RajivGandhiUniversityof Health Sciences,
Karnataka, Bangalore
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the Candidate & Address / FEMY MOL BABYW/O Ajish George,
Olapurakal house,
Vengoor,Kuppadi - Post
Sulthan Bathery,Wayanad. 673592
2. / Name of the Institution / K.T.G.COLLEGE OF PHYSIOTHERAPY
Hegganahalli Cross, Vishwaneedam Post,
Sunkadakatte via Magadi Road,
Bangalore-560091.
3. / Course of Study & Subject / MASTERS IN PHYSIOTHERAPY
(Neurological and psychosomatic disorders)
4. / Date of Admission to the Course / 09th June 2012
5 / Title of the Topic:
“EFFECTIVENESS OF MIRROR THERAPY AS A HOME PROGRAM IN REHABILITATION OF HAND FUNCTION IN SUBACUTE STROKE”.
6 / Brief Resume of the Intended Work:
6.1 Need of the Study:
Stroke is defined a rapidly developing clinical sign of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin.1
Stroke is a leading cause of serious long term disability in adults. More than 60% of stroke survivals suffer from persistent neurological deficit. Stroke patient incidence rate range from 0.2 to 2.5 per 1,000 populations per year in India. Prevalence rate in South India was reported to be 56.9 per 100,000.1
Traditionally, acute, sub-acute and chronic phases after stroke are distinguished. The time ranges characterizing these 3 phases strongly vary in literature. Mostly, the first three to seven days are referred to as the acute phase. The first one to six months are defined as the sub-acute phase, and the chronic phase begins after three or six months in most studies.16
Upper extremity motor function after stroke is often impaired, causing restriction in functional activities3. Up to 85% of the approximately 566,000 stroke survivors experience hemiparesis, resulting in impairment of an upperextremity immediately after stroke, and between, 55% and 75% of survivors continue to experience upper extremity functional limitations, which are associated with diminished health related quality of life, even 3 to 6 months later4.
Chronic deficits are especially prevalent in the hand. In fact, finger extension is the motor function most likely to be impaired. This distal limb impairment is especially problematic, because proper hand function is crucial to manual exploration and manipulation of the environment. Indeed, loss of hand function is a major source of impairment in neuromuscular disorders, frequently preventing effective occupational performance and independent participation in daily life.2
A number of intervention have been published evaluating the effect of various rehabilitation methods in improving upper extremity motor control and functioning, such as exercise training of the paretic arm, constrained induced movement therapy, impairment – oriented training of the arm, functional electric stimulation, robotic-assisted rehabilitation, and bilateral arm training. However, most of the treatment protocol for the paretic upper extremity are labor intensive and require 1-to-1 manual interaction with therapist for several weeks. This makes the provision of intensive treatment for all patients difficult.7
Mirror therapy is a relatively new approach in rehabilitation used in different neurological disorders, including stroke. In mirror therapy, patients sits in front of a mirror that is oriented parallel to his mid line blocking the view of the affected limb, positioned behind the mirror. When looking into the mirror the person sees the reflection of the unaffected limb. This creates a visual illusion whereby movement or touch to the intact limb may be perceived as affecting the paretic or painful limb.7
It has been suggested that mirror therapy is a simple inexpensive and most importantly patient directed treatment that may improve upper extremity function and it has no side effects. So it can be used for old patients those who have difficulties to perform other type of exercise.8
Studies have been found that intense mirror therapy in chronic stroke patients resulted in significant recovery of grip strength and hand movement of paretic arm, ROM, speed and accuracy of arm movements shown improved after mirror therapy.7Another study found that patients trained with mirror therapy had an increase in Fugl Meyer assessment score, movement speed and hand dexterity. Passive movement observation in the absence overt movement of either limb facilitate M1 excitability specifically for muscle engaged in the observed action.23
In post stroke who are hemiplegic, loss of hand function is a major source of impairment, frequently preventing effective occupational performance and an independent participation in daily life4. From the literature it is hypothesized that visual feedback from mirror therapy of non-paretic upper extremity would help to restore function in affected upper extremity.
