CONSTRAINT-INDUCED MOVEMENT THERAPY AND MIRROR THERAPY SUPPORTING POST STROKE REHABILITATION

A LITERATURE REVIEW

By: Justin H. Mathis Advisor: Jay E. Elliott, B.A., M.Ed., D.C. June 25, 2012

Abstract

Objective: The purpose of this study is to review the current conservative rehabilitation methods such as constrained-induced movement therapy and mirror therapy, in relation to and post stroke rehabilitation. The significance of the study is to review the application and efficacy of constraint-induced movement therapy and mirror therapy and to provide conclusions for their applications on stroke rehabilitation.

Methods: Peer reviewed journals, research articles, and book publications were collected, and computer searches of PubMed, Google Scholar, EBSCO Host, and the Logan College of Chiropractic Library Resource Center were utilized for searching articles containing constraint- induced movement therapy, mirror therapy, and neuroplasticity with relevant information on rehabilitation of post stroke patient therapies.

Results: Constraint-induced movement therapy and mirror therapy are just a couple specific treatment therapies available for post stroke rehabilitation when there has been neuromusculoskeletal deficits obtained from the stroke, and the need for ongoing functional improvement.

Conclusion: This literature review revealed that the majority of individuals will survive the debilitating effects from a stroke, and require rehabilitation in an effort to recover loss of body function. The type of rehabilitation that is best for a person who has suffered a stroke largely depends on the degree of their disability and their ability to follow the rehabilitation protocols. Constraint-induced movement therapy and mirror therapy are just a couple therapies to take into consideration, but the best therapeutic outcomes are reliant on each patient exclusively due to the differences of post stroke patient disabilities.

Key Indexing Terms: Stroke Prevention, Causation of Strokes, Stroke Rehabilitation, Post Stroke Patient Care, Alternative Care for Stroke Patients, Conservative Management Rehabilitation, Neuroplasticity, Mirror Therapy, Constraint-Induced Movement Therapy, Standard Stroke Protocol.

Introduction

The brain is a very complex organ that controls our body functions. When a stroke occurs due to either clot formation, or vessel rupture leading to the brain or within the brain, it cannot get the essential nutrients and oxygen needed to carry out proper function, and the region of the brain affected will begin to die.1 Stroke signs and symptoms typically start suddenly, over seconds to a matter of minutes, and in most cases does not advance any further. The signs and symptoms seen depend on what region of the brain is affected from the stroke, and may affect your speech, senses, memory, thoughts, emotions, or may even paralyze one side of the body.2

The more extensive the area of the brain affected the more functions that are likely to be lost.

According to the American Stroke Association, strokes are the fourth most common cause of death in the United States which affects approximately 795,000 Americans annually, involving

40% male and 60% female, and costs 73.7 billion dollars per year for medical costs and disability.1

Types of Strokes

In brief discussion there are two main types of strokes that should be taken into consideration. The first type of stroke is known as an ischemic stroke where a clot forms within the vessel leading to the brain or within the brain, and may occur from a thrombosis, embolism, or systemic hypo-perfusion which impedes proper blood flow to the brain leading to dysfunction of the tissue in that region. The second type, which will show specific symptoms is a hemorrhagic stroke, and this is when the actual vessel in question bursts within the brain and blood begins to pool within the cranial vault.3 When either of the two previously mentioned happens the brain cannot get the proper amount of blood carrying oxygen to the brain, and the brain will start to expire.1 Lastly, an transient ischemic attack, which may last from minutes up to twenty-four hours is an event of distinct signs and symptoms that may be a warning sign that a much more severe stroke is about to happen.1

Stroke rehabilitation

Post stroke rehabilitation is an essential part of recovery for many stroke patients. Strokes may leave deficits that mean the patient must learn to change, relearn, or redefine how they live.28 Approximately two-thirds of the stroke patients that survive the stroke develop the inability to move one or more limbs on one side of their body which may leave them debilitated and require various rehabilitation efforts in an attempt to aid in the recovery process of body function.2 The purpose of this paper is to review the literature on constraint-induced movement therapy and mirror therapy, and their role in neuroplasticity when considering the disabilities observed in the neuromusculoskeletal system in relation to motor and sensory deficits in post stroke patients. Complications observed in the neuromusculoskeletal system following a stroke may be a decrease range of motion in the extremities due to limb contractures, muscle tone abnormalities, postural deviations, abnormal gait patterns, and decrease .

