CONSTRAINT INDUCED MOVEMENT THERAPY AND MIRROR THERAPY

CONSTRAINT INDUCED MOVEMENT THERAPY AND MIRROR THERAPY

1. CONSTRAINT INDUCED MOVEMENT THERAPY AND MIRROR THERAPY – Simran A. Mishra,

2. Contents Introduction CIMT Theoretical approach development Mechanism Screening pathways Components of CIMT Modified vs traditional Application and Recent advances Introduction to mirror therapy Principals and Mechanism Different conditions Recent advances

3. INTRODUCTION What is Constraint Induced Movement Therapy (CIMT) ? An evidence based Intensive Physical Therapy Rehabilitation Technique aimed at reorganizing and reprogramming the brain after a damage. It involves training of the weaker arm while restricting the use of the stronger arm. How did CIMT therapy came into existence ? It is derived from behavioural neuroscience research of Dr. Edward taubs which was done on monkeys between 1960’s and 1980’s , deafferentation of sensory nerves in forelimb results in decreased functional use of affected arm and increase functional reliance on unaffected limb. (Taub et al. 1993;) Constraint-Induced Movement Therapy – Upper Extremity, Annabel McDermott, OT 2016 Limiting the use of Normal side, using constraint.

4. Development of theoretical approach Injury e.g. stroke Depressed CNS Movement becomes effortful Less movement Unsuccessful motor attempts Failure Learning of non use Constriction of cortical zones Negative reinforcement Compensatory behaviour pattern Modified from taubs , www.cimt.co.uk.

5. Reversing learned non-use Restricting use of unaffected limb for 24 hours resulted in improved use of affected limb. Reverts back to original pattern once restriction removed. Restriction for longer period results in carry over. Limb use clumsy but functional. Positive Reinforcement Specific task training improves quality of activity Modified from taubs , www.cimt.co.uk.

6. Mechanism CIMT- influence of restraint and type of training on performance and on brain plasticity - Christina Brogårdh

7. Cortical reorganization Violin players (Elbert et al, 1995) Braille readers ( Sterr et al, 1998) Stroke patients ( liepert et al, 1998) Representation of body is continuously reorganized on the cortex. Liepert et al (2000), increase in cortical regions of the affected hand after CIMT where changes were remained on 6 months follow up. Stavrinou et al, (2007) Changes last for 2 hours when webbed for 5-6hours. CIMT is use dependent

8. Screening pathways Identifying ‘learned Non-use’ Standard criteria for movement recovery Should pass the tests

9. Exclusion criteria No movement in hand or Upper Limb Excessive fatiguability Excess pain Medically unstable Cognitive or behavioral problem Immediate post stroke period (<2 weeks)  Clinical Guidelines for Stroke Rehabilitation (2016), ISWP, immediate post stroke patients can involve. 

10. Components OF CIMT The repetitive training of tasks. It simulates part of a functional activity Task practice consists of a complete functional activity. Restriction or limiting the use of Unaffected arm. Adherence enhancing behavioural methods. Yadav RK, Sharma R, Borah D, Kothari SY, 2016 , 10 (11):1-5.

11. Ada Cristina Silva da Silva , Dayanna Letícia Silva Santos, 103-5150, Curitiba, v. 32, e003217, 2019

12. Dos Anjos S, Morris D, Taub E. Constraint-Induced Movement Therapy for Lower Extremity Function: Describing the LE-CIMT Protocol. Phys Ther . 2020 Apr 17;100(4):698-707 12

13. TYPES OF CONSTRAINT Mitt Triangular bandage Half glove Sling combined with resting hand splint

14. Traditional CIMT modified CIMT Six hours/day (five days/week) R estraint for 90% of waking hours Treatment duration upto 3 weeks Two Hours /day (2-7 days/week) Treatment duration upto 2-12 weeks Restraint to 5 hours/day. Constraint-Induced Movement Therapy after Stroke, Gert Kwakkel, PhD1,2, Janne M. Veerbeek

15. Original Vs Modified CIMT Original CIMT, although seen as the ‘gold standard’ of CIMT, has been investigated in merely one RCT. Significant post intervention effect were found for arm-hand activities , self-reported amount of arm-hand use in daily life and self-reported quality of arm-hand movement in daily life. Effects of original CIMT for these three outcomes were sustained at follow-up (4 months). mCIMT has been investigated in a vast amount of RCTs (n=44). Significant effect have been found post intervention in terms of motor function of the paretic arm, muscle tone, arm-hand activities , self-reported amount of arm-hand use in daily life , self-reported quality of arm-hand movement in daily life, and basic ADL The effects were sustained at follow-up (mean 21.58 (SD 13.21) weeks). Constraint-Induced Movement Therapy after Stroke, Gert Kwakkel, PhD1,2, Janne M. Veerbeek

16. APPLICATION OF CIMT STROKE CEREBRAL PALSY TRAUMATIC BRAIN INJURY (TBI) FOCAL HAND DYSTONIA PHANTOM LIMB PAIN Edward Taub . CIMT: A New Family of Techniques with Broad App to Physical Rehabilitation--A Clinical Review. Vol. 36 No. 3, July 1999

17. LIMITATIONS OF CIMT Bonifer and Anderson. Application of CIMT for an Individual With Severe Chronic Upper-Extremity Hemiplegia Physical Therapy . Volume 83 . Number 4 . April 2003 Constraint Induced Movement Therapy influence of restraint and type of training on performance and on brain plasticity Christina Brogårdh Department of Community Medicine and Rehabilitation 17 CIMT is not widely viewed by clinicians considered unfeasible due to patients’ concerns about intensive schedule of treatment CIMT program is difficult & frustrating. If physical progress occurs, happens slowly, only as the result of tremendous amount of effort & time by all participants

18. CIMT influence on balance is unclear, effect of upper extremity restraint on balance has not been fully explored, and the existence of ambiguity in this treatment technique requires further investigation. Therefore, the aim of the current study was to evaluate the influence of and upper extremity and lower extremity CIMT on balance and functional mobility in patients after a stroke.

19. The outcome measures utilized to assess balance were the BBS, limits of stability, toward the affected side and toward the unaffected side, center of mass displacement, center of pressure translation in medial to lateral and anterior to posterior directions, Functional Reach Test (FRT), modified-FRT, and Trunk Impairment Scale . Descriptions and outcome measure The mean age ranged from 52.46 years to 61.58 years. Out of the eight randomized controlled trials, 2 assessed UE, and the 6 investigated LE, CIMT. The control group interventions primarily included conventional physiotherapy concepts such as muscle strengthening, facilitation, activity training, balance, and gait training; however, in two studies, the control intervention involved concept-based interventions such as NDT.

20. Conclusion The results of the systematic review indicated that the CIMT has either positive effects or equal effects compared to the controlled interventions. This systematic review revealed positive effects of CIMT on balance in three studies and equal effects in five studies, compared to the control group interventions such as conventional physical therapy, NDT, gait training and forced-use therapy. A meta-analysis demonstrated a positive effect size of 0.51 (P = 0.01), showing that balance improved more with the experimental group CIMT intervention than control group interventions.

21. Mirror therapy Introduction It is an intervention that uses a mirror to create a reflection of the unaffected upper or lower limb, thus providing patient with visual feedback for normal movement of affected limb. Purpose is to increase the brain’s activity and to increase its ability to re-organize affected areas of brain by giving proper feedback to it. Shirley Ryan , Henry B, Rehabilitation Institute of Chicago, 2017, (312 ) 238.

22. First proposed by Vilayanur S. Ramachandran 1990 – for phantom pain. “Learned Paralysis ̎ of Phantom limb pain To retrain the brain - thereby eliminate the learned paralysis – created a Mirror box Moseley GL, gallace A, spence C. Is mirror therapy all it is cracked up to be ? Current evidence and future directrions . Pain. 2008;138(1):7–10.

23. Mechanism MT increases cortical and spinal motor excitability It has effect on Mirror neuron system. Responsible for laterality reconstruction. The observation of movement to stimulate the motor processes involved. Natural inclination to prioritize visual feedback over all other. Similar to Motor Imaginary Technique Ramachandra, V.S.: Rogers Ramachandra (1996), Proceedings of Royal Society, London.

24. Existence of two main network with mirror properties Voluntary behaviour Affective behaviour Luigi Cattanro et al, The Mirror Neuron System, archives, neurology. 2009

25. Mechanism responsible for benefit of mirror therapy Altschuler et al 1999, M. I. Garry et al 2005

26. Even Short immobilization can produce functional reorganization of the CNS. Decrease the cortical representation areas of brain. Temporary forgetting of affected limb function. Strafella and Paus 2000, M. I. Garry 2005

27. How to perform During Mirror Therapy, patient positions their both hands on either side of mirror. Patients see the reflected image of the healthy hand as their affected hand. Unaffected limb Affected limb Mirror

28. Ramachandran VS, altschuler EL. The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain. 2009 jul 1;132(7):1693-710 . 29 Mirror therapy Technique Mirror box consists of a 2× 2 foot mirror vertically propped up sagittally - middle - rectangular box   Patient places - unaffected limb into one side, and the stump into the other. making "mirror symmetric" movements Reflection seems visually superimposed on the felt location of the phantom Creating the illusion that the phantom - Resurrected – given for 2 weeks 10 min each day.

29. The graded motor imagery handbook, Moseley GL, Butler DS Beames , 2012

30. 31 Systematic review of the effectiveness of Mirror Therapy in Upper Extremity Function Daniel Lleezendam et al, disability and rehabilitation, 2009 15 studies 5 stroke 2 amputation of Upper Limb 5 CRPS 1 1 CRPS 2 2 Hand surgery except amputation

31. Mirror therapy for stroke Changes observed in terms of ROM, Speed and Accuracy. Significant effect in terms of Motor recovery and hand related functioning. No effect on spasticity. Sensorimotor coupling Compromised task intrinsic feedback Augmented feedback in form of visual feedback Mirror therapy for CRPS Immediate analgesic effect Reduction in stiffness Improvement in ROM Moseley – Sequential activation of cortical premotor and motor area or sustained attention on affected limb. Patients are in vicious circle of pain and disuse.

32. Mirror therapy: stroke rehabilitation Andreas Rothgangel , 2013.

33. Aims and general requirements Principle

34. 35 Positioning Non affected arm in front mirror Diagonal positioning of the mirror in a patient with neglect of the left side of the body Frequency & Duration of treatment Once daily – Min 10 mins & - Max 30 mins Split into 2 sessions 10-15 mins each

35. 36

36. 37 Training of motor function

37. Some examples of simple exercises and functional exercises

38. 40 Recent advance Study developed a robotics-assisted device for the stroke patients to perform the hand rehabilitation. The system can perform passive range of motion exercises for impaired hand, and mirror therapy for pinching and hand grasping motions under the guidance of the posture sensing glove worn on patient’s functional hand.

39. 41 System provides proprioceptive input to the sensory cortex during the mirror therapy using the robot

40. 42 With a posture sensing glove worn on the functional hand of the patient, joint angles and hand gestures can be recognized and imported as control commands to the system to manipulate the patient’s impaired hand to follow and perform the same motion of the patient’s functional hand.

41. 43 THANK YOU