascular origin’.1 it includes patients

presenting clinical signs and symptoms suggestive of subarachnoid

hemorrhage, intracerebral hemorrhage or cerebral ischemic necrosis. It does

not include transient cerebral ischemia or stroke events in cases of blood

disease (e.g. leukemia, polycythaemia Vera), brain tumor or brain metastases.

Secondary stroke caused by trauma should also be excluded 2.

Strokes can be divided into two broad categories according to the nature of the

cerebral lesion: infarcts and hemorrhages. A cerebral infarct is the result of

temporary or permanent occlusion of a feeding artery, extra cranially or

intracranially, or (more rarely) of venous thrombosis.3 A spontaneous cerebral

hemorrhage is due to the rupture of an abnormal artery (aneurysm or AVM) or

arteriole in the brain parenchyma. Often it is difficult to distinguish clinically

between cerebral infarction and cerebral hemorrhage, and their relative

occurrence varies from country to country.3 90% of strokes are ischemic,

caused by either embolic or thrombotic clots to the central nervous system. 

10% are hemorrhagic, manifesting as either intracerebral or subarachnoid

bleeds 4.  Most common causes of ischemic strokes are atheromatous diseases

in medium and large vessels, cardioembolic conditions such as atrial

fibrillation, and small vessel ischemic disease.  Other diseases that damage

blood vessels (hypertension, diabetes, dyslipidemia) and lifestyle issues

(tobacco use, cocaine, heroin, or amphetamine use) are also implicated.  The

location of the stroke subsequently defines the types of deficits a person will

experience4.

Symptoms of stroke include numbness, weakness or paralysis, slurred speech,

blurred vision, confusion and severe headache.3 Common impairments of

stroke are Motor weakness (Right hemiparesis, Left hemiparesis, Bilateral

hemiparesis), Sensory deficits, Dysarthria, Aphasia, Cognitive deficits,

Visuoperceptual deficits, Depression, Bladder incontinence, Dysphagia and

Hemianopsia4. The most common movement impairment is hemiplegia, which

affects roughly 80% of stroke patients, causing weakness or the inability to

3

move one side of the body. Weakness can impact arms, hands, legs and facial

muscles. Those impacted may have trouble performing everyday activities

such as eating, dressing, using the bathroom and grabbing objects.5 The use of

computed tomography (CT scans) makes a diagnosis more reliable and adds

important information about the nature, extent, and location of lesions.3

The overall age-standardized incidence of stroke in people aged ≥55 years

ranged from 4·2 to 11·7 per 1000 person-years. Proportions ranged from 67%

to 81% for ischemic stroke, 7% to 20% for primary intracerebral hemorrhage,

1% to 7% for subarachnoid hemorrhage, and 2% to 15% for undetermined

type6. In Bangladesh a study shown that 67.9% of strokes are ischemic and

32.1% are hemorrhagic25. Bangladeshi male populations in rural areas are

found to have stroke more than urban people.7 Stroke  is  the  third  leading 

cause  of  death  and  the  first  cause  of  disability,  in  the 

developed countries.8 In Bangladesh disability prevalence from World Health

Survey, 2002–2004 is 31.9%9. Severe disability at Hospital discharge found in

ischemic stroke survivors10.

Risk factors for a first stroke were classified according to their potential for

modification (non-modifiable, modifiable, or potentially modifiable) and strength

of evidence (well-documented or less well-documented) 11.Non-modifiable risk

factors include age, sex, low birth weight, race/ ethnicity and genetic factors.

Well-documented and modifiable risk factors include hypertension, exposure to

cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions,

dyslipidemia, carotid artery stenosis, sickle-cell disease, postmenopausal

hormone therapy, poor diet, physical inactivity and obesity and central body fat

distribution11.

The World Health Organization has recently proposed a new International

Classification of Functioning, Disability and Health that defines disability is an

umbrella term for impairments, activity limitations, and participation restrictions.

An impairment is a problem in body function or structure; an activity limitation is

a difficulty encountered by an individual in executing a task or action; while a

participation restriction is a problem experienced by an individual in

involvement in life situations12,24. According to 1980 definition of WHO Disability

4

defined as any restriction or lack resulting from an impairment of the ability to

perform an activity in the manner or within the range considered normal for a

human being14,23.Thus disability is a complex phenomenon, reflecting an

interaction between features of a person’s body and features of the society in

which he or she lives 12,13.

