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In contrast to varied therapy approaches, mirror therapy (MT) can be used even in completely plegic stroke survivors, as it uses visual stimuli for producing a desired response in the affected limb. MT has been studied to have effects not just on motor impairments but also on sensations, visuospatial neglect, and pain after stroke. This paper attempts to systematically review and present the current perspectives on mirror therapy and its application in stroke rehabilitation, and dosage, feasibility and acceptability in stroke rehabilitation. An electronic database search across Google, PubMed, Web of Science, etc., generated 3871 results. After screening them based on the inclusion and exclusion criteria, we included 28 studies in this review. The data collected were divided on the basis of application in stroke rehabilitation, modes of intervention delivery, and types of control and outcome assessment. We found that most studies intervened for upper limb motor impairments post stroke. Studies were equally distributed between intervention in chronic and acute phases post stroke with therapy durations lasting between 1 and 8 weeks. MT showed definitive motor and sensory improvements although the extent of improvements in sensory impairments and hemineglect is limited. MT proves to be an effective and feasible approach to rehabilitate post-stroke survivors in the acute, sub-acute, and chronic phases of stroke, although its long-term effects and impact on activities of daily living need to be analysed extensively.
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REVIEW
Mirror Therapy in Stroke Rehabilitation: Current
Perspectives
This article was published in the following Dove Press journal:
Therapeutics and Clinical Risk Management
Dorcas BC Gandhi
1,2
Albert Sterba
3
Himani Khatter
2
Jeyaraj D Pandian
2
1
College of Physiotherapy, Christian
Medical College & Hospital Ludhiana,
Ludhiana, Punjab, India;
2
Faculty of
Medicine, Masaryk University, Stroke
Brno, International Clinical Research
Center, St. Anne´s University Hospital,
Brno, Czech Republic;
3
Department of
Neurology, Christian Medical College &
Hospital Ludhiana, Ludhiana, Punjab, India
Abstract: In contrast to varied therapy approaches, mirror therapy (MT) can be used even in
completely plegic stroke survivors, as it uses visual stimuli for producing a desired response
in the affected limb. MT has been studied to have effects not just on motor impairments but
also on sensations, visuospatial neglect, and pain after stroke. This paper attempts to system-
atically review and present the current perspectives on mirror therapy and its application in
stroke rehabilitation, and dosage, feasibility and acceptability in stroke rehabilitation. An
electronic database search across Google, PubMed, Web of Science, etc., generated 3871
results. After screening them based on the inclusion and exclusion criteria, we included 28
studies in this review. The data collected were divided on the basis of application in stroke
rehabilitation, modes of intervention delivery, and types of control and outcome assessment.
We found that most studies intervened for upper limb motor impairments post stroke. Studies
were equally distributed between intervention in chronic and acute phases post stroke with
therapy durations lasting between 1 and 8 weeks. MT showed denitive motor and sensory
improvements although the extent of improvements in sensory impairments and hemineglect
is limited. MT proves to be an effective and feasible approach to rehabilitate post-stroke
survivors in the acute, sub-acute, and chronic phases of stroke, although its long-term effects
and impact on activities of daily living need to be analysed extensively.
Keywords: mirror therapy, stroke, rehabilitation, motor, sensory, hemineglect, unilateral
neglect, pain
Introduction
Stroke is the 3rd leading cause of years of life lost (YLL) across the world: age-
standardised YLL increased by 12.9% (10.615.2) from 1990 to 2007 and by
12.1% (9.914.1) from 2007 to 2017. Deaths from stroke increased from 5.-
29 million (5.225.40) to 6.17 million (6.046.33) across the globe between 2007
and 2017.
1
The rise of multi-morbidity and effects of longevity reported by the
GBD (global burden of disease) thus increased DALYs (disability-adjusted life
years) due to stroke from 3.54% to 9.66% from 1990 to 2013 and there were
approximately 25.7 million stroke survivors in 2013, globally.
2
HIC (high-income
countries) showed a 42% decrease in stroke while LMIC (low and middle-income
countries) showed a 100% increase in the past four decades.
3
There are approxi-
mately 62 million stroke survivors across the world and one-third of them live with
severe disabilities.
4
More than 80% of DALY occur in LMIC.
5,6
In the post-stroke acute phase, approximately 6080% of survivors present with
upper or lower limb motor impairments.
710
Only 20% of severely paretic survivors
achieve full upper limb function as compared to 80% of mildly paretic stroke
Correspondence: Jeyaraj D Pandian
Department of Neurology, Christian
Medical College & Hospital, Ludhiana,
Punjab 141008, India
Tel +91 9915784750
Email jeyarajpandian@hotmail.com
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survivors.
10
Fifty per cent of stroke survivors with an
initial presentation of plegic upper and lower
limbs regain partial motor function.
7,9
Painful upper limb
(especially around the shoulders) and complex regional
pain syndrome-type I (CRPS-type I) are experienced in
approximately 50% of stroke survivors in the rst year
post stroke, affecting their activities of daily living
(ADL).
1114
Around 40% with an acute right hemispheric
stroke and 20% of people with a left hemispheric stroke
present with hemineglect, especially visuospatial neglect,
which reduces to 15% and 5% respectively at the 3rd
month.
15
Spatial neglect has proven to be detrimental for
functional recovery
16,17
and is associated with reduced
quality of life.
18
Long-term functional recovery is also
directly dependent on the initial severity of paresis.
19
Rehabilitation strategies are required to be repetitive,
intensive, and task-specic for neuroplasticity to produce
recovery.
2022
It is reported that when therapy begins within
16 hrs to 6 months post stroke, there is signicant improve-
ment in ADL performance with augmented exercise
therapy.
23
In contrast to varied therapy approaches which
require some degree of voluntary movement, mirror therapy
(MT) can be used even in completely plegic, severely
paretic stroke survivors, as MT uses visual rather than
somatosensory stimuli for producing a desired response in
the affected limb.
24
Mirror therapy is a type of rehabilitation
approach where the reection (visual input) of a moving
non-affected limb gives the illusion of movement in the
affected limb. This is achieved by placing a mirror between
the arms or legs. MT has been studied to have effects not
just on motor impairments but also on sensations, visuos-
patial neglect, and pain after stroke.
25
This paper attempts to systematically review and pre-
sent the current perspectives on mirror therapy with
respect to its:
1. Application in stroke rehabilitation
2. Dosage, feasibility, and acceptability in stroke
rehabilitation
Methods
Inclusion criteria are as follows:
1. Study on mirror therapy for motor, sensory, and
perceptual impairments after stroke
2. Rehabilitation in the acute, sub-acute, and chronic
phases after stroke
3. Only randomised controlled trials
4. Articles published from January 2010 till June 2019
Exclusion criteria are as follows:
1. Studies written in languages other than English
2. Studies studying synergistic effects of mirror ther-
apy with other forms of therapies
3. Studies on other forms of therapy targeting the
mirror neuron system
Search Strategy
We conducted this review using PRISMA guidelines. An
electronic database search was performed using the follow-
ing databases: PubMed, Web of Science. The search strategy
includes keywords combined with Boolean operators: mirror
AND (therapy OR rehabilitation) AND (stroke OR post-
stroke OR post-stroke). The selection strategy of the studies
is shown in the PRISMA ow chart (Figure 1).
