Curriculum Development Cell
Registration No. / :
Name of the Candidate / : Ms. PRIYA RAJENDRA PAWAR
Address / : S.D.M. College of Physiotherapy,
Manjushree Nagar, Sattur, Dharwad.
Name of the Institution / : S.D.M. College of Physiotherapy, Dharwad.
Course of Study and Subject / : M.P.T. (Master of Physiotherapy in Neurological And
Psychosomatic Disorders).
Date of Admission to Course / : 15/ 07 /2013
Title of the Topic / : “A STUDY TO FIND OUT EFFECTIVENESS OF CONSTRAINT INDUCED MOVEMENT THERAPY ALONG WITH MIRROR THERAPY FOR IMPROVEMENT OF HAND FUNCTION IN SUBACUTE STROKE PHASE” .
Brief resume of the intended work / : Attached
Signature of the Student / :
Guide Name / : Dr.DHARMESH KUMAR
Remarks of the Guide / : Recommended for Registration
Signature of the Guide / :
Co-Guide Name / :
Signature of the Co-Guide / :
HOD Name / : Dr. RAVI SAVADATTI
Signature of the HOD / :
Principal Name / : Dr. RAVI SAVADATTI
Principal Mobile No. / : 09845051209
Principal E-mail ID / :
Remarks of the Principal / :
Principal Signature / :
(A) / BRIEF RESUME OF THE STUDY
INTRODUCTION:
Paralysis of the extremities is among the most debilitating injuries that body can experience following an injury, a disease or the degenerative process of aging. People with disability are entirely dependent on other people or devices for even the simple tasks, which are normally taken for granted. Augmenting independence for a human, providing reintegration into society, and allowing him/ her to be productive, will ultimately lead to improved quality of life1.Stroke is the leading cause of serious long term disability in adults2. Stroke is defined as rapid onset of focal neurological deficit, resulting from diseases of the central vascular and its contents.
Stroke is a world-wide health problem; with incidence ranging from 0.2 to 2.5 per thousand per year. According to WHO Collaborative Study in 12 countries, it accounts for 20% of neurological admissions. Till date, in India there have been only a few community based studies for either prevalence or incidence of stroke; with one reporting a prevalence rate of 334/100,000 and an incidence of 73/100,000 in 1990. Post-stroke hemiplegia is one of the most common causes of disability in adults. Prevalence of hemiplegia in South India is 56.9 per 100,000; as compared to 150 to 186 per 100,000 in the USA and Europe.3.
Ischemic and Haemorrhagic stroke are the two major types of stroke. Ischemic stroke is the most common type affecting about 80% of the individuals with stroke, and results when a clot blocks or impairs blood flow, depriving the brain of essential oxygen and nutrients. Haemorrhagic stroke occurs when blood vessels rupture, causing leakage of blood in or around the brain.
Clinically, a variety of deficits are possible, including changes in the level of consciousness and impairment of sensory and motor function.
Motor deficits are characterized by –
Hemiplegia – Paralysis typically on one side of the body, opposite to the site of the lesion.
Hemiparesis - Weakness typically on one side of the body, opposite to the site of the lesion.