The most commonly used scales to rate outcomes (disability) after stroke are

the BI, the Functional Independence Measure (FIM), Fugl-Myer Scale, the Katz

index of Activities of Daily Living (ADL), the Frenchay Activities Index, and the

Pulses Profile . In addition the Mini Mental State Examination (MMSE) is used

to measure cognitive outcomes after stroke. Presently BI is the most widely

used clinical rating instrument to assess ADLs and stroke related disability in

clinical trials and epidemiologic studies on stroke 15.

Post-stroke rehabilitation should begin as soon as the patient is clinically

stable16 (afebrile, with stable vital signs, without important changes in medical

conditions or required changes in treatments within 48 hours prior to the

interview, with neurological deficits unchanged or improving, being able to take

adequate nutrition orally or having an enteral route for nutrition and hydration

established)17. Rehabilitation treatment should be begun within 20 days as is

associated with a 6-times-greater probability of high response compared with

delayed treatment18. Recovery of ADL function tends to occur more slowly, but

at 12.5 weeks post- stroke, optimal recovery is achieved by most patients.

Patients with the most severe initial functional disability, best functional

recovery is achieved within the first 5 months.16

11. Stroke is one of the most important causes of long hospital admission and long

term disability19 especially in underdeveloped countries like Bangladesh, where

health support system including rehabilitation is not expectedly available20. It

causes major financial burden on medical health care but also causes extensive

human and family suffering, prolong functional disability and associated

mortality19. Every year a significant number of stroke survivors are left with

residual disabilities varying from mild to severe form20. In the hospital population,

patients after hemorrhagic stroke generally have more severe neurological

impairments during the acute phase than patients after ischemic stroke and the

5

Rationale

of the

study:

mortality rate from hemorrhagic stroke is higher than that from ischemic stroke21.

Furthermore, severe disability at Hospital discharge found in ischemic stroke

survivors21, 22. From the perspective of rehabilitation medicine, it is more

important to know what differences are in terms of functional recovery as well as

disability are present in stroke patients. It is worthwhile for our country to find out

the disability level among the stroke patients for appropriate rehabilitation

management.

12. Hypothesis Disability is more in hemiplegic patients of ischemic stroke than hemorrhagic

stroke.

13. Objectives General:

To find out the disability of Hemiplegic patients within 3 weeks of stroke.

Specific:

1. To assess the disability in hemiplegic ischemic stroke patients.

2. To assess the disability in hemiplegic hemorrhagic stroke patients.

3. To compare the level of disability of hemiplegic patients between ischemic &

hemorrhagic stroke.

14 Materials

and methods

a. Main Outcome

Variables to be

studied:

1. Hemiplegia.

2. Hemorrhagic stroke.

3. Ischaemic stroke.

4. Impairments.

5. Disability (Barthel Index Score).

b. study population: All patients with hemiplegia attending in the

department of PM&R, CMCH

c. Sample size: 39 in each group.

The Sample size was determined by following formula

n=⟦Z β√ {P1 (1−P1 )+P2 (1−P2 )}+Zα√2P (1−P)⟧2

(P¿¿1−P2)2¿

Where,

6

n= The desired sample size

Zβ=1.96at 5% level of significance

Zα=1.28at 90% power

P1 =Population proportion of ischemic stroke

= 67.9%

= 0.67

P2 = Population proportion of hemorrhagic stroke

= 32.1%

= 0.32

P= (P1 + P2)/2

Therefore, P=(0.67+0.32)/2

= 0.495

Putting the values in the above equation the sample size,

n=⟦1.96√ {0.67 (1−0.67 )+0.32 (1−0.32 ) }+1.28√2(0.495)(1−0.495)⟧2

¿¿

= 39.00

Therefore, n= 39

So, 78 subjects will be included; 39 will be in each group.

d. Screening

method:

History and clinical examination

e. Sampling

method:

Consecutive sampling

f. Selection of the

patient:

Inclusion criteria:

Patients with hemiplegia due to stroke

within 20-85 years of age.

First episode of stroke.

Duration of stroke < 3weeks.

7

Exclusion criteria:

Seriously co-morbid patients (Like

unconsciousness, recent MI).