26
Review Process
The studies were screened by two independent reviewers
based on their titles and abstracts. RCTs were identied and
full articles were obtained for the selected RCTs. All of the full
articles were then assessed in order to check the fullment of
the inclusion criteria. In case of a disagreement between the
reviewers, the decision was made by a third reviewer.
Data Extraction
After the selection of studies, the data were extracted for
information on the title, inclusion and exclusion criteria, type
of intervention, sample size, study methodology, primary and
secondary outcomes, study limitations,feasibility, and adher-
ence. The data collected weremainly divided on the basis of
application in stroke rehabilitation, modes of intervention
delivery, and types of control and outcome assessment.
Risk of bias evaluation and methodological quality: the
COCHRANE risk of bias tool was used to perform the risk
of bias assessment. The methodological quality of each
study was performed using the PEDro scale.
27
Results
Application in Stroke Rehabilitation
Motor Upper Limb
Out of the 28 studies included (Tab le 1) in this review, 78.6%
of them studied the effects of MT on motor functions of upper
extremities, in addition to sensory function in 6 studies
2833
and ADL/QOL in 9 studies. We noted a reduction in
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impairment as recorded by FMA in almost all except for 5
studies. Improvement in upper limb motor function was
reported in terms of either improved dexterity, gross and ne
motor movements, grip force, decreased movement time, or
proximal motor control in 10 studies.
28,29,32,3440
Two o ther
studies reported no signicant difference with MT, in outcomes
measuring motor, sensory, and ADL components.
41,42
Only 4
studied the effects of MT on spasticity, out of which 3 reported
no improvement as recorded on the Modied Ashworth
scale
28,37,43
and one showed improvement on the Ashworth
scale,
44
with 6 weeks of MT along with conventional rehabi-
litation. Sensory impairments were measured in 6 studies, and
4 report improved response to either noxious, tactile, or tem-
perature stimuli.
2831
Twelve of the studies
2832,36,3840,4547
intervened in the chronic phase of upper limb decits after
stroke (ie after 6 months) while the rest intervened within the
acute and sub-acute phases. Duration of intervention ranged
between 3 and 8 weeks with MT sessions lasting between 20
and 45 min; 4 studies provided no additional conventional
rehabilitation.
32,40,45,47
Motor Lower Limb/Gait/Balance
Six studies reported on effects of MT on lower extre-
mity impairment/function, gait, and balance.
33,39,43,4850
Records identified through database
searching
(n =3871)
Screening
Included Eligibility noitacifitnedI
Records after duplicates removed
(n =635)
Records screened
(n =635)
Records excluded
(n =573)
Full-text articles assessed
for eligibility
(n =62)
Full-text articles excluded,
with reasons
(n =34)
Studies included in
qualitative synthesis
(n =28)
Figure 1 PRISMA ow chart.
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These studies showed improved motor recovery as
recorded on Brunnstrom stages and improved lower
extremity function through improved walking speed,
single limb stance, step and stride lengths, static and
dynamic balance, and decreased mediolateral and ante-
roposterior sway in standing. Two studies also reported
a reduction in lower extremity impairment. Improved
forward reach in standing and coordination was also
reported but no improvement in cadence or stance or
swing phase velocity was seen.
Activities of Daily Living and Quality of Life
Eight of the 22 studies
28,34,36,41,47,5153
reported on the
effects of MT on ADLs and one on the quality of life through
the Euro-QOL-5 Domain (EQ5D) scale.
32
ADLs showed no
improvement with MT in 3 studies, and neither did quality of
life. The rest of the studies did show improved performance
in ADLs through mainly the Functional Independence
Measure (FIM), otherwise through the Barthel Index and
Reptys Functional Index. All of these studies did not report
on the long-term effects of MT on ADLS or QOL.
Sensory
We report paucity in the number of studies treating and
recording change in sensory impairments after stroke. Six
studies record changes in sensory impairments like pain,
tactile discrimination, response to touch, temperature, etc.
Only1study
30
intervened for sensory issues by providing
varied texture stimulus during MT sessions to the affected
upper limbs. There was improved response to temperature
Table 1 Summary of Included Studies
First Author/Year Phase Intervention Target Duration of
Therapy (Weeks)
Mode of MT Sample
Harmsen, 2015
40
Chronic UL motor 1 session Action-observation, u/l 37
Lin, 2014
39
Chronic UL motor, ambulation,
ADL
4 MB, b/l 29
Amasyalı, 2016
38
Chronic Hand motor 3 MF, u/l 17
Gurbuz, 2016
53
Sub-acute UL motor 4 MF, u/l 31
Mohan, 2013
50
Acute LL motor, balance 2 MF 22
Xu, 2017
43
Sub-acute LL, ambulation, spasticity 4 MF 46
Vural, 2015
28
Chronic CRPS, UL motor, ADL,
spasticity
4 MR, b/l 30
Wu, 2013
29
Chronic UL motor and sensory 4 MF, b/l 23
Rodrigues, 2015
45
Chronic UL motor 4 MB, b/l 16
Arya, 2018
46
Chronic UL sensory 6 MF, b/l 31
Samuelkamaleshkumar, 2014
37
Sub-acute Wrist and hand motor 3 MB, b/l 20
Cristina, 2015
44
Sub-acute UL motor 6 MF, b/l 15
Thieme, 2012
52
Sub-acute UL motor, ADLS, QOL,
visuospatial neglect
5 MF, b/l 60
Colomer, 2016
31
Chronic UL motor and sensory 8 MB, b/l 31
Michielsen, 2011
32
Chronic UL motor, pain, QOL 6 MF, b/l 40
Pandian, 2014
54
Acute Unilateral neglect 4 MB, b/l 47
Antoniotti, 2019
41
Acute UL motor 4 MF, u/l 35
Tyson, 2015
33
Acute UL and LL, motor and
sensory
1MF 85
Chan, 2018
42
Acute UL motor 4 MF, b/l 35
Arya, 2015
46
Chronic UL motor 8 MB, u/l 33
Park, 2015
47
Chronic UL motor, ADL 4 MF, u/l 30
Radajewska, 2013
51
Sub-acute UL and hand motor, ADL 3 MF, b/l 60
Ji, 2015
49
Sub-acute Gait 4 MF, u/l 34
Park, 2015
36
Chronic UL motor, ADL 6 MF, u/l 30
Lee, 2012
35
Acute and sub-acute UL motor 4 MB, b/l 26
Invernizzi, 2013
34
Sub-acute UL motor, ADL 4 MF, u/l 26
In, 2016
48
Chronic Balance, gait 4 MB, VRRT 25
Yang, 2015
55
Sub-acute Pushers syndrome 3 MF 12
Abbreviations: UL, Upper Limb; u/l, Unilateral; ADL, Activities of Daily Living, MB, Mirror Box; b/l, bilateral; MF, Mirror Frame; LL, Lower Limb; CRPS, Complex Regional
Pain Syndrome; QOL, Quality of Life; VRRT, Virtual Reality Reection Therapy.
