RATIONALE OF STUDY
One of the most common problems in post stroke patients is upper limb disability. Without functioning upper extremities ADL activities can not be performed efficiently. So upper extremity performance has been identified as an important early predictor of functional outcome in post stroke patients.
Although various treatment protocols are available to treat this condition but there is very few research evidence present regarding efficacy of MRP and Mirror Therapy, but both MRP and Mirror Therapy claims to produce improvement of upper extremity functioning in post stroke patients.
Thus this study will be conducted to find out which of the techniques between MRP and Mirror Therapy is more effective for the improvement of upper extremity functioning in post stroke patients.
HYPOTHESIS
NULL HYPOTHESIS (H0):
There will be no significant difference between the effectiveness of Motor Relearning Programme and Mirror Therapy over the improvement of Upper Extremity functions in post stroke patients.
ALTERNATIVE HYPOTHESIS(H1): There will be significant difference between the effectiveness of Motor Relearning Programme and Mirror Therapy over the improvement of Upper Extremity functions in post stroke patients.
INTRODUCTION
Stroke is a global health problem that is the second commonest cause of death and fourth leading cause of disability worldwide. Stroke is a common nervous system disorder that occurs due to abnormal blood circulation in the brain.
WHO defines stroke as ‘The rapid development of clinical signs and symptoms of a focal neurological disturbance lasting more than 24 hours or leading to death with no apparent cause other than vascular origin’.
TYPES OF STROKE:
Stroke is mainly of two types:
Ischemic
Hemorrhagic.
1. Ischemic Stroke: Ischemic stroke occurs as a result of an obstruction within a blood vessel supplying to the brain. The usual cause of this type of obstruction is acute thrombus formation at the site of an atheromatous plaque or embolism from the hearth. It can be divided into two categories. These are:
Thrombotic: Obstruction of a blood vessel by a blood clot or atherosclerotic plaque. As a result, blood flow through the vessel is reduced.
Embolic: Obstruction due to an embolus from elsewhere in the body. The embolus can lodge in a cerebral blood vessel, occlude it. It can cause death or infarction of cerebral tissue.
2. Hemorrhagic Stroke: It is mainly caused by hemorrhage. The arterial walls weaken and as a result small herniations or micro-aneurysms develop. These may rupture and the resultant haematoma may spread along planes of white matter and forms a substantial mass lesion. Haematomas usually occur in the deeper parts of the brain. It can be divided into two categories. These are -
Intracerebral Hemorrhage: There is bleeding from a blood vessel within the brain itself, due to either intraparenchymal hemorrhage or intraventricular hemorrhage.
Subarachnoid Hemorrhage (SAH): There is bleeding that occurs outside of the brain tissue but still within the skull, and precisely between the arachnoid mater and pia mater.
RISK FACTORS: There are various risk factors that predispose the incidence of stroke. The risk factors for stroke may be classified as modifiable and non- modifiable. The modifiable risk factors are hypertension, cigarette smoking, tobacco use, diabetes, hyperlipidemia, pre-existing heart disease, obesity, alcohol and drug abuse etc. The non- modifiable risk factors are age, gender, race, ethnicity and heredity. Although these factors can not be modified, their presence helps identity those at greatest risk, enabling vigorous treatment of those risk factors that can be modified.
Hemiparesis results in decreased muscle strength and range of motion in people after a stroke leading to decrease in function of the upper extremity. Hemiparesis can impact all areas of occupation, especially ADLs (bathing, grooming, dressing, eating) and IADLs (home management). These deficits may also hinder participation in activities requiring bilateral movements, such as cutting, shaving, buttoning, wearing shoes, driving or donning pants. People with hemiparesis after a stroke may also experience additional impairments such as cognitive deficits, sensation loss, or depression that may further influence their performance in desired occupations. Cognitive deficits and sensation loss can influence a person’s safety, such as a loss in judgement or an unawareness of hot surface touching the limb. Psychosocial issues can influence motivation and quality of life. That is why rehabilitation in upper limb function is so necessary to stroke patients.
The quality of life and independence in “basic†activities of daily living (washing, grooming, feeding, dressing, “instrumental†home/financial management, etc.) are significantly impacted by the loss of upper limb function independence. Relearning of motor skills is a necessary part of recovering motor function after a stroke and neuroplasticity plays a role in this. In order to maximize upper extremity functions after a stroke, recent studies have focused on designing rehabilitation procedures that encourage such neuroplasticity.
