- •Current studies on mirror therapy after stroke are not consistent in the assessment tools that are used to determine hand function.
- •Outcome measures used in the included studies are not fully reflective of the International Classification of Functioning, Disability and Health.
- •Most outcome measures used in the included studies are rated by the therapist and have determined validity, reliability, and responsiveness; however, responsiveness is the least investigated psychometric property.
- •Integrating a combination of measures that are psychometrically sound and reflective of the International Classification of Functioning, Disability and Health should be considered for assessment of hand function after mirror therapy after stroke.
Archive for category Mirror therapy
[Abstract] Combining tDCS and computerized mirror therapy in upper limb rehabilitation in stroke patients. A feasibility study
Mirror therapy (MT) relies on a mirror and movements of the healthy limb to generate visual illusions of movement of the paralyzed limb. MT has proven to be effective for the motor rehabilitation of the upper limb of stroke patients, but suffers several limitations for patients. To overcome these difficulties, a computerized mirror therapy device was developed (IVS3™, Dessintey). MT