Association between Patients with Spatial Neglect after Stroke and Their Shoulder Pain - Article Example

Reliability of an Association between Patients with Spatial Neglect after Stroke and their Shoulder Pain Abstract The study attempts to find the relation between post-stroke patients with spatial neglect and shoulder pain. The major motivation behind conducting this study is to help in the rehabilitation of post-stroke patients with spatial neglect suffering from shoulder pain. Due to the cognitive disorder of spatial neglect, shoulder pain in post-stroke patients may become critical and hinder the rehabilitation of the patients as well. Thus, the results from this study would help in managing and treating shoulder pain in such patients. In order to determine the relation, five post-stroke patients with shoulder pain were studied and spatial neglect was measured using tests such Albert’s Test and Bells Test. Thereafter, the patients underwent Visual Analogue Scale (VAS) test to determine shoulder pain. The Chi-square analysis was used to determine the relation between post-stroke shoulder pain and spatial neglect. The study found that sixty per cent of the participants were suffering from spatial neglect. However, only one participant with spatial neglect was found to be suffering with shoulder pain. Meanwhile, the chi-square analysis revealed that spatial neglect and shoulder pain are statistically independent. Therefore, it might be concluded statistically that there is no relation between spatial neglect and shoulder pain in post-stroke patients. Chapter 1: Introduction Research indicates shoulder pain in post-stroke patients often results in disrupting the rehabilitation program and causing mental and physical discomfort to the patient (English, Hillier, Stiller & Warden-Flood, 2007). Further, shoulder pain may result into serious disabilities such as paralysis and spasticity and therefore, should be given due importance (Lindgren, Jonsson, Norrving & Lindgren, 2007), however, it is interesting to note that assessment of shoulder pain in post-stroke patients has not been evaluated definitively, especially in patients with spatial neglect (Turner-Stokes & Jackson, 2002). It is often found to be difficult and time consuming to identify the cause or nature of shoulder pain in post-stroke patients. Therefore, most physicians attribute shoulder pain to lack of movement (Turner-Stokes & Jackson, 2002; Lo et al., 2003), long-term hospitalisation (Roy, Sands, & Hill, 1994) or even depression (Gamble et al., 2000). However, the diagnosis may become complicated in case the patient suffers from behavioural syndrome of spatial neglect, which makes it difficult for the patient to express his or her problems properly to the physician. Spatial neglect will lead to patient’s inability to report shoulder pain, which if left untreated may result into permanent disabilities (Turner-Stokes & Jackson, 2002). Thus, the serious implication of the behavioural syndrome on the general wellness of the patient emphasises the importance of conducting this study to find out the relation between post-stroke patients with shoulder pain and spatial neglect. Further, secondary research has revealed that minimal studies have been conducted so far to establish the link between shoulder pain and spatial neglect (Turner-Stokes & Jackson, 2002). Although there have been various studies on shoulder pain in patients with hemiplegia (Wanklyn, 1996) and the general cause of shoulder pain in post-stroke patients, not much studies have been found that focused on shoulder pain in post-stroke patients with spatial neglect. One such study that focused on finding relation between neglect and shoulder pain was conducted by De Courval et al. (1990) on 94 hemiplegic patients. The aim of the study was to discover the role of hemi neglect in shoulder pain. The results indicated that 45 patients had shoulder pain and 24 patients had hemi neglect. However, De Courval et al. were unable to find any association between shoulder pain and hemi neglect. Although, De Courval et al were able to establish the importance of conducting a study that focused on finding the relation between shoulder pain and hemi neglect, they were unable to find any association between the two variables. Thus, through this study, the researcher would carry forward from where De Courval left and would try to find the relation between shoulder pain and spatial neglect. Further, De Courval et al. conducted the study using two groups, including a control group and compared the results between the two groups by studying various variables such as age, gender, diseases such as diabetes, arthritis and health conditions such as heart failure and cardiac ischemia. It might be possible that due to so many variables, the authors were unable to establish the relation between shoulder pain and hemi neglect. Therefore, in this study, it was decided not to include any control group or too many variables while conducting the analysis. The central aim of the study was to find the relation between spatial neglect and shoulder pain in post-stroke patients, therefore, other variables were not considered for analysis. It was expected that