Pengaruh Mirror Neuron System Exercise Pada Latihan Task Program Terhadap Gerak Fungsional Ekstremitas Atas Pasien Pasca Stroke Putri Martina A1), Miranti Yolanda A., S. Ft, M. Fis2), Abdul Chalik Meidian, Amd., Ft, SAP, M. Fis3), Pramudya Utama, SSt. Ft, M. Fis4)
1) Peneliti 2) Dosen Pembimbing I 3) Dosen Pembimbing II 4) Dosen Penguji
Abstrak. [Tujuan] Mengetahui perbedaan pengaruh pemberian latihan task program dengan kombinasi mirror neuron system exercise menggunakan task program terhadap kemampuan gerak fungsional ekstremitas atas pasien pasca stroke. [Subyek] 12 orang yang diambil secara acak, lalu dikelompokkan menjadi kelompok kontrol (n=6) dan kelompok perlakuan (n=6). [Metode] Pasien kelompok control melakukan intervensi task program dan kelompok perlakuan menggunakan media mirror dengan melakukan intervensi task program sebanyak 12 kali intervensi dengan frekuensi 3 kali seminggu selama 30 menit. Alat ukur yang digunakan menggunakan Functional Independence Measure (FIM). [Hasil] Penambahan mirror neuron system exercise pada intervensi menggunakan task program dibandingkan dengan pemberian latihan task program adalah sama dalam meningkatkan kemampuan fungsional ekstremitas atas pasien pasca stroke. Kata Kunci: Task program, Mirror neuron system exercise, kemampuan fungsional ekstremitas atas pada pasien pasca stroke.
dalam melakukan aktifitas sehari-hari,
PENDAHULUAN Faktor yang menyebabkan pasien stroke
menjadi
tergantung
diantaranya adalah adanya keterbatasan
dengan
fungsional anggota gerak atas (AGA)
orang lain, menjadi tidak mandiri
yang mengalami kelemahan akibat
dalam memenuhi kebutuhannya dan
stroke. Dimana fungsi anggota gerak
atas amat diperlukan setiap individu
dari mirror neuron system exercise
dalam melakukan aktifitasnya, seperti
dengan tugas-tugas yang diberikan
makan, minum, berpakaian, memakai
kepada penderita stroke.
bawahan, toileting, berias diri, dan
Sehingga dalam penelitian ini
aktivitas-aktivitas lainnya. Sehingga
peneliti berhipotesis: (1) intervensi
diperlukan intervensi yang mana dapat
menggunakan
membantu
meningkatkan
meningkatkan
kembali
task
program
dapat
kemampuan
dalam melakukan functional activity of
fungsional
daily living. Mirror neuron system
paska stroke, (2) intervensi mirror
exercise dengan menggunakan media
neuron system exercise menggunakan
cermin
task program
dapat
meningkatkan
pelaksanaannya tidak membutuhkan
kemampuan
gerak
fungsional
modal yang mahal, dan alat-alat yang
ekstremitas atas pasien paska stroke,
mudah
(3) ada perbedaan pemberian mirror
yang
untuk
mana
dalam
didapatkan
dapat
digunakan sebagai intervensi.
ekstremitas
gerak pasien
neuron system exercise pada latihan
Metode ini berkonsentrasi pada
task program dengan task program
penanganan klinis bagi penderita stroke
terhadap
untuk memulihkan kapasitas fisik dan
gerak
kemampuan
pasien pasca stroke.
fungsional
atas
termasuk
peningkatkan
fungsional
kemampuan
ekstremitas
atas
tentunya fungsi AGA yang mengalami kelemahan
(weakness)
akibat
lesi
SUBYEK DAN METODE
neurologis saraf pusat yang dialami. Dalam
penggunaan
penelitian
ini
sample
ini
penelitian berjumlah 12 orang yang
meningkatkan
terbagi dalam dua kelompok berasal
neuroplastisitas pada otak, yang mana
dari Stroke Service Klinik Sasana
neuroplastisitas dapat terbentuk jika
Husada Jakarta Selatan. Pasien berasal
dilakukan secara terus-menerus dan
dari kriteria penerimaan: (a) pria dan
diulang-ulang.