The studies have been done on mirror therapy on inpatients rehabilitation in post stroke patients that have found that hand functioning improved more after mirror therapy in addition with conventional rehabilitation program compared with a control treatment immediately after 4 weeks of treatment and at the 6 months follow-up.7
Conventional treatment of mirror therapy in hand rehabilitation following post strokehemiplegia last for 30 minutes. Treating subjects with this duration as inpatients or outpatients rehabilitation is cost effective and time. The previous studies were limited, to study the effectiveness of supervised mirror therapy as a home program withoutpatient conventional rehabilitation exercises in hemiplegics. Therefore there is a need to know the effect of home based supervised mirror therapy in rehabilitation of hand with outpatient conventional rehabilitation in subject with sub-acute stroke.Knowing the effectiveness will be beneficial in reducing cost effectiveness and time saving to patients on recommending home based mirror therapy.
Hence the present study is aiming to study the effect of mirror therapy as a home program with outpatients conventional rehabilitation program on functional recovery of hand in subjects with sub-acute stroke.
Research Question:
Whether the mirror therapy as a home program does have an effect on functional hand recovery in rehabilitation of hand function in subjects with sub-acute stroke?
HYPOTHESIS
NullHypothesis:
There will be no significant effect of mirror therapy as a home program on functional hand recovery in rehabilitation of hand function in sub-acute stroke.
Alternate Hypothesis:
There will be a significant effect of mirror therapy as a home program on functional hand recovery in rehabilitation of hand function in sub-acute stroke.
6.2 Review of Literatures:
Review on Stroke:
Kelly – Hayes et al (1998): Stroke is an acute neurological event that is caused by an alteration in blood to the brain. It can be either a deprivation of blood to the brain tissue (ischemic stroke) or spilling of blood (Hemorrhagic Stroke) to the brain tissue. Stroke is a leading cause of adult disability.
Review on Mirror Therapy:
Marian E Michielsen et al (2011): studied on neuronal correlates of mirror therapy: an fMRI study on mirror induced visual illusion in stroke patient. The aim of study was to investigate the neuronal basis for the effect of mirror therapy in stroke patient. They found that mirror illusion increases activity in precuneus and posterior cingulated cortex, areas associated with awareness of self and spatial attention.8
Marian E. Michelson et al (2010): Studied on Motor Recovery and Cortical reorganization after Mirror Therapy in Chronic Stroke Patients. The purpose of study was to evaluate for any clinical effects of home-based mirror therapy and cortical reorganization in patients with chronic stroke with moderate upper extremity paresis. Outcome measure was the Fugl-Meyer Motor assessment.This phase II trial showed some effectiveness for mirror therapy in chronic stroke patients.9
V.S Ramchandran and Eric Altsculer et al (2009): studied on use of visual feedback, in particular mirror visual feedback, in restoring brain function. They collected 18 clinical studies of mirror therapy. They suggested that mirror visual feedback [mirror therapy ] can accelerate recovery of motor function from wide range of neurological disorder such as phantom pain, hemiparesis from stroke, complex regional pain syndrome and peripheral nerve injury. They suggest that mirror therapy stimulate the mirror neuron. Mirror neuron provides visual input to revive motor neurons.6
Gunes Yauzer et al (2008): studied on effect of mirror therapy in improving hand function in sub-acute stroke patients. 40 inpatients, within 12months of post stroke were selected & they randomly assigned in two groups; one group did mirror therapy to upper limb along with conventional therapy &other group did sham mirror therapy along with conventional therapy. They used Modified Ashworth scale, self-care items of the FIM instrument. They concluded that in sub-acute stroke patients hand function improved more after mirror therapy program.7
Chirstian Dohle et al(2008): had done comparative study on mirror therapy promotes recovery from severe hemiparesis. They included 36 patients with severe hemiparesis not more than 8 weeks after the stroke. They randomly assigned patient either mirror therapy or equivalent control therapy. The main outcome measure used was the Fugl- Meyer sub scores for upper extremity.They concluded that mirror therapy early after stroke is promising method to improve sensory and attention deficits and to motor recovery in distal plegic.10
Serap Sütbeyaz et al (2007): studied on Mirror Therapy Enhances Lower Extremity Motor Recovery and Motor Functioning after Stroke. They used the Brunnstrom stages of motor recovery, Modified Ashworth Scale (MAS), walking ability (Functional Ambulation Categories [FAC]), and motor functioning (motor items of the FIM).They concluded that mirror therapy combined with a conventional stroke rehabilitation program enhances lower-extremity motor recovery and motor functioning in sub-acute stroke patients.18