such a method would result into giving a different result than that of De Courval’s study. The results from the study would greatly help in preventing and managing shoulder pain in such patients. It would also reduce the rehabilitation period and resources spent on treating these patients. Finally, in order to reduce the healthcare cost and services efforts, it is important to identify shoulder pain in post-stroke patients with spatial neglect at the onset and provide the right treatment. Chapter 2: Methodology 2.1: Research Design The main objective of the study was to find the relation between post-stroke shoulder pain in patients and spatial neglect. In order to determine the relation, five post-stroke patients with shoulder pain were studied and spatial neglect was measured using tests such as Visual Analogue Scale (VAS), Albert’s Test and Bells Test. VAS is considered to be a reliable measurement instrument that provides the output regarding attitudes or characteristics which need to be measured across a range and it might not be possible to measure such range directly. For instance, it might be difficult to measure the correct amount of pain felt by a person, as a patient might feel a range of pain varying from extreme amount to none. Further, most patient indicates that pain appears to be continuous and cannot be measured by bucketing it as mild or extreme at one go. Instead pain appears to be constant and follows a range (Wewers & Lowe, 1990). As it is tough to measure accurate amount of pain felt by a patient, it was decided to use VAS, which is considered to be a fairly reliable means of measuring such un-quantifiable aspects. While VAS was conducted to find out about the intensity of shoulder pain in the selected patients, Albert's Test and Bells Test were used to detect spatial neglect in post-stroke patients. Albert’s Test is a type of screening test wherein the post-stroke patients are asked to cross out various lines drawn across a paper in a random order. If a patient suffers from spatial neglect, he or she would leave the lines uncrossed on a single side of the page . This would indicate that the patient is suffering from motor deficit (Albert, 1973). Similarly, Bells Test is also conducted to assess visual neglect through various qualitative and quantitative tests (Gauthier, Dehaut & Joanette, 1989). Spatial neglect is mostly being measured through line bisection or cancellation tests however, a recent study has shown that these tests might not be the most reliable ones as some patients have shown varying results using these two tests to find the occurrence of spatial neglect. On the other hand, the same study found that Bells Test provided far more superior results and only missed 6 per cent of the cases analysed. Therefore, it is believed that Albert’s and Bells Tests are much more reliable tests for the detection of spatial neglect (Ferber & Karnath, 2001). Further, the information was collated and the data was analysed using chi square. The results helped in identifying the underlying problems in each patient easily as well as understanding whether a relation existed between shoulder pain in post-stroke patients with spatial neglect. The entire study was conducted within eight weeks on five patients with stroke diagnosis after 72 hours of their hospital admission. The primary outcome was measured using VAS on every second day to find out stiffness and pain in the shoulder. The secondary outcome was measured by analysing the data using chi square. However, before undertaking the test, the patients were asked to sign consent forms and were given a brochure containing all the required information about the study. 2.2: Sampling Strategy For this study five patients with stroke diagnosis who were hospitalised for more than 72 hours were considered. Patients who were 18 years and above and complained of shoulder pain on a regular basis were considered for this study. The patients who had history of cardiac problems and hemodynamic instability were excluded from the study. Further, patients who suffered from uncontrolled seizures and required constant vigilance were also not considered. The intended patients were first approached individually and were told about the study in detail. It was during this meeting, formal consents were signed from the patient. These patients were also given a participant information sheet and consent form to sign. Consents were also taken for access to identified medical or other health records as well as for direct participation of persons in research. Patients were also given the option to withdraw from the study anytime on a voluntary basis. However, all the patients completed the study. 2.3: Discussion of Study of Population/Sample The entire study was conducted over a period of eight weeks at the Jhon hospital ward (A) on five post-stroke patients suffering from shoulder pain. The study included conducting VAS to measure shoulder pain in the selected patients. However, while undertaking all these examinations and other tests, the researcher was careful to monitor any adverse effects shown by the patients. The patients were also assured of data confidentiality. Utmost care was taken to maintain the confidentiality for both identifying and non-identifying information particularly information contributed by members of focus groups. This was done by segregating the information in separate folders. Participants were informed of their right to check, withdraw or limit information, including their right to refuse to answer particular questions. The participants were treated in a culturally sensitive manner, and special care was taken to deal with participants from non-English speaking background. 