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and tactile sensation.
28
reported decrease in pain experienced
post stroke. Another study intervening through task-based
MT
46
reported that some of their patients experienced cer-
tain perceptionsin the affected upper limb like tingling,
movement icker, mild pain, pinprick, and associated move-
ments after 68 weeks of MT, although this study did not
actively intervene for sensory issues.
Unilateral Neglect
Studies by Pandian et al and Thieme et al
52,54
reported
recovery in visuospatial neglect in post-stroke patients with
MT for 4 and 5 weeks respectively. The patients showed
improvement in neglect in the near extrapersonal space and
representational neglect. It is important to note that both of
these studies intervened during the acutesub-acute phases
post stroke. The study by Thieme et al
52
studied effects of
MT in visuospatial neglect only in a small percentage of their
sample and the outcome was not blindly assessed. The
MUST trial by Pandian et al
54
reports improved mean scores
for star cancellation, line bisection, and picture identication
tests at the 6th-month follow-up. This article also reports
a 2-study meta-analysis concluding that MT was effective
in treating unilateral neglect after stroke.
Yang et al
55
intervened in the sub-acute phase for Pusher
syndrome post stroke. These patients showed improvement
by decreased severity of the syndrome and lower extremity
motor function improved on FMA. Another study reported
the positive effects of MT in reducing pain and improving
motor function in patients with complex regional pain syn-
drome after stroke. It is noteworthy that the intervention was
in the chronic phase of stroke. One of the studies by
Michielsen et al
32
describes improved activation within the
affected motor cortex as an outcome measure with 6 weeks of
MT training which included home-based sessions as well.
Intervention Details
Stage of Intervention
Thirteen of the studies studied the effects of MT in the
chronic phase of stroke, ie after 6 months of the onset
(those mentioned above and in 2016
48
). The rest of the
studies either intervened in the acute or sub-acute phase of
stroke. The longest duration of intervention of 8 weeks
was seen in chronic stroke in two studies, both intervening
for upper extremity impairments.
Modes of Intervention Delivery
A majority of the studies (92.8%) used either mirror boxes or
mirror frames to deliver MT training. A mirror box is
a 3-D structure with the facility to place the affected limb
within it to avoid direct viewing of it by the patient, whereas
a 2-D mirror frame is placed between the 2 arms either
vertically or inclined in such a way so that the patient is
able to view the reection of the normal arm in the mirror
without viewing the affected arm. The dimensions varied
based on which part of the body was being treated: upper
or lower extremity. Among the studies using the above-
mentioned mode of MT, 13 studies included bilateral sym-
metrical movements of the limbs
2830,32,35,37,39,42,44,45,51,52,54
as opposed to the remaining 13 studies which intervened with
unilateral movement of the unaffected limb. The study by
Harmsen et al
40
delivered a modied form of therapy using
the participant-specic videos with reaching movements
from the unaffected arm that were videotaped and mirrored,
creating maximal postural familiarity and the illusion that the
affected arm performed the reaching movements in a normal
movement pattern. This form of action-observation mode
showed improved speed of upper limb movements, although
the long-term effect was not measured. A study by In et al
used Virtual Reality Reection Therapy (VRRT) in treating
balance and gait after stroke. This is a technically enhanced
version of MT training where the patients in a high sitting
position placed their affected lower extremity into the VRRT
box and observed the projected movement of the unaffected
limb without visual asymmetry otherwise causing tilting of
the head and trunk. The movements of the unaffected limb
were captured through the camera and displayed over the
affected limb as the virtual reality reection. This study
reported improved balance scores both in static and dynamic
tests, decreased anteroposterior sway with eyes open, and
decreased mediolateral sway with eyes open and closed, as
well as improved walking speed on a 10-metre walk test.
Four studies used task-based activities during MT
sessions
30,33,46,47
while the rest used reaching activities
or simple graded movements of the limbs for therapy.
Two studies also included home-based sessions of mirror
therapy. It is important to note that no form of conven-
tional therapy was provided to the intervention group in 4
studies. Out of these, 2 studies (Rodrigues LC 2015, Park
Y 2015) showed denitive improvement in motor scores
for the upper limb and functional activities. Although, 1
study for chronic stroke reported that these gains did not
persist at the 6th-month follow-up.
32
Intensity
The total duration of intervention varied from 1 week to 8
weeks. Fifty per cent of the studies had an intervention
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period of 4 weeks with the frequency ranging from 3 to 5
sessions per week. Each sessions duration varied from 20
to 90 min; in some cases excluding 2030 min of control/
conventional therapy. One study reported the effects of 1
session of action-observation-based MT which was quite
intensive with 70 repetitions within a 10 trial set of MT.
40
This study showed improvement in speed in upper limb
movements.
Studies on upper extremities report positive effects
with treatment sessions lasting between 20 and 60 min
per day for 5 days a week, except for 2 studies that
reported no difference in motor scores between the inter-
vention and control groups. For the lower extremity, the
treatment sessions lasted between 15 min and 1 h, for 56
days a week.
Types of Control
We found 2 broad categories of control arms, one provid-
ing sham mirror therapy/placebo (53.57% of studies) and
the other providing conventional therapy (46.43%) to the
control arm. Sham MT was provided either by using
a non-reecting surface placed between the limbs or by
covering the mirror with a cloth or by displaying static
images/interactive visual feedback or by placing no mirror
between limbs. Conventional therapy varied from passive
movements/strengthening of the affected limb to compre-
hensive treatment combining physical and occupational
therapy along with speech and language therapy whenever
needed. Functional and task-based activities were included
in few of the studies as part of the control programme. All
conventional rehabilitation sessions were tailor-made to
patient needs and the duration lasted between 45 min and
5 hrs per day.
Types of Outcome Measures
The included studies present a varied range of outcomes
measuring motor, sensory, and perceptual impairments along
with balance/gait, ADLs, and QOL. We have categorised these
scales based on the ICIDH, ie International Classication of
Impairment, Disability (activity limitation) and Handicap (par-
ticipation restriction), as presented in Tab le 2.
Feasibility and Acceptability/Adherence
Fourteen studies did not contain any information about fea-
sibility or adherence at all.
2831,36,38,4043,4648,51,53
Apart
from several occasional and short-lived episodes of fatigue,
soreness, or swelling in the paretic limb,
33,42
the MT was
generally well tolerated and no serious adverse effects were
reported.
