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Bondoc, Budde, Caruso & Earl (2016) - use with permission
4/5/16
Contact: [email protected] 1
Mirror Therapy and Task Oriented Training to Facilitate Upper Extremity Recovery in Persons with Stroke
99th AOTA nnual Conference – Chicago, IL
April 7-9, 2016
SalvadorBondoc,OTD,OTR/L,FAOTAGraceBudde,MOT,OTR/L
KatelynCaruso,MOT,OTR/L
Bri?anyEarl,MOT,OTR/L(incollabora+onwithJulieBooth,DPT,MichelleDeSousa,DPT,JillHumphry,DPT,KateHammerton,DPT)
QUINNIPIACUNIVERSITY
Objectives • ObjecCve1:StatetheindicaConsandexpectedoutcomesforusingacombinedmirrortherapyandtask-orientedtrainingforclientswithchronicstroke
• ObjecCve2:DescribetheelementsofanintervenConprotocolandidenCfyspecificstrategiesforimplemenCngmirrortherapyandtask-orientedintervenConsforclientswithchronicstroke
• ObjecCve3:AppreciatetranslaConofevidenceintopracCceasanapproachtodemonstraCngthedisCnctvalueofoccupaConaltherapy
OUTLINE
1. BackgroundInformaCon
• MentalPracCceandMirrorTherapy
• TaskOrientedTrainingPrinciples
2. ReviewofEvidence• MirrorTherapy• TaskOrientedTraining• MirrorTherapy+Task
OrientedTraining
3. ImplementaConStrategies
• MirrorTherapySet-up• TaskOrientedTrainingusingBrunnstromLevels
4. PilotStudy
• Design/Methods• OutcomeMeasures• IntervenConProtocol• Results
Background Information
• Strokeisleadingcauseoflong-termdisability– Approx.2/3rdsurviveoutofthe700,000(AHA,2013)– 80percenthavehemiparesisat>6months
• LossofupperextremityfuncConresultsinsignificantlimitaConsinaperson’sabilitytotoperformdailytasks(Laietal,2002).
Background Information
• AdvancesinneurorehabilitaCon(Carteretal,2010)– Constraint-inducedmovementtherapy– Robot-assistedtherapy– Virtualreality/game-basedintervenCon– EMGtriggeredElectricalSCmulaCon
• LimitedbypragmaCcconsideraCons– Costtodeliver>revenue– PaCentAccess– Therapisttraining– Criteria
Mental Practice (MP) of Movement or Motor Imagery
• WhatisMP?– Istheinternalreproduc;onofagivenmotoract,whichwhenpracCced,maypromotelearningofmovementorjusttoimproveagivenmotorskill
– Requirestheconscious,inten;onalact
• TWOPRINCIPLES:1. InternalImageryàmentalsimulaConofanact2. ExternalImageryàwatchingmovementbyanother
individualorofownbody
Bondoc, Budde, Caruso & Earl (2016) - use with permission
4/5/16
Contact: [email protected] 2
Mirror Therapy
• MirrorTherapyinvolves– synchronousbilateralhandmovementswhileobservingthemirrorreflecConoftheunaffectedlimbintheposiConoftheiraffectedlimb(Rossiteretal,2015)
• AmirrorisplacedinthepaCent’smidsagi?alplanetoreflectmovementsofthenon-involvedsideasifitweretheaffectedside(Thieme,2012)
Some background…
• Ramachandran(1994)proposedtheuseofmirrortherapyforpersonswithphantomlimbpain.
• EarlyevidenceofmirrortherapysuggestssignificantimprovementsintheCRPSandPhantomLimbcondiCons
• Ramachandrian&Rogers(1995?)testedtheintervenCononstrokesurvivorswithCRPS
Cortical Mechanisms
• Garry,Lojus&Summers(2005)– TranscranialmagneCcsCmulaCon(TMS)studyinhealthysubjectsshowincreasedexcitabilityinprimarymotorcortex(M1)inbothhemispheres
• Rossiter,Borrelli,Borchert,Bradbury&Ward(2015)– Magnetoencephalography(MEG)studyshowincreasedsymmetryinbilateralhemisphericacCvaConwhenengagedinmirroredmovements
Mirror neurons in the parietal-frontal circuit, suggests that the observation of an action activates the cortical area of the observer’ s brain.
