Here is CTE;
The effects of cognitive exercise therapy on chronic stroke patients’ upper limb functions, activities of daily living and quality of life
Mirror therapy has been out there a long time. Hasn't your competent? doctor been using mirror therapy for years already? NO? So you don't have a competent doctor? Why are you seeing them and why haven't they been fired?
mirror therapy (119 posts to October 2012)
Efficacy of a Rehabilitation Program Using Mirror Therapy and Cognitive Therapeutic Exercise on Upper Limb Functionality in Patients with Acute Stroke
1
and 1
and 1
1
Department of Health Sciences, University of Burgos, 09001 Burgos, Spain
2
Faculty of Health Science, University Isabel I, 09003 Burgos, Spain
3
BioVetMed & SportSci Research Group,
Department of Physical activity and Sport, Faculty of Sport Sciences,
University of Murcia, San Javier, 30720 Murcia, Spain
*
Author to whom correspondence should be addressed.
Healthcare 2024, 12(5), 569; https://doi.org/10.3390/healthcare12050569
Submission received: 13 December 2023
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Revised: 26 January 2024
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Accepted: 27 February 2024
/
Published: 29 February 2024
(This article belongs to the Special Issue Non-pharmacological Approaches and Their Impact on Noncommunicable Diseases)
Abstract
Applying evidence-based therapies in stroke
rehabilitation plays a crucial role in this process, as they are
supported by studies and results that demonstrate their effectiveness in
improving functionality, such as mirror therapy (MT), cognitive
therapeutic exercise (CTE), and task-oriented training. The aim of this
study was to assess the effectiveness of MT and CTE combined with
task-oriented training on the functionality, sensitivity, range, and
pain of the affected upper limb in patients with acute stroke. A
longitudinal multicenter study recruited a sample of 120 patients with
acute stroke randomly and consecutively, meeting specific inclusion and
exclusion criteria. They were randomly allocated into three groups: a
control group only for task-oriented training (TOT) and two groups
undergoing either MT or CTE, both combined with TOT. The overall
functionality of the affected upper limb, specific functionality,
sensitivity, range of motion, and pain were assessed using the
Fugl–Meyer Assessment Upper Extremity (FMA-UE) scale validated for the
Spanish population. An initial assessment was conducted before the
intervention, a second assessment after completing the 20 sessions, and
another three months later. ANCOVA analysis revealed statistically
significant differences between the assessments and the experimental
groups compared to the control group, indicating significant improvement
in the overall functionality of the upper limb in these patients.
However, no significant differences were observed between the two
experimental groups. The conclusion drawn was that both therapeutic
techniques are equally effective in treating functionality, sensitivity,
range of motion, and pain in the upper limb following a stroke.
1. Introduction
Stroke,
also known as cerebrovascular accident (CVA), is one of the most severe
and common medical emergencies worldwide. It is of vascular origin,
causing signs of neurologic deficit with rapid onset. These clinical
signs can be focal or global, and if they last more than 24 h, without a
clear cause that can cause death [1,2].
Since 1990, the incidence of strokes has increased by 70%, and deaths
from strokes has increased by 43%, with a worrying rising trend in those
under 70 years of age [3]. Today, this disease is the second leading cause of death worldwide and ranks third in terms of mortality and disability [2]. In 2019, there were 12.2 million strokes and 101 million prevalent strokes [4,5].
The vast majority of stroke cases occur due to potentially modifiable
risk factors, which demonstrates the huge work that remains to be done
to improve the prevention of this disease by reducing exposure to risk
factors such as hypertension, diabetes, tobacco use, sedentary
lifestyle, and abdominal fat [5,6].
In Spain, stroke is considered the leading cause of disability in
adulthood and the second cause of dementia, significantly reducing the
quality of life of patients and therefore that of their close social
circle, directly affecting the health system [2].
One
of the main sequelae resulting from a stroke is the loss of
functionality, which can be significant, especially concerning the
affected upper limbs. Following a stroke episode, it is common to
experience a decline in function in the upper limbs, characterized by
difficulties in performing activities of daily living (ADLs) or
instrumental activities of daily living (IADLs) [7,8].
This loss of function may be related to muscle weakness, lack of motor
coordination, or an inability to control movements. Motor impairment in
the upper extremities occurs in approximately 80% of survivors, with 50%
reporting pain in the upper limb during the first 12 months after the
episode [9,10,11].
Furthermore,
sensitivity in the affected limb can also be altered. Issues with
tactile sensitivity may arise, such as decreased or loss of touch
sensation, along with changes in temperature or pressure perception.