2.4: Data Collection Procedures The initial data was conducted through a screening process by identifying post-stroke patients who were admitted to the rehabilitation ward for 72 hours or more. This screening considered three main tests: Albert’s Test and Bells Test. After these tests, regular examinations of shoulder pain were conducted using VAS. VAS was conducted every second day to monitor stiffness and pain in the shoulder. 2.5: Statistical Procedures Used This study would be a blind, cross-sectional study. Two researchers would be involved in this study. One of them will examine shoulder pain. The other one will examine the presence of spatial neglect. The two researchers will be blind to the other results. All data will be entered and processed by a third researcher. This would help to identify the underlying problems and improve understanding of the best practices to be followed while treating post-stroke patients with shoulder pain Chapter 3: Finding & Results 3.1: Assumption Testing In order to conduct a chi-square, non-parametric statistical analysis, it is important to test certain underlying assumptions as well. For this study, random sampling and independence of observation were used before conducting the chi-square analysis, so that the data selected should be without any bias. Random sampling: In order to collect un-biased data, it is important to collect random sample, rather than conducting research on targeted patients. For this study, any post-stroke patient, over the age of 18 years, who has been admitted for more than 72 hours, was selected. Independence of observation: Every participant in this study was observed independently and therefore, the subjects presented differing responses to the study, which helped in identifying the trend in the study. 3.2: Descriptive Statistics In order to find out the relation between spatial neglect and shoulder pain in post-stroke patients chi-square tests were conducted. The tests provided the following frequencies: Table 1: Spatial Neglect Observed N Expected N Residual No 2 2.5 -.5 Yes 3 2.5 .5 Total 5 Table 2: Shoulder Pain Observed N Expected N Residual N0 2 2.5 -.5 Yes 3 2.5 .5 Total 5 Table 1 indicates that there were three patients who reported spatial neglect while two were observed without spatial neglect. Similarly, Table 2 indicates that three patients observed shoulder pains, while two did not record any shoulder pain. Table 3: Detailed data sample Variables I.D Age Gender Stroke Type Number of days since last episodes Spatial neglect Spatial neglect Side Shoulder pain Shoulder pain Side FIM in Hand dominant 1 80 Male Left Hemorrhagic 4 Yes Right No Not applicable 43 Right 2 77 Female Right Hemorrhagic 5 No Not applicable Yes Moderate (VAS=5) Right 65 Right 3 69 Male Right Ischemic 3 No Not applicable Yes Mild (VAS=3) Left 44 Right 4 76 Male Left Ischemic 3 Yes Right No Not applicable 18 Right 5 73 Male Left Ischemic 3 Yes Right Yes Moderate (VAS=4) Right 65 Right The above table indicates that five patients in the age group of 73-80 were studied. Out of the five patients, four were male, while a single female patient participated. Figure 1: Stroke type Around 40 per cent participants reported left ischemic stroke type with the rest suffering from left hemorrhagic, right hemorrhagic and right ischemic stroke types. Figure 2: Patients with spatial neglect Sixty per cent of the participants were found to be suffering from spatial neglect. However, it is interesting to note that only one person with spatial neglect was found to be suffering with shoulder pain. However, all the patients with spatial neglect indicated to their right hand side. Further, only one participant with low FIM (44) indicated mild shoulder pain of left-hand side. Patient age and shoulder pain/spatial neglect As the patients were in a similar age group of 69-80 years, it is difficult to establish any trend related to age and shoulder pain/spatial neglect. Three patients were detected with spatial neglect, however, only one of them suffered from shoulder pain, who is aged 73 years. Thus, this result states that aged people in their 70s with spatial neglect may or may not suffer from shoulder pain as well. In order to find out age-specific results with regards to spatial neglect and shoulder pain, it is imperative to conduct more such studies with larger number of subjects in different age groups. 