The primary goal in stroke rehabilitation is to promote maximum patient recovery, and to reduce brain injury. Prompt detection and emergency medical attention are essential for optimizing patient outcomes.24 Stroke rehabilitation is a process where patients with functional disabilities undergo treatment to help them return back to their normal lives as much as possible by regaining and relearning skills needed for everyday living. The rehabilitation involves the skills from a multidisciplinary team and should be started as soon as possible, and may last from only a few days to over a year. Through proper conservative rehabilitation efforts on post stroke victims we are able to recognize the importance we have on helping the patient recover what they have lost, and enhancing their lives once again.

When considering stroke rehabilitation for a family member one has to take into consideration the “stroke Unit.” A stroke unit is an organized inter-disciplinary group of healthcare professionals with experience in stroke rehabilitation working closely together to provide comprehensive rehabilitation programs for stroke patients. Stroke unit programs can vary in the degree of therapies provided, as well as their intensity and duration, and length of time provided. Stroke units may also work on recognition, prevention, and treatment of co- morbidity and medical complications perceived when assessing the patient to maximize benefits.27

Discussion

Post stroke rehabilitation often begins after the individual’s condition has been stabilized.

Rehabilitation may begin 24-48 hours after the stroke, or may take longer due to the severity of the stroke or the individual’s current status.10 Post stroke rehabilitation is important in helping the patient to re-learn functions that were lost from brain damage due to the stroke in the shortest amount of time possible. The degree of the disability depends on what type of stroke the patient has had, and what region of the brain has been damaged.

Neuroplasticity

Neuroplasticity is the ability of the brain to re-organize new neural connections throughout life, and permits neurons in the brain to compensate from an injury such as a stroke to adjust the activities in response to situations or to change in their environment.4 Certainly this highlights the impact that our surrounding environment has on influencing and shaping our nervous system. Neuroplasticity is formed on the concept of neuro-rehabilitation of the nervous system. The foundation of stroke rehabilitation observed with constraint-induced movement therapy and mirror therapy are exercises based on the concept of neuroplasticity.

With the therapies mentioned above, those who have suffered a stroke are able to make recovery or improvements in some or all motor function through neuroplasticity. This is due to the fact that the more the stroke patient uses their brain through exercise the stronger it will grow. When the post stroke patient performs repetitive tasks originally involving the use of damaged regions of the brain, it forces the brain and nervous system to adapt, and find new ways to execute those movements properly by way of new connections.

Constraint-induced Movement Therapy

Constraint-induced movement therapy was developed by Dr. Edward Taub of the University of Alabama at Birmingham. Dr. Taub argued that after the stroke the patient stopped using the affected limb due to the fact of only the difficulty in trying to move it.6 Dr. Taub’s considered this as a learned non-use behavior because of the negative feedback mechanism the patient perceived after the stroke by not trying to use the affected limb any longer. According to the American Stroke Association, they recognize constraint-induced movement therapy as a forefront on post stroke rehabilitation.7 Constraint –induced movement therapy has also been shown to be effective regardless of the extent of vascular insult to the brain, or the level of chronicity and motor inability of the patient.8,9 When the patient begins rehabilitation efforts after the stroke utilizing constraint induced movement therapy, and only uses the affected limb for activities they begin to incorporate new neuronal pathways within their brain. This is because of the neuroplasticity going on within the brain that allows for change within the damaged region to reorganize its neural connections to new areas of the brain for improvement in function. Upper extremities focuses on arm contractures do to the effects of the neurological motor damage perceived with strokes by increasing their use of the affected upper limb.

Constraint-induced movement therapies main goal is to constrain the unaffected upper extremity while extensively using the affected upper extremity. This rehabilitation involves restraining the non-affected upper limb for at least 90% of waking hours over a course of 2-6 weeks while performing daily training sessions of the affected upper extremity for a minimal of

6 hours per day. Constraint-induced movement therapy is based on the premise of learned non-use therapy, which depicts the individual with a hemiparesis feels the damaging consequences of the increased effort required to use the affected upper extremity while at the same time feeling confident with using compensatory tactics on the non-affected upper extremity. The result of Constraint-induced movement therapy is a learned behavioral response of the upper extremity through non-use despite the possibility that the injured upper extremity may physically still be able to perform determined motor skills. The objective of constraint- induced movement therapy for the stroke patient is to regain function and increase purposeful movement of the affected upper extremity. The goals seen are improved dexterity, motor function, and improving the functional standing for the survivor.

