MOD004054 Healthcare Environment

The patient scenario adopted for this paper is concerned with case history of Mr. A, a 59-year-old male, works has sales assistant in car part store, who has been diagnosed with stroke three weeks ago. The patient’s right side of the body is affected and he is currently admitted in the stroke unit of the hospital with treatment for the dominant right hand. The patient is experiencing decreased range of motion, with weakening of muscle strength and poor fine motor control of upper limb. These impairments make many ADLs difficult, especially those activities that depend on co-ordination between both upper limbs or fine finger movements. At this time, Mr. A has not been able to manage his condition independently and he remains functionally limited. He expects to do feeding and dressing activity independently and returning to work.

Overall Management Plan

The following table shows the area of focus for the management plan and the subsequent interventions to achieve the objectives. (table 1)

Upper limb functional disability is a common complication of stroke, affecting around 85 percent of stroke survivors (Yeldan et al. 2015). Upper-limb function is crucial for performing detailed activities in this respect, and as such, its therapeutic value should be stressed throughout rehabilitation programmes (Broderick et al. 2018). Based on the clinical impression initial treatment focuses on stretching ,early mobilisation and resistance training to improve movement control and strength. Following numerous rehabilitative therapies have been developed to enhance upper limb motor control and functionality, including paretic arm exercise training, neuromuscular electrostimulation, constraint-induced movement therapy, robotic therapy, and bilateral arm training. MirrorTherapy is recommended to enhance upper limb functionality in several studies (Yeldan et al. 2015; Michielsen et al. 2011). However, whether it should be applied to Mr. A is still controversial, as one study (Gurbuz et al. 2016) claims that this approach should mainly be applied to patients with pronounced motor impairments at 4 weeks post stroke.

However, the majority of treatment protocols are either costly or time consuming, and often involve manual engagement from the therapist for several weeks, making intense treatment for many patients challenging. Limited treatment alternatives exist for individuals with severe to total upper limb disability.

The following sections of the paper will exclusively focus on mirror therapy as the selected approach for the neurorehabilitation and improvement of patient’s upper limb motor function.

Stroke is a leading cause of disability in the developed world, and upper limb paresis is one of the most severe complications. Intensive rehabilitation regimens, particularly if initiated early, may aid in the return of upper limb function and brain restructuring. When sensory-motor deficits are significant, however, rigorous rehabilitation regimens are difficult to complete successfully. Reduced active motor engagement in the patient changes the cerebral representation of the affected limb and impairs the recovery caused by neurorehabilitation (Deconinck et al. 2015). A rehabilitation programme based on mirror neuron stimulation may be a viable technique to deal with and substantially overcome these limitations. Mirror neurons, particularly those in the parietal-frontal network, are active not just during movement, but also during observation of another's motor action (Gandhi et al. 2020). It has been observed that activation of premotor cerebral regions as a result of monitoring of a motor act can have a facilitative influence on the activation of brain regions involved for movement execution.

Ramachandran developed the mirror treatment programme (MTP) in 1996 to alleviate phantom limb pain following amputation. This study laid the groundwork for future research on the peripheral and central nervous systems' neuroplasticity (Michielsen et al. 2011). When the reflected hand's movement is noticed, the mirror neuron system can stimulate motor processes and even cause the invisible hand behind the mirror to move (Brunetti et al. 2015). Additionally, the mirror-neuron system regulates movement when two hands are attempted to move concurrently, contributing to the improvement of bimanual spatial connection while completing activities requiring both hands.

Mirror treatment works by supplying a false input to the brain, which combines it into a multimodal feeling or action: the patient believes that the healthy limb movement in the mirror is the diseased limb (which is concealed behind it), and correlates proper movement with his intention/tentative. The precise methods by which therapeutic stimuli are mirrored are unknown (Garry et al. 2005). Different methods for assessing cortical reactivity and various clinical paradigms make comparisons and interpretations challenging; yet, it is obvious that mirror-assisted movement alters interhemispheric dialogue and activates more than simply motor regions (Samuelkamaleshkumar4 et al. 2014).

The mirror illusion stimulates activity in the precuneus and posterior cingulate cortex, regions involved with self-awareness and spatial attention, respectively (Matthys et al. 2009). Additionally, bilateral motion via the mirror illusion activated neurons in the part of the brain that governs attentiveness and spatial awareness (Guo et al. 2019).