M.I. Garry A.Loftus et al (2005): tested using single – pulse trans cranial magnetic stimulation (TMS) in eight neurologically health subjects. Excitability of M1 ipsilateral to a phasic, unilateral hand movement was measured while subjects performed, unilateral index finger-thumb opposition movements. MEPs were enhanced during ipsilateral hand movement compared with the Rest condition. Excitability of M1 ipsilateral to a unilateral hand movement is facilitated by viewing a mirror reflection of a moving hand. This finding provides neurophysiological evidence supporting the application of mirror therapy in stroke rehabilitation.23
Chirstian Dohle et al (2004): studied on effect of body scheme Gates Visual processing used to find out functional magnetic resonance imaging (fMRI) to explore how guidance of motor act is influenced by visually perceived body scheme.They concluded that execution of action, motor behavior can tune visual area of cortex in the same fashion as attention .This study support the motion that controls heavily relives on perceptual cues.11
Review on Brunnstrom:
Brain Injury (2010):A neurophysiological and clinical study of Burnnstrom recovery stages in the upper limb following stroke. To determine the extent to which the Brunnstrom recovery stages of upper limb in hemiparetic stroke patients are correlated to neurophysiological measures and the spasticity measure of Modified Modified Ashworth scale (MMAS). 30 patients with upper limb spasticity were recruited. Wrist flexor spasticity was rated using MMAS. There was a significant moderate correlation between the Brunnstrom recovery stages, neurophysiological measures, and highly with the MMAS. The Brunnstrom recovery stages can be used as a valid test for the assessment of patients with Post- strokehemiplegia.19
Review on Conventional Exercises:
Riccio et al (2010): Studied on sub-acute stroke patients. Group A underwent conventional neuro-rehabilitation protocol 3 weeks followed by 60 mins mental practice plus next 3 weeks conventional therapy. Group B conventional therapy plus mental practice for 3 weeks and rehabilitation alone for 3 weeks. They found that group A showed higher improvement.
Kim Brock, Gerlinde Haase et al (2010): Compared the short term effects of Bobath concept in conjunction with task practice compared to structured task practice alone, in walking abilityin people with stroke, for two weeks. This pilot study indicates short term benefits for using interventions based on the Bobath concept for improving walking velocity in people with stroke.25
Gunes Yauzer et al (2008): Studied effect of mirror therapy in improving hand function in sub-acute stroke. One group did mirror and conventional therapy and other group did sham mirror therapy and conventional therapy. They concluded that there was improvement in mirror and conventional group.7
Pollock et al (2007): Studied the effects of physiotherapy treatment approaches aimed at promoting postural control and lower limb function such as neuro developmental techniques, Burnnstrom Proprioceptive neuro muscular facilitation and motor relearning program. They found that currently no evidence exists that one is superior to the other.
Ray-Yau Wang et al (2005): To find out the effectiveness of Bobath on stroke patients at different motor recovery stages by comparing their treatment with orthopedic treatment. 21 patients with spasticity and 23 with relative recovery stage participated. Patients with spasticity benefited more from the Bobath treatment in Motor Assessment Scale (MAS) and Stroke Impact Scale (SIS) than from orthopedic treatment.26
PM Van Vliet NB Lincoln A Foxall (2005): Studied the comparison of Bobath based and movement sign based treatment for stroke. 120 patients were divided into 2 groups. This study evaluated the effect of Bobath and Movement sign based treatments on movement ability and functional independence. Outcome measures used were River mead motor assessment and motor assessment scale. The study did not show that one approach was more effective than the other in stroke patients.27
David A. Gelber, B. Josefczyk et al (1995): Evaluated patients with pure motor hemiparetic strokes randomized them to treatment with either a traditional functional retraining approach or neuro developmental techniques. This data suggests that TFR and NDT approaches are equally efficacious in treating pure motor hemiparetic strokes in terms of functional outcomes, gate measures and upper extremity motor skills.24
Review on Chedoke Arm and Hand Activity Inventory:
Rowland TJ, Turpin M, Gustafsson L, (2011): The Chedoke Arm and Hand Activity Inventory-9 (CAHAI) is an activity- based assessment developed to include relevant functional tasks and to be sensitive to clinically important changes in upper limb function. Five clients within 14 days of stroke were recruited by consecutive sampling. All clients with stroke felt that the assessment provided reassurance regarding their recovery. The findings indicate that CAHAI-9 shows promise as an upper limb ability assessment for clients within 14 days of stroke.22
Barreca and co researchers20 2005 in a study concluded that CAHAI has a high inter rater reliability and more sensitive when compared to ARAT in a construct validation process which involved 39 survivors of stroke.