3.3: Chi-square Non-parametric Statistical Analysis In order to investigate the relation between spatial neglect and shoulder pain, an independent chi-square test analysis was carried out. The Chi-Square test yielded the following results: Table 4: Chi-square test analysis Shoulder Pain No Shoulder pain significance x² Df p Cramer's V Spatial Neglect 1 2 2.222 1 0.136 0.667 No Spatial Neglect 0 2 The results in the above table indicate that there is no significant relationship between the two variables i.e. spatial neglect and shoulder pain. Compared to the tabulated Chi-square at 1 degree of freedom, the chi-square statistics for this test give strong evidence that these two variables are independent. The p-value is also 0.136 which is greater than the critical value at 5 per cent level of significance. The value of Cramer’s V ranges from 0 to 1 and a hence is too low implying a weak association. Hence, the null hypothesis is not rejected and the conclusion is that spatial neglect and shoulder pain are statistically independent. Therefore, it might be concluded statistically that there is no relation between spatial neglect and shoulder pain in post-stroke patients. Chapter 4: Discussion The study clearly indicates that statistically the hypothesis could not be proved. In the Chi-square analysis, the Cramer’s V range stood at 0.667, which is too low to imply any association between the variables i.e. spatial neglect and shoulder pain in post-stroke patients. The study further found that although 60 per cent of the participants suffered from spatial neglect, only one participant reported shoulder pain that too moderate pain. Thus, the data was too insufficient to conclude that there is a relation between shoulder pain and spatial neglect. The study also found different trends in the results. The participant with the lowest FIM (18), although had spatial neglect but did not report any shoulder pain. However, the participant with highest FIM (65) reported moderate shoulder pain, although no spatial neglect. Interestingly, the only two patients who did not have spatial neglect reported to have shoulder pain. Further, the study also cannot conclude that patients with Left Ischemic stroke may be prone to spatial neglect and shoulder pain, as the other participant with similar stroke type gave differing result. However, the above analysis is based on only five observations and the figure is too low to find any trend. For a study of this proportion, at least 20 participants need to be analysed. Nonetheless, none of these above statements can be issued for sure for this research as the results were not able to find any trend in the data. However, the paper does establish some of the hypotheses projected by various experts and researchers. For instance, as per Lindgren et al. (2007), around one-third of post-stroke patients complain of shoulder pain within the first four months of suffering a stroke. Bohannon, Larkin and Smith (1986), and Van Langerberghe and Hogan (1988) also discovered that 72 per cent of stroke patients suffered from shoulder pain within the first month of the stroke. The research also indicates that most of the participants complained of shoulder pain following stroke. Andersen, Vestergaard, Ingeman-Nielsen & Jensen (1995) concluded that approximately eight per cent of post-stroke patients suffered from chronic shoulder pain. However, it should be noted that most of these post-stroke patients were elderly people who were already suffering from age-related diseases such as arthritis and other musculoskeletal ailments (Kehayia et al., 1997). However, no such assumptions can be established for this study as all the subjects for this research were elderly people. Further, it cannot be said for certain that higher number of subjects for the study would have indicated a different result. For instance, Bohannon et al. (1986) were also not able to establish the relation between hemiplegic patients and shoulder pain, in spite of studying 50 subjects. Bohannon et al. studied 50 hemiplegic patients and found that 36 patients were suffering from shoulder pain. The study although, established that there is a significant relation between shoulder pain and shoulder motion, it was not able to find that hemiplegia was not significant factor for shoulder pain or not. Thus, the study concluded that shoulder pain in a hemiplegia patient might be due to adhesive capsulitis. Bohannon et al. in their study were able to find the cause for shoulder pain in hemiplegia patient and focused on adhesive capsulitis as the prominent reason for shoulder pain. In the current study, the researcher also wanted to find out the underlying cause of shoulder pain and whether spatial neglect was a contributing factor or not. Although, not much study was found that focused on the relation between spatial neglect and shoulder pain in post-stroke patients, De Courvel et al’s (1990) study of heiplegic patients came closest to finding relation between neglect and shoulder pain. Although, they were able to establish the importance of conducting such a study, they could not find any association between the two variables. This has been the case with our study as well, wherein, although we were able to state the importance of finding the association between spatial neglect and shoulder pain in post-stroke patients, we were not able to prove our hypothesis. Also De Courval et al used a lot of variables such as age, gender, diseases such as diabetes, arthritis and health conditions such