33,34,37,39,42,44,50,54,55
Overall, adherence to the MT
is assumed to be high, regarding that the majority of trials
employ directly supervised intervention;
33
two studies even
Table 2 Types of Outcome Measures
Category Scales Used
Impairment Activity
Limitation
Participation
Restriction
Motor:
upper and
lower
extremity
FMA
Myoton 3
myometer
PROM
MCSI
MAS
Movement
time
Grip force
Wrist
extension
Bhakta test
Tardieu scale
Motricity
index
Brunnstrom
stages
MSS
WMFT
BBT
10-metre walk
test
MFT
Upper extremity
performance test
for the elderly
ARAT
Stroke-ULAM
BI
FIM
Sensory FMA
RNSA
RASP
TDT
VAS
NA NA
Unilateral
neglect
SCT
LBT
PIT
NA NA
Balance Postural sway BBS
BBA
FRT
TUG
Others Scale for
Contraversive
Pushing
Motion analysis
device
FAC
FAT
SIS
ABILHAND
mRS
EQ 5D
RFI
Abbreviations: FMA, Fugl Meyer Assessment; PROM, Passive Range Of Motion;
MCSI, Modied Composite Spasticity Index; MSS, Motor Status Score; MFT, Manual
Function Test; ULAM, Upper Limb Activity Monitor; BI, Barthel Index; FIM,
Functional Independence Measure; RNSA, Revised Nottingham Sensory
Assessment; NSA, Nottingham Sensory Assessment; RASP, Rivermead
Assessment Of Sensory Perception; TDT, Tactile Discrimination Test; SMT,
Semmes-Weinstein Monolament Test; VAS, Visual Analog Scale; SCT, Star
Cancellation Test; LBT, Line Bisection Test; PIT, Picture Identication Task; BBS,
Berg Balance Scale; BBA, Brunel Balance Assessment; FRT, Functional Reach Test;
TUG, Timed Up and Go Test; FAC, Functional Ambulation Categories; FAT,
Frenchay Arm Test; MAL, Motor Activity Log; mRS, Modied Rankin Score; EQ-
5D, EuroQOL-5 Domains; RFI, Repty Functional Index.
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explicitly stated a 100% participation rate.
32,49
The highest
drop-out rate of 18.6% was recorded in a study comparing
effectiveness of MT in a group vs individual setting; this
study, however, concluded that the compliance and retention
rates in the group intervention are comparable to the indivi-
dual approach, and thus the MT group seems to be possible
even for severely disabled stroke patients.
52
A study comparing two patient-led therapies (MT vs
lower limb exercises) reported that both interventions
were feasible, with 90% adherence. Nevertheless, both
groups did less therapy than recommended; and participants
receiving MT inclined to do less practice than those under-
going lower limb exercises. Furthermore, those with neglect
performed 69% less MT than those without, which was not
observed in the exercise group.
33
In another study on add-
ing object-related bilateral symmetrical training to MT in
chronic stroke, the physiotherapist conducted the rehabilita-
tion programme at the patient's home in order to increase
participation. Despite 16% of sessions not being performed,
all subjects obtained an identical number of sessions and
nished the treatment.
45
A 14.6% drop-out rate was calcu-
lated in stroke patients with a severely impaired arm.
42
At
last, patients experiencing MT demonstrated higher levels
of motivation compared to those receiving sham therapy.
35
Limitations
A small sample size was the prevailing limitation
among the included studies.
29,31,33,37,38,40,41,43,45,46,49,52,53,55
Additionally, the absence of follow-up did not allow assess-
ment of long-term retention of functional improvement in
patients after rehabilitation.
28,31,3437,41,43,44,46,47,49,53,55
A number of studies reported difculties with generalisation
of the outcomes due to specic pre-selection
criteria
32,36,38,47,48,51
or because they included patients with
a distinct level of functional impairment and time post
ictus.
29,31,32,39,41,52
Another complication to the interpretation
of the MT effectiveness was that three studies observed
a difference in baseline measurements between the experimen-
tal and control groups.
37,50,54
The impact of MT on changes in
cortical reorganisation and neural activation pre and post ther-
apy could not be examined as only one study implemented
fMRI in its protocol.
32
Besides the aforementioned, there were some other
limitations declared by individual research teams which
may be pertaining to the remainder of studies as well.
First, the interactive character of the experimental condi-
tion excluded the blinding of both the therapists and the
participants.
37,52
Second, the design of the mirror box
precludes movements such as shoulder overhead motion
and rotation, which might be the cause of less pronounced
improvement in the upper arm movement compared to the
wrist and hand in the intervention group.
46
Third, several
authors expressed the lack of quality of movement
46,49
or
the active range of motion
43
assessment as one of their
limitations. When applying attention-dependent rehabilita-
tion techniques, a comprehensive cognition and depression
evaluation both before and during or after the treatment
would be of value.
28,41,44
The role of MT in patients
presenting with an additional effect of the presence of
cognitive impairments (seen commonly in lacunar
strokes)
56,57
needs to be analysed. Our study does not
evaluate the effect of MT in those with cognitive impair-
ments. Extending our results to such a group of patients
needs to be extensively researched.
Future studies should involve a larger sample size and more
homogeneous distribution in relation to sensory impairment or
motor paresis.
38
Further on, new studies ought to be executed
on optimal duration, intensity, and content
38
while also focus-
ing on ADL.
53
Risk of bias and methodological quality: the average
PEDro score was 7±0.93 and no study showed a poor
score (score <4), 2 (7.1%) of the studies showed fair
quality (score 45), and most studies (89.3%) had a good
methodological quality. Only 1 study (3.6%) showed
excellent quality (score 910). The risk of bias scored on
the Cochrane tool is depicted in Figure 2.
Discussion
Various hypotheses have been postulated on the neurophy-
siological basis of MT. The rst hypothesis suggests the
presence of a mirror neuron system (MNS) in the frontotem-
poral region and superior temporal gyrus (STG)
58,59
which
discharges with a goal-oriented hand action or through obser-
vation of a similar action by another person.
60,61
This action-
observation facilitates the corticospinal pathway; in turn
improving motor function by eliciting mental imagery
62
and inducing motor learning.
63
Observation of biological
motion also is thought to aid in recovery from neglect by
activation of the STG.
64,65
The second hypothesis suggests
potential mechanisms like increased self-awareness and spa-
tial attention by activation of the STG, precuneus, and poster-
ior cingulate cortex (PCC). MT increases activity in primary
and secondary visual and somatosensory areas, thus enhan-
cing attention, conscious awareness of sensory feedback, and
avoidance of learned non-use of the affected limb.
6669
The
third hypothesis describes the role of MT in activation and
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recruitment of the otherwise dormant, ipsilateral motor path-
ways originating in the unaffected hemisphere and projecting
ipsilaterally to the paretic side of the body.
7072
The role of
MT in promoting normalisation of balance within the hemi-
spheres post stroke by modulating the excitability of the
primary motor cortex (M1) has also been hypothesised.
24,73
During MT, both the affected limb movement and the passive
observation of movement of the unaffected limb as reected
in the mirror inuence M1 excitability.
