Abstrakti
Cerebral vascular accident (AVC) is one of the most common diseases in the world
incidence and ranks first in terms of disability. AVC appears with motor, sensory deficits,
speech disorders as well as alterations of cortical nerve functions. This post-AVC condition
makes activities of daily living very difficult, especially demanding activities
hand use.
The purpose of this study is to determine the validity of the treatment for hand and arm rehabilitation
and shoulder, in patients with cerebrovascular accident, comparing two treatment methods,
Action Observation Therapy and Mirror Therapy.
The study is of the randomized control trial type
During the treatment period, 16 cases were included, which were randomly divided into two
groups; the MT group and the AOT group. All patients underwent The DASH questionnaire
Questionnaire before starting the therapy and after the end of the 6-week treatment. Results obtained
were analyzed and compared with the initial results.
Both groups were treated for 6 consecutive weeks, 5 times a week. Both therapies, AOT and MT, worked
effective in the treatment of post AVC patients, for the rehabilitation of the hand, arm and shoulder, after 6
weeks of treatment, with a general difference of 2.79% in favor of AOT (AOT 23.33 % and MT
20.54%). AOT was shown to have a greater effect on activities that require control skills
global movements. While MT showed to have more effect on activities that require skills in
control of fine movements. Patients treated with AOT, during treatment, showed some signs of pain
at the moment they moved the limb. Both therapies had an effect on improving sleep. MT
there was a greater improvement in sleep, a change which may have come due to the reduction of
considerable degree of pain.
Keywords: Mirror Therapy, Action Observation Therapy, Rehabilitation, Post AVC, AVC.
1 Materials and Methodology
1.1 Type of study
The type of this study was Randomized Controlled Trial.
1.2 Data Collection
A total of 23 patients were recruited to perform this study. These patients were recruited through the referral of doctors and physiotherapists in 3 medical and physiotherapy clinics in Tirana. The purpose of this study was explained to the doctors and physiotherapists, where only 3 of them agreed to cooperate in conducting this study. All 23 patients were recruited at different time periods, where after the purpose of the study and the method of treatment were explained to them, 19 of them agreed to participate in the study. All patients, after being informed about the procedures and purpose of the study, underwent the signing of a contract for consent to participate in this study. Appendix 1 All 19 patients underwent The DASH Questionnaire, after being divided into the respective therapy groups (9 AOT and 10 MT, where from the AOT group 1 patient was excluded from the study as he did not meet the conditions of participation and from the MT group there were 2 non-compliant patients who were also excluded. The way of dividing patients into the respective therapy groups was randomly. Through two closed letters it was decided which therapy the first patient would participate in, to be followed by the second patient in the next therapy continuing with this selection method until the end. All patients were completed questionnaires before starting therapy to assess their abilities beforehand and document them.Each patient was treated for a period of 6 weeks, 5 days a week. After the end of the 6-week treatment, the patients were again tested with the DASH Questionnaire. The results obtained were documented and compared with the initial results.
1.3 Inclusive criteria and exclusion criteria
The inclusion criteria of the participants were: (1) diagnosed with AVC of the anterior circulation, (2) time period 2 weeks after diagnosis up to 8 weeks, (3) age 20 to 60 years, (4) having been evaluated > 50 % and < 75% with the DASH questionnaire neurological test. Exclusion criteria were: (1) global or receptive aphasia, (2) major medical problems causing severe pain, (3) score below 50% and above 75% on The DASH Questionnaire.
1.4 Evaluation of patients
Subjects enrolled in the study before treatment were familiarized with the medical diagnosis, objectives and goals of this treatment. They were assessed with the DASH Questionnaire. All patients underwent a questionnaire before starting therapy to assess their abilities beforehand and to document them.
1.5 The “DASH” Questionnaire
The DASH Questionnaire (Disabilities of the Arm, Shoulder And Hand) Appendix 2 is a 30-item, self-report questionnaire designed to measure patients’ physical function and symptoms. The questionnaire was designed to help describe disability and also to monitor changes in upper limb symptoms and function following various medical therapies or interventions.
1.6 Measurement of results
Evaluation of the result during the performance of AOT but also in MT is the most important thing to consider. The use of a suitable measurement unit or outcome index is a fundamental condition to analyze the efficacy of any rehabilitation therapy.