In a comparative study conducted by Barreca et al21 2005, compared 2 versions of Chedoke Arm and Hand Activity Inventory (CAHAI) with Action Research Arm Test (ARAT) and found that both versions of CAHAI demonstrated more sensitivity to change than Action Research Arm Test in 105 subjects.
Review on Modified Ashworth Scale:
Richard W, Bohannon et al(1987): studied on interrater reliability of modified Ashworth scale of muscle spasticity .The purpose of study was to determine the interrater reliability of manual test of elbow flexors group spasticity using the modified Ashworth Scale. Each patient was tested by his or her own physiotherapist and then by according to Kendall’s Tau correlation. They concluded that modified Ashworth scale is reliable & valid to measure spasticity3.
6.3Objectives of the Study:
The objectives of the study are:
- To measure functional hand recovery pre and post treatment in mirror therapy group and Sham therapy group.
- To compare the functional hand recovery pre and post treatment between mirror therapy and Sham therapy group.
7 / Material and Methods:
7.1Study Design:
Experimental study design with two groups – Mirror Therapy Group and Sham Therapy Group
7.2 Methodology:
Study Subject:
Subjects with sub-acute stroke within 4 weeks
Sample Size:
Study will be done on 30 subjects (15 in Mirror Therapy Group and 15 in Sham Therapy Group).
Study setting and source of data:
Study will be conducted in K.T.G.Hospital, Bangalore and other Rehabilitation centers.
Sampling Method:
Simple random sampling method.
Study Duration:
4 weeks study. One session in a week for 4 weeks. Both group trained once a week under supervision of a Physiotherapist at the rehabilitation center and practiced mirror therapy at home 30 minutes daily, 5 times a week.
Sample Selection:
Inclusion Criteria:
- Stroke patients diagnosed by neurologist after confirmed by CT/MRI and referred to Physiotherapy treatment.
- First episode of right hemiplegia within the duration of 4 weeks in sub-acute stroke.
- Age 40 to 65 years.
- Both Male and Female.
- Subjects who are in the stage III to IV on Brunnstrom stage of motor recovery of upper extremity.
- Modified Ashworth scale score between 1 to 3.
- No severe cognitive disorders (MMSE score >24).
- Associated psychological disorders.
- Perceptual disorders.
- Significant visual & auditory impairment.
- Any orthopedic disorders.
- Mirror Therapy Box
- All the materials required to evaluate Chedoke Arm and Hand Activity Inventory – Version-9.
- Ethical Clearancewill be obtained from the ethical committee of K.T.GCollege of Physiotherapy. All the subjects fulfilling the inclusion and exclusion criteria will be informed about the study and a written consent will be taken (Annexure–1) and randomly allocated to either mirror therapy group or Sham therapy group. The patients will be randomly allocated into two groups of 15. Thirty pieces of paper used, with fifteen pieces having the word “Mirror Therapy Group” written on them, and fifteen having the words “Sham Therapy Group” written on them. All the pieces of paper will be tightly folded and placed in a box. After shaking the box each piece of paper will be withdrawn individually and the group name will be written on a list that corresponds with the patient numbers from 1 to 30.
Sham Therapy Group: Sham therapy with conventional therapy.
- Pretreatment measurements on functional recovery of hand will be measured using Chedoke Arm and Hand activity inventory scale. (Annexure - 2)
- Mirror Therapy Group: In this group subjects will be given, mirror therapy and conventional therapy. Subjects first will receive conventional therapy.