24
Bhasin et al
74
observed an increase in the activation of primary motor
area Brodmann area 4 post MT (restitution principle of
neuroplasticity).
Our review has reported effects of MT in rehabilitation
post stroke. More than half of the studies intervened and
recorded improvements in the acute phase of stroke. This
can potentially change clinical practice as MT can inter-
vene for a completely accid limb, unlike other rehabilita-
tion approaches (Constraint Induced Movement Therapy
(CIMT), therapy with computer games, virtual reality, etc.)
where a minimal amount of voluntary movement is a pre-
requisite for initiating therapy.
Few studies have previously reported that MT, when
combined with bilateral arm training, increases the visual
or mental imagery feedback, which in turn facilitates
upper limb motor function.
75
Our review supports this
nding and additionally reports that bilateral arm training
shows positive results in both sub-acute and chronic motor
impairments of the upper limb and for hemineglect.
A future scope for MT would be to identify its relation
to the differing presentations of stroke among men and
women. The differing risk factors, stroke severity, and
neurological outcomes between men and women may
demand a modied application of MT for rehabilitation
in individual genders.
76
Research is also needed into the
effect of MT in different subtypes of stroke, be it pure
motor strokes or those with sensory and other components.
The role of MT in rehabilitating acute and chronic lacunar
strokes (which show better functional prognosis), its long-
term effects, and associated improvement in quality of life
can be investigated to set the stage.
77
Conclusion
MT is a feasible method for training post-stroke impairments
(motor, sensory, perceptual decits) in acute, sub-acute, and
chronic phases. Inclusion of bilateral arm training improves
patient response to MT. The required dosage of MT, long-term
effects, and impact on ADLs and QOL on various subtypes of
stroke need to be analysed extensively in larger populations.
Disclosure
Dr Dorcas BC Gandhi reports grants from Wellcome Trust
Research Training Fellowship, outside the submitted work.
The authors report no other conicts of interest in this work.
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Introdução: A terapia espelho (TE) tem sido recomendada para melhoria da funcionalidade após o acidente vascular cerebral (AVC). A TE convencional demanda alta concentração e pode se tornar desmotivante, restringindo a participação ativa e engajamento do paciente, além de levar a alterações posturais e de equilíbrio. A TE baseada em realidade virtual (RV) tem por intuito minimizar estes déficits e facilitar o controle dos movimentos. Objetivo: Analisar os efeitos de intervenções de TE baseadas em RV em pacientes com disfunções motoras pós-AVC. Métodos: Revisão sistemática da literatura, nas bases Pubmed, Embase, ICTRP, Cinahl, Medline e Lilacs. Resultados: Foram selecionados 6 ensaios controlados e randomizados. TE+RV demonstraram melhoria na marcha, equilíbrio, funcionalidade de membro superior, inferior e face, e reduziram as consequências negativas encontradas na TE convencional. Conclusão: Melhora das disfunções motoras pós-AVC na TE+RV, reduzindo as limitações observadas na TE convencional. Sugerem-se estudos futuros para desenvolver e validar abordagens de TE+RV com menor impacto financeiro.
... This study concluded that somatosensory retraining has positive impact on improvement of balance but not on gait after stroke. (10) While in current study association of somatosensory deficit with balance and gait in sub-acute stroke patient was found. Out of 204 patients 18 (8.82%) ...
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Objective: The aim of the study is to evaluate the effectiveness of belfast protocol in Flexion tendon injury of zone v through TAM scoring. Methodology: A prospective study will be directed to find out the outcome of Belfast protocol in flexor tendon injury in the premises of plastic surgery ward civil hospital Karachi, we were use non probability sampling technique to enlist the patient .we were systematized a well-designed questionnaire and through TAM scoring to measure the intervention outcome in term of functional ADL. Results: The results showed that there were 76% male and 24% female patients were affected. Most of the injury happened at work in 29% and at home 21% patients.44% patients were (21-30 ) years of age , 36% patients were (31-40) 4% of patients were (41-50) , 2% of patients were (51-60). TAM Score was observed that total 22 patients had excellent outcome (Score 100), 19 patients had good outcome (Score 75-99), 4 patients had fair outcome (score50-74 ) and only 5 patients had poor outcome. It was observed that treatment was effective in 45 patients because their TAM Score was >50 and in only 5 patients the treatment was ineffective because their TAM Score was <50. Conclusion: We concluded that belfast regime (early passive and active range of motion of fingers the rate of tendon adhesion and rupture rate was very low and gave good result , most commonly men was affected with the injury that’s 76% and commonly injury happened at work place by accident . There is no standard protocol and therapist must communicate with the surgeon and patients before selecting an appropriate therapy program.. Keywords : Rehabilitation ,Flexor injury , Zone V, Early mobilization ,Belfast technique.
... Patients enrolled in the study group were rehabilitated using either the PNF concept [24][25][26] or MT method [27][28][29]. The exercise schedule was set at five times each week. ...
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Stroke is a serious cause of premature death among adults and the reason for much long-term disability. Understanding the mechanisms of disability and the potential for recovery of stroke patients should be one of the highest priorities of the health care system. Neurorehabilitation of post-stroke patients focuses on functional recovery by activating mechanisms of natural reorganization. Proprioceptive neuromuscular facilitation (PNF) and mirror therapy (MT) are neurorehabilitation methods activating brain plasticity, and their clinical utility for stroke survivors is still under studied. This study compared two neurorehabilitation methods using PNF or MT on functional recovery in patients after a first-ever ischemic stroke. This prospective and interventional randomized clinical study involved a group of 50 patients (34 males and 16 females) with first-ever ischemic stroke, aged 48–82 years being in the recovery-compensation stage and admitted to the unit for early post-stroke rehabilitation. Patients were randomly enrolled into two groups in terms of rehabilitation method used: PNF (n = 26) or MT (n = 24). Barthel Index (BI) was used for assessing functional status at baseline (M0), and 3 (M1) and 6 weeks (M2) after intervention), and modified Rankin Scale (mRS) was used for assessing a disability level at baseline (M0), and 6 weeks (M2) after the intervention. Statistically significant differences were noted in the two study groups in BI (main effect:
... This study concluded that somatosensory retraining has positive impact on improvement of balance but not on gait after stroke. (10) While in current study association of somatosensory deficit with balance and gait in sub-acute stroke patient was found. Out of 204 patients 18 (8.82%) ...