1.7 Equipment and instruments used
The devices used in this study are AOT and MT. For the development of AOT therapy, 10 video clips were created, which in their content focused on three main phases: (a) exercises and active movements of the trunk, (b) movement of the trunk and object grasping, and (c) manipulation functional of the object according to certain tasks. The AOT group watched video clips illustrating upper extremity movements and then reproduced the movement according to their motor skills. The movement phases were of a certain duration and varied: the first phase 10-20 minutes, the second phase 20-25 minutes and the third phase 30 to 35 minutes. 60 to 80 minutes in total. During the first phase, the patients observed the exercises and active movements on video clips and moved both upper limbs simultaneously. In the second phase, the patients observed on video the way of grasping the object and then they were asked to execute the same movement within their motor capabilities, repeating it 3 to 4 times. The third phase contained both of the above uninterrupted tasks. For example, opening the lid of a jar would be executed sequentially according to these steps: (a) grasping the jar, (b) opening the lid of the jar, and (c) lifting the jar. Some other examples of video content are: reading and flipping through a magazine, folding a towel, pouring water into a glass and lifting the glass to drink water, wiping the table, opening the cell door, etc. For the treatment with MT, 15 basic exercises and some specific movements that helped these exercises were set. The MT group was treated for 40 to 50 minutes with a triangular mirror box. During the treatment, the patient sat in front of a table which was high up to the level of the patient’s elbows and the mirror was placed in front of them in the direction of the affected hand. The affected arm was placed inside the mirror while the unaffected arm was placed in front of the mirror. The patient was instructed to observe the reflection of the intact arm in the mirror. During treatment, the patient was instructed to actively move the affected arm at the same time as the unaffected arm without looking in the mirror, but if this was impossible, intervention was made by making possible passive movements of the affected arm at the same time as intact arm. MT treatment was also organized into three phases: (a) Active movement 10 minutes, (b) grasping and moving the object 10-15 minutes, and (c) executing functional tasks and practicing them 20-25 minutes. Some of the movements performed were: grasping a glass of water and lifting it, grasping a pen stimulating writing, grasping a door key, pulling a rubber band, grasping a handle and turning it, opening and closing the hand etc.
1.8 Data analysis and statistics.
The statistical procedures and techniques used in the current paper are presented in detail below: • For numerical variables, the sizes of central tendency (arithmetic mean, median and mode) and sizes of dispersion (standard deviation and interquartile range) were calculated. • Frequency distributions (absolute values and corresponding percentages) were presented for the categorical variables. • The DASH test was used to calculate the difficulty of performing daily physical activities, the calculation of pain, difficulty in sleeping and self-confidence and self-evaluation before and 6 weeks after the development of the therapy • Binary logistic regression was used to evaluate the differences (changes) of the difficulty of performing daily physical activities, the calculation of pain, difficulty in sleeping and self-confidence and self-evaluation as well as the total change for the patient and the change and result of the methods taken in the study. • All statistical analysis was performed in the MS Excel program (Microsoft Excel 2016). After the forms were filled in by the patients in the first preliminary phase, the obtained data were entered into the Microsoft Excel electronic platform and calculated based on the questionnaire formula for data calculation. After completing the calculation of the preliminary data, they were stored in the same electronic program, where the AOT data was stored in a separate table and the MT data in another table. Three patients from the total number of patients who filled out the form were excluded from the study for the following reasons; 1. score below 50% and above 75% on The DASH Questionnaire. 2. score below 50% and above 75% in The DASH Questionnaire. 3. Age over 60 years
2 Discussions
2.1 Summary of the main findings of the study
Our study generated very interesting data regarding hand, arm and shoulder treatment in post AVC patients. The findings divided into categories according to the objectives set in this study are: Both therapies, AOT and MT, were effective in the treatment of post-stroke patients, for the rehabilitation of the hand, arm and shoulder, after 6 weeks of treatment, with a difference of overall 2.79% in favor of AOT (AOT 23.33% and MT 20.54%). Accordingly, the findings according to each of the therapies, each divided into 4 directions, are:
AOT
After the AOT treatment of post AVC patients, in the rehabilitation of the hand, arm and shoulder, with an initial percentage of the degree of difficulty of 64.58%, it reached 43.44%. So an overall improvement rate of change of 23.33% was generated.
After AOT treatment of post AVC patients, in the rehabilitation of the hand, arm and shoulder, in terms of activities of daily life, with an initial percentage of the degree of difficulty of 66.17%, it reached 41.58%. So an overall improvement change rate of 27.16% was generated.