Patients having Subarachnoid

hemorrhage.

g. Operational

definitions of

variables:

Operational procedure: On fulfillment on inclusion and

exclusion criteria and after taking informed written

consent, a through history and clinical examination will be

done. All information will be recorded in the data

collection sheet. Disability level will be measured by using

the Barthel index (BI). The BI is considered a reliable

disability scale for stroke patients. It has high inter-rater

reliability, internal consistency, and validity. The index

will be completed through direct observation and self-

report. The items (ADLs) are related to self-care (feeding,

grooming, bathing, dressing, bowel and bladder care, and

toilet use) and mobility (ambulation, transfers, and stair

climbing). (Appendix-05). The response categories of

disability in an activity were defined and rated in scale

steps (0, 5), (0, 5, 10), (0, 5, 10, 15) dependent on the

item. An overall score is formed by adding scores on

each rating. Scores of 0-20 indicate "total" dependency,

21-60 indicate "severe" dependency, 61-90 indicate

"moderate" dependency, and 91-99 indicates slight"

dependency. Then disability scores of ischemic and

hemorrhagic stroke patients will be compared.

h. Flow-chart

showing the

sequence of tasks

Appendix-03

i. Procedures of

preparing the

Patients with hemiplegia will be allocated to two equal

groups: ischemic stroke and hemorrhagic stroke. No

8

material and

grouping

randomization will be applied. All data will be recorded

systematically in Semi-structured questionnaire.

j. Nature of

controls:

Not applicable

k. Randomization

and blinding:

Not applicable

l. Equipment to be

used:

Weight machine, measuring tape, computer, calculator

m. Procedures of

collecting data:

Patients with Hemiplegia within 3 weeks of stroke

attending the OPD of PM&R, CMCH will be registered by

junior post graduate trainee doctors. Then registered

patients will be referred to the investigator. Written consent

will be taken from the patient. Detailed history will be taken

and clinical examination will be done systematically. A pre-

set data form will be filled up for every patient. Patients

with recurrent attack, seriously co-morbid patients,

subarachnoid hemorrhage were excluded to obtain a more

homogenous sample. Information on certain

sociodemographic variables will be obtained from the

patients and/or their caregivers. Impairments during

disability assessment, Non-modifiable risk factors, well-

documented and modifiable risk factors will be recorded.

Area of involvement and type of stroke by CT will also be

recorded.

n. Professional assistance from expert:

Assistance will be taken regarding research methodology,

data analysis and collecting information from:

1. Professor (Dr.) Aminuddin A Khan. FCPS

Head, Department of PM&R, CMCH.

2. Dr. Md. Shaik Ahmad FCPS

Associate professor, Department of PM&R,CMCH.

3. Dr. Md. Maidul Islam FCPS, MS.

9

Assistant professor, Department of PM&R, CMCH.

o. Procedure of data analysis

Data will be analyzed by SPSS (Statistical Package for

Social Sciences) 15 version. Descriptive statistics will be

analyzed to calculate the frequency, percentage, mean

and standard deviation of observed data. Unpaired t test

will be dne. Chi-square or Fisher’s Exact Probability test

will be applied in order to test the hypothesis for

comparison of data presented in categorical scale. Level

of significance will be set at 0.05 and p < 0.05 will be

considered significant. Important tables, charts and

diagrams will be prepared on the basis of findings relevant

to risk factors, impairments and disability.

p. Quality

assurance

strategy:

It is extremely important that data collection will be of good

quality. In any critical situation expert opinion will be taken

from supervisor and professors of different disciplines.

Data collection sheet will be periodically checked by the

supervisor of the study.

q. Work schedule Appendix-2

15. Ethical

implications

Every respondent will be informed verbally about the design, nature and purpose

of the study according to Helsinki Declaration for Medical Research Involving

Human Subjects 1964. A written consent (Appendix-1) will be taken from the

respondent. There is no involvement of privacy and no chance of physical and

social risks. All the records will be kept under lock & key. Every patient has the

opportunity to receive or withdraw himself/herself from the study at any time.

16. Total Budget1. Personnel cost: Statistician honorarium 5000 BDT

2. Field expenses NA

3. Office items. Files (20), White papers (500), 20,000

10

Pen (10), Calculator (1), Some pencils and

others

4. Patient costs NA

5. Travel cost NA

6. Printing and reproduction, photocopy,

binding

40,000

7. Contractual services (lab) NA

8. Administrative overhead NA

9. Miscellaneous 5,000

10. Total budget 65,000 BDT

17. Source of

funding

Self-funding

18. Facilities

available at

the place of

study

Chittagong Medical College Hospital is a very renowned and tertiary care

hospital. A large number of patients over the Out-patient department of Physical

Medicine and Rehabilitation is there. It is well equipped and available with

modern treatment options and all necessary pathological and imaging facilities.