Article
Background: A stroke occurs when the blood supply to part of your brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. There are three types of stroke ischemic stroke hemiplegic stroke and transient ischemic stroke. Objective: To determine the association of lower extremity somatosensory deficit in balance and gait in sub-acute stroke patients. Methods: Cross sectional survey was used in this study. The age group of participants was 40 to 75 years. Sample size was 204 calculated from Rao software and non-probability convenient sampling technique was used. Data was collected from Lahore General Hospital. Data was obtained from patient by applying distal proprioception test to assess the joint position sense. For the assessment of two point discrimination bolay gauge was used. The cutaneous vibration sensation was assessed through tuning fork. Soft goat hair brush was used to check the light touch pressure. For balance assessment berg balance scale and time up and go test was used. Gait was observed through Wisconsin gait index. Results: Mean value and standard deviation of age of participants were 62.99and 6.592 respectively. There was association of berg balance scale with two point discrimination test, light touch pressure and distal proprioception. There was no association between berg balance scale and vibration sense. Mean value and standard deviation of Wisconsin gait index was 23 and 4.986 respectively. Association between TUG and two point discrimination was found. There was no association of TUG with vibration sense, distal proprioception test and light touch pressure. Conclusion: This study concluded that balance was affected in sub-acute stroke patients due to the somatosensory deficit. Fall risk increased in the sub-acute stroke patient as the patients performance measured in time up and go test and berg balance scale. It was also inferred that while patients performing Wisconsin gait index scale, gait was affected in sub-acute stroke patients. Keywords: Balance, Gait, Sub-acute Stroke, fall risk, Somatosensory, Lower extremity
... [13,16,28,38] Our data showed that MVF activated the ipsilesional sensorimotor network in patients with stroke with severe paresis, in congruence with Wang et al. [15] They reported ipsilesional activation of the precuneus with fMRI in patients with stroke with severe hemiparesis. Considering that MVF is regarded as a therapeutic approach that can be used in patients with stroke with severe hemiparesis, [39] our ndings will add more neurophysiological grounds for using MVF in the severely paralyzed patient population with stroke. [9] The use of immersive VR was another notable feature of our study. ...
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Background: This study aimed to investigate the activation pattern of the motor cortex (M1) and parietal cortex during immersive virtual reality (VR)-based mirror visual feedback (MVF) of the upper limb in patients with chronic stroke. Methods: Fourteen patients with chronic stroke with severe upper limb hemiparesis (Brunnstrom stage of hand 1-3) and 21 healthy controls were included. The participants performed wrist extension tasks with their unaffected wrists (or the dominant side in controls). In the MVF condition, the movement of the affected hand was synchronized with that of the unaffected hand. In contrast, only the movement of the unaffected hand was shown in the no-MVF condition. Electroencephalography was obtained during experiments with two conditions (MVF vs no-MVF). Mu suppression in the bilateral M1 and parietal cortex and mu coherence between the ipsilateral M1 and parietal cortex in each hemisphere and interhemispheric M1 were used for analyses. Results: In patients with stroke, MVF induced significant mu suppression in both the ipsilesional M1 and parietal lobes (p=0.006 and p=0.009, respectively), while significant mu suppression was observed in the bilateral M1 (p=0.003 for ipsilesional and p=0.041 for contralesional M1, respectively) and contralesional (contralateral hemisphere to the moving hand) parietal lobes in the healthy controls (p=0.036). The ipsilesional mu coherence between the M1 and parietal cortex in patients with stroke was stronger than that in controls regardless of MVF condition (p<0.001), while mu coherence between interhemispheric M1 cortices was significantly weaker in patients with stroke (p=0.032). Conclusion: In patients with stroke, MVF using immersive VR induces mu suppression in the ipsilesional M1 and parietal lobe. Our findings provide evidence of the neural mechanism of MVF using immersive VR and support its application in patients with stroke with severe hemiparesis.
... The reflection of the normal side appears to be the stroke affected limb to the user and any activity performed by the normal side appears to the user as being performed by the stroke-affected side. Studies have shown that mirror therapy has influenced re-learning of activity in the brain [27][28][29], and mirror therapy combined with electrical stimulation is even more beneficial [30][31][32]. ...
Article
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Upper limb impairment following stroke is often characterized by limited voluntary control in the affected arm. In addition, significant motor coordination problems occur on the unaffected arm due to avoidance of performing bilateral symmetrical activities. Rehabilitation strategies should, therefore, not only aim at improving voluntary control on the affected arm, but also contribute to synchronizing activity from both upper limbs. The encoder-controlled functional electrical stimulator, described in this paper, implements precise contralateral control of wrist flexion and extension with electrical stimulation. The stimulator is calibrated for each individual to obtain a table of stimulation parameters versus wrist angle. This table is used to set stimulation parameters dynamically, based on the difference in wrist angle between the set and stimulated side, which is continuously monitored. This allows the wrist on the stimulated side to follow flexion and extension patterns on the set side, thereby mirroring wrist movements of the normal side. This device also gives real-time graphical feedback on how the stimulated wrist is performing in comparison to the normal side. A study was performed on 25 normal volunteers to determine how closely wrist movements on the set side were being followed on the stimulated side. Graphical results show that there were minor differences, which were quantified by considering the peak angles of flexion and extension on the set and stimulated side for each participant. The mean difference in peak flexion and extension range of movement was 2.3 degrees and 1.9 degrees, respectively, with a mean time lag of 1 s between the set and the stimulated angle graphs.
... As a result, the illusion of normal movement of the paretic hand in the mirror as well as motor imagery of moving the paretic hand is created. Feedback from the affected side prevents or decreases learned nonuse phenomena and also promotes neural plasticity (Gandhi et al., 2020;Thieme et al., 2018). Ramachandran and Roger-Ramachandran pioneered this therapy method for the treatment of phantom limb pain (Ramachandran & Hirstein, 1998;Ramachandran & Rogers-Ramachandran, 1996;Stoykov & Corcos, 2009;Yavuzer et al., 2008). ...
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Introduction In stroke survivors, the prevalence of upper motor disability remains high. There has not been much report on the success of post-stroke mirror therapy, especially in developing countries. Objective The focus of this research is to see how mirror therapy, in addition to standard rehabilitation for hand paresis, affects upper limb motor recovery and level of independence in self-care after stroke at an Indonesian teaching hospital. Method This was a randomized controlled trial with no assessor blinding. The study included 18 subacute stroke patients who did not have cognitive or visual impairment. The mirror group received a 20-minute mirror therapy session in addition to conventional rehabilitation, while the control group received only the standard program for 5 weeks (2 times per week). The Brunnstrom score and self-care level of independence elements of the Functional Independence Measure (FIM) were used as outcome measures. Results Baseline comparisons of lesion type and Brunnstrom score showed significant between-group differences. The ANACOVA test showed the difference had no effect on the FIM change in scores (P > 0.05). One patient (mirror group) was dropped out from the study. After 5 weeks (n=17), the mirror group showed improvement in both the Brunnstrom and FIM scores (P < 0.05) compared to the control group. Conclusions Mirror treatment improves upper limb motor recovery and level of independence in self-care after stroke when combined with standard hand paresis rehabilitation 2 times a week for 5 weeks.
