Archive for category Mirror therapy

[ARTICLE] The effect of mirror therapy on lower extremity motor function and ambulation in post-stroke patients: A prospective, randomized-controlled study – Full Text

Abstract

Objectives: This study aims to evaluate the effects of mirror therapy (MT) on lower extremity motor function and ambulation in post-stroke patients.

Patients and methods: A total of 42 post-stroke patients (25 males, 17 females; mean age 58 years; range, 32 to 71 years) were included. All patients were randomly divided into two groups as the control group (n=21) receiving a conventional rehabilitation program for four weeks (60 to 120 min/day for five days a week) and as the MT group (n=21) receiving MT for 30 min in each session in addition to the conventional rehabilitation program. The Brunnstrom stages of stroke recovery, Functional Independence Measure (FIM), Berg Balance Scale (BBS) and Motricity Index (MI) scores, six-minute walking test (6MWT), Functional Ambulation Category (FAC), and the degree of ankle plantar flexion spasticity using the Modified Ashworth Scale (MAS) were evaluated at baseline (Day 0), at post-treatment (Week 4), and eight weeks after the end of treatment (Week 12).

Results: There were significant differences in all parameters between the groups, except for the degree of ankle plantar flexion spasticity, and in all time points between Week 0 and 4 and between Week 0 and 12 (p<0.05).

Conclusion: These results suggest that MT in addition to conventional rehabilitation program yields a greater improvement in the lower extremity motor function and ambulation, which sustains for a short period of time after the treatment.

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[ARTICLE] Effect of mirror therapy on upper extremity function in chronic stroke patients: An experimental study – Full Text PDF

By Dr. Pooja Vyas and Dr. Shraddha Diwan

Abstract

Stroke is defined by the World Health Organization as a condition characterized by rapidly developing
symptoms and signs of a focal brain lesion, with symptoms lasting for more than 24 hours or leading to
death, with no apparent cause other than that of vascular origin. Several treatment approaches in stroke
rehabilitation are delivered in the form of – Bobath approach, Brunstorm approach, Motor Relearning
Program, Task Oriented Approach, Functional Electrical Stimulation, EMG biofeedback etc. It is a
Neuro-rehabilitation technique designed to remodulate cortical mechanisms of pain and has proved
successful in phantom pain, stroke, and CRPS. In Mirror therapy, patients perform movements of the
unaffected limb while watching its mirror reflection superimposed over the (unseen) affected limb, thus
creating a visual illusion (and therefore positive feedback for the motor cortex) of the affected limb
movement. Thus, the aim of the study was to find out the effect of mirror therapy on paretic upper limb
in chronic stroke patients.

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[WEB PAGE] Gait & Balance Product Showcase – Physical Therapy Products

Posted by Deborah Overman | Mar 24, 2021     

Gait & Balance Product Showcase

SLIP TRAINER 6.0

MASS Rehab Inc offers a tool built to be simple, affordable and effective for providing reactive perturbation and step training. Supported by the latest research, the Slip Trainer 6.0 is engineered to allow therapists to improve balance and reduce fall rates among their client base. Using Reactive Training instead of the typical anticipatory training, the Slip Trainer 6.0 allows therapists to quickly and dramatically improve reactive stepping responses in as little as one visit.

For more information, contact MASS Rehab Inc, (937) 760-4874; www.massrehabinc.com

AFOS FOR FOOT DROP

ToeOFF 2 ½, ToeOFF Flow 2 ½, and BlueROCKER 2 ½ AFOs from Allard USA, Rockaway, NJ, are designed with a reduced heel height to accommodate shoes with lower heel heights. In addition, the footplate has a lower toe lift for more space in the shoe box. ToeOFF 2 ½ Addition models offer three surface options: Camouflage, Birch, and Black. Both offer a choice of wrap-around or D-Ring straps that are easily applied for right or left hand “pull” and shorter, more gently contoured wings that fit comfortably to the anatomy. Allard now offers 13 different AFO models that aim to improve outcomes for more patients. E-mail info@allardusa.com to receive a free Product Selection Guide.