Task specific exercises are generally thought to have the greatest advantage for stroke patients because they are thought to promote neural plasticity. The MRP for stroke developed by Janet Carr and Roberta Shephard is an excellent example of this approach. The method includes multiple aspects of motor learning theory and provides beneficial recommendations for enhancing functional skills.
MOTOR RELEARNING PROGRAMME:
Motor relearning programme developed by Australian physical therapist Roberta Carr and Janet Shepherd (1983). MRP based on skill acquisition and motor development theories especially cognitive motor learning theory. It considers factors other than CNS damage that may be affecting performance. MRP stress on practice that fits the nature of the task. MRP is based on distributed control model and emphasize the interaction between the performers and environment. Motor learning has been defined as set of processes associated practice or experiences leading to relatively permanent change in the capability for producing skilled action. Learning results from experience or practice. It produces relatively permanent change in behaviors. MRP is practiced in four steps which are-
Ø Postural Adjustment
Ø Compensator Strategies
Ø Analysis of normal motor performance of functional task
Ø Motor Learning
Postural Adjustment: Automatic, anticipatory and ongoing muscle activation that enables an individual to maintain balance against gravity, optimal alignment between body parts and optimal orientation of head, trunk and limbs in relation to the environment.
Compensator Strategies: These are motor pattern on fixation which developed in response to obstruction to normal movement. The effect of compensatory strategies, prevention of abnormal muscle shortening, muscle weakness and fixation pattern.
Analysis of normal motor performance of functional task: Explanation of goal, visual and verbal feedback, manual guidance and re-evaluation.
Motor Learning: Motor learning is a process of acquiring the capability for skilled action results from experience or practice. Learning can not be measured directly and produce relatively permanent change in behaviors.
Mirror Therapy:
Mirror therapy is a form of imagery treatment in which a mirror is used to convey visual stimuli to the brain through observation of one’s unaffected body part as it carries out a set of movements. The underlying principle is that movement of the affected limb can be stimulated via visual cues originating from the opposite side (normal side) of the body. Hence it is thought that this form of therapy can prove useful in stroke patients who have lost movement of an arm.
Visual stimuli enhance neuroplastic changes within the brain. When normal somatosensory feedback is missing, visual feedback restores the information flow from the posterior parietal cortex to the pre motor cortex. Recruiting the posterior cortex or rebuilding the motor programme in the pre motor cortex by providing visual feedback could reduce pain and facilitate the limb movement. To achieve visual feedback patient can be treated with mirror therapy.
Mirror therapy works on the principle of “Mirror Neuronsâ€. Mirror Neurons accounts for about 20% of all the neurons present in a human brain. These mirror neurons are responsible for laterality reconstruction i.e., ability to differentiate between the left and the right side. When using the Mirror box, these mirror neurons get activated and helps in the recovery of affected parts.
Using mirror therapy is easy, by placing the affected limb in the mirror box and unaffected limb in front of the mirror, then using both limbs to do the gentle symmetrical exercises. It is very important to practice symmetrical movements for e.g. keeping the hand still and moving the hand outside the box or vice versa, may make the condition worse. Some patient may find difficult in using the mirror at first and more painful, so we should then consider practicing to visualize moving the limb first, think about easy movement initially such as clenching of fingers and then move on to visualizing more complex exercises and this may take several weeks. Improvement comes with repeated exercises.
Motor recovery from stroke appears to involve centraly generated submovements and through the recovery process, change in submovements are accepted. Participants who experience stroke and are trained on point to point movement with assistance of a rehabilitation robot were able to generalize training to an untrained task, showing fewer submovements that lasted longer resulting in smoother and more accurate movements. Task based, goal directed activities with real objects results in improved movements and performance of people recovering from stroke who have hemiparesis.
Several studies have examined the effects of MRP and Mirror Therapy on stroke patients, but very little has been established regarding the best ways to implement the various exercise techniques. This would be the first randomized control trial which properly defined the exercise programme and evaluate the impact of MRP and Mirror Therapy on upper extremity functions in post stroke patients.
STUDY TECHNIQUES
TREATMENT PROCEDURE:
Post stroke 30 patients fulfilling the inclusion and exclusion criteria will be chosen by convenient sampling and will be allocated randomly into two groups; GROUP-A & GROUP-B. Each group consist of 15 patients.
INTERVENTION TECHNIQUES:
GROUP-A will receive Motor Relearning Programme &
GROUP-B will receive Mirror Therapy.
GROUP-A: In this group, patients will receive Motor Relearning Programme. Treatment session will be 6 days per week upto 4 weeks.
Motor Relearning Programme:
Different Techniques:
1 Analysis of Motor Performance: Reaching actions are significantly impacted by the weakness of the glenohumeral joint’s abductors, flexors, external rotators and supinators while the ability to manipulate objects is impacted by weak wrist extensors, finger and thumb flexors, extensors, abductors and adductors.
2. Observational Analysis: Therapists must rely on their own visual observations of motor performance as part of daily motor training in order to conduct analysis and serve as a guide for intervention.
3. Focusing Attention: Determining what the patient should pay attention to throughout practice is significant. Verbal instruction and live video illustration are two methods for focusing attention.
4. Soft Tissue Stretching: To reduce muscle stiffness before exercise and as needed throughout, quick passive stretches are performed right before and during the exercise session. Active stretching occurs with active exercise.
5. Training:
Active Exercises:
Sitting position: Lifting and lowering a glass held by the palm and fingers while keeping one arm on the table. Placing the glass to the left and right by flexing and extending the wrist, lifting it off the table with the forearm in mid-rotation. Tapping the tabletop with all of fingers. Supinating while holding a ruler and placing the ruler’s end on a surface. Transfer the cup patient is holding, which is full of water, to the other hand and set it where patient would like to be. While holding the forearm in the middle of its rotation, slide the glass forward in a different direction to touch the targets. With the elbow extended and flexed, slide the glass backwards and forwards until it touches the target. When the shoulder is at 90 degrees of flexion, it can reach and point within a controlled range above that angle, and its forward and sideways range gradually expands. Putting the forearm on the lap while shrugging the shoulders. Lifting hands to comb hair.
Reaching and Balancing Practice: Exercises perform while sitting on a stool include reaching forward, sideways or backward to pick up an object, moving it to another location (such as the floor), picking it up again, reaching as far as patient can in one direction, then setting it down.
Manipulation and Dexterity Practice: Exercises on a peg board, hand-cupping exercises to practice opposing the radial and ulnar sides of the hand, scooping coins off a tabletop into the palm of the opposite hand, picking up a glass of water and drinking it and tapping exercises to quickly touch the tips of each finger to the thumb are among the best methods to strengthen patient’s hands.
Bimanual Practice: Bimanual training should begin as soon as the patient is able to control basic motions with the damaged limb; exercises include holding objects between the ring and little fingers and palm while trying to remove them with the opposite hand. Holding the spoon and transferring the liquid to the mouth are activities involved in spoon-drinking. Practice moving patient’s hand while preventing spillage.
Strength Training: Without increasing spasticity, strength training may enhance muscle power. The progression of elastic band exercises involves switching to a different colored band. Examples include gripping activities utilizing progressively larger objects when performing reaching, lifting and manipulating tasks.
6. Feedback: The feedback learners get regarding the way they do an action is a crucial component of skill development. There are two main types of feedback: extrinsic feedback, which provides knowledge of the action’s outcomes and knowledge of the performance itself and intrinsic feedback, which is the naturally occurring sensory feedback (visual, proprioceptive and tactile) occurring as part of the activity.
7. Transfer of Learning: Facilitating the patient transfer training (learning) from the practice environment (the rehabilitation setting) to other surroundings is one of the main goals of the therapist’s role as facilitator and instructor.
GROUP-B: In this group, patients will receive Mirror Therapy. Treatment session will be 6 days per week upto 4 weeks.
Mirror Therapy:
1. Positioning of Arm: In mirror therapy, the patient sits near to a table and the mirror box is placed upon the table. The paretic hand is placed behind the mirror and non-paretic hand in front of the mirror. The patient is instructed to try to make the identical motions with the paretic hand while moving the non-paretic hand during the session. Bimodal visuomotor neurons known as mirror neurons are active during action execution, mental stimulation (imagination), and active observation.
2. Practice of Movements (Different Techniques): The exercises include writing or drawing circles, squeezing a ball, utilizing all the fingers to oppose one another, reaching, gripping, lifting and placing things (different sizes and shaped weighted objects), counting with fingers, opening and closing of the hands and forearm supination and pronation.
Pre and post outcome measure will be taken during and after the treatment procedure.
EXPECTED OUTCOME:
Both the groups are expected to show improvement as four weeks of intervention should produce some results. However whether they are statistically significant and if there will be any difference the two interventions remains to be seen.