as heart failure and cardiac ischemia to find out the relation between shoulder pain and hemi neglect. In this study, so many variables were not used, with the belief that this would provide a generic result and prove the relation between shoulder pain and spatial neglect. However, even in the absence of variables, this study was not able to prove the hypothesis, majorly because of lack of data. As the report is not able to establish the relation between spatial neglect and shoulder pain, it can be said that the shoulder pain reported by patients without spatial neglect might be attributed to lack of movement (Turner-Stokes & Jackson, 2002; Lo et al., 2003) or depression (Gamble et al., 2000). Therefore, this research found that shoulder pain may or may not occur due to spatial neglect and further studies are required to be conducted to find a dominant trend and prove the hypothesis. 4.1: Research limitations This research has the basic limitation of number of participants. As only five subjects participated for this study, it was very difficult to arrive at a trend or conclusion. Every subject had a different result for the tests, which might be due to several variables. Thus, in order to find out a conclusive result for this study, it is important to conduct the test with at least 20 subjects. However, it is also difficult to find so many participants. One of the major difficulties was to find patients who were fit enough to participate for the study. It was found that most post-stroke patients were critically ill and were under observation. These patients could not be considered for the study as there were too many variables involved in their treatment and were not on the same platform as other patients. Further, the researcher also could not study post-stroke patients of other hospitals, as ethical approval was given for only one hospital by the ethics committee. The researcher was also not given sufficient time to collect more data. Further, researcher received very late approval from the ethics committee, which delayed the study and the researcher could only assess five patients, instead of the intended 20 subjects. 4.2: Clinical message The research therefore indicates that: Post-stroke patients with spatial neglect may or may not suffer from shoulder pain. Post-stroke patients with spatial neglect may or may not suffer from right hand side shoulder pain. Shoulder pain may occur without spatial neglect as well. Due to the crucial nature of the subject matter further studies need to be conducted with more number of subjects to find out relation between spatial neglect and shoulder pain in post-stroke patients. Chapter 5: Conclusion The study was undertaken to find the relation between post-stroke patients with spatial neglect and shoulder pain. The previous literature found that very few studies have been undertaken in the past on neglect and shoulder pain. However, the subject matter is of importance as it focuses on the cognitive disorder of spatial neglect, wherein the patient is unable to express pain or any such problems. Therefore, research indicated that patients with spatial neglect might not be able to feel shoulder pain and this might become critical for the rehabilitation of post-stroke patients. Thus, the study was undertaken with five patients who were admitted for more than 72 hours. Several tests were conducted to establish spatial neglect in these patients. These tests included Albert’s Test and Bells Test. Thereafter, regular examinations of shoulder pain were conducted using VAS. However, the results from these tests were not conclusive. The Chi-square analysis found the Cramer’s V range at 0.667, which was too low to imply any association between the two variables of spatial neglect and shoulder pain in post-stroke patients. Thus, statistically it was found that the hypothesis could not be proved and there is no relation between post-stroke patients with spatial neglect and shoulder pain. However, a conclusive statement still cannot be made from this study, as only five subjects were taken for this research. A study of this proportion requires more subjects to establish a trend or conclusive statement. In this case, only five respondents were found who provided varying results. This could be due to fact that various variables could have impacted the result. As a conclusive statement could not be arrived at, the results cannot be implemented for the rehabilitation program for post-stroke patients as well. However, as this subject is a critical one and requires utmost attention, it is suggested that further tests should be carried out with more patients to find out a conclusive result for this paper. References: Albert M.L. (1973). A simple test of visual neglect. Neurology, 23, 658–664. Andersen, G., Vestergaard, K., Ingeman-Nielsen, M. & Jensen, T.S. (1995). Incidence of central post-stroke pain. Pain, 61, 187-193. Bohannon, R.W., Larkin, P.A. & Smith, M.B. (1986). Shoulder pain in hemiplegia; statistical relationship with five variables. Archives of Physical Medicine and Rehabilitation, 67, 514-516. English, C., Hillier, S., Stiller, K. & Warden-Flood, A. (2007). 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