These sensory changes can hinder precise movement execution or object
recognition through the sense of touch. Similarly, the range of motion,
i.e., the ability to move the joints of the upper limb, may also
decrease after a stroke. This might manifest as restricted natural
movements in the shoulder, elbow, wrist, or fingers, further
complicating the performance of everyday tasks [12,13].
Pain
affecting the upper limbs is another common outcome after a stroke.
Pain can be neuropathic or related to posture, movement, and muscle
stiffness. The presence of pain can negatively impact rehabilitation and
the ability to perform exercises or therapies aimed at recovering limb
functionality [12,14].
All
of these factors together can trigger hemiplegia or hemiparesis, common
conditions after a stroke involving paralysis or muscle weakness on one
side of the body, primarily affecting an upper and lower limb on the
same side. This signifies a change in the ability to achieve a normal
level of muscle strength, including sensory alteration, loss of motor
control, and spasticity [15,16].
This condition can significantly impact a person’s functionality.
Hemiplegia can range from mild weakness to complete paralysis on one
side of the body, affecting the ability to move and perform daily tasks.
Collectively,
these effects can complicate daily life and the recovery process after a
stroke. Rehabilitation in these cases usually aims to address these
challenges, seeking to improve function, sensitivity, and range of
motion and to manage pain to regain the maximum possible functionality
of the affected upper limb. This post-stroke rehabilitation period
should commence as early as possible, with function recovery
predominantly occurring in the first few weeks [17],
although there are studies indicating that patients go through a phase
known as spontaneous recovery during the initial weeks [18].
Before
initiating rehabilitation, conducting a thorough assessment to
determine the stroke’s aftermath is crucial. Understanding where to
begin is vital for implementing quality rehabilitation. To achieve this,
there are several instruments used to assess the functional state of
stroke survivors. The Fugl–Meyer Assessment—Upper Extremity (FMA-UE)
scale is currently the most widely used quantitative evaluation to
measure functionality and motor recovery post-stroke [12,19,20].
Regarding
rehabilitation, therapies supported by scientific evidence play a
crucial role in this process, as they are backed by studies and outcomes
demonstrating their effectiveness in improving functionality and
recovering lost skills. Some of these include mirror therapy (MT),
cognitive therapeutic exercise (CTE), and task-oriented training.
MT
is a rehabilitation technique that utilizes visual illusion to enhance
motor function in individuals who have experienced strokes, limb
injuries, or lost functionality in a limb. This therapy involves using a
mirror to create the illusion that the affected limb is functioning
normally [21].
A mirror is positioned to reflect the unaffected limb, while the
affected limb remains hidden behind it. Moving the unaffected limb
creates a reflection in the mirror, simulating movement in the affected
limb, tricking the brain into perceiving normal movement. This therapy
focuses on repeating controlled and specific movements, which may
promote neuroplasticity—the brain’s ability to reorganize and adapt
through experience and repetitive practice. It is believed that this
therapy could help restore motor function, enhance coordination, and
alleviate chronic pain associated with the affected limb [11,22,23].
As
for CTE, also known as the Perfetti method, is a neurorehabilitation
approach offering personalized and specific treatment for each patient.
Its goal is to recover lost or altered movement due to central nervous
system damage. This method involves assigning the patient a specific
problem-solving task that can be resolved through fragmented movement of
body segments guided by the therapist. CTE aims to improve the specific
motor deficit in the hemiplegic upper limb by addressing patterns such
as abnormal reactions to stretching, abnormal irradiation, motor
mobility of elementary schemes, and promoting efficient and high-quality
motor recruitment. Essentially, it aims to reactivate and strengthen
neural connections damaged by stroke [24,25].
On
the other hand, these patients can benefit from task-oriented training,
which is an effective way to encourage and develop motor skills and
brain plasticity through the repetition of specific and functional
tasks. It relies on tailored and personalized activities that mimic
daily actions. Therapists design specific training programs for each
patient, considering their individual needs, motor deficiencies, and
recovery goals. These programs focus on activities resembling the tasks
the patient needs to perform in their daily life. The effectiveness of
task-oriented training lies in its emphasis on functionality and
practical application of motor skills in real-life situations. This
approach aims not only to restore motor function but also to improve the
patient’s independence in daily activities, which can have a
significant impact on their quality of life [26].
Recent
studies have demonstrated that the combined use of these therapies
activates central nervous system plasticity more effectively than when
used individually, to improve motor function [27,28,29,30].
However, to date and to the authors’ knowledge, there is no article
comparing if any of these combinations (MT or CTE combined with
task-oriented training) are the most effective in improving upper limb
function after a stroke.
Therefore, the aim of
the present study is to verify the effectiveness of combining these
techniques on upper limb functionality after a stroke and to determine
which of them yields better results.
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