Bondoc, Budde, Caruso & Earl (2016) - use with permission
4/5/16
Contact: [email protected] 3
Mirror Neurons
• Inbothanimalandhumanstudies,– observaConoftasksperformedwiththehands,feetandmouthàproducegreatestbrainacCvity
• Themirrorneuronsystemis
– abletoidenCfyacConcomplexity– unconsciouslyimitateswhatwesee,hearorperceive
Mirror Intervention is not Enough
• MirrorTherapyshouldbeusedasaprimingapproachtoperformance
• Task-basedexercisesmayalsobeusedasaformofpriming– Yieldsbe?erresultsthanimpairment-focusedintervenCons(e.g.,weakness,spasCcity)
Task-Oriented Training
• MulCpletermsàkeyword“Task”
• RepeCCvetasktrainingcombineselementsof– relevancetofuncConalacCvity,and– intensityofpracCce(Beverleyetal.,2010).
• IntensivetherapycanimprovetherateofrecoveryinADLs,butmoresowhenafuncConalapproachisadopted(Beverleyetal.,2010).
Motor Learning Principles
1. Task-specificity2. PracCceintensityandschedule
– HighrepeCCon– BlockpracCcetovariablepracCce
3. Enhancedfeedback– Knowledgeofresults– Knowledgeofperformance
In addition…
FromanOTPerspecCve1. Client-centered
• Meaningful• Fitsinclient’slifestyleandinterests
2. Context-rich• Naturalenvironments• Contextualinterferences
Top Stroke Rehabil 2005;12(3):58–65
AnimalStudies• RepeCConaloneisnot
sufficienttoproducecorCcalreorganizaCon
• MeaningfultasksresultsingreatercorCcalreorganizaCon
• Task-specificityisaprerequisitetocorCcalreorganizaCon
HumanStudies• RepeCConandconsistent
pracCceinducecorCcalchanges
• Rehaboutcomesarebe?erwhentasksaremoremeanigfultotheclient
• Task-specifictrainingresultsinlong-lasCngneuroplasCcchangesinthebrain
Bondoc, Budde, Caruso & Earl (2016) - use with permission
4/5/16
Contact: [email protected] 4
REVIEW OF EVIDENCE
PartIIMIRRORTHERAPY
TASKORIENTEDTRAININGCOMBINEDMT+TOT
Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. Mirror therapy for improving motor function after stroke.
Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD008449. DOI: 10.1002/14651858.CD008449.pub2.
Arya et al. (2012)
• N=103chronicstroke(4-24weekspoststroke)• Design=Randomized,controlled,doubleblindedtrIal,• IntervenCon
– MeaningfulTaskSpecificTraining(MTST)group(n=51)basedonBrunnstromstagesvs.
– Standardtherapycontrolgroup(n=52)basedonBobathneurodevelopmentaltechnique
– Fourdaysaweekfor4weeks(40min/day)• Results:
– MTSTgroupshowedaposiCveimprovementinthemeanscoreontheoutcomemeasuresatpostandfollow-upassessmentsincomparisontothecontrolgroup.
Byl et al. (2013) • N=15communityindependentstrokesurvivors>6monthspost
stroke,FuglMeyerUEscores16-39• Design=Randomizedfeasibilitystudy,randomlyassignedtoone
ofthreeintervenCongroups• IntervenCon
– SixweeksofrepeCCvetasktraining(40minutes/day5days/week)1. ActualTaskSpecificRepeCCveTraining(TSRT)workingwithaPT2. VirtualTSRTguidedroboCcorthosisbilaterally3. VirtualTSRTguidedbyroboCcorthosisusedunilaterally.
• Results:– EachtraininggroupsignificantlyimprovedULFMscoresandrangeormoCon.
