Accepted Manuscript Inadvertent Recovery in Communication Deficits Following The Upper limb Mirror Therapy in Stroke: A Case Report Kamal Narayan Arya, MOT, PhD Shanta Pandian PII: S1360-8592(14)00012-6 DOI: 10.1016/j.jbmt.2014.02.005 Reference: YJBMT 1104 To appear in: Journal of Bodywork & Movement Therapies Received Date: 12 December 2013 Revised Date: 8 February 2014 Accepted Date: 19 February 2014 Please cite this article as: Arya, K.N., Pandian, S., Inadvertent Recovery in Communication Deficits Following The Upper limb Mirror Therapy in Stroke: A Case Report, Journal of Bodywork & Movement Therapies (2014), doi: 10.1016/j.jbmt.2014.02.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. ACCEPTED MANUSCRIPT Running title: Mirror therapy for communication deficits 1 2 RI PT 3 4 6 Title – Inadvertent Recovery in Communication Deficits Following The Upper limb Mirror Therapy in Stroke: A Case Report SC 5 7 Authors: Kamal Narayan Arya1*, Shanta Pandian2* 9 Affiliations: 10 11 12 M AN U 8 1 Sr. Occupational Therapist, MOT, PhD 2 Superintendent OT (OPD), MOT (Neuro.) *Department of Occupational Therapy, Pandit Deen Dayal Upadhaya Institute for the Physically Handicapped, 4 VD Marg, New Delhi- 110002, India. 14 15 16 TE D 13 Corresponding Author – Dr. Kamal Narayan Arya, Department of Occupational Therapy, Pt. Deendayal Institute for the Physically Handicapped, 4 VD Marg, New Delhi-110002, India. Emailkamalnarya@yahoo.com Telephone – 91-9899897408 19 20 21 AC C 18 EP 17 22 23 24 1 ACCEPTED MANUSCRIPT Abstract 26 Broca’s aphasia is the most challenging communication deficit in stroke. Left inferior frontal 27 gyrus (IFG), a key region of the mirror-neuron system, gets lesioned in Broca’s aphasia. Mirror 28 therapy (MT), a form of action-observation, may trigger the mirror neurons. The aim of this 29 study was to report a case of poststroke subject with Broca’s aphasia, who exhibited an 30 inadvertent and significant improvement in speech after MT for the paretic upper limb. The 20- 31 month old stroke patient underwent MT through goal-directed tasks. He received a total absence 32 of spontaneous speech, writing, and naming. After 45 sessions of task-based MT for the upper 33 limb, he showed tremendous recovery in expressive communication. He had fluent and 34 comprehensive communication; however, with a low pitch and minor pronunciation errors. He 35 showed a substantial change (from 18/100 to 79/100) on the Communicative Effective Index, 36 particularly, on items such as expressing emotions, one-to-one conversation, naming, and 37 spontaneous conversation. 38 Key words: Action-observation, Aphasia, Broca’s area, Mirror neuron, Mirror therapy, 39 Task-based therapy 42 43 44 SC M AN U TE D EP 41 AC C 40 RI PT 25 45 46 47 2 ACCEPTED MANUSCRIPT 48 Introduction 49 Broca’s aphasia is the most common and challenging poststroke deficit. It is characterized by 51 impairment in expression, articulation, and fluent speech. Further, it exhibits poor production of 52 normal grammatical sentences and melodic lines (Fazio et al., 2009). There is no universally 53 accepted method for the management of Broca’s aphasia. RI PT 50 SC 54 The left inferior frontal gyrus (IFG) is the responsible area of expressive language.(Fazio et al., 56 2009) IFG is a vital area for coordinating mirror-neuron system. Although the Broca’s area is 57 chiefly responsible for speech production, the area also gets triggered off due to the hand motor 58 activity via the mirror neuron system (Fazio et al., 2009; Sale & Franceschini, 2012). Mirror 59 therapy (MT), being a form of action-observation, has the basis of mirror neurons (Bhasin, 60 Padma Srivastava, Kumaran, Bhatia, & Mohanty, 2012; Ramachandran & Altschuler, 2009). TE D M AN U 55 61 Although there is a connection between the lesioned area (Broca’s aphasia) and neuronal 63 activation by MT, no work has been performed to ascertain the effect of MT for speech deficits. 64 The present study reports an inadvertent finding of speech improvement in a poststroke 65 hemiparetic subject with Broca’s aphasia who underwent task-based MT for the paretic upper 66 limb. AC C 67 EP 62 68 Case description 69 A male subject in his late thirties, management graduate, who was an editor, had an episode of 70 the stroke. He had severe paresis of the right body-side. He was chronic hypertensive, smoker 71 and alcoholic prior to the episode. Stroke with Broca’s aphasia was diagnosed by a neurologist. 3 ACCEPTED MANUSCRIPT His MRI findings revealed left gangliocapsular bleed with hyperdense and air foci in the left 73 frontal and parietal region. He underwent left fronto-temporal-parietal craniotomy for 74 evacuation of haematoma. Post surgical MRI findings also showed encephamalacic changes in 75 the left frontal lobe. Poststroke, he had taken home-based physiotherapy for a few months. He 76 also took 10 conventional speech therapy sessions; however, discontinued the therapy due to no 77 change in the communication ability. 78 He reported to the occupational therapy unit of the study site 10 months post stroke with chief 79 complaints of inability to use his right upper limb in daily functions, impaired walking, and no 80 verbal and written communication. The subject was on hypertensive medication and had quit 81 smoking and alcohol. He had been given conventional occupational therapy management for the 82 next 10 months. The management could induce minimal motor recovery while no change in 83 communication abilities. M AN U SC RI PT 72 TE D 84 Considering the stagnation in motor recovery, the task-based MT along with the conventional 86 occupational therapy was introduced. The protocol (Box-1) was based on the previous work of 87 the authors of the present study (Arya & Pandian, 2013). The subject underwent 45 therapy 88 sessions over the period of 3 months. 89 Box 1: Tasks and associated movements used in the task-based mirror therapy AC C EP 85 Task Key movements Lifting a glass: hand to mouth Shoulder flexion-extension and abduction, elbow flexion-extension and forearm pronation 4 ACCEPTED MANUSCRIPT Shoulder adduction, elbow flexion and Rotating a cylindrical can forearm pronation-supination radial-ulnar deviation Wiping table using a duster by wrist RI PT Forearm pronation, wrist dorsiflexion and Lifting a cubical block Forearm pronation, wrist radial-ulnar thumb opposition Wrist extension, mass finger flexion- M AN U Grasping / releasing a soft ball SC deviation and mass finger flexion and extension and thumb palmar abductionadduction and opposition-reposition In-hand manipulation and finger Picking up U-clips TE D prehension 90 Pre-intervention, the subject had no visual and hearing deficits. His cognitive and perceptual 92 abilities were recorded within normal limits. He exhibited Brunnstrom recovery stage (BRS) of 93 3 (spasticity at peak with strong flexor and extensoor synergy) and 2 (little or no active finger 94 flexion) for arm and hand, respectively. His Fugl-Meyer assessment (FMA): upper limb score for 95 the right side was 13/66. His clinical language evaluation showed total absence of spontaneous 96 speech and writing. Nonetheless, he had receptive communication and reading abilities. He could 97 not name the familiar objects (comb, book), place (residential address) or persons (spouse, 98 children). He expressed his day-to-day communication by gestures alone. The family members AC C EP 91 5 ACCEPTED MANUSCRIPT 99 had adequate comprehension for the gestures; however, no efforts were made to explore other 100 means of communication. 102 Box 2: Brunnstrom recovery stages and Fugl-Meyer’s assessment 103 105 106 Brunnstrom recovery stages (BRS) range from no voluntary movement (stage-1) to isolated voluntary movement (stage-6); higher stage indicates positive motor recovery. Fugl-Meyer’s assessment (FMA) is an objective measure of poststroke motor recovery. 9-item upper extremity subsection (FMA-UE) is scored from 0 (no motor recovery) to 66 (complete motor recovery). SC 104 RI PT 101 M AN U 107 Pre- and post-MT, the functional communication was assessed by using the Communicative 109 Effective Index (CETI). The CETI has 16 items (assessing scored on a 10 cm visual analogue 110 scale) subject’s ability to communicate in various functional contexts. The measure is a reliable 111 (r= 0.73 to 0.94), valid (Western Aphasia Battery, r=0.61) and responsive tool for stroke patients 112 (Code, Torney, Gildea-Howardine, & Willmes, 2010; Lomas et al., 1989). The assessor of the 113 present study had significant experience in using CETI. TE D 108 EP 114 Post-intervention, the subject achieved BRS 4 (spasticity reduces with fair motor control) for the 116 arm with no change for the hand. FMA upper limb recovered to 19 from a score of 13. 117 Unexpectedly, the study reported a tremendous improvement in speech ability without speech 118 therapy. On post-assessment, he demonstrated a remarkable change in expressive 119 communication. He could speak fluently with minor errors in pronunciation. His speech was 120 clear, audible, and comprehensive. Similarly, he could write with minor grammatical errors. The AC C 115 6 ACCEPTED MANUSCRIPT 121 content of communication was in order and appropriate; however, the pitch was low with some 122 pauses. Further, he was not able to utter long sentences and sustain prolonged communication. 123 Before MT, his CETI score was 18/100. However, post-MT, he showed a great achievement of 125 79/100. The subject demonstrated remarkable improvement on all the items, especially, 126 expressing his emotions (from 0 to 8), one-to-one conversation (from 0 to 9), naming (from 0 to 127 9), and spontaneous conversation (from 0 to 8). SC RI PT 124 128 M AN U 129 Discussion 131 Although the objective of the task-based MT was to induce upper limb motor recovery, the 132 present case reported an astonishing recovery of verbal communication. Aside from clinical and 133 standardized assessments, the inadvertent changes in speech was also reported and confirmed by 134 the other family members and friends. Importantly, the changes were observed 20 months post- 135 stroke without any speech therapy. EP 136 TE D 130 It is assumed that the activation of mirror-neuron system (IFG) by task-based MT not only 138 induced the upper limb motor recovery but also enhanced the speech production. The task-based 139 MT has visuo-motor-proprioceptive component. Broca’s area (mirror neurons) gets triggered 140 when the goal-directed tasks are performed, heard or seen (Casile, 2013; Kohler et al., 2002). 141 The mirror-neuron system may be exploited for the treatment of post-stroke; however, the 142 evidence is still awaited. AC C 137 143 7 ACCEPTED MANUSCRIPT There is a functional connectivity between the cortical representations of hand motions and voice 145 communication. The connectivity is recommended to be explored for the management of aphasia 146 (Meister et al., 2006). Further studies should be done by incorporating functional 147 communication components (variety of hand movements for gesture) and expanding MT 148 protocol to enhance greater language recovery. Although the findings of the present study were 149 observed after many months of stroke onset, the changes may be a chance of occurrence which 150 needs to be validated in a case series. 151 Since the observations of the study were inadvertent, fMRI could not be planned. Similar 152 neuroimaging toolscan further explore changes at the neural level in future studies. M AN U SC RI PT 144 153 Conclusion 155 In a post-stroke subject, task-based MT provided for the paretic upper limb, led to unpredictable 156 and remarkable improvement in expressive communication. The achievement could be attributed 157 to MT-induced activation of the mirror-neuron system, centered in the Boca’s area. TE D 154 158 AC C EP 159 8 ACCEPTED MANUSCRIPT References 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 Arya, K. N., & Pandian, S. (2013). Effect of task-based mirror therapy on motor recovery of the upper extremity in chronic stroke patients: a pilot study. 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