Among all the different syndromes following stroke, a severely paretic arm is one of the most devastating. A few effective therapeutic options exist for its alleviation. Basic research demonstrated, that the functional deficits after stroke are determined by factors that include the extent of structural damage.4
Motor recovery of upper extremity in stroke patients is an important goal of rehabilitation. Motor recovery can be measured using the fugal- Meyer (FM) assessment, Brunnstrom motor recovery stage (BMRS), Manual function test (MFT) , Modified Ashworth Scale and activity by the self care items of the functional independence measure (FIM) , action research arm test, Motor activity log (MAL) ,wolf motor function test (WMFT).5
The basis of all stroke rehabilitation is the assumption that patients will improve with spontaneous recovery, learning and practice. Recent studies show that reorganization in the brain can occur with both recovery and learning but improves significantly in both with practice. It is also clear that motor learning mechanisms are operative during spontaneous stroke recovery and interact with rehabilitative training. In addition, studies suggest that retention of motor learning is best accomplished with variable training schedules and, for optimal result, rehabilitation techniques need to be geared towards patient a specific motor deficit. Several promising new rehabilitation approaches have been developed on theories of motor learning and include impairment oriented training, constrain induced movement therapy, electromyogram triggered neuromuscular stimulation, robotic interactive therapy and virtual reality.6
Constrain induced movement therapy : (CIMT)
CIMT is based on the initial research by DR. Edward Taub professor of psychology, which was conducted in 1970s -1980s. CIMT is based on the theory of “learned non-use.”7
According to the American Stroke Association, they recognize constraint-induced movement therapy as a forefront on post stroke rehabilitation. Behavioural “shaping” of the affected upper extremity, using the technique of successive approximations, was carried out for 3 hours a day, training the impaired upper limb in various tasks related to activities of daily living.7
Dr. Taub’s considered this as a learned non-use behaviour because of the negative feedback mechanism the patient perceived after the stroke by not trying to use the affected limb any longer. 8
CI therapy constitutes a family of treatment. the most frequently used variant involves motor restriction of the unaffected upper extremity by resting hand splint and sling and training to affected extremity 9
MIRROR THERAPY:
Mirror therapy is a relatively new therapeutic intervention that focuses on moving the unimpaired limb. It was introduced by Ramchandran and co-workers.2
Mirror neurons seem to be involved in the mechanism underlying mirror therapy. Their nervous cell with visiomotor properties discovered in the F5 brain area of the macaque. This particular type of neuron, also present in human brain, is active when an action is in progress and when the action is observed been performed by others. Altschular et. al. . Introduced MT in rehabilitation of hemiparetic stroke survivor, showing improvements in their range of motion, speed and dexterity of paretic arm. MT has been utilized to improve upper limb function mainly in chronic stroke survivors.
Mirror therapy is inexpensive, simple and most importantly patient directed treatment that may improve upper extremity function 10
NEED FOR THE STUDY:
Neurorehabilitation is a complex medical process based on knowledge of neurology and neuroscience. It emphasizes improvement of the nervous system during the medical process, and it has been reckoned that the recovery of sensorimotor and psychological functions comes from convalescence of the nervous system. One critical point of advancing neurorehabilitation is to translate the findings of neurology and neuroscience research into medical therapies for patients with neurologic diseases. Accumulating knowledge about neural recovery by noninvasive and real-time brain imaging has recently promoted the development of new neurorehabilitative therapies and has been expected to foster personal medical care in the future. In the past few years, a number of multicenter randomized clinical trials, including the Extremity Constraint-Induced Therapy Evaluation(EXCITE), Spinal Cord Injury Locomotor Trial(SCILT), Mirror Therapy and Robot-Assisted Therapy for long-term upper-limb impairment after Stroke, have been developed as good paradigms of transitional research in the field of neurorehabilitation. The effectiveness of CIMT and Mirror therapy was evaluated in real medical conditions and was compared with other therapies and was found simple and non expensive, but during our search for review of literature , no studies were found related to combined effectiveness of two therapies together in Indian population. So the need is to evaluate the effectiveness of constraint induced movement therapy along with mirror therapy on improvement in hand function among Indian patients.
