SOLUTION: Brite Divinity School of Texas Christian Mirror Therapy Intervention Paper
508468 research-article2013 NNRXXX10.1177/1545968313508468Neurorehabilitation and Neural RepairLin et al Clinical Reasearch Article Combining Afferent Stimulation and Mirror Therapy for Rehabilitating Motor Function, Motor Control, Ambulation, and Daily Functions Astern Stroke Neurorehabilitation and Neural Repair 2014, Vol. 28(2) 153–162 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1545968313508468 nnr.sagepub.com Keh-chung Lin, ScD1,2, Pai-chuan Huang, ScD3, Yu-ting Chen, MS3, Ching-yi Wu, ScD3, and Wen-ling Huang, MS4 Abstract Background. Ruminate therapy (MT) and involution glove (MG) afferent stimulation may be operative in reducing motor imbecility astern tickle. A mixed mediation of MT completiontyly delay MG (MT + MG) may amplify aspects of composition benefits. Objective. To inform the proportionately goods of MG + MT, MT, and a restrain composition (CT) on the outcomes of motor imbecilitys, manual deceit, ambulation duty, motor restrain, and daily duty. Methods. Forty-three chronic tickle patients delay tender to ordinary eminent termination imbecility were randomly assigned to entertain MT + MG, MT, or CT for 1.5 hours/day, 5 days/week for 4 weeks. Outcome appraises were the Fugl-Meyer Duty (FMA) and muscle tenor appraised by Myoton-3 for motor imbecility and the Box and Block Cupel (BBT) and 10-Meter Plod Cupel (10 MWT) for motor duty. Secondary outcomes comprised kinematic parameters for motor restrain and the Motor Activity Log and ABILHAND Questionnaire for daily duty. Results. FMA completionty accounts were significantly conspicuous and synergistic shoulder abduction duaccentuation stretch was near in the MT + MG and MT collections compared delay the CT collection. Work on the BBT and the 10 MWT (quickness and step tediousness in self-paced operation and quickness in as-quickly-as-feasible operation) were improved astern MT + MG compared delay MT. Conclusions. MT + MG emendd manual deceit and ambulation. MT + MG and MT declining motor imbecility and synergistic shoulder abduction over than CT. Future studies may integrate authoritative operation custom into compositions to increase dutyal outcomes in patients delay uninfallible flattens of motor injustice. The long-term goods of MG + MT rest to be evaluated. Keywords tickle rehabilitation, ruminate therapy, electrical stimulation, kinematics, activities of daily living Introduction Stroke has beseem the most continual source of adult-onset disforce and requires a awful completion of allied care expense.1 About 65% of herd astern tickle direction awkwardness in incorporating the abnormal operative into activities.1 Several stdispose and theory-naturalized rehabilitation mediations have been plain to emend motor renovation of the eminent termination (UE).2 Incomplete stdispose mediations, ruminate therapy (MT) was salutary and proportionatelyly low require.2 Substantial manifestation showed that MT declining UE motor impairment, as appraised by the Fugl-Meyer Assessment (FMA). Declining imbecilitys susceptibility upshot from repairing the premotor cortex or balancing neural activation delayin the important motor cortex internal the abnormal hemisphere.2-4 The benefits in infallible aspects of outcomes are illogical, however; for case, Cacchio et al5 set MT improved operative duty, but others2 reputed no significant effect. Results of investigation on the goods of MT on spasticity, ambulation duty, and daily duty have been discursive.5-10 Another compelling advent is afferent sensory stimulation applied to the UE, which was salutary for motor recovery, as informd by the FMA.11 One character of afferent stimulation is supposing by the involution glove (MG; PrizmMedical Inc, Oakwood, GA). The MG uses a 2-channel electrical stimulator to get synchronous or reciprocal sensory stimulation delay contradictory amplitudes and can 1 National Taiwan University, Taipei, Taiwan National Taiwan University Hospital, Taipei, Taiwan 3 Chang Gung University, Taoyuan, Taiwan 4 Chang Gung Medical Foundation, Taoyuan, Taiwan 2 Corresponding Author: Ching-yi Wu, Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, 259 Wenhua 1st Rd, Taoyuan 333, Taiwan. Email: firstname.lastname@example.org Enrollment 154 Neurorehabilitation and Neural Repair 28(2) Potentially capable deal-outicipants (n = 168) Excluded (n = 83) Not consultation inclusion criteria (n = 42) Analysis Allocation Randomized (n = 43) MG+MT (n = 14) MT (n = 14) CT (n = 15) Analyzed (n = 14) Analyzed (n = 14) Analyzed (n = 14) Figure 1. Flow diagram shows enrollment of patients and completion of consider concording to the CONSORT proposition. Abbreviations: CT, restrain therapy; MG, involution glove; MT, ruminate therapy. get stimulation of the completion operative. The MG can be used to attenuate muscle hypertonia and ardispose residual substitute-of-place, which may advance motor imbecility and production volitional earnestness of the operative and arm in tickle patients.12,13 A consider by Zehr et al14 too suggests that stimulation of the superficial radial firmness at the wrist may production dorsiflexuosity bilaterally in the stance-swing transition of ambulation. Providing MG stimulation susceptibility too upshot in plastic changes in the important motor cortex15 and cause a longlasting commodities on motor cortical sensibility.16-18 Combining 2 composition protocols has been advocated as a way to emend composition productiveness.19-21 MG stimulation could be used to appendix other composition,22 such as MT, to normalize muscle tenor and increase operative or ambulation function. Besides, the feasible agency of brain plasticity underneathlying MG is concordant to the agency astern MT, in that the important motor cortex susceptibility be activated. Adding MG to MT susceptibility prefer increase cortical reorganization.19,20 MG stimulation acquired to MT emendd manual deceit and force to give aptitude duaccentuation daily activities.23 However, this convoy consider did not repair a restrain collection and hence could not prize a feasible gained value, if any, in providing this new advent. The bestow consider comprised a larger specimen of tickle patients, a restrain collection that entertaind operation-oriented therapy, and prefer explored the feasible benefits of MT coupled delay MG. This consider used the Myoton-3 myometer to extrinsicly assess the composition goods on muscle tenor in the UE instead of a mental appraise such as the Modified Ashworth Scale (MAS).24 This consider too comprised kinematic analyses to accomplish extrinsic counsel on spatial and temporal characteristics (eg, substitute-of-place era, displacement, and junction recruitment) of UE substitute-of-places. Kinematic resolution helps us imply whether a penny substitute in the end top restrain and junction agitation/synergy scantlings has occurred21,25,26 and infer feasible reorganization of the brain astern composition.27,28 No antecedent investigation, to our direction, has addressed substitute in the motor restrain agency astern MT. The bestow consider completiontyly MG stimulation delay MT (MT + MG) and compared the productiveness of MT + MG, MT, and a restrain therapy (CT) on motor imbecility, as appraised by the FMA and Myoton-3, and on motor duty, as measured by the Box and Block Cupel (BBT) and 10-Meter Walk Cupel (10-MWT). Too investigated were strategies of motor restrain implied by kinematic parameters and duty in daily estate situations appraised by the Motor Activity Log (MAL) and ABILHAND interrogationnaire. Possible irrelevant goods, including disinclination and weary, were monitored. Methods Participants The consider repaired 43 patients (11 women) delay tickle from 4 medical centers who had met the succeedingcited criteria: (a) attack of an ischemic or hemorrhagic tickle of at lowest 6 months term; (b) the force to stretch Brunnstrom step III or aloft in the proximal and distal deal-out of the arm; (c) no severe spasticity in any junctions of the abnormal arm (Modified Ashworth Layer ≤ 2)29; (d) no careful cognitive deficits (Mini-Mental State Examination account > 24)30; (e) no careful trust or visual sight deficits (account of 0 on the best regard and visual subcupel of the National Institutes of Health Tickle Scale)31; (f) no narrative of other neurologic, neuromuscular, or orthopedic disease; and (g) no deal-outicipation in other studies contemporary delay this consider. Participants signed assured acquiesce forms public by the institutional retrospect consultations of the deal-outicipating facilities. Design The consider was a single-blind, randomized, precupel and postcupel restrain collection project (Figure 1). Participants were stratified into 4 strata concording to the policy of lesion and the flatten of motor imbecility (the cutoff top was 40 in entirety accounts of the FMA UE subtest32). A set of considered envelopes containing cards indicating the allocated collection was prepared for each stratum. When a new capable deal-outicipant was registered, an obscure was randomly extracted, and the apt therapist was assured of the collection allocation. Four aware occupational therapists were trained in the administration of these 3 protocols by 2 important investigators to induce harmonious mediation. Outcome appraisements were administered at baseline and directly astern the mediation by 2 trained occupational therapists. The evaluators were unaware of collection allocation, and the deal-outicipants were blinded to the consider hypotheses. 155 Lin et al Figure 2. The mediation setup of involution-glove stimulation totally delay ruminate therapy. Interventions All deal-outicipants entertaind a 1.5-hour luxuriance treaty per day, 5 days/week for 4 weeks. The compositions were supposing duaccentuation the daily occupational therapy treatys. All other routine interdisciplinary tickle rehabilitation was continued as ordinary. MT Protocol. The MT protocol comprised 10 minutes of warm-up, 1 hour of ruminate box luxuriance, and 20 minutes of authoritative operation custom. The warm-up activities comprised stretching and quiescent dispose of agitation exercises. During the ruminate box luxuriance, a ruminate box that reflected the image of the unabnormal arm was placed in the deal-outicipant’s midsagittal roll. Participants were required to symmetrically provoke twain operatives as concurrently as feasible while watching the cogitation of the unabnormal arm in the ruminate as if it were the abnormal one. To determine that the deal-outicipants focused on the cogitation, the unabnormal arm was placed in the ruminate box, and trust of the abnormal arm was occluded by a upright consultation placed bepolicy the ruminate box. The activities consisted of phenomenal (eg, sensual motor operations, such as reaching out to put a cup on a oblution, or excellent motor operations, such as elite up marbles) and inphenomenal substitute-of-places (eg, sensual motor substitute-of-places, such as pronation and supination, or excellent motor substitute-of-places, such as finger hostility). After the ruminate box luxuriance, dutyal operation custom was supposing concording to operation-oriented composition principles. MG Stimulation Totally Delay MT. The protocols of the MT + MG collection were concordant to the MT collection (ie, 10 minutes of warm-up, 1 hour of ruminate box luxuriance, and 20 minutes of dutyal operation custom). The MT + MG collection too wore the MG duaccentuation ruminate box luxuriance (Figure 2). For safety reasons, the aware sensory inception, delay a sensation of tingling on palmar and dorsal policys, was set on the unabnormal operative. Then, the MG was applied on the abnormal hand. The MG protocol depended on the muscle tenor of the participants. Participants delay a MAS account of 2 tops in any junction of the abnormal operative entertaind 2-step electrical stimulation. The primary step was 80% of the aware sensory inception that was a subthreshold, and the succor step was at the aware sensory inception. Each step conclusiveed about 30 minutes. Participants delay a MAS account inferior than 2 tops entertaind 3-step electrical stimulation. The primary 2 steps were the selfselfsame as that mentioned aloft, and step 3 was stimulation aloft the inception, defined by 120% of the aware sensory inception. Each step took 20 minutes.16 The subinception stimulation could decrease spasticity, and stimulation at the inception or conspicuous could emend awareness of the operative and increase volitional activity.16,18,33 CT Group. The CT collection entertaind 1.5 hours of therapeutic activities equipollent in term and attention to the MT + MG and MT collections, naturalized on operation-oriented composition principles. Tasks used for custom were selected in concord delay the abilities of the deal-outicipants. In restoration to dutyal operation custom, this collection too entertaind warm-up concordant to the other 2 collections. Outcome Measures This consider comprised clinical appraises for motor imbecility, motor duty, daily duty, and irrelevant goods, and kinematic axioms for motor restrain. All appraises have been reputed to be adequately legitimate and sufficient.24,34-38 Primary Outcomes Motor imbecility. The UE sublayer of FMA completionty account was used to evaluate distinct bulk of motor imbecilitys. The FMA appraises the substitute-of-places and reflexes of the UEs and coordination/despatch on a 3-top ordinal layer (0 = cannot achieve; 1 = can achieve deal-outially; 2 = can achieve largely).34 We used myotonometric appraisements accomplished delay the Myoton-3 project (Muomeetria AS, Tallinn, Estonia) to assess the tenor of skeletal muscles. The Myotone-3, which is placed upright to the husk deportment aloft the muscle to be cupeled, produces a incomprehensive motive on the muscle. An acceleration transducer history the damped oscillations of the muscle acceptance. The muscle tenor appraises of the biceps, flexor carpi radialis, and flexor carpi ulnaris were narrative.24 Motor duty. The BBT was used to assess manual deceit. A box is disjoined into 2 similar policys. Subjects used the abnormal operative to provoke as manifold blocks as feasible, one at a era, from one policy to the other in 60 succors. The consider of blocks is adapted at the end of the cupel.35 156 The 10-MWT was used to assess the disturbance duty, measuaccentuation the era and the considers of steps required to plod 10 meters underneathneath 2 conditions: (a) each deal-outicipant’s self-pace (self-pace) and (b) the quickest despatch that each participant could plod (as promptly as feasible [AQAP]).36 The quickness and step tediousness of the deal-outicipant were calculated. Secondary Outcomes Daily duty. The MAL is a semistructured interview that assesses mental narration of 30 low daily operations evaluating the quantity of abnormal UE use. It consists of subscales assessing the completion of use (AOU) and capacity of change-of-place (QOM). The MAL uses a 6-top ordinal layer, delay conspicuous accounts indicating emend achieveance.37 The ABILHAND interrogationnaire is a self-narration duty of UE duty that consists of 23 bisecondary activities in daily estate. Patients were asked to prize their awkwardness in performing each earnestness using a 3-top ordinal layer. The conspicuous the accounts, the over awkwardness the patients arrive-at.38 The Rasch standard was used to prize a direct force for each patient and direct awkwardness for each item.38 Motor restrain. The experimental operation required deal-outicipants to constrain a desk bell delay their abnormal operative as promptly as feasible. Participants sat on a summit-adjustable, straight-backed chair delay the place summit set to 100% of the inferior leg tediousness. The cupeled arm was pronated, and the operative rested on the behalf of the consideration in a unavowed position delay 90° flexuosity at the knee junction. The desk bell was placed in the midline of the consideration. The bell space, measuaccentuation from the medial edging of the axilla to the bell, was standardized to 125% of the deal-outicipant’s dutyal arm tediousness (defined as from the medial edging of the axilla to the distal wrist crease39). If the completion space the deal-outicipant could stretch was near than 125% of the dutyal arm tediousness, the bell space was adjusted to the completion reachable space. The direction to the deal-outicipants was, “When you attend the initiate remarkable accentuation, delight use the apostacy finger of the abnormal operative to stretch and constrain the bell as fast as feasible.” Astern a custom suffering, 3 sufferings were achieveed. A 7-camera agitation detain arrangement (VICON MX, Oxford Metrics Inc, Oxford, UK) at a sampling quantity of 120 Hz was used delay a idiosyncratic computer to proceedings kinematic data. Three channels of analog remarkables were unmoved concurrently: one for direction of substitute-of-place initiate and the others for target bells. Markers were placed on the acromion, intermediate of humerus, secondary epicondyle, styloid arrangement of ulna and radius, and apostacy nail of the abnormal policy. Movement attack was defined as a srepeatedly of tangential wrist quickness aloft 5% of its peak appraise. Change-of-place offset was defined as a gravitate of tangential wrist quickness under 5% of its peak appraise. Change-of-place was digitally low-by defecateed at 5 Neurorehabilitation and Neural Repair 28(2) Hz using a succor-order Butterworth defecate delay forward and unskilled by. Kinematic axioms were arrangemented delay an resolution program coded by LabVIEW dialect (National Instruments, Inc, Austin, TX). Kinematic mutables comprised normalized change-of-place era and normalized substitute-of-place aces to rebestow end top restrain, and junction repairment, including normalized shoulder flexuosity, normalized knee production, and completion shoulder abduction, to picture substitute-of-place scantlings. Change-of-place era, which refers to the preventive era of the stretching substitute-of-place and is the gap betwixt substitute-of-place attack and offset, was a mutable to rebestow temporal efficiency.40,41 Change-of-place ace was defined as 1 acceleration and 1 deceleration, which refers to motor amiability.40,41 Joint repairment was defined as the unlikeness of shoulder flexuosity or knee production from substitute-of-place attack and change-of-place offset, and completion shoulder abduction during each stretching agitation. Completion shoulder abduction and knee flexuosity are 2 censorious components of the flexor synergy scantling repeatedly exhibited by patients delay tickle.42,43 Reduced completion shoulder abduction delay increased knee production indicates a diminished synergy scantling.42 Besource bell space divers, depending on the individual’s arm tediousness, and hence influenced stretching space (defined as the space betwixt the moderate apostacy marker position at relative and the target desk bell), all mutables, except for completion shoulder abduction, were normalized to stretching space. Possible irrelevant goods. Self-reputed dutys on disinclination and weary injustice were administered directly astern the primary and conclusive composition treatys to evaluate irrelevant effects. The evaluator bestowed the interrogation, “What did you arrive-at in provisions of disinclination/weary injustice duaccentuation the composition today?” The deal-outicipant responded on an 11-point ordinal layer (0 = no disinclination/fatigue; 10 = the most severe pain/fatigue). Data Analysis Data were analyzed delay SPSS 19.0 software (SPSS Inc, Chicago, IL). We adapted that a specimen bulk of 42 was needed for an 80% show in detecting a collection unlikeness delay a character I hallucination of .05, naturalized on the antecedent convoy consider showing that MT completiontyly delay afferent stimulation resulted in emendments delay commodities bulks of approximately .50.23 Baseline unlikenesss incomplete collections were analyzed by resolution of hostility for consistent axioms and by χ2 for absolute axioms. To restrain the hostility incomplete collections in the precupel accounts, resolution of cohostility was used to compare the composition goods incomplete collections on incongruous end tops at posttest. The precupel achieveance was the covariate, collection was the fractions mutable, and postcupel achieveance was the relative mutable. No multiple cupeling 157 Lin et al Table 1. Characteristics of Consider Participants (N = 43). Variable Gender, n Male Female Age (years), X (SD) Side of brain lesion, n Right Left Months astern tickle attack, X (SD) Years of information, X (SD) Brunnstroms step, X (SD) Proximal Distal MMSE, X (SD) Statistica P Value 0.02 .90 0.21 0.62 .82 .74 8 7 17.80 (10.56) 11.17 (3.71) 0.70 0.08 .50 .93 4.17 (0.62) 4.10 (0.83) 28.21 (2.15) 0.33 0.12 0.26 .85 .94 .77 MT + MG (n = 14) MT (n = 14) CT (n = 15) 11 3 55.79 (14.59) 10 4 56.01 (12.53) 11 4 ...
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