wanita pasca stroke, (b) usia 45 – 60
diharapkan
Stevens melaporkan
dapat
metode
Pada
dan Stoykov (2004) peningkatan
yang
tahun, (c) kondisi hemiplegi dengan adanya
gangguan
kemampuan
signifikan pada ektremitas atas dan
fungsional anggota gerak atas, dan (d)
activity of daily living sebagai akibat
dapat
mobilisasi
keduduk
dengan
kondisi stabil. Pasien akan ditolak bila:
latihan task program dan kelompok
(a) ada komplikasi (kontraktur, dan
perlakuan diberikan latihan mirror
lain-lain)
gangguan
neuron system exercise menggunakan
kognitif, kesadaran, penglihatan dan
task program. Intervensi dilakukan
pendengaran,
sebanyak 12 kali dengan frekuensi 3
dan
sonde/alat
adanya
(b)
menggunakan
bantu,
(c)
mengalami
kali
seminggu
selama
30
menit.
ganggan sensoris, (c) kondisi umum
Latihan task program yang diberikan
yang belum stabil, seperti tekanan
terdiri
darah, HR (heart rate), RR (respiration
dilakukan yaitu: (1) mencapai dan
rate) yang belum stabil, (d) penderita
menekan sebuah tombol/saklar, (2)
diabetes mellitus berat atau tidak
mencapai dan memegang cone, (3)
terkontrol, (e) pernah mendapatkan
memegang
mirror
memegang cangkir, (5) mengangkat
neuron
system
exercise
sebelumnya.
dari
delapan
bean
tugas
bag
yang
kecil,
(4)
botol plastik, (6) mengangkat cangkir, (7) meletakkan koin ke dalam lubang di
Tabel 1. Distribusi Sampel Menurut Usia Kelompok Kelompok Umur Perlakuan I Perlakuan II (Tahun) Frekuensi % Frekuensi % 45 – 50 1 16,6 2 33,3 51 – 55 3 50,0 3 50,0 56 - 60 2 33,3 1 16,6 Jumlah
6
100
6
100
Data Penelitian di Klinik Sasana Husada Stroke Services
kotak uang, dan (8) mengambil dan menempatkan batu baduk di telapak tangan. Yang membedakan adalah pada kelompok perlakuan diberikan media mirror sebagai alat penunjang selama penelitian. Mekanisme intervensi pada kelompok
Tabel 2. Distribusi Sampel Menurut Jenis Kelamin Jenis
Kelompok
Kelompok
Perlakuan I
Perlakuan II
perlakuan
yaitu
tangan
pasien yang mengalami kelemahan ditempatkan dibelakang cermin, dan
Kelamin Frekuensi
%
Frekuensi
%
Perempuan
4
66,7
3
50,0
Laki-laki
2
33,3
3
50,0
cermin. Ketika program dimulai, pasien
Jumlah
6
100
6
100
diinstruksikan
Data Penelitian di Klinik Sasana Husada Stroke Services
tangan yang sehat ditempatkan didepan
ekstremitas
atas
untuk yang
menatap sehat
dan
tercermin dalam cermin. acak
Alat ukur yang digunakan dalam
kemudian dibagi menjadi 2 kelompok,
penelitian ini yaitu untuk kinerja
dimana kelompok kontrol diberikan
perawatan diri diukur menggunakan
Pasien
diambil
secara
Functional (FIM).
Independence Dalam
Measure
penelitian
ini,
menggunakan item perawatan diri dari FIM:
makan,
berpakaian
berdandan,
bagian
atas
mandi, tubuh,
berpakaian bagian bawah tubuh, dan toileting. Dalam penelitian ini perhitungan statistik
menggunakan
SPSS
(Statistical
Program
Social
for
Science) dalam perhitungan data yang diperoleh.