Constraint-induced movement therapy employs two different protocols for repetitive task training, and is divided into two subcategories of shaping or tasking practices.21 Shaping practices is based upon behavioral training in a series of tasks where the task at hand may have a decrease in time, or the task may be made more difficult to complete. During each set, the task will last approximately 30 seconds and a response will be monitored from the patient at the end of each session. The second subcategory is tasking practices. Tasking practices are based upon the patient’s activities of daily living, and utilizes more of an overall task on a local or large scale and are routinely performed up to 20 minutes per session.21 Research in repetitive task training when applying either shaping or tasking practices are showing positive results in post stroke rehabilitation, and allowing the patient’s deficient upper extremity to function at a higher level.21

In a study conducted in 2001 by Levy, Nichols, Schmalbrok, Keller, and Chakeres on constraint-induced movement therapy and its efficacy, they were looking for evidence of cortical reorganization with the utilization of constraint-induced movement therapy on patients with upper limb contractures due to the stroke with the use of a functional MRI to measure the outcomes. The study consisted of two subjects both with chronic upper limb contractures due to strokes, and both subjects were discharged from customary therapy due to the fact that they were no longer showing signs of improvement. The test subjects were then introduced to constraint-induced movement therapy and the treatment consisted of six hours of therapy per day for a total of two weeks of treatment on the affected upper extremity. At the same time the therapies were being performed by the test subjects a functional MRI was implemented on a 1.5-T with echo-planar imaging. After the two week trial the results revealed that the performance time of the two test subjects improved by 24% immediately after the therapy, and continued to improve after three months of therapy by an additional 33% in comparison to the baseline. Initially, taking a closer look at the functional MRI on the test subjects individually, test subject 1 showed improvement with activated scattered regions in the ipsilateral posterior parietal and occipital cortices, and after the utilization of constraint-induced movement therapy test subject 1 had improvement with activity adjacent to the lesion, bilateral activation with motor cortices, along with ipsilateral activation within the primary motor cortex.22 Initially on functional MRI with test subject 2, approximately no activation was noted within the brain, but after the treatment with constraint-induced movement therapy test subject 2 had improvement with activation neighboring the lesion site.22 The conclusion in this case helps to disclose that constraint-induced movement therapy when monitored with imaging like a functional MRI does display an expressive improvement in the patients function.

A randomized controlled trial conducted in 2007 examined the benefits of constraint-induced movement therapy on 26 elderly patients with the mean age of 72 and a post onset of stroke sign and symptoms at 0.5 – 31 months. The trial examined motor function, daily function, and health related quality of life in elderly stroke survivors after three weeks of traditional therapy in relation to constraint-induced movement therapy. After the three weeks of therapy the elderly patients that received constraint-induced movement therapy exhibited a greater improvement in motor function, daily function, and health related quality of life than those that were treated by traditional means. The findings suggest that constraint-induced movement therapy is an encouraging therapy of choice no matter the age of the patient in improving function and patient quality of life.23

Since its introduction constraint-induced movement therapy has been growing in popularity as a therapeutic intervention for post stroke patients because of the evidence that supports its treatment and outcomes.29 Conversely, there is still no well-known causal relationship between constrain-induced movement therapy and observed changes seen in brain function, structure and the motor gains.29,30

Mirror Therapy

Mirror therapy is a form of motor imagery in which a mirror is used to convey visual stimulus to the brain through visual observation of the patients unaffected body part in a mirror while they carry out a specific set of movements. The principle of mirror therapy is that movement of the affected limb may be stimulated through visual cues initiating from the other side of the body. Mirror therapy is a form of therapy that may prove to be useful in patients who have suffered from a stroke.27

Mirror therapy was first introduced and utilized in treating amputees having phantom .

Mirror therapy is now employed in post stroke patients for rehabilitation efforts as well. This involves the use of a mirror box being placed in front of the patient with the mirror image showing the unaffected limb. Movements are then introduced with the unaffected limb, with the affected limb out of view while the patient watches the mirror. The patient perceives that they are watching the affected limb move in the mirror. This mirror therapy elicits an illusion to the patient which in turn increases the motor activation of the affected hemisphere of the brain. Mirror therapy has been used in post stroke rehabilitation with very successful results. It has been shown to accelerate recovery of function and most effective if introduced within the first three months post stroke. An assortment of functional actions have been noted, including reaching and grasp movements, as well as improvement in light touch sensations to the affected limb.