Chapter
The use of assistive devices has shown to be beneficial in clinical services for the motor rehabilitation of the lower limbs. Its use facilitates the rehabilitation of patients and increases their participation in daily life. However, unlike some countries like the USA, Japan and Germany, in practice, these technologies are not necessarily available in Latin American countries due to a lack of resources, and demographic access barriers. In this work we present the design, development, and preliminary evaluation in terms of functionality and usability of MoveLeg, a low-cost assistive device for the motor rehabilitation of the lower limbs of patients with sequelae of stroke. The proposed device is based on design insights obtained from 14 motor rehabilitation specialists from different institutions, with characteristics that allow to: (i) care for remote patients, (ii) manage the therapy program online, (iii) personalize and monitor each session based on a mirror therapy, and (iv) decrease the intensity or stop the exercise in real-time. The results of the preliminary functional evaluation establish that the device is working properly. In addition, the results of the usability evaluation with an older adult and a physiotherapist suggest that the device is perceived as easy to use, easy to learn, and with a high intention to use, while providing motor tele-rehabilitation in real-time, in a supervised and safe way.KeywordsAssistive deviceTele-rehabilitationLower limbStroke
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Purpose: Poststroke rehabilitation is an inevitable element of the treatment for stroke survivors. This study aimed to investigate the effect of balance training with mirror therapy in older adults with poststroke balance impairment. Design/methods: The study adopted a two-arm randomized clinical trial and included 38 older adults with poststroke balance impairment. The intervention group received balance exercises with mirror therapy, whereas the control group received the same balance exercises without mirror therapy (a nonreflective plate was used instead). The patient outcome, the balance score, was measured using the Berg Balance Scale. Analysis of covariance was used for statistical analysis. Results: Results showed that balance exercises combined with mirror therapy were significantly more effective than balance exercises without mirror therapy in improving balance in the stroke survivors (p < .001). Conclusion: Mirror therapy combined with regular balance exercises is an effective and practical method for enhancing balance in older adults suffering from balance impairment. Clinical relevance: Balance training combined with containing mirror therapy may be included in the rehabilitation programs of older adults with poststroke balance impairment.
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Introduction The efficacy of task-based mirror therapy for upper limb motor function remains controversial in stroke patients. We conduct a systematic review and meta-analysis to explore the influence of task-based mirror therapy on upper limb motor function in stroke. Methods We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through August 2021 for randomized controlled trials (RCTs) assessing the effect of task-based mirror therapy on functional improvement in stroke. This meta-analysis is performed using the random-effect model. Results Six RCTs are included in the meta-analysis. Overall, compared with conventional rehabilitation for stroke, task-based mirror therapy significantly improved Fugl-Meyer Assessment (MD=4.60; 95% CI=1.15 to 8.06; P=0.009), and obtained the comparable impact on Modified Barthel Index (MD=4.96; 95% CI=−4.44 to 14.35; P=0.30), grip strength (MD=3.74; 95% CI=−1.61 to 9.09; P=0.17), modified Ashworth Scale (arm, MD=0.34; 95% CI=−0.67 to 1.35; P=0.50) and modified Ashworth Scale (hand, MD=0.10; 95% CI=−0.58 to 0.77; P=0.78). Conclusions Task-based mirror therapy is effective to improve upper limb motor function in stroke patients.
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Background Virtual reality reflection therapy (VRRT) is a technically enhanced version of the mirror therapy concept. The aim of this study was to investigate whether VRRT could improve the postural balance and gait ability of patients with chronic stroke. Material/Methods Twenty-five patients with chronic stroke were randomly allocated into the VRRT group (n=13) and the control group (n=12). The participants in both groups performed a conventional rehabilitation program for 30 minutes. The VRRT group also performed a VRRT program for 30 minutes, five times a week for 4 weeks. The control group performed conventional rehabilitation program and a placebo VRRT program. Outcome measures included Berg Balance Scale (BBS), the Functional Reaching Test (FRT), and the Timed Up and Go (TUG) test (for dynamic balance ability), postural sway (for static balance ability), and 10 meter walking velocity (10 mWV) for gait ability. Results There were statistically significant improvements in the VRRT group compared with the control group for BBS, FRT, TUG, postural sway (mediolateral sway distance with eyes open and eyes closed, anteroposterior and total sway distance with eyes open but not with eyes closed), and 10 mWV (p<0.05). Conclusions Applying VRRT (even as a home treatment) along with a conventional rehabilitation program for patients with chronic stroke might be even more beneficial than conventional rehabilitation program alone in improving affected lower limb function. Future studies should investigate the effectiveness of VRRT with optimal patient selection, and duration and intensity of training.
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[Purpose] This study aimed to evaluate the effectiveness of mirror therapy combined with a conventional rehabilitation program on upper extremity motor and functional recovery in stroke patients. [Subjects and Methods] Thirty-one hemiplegic patients were included. The patients were randomly assigned to a mirror (n=16) or conventional group (n=15). The patients in both groups underwent conventional therapy for 4 weeks (60–120 minutes/day, 5 days/week). The mirror group received mirror therapy, consisting of periodic flexion and extension movements of the wrist and fingers on the non-paralyzed side. The patients in the conventional group performed the same exercises against the non-reflecting face of the mirror. The patients were evaluated at the beginning and end of the treatment by a blinded assessor using the Brunnstrom stage, Fugl-Meyer Assessment (FMA) upper extremity score, and the Functional Independence Measure (FIM) self-care score. [Results] There was an improvement in Brunnstrom stage and the FIM self-care score in both groups, but the post-treatment FMA score was significantly higher in the mirror therapy group than in the conventional treatment group. [Conclusion] Mirror therapy in addition to a conventional rehabilitation program was found to provide additional benefit in motor recovery of the upper extremity in stroke patients. © 2016 The Society of Physical Therapy Science. Published by IPEC Inc.
Article
Objective: The aim of this study was to investigate the efficacy of mirror therapy on upper-limb recovery in early post-stroke patients. Design: Assessor-blinded randomized controlled trial. Setting: Inpatient rehabilitation clinic. Subjects: A total of 40 patients with upper-limb impairment due to a first-ever ischaemic or haemorrhagic stroke, within four weeks from the cerebrovascular accident. Intervention: The intervention group received mirror therapy, while the control group received sham therapy. During mirror therapy, patients' sound hand was reflected by a mirror. During sham therapy, an opaque surface replaced the mirror-reflecting surface. Both the mirror therapy and sham therapy groups practised their sound hand with exercises, ranging from the simple elbow flexion-extension to complex tasks (e.g. reaching and grasping). Mirror therapy and sham therapy were added to conventional rehabilitation. Main measures: Primary outcome includes Fugl-Meyer upper extremity scale. Secondary outcomes include action research arm test (ARAT) and functional independence measure (FIM) scale. Outcomes were measured at the beginning (T0) and end (T1) of the treatment. Results: At baseline, both groups (sham therapy vs. mirror therapy; mean (SD)) were comparable for Fugl-Meyer (30.9 (23.9) vs. 28.5 (21.8)), ARAT (25.1 (25.5) vs. 23.5 (24)) and FIM (71.0 (20.6) vs. 72.9 (17.8)) scores. At the end of the treatment, both groups significantly improved in the Fugl-Meyer (40.6 (21.3) vs. 38.3 (23.4)), ARAT (31.9 (23.0) vs. 30 (24.1)) and FIM (100.3 (21.9) vs. 99.4 (22.6)) scores. However, at T1, no significant difference was observed between the sham therapy and mirror therapy groups, neither for the Fugl-Meyer, nor for ARAT and FIM scores. Conclusion: Compared with sham therapy, mirror therapy did not add additional benefit to upper-limb recovery early after stroke.