For more information, contact Allard USA, (888) 678-6548; https://www.allardusa.com/products/foot-drop-afos

PEDIATRIC ROLLATOR/GAIT TRAINER

The Marcy anterior rollator/gait trainer from Clarke Health Care Products, Oakdale, Pa, can be a child’s new best friend for indoor or outdoor play and all the adventures walking offers. Marcy is sized to assist toddlers and children in their first attempts at mobility. Four sizes are available, each with growth adjustability. Color customization options encourage the child’s attention and participation in walking and play. Accessories include braking options for safety and control.

For more information, contact Clarke Health Care Products, (888) 347-4537; www.clarkehealthcare.com

SOLAR-BASED GAIT ANALYSIS

GAITRite from CIR Systems Inc, Franklin, NJ, introduces a new level of portability to the world of gait analysis. GAITRite Safari offers all of the exceptional performance of a standard GAITRite system, but also allows for use in remote locations where on-grid power is not readily available. With GAITRite Safari’s solar-based power system, therapists are free to collect gait data anywhere in the world. GAITRite Safari removes the requirement to bring a subject to the artificial environment of the lab and allows for unlimited opportunities to study gait in the real world. All system components can be stored and transported in a standard GAITRite rolling case.

For more information, contact CIR Systems Inc, (888) 482-2362; www.gaitrite.com

SOLUTIONS THAT TRANSFORM THERAPY

Exclusively distributed by DIH, Norwell, Mass, are the SafeGait 360° Balance and Mobility Trainer and SafeGait ACTIVE Dynamic Mobility Trainer by Gorbel; comprehensive gait and balance solutions for inpatient and outpatient therapy. Designed to follow patients through the continuum of care, these advanced dynamic body-weight support and fall protection systems aim to help facilitate increased challenge and patient confidence, leading to faster recovery.

For more information, contact DIH, (877) 944-2200; www.DIH.com/SafeGait

BALANCE SYSTEM SD

The Biodex Balance System SD from Biodex Medical Systems Inc, headquartered in Shirley, NY, is a versatile balance testing and training device designed to add value with features including turnkey programs to help therapists grow their businesses. Access science-based technology solutions, from fall risk to concussion management. Objective data and reporting help meet requirements for value-based care.

For more information, contact Biodex, (800) 224-6339; www.biodex.com/balance

LEG LENGTH MEASURING PAD

The LIMP—from G&W Heel Lift Inc, Cuba, Mo—is designed to determine leg-length deficiency when using the indirect method of measuring. It consists of eight layers of tinted vinyl measuring 3mm per layer, each one separated at the toe and reattached using static electricity. It is placed under the patient’s short leg with layers added or removed until therapists determine that the pelvis is level. The material does not absorb moisture or support bacterial growth, and each layer can be cleaned with soap and water.

For more information, contact G&W Heel Lift Inc, (800) 235-4387; www.gwheellift.com

INSTRUMENTED TREADMILL

The C-Mill HERO, available from Hocoma Inc, Norwell, Mass, is engineered to address a patient’s functional goals related to improving gait, balance, and motor control and coordination issues. The C-Mill HERO includes an instrumented treadmill with a force plate, which provides objective balance, gait, and running assessments, offering clinically relevant outcome measures for treatment planning and monitoring progression. C-Mill HERO’s intuitive exercise gaming with real-time feedback about performance is made to be fun, motivational, and engaging, offering therapists the right tools to provide targeted functional therapy goals for their patients.

For more information, contact Hocoma, (877) 944-2200; www.hocoma.com

NEUROLOGICAL WALKER

The U-Step Neuro Walker, a family of three advanced versions (Standard, Platform, Press-Down) from In-Step Mobility Products Inc, is designed to increase independence and eliminate falling among those with neurological conditions. The U-Step Neuro Walker’s features are designed to make it a superior walking aid that offers excellent stability, maneuverability and control. The U-Step Neuro Walker can be beneficial for patients with various neurological conditions, including: Parkinson’s Disease, multiple sclerosis, balance disorders, brain injuries, ALS, PSP/MSA, ataxia and stroke. Optional electronic visual/audio cueing module is available for addressing Parkinson’s freezing.