– IntreatmentwithroboCcorthosis,grossmotorskillswereimprovedaroundtheshoulderandelbow
Yavuzer, et. al. (2008) • N=40inpaCentswithseverehemiparesis,within1yearpostCVA• Design=Randomizedcontrolledtrial• IntervenCon
– 5daysaweekfor4weeks– Mirrortherapygroupreceived30minutesofmirrortherapyin
addiContoconvenConaltherapy– ControlgroupreceivedconvenConaltherapyincludingPTandOT
• Results– ThemirrorgroupshowedstaCsCcallysignificantimprovementinUE
funcConmeasuredbytheFMA– ThecontrolgroupalsoshowedimprovementsinUEfuncCon– Theseresultsshowedthatmirrortherapyworkswellwhenitis
combinedwithanotherformoftreatmentinordertoimproveUEfuncCon
Bondoc, Budde, Caruso & Earl (2016) - use with permission
4/5/16
Contact: [email protected] 5
Yoon, et. al. (2014)
• N=26paCentswithsubacutestroke• Design=randomizedcontrolledtrial• IntervenCon:AllgroupsreceivedconvenConaltherapyfor40minutesperdayfortwoweeks1. CIMTx6hours/day+withmirrortherapyx30mins/day2. CIMTonly3. Controlgroup
• Results– TheCIMT+mirrortherapygroupshowedthehighestamountofimprovementinfuncConcomparedtotheothertwogroups
IMPLEMENTATION STRATEGIES
PARTIII
Getting Started
• MirrorBoxQuality– Notwarped,notmagnified– Flexibleorsha?erproof(e.g.,Perspex)– KeptverCcal– Minimumsize15”heightx18”length
• KeeptheHandsasIdenCcal– Removejewelry,accessory– Coveroroccludebirthmarks,ta?oos
Choosing a Mirror
Getting Started
• PaCentsitscomfortablywiththeinvolvedhandinthebox,keepingithiddenfromview
• Theotherhandrestsinfrontofthemirror.
• PaCentleansforwardandmaintainsconsistentlineofviewattheimagecreatedinthemirror.
Mirror Therapy Sequence
• Stage1– IniCalobservaConoftheresCnghand– Basichand(finger)movements
• Stage2– A?emptbilateralmovements,gentleàintense– Incorporatewristandforearmmovements
• Stage3– Incorporatetools,objects
Bondoc, Budde, Caruso & Earl (2016) - use with permission
4/5/16
Contact: [email protected] 6
Stage 2 Stage 2
Incorporating Task Practice
• Afew“musts”– Meaningfultotheclientà UseacCvity/taskanalysis
– “Just-right”à BrunnstromLevelsisagoodguide)
– DocumentedoverCmeà Trackforobservablechange
BREAKDOWN OF LEVEL III
ARMFUNCTION• Flexorsynergy
– Lijingofarmaccompanieselbowflexion;
– Handreachestohead
• Extensorsynergy– Reachingforwarddeviates
intomidline– Doesnotelevatehigherthan
chestheight
HANDFUNCTION• Massgraspfrompassive
extension– Cankeepobjectinhand– Lacksabilitytocontrol
pressureonobject
• NoacCverelease– Maybetrainedtorelaxoruse
tenodesis-poweredrelease(iftoneisnottoohigh)
Sample Activities at Level III
• EaCngwithaspoon• Drinkingwithacup• Wipingatable• Brushinghair• Carryagrocerybag• Puungonglasses
BREAKDOWN OF LEVEL IV
ARMFUNCTION• Abletoreachforwardat
shoulderheightwithlessdeviaContomidline
• Abletoreachbehindback(extendsandinternallyrotatestheshoulder)
• Abletorotatetheforearmwiththehumerusadductedtothetorso
HANDFUNCTION• Abletograspwithbe?er
control• CanparCallyopenhand
(lessthan50%oftotalextension)
• Canusethumbforkeypinch
• Hasbe?ercontroloftenodesis-poweredrelease