Despite accumulating data supporting the efficacy of mirror therapy in stroke patients, researchers have discovered several variances in mirror therapy treatment regimens, such as the type of movement done. For instance, patients have been encouraged to move the uninjured leg or both limbs as coordinated as possible. Additionally, in one trial, therapists assisted with the mobility of the afflicted leg (Ezendam et al. 2009). At the moment, there is insufficient evidence to draw definitive judgments about which of these therapy qualities is more beneficial. Due to the fact that treatment procedures vary, this practical procedure was developed to aid in the adoption of mirror therapy in everyday care. This protocol was created primarily to assist rapid and simple orientation, providing therapists with a comprehensive understanding of the basic approach to mirror treatment following stroke (Thieme et al. 2018; Gurbuz et al. 2016).

Mirror treatment has been shown to enhance range of motion, precision and efficiency of movement, squeezing strength, and motor function and rehabilitation in chronic stroke patients. Additionally, mirror treatment has been shown to improve upper-limb motor recovery and self-care abilities in individuals suffering from subacute stroke (Zeng et al. 2018). Furthermore, mirror treatment has been shown to improve the motor function of the distal region of the upper limbs in acute stroke patients. However, further study is required to determine the ideal patient selection criteria, application regimens, and duration and intensity of mirror treatment (Rothgangel et al. 2013). Additionally, there are very few researches on individuals with acute stroke who present within six months after start and are predicted to benefit more from mirror treatment.

In summary, the interaction inside M1 between the processes mediating excitability as a result of motion and the processes mediating excitability as a result of observation may serve as an explanation for the better functional recovery observed in stroke patients treated with mirror treatment (Samuelkamaleshkumar et al. 2014).

Mirror Therapy and its effectiveness

Motor recovery in stroke patients follows a fairly normal pattern, with early improvement in proximal, global movement patterns and later (and frequently partial) improvement in distal abilities. When producing highly precise motions, more deliberate effort is required in comparison to crude, primal patterns of movement. Three studies concentrating on acute and subacute stroke patients are critically appraised following a rigorous electronical search, and the data are shown in Table 2.

Abbreviations: sample size (n),FMA: Fugl-Meyer Assessment, MFT: Manual Function Test, ARAT: Action Research Arm Test , FIM: Functional Independence Measure, MI: Motricity Index. Special characters: “+”- improve/effective

Critical evaluation of the results from the study by Lee et al. (2012), in which 28 substroke patients were observed and given the intervention, revealed that mirror therapy led to the significant reduction in the reaction tome of hemiparetic wrist. The findings are consistent with other two studies by Invernizzi et al. (2012) and Cristina et al. (2015), where the group receiving mirror therapy along with conventional therapy benefitted with improved upper limb functionalty, including improvements in B&B, MAS and FMA. The results from these studies offer significant indication that mirror therapy could be very beneficial in Mr A’s case and will lead to faster improvement in upper limb functionality, allowing him to carry on with his activities of daily life much independently.

Intensive/enhanced rehabilitation techniques are often targeted at this stage of the healing process, and while they appear to be successful, their mechanism of action is unknown (Paik et al. 2014). Although there is no information on the brunnstorm recovery stage in the adapted scenario, based on his motor function performance, it can be assumed that the brunnstorm score of the affected limb is between 1 and 4. By supplement of conventional motor techniques with multimodal stimulation and, perhaps more importantly, with continuous stimulation of conscious control mechanisms, endurance and skilful movement, and sensory attention—all of which may activate dormant plasticity processes (Mathieson et al. 2018).

 On a clinical level, when a limb is disabled for an extended length of time, learned inactivity contributes to the original dysfunction, and the limb is no longer considered since the patient handles all actions with the functioning limb (Lee et al. 2012). On a cortical reactivity level, the initial disbalance of hemispheric activity may be followed by the healthy hemisphere inhibiting the lesion side, preventing it from attaining its full potential. Therefore, by applying MT's 'appropriate visual input' may compensate for part of the damaged body side's lacking proprioceptive information. Facilitating self-awareness, enhancing spatial attention, and requiring strong focus to execute the bimanual activity may all lead to enhanced resource use and movement quality (Kim, Lee and Song 2014). It has been demonstrated that introducing mirror therapy into a typical stroke rehabilitation programme during the early phases of treatment, but also in early chronic stroke, and using it for an extended length of time may result in an additional improvement in upper limb function (Invernizzi et al. 2013).

Mr.A underwent a physical evaluation ,where he has active ROM but reduced strength of upper limb. Numerous studies examining the effect of mirror treatment on the upper extremities in patients with stroke have also revealed increases in movement range, speed, and accuracy, as well as grip strength (Toh and Fong 2012). Additionally, another study found that acute stroke patients' self-care capability increased by 21% and their motor capabilities for motor items on the Functional Independence Measure scale increased by 36% (Cristina et al. 2015). The purpose of this study was to examine variations in upper-limb motor function by assessing shoulder and hand performance independently in the upper-limb function test. As a consequence, shoulder function increased by 78%, while hand function increased by 44%. Yet, the tool used to assess upper-limb motor function was different from prior research; however, the fact that shoulder range of motion in abduction, extension, flexion, and adduction was increased, as well as functional gains in grip strength and finger manipulation, implies that mirror treatment is beneficial at enhancing function movement (Yavuzer et al. 2008).

To summarise, the addition of MT to conventional therapy has a favourable effect on motor capacities. While rehabilitation improvements were significant throughout therapy, they may readily be lost if rehabilitation is discontinued — particularly in the case of acute and subacute patients. Only a few prior researches included a long-term follow-up period. The extent to which the benefit achieved by the use of MT sustains over time is unknown, and follow-up may have revealed intriguing information regarding the therapeutic efficacy of our technique (Paik et al. 2014).

Prior to the first session, Mr A should be well informed regarding the history and goals of mirror therapy, as well as any potential adverse effects. Additionally, Mr A should be allowed to participate in this type of treatment and be urged to assume that the mirror image represents their damaged limb. There is some evidence that the strength or vibrancy of the "mirror illusion" may be predictive of treatment success. As a result, fashion or clothing accessories and other visual identifiers should be removed to assist the patient in seeing the reflection in the mirror as their afflicted limb.

Mr A should have reasonable expectations for the gains that mirror treatment can provide. He should understand the value of ongoing, and regular training. The mirror image of two healthy limbs can elicit strong emotional responses. Other physiological responses such as nausea, dizziness, or sweating may be elicited in particular patients when they observe their image in a mirror. Patients are told to stop looking into the mirror and instead concentrate on the unaffected limb or the other place in the room in such circumstances. The mirror may be pushed away slightly from the patient's body, revealing only a portion of the damaged limb (e.g., the hand). Patients should then be told to look at the mirror image for a brief moment before shifting their sight to the unaffected limb. This method should be performed numerous times to resolve any negative effects.

According to the current research, mirror treatment should be performed at least once day for a minimum of 10 minutes. The maximum time of each session is determined by the patient's cognitive capacity and/or adverse side effects, but is often approximately 30 minutes. In this particular case, as Mr A’s skills do not permit lengthier sessions, one session might be broken into two shorter sessions of 10 to 15 minutes each with a little pause in between. In many therapeutic settings, a daily treatment session with mirror therapy will be impractical. In such circumstances, Mr A would require early instruction in unsupervised training with a mirror to maximise therapy intensity.

The injured limb of Mr A should be elevated on a height adjustable table to allow for adjustment to the length of the patient's trunk and arm. The injured limb is positioned behind the mirror in a safe and, ideally, comfortable posture. In the case of significant muscular spasticity, pre-positioning manual mobilisation may be essential and beneficial. By aligning the position and picture of the non-affected limb to the afflicted side, the patient can enable a strong "mirror illusion" (mirror image interpreted as the afflicted limb).

A minimum of 5-6 weeks of continuous MT should be undertaken to assess the treatment's potential effects (Wang et al. 2017). The entire period of therapy is determined by how long the particular patient and/or therapist notice functional gains and/or to what extent the patient believes the treatment is effective. Treatment should be discontinued if adverse effects persist or if unguided training alone is adequate. Except for a few brief instances of weariness, pain, or oedema in the paretic limb, the MT will be usually well tolerated in Mr A, with no major side events noted.

Conclusion

Mirror Therapy (MT) is a rehabilitative technique that involves placing a mirror beside the patient's torso to conceal the paretic upper limb and reflect the contralateral healthy arm. By moving one half of the body and gazing into the mirror, one may create the illusion that motions are being performed by the contralateral half, which is concealed and invisible. In pathological circumstances such as hemiparesis, the mirror covers the damaged limb and reflects the healthy one. Thus, when the patient moves the sound hand, he observes the movement of the damaged limb. MT was initially evaluated in the treatment of phantom pain with great results.

Shared mirror treatment and a scheduled treatment can be aided in the recovery and functioning of the subacute stroke patients' Mr A’s upper-extremity motor abilities. It is advantageous in terms of enhancing the impact and result of upper limb neuro- rehabilitation and functioning. And also mirror therapy is considered as cost-effective and patient-oriented treatment. Mirror therapy is a relatively recent form of therapy that emphases on the unimpaired limb's movement. In Mr. A, it entails moving the unimpaired limb while seeing its mirror image overlaid over the impaired limb, providing the optical illusion of the defective limb having improved movement capabilities.

In conclusion, while the results reported thus far with MT are encouraging, there is currently no ideal MT strategy for Mr A with hemiparesis who may or may not exhibit spatial neglect. Additionally, whereas several researches have been conducted on the efficacy of initiating neurorehabilitation soon following a brain injury, very few research on MT have been initiated in the early post-acute period.

References