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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


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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.


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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


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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


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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


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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


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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


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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


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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


Figure 3. Motor Activity Log Quality of Movement Index3

(Max Score = 5; MDC= +15%)

Subject 1^

Subject 2

Subject 3*^

Subject 4*^


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FMA Hand and Arm

0

5

10

15

20

25

30

35


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


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)


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