Advances in Neurological OT
by Joanne Boothroyd, Neurological Rehabilitation Occupational Therapist at The OT Practice
Introduction
The last decade has seen some exciting advances in neurological occupational therapy practice with some significant benefits to clients. This article focuses on two approaches to upper-limb rehabilitation that are being used more frequently and successfully over time.
Ten years ago, mirror therapy and constraint induced movement therapy were less-familiar forms of upper limb rehabilitation in neurological occupational therapy, with limited research demonstrating its clinical effectiveness. Over the last ten years, there has been an increase in research in both of these areas which has resulted in a more widespread use within occupational therapy treatment programmes.
Mirror Therapy
What is Mirror Therapy?
Mirror therapy is an occupational therapy intervention used for the treatment of hemiplegia in people with stroke and brain injuries. It also can be used for the treatment of pain including phantom limb pain and complex regional pain syndrome.
The therapy involves the person placing their affected upper limb (the lower limb can also be used) into a mirror box, which completely obscures it from their view. They then perform prescribed symmetrical exercises with their non-affected upper limb whilst simultaneously attempting to perform the exercise with their affected upper-limb and watching the reflection in the mirror box. Watching the reflection, provides the person with an image of a hand and arm moving normally, in the place of their affected upper limb. During the use of the mirror box, it is essential that the person focuses on this reflection and imagines that the reflection is their affected limb moving. The brain then associates this image with the affected limb.
How does mirror therapy work?
It is suggested that visualising and practising bilateral movements influences neuroplasticity changes (the forming of new connections to compensate for the injury) in the person’s brain, which helps with the re-learning of normal movement patterns.
What is involved in participating in a mirror therapy programme?
Evidence suggests that to benefit from the intervention, a person needs to complete the mirror therapy over a period of 4 weeks, performing the prescribed tasks for a minimum period of 30 minutes over no less than 5 days per week. All jewellery and watches must be removed before commencing therapy, to help with the illusion.
Whilst ensuring all parts of the affected upper limb are covered in the mirror box, the person can perform movements at the shoulder, elbow, wrist, fingers and thumb and actions such as gripping, tapping and lifting. The person can also perform tasks using everyday objects such as beads, pegs, cups, coins as well as using therapy equipment such as Thera-putty and pegboards. The movements must be done simultaneously with both hands, however if an object is involved the affected limb only needs to copy the movement but does not require the object. It is recommended the movements are done in 5 or 10 seconds.
Who can use mirror therapy?
- Mirror therapy can be used as a treatment for people with weakness (hemiparesis) of their upper or lower limb as a result of a neurological event or injury. Although most research findings demonstrate effectiveness in people who have experienced a stroke, the results are transferable to people with other brain injuries with a limb weakness.
- The client needs to be motivated to participate in this therapy as this is crucial to its success.
- Mirror therapy can be used with people with reduced active movement in their upper limb however research indicates there are less benefits for this client group.
- A person’s cognitive ability should be considered prior to the commencement of the therapy, as they will be required to follow instructions, understand the purpose of the treatment and be able to visualise.
- Mirror therapy is not recommended to use with people who have severe depression or a recent history of drug or alcohol abuse.
What are the advantages of using Mirror therapy?
- Mirror therapy has been shown to be effective in people who have recently experienced a stroke as well as those who had their event for longer (within the last six months).
- Research has demonstrated that people have accepted the invention well and have performed the prescribed programme as directed.
- There are no known adverse effects of using mirror therapy.
- Mirror boxes are portable and can be used in with both ambulant and less-ambulant people, for example those who have difficulty moving from their chair or bed. Also, they can be easily transported and therefore a person can perform the therapy even when they are not at home (for example on holiday).
What results can be expected?