19. Other

facilities

needed

Referring the stroke patients from department of neuromedicine and medicine.

20. Disseminatio

n and use of

findings

I long for publishing this study in a quality journal and disseminate the findings. I

hope my findings will play a good role in the field of rehabilitation science and

pave the way of future research.

21. References 1. Hatano S, Experience from a multicentre stroke register: a preliminary report. Bulletin of the World Health Organisation 1976, 54:541–53.

2. MONICA Manual, Part IV: Event Registration. Section 2: Stroke event registration data component. Office of Cardiovascular Diseases, World Health Organization; 1999 [cited 16 Oct 2008] [internet] Available from : http://www.ktl.fi/publications/monica/manual/part4/iv-2.htm.

3. Goldstein M, Barnett HJM, Orgogozo JM, Sartorius N, Symon L, Vereshchagin NV et al. Stroke--1989. Recommendations on stroke prevention, diagnosis, and therapy. Report of the WHO Task Force on Stroke and other Cerebrovascular Disorders. Stroke. 1989;20:1407-1431

4. Drača S. Functional recovery of patients after the first-ever unilateral

11

ischemic or hemorrhagic stroke. Curr top neurol psychiatr relat discip.2012;XX:1-2.

5. National stroke association. Paralysis August 2012. Available from: http://www.stroke.org/site/PageServer?pagename=hemiparesis

6. Feigin VL, Lawes CMM, Bennett DA, Anderson CS. Stroke epidemiology: a review of population based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurology 2003;2:43–53

7. Mohammad QD, Habib M, Hoque A, Alam B, Haque B, Hossain S et al. Prevalence of stroke above forty years. Mymensingh Med J.  2011;20(4):640-4.

8. Sulter G, Steen C and Keyser JD. Use of the Barthel Index and Modified Rankin Scale in acute Stroke Trials. Stroke 1999, 30:1538-1541

9. World report on disability 2011 (World Health Organization, World Bank). Available from: http://whqlibdoc.who.int/publications/2011/9789240685215_eng.pdf

10.World report on disability : World Health Organization, World bank

[internet] 2011. available from: http://whqlibdoc.who.int/publications/2011/9789240685215_eng.pdf

11. Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, et al. Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline. Circulation 2006;113(24):873–923

12. Disability: World Health Organization [internet] 2012 . Available from: http://www.who.int/topics/disabilities/en/

12

13.World report on disability : World Health Organization, World bank

[internet] 2011. available from: http://whqlibdoc.who.int/publications/2011/9789240685215_eng.pdf

14. Schepers VPM, Ketelaar M, Visser-Meily AJM, Groot VD, Twisk JWR, Lindeman E. Functional recovery differs between ischaemic and haemorrhagic stroke patients. J Rehabil Med 2008;40:487–489

15. Mohr JP, Wolf PA, Grotta JC, Moskowitz MA, Mayberg MR, Kummer R V,Stroke: pathophysiology, diagnosis and management 5th edition; Philadelphia: Saunders, an imprint of Elsevier Inc. 2011:321.

16. Saxena SK, Koh GCH, Ng TP, Fong NP, Yong D. Determinants of length of stay during post-stroke rehabilitation in community hospitals. Singapore Med J 2007;48(5):400

17. Salter K, Jutai J, Hartley M, Foley N, Bhogal S, Bayona N et al. Impact of early vs delayed admission to rehabilitation on functional outcomes in persons with stroke. J Rehabil Med 2006;38:113-117

18. Paolucci S, Antonucci G, Grasso MG, Bragoni M, Coiro P, Angelis DD et al.Functional Outcome of Ischemic and Hemorrhagic Stroke Patients After Inpatient Rehabilitation :A Matched Comparison. Stroke. 2003; 34:2861-2865.