Background: Poststroke, sensory deficits are not uncommon. In spite of the close association between the sensory and motor recovery, the deficits are usually underemphasized. Mirror therapy (MT), a neural-based approach for the motor deficit has not been explored for the sensory impairment. The objective of the present study was to develop and determine the effect of a MT program for sensori-motor impairment among poststroke subjects. Methods design: Randomized controlled trial. Setting: Functional therapy laboratory of Rehabilitation Institute. Participants: Thirty-one chronic poststroke subjects (17 experimental and 14 controls), aged between 30 and 60 years, with ≤ diminished light touch in the hand. Outcome measure: Semmes Weinstein Monofilament (cutaneous threshold), 2-Point discrimination test (touch discrimination) and Fugl-Meyer Assessment (hand motor recovery). Intervention: The experimental group received sensory stimulus such as tactile perception and motor tasks on the less-affected hand using mirror box. The control counterparts underwent only dose-matched conventional program. 30 sessions with a frequency of 5/week were imparted to the groups. Results: Post intervention, there was a significant (P < .004) increase up to 30% positive touch-response for the hand quadrants among the experimental group in comparison to only 13.5% rise for the same among the controls. The cutaneous threshold of the less-affected palm also improved significantly among the experimental subjects in comparison to the controls (P = .04). Conclusion: MT may be considered as a promising regime for enhancing cutaneous sensibility in stroke. The mirror illusion induced by MT may be utilized for sensory and motor deficits as well as for the more-affected and less-affected hands.
Article
Background: Mirror therapy is used to improve motor function after stroke. During mirror therapy, a mirror is placed in the person's midsagittal plane, thus reflecting movements of the non-paretic side as if it were the affected side. Objectives: To summarise the effectiveness of mirror therapy compared with no treatment, placebo or sham therapy, or other treatments for improving motor function and motor impairment after stroke. We also aimed to assess the effects of mirror therapy on activities of daily living, pain, and visuospatial neglect. Search methods: We searched the Cochrane Stroke Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, PsycINFO and PEDro (last searched 16 August 2017). We also handsearched relevant conference proceedings, trials and research registers, checked reference lists, and contacted trialists, researchers and experts in our field of study. Selection criteria: We included randomised controlled trials (RCTs) and randomised cross-over trials comparing mirror therapy with any control intervention for people after stroke. Data collection and analysis: Two review authors independently selected trials based on the inclusion criteria, documented the methodological quality, assessed risks of bias in the included studies, and extracted data. We assessed the quality of the evidence using the GRADE approach. We analysed the results as standardised mean differences (SMDs) or mean differences (MDs) for continuous variables, and as odds ratios (ORs) for dichotomous variables. Main results: We included 62 studies with a total of 1982 participants that compared mirror therapy with other interventions. Of these, 57 were randomised controlled trials and five randomised cross-over trials. Participants had a mean age of 59 years (30 to 73 years). Mirror therapy was provided three to seven times a week, between 15 and 60 minutes for each session for two to eight weeks (on average five times a week, 30 minutes a session for four weeks).When compared with all other interventions, we found moderate-quality evidence that mirror therapy has a significant positive effect on motor function (SMD 0.47, 95% CI 0.27 to 0.67; 1173 participants; 36 studies) and motor impairment (SMD 0.49, 95% CI 0.32 to 0.66; 1292 participants; 39 studies). However, effects on motor function are influenced by the type of control intervention. Additionally, based on moderate-quality evidence, mirror therapy may improve activities of daily living (SMD 0.48, 95% CI 0.30 to 0.65; 622 participants; 19 studies). We found low-quality evidence for a significant positive effect on pain (SMD -0.89, 95% CI -1.67 to -0.11; 248 participants; 6 studies) and no clear effect for improving visuospatial neglect (SMD 1.06, 95% CI -0.10 to 2.23; 175 participants; 5 studies). No adverse effects were reported. Authors' conclusions: The results indicate evidence for the effectiveness of mirror therapy for improving upper extremity motor function, motor impairment, activities of daily living, and pain, at least as an adjunct to conventional rehabilitation for people after stroke. Major limitations are small sample sizes and lack of reporting of methodological details, resulting in uncertain evidence quality.
Article
Objective: This study aimed to examine the effectiveness of mirror therapy (MT) on recovery in the severely impaired arm after stroke. Design: Using single-blind randomized controlled design, patients with severely impaired arm within 1-month post-stroke were assigned to received MT (n=20) or control therapy (CT) (n=21), 30min. twice daily for 4 weeks in addition to conventional rehabilitation. During MT and CT, subjects practiced similar structured exercises in both arms, except that mirror reflection of the unaffected arm was the visual feedback for MT, but mirror was absent for CT so that subjects could watch both arms in exercise. Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) were the outcome measurements. Results: After the intervention, both MT and CT groups had significant arm recovery similarly in FMA (p=0.867), WMFT-Time (p=0.947) and WMFT-Functional Ability Scale (p=0.676). Conclusion: MT or CT which involved exercises concurrently for the paretic and unaffected arms during subacute stroke promoted similar motor recovery in the severely impaired arm.
Article
Objective: To investigate the effectiveness of mirror therapy combined with neuromuscular electrical stimulation in promoting motor recovery of the lower limbs and walking ability in patients suffering from foot drop after stroke. Design: Randomized controlled study. Setting: Inpatient rehabilitation center of a teaching hospital. Subjects: Sixty-nine patients with foot drop. Intervention: Patients were randomly divided into three groups: control, mirror therapy, and mirror therapy + neuromuscular electrical stimulation. All groups received interventions for 0.5 hours/day and five days/week for four weeks. Main measures: 10-Meter walk test, Brunnstrom stage of motor recovery of the lower limbs, Modified Ashworth Scale score of plantar flexor spasticity, and passive ankle joint dorsiflexion range of motion were assessed before and after the four-week period. Results: After four weeks of intervention, Brunnstrom stage ( P = 0.04), 10-meter walk test ( P < 0.05), and passive range of motion ( P < 0.05) showed obvious improvements between patients in the mirror therapy and control groups. Patients in the mirror therapy + neuromuscular electrical stimulation group showed better results than those in the mirror therapy group in the 10-meter walk test ( P < 0.05). There was no significant difference in spasticity between patients in the two intervention groups. However, compared with patients in the control group, patients in the mirror therapy + neuromuscular electrical stimulation group showed a significant decrease in spasticity ( P < 0.001). Conclusion: Therapy combining mirror therapy and neuromuscular electrical stimulation may help improve walking ability and reduce spasticity in stroke patients with foot drop.