Bondoc, Budde, Caruso & Earl (2016) - use with permission
4/5/16
Contact: [email protected] 7
Sample Activities at Level IV
• Turningpagesofabook• Turningakey• Tuckinginashirt• Puungajacketon• Puungabelton• Throwingawaytrash• Lijinghamperbin
BREAKDOWN OF LEVEL V
ARMFUNCTION • Abletomoveawayfrom
synergy• Abletoreach(flex)higher
thantheshoulderheight• Abletoabductorreach
sideways• PronaConandsupinaCon
withelbowfullyextended:spasCcitywaning
HANDFUNCTION• Palmarprehension(pincer
ortripod)• Cylindricalgrasponalarger
object• Sphericalgrasp(awkward)• Voluntarymassfinger
extension(variablerangeofmoCon)
• Stablewristcontrol
Sample Activities at Level V
• Reachingforahighshelf• Puunggroceriesintobag• Dialingaphonenumber• Lijingaheavycan• Openingajar• Brushingteeth• Pickingupcoinsfromatable• Tyingshoes
PILOT STUDY PARTIV
OUR STUDY
Methods
• DESIGN:– CaseSeries:Pretest-Midtest-Pos?est-FollowUp
• SamplingandRecruitment• IntervenConFeatures
– In-clinicvs.HomepracCce– StraightPlainMirrorTherapy– Client-centeredTask-OrientedTraining
Bondoc, Budde, Caruso & Earl (2016) - use with permission
4/5/16
Contact: [email protected] 8
Participants
Subjects Age/Sex Onset Side Co-Morbid
Anita 55/F 5y10m Right HighCholesterol
Elizabeth 22/F 6m Lej N/A
Leslie 60/F 10m Right N/A
Oliver 67/M 6y3m Lej Depression,MIin1995
Outcome Measures
• OUTCOMEMEASURES– PATIENTSPECIFICFUNCTIONALSCALE(PSFS)– MOTORACTIVITYLOG(MAL)– FUGL-MEYERMOTORASSESSMENT(FMA)
• INTER-RATERRELIABLITY
– DeterminedbasedonthecomparisonoftheFMAscoringamong2teamsofOT-PTstudentresearchers
PATIENT SPECIFIC FUNCTIONAL SCALE (PSFS)
• QuesConnaireusedtogatherasubjecCvemeasurementofthepaCent’sleveloffuncCon
• PaCentratestheirperformanceonascaleof0-10forthethreetasksthattheyselectedtoworkonduringtherapysessions
Motor Activity Log (MAL)
• QuesConnaireconsisCngof35funcConalacCviCes
• ParCcipantresponds“yes”or“no”toanyoftheacCviCescompletedinthepastweek
• ThenparCcipantrates
– Amountusedintheaffectedascaleof0-5(AoU)– Howwellwasthetaskcompletedonascaleof0-5(QoM)
Motor Activity Log (MAL) Fugl-Meyer Motor Assessment (FMA)
• PerformancebasedimpairmentindextoassessapaCentwithhemiplegia’sUEfuncCon
• ThemotorassessmentisusedtodetermineapaCent’sleveloffuncConinthehandandarm
• ThepaCentisinstructedtocompleteaseriesofmovementsandtheratergivesthepaCentascorebasedonthequalityofthemovementproduced
• ThetherapistcanusethepaCent’sscoreinordertodetermineappropriateintervenConacCviCes
Bondoc, Budde, Caruso & Earl (2016) - use with permission
4/5/16
Contact: [email protected] 9
Fugl-Meyer Motor Assessment (FMA) PROTOCOL – Mirror Therapy
• INCLINIC(2x/wk):– 150repeCConsofsingleplanemoCons:reachingforward,elbowflex/ext,forearmpron/supn,wristflex/ext,grossgrasp/release,opposiCon
– ParCcipantsgivenfeedbackregardingcorrectposturingoftheUE
• ATHOME(4x/wk):
– ConCnuedin-clinicprotocol– ParCcipantsencouragedtodocumentrepeCConsandamountofCmetocomplete
PROTOCOL – Task Training