19. Qari FA. Profile of stroke in a teaching university hospital in the western region. Saudi Medical Journal 2000;21(11):1030-1033

20. Nessa J, Khaleque MA, Begum S, Ahmed AH, Islam MS, Afsan M. Rehabilitation of Stroke Patients - Effects of Early Intervention of Physical Therapy on Functional Outcome Bangladesh. Journal of Anatomy January 2009,7(1):62-67

21. Karkouli G, Kapadohos T. Functional disability of ischemic stroke patients. ‘To Vima tou Asklipiou’ 2010;09(2):144-157

22. Paciaroni M, Arnold P, Van Melle G, Bogousslavsky J.Severe disability at Hospital discharge in ischemic stroke survivors. Eur Neurol. 2000;43(1):30-4.

13

23. Braddom R, Chan L, Harrast MA, Kowalske KJ, Matthews DJ, Ragnarsson KT et al. Physical Medicine and Rehabilitation 4th edition, Philadelphia: Saunders, an imprint of Elsevier Inc. 2011:3-40

24. Goljar N, Burger H, Vidmar G, Leonardi M, Marinček Č, Measuring patterns of disability using the international classification of functioning, disability and health in the post-acute stroke rehabilitation setting. J Rehabil Med 2011:43:590–601.

Rahman MS, Shakoor MA, Nahar S, Jahan KS, Uddin MT, Moyeenuzzaman M et al. Stroke pattern in a private hospital and its association with two modifiable risk factors- Hypertension and Diabetes Mellitus. Bangladesh Journal of Neuroscience 2006:22(1):15-20

2

22

I solemnly pledge that this research protocol shall be implemented in accordance with

the relevant ordinance of BCPS and funding agencies as and when it may be applicable.

14

I hereby declare that no part of the proposed research has been used in any

thesis/dissertation in partial fulfillment of any degree/fellowship or any publication.

I also understand that the BCPS reserves the right to accepting or rejecting this protocol.

--------------------------- --------------------------------------

Date Signature of the investigator

Signature of the

supervisor:

Name: Prof. (Dr.) Aminuddin A. Khan

FCPS (Physical Medicine & Rehabilitation)

Designation: Professor & Head

Department of Physical Medicine & Rehabilitation

Chittagong Medical College Hospital, Chittagong And

Vice Principal

Chittagong Medical College, Chittagong.

Seal:

Appendix-01

15

Informed written consent

1. Protocol ID:

2. Patient’s name & ID:

3. Title of the study: “Disability assessment of Hemiplegic patients within 3 weeks of stroke”.

4. Investigator’s name: Dr. Md. Nurul Hoque Miah

5. Institution: Department of Physical Medicine & Rehabilitation, Chittagong Medical College

Hospital, Chittagong

6. Purpose of the study: a. To assess the impairments in hemiplegic stroke patients.

b. To compare the level of disability of hemiplegic patients between ischemic & hemorrhagic

stroke.

7. Selection of the participant: Patients will be attended in the Department of Physical Medicine

& Rehabilitation, Chittagong Medical College Hospital, Chittagong

8. Expectation form and involvement of the participant: You will be asked some questions

according to a semi-structured questionnaire that is about your disease. I expect the information

given by you will all be correct.

9. Risk and benefit: There is usually no risk.

10. Privacy, anonymity and confidentiality: We ensure that all information provided by you will be

kept confidential and will be used for the purpose of the study only.

11. Right to withdraw: You are free to take part or withdraw yourself from the study at any time for

any reason what so ever. If you agree to participate in the study, please submit by signing

below.

Thank you for your co-operation

--------------------------------------------Signature or left thumb impressionof participant

--------------------------------------------Signature or left thumb impressionof attendant

----------------------------------Signature of investigator

Appendix-02

16

Time table /work schedule of the dissertation

Name of the work

July-12 August-12 September-12

October12 November12 December-12 January-13 February-13 March-13

Selection of the topic

Literature review

Selection of the study area

Determination of sample

Development of instrument

Submission for finalizing

Data collection

Data compilation & analysis

Report writing

Draft report submission

Finalizing, Typing & binding

Final report submission

17

APPENDIX-03

Flow-chart showing the sequence of tasks: “Disability assessment of Hemiplegic patients

within 3 weeks of stroke”.

CT Scan CT Scan

18

Hemiplegic patients within 3 weeks of stroke

Patient with H/O recurrent

attack will be excluded

Patient with <20 and >85 yrs will be excluded

Total participants under study

Ischemic stroke Hemorrhagic stroke

Hemiplegic patients of different ages

Subarachnoid hemorrhage stroke will be excluded

Seriously co-morbid patients will be excluded

Disability scoring using Barthel disability index.

Assessment of impairments

Assessment of risk factors

Recording of the sociodemographic variables

Disability scoring using Barthel disability index.

APPENDIX-04:

DATA COLLECTION SHEET

Department of Physical Medicine and Rehabilitation

Chittagong Medical College Hospital, Chittagong.

Title: “Disability assessment of Hemiplegic patients within 3 weeks of stroke”.

1. Code no.: Registration no.: Date:

2. Name: Contact no. with mailing address:

3. Age (in Years):

4. Gender: Male= 1 / Female= 2

5. Education: Illiterate=1 / primary=2 / secondary=3 / higher secondary =4 / graduate=5 /

Postgraduate=6 .

6. Occupation: House wife=1 / Service=2 / Farmer=3 / Businessman=4 / Laborer=5 /

unemployed=6 / retired=7 / others=8.

7. Residence: Urban=1 / Semi-urban=2 / Rural=3.

8. Height (in m):

9. Weight (in kg):

10. Number of days from stroke onset:

11. Hemiplegia: yes=1, no=2

12. Hemiplegia side: Right=1/ left=2

13. Spasticity: yes=1, no=2

14. Speech abnormality yes=1, no=2

15. Incontinence of bowel : yes=1, no=2

16. Incontinence of bladder: yes=1, no=2

17. Dysphagia: yes=1, no=2

18. Visual field defect : yes=1, no=2

19. Sensory involvement : yes=1, no=2

20. Apraxia : yes=1, no=2

21. Hemi neglect syndrome=1, no=2

22. Other impairmens:

19

23. Risk factors(modifiable): Hypertension =1/ Hyperlipidemia=2 /Diabetes mellitus =3/

Ischemic heart disease =4/ Valvular heart disease =5/ Smoking =6/ Physical inactivity=7/

Stress=8 /Prior TIA=9/ postmenopausal hormone therapy=10/ Others=11.

24. Risk factors(non-modifiable): Age (after 55 years)=12/ positive family history=13/H/O

previous stroke or heart attack=14 /Gender (men)=15

25. CT findings: Supratentorial=1/ Infratentorial=2

26. The Barthel Disability Index scoring:

"total" dependency(0-20)

"severe" dependency(21-60)

"moderate" dependency (61-90)

"slight" dependency (91-99)

First contact (within 3 weeks of stroke)

20

APPENDIX 05

THE BARTHEL DISABILITY INDEX

FEEDING 0 = unable5 = needs help cutting, spreading butter, etc., or requires modified diet10 = independent BATHING 0 = dependent5 = independent (or in shower) GROOMING 0 = needs to help with personal care5 = independent face/hair/teeth/shaving (implements provided)

DRESSING 0 = dependent5 = needs help but can do about half unaided10 = independent (including buttons, zips, laces, etc.) BOWEL 0 = incontinent (or needs to be given enemas)5 = occasional accident10 = continent

BLADDER 0 = incontinent, or catheterized and unable to manage alone5 = occasional accident10 = continent TOILET USE 0 = dependent5 = needs some help, but can do something alone10 = independent (on and off, dressing, wiping)

TRANSFERS (BED TO CHAIR AND BACK 0 = unable, no sitting balance5 = major help (one or two people, physical), can sit10 = minor help (verbal or physical)15 = independent

MOBILITY (ON LEVEL SURFACES) 0 = immobile or < 50 yards5 = wheelchair independent, including corners, > 50 yards10 = walks with help of one person (verbal or physical) > 50 yards15 = independent (but may use any aid; for example, stick) > 50 yards

21

STAIRS 0 = unable5 = needs help (verbal, physical, carrying aid)10 = independent TOTAL (0–100):

Administration and Scoring:

The response categories of disability in an activity were defined and rated in scale steps (0, 5),

(0, 5, 10), (0, 5, 10, 15) dependent on the item25.

An overall score is formed by adding scores on each rating26. Scores range from 0 to 100, in

steps of 5, with higher scores indicating greater independence. The maximal score is 100 in 5-

point increments, indicating that the patient is fully independent in physical functioning. The

lowest score is 0, representing a totally dependent bedridden state16,25.

Interpretation of scores:

Several authors have proposed guidelines for interpreting Barthel scores. Shah et al.

suggested that scores of 0-20 indicate "total" dependency, 21-60 indicate "severe" dependency,

61-90 indicate "moderate" dependency, and 91-99 indicates slight" dependency25.

22