After the AOT treatment of post AVC patients, in the rehabilitation of the hand, arm and shoulder, in terms of pain or numbness, with an initial percentage of the degree of difficulty of 57.50%, it reached 53.13%. So an overall improvement rate of change of 5.00% was generated.
After AOT treatment of post AVC patients, in the rehabilitation of the hand, arm and shoulder, in terms of difficulty in sleeping, with an initial percentage of the degree of difficulty of 43.75%, it reached 31.25%. So an overall improvement rate of change of 18.75% was generated.
After the AOT treatment of post AVC patients, in the rehabilitation of the hand, arm and shoulder, in terms of self-confidence and self-esteem, with an initial percentage of the degree of difficulty of 84.38%, it reached 50.00%. So an overall improvement rate of change of 31.46% MT was generated
After MT treatment of post AVC patients, in the rehabilitation of the hand, arm and shoulder, with an initial percentage of the degree of difficulty of 63.96%, it reached 44.69%. So an overall improvement change rate of 20.54% was generated.
After MT treatment of post AVC patients, in the rehabilitation of the hand, arm and shoulder, in terms of activities of daily life, with an initial percentage of the degree of difficulty of 68.21%, it reached 48.91%. So an overall improvement rate of change of 19.59% was generated.
After MT treatment of post AVC patients, in the rehabilitation of the hand, arm and shoulder, in terms of difficulty in sleeping, with an initial percentage of the degree of difficulty of 43.75%, it reached 28.13%. So an overall improvement change rate of 19.79% was generated.
After MT treatment of post AVC patients, in the rehabilitation of the hand, arm and shoulder, in terms of self-confidence and self-esteem, with an initial percentage of the degree of difficulty of 75.00%, it reached 40.63%. So an overall improvement change rate of 34.38% was generated.
2.2 Comparison of results with literature reports
Functional impairments of the upper extremity are common consequences of various strokes. Therefore, continued studies on effective interventions for upper extremity functions after strokes are a must. According to Fu J et al, 2017[22] , who conducted a study on AOT, with the aim of exploring the effects of action observation therapy on upper extremity motor function, activities of daily living and movement potential in patients post AVC. Where post AVC patients were randomly assigned to an experimental group (28 patients) and a control group (25 patients). Conventional rehabilitation treatments were implemented in both groups, but the experimental group received an additional action observation therapy for 8 weeks (6 times a week, 20 minutes in time). The data obtained from this study show that the combination of movement observation and traditional upper limb rehabilitation treatment technology can significantly increase the movement function of post AVC patients in the subacute phase. Invernizzi M et al, 2013, to assess whether the combination of Mirror Therapy (MT) with conventional therapy (CT) can improve motor recovery of the upper limbs in post AVC patients, conducted a study with twenty-six post AVC patients (time from stroke <4 weeks) with upper limb paresis. After one month of treatment, patients of both groups showed statistically significant improvements in all measured variables (P < 0.05). Furthermore, patients in the MT group had greater improvements compared to the CT group (P < 0.01, Glass Effect Size Δ 1.18). In this study we are shown that MT is a promising and easy method to improve upper limb motor recovery in patients with subacute stroke. Annino G et al 2019[23], conducted a study on the effect of segmental muscle vibration. Segmental muscle vibration (SVM) is one of the interventions that incorporate sensory stimulation to improve cortical motor excitability. The aim of this study was to investigate the impact of 5-minute VSM application together with supervised physical therapy (TFM) on improving activities of daily living and motor recovery in the upper extremity of post AVC patients. Thirty-four patients completed the study. Patients in both groups improved significantly after treatment in ulnar joint ROM and ulnar muscle strength. TFM intervention can improve functional outcomes of the upper extremity of Post AVC Patients. The use of VSM can have a high effect on improving muscle tone after various strokes. Schuster-Amft C et al [24] , 2018, another study which was conducted in order to compare reality-based virtual training with conventional therapy. Virtual reality-based training has found increasing use in neurorehabilitation to improve upper limb training and facilitate motor recovery. 54 patients participated in this study. Patients in the experimental and control groups showed similar effects, with the greatest improvements seen as early as the first two weeks and continuing until the end of the two-month follow-up period. Patients who were less impaired showed higher improvements in favor of the experimental group. This result may suggest that virtual reality-based training may be more applicable to such patients than to more impaired patients.