• INCLINIC(2x/wk):– ParCcipantsselected1of3tasksfrompreviouslyselectedgoalsusingthePSFS;completed150repeCCons
– TaskswereanalyzedbyOTstudentsforopCmalcombinaConofmovements;
– Knowledgeofperformance(KP)feedbackwasgiventopromotequalityofmovement
• ATHOME(4x/wk):
– ParCcipantsencouragedtoalternatecompleConofacCviCesthroughout6-dayprotocol(e.g.CrocheCng2x/wk,beading2x/wk,painCngnails2x/week)
Patient Specific Goals
Subjects Self-IdenCfiedGoals(Tasks)
Anita CrocheCng,Beading,PainCngNails
Elizabeth DumbBellExercises,WashingHair,DonningShirt
Leslie Kniung,DrinkingfromCup,TurningKey
Oliver DrinkingfromCup,PickingCoins,TuckingShirt
Case Example: “LESLIE”
• ComplianceLog– #mirrortherapyrepeCCons(150)– #tasktrainingrepeCCons(150each)
• Drinkingfromacup(M,TH)• Kniung(T,F)• Turningkey(W,Sa)
PSFS and MAL
0
1
2
3
4
5
6
7
8
9
Pretest Midtest Posttest 1 Posttest 2
Figure 2. Patient Specific Function Scale Index2
(Max Score = 10; MDC=+2)
Subject 1*^
Subject 2^
Subject 3*^
Subject 4*^
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Pretest Midtest Posttest 1 Posttest 2
Figure 3. Motor Activity Log Quality of Movement Index3
(Max Score = 5; MDC= +15%)
Subject 1^
Subject 2
Subject 3*^
Subject 4*^
Bondoc, Budde, Caruso & Earl (2016) - use with permission
4/5/16
Contact: [email protected] 10
FMA Hand and Arm
0
5
10
15
20
25
30
35
Pretest Midtest Posttest 1 Posttest 2
Axi
s T
itle
Figure 1a. FMA – Arm Component (Max Score = 36)
Subject 1
Subject 2
Subject 3
Subject 4
0
5
10
15
20
25
30
Pretest Midtest Posttest 1 Posttest 2
Axi
s T
itle
Figure 1b. FMA – Hand Component (Max Score = 30)
Subject 1
Subject 2
Subject 3
Subject 4
Number of Activities Attempted
Subjects Pretest Midtest Postest Posteset2
Anita 16 19 22 25
Elizabeth 24 25 23 25
Leslie 16 22 24 23
Oliver 14 17 19 18
Findings: Fugl-Meyer
• AllsubjectsshowedsometypeofimprovementsinboththeirwristandhandaswellasintheirarmfuncConing,– howevermostimprovementswereseeninthewristandhandindicaCngthesuccessofthisprotocolifusedforfinemotormovements.
Findings: Motor Activity Log
• TheMALyieldedmixedresultsoverall– AllparCcipantsshowedanincreaseinthenumberofacCviCesa?emptedfrompre-testtopost-test2
• WhiletheAOUshowedmixedresults,theQOMshowedclinicallymeaningfulresults.– ParCcularlywithclientswithchroniconset,qualityofmovementisofconcern
Findings: Patient-Specific Functional Scale
• ThemostclinicallymeaningfulchangeswereseeninthePSFS.– Improvementsmaybeassociatedwithtasksbeingperson-specificandintrinsicallymoCvaCng.
• ThePSFSchangesmaysuggestanincreasedself-percepCon,whichmaycarry-overtoincreasedconfidenceandincreaseduse.
Discussion
AmountandqualityoffuncConinthehemiplegicUEcanincreaseevenajerseveralyearspost-strokewith
• Intensivetrainingcombiningwithmirrortherapyasaprimingmethodwith
• Taskorientedtrainingbasedonself-selectedtasks
Onsetofstrokedidnotseemtoinfluencethepa?ernofoutcome
• ParCcipantswithrecentonset(6m,10m)hadsimilarpa?ernsofimprovementsasthosewithachroniconset(5y10m,6y3m)