There is evidence in the research that mirror therapy, used alongside conventional rehabilitation, improves motor function and motor impairment after stroke (Thieme at al 2018) and these effects can be applied to people with brain injuries. The therapy was thus shown to improve a person’s ability to perform their activities of daily living and effects were still evident six months after the end of the intervention. Pain was also reduced following the mirror therapy and also six months after.
The role of the occupational therapist
The occupational therapist would complete an initial assessment and decide in conjunction with the client, whether mirror therapy would be an appropriate method of treatment. They will then design a bespoke mirror box therapy plan for the client. This will involve prescribing the activities performed and the length and frequency of the sessions. The occupational therapist will complete outcome measures prior to commencing the programme in order to evaluate its effectiveness.
During a treatment session, the occupational therapist would demonstrate the correct movement or actions required for the client to copy and also review and evaluate the session. If considered appropriate by the therapist, the client can complete follow-up sessions with a carer, support worker or in some cases would be able to complete on an individual basis.
At the end of the therapy the occupational therapist would re-administer the outcome measures and evaluate the effectiveness of the therapy.
Constraint-Induced Movement Therapy
What is Constraint Induced Movement Therapy?
Constraint-Induced Movement Therapy (CIMT) is another occupational therapy intervention used for the treatment of hemiplegia in people with stroke and brain injury, where the movements of the affected arm are constrained inducing increased movement and reliance on the affected upper limb. How does Constraint-Induced Movement Therapy work?
It is currently unknown how CIMT works however it is suggested that it enlarges the area in the brain that controls the affected side.
What is involved in participating in Constraint-Induced Movement Therapy?
The person participating in the therapy is required to wear a sling or mitt constraining the movement on their unaffected upper limb for six hours per day over a two to three-week period. They then perform their daily activities using their affected upper limb, thus increasing use. There is a less intensive method (Modified CIMT) where the person wears the sling at a reduced intensity. This can be completed within a therapy session.
Who can use Constraint-Induced Movement Therapy?
- CIMT is used as a treatment approach with weakness (hemiparesis) of their upper or lower limb as a result of a neurological event or injury. Again, similar to mirror therapy most research findings demonstrate effectiveness in people who have experienced a stroke, however these results are also transferable to people with other brain injuries with a limb weakness.
- CIMT must have commitment from the client.
- Client’s participating in CIMT will require some active movement in upper limb. What are the benefits of using Constraint-Induced Movement Therapy?
- After direction from the therapist, CIMT can be used by the client independently thus can require less direct therapy hours compared with other treatment methods.
What results can be expected?
Treatment can achieve increased upper limb movement and function. Although current research debates about whether CIMT improves a person’s ability to participate in their activities of daily living, CIMT has been found to be effective at improving arm movement.
The role of the occupational therapist
As with Mirror Therapy, the occupational therapist would complete an initial assessment and evaluate if CIMT is an appropriate method of treatment for the client. They will then fit and demonstrate use of the sling, discussing with the client appropriate activities and tasks to complete whilst wearing the sling, as well as the agreed length of use. The client then would be expected to complete the programme as directed with regular reviews from the occupational therapist. As with Mirror Therapy, outcome measures will be completed prior to and at the end of the treatment to evaluate any benefits.
Conclusion
With the use of these treatment approaches increasing in neurological occupational therapy, it is likely that research will continue in these areas in the future. This will provide a higher quality of evidence, further substantiating this occupational therapy treatment, as well as helping clinicians in improving their practice further.
Useful links
References
Corbetta, Sirtori, Castellini, Moja and Gatty (2015) Constraint induced movement therapy for upper limb extremities in people with stroke (Review). Cochrane Database of Systematic Reviews, 2015 (8). DOI: 10.1002/14651858.CD004433.pub3.
Theime, Morkisch, Mehrholz, Pohl, Behrens, Borgetto and Dohle (2018). Mirror therapy for Improving motor function after stroke (Review), Cochrane Database of Systematic Reviews, 2018 (7). DOI: 10.1002/14651858.CD008449.pub3.