meningkatkan
statistik
program upaya gerakan
dalam fungsional
anggota gerak atas (AGA), mirror neuron system exercise merupakan salah satu metode yang dapat diberikan guna meningkatkan kemampuan dalam menghasilkan
Data
menunjukkan
bahwa pemberian program latihan task HASIL
Sebagai
Tabel 4. Perbedaan Nilai Sebelum dan Sesudah Functional Independence Measure (FIM) pada Kelompok Perlakuan II FIM FIM Sampel Selisih sebelum sesudah 1 8 14 6 2 14 20 6 3 9 16 7 4 7 13 6 5 9 13 4 6 10 15 5 Mean± 9.5±2.43 14.67±2.5 5.17±1.47 SD 7 12 3 Min 14 19 7 Maks Data Penelitian di Klinik Sasana Husada Stroke Services
ROM
(Range
of
Movement), kecepatan dan ketepatan gerakan lengan. Tabel 3. Perbedaan Nilai Sebelum dan Sesudah Functional Independence Measure (FIM) pada Kelompok Perlakuan I FIM FIM Sampel Selisih sebelum sesudah 1 8 12 4 2 9 11 2 3 10 13 3 4 13 19 6 5 8 11 3 6 7 9 2 Mean±SD 9.17±2.14 12.5±3.45 3.33±1.51 Min 7 9 2 Maks 13 19 6 Data Penelitian di Klinik Sasana Husada Stroke Services
dapat
meningkatkan
kemampuan fungsional anggota gerak atas pada pasien pasca stroke hal ini terlihat
pada
data
statistik
pada
kelompok perlakuan I (p<0.05) (tabel 3), dan terlihat pula pada kelompok perlakuan
II,
yaitu
penambahan
program latihan mirror neuron system exercise dengan task program dapat meningkatkan kemampuan fungsional anggota gerak atas pada pasien pasca stroke (p<0.05) (tabel 4). Penambahan system
exercise
mirror pada
neuron intervensi
menggunakan
task
program
dibandingkan
dengan
pemberian
latihan task program adalah sama dalam
meningkatkan
fungsional
ekstremitas
kemampuan atas
pasca stroke (p>0.05) (tabel 5).
pasien
korteks Tabel 5. Uji Hipotesis III Menggunakan FIM Kelompok Keteran Mean±SD p Perlakuan gan Selisih I
3.33±1.51
Selisih II
5.17±1.47
0.06
Sama
motorik.
Selain
plastisitas dapat
itu,
agar
terjadi diperlukan
pengulangan yang terus menerus dan dilakukan secara kontinu. Faktor lain yang dapat mempengaruhi yaitu adanya
Data Penelitian di Klinik Sasana Husada Stroke
rasa ketertarikan terhadapat intervensi
Services
yang akan dilakukan serta motivasi pasien itu sendiri selama melakukan
DISKUSI Kemungkinan penyebab dapat terjadi
diantaranya
pengaruh
faktor
intervensi. Jika rasa ketertarikan dan
adalah
karena
motivasi menurun terhadap intervensi
periode
waktu
yang
diberikan,
maka
dapat
penelitian yang singkat hanya selama
menyebabkan terbentuknya plastisitas
12 kali intervensi dengan frekuensi 3
pada otak berhenti tidak terbentuk lagi.
kali seminggu selama 30 menit, pada
Dapat dikatakan terjadi kejenuhan yang
setiap kelompok sehingga mungkin
mengakibatkan
saja diperlukan waktu yang lebih
plastisitas pada otak.
perubahannya yang mana pada periode
peneliti
ini
keterbatasan
nampak
adanya
terbentuknya
Selama penelitian berlangsung,
panjang agar lebih tampak perbedaan
sudah
tidak
mengalami
keterbatasan-
dalam
melakukan
kecenderungan pengikatan kemampuan
penelitian ini, antara lain: (1) aktivitas
fungsional anggota gerak atas. Hal lain
sampel yang tidak terkontrol, hal ini
yang dapat menyebabkan tidak adanya
karena peneliti tidak bisa memantau
perbedaan yaitu pada kedua intervensi
aktivitas sampel diluar penelitian. Hal
tersebut memiliki tujuan yang sama
ini
yaitu menambah plastisitas pada otak.
mengetahui
Faktor visual dan sentuhan sangat
maupun pengukuran sampel dalam
mempengaruhi terbentuknya plastisitas
keadaan optimal. Dalam keadaan ini
pada otak, dimana dengan adanya
akan menyebabkan hasil pengukuran
visual dan sentuhan akan terbentuk
yang tidak optimal pula, (2) tingkat
persepsi, kemudian informasi yang
emosional pasien yang tidak stabil
didapat akan dikirim melalui korteks
sehingga mempengaruhi proses latihan.
sensorik yang selanjutnya di kirim ke
Adanya jeda waktu antara latihan satu
menyebabkan apakah
peneliti saat
tidak latihan
dengan latihan selanjutnya sehingga dapat
mempengaruhi
peningkatan
Keysers, C., Gazzola, V. 2010. Social Neuroscience: Mirror Neurons
kemampuan fungsional anggota gerak
Recorded
in
atas.