Even though mirror therapy has been shown to be an effective treatment for stroke patients there is still no widely accepted theory on how mirror therapy actually works.25 A large scale review was conducted by (Rothgangel et al. 2011) pertaining to the effectiveness of mirror therapy on stroke patients and summarized as follows:

“For stroke patients there is a moderate quality of evidence supporting that mirror

therapy as an additional intervention improves recovery of arm function, and a low

quality of evidence regarding lower limb function and pain after stroke.”25

Rothgangel emphasized that future studies need to focus more on clear descriptions of intervention protocols of outcome measures and their adverse effects.

In 2009, a randomized controlled trial was conducted to investigate the outcome of mirror therapy in relation to an equivalent control therapy on patients who had suffered severe hemiparesis in an upper extremity after a stroke. The goal of the trial was to look at the effectiveness mirror therapy had on the treatment of the severely affected paretic upper extremity. Thirty-six patients with a severe hemiparesis in an upper extremity sustained from an ischemic stroke were signed up eight weeks post stroke. All thirty-six patients completed a six week protocol of additional therapy beginning five days per week for thirty minutes per session. The thirty-six patients were randomly assigned either mirror therapy or a control therapy, and at the end of the trial outcome measures were assessed. During the six week trial the patients went through a series of functional and neuropsychological testing, and the Fugl-

Meyer outcome assessment tool was the main assessment tool utilized. The results after the six week trial revealed that those patients that employed mirror therapy regained more distal function in their upper extremity than the control therapy group. Furthermore, the patients that underwent mirror therapy also gained more surface sensibility. Mirror therapy encouraged recover from the hemiparesis, and neither of the effects depended on the side of hemispheric lesion. The conclusion of the trial shows a promising outcome with mirror therapy utilization on post stroke patients that has functional and sensory disabilities, with helping to regain motor function in the affected upper extremity.26

In 2004, a crossover study was conducted to see how mirror therapy utilization would work among healthy individuals, Garry, Loftus, and Summers who have not suffered from a stroke while monitoring their brain activity. The crossover study revealed that when viewing active movements of one’s hand in a mirror directly excited neurons in the ipsilateral primary motor cortex much more than just viewing the inactive hand directly or without a mirror.27 Even though the study was conducted on healthy individuals, this does reveal that mirror therapy as an effective treatment for rehabilitation efforts should be taken into consideration for stroke patients due to its neuron excitability through neuroplasticity. Mirror Therapy has been used with some success in improving post stroke patient deficits.

The most encouraging outcomes have come from combining mirror therapy and conventional therapies in clinical studies to demonstrate its effective use.31 Then again; there is still no strong suggestion as to its efficacy on stroke rehabilitation.

Conclusion

Strokes can be devastating and leave the patient in question in a debilitating state in need of rehabilitative care. The primary goal of stroke rehabilitation is to reduce brain injury and promote maximum recovery for the patient. Rapid detection of stroke signs and symptoms with appropriate medical attention are vital for enhancing health consequences for the patient.29

The literature reviewed discloses that constraint-induced movement therapy and mirror therapy accompanies post stroke rehabilitation, and aims at helping stroke survivors regain function that was lost and to re-learn to manage their disabilities through neuroplasticity. Post stroke rehabilitation may require months to years of conservative care to successfully treat these patients effectively, and to help focus on individual needs. With stroke patients successfully participating in the therapeutic approaches described above they are essentially beginning the process of neuroplasticity within their brain and nervous system with re- organization of new connections. While stroke rehabilitation does not cure the stroke it does allow an enhancement of the quality of life for stroke patients. Today, research is proving that the brain has the ability to change through therapeutic activities such as constraint-induced movement therapy and mirror therapy by way of neuroplasticity. Though this process is a continual change and can take several months to several years to accomplish. The patient must obtain an active role to get the most benefit from recovery.

Although the application of mirror therapy has been shown to be successful in numerous cases there is still no widely accepted theory of how it actually works within post stroke rehabilitation.32 Additional studies need to be further investigated in the applicable use of mirror therapy in relation to post stroke rehabilitation. The additional studies need a prerequisite set of protocol procedures that specifically looks at the outcome measures and any recognized unfavorable effects of the patient before, during, and after mirror therapy treatment, to give the patient the best outcomes possible so they may regain any functional deficits that were lost during the stroke event.

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