HYPOTHESES:
Null Hypothesis (H0):CIMT along with mirror therapy will not be effective in improvement of hand function in subacute stroke phaseResearch Hypothesis (H1):CIMT along with mirror therapy will be effective in improvement of hand function in subacute stroke phase
REVIEW OF LITERATURE
Randomly assignment to either mirror therapy (MT) or an equivalent control therapy (CT) on 36 patients with severe hemiparesis. Outcome measure done by Fugl-meyer subscores for upper extremity, evaluated by independent rater videotape. Result shows that MT patient regained rater more distal function than control therapy given patient. It is concluded that MT early after stroke is a promising method to improve sensory and attentional deficits and to support motor recovery in a distal plegic limb.4
A study done on Constraint-Induced Movement Therapy for Motor Recovery in Chronic Stroke Patients. It was intervention study pretreatment to post treatment measures and follow-up 3 months after intervention. Five chronic stroke patients with moderate motor deficit. Convenience sample taken for this study. Outcome measure assessed by Actual Amount of Use Test (AAUT), Motor Activity Log (MAL), Wolf Motor Function Test (WMFT), and Arm Motor Ability Test (AMAT). The result shows that There was a substantial improvement in the performance times of the laboratory tests and in the quality of movement. it is concluded that
CI therapy is an efficacious treatment for chronic stroke patients, especially in terms of real world outcome.5
Constraint induced movement therapy is effective in the “real world” environment this work was carried out in American laboratory. The aim was to determine whether these results could be replicated in another laboratory located in Germany, operating within the context of healthcare system in which administration of conventional type of physical therapy is generally more extensive than in the United States. Result shows significant and very large degree of improvement from before to after treatment on the affected extremity in activities of daily
living in the life setting, with no decrement of performance at 6 month follow–up. It is concluded that results replicate in Germany the findings with CI therapy in an American laboratory, suggesting that the intervention has general applicability.9
A study to evaluate the effects of mirror therapy on upper extremity motor recovery, spasticity, and hand related functioning of inpatients with subacute stroke. Randomiselly 40 stroke patient selected and 30 minutes of mirror therapy program a day consisting of wrist and finger flexion and extension movements or sham therapy in additional to conventional stroke rehabilitation. Outcome measure assessed by brunnstrom stage of motor recovery, spasticity assessed by Modified Ashworth Scale. It concluded that hand function improved more after mirror therapy.10
A study done to compare the effect of two week multisite program of CIMT vs. usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 month. This study done on 223 stroke patients. The outcome measure done by wolf motor function test (WMFT), a measure of laboratory time and strength based ability and quality of movement, motor activity log. It is concluded that among patients who had stroke within previous 3 to 9 month, CIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least one year. 11
A single blinded, randomized controlled trial done on 33 patients, to compare the effect of mirror therapy (MT) verses control treatment on movement performance, motor control, sensory recovery and performance of activities of daily living in people with chronic stroke outcome measurement done by fugal–Meyer assessment, kinematic reaction. It is concluded that application of MT after stroke might result in beneficial effect on movement performance and motor control.12
Randomized allocated 23 stroke patient into experimental group and control group. Experimental group received functional electrical stimulation with MT, and control group received functional electrical stimulation without MT. Motor recovery measured by
Brunnstrom motor recovery stage (BMRS), manual function test, Box and block test. it is concluded that motor functions of upper extremity were improved by functional electrical stimulation with mirror therapy.13
A study to evaluate the efficacy of mirror therapy in the upper limb rehabilitation of people with sub acute stroke. A randomized controlled trial on with severe hemiparesis within one year suffered from first stroke. Motor recovery was measured using the brunnstrom stage, spasticity by Modified Ashworth scale (MAS) and functional independence measure. it concluded that mirror therapy , in addition to conventional therapy , improve hand function in patient with severe hemiparesis both post treatment and at six month follow up.14
Randomized selection of twenty six subacute stroke patients, divided into two group. Group A given mirror therapy and other group given conventional therapy to evaluate if adding mirror therapy in conventional therapy (CT) can improve motor recovery of upper limb in subacute stroke patient . Action research arm test (ARAT), Motricity index (MI) and functional outcome measure were the outcome measures. It is concluded that MT is a promising and easy method to improve motor recovery of upper limb in subacute stroke patient.15