Amsterdam
:
Humans. University
of
Groningen. p. 1-2 Kohler, F., Dickson, H., et al. 2009.
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M.
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Agreement
of
functional
Empathy, and Mirror Neurons.
independence
Californnia : Brain Research
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The Impact of Mirror Neuron System Exercise of Task Program to Upper Extremity Functional Motion Post-Stroke Patients Putri Martina A1), Miranti Yolanda A., S. Ft, M. Fis2), Abdul Chalik Meidian, Amd., Ft, SAP, M. Fis3), Pramudya Utama, SSt. Ft, M. Fis4)
1) Researcher 2) Supervisor I 3) Supervisor II 4) Examiner
Abstract. [Purpose] Knowing the difference in the effect of task training program with a combination of mirror neuron system use task exercise program on functional range of movement of the upper limb post-stroke patients. [Subject] 12 people taken at random, and then divided into a control group (n = 6) and the treatment group (n = 6). [Methods] Patients task group intervention program control and treatment groups using the media mirror by intervening task as much as 12 times the intervention program with a frequency of three times a week for 30 minutes. Measurement tool using Functional Independence Measure (FIM). [Results] The addition of a mirror neuron system in the exercise intervention program using the task as compared to the provision of training programs are the same task in improving functional ability of patients with post-stroke upper limb. Keywords: Task program, Mirror neuron system exercise, upper extremity functional ability in patients after stroke
experienced weakness due to a stroke.
INTRODUCTION The factors that cause stroke
Where the function of the upper limbs
patients become dependent on other
are necessary every individual in
people,
performing activities, such as eating,
become
self-sufficient
in
meeting their needs and in doing
drinking,
dressing,
taking
a
everyday activities, such is the lack of
subordinate, toileting, self make up,
functional upper extremity (UE) which
and other activities. So that the
necessary interventions which can help
program can improve the ability of
to increase again in doing functional
motion functional upper limb post-
activity of daily living. Mirror neuron
stroke patients, (3) No differences in
system using the media mirror exercise
the provision of mirror neuron system
which in practice does not require
in the training exercise program task by
expensive capital, and tools that are
task program at enhancing the ability of
easy to obtain can be used as an
the functional motion of the upper limb
intervention.
post-stroke patients.
This method concentrates on clinical treatment for stroke patients to
SUBJECTS AND METHODS
recover functional ability and physical
In this study, the research sample
capacity including of course the UE
numbering 12 people, divided into two
function
weakness
groups come from the Stroke Service
(weakness) as a result of neurological
Clinic Sasana Husada South Jakarta.
lesions
nervous
The patients came from the acceptance
experienced. In the use of this method
criteria: (a) men and women after a
is expected to increase neuroplasticity
stroke, (b) age 45-60 years, (c) the
in the brain, which neuroplasticity can
conditions with their impaired ability
be formed if done continuously and
hemiplegi functional upper limb, and
repeated.
(d) can mobilize keduduk with stable
experienced
of
Stevens
the
and
central
Stoykov (2004)
condition. Patients will be denied if: (a)
reported a significant increase in upper
there are complications (contractures,
extremity and activity of daily living as
etc.) and the presence of cognitive
a result of the mirror neuron system
impairment, awareness, vision and
exercise with the tasks given to stroke
hearing, (b) using a sonde / tools, (c)
patients.
experience
ganggan
sensory,
(c)
So that in this study researchers
general conditions unstable, such as
hypothesize: (1) the intervention using
blood pressure, HR (heart rate), RR
a task program can improve the ability
(respiration rate) unstable, (d) patients
of motion functional upper limb post-
with
stroke patients, (2) intervention mirror
uncontrolled, (e) never get a mirror
neuron system exercise using the task
neuron system previous exercise.
severe
diabetes
mellitus
or
Table 1. Sample Distribution by Age Age (Year) 45 – 50 51 – 55 56 - 60
Group I Frequency % 1 16,6 3 50,0 2 33,3
Jumlah
6
100
the study. Mechanism intervention in
Grouop II Frequenci % 2 33,3 3 50,0 1 16,6 6
100
Research in Clinical Stroke Services Sasana Husada
experienced weakness hand is placed behind the mirror, and healthy hands placed in front of the mirror. When the program
begins,
the
patient
is
instructed to gaze upon the healthy
Table 2. Samples Distribution by Gender Group I
the treatment group ie patients who
Group II
Gender
limb and reflected in a mirror.
Frequency
%
Frequency
%
Perempuan
4
66,7
3
50,0
Measuring instruments used in
Laki-laki
2
33,3
3
50,0
this research to the performance of self-
Jumlah
6
100
6
100
care
was
measured
using
the
Research in Clinical Stroke Services Sasana Husada
Functional
Independence
Measure
Patients are taken randomly and
(FIM). In this study, using self-care
then divided into two groups, in which
items from the FIM: eating, dressing,
the control group was given the task
bathing, dressing upper body, lower
exercise program and the treatment
body dressing, and toileting.
group was given training exercise using
In
this
study,
statistical
a mirror neuron system task program.
calculations using SPSS (Statistical
Interventions performed 12 times with
Program for Social Science) in the
a frequency of three times a week for
calculation of the data obtained.
30
minutes.
program
Exercise
consists
of
task
given
eight
tasks
RESULTS
performed are: (1) reach and push a
In an effort to improve functional
button / switch, (2) reaches and holds
movement of the upper limbs (AGA),
the cone, (3) holding the bean bag is
the mirror neuron system is one method
small, (4) holding the cup, (5) lift
of exercise that can be given in order to
plastic bottles, (6) lift the cup, (7)
improve the ability to produce the
putting coins into a hole in a box of
ROM (Range of Movement), the speed
money, and (8) take out and put the
and accuracy of arm movements.
stone in the palm baduk. The difference is in the treatment group was given media mirror as a supporting tool for
Table 3. Differences Values Before and After Functional Independence Measure (FIM) in the Group I FIM FIM Samples Difference before after 1 8 12 4 2 9 11 2 3 10 13 3 4 13 19 6 5 8 11 3 6 7 9 2 Mean±SD 9.17±2.14 12.5±3.45 3.33±1.51 Min 7 9 2 Maks 13 19 6 Research in Clinical Stroke Services Sasana Husada
Table 4. Difference Values Before and After Functional Independence Measure (FIM) in the group II FIM FIM Samples Difference before after 1 8 14 6 2 14 20 6 3 9 16 7 4 7 13 6 5 9 13 4 6 10 15 5 Mean± 9.5±2.43 14.67±2.5 5.17±1.47 SD 7 12 3 Min 14 19 7 Maks Research in Clinical Stroke Services Sasana Husada
program using the task as compared to the provision of training programs are the same task in improving the functional abilities of the upper limb poststroke patients (p> 0.05) (Table 5).
Table 5. Hypothesis III Using FIM Inform Group Mean±SD p ation Selisih I
3.33±1.51
Selisih II
5.17±1.47
0.06
Sama
Research in Clinical Stroke Services Sasana Husada
DISCUSSION Possible causes can occur which are due to the influence of the time period the research brief just over 12 times the intervention with a frequency of three times a week for 30 minutes, each group so it might take longer to
that
make it more visible differences in the
administration training program task
changes which in this period has been
program can improve functional ability
appear to have a tendency binding
of the upper limbs in patients with
functional capabilities upper limbs.
post-stroke as seen in the statistics in
Another thing that can cause no
the treatment group I (P <0.05) (Table
difference that
3), and seen also in the treatment group
interventions have the same goal which
II, the addition exercise program mirror
adds to the plasticity of the brain.
neuron system with task exercise
Visual and tactile factors greatly
program can improve functional ability
influence the formation of plasticity in
of the upper limbs in patients with
the brain, where the presence of visual
post-stroke (p <0.05) (table 4).
and tactile perception will be formed,
Statistics
show
in both of these
The addition of a mirror neuron
then the information obtained will be
system in the exercise intervention
sent through the sensory cortex which
then is sent to the motor cortex. In
the improvement of functional ability
addition, in order that the necessary
of the upper limbs.
repetition plasticity can occur
in
ongoing and carried out continuously. Another factor that can influence that their
sense of interest
REFERENCES Iacoboni,
M.
2009.
Imitation,
terhadapat
Empathy, and Mirror Neurons.
interventions to be performed and the
Californnia : Brain Research
patient's
Institute. p. 667
own
motivation
for
intervention. If a sense of interest and
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