For more information, contact In-Step Mobility Products Inc, (800) 558-7837; www.ustep.com

ZENO ELECTRONIC WALKWAY SYSTEM

Managing and synthesizing accurate gait data is essential to outcomes-driven healthcare. The Zeno Walkway from ProtoKinetics, Havertown, Pa, is a portable solution with a wide, flat surface that allows for the capture of loading patterns of the patients’ footsteps without any impedance to assistive device performance. PKMAS software is engineered to automatically eliminate walker tracks, while expertly identifying overlapping steps, to provide robust temporal-spatial measurements for even the most complicated gait patterns. Recent implementation of the enhanced Gait Variability Index (eGVI), automated Four Square Step Test and Limits of Stability balance test are examples of rehabilitation-related outcome measures that can assist in clinical treatment planning and hospital discharge decisions.

For more information, contact ProtoKinetics, (610) 449-4879; www.protokinetics.com

IN-SHOE, WIRELESS ANALYSIS SYSTEM

The F-Scan64 from Tekscan, South Boston, is engineered to be an easy-to-use, wireless in-shoe pressure measurement system, offering quick set-up and flexibility to collect pressure, force, and temporal gait parameters. Featuring small and lightweight data acquisition electronics, which can connect directly to the patient’s shoe, F-Scan64 is designed to allow for a more natural gait collection environment free from cords and excessive weight or bulk to patients. The combination of a simple set-up process and gait analysis software essentials is meant to help clinicians save time when working with patients, without sacrificing data quality or reporting capabilities.

For more information, contact Tekscan, (800) 248-3669; www.tekscan.com/f-scan64

BALANCE STEPPER

The Stepping Wolf from Stretchwell, Warminster, Pa, is an air stepper designed to be versatile. The product can be used to help improve balance, perform core stability exercises, build ankle and calf muscle strength, and massage the feet.

For more information, contact Stretchwell, (888) 396-2430; www.stretchwell.com

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[ARTICLE] Lower Extremity Rehabilitation in Patients with Post-Stroke Sequelae through Virtual Reality Associated with Mirror Therapy

Abstract

More innovative technologies are used worldwide in patient’s rehabilitation after stroke, as it represents a significant cause of disability. The majority of the studies use a single type of therapy in therapeutic protocols. We aimed to identify if the association of virtual reality (VR) therapy and mirror therapy (MT) exercises have better outcomes in lower extremity rehabilitation in post-stroke patients compared to standard physiotherapy. Fifty-nine inpatients from 76 initially identified were included in the research. One experimental group (n = 31) received VR therapy and MT, while the control group (n = 28) received standard physiotherapy. Each group performed seventy minutes of therapy per day for ten days. Statistical analysis was performed with nonparametric tests. Wilcoxon Signed-Rank test showed that both groups registered significant differences between pre-and post-therapy clinical status for the range of motion and muscle strength (p < 0.001 and Cohen’s d between 0.324 and 0.645). Motor Fugl Meyer Lower Extremity Assessment also suggested significant differences pre-and post-therapy for both groups (p < 0.05 and Cohen’s d 0.254 for the control group and 0.685 for the experimental group). Mann-Whitney results suggested that VR and MT as a therapeutic intervention have better outcomes than standard physiotherapy in range of motion (p < 0.05, Cohen’s d 0.693), muscle strength (p < 0.05, Cohen’s d 0.924), lower extremity functionality (p < 0.05, Cohen’s d 0.984) and postural balance (p < 0.05, Cohen’s d 0.936). Our research suggests that VR therapy associated with MT may successfully substitute classic physiotherapy in lower extremity rehabilitation after stroke.

1. Introduction

Stroke is a significant cause of disability, with millions of stroke patients burdened with permanent neurological deficits, mainly motor and psychological. In most cases, post-stroke recovery requires long-time interventions in a multidisciplinary team, primarily depending on the severity of the stroke, the associated pathologies, the patient’s age, the time since stroke and the beginning of rehabilitation [1,2]. Neurorehabilitation after a stroke engages the recovery of the motor deficit and the recovery of language function, cognitive recovery, sensory and sphincter functions, and the functional reintegration as much as possible, as active as possible, into family and socio-professional life components. Post-stroke rehabilitation in the subacute phase begins when the patients’ are clinically balanced and stable, especially with regards to cardiorespiratory functions, and last but not least, when the tasks can be understood and supported by the patients’ participation and involvement in the rehabilitation program. It starts with the fifth week after stroke and has a relative duration of about three months [3]. Also, significant features in the physical rehabilitation of post-stroke patients are related to behavioral, cognitive and contextual factors that should be taken into account when planning therapy [4,5].Rehabilitation in the chronic phase begins after the patient has passed the subacute stage entering the chronic phase, followed by a constant and consistent rehabilitation program necessary to be continued throughout his life. The maximum level of complexity of the physiotherapy program is reached in the chronic phase when the highest acquisition and velocity of motor improvement are also expected. Regardless of the pathology stage, the basic principle is to stimulate and activate somatic structures through different activities and tasks. The most commonly used post-stroke rehabilitation techniques usually refer to correct posture, avoiding synkinesis, increasing muscle strength, active mobilization, proprioception, balance, and daily activities training. All these techniques and objectives are achieved in rehabilitation programs designed to repeatedly challenge the body during the day and through relaxation and a correct posture during the night [6,7].Mirror therapy (MT) is a type of rehabilitation method which activates the so-called mirror neurons. By visualizing in the mirror, the movement of the opposite healthy limb, the mirror neurons receive the necessary feedback to initiate the process of neuroplasticity. The healthy extremity is placed in front of a mirror and the illusion of the movement of the paretic side is created when the healthy part is activated. MT showed good results on motor deficiencies, as well as on sensations, visual-spatial neglect and pain after stroke [8].Therefore, MT is a method successfully used in the post-stroke patient’s rehabilitation. This method, along with virtual reality (VR), is used to improve the motor function of the lower extremity (LE), helping to regain balance, stability, and coordinated gait by training the muscles responsible for these activities. MT has been shown to improve the voluntary control of the impaired lower limb, especially the ankle joint by amplifying information (visual pathway, motor pathway, proprioceptive pathway), which determine a more complex efficiency of neurological deficit recovery. By applying MT to the lower limbs affected by stroke, it was observed the improvement of the stability of the patients, as the lower limbs play an essential role in performing ambulation and stability during daily activities. This approach exploits the brain’s preferences to prioritize the visual reaction over the somatosensory reaction regarding limb position [9,10,11]. New research is evaluating MT efficiency when combined with other techniques, such as cognitive therapeutic exercise, and other research shows that MT combined with other types of therapies has a better effect on the physical rehabilitation of post-stroke patients [12,13].VR is a new technology involving several scientific fields’ collaboration: biomechanics, internet technology engineering, rehabilitation and cognitive neuroscience. One of the most applicable areas of this modern technology is the medical field. VR has emerged as a new treatment approached in stroke rehabilitation, assuming the use of exercise programs designed to simulate real-life objects and activities using a computer [14]. This new approach is very advantageous as recovery programs design provided by the new environment and seems to be more exciting and enjoyable than traditional physiotherapy tasks, thus encouraging more repetition and involving the patient in the therapeutic program through “gamification” [15,16]. Patients become more motivated as they achieve increasingly performances and complexity.VR is a technology that allows the user to interact with a computer-simulated environment, whether that environment is a simulation of the real or merely an imaginary world, which influence the patient’s visual and proprioception feedback mechanism, therefore, facilitating the therapy outcomes. The VR therapy involves a computer generation of a virtual environment capable to interact with the patients through the sensory-motor functions. Real-time interaction with a multidimensional and multisensory environment is the critical element of VR therapy. The patient interacts not only with the virtual environment but also with various objects that are part of that environment [17,18].VR began to be successfully used in post-stroke patient’s rehabilitation due to the many advantages it entails:(a)the access in a safe environment to real-life situations, otherwise inaccessible to patients due to cognitive, motor and psychological limitations(b)the possibility to alter the exercises, to emphasize specific movements during patient execution, thus becoming more comfortable to perform,(c)the unique and personalized character of the exercises from one patient to another [19].VR technology is currently being explored for its potential benefits as a therapeutic intervention for training coordinated movement patterns, as well as for its entrepreneurial outcomes [20]. This technology offers the ability to create an environment in which the intensity of feedback and training can be systematically manipulated and improved to create the most appropriate paradigm of individualized motor learning. Most literature reviews have shown that VR has good results in post-stroke patients’ therapy, especially as an adjunct to classical physiotherapy [21,22,23].Researches address the burden of the individuals and families of the society and the health care systems concerning post-stroke patients who have disabilities and often can no longer reintegrate into socio-professional activities. Therefore, more and more emphasis is placed on developing facilities to speed patients’ physical rehabilitation after stroke [24,25,26]. Therefore, this study aims to determine the effectiveness and particularities of the use of VR associated with MT in the recovery of the LE of patients with post-stroke sequelae, compared to a standard physiotherapy program, as a novel approach in LE post-stroke rehabilitation, to contribute to the amendment of the efficient techniques and methods used in post-stroke rehabilitation. […]

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[Abstract] The Effectiveness of Movement Training with Mirror Therapy Approach on Gait of Subacute and Chronic Stroke Patients

Abstract

Introduction: Stroke is a long-term lesion and one of the major causes of adult disability. Motor disorders are the most common clinical symptoms of stroke that disrupt patientschr(’39’) daily activities. The purpose of this study was to compare the effect of mirror therapy on gait in subacute and chronic stroke patients.
Methods: The present study was a quasi-experimental with pre-test and post-test design. The statistical population consisted of subacute and chronic stroke patients referred to Tehran Tabasom Clinic, among whom 15 subacute and 15 chronic patients were voluntarily selected and participated in the study after completing written consent. Subjects in both groups before and after eight weeks of training participated in gait assessment and intervention tool (GAIT). The training program was similar in the two groups and consisting of eight weeks each week, two sessions each session 90 minutes included 60 minutes of routine rehabilitation and 30 minutes of mirror therapy. Data were analyzed by paired t-test, independent t-test, and covariance analysis with SPSS.23 software at the error level of 0.05.
Results: The mean pre-test score of abnormal GAIT in the subacute group was 20, which decreased to 14 in the post-test, indicating a considerable improvement in their GAIT performance and in the chronic group, the mean pre-test score decreased from 22 to 20 in the post-test. The Results showed that there was a significant difference between pre-test and post-test of gait in each subacute and chronic group (p = 0.001). There was also a significant difference in post-test of gait between subacute and chronic groups (p = 0.001).
Conclusion: Mirror therapy at the subacute phase had more effect on gait than the chronic phase. Therefore, it is recommended to use mirror therapy in the subacute phase after stroke.

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[Abstract] Mirror VR: The design of a fully immersive virtual reality game for upper limb rehabilitation post-stroke using mirror therapy

Abstract

Motor rehabilitation post-stroke requires practice that is high-intensity, repetitive, task-specific, challenging, and goal-oriented to promote neuroplasticity to maximise functional recovery outcomes. There is concern that people with stroke (PwS) are not engaging in sufficient therapy dose to induce significant neuroplastic changes. PwS can utilise motor priming techniques, such as mirror therapy (MT), that are low-cost adjuncts to conventional physical rehabilitation proposed to induce neuroplasticity. However, the repetitive and perceived boring elements of conventional physical therapy exercises are potential reasons for low adherence in home-based independent rehabilitation. Interactive rehabilitation-focused video games have shown initial promise for facilitating engagement in rehabilitation. Virtual reality (VR) games focus on movement and promote increased immersion in virtual environments compared to 2D interfaces. The recent emergence of low-cost and standalone consumer-based VR headsets opens the accessibility of VR to new audiences. VR, in combination with interactive gaming, affords opportunities to extend the visual and proprioceptive feedback employed in MT and use gamification to facilitate engagement in rehabilitation. This thesis involved the design of a fully immersive VR game based on MT. The research comprised three stages: empathic design through a design thinking workshop, iterative prototyping, and expert review of game design with clinicians. A design thinking workshop involving PwS and stroke rehabilitation experts informed the construction of design criteria for the game. Research through design, using the design criteria, was conducted iteratively. An expert review by clinicians evaluated the potential usability of the game as well as validated the game against our design criteria. VR enhanced the visual illusion employed in mirror therapy and could provide an immersive and novel self-management tool for PwS to positively engage with their rehabilitation. Future directions will include testing how VR could facilitate engagement in rehabilitation through qualitative and quantitative analysis of the user testing with PwS.

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[ARTICLE] Effect of mirror therapy on hand functions in Egyptian chronic stroke patients – Full Text

Abstract

Background

Most stroke survivors (more than 60%) suffer from persistent neurological impairments that significantly affect activities of daily living. Hand functions are essential for doing daily living and working activities. Mirror therapy is shown to be effective in improving hand functional recovery in stroke patients.

Objective

This study aimed to determine the effect of mirror therapy on improving hand functions in Egyptian chronic stroke patients.

Subjects and methods

Thirty chronic ischemic stroke patients from both sexes participated in the study. Their ages ranged from 45 to 65 years. They were randomly assigned into two equal groups: the study group that received a selected physical therapy program in addition to the mirror therapy and the control group that received the same selected physical therapy program but without a mirror therapy. Treatment sessions were conducted three times per week for 8 weeks. Range of motion (ROM) of the wrist extension and forearm supination, hand grip strength, and the time of Jebson Hand Function Test (JHFT) were measured before and after the treatment program.

Results

There were statistically significant increases in the range of motion of the wrist extension and forearm supination and hand grip strength with a decrease in the time of Jebson Hand Function Test in both groups post-treatment. Post-treatment improvement was more significant in the study group compared to the control group.

Conclusion

Mirror therapy had a positive effect on improving hand motor functional skills in a sample of Egyptian chronic stroke patients.

Introduction

Upper limb paresis is one of the most common and disabling consequences of stroke that significantly limits activity. It has been stated that 85% of stroke patients complain of hemiparesis and that 55 to 75% of them continue to have deficits in the upper extremity activities [1]. Approximately 30–66% of stroke patients never recover hand motor functional skills, which seriously impacts their performance of the activities of daily life [2].

Numerous rehabilitation techniques for stroke patients have been used to improve hand motor functional skills. These techniques include exercise training for the arm paresis [3], impairment-oriented training of the arm or Bobath therapy for severe arm paresis after stroke, functional electrical stimulation [4], robot-assisted rehabilitation [5], and bilateral arm training [6] constraint-induced movement therapy [78]. However, most of those rehabilitation techniques for the upper extremity paresis are intensive, involve high equipment costs, and require therapist’s manual interaction for a long time, which makes the administration of those treatments difficult for all patients [9].

Mirror therapy (MT) is a cheap, easy, and, most importantly, patient-directed treatment that may improve the recovery of hand motor functional skills [10,11,12,13]. MT consists of repeated bilateral, symmetrical movements in which the patient moves the affected body part as much as he/she could while observing the reflection of the same unaffected body part in a mirror placed in between those body parts while obscuring the affected part [14]. Researches of neural activities stated that MT might stimulate the areas within the somatosensory and premotor cortex and/or the mirror neuron system in the fronto-temporal region and superior temporal gyrus. This cortical stimulation might produce motor output in patients with stroke [1516].

This study was designed to assess the efficacy of mirror therapy on improving hand motor functions in a sample of Egyptian chronic stroke patients.[…]

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[Abstract + References] Mirror therapy simultaneously combined with electrical stimulation for upper limb motor function recovery after stroke: a systematic review and meta-analysis of randomized controlled trials

Abstract

Objective:

To evaluate the current evidence on the effectiveness of simultaneous combination of mirror therapy and electrical stimulation in the recovery of upper limb motor function after stroke, compared with conventional therapy, mirror therapy or electrical stimulation isolated.

Data sources:

Articles published in PubMed, Web of Science, Scopus, Physiotherapy Evidence Database (PEDro), Cochrane Central register of controlled trials and ScienceDirect up to July 2020.

Review methods:

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Methodological quality was assessed using the PEDro tool. The RevMan 5.4 statistical software was used to obtain the meta-analysis, through the standardized mean difference and 95% confidence intervals (CI), and to evaluate the risk of bias. The GRADE approach was employed to assess the certainty of evidence.

Results:

Eight articles were included in this systematic review, seven were included in the meta-analysis. A total of 314 participants were analyzed. The overall quality of the articles included in this review was good. There was no overall significant mean difference on upper limb motor function after stroke using the Upper-Extremity Fugl-Meyer Assessment by 1.56 (95% CI = –2.08, 5.20; P = 0.40; moderate-certainty evidence) and the Box and Block Test results by 1.39 (95% CI = –2.14, 4.92; P = 0.44; high-certainty evidence). There was overall significant difference in the Action Research Arm Test by 3.54 (95% CI = 0.18, 6.90; P = 0.04; high-certainty evidence).

Conclusion:

Direct scientific evidence about the effectiveness of the combined therapy of mirror therapy and electrical stimulation simultaneously for the improvement of the upper limb motor function after stroke is lacking. Further high-quality and well-designed research is needed.

References

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Source: Mirror therapy simultaneously combined with electrical stimulation for upper limb motor function recovery after stroke: a systematic review and meta-analysis of randomized controlled trials – Alberto Saavedra-García, Jose A Moral-Munoz, David Lucena-Anton, 2020

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[ARTICLE] Timing-dependent effects of transcranial direct current stimulation with mirror therapy on daily function and motor control in chronic stroke: a randomized controlled pilot study – Full Text

Abstract

Background

The timing of transcranial direct current stimulation (tDCS) with neurorehabilitation interventions may affect its modulatory effects. Motor function has been reported to be modulated by the timing of tDCS; however, whether the timing of tDCS would also affect restoration of daily function and upper extremity motor control with neurorehabilitation in stroke patients remains largely unexplored. Mirror therapy (MT) is a potentially effective neurorehabilitation approach for improving paretic arm function in stroke patients. This study aimed to determine whether the timing of tDCS with MT would influence treatment effects on daily function, motor function and motor control in individuals with chronic stroke.

Methods

This study was a double-blinded randomized controlled trial. Twenty-eight individuals with chronic stroke received one of the following three interventions: (1) sequentially combined tDCS with MT (SEQ), (2) concurrently combined tDCS with MT (CON), and (3) sham tDCS with MT (SHAM). Participants received interventions for 90 min/day, 5 days/week for 4 weeks. Daily function was assessed using the Nottingham Extended Activities of Daily Living Scale. Upper extremity motor function was assessed using the Fugl-Meyer Assessment Scale. Upper extremity motor control was evaluated using movement kinematic assessments.

Results

There were significant differences in daily function between the three groups. The SEQ group had greater improvement in daily function than the CON and SHAM groups. Kinematic analyses showed that movement time of the paretic hand significantly reduced in the SEQ group after interventions. All three groups had significant improvement in motor function from pre-intervention to post-intervention.

Conclusion

The timing of tDCS with MT may influence restoration of daily function and movement efficiency of the paretic hand in chronic stroke patients. Sequentially applying tDCS prior to MT seems to be advantageous for enhancing daily function and hand movement control, and may be considered as a potentially useful strategy in future clinical application.

Introduction

Stroke remains one of the leading causes of long-term disability [1]. Most stroke patients have difficulties performing every day activities due to paresis of upper limbs, which results in impaired activities of daily living (ADL) and reduced quality of life [23]. Identifying strategies that can facilitate functional recovery is thus an important goal for stroke rehabilitation. In recent years, several neurorehabilitation approaches have been developed to augment functional recovery, for example repetitive, task-oriented training and non-invasive brain stimulation (NIBS) [45]. Repetitive, task-oriented training emphasizes repetitive practice of task-related arm movements to facilitate motor relearning and restore correct movement patterns [6]. On the other hand, non-invasive brain simulation aims to maximize brain plasticity by externally applying electrical stimulation to modulate cortical excitability [7]. Since these two types of approaches individually have been shown to improve stroke recovery, it has been proposed that a synergistic approach that combines both of them may further augment overall treatment effects [89].

Mirror therapy (MT) is one type of repetitive task-oriented training that has been widely used in clinical and research settings [10]. During MT training, a mirror is positioned in between the paretic and non-paretic arm. The paretic arm is behind the mirror and participants can only see the non-paretic arm and its mirror reflection. Participants are required to focus their attention on the mirror reflection and imagine it is the paretic arm while performing bilateral movements as simultaneously as possible. This mirrored visual feedback is hypothesized to restore the efferent-afferent loop that is damaged after stroke and facilitate re-learning of correct movement patterns [11]. MT has been demonstrated to reduce arm impairment and improve sensorimotor function and quality of life in individuals with stroke [10,11,12,13].

Transcranial direct current stimulation (tDCS) is a commonly used NIBS technique in stroke rehabilitation. tDCS applies weak direct current to the scalp to modulate brain excitability [14]. This weak direct current gradually changes neural membrane potentials to facilitate depolarization (excitation) or hyper-polarization (inhibition) of the neurons to enhance plasticity of the brain [15]. tDCS has been demonstrated to modulate neural networks and enhance motor learning in stroke patients [716,17,18]. Although tDCS can be used alone, it is often combined with other rehabilitation approaches to boost responses of the brain to therapies [81920]. A recent meta-analysis further showed that combining tDCS with rehabilitation interventions could produce greater treatment effects on recovery of motor function than tDCS alone in stroke patients [21].

Combining tDCS with MT is a potentially promising approach to not only augment neural responses of the brain but also increase treatment benefits of MT. Nevertheless, one crucial factor that needs to be considered when combining tDCS with MT is the timing of tDCS [22]. tDCS can be applied prior to MT (i.e., offline tDCS) or concurrently with MT (i.e., online tDCS). To our knowledge, only two studies have examined the synergistic effects of combined tDCS with MT in chronic stroke patients [2324]. Cho et al. (2015) applied tDCS prior to MT or motor training without mirror reflection. They found significant improvements in manual dexterity and grip strength in the combined tDCS with MT group, suggesting that sequentially applying tDCS prior to MT could improve motor function. By contrast, Jin et al. (2019) delivered tDCS prior to or concurrently with MT and found advantageous effects on hand function in the concurrent tDCS with MT group. The conflicting results between these two studies indicated further needs to explore the interaction effects of the timing of tDCS with MT to determine the optimal combination strategy.

The important factor to consider when examining the effects of combined tDCS with MT is the treatment outcomes, especially for outcomes that are related to daily activities. ADL such as the basic ADL and complex instrumental ADL (IADL) are essential for independent living and well-being of stroke patients. Therefore, restoring daily function should be one of the priority goals of stroke rehabilitation. However, the previous two studies only examined the effects of combined tDCS with MT on motor function [2324]. No studies to date have examined the timing-dependent effects of tDCS with MT on daily function in chronic stroke patients. Whether the timing of tDCS can affect restoration of daily function with MT remains uncertain.

In addition to daily function, investigating arm movement kinematics changes with respect to the timing of tDCS with MT is also critical for determining the optimal combination strategy. Movement kinematics of the arms can provide information of whether true behavioral changes or compensation strategies occur during training [2526]. However, the two previous studies included only clinical motor function measurements [2324]. While these clinical measurements can inform clinicians/researchers of motor function changes, they may not necessarily capture spatial and temporal characteristics of movement as well as motor control strategies changes after the combined interventions [2627]. Assessing movement kinematics changes with respect to the timing of tDCS with MT would help to unravel the benefits of combined approach on motor control of the paretic arm.

The purpose of this study was to examine the timing-dependent effects of tDCS with MT on daily function, upper extremity motor function and motor control in chronic stroke patients. The tDCS was applied sequentially prior to MT (i.e., sequentially combined tDCS with MT group, SEQ) or concurrently with MT (i.e., concurrently combined tDCS with MT, CON). The sham tDCS with MT was used as the control condition. In addition to motor function outcomes, we further included the ADL/IADL measurement and movement kinematics assessments. We hypothesized that the SEQ and COM groups would demonstrate differential improvements in daily function, motor function and motor control.[…]

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Source: https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-020-00722-1

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