A study done on Does the application of constraint – induced movement therapy during acute rehabilitation reduced arm impairment after ischemic stroke? In this study 23 people randomized, controlled trial that compared CIM with traditional therapies outcome measure measured by Action Research Arm Test (ARA). Differences in the mean ARA grip, grasp, and gross movement subscale scores did not reach statistical significance. UE activities of daily living performance were not significantly different between groups, and no subject withdrew because of pain or frustration. It is concluded that clinical trial of CIM therapy during acute rehabilitation is feasible. CIM was associated with less arm impairment at the end of treatment.16
A study done on efficacy of modified constraint – induced movement therapy in chronic stroke: A single blinded randomized controlled trial. In this study seventeen stroke patients participated in structured therapy sessions emphasizing more affected arm in valued activity. Outcome measures assessed by action research arm test, motor activity log , Fugl-meyer assessment of motor recovery. It is concluded that modified constraint-induced movement therapy may be efficacious method of improving function and use of the more affected arm of chronic stroke patient. 17
A new family of rehabilitation techniques, termed Constraint-Induced Movement Therapy or CI Therapy, has been developed that controlled experiments have shown is effective in producing large improvements in limb use in the real-world environment after Cerebrovascular accident (CVA).A number of neuroimaging and transcranial magnetic stimulation studies have shown that the massed practice of CI Therapy produces a massive use-dependent cortical reorganization that increases the area of cortex involved in the innervations of movement of the more-affected limb. The CI Therapy approach has been used successfully to date for the upper limb of patients with chronic and subacute CVA and patients with chronic traumatic brain injury 18
A study on 68 chronic stroke patients on constraint induced movement therapy in which the MAL was used to assess how stroke survivors use their more impaired arm outside the laboratory and concluded MAL can be used exclusively reliable and valid measure in real-world upper extremity rehabilitation outcome and functional status.19
A study is done to determine the intra- and interrater reliability of the Action Research Arm (ARA) test, to assess its ability to detect a minimal clinically important difference (MCID) of 5.7 points, and to identify less reliable test items.20 chronic stroke patients taken for this study, outcome measure assessed by Spearman’s rank-order correlation coefficient (Spearman’s rho); intraclass correlation coefficient .this study conclude that The high intra- and interrater reliability of the ARA test was confirmed, as was its ability. 20
OBJECTIVES OF THE STUDY:
- To determine the effectiveness of CIMT along with MT on improvement in hand function
B) / PROCEDURE, MATERIALS AND METHODS:
SOURCE OF DATA COLLECTION:
The following departments of S.D.M. College of Medical Science and Hospital, Dharwad.
- Department of Neurology
- Department of Neuro Surgery
- Department of Physiotherapy
C) / METHOD OF COLLECTION OF DATA:
Ethical Clearance has been obtained from S.D.M. college of Medical Science And Hospital. All stroke patients visiting the Departments of Neurology, Neuro surgery and/ Physiotherapy will be included in the study. All type of stroke patients will be included in the study after screening them as per the inclusion & exclusion criteria, depending on their willingness to participate in the same. A written informed consent will be obtained from the patient for participating in the study. The demographic data of the stroke survivor will be collected from the relevant records.
MATERIALS USED FOR THE STUDY :
- Mirror box
- Arm sling.
- All type of stroke experienced within previous 9 months
- Ability to extend at least 20 degree at the wrist and 10 degree at finger
- Either sex of hemiplegic stroke
- Age between 18 to 75 year
- Grade 2 on Modified Ashworth Scale i.e. More marked increase in muscle tone through most of the ROM, but affected part (s) easily moved.
- Global aphasia or cognitive impairment, which may interfere with the understanding of intructions for motor testing
- Heart pacemaker
- Epilepsy
- Pregnancy
- Any traumatice condition in lastoneyear prior tostroke
- Any serious uncontrolled medical condition
- Strokedueto head injury
- Participating in any experimental rehablitation or drugstudies
- Spasticity grade 3 and aboveonModified ashworth scale
Experimental study
STUDY DURATION: 1 year
SAMPLE SIZE:
Incidence of stroke patients admitted in SDMCMS&H from Jan 2012 to date is 993 out of which 647 were male, 343 females and 3 children. All the stroke patient who will be referred for physiotherapy by different departments from January 2014 to December 2014 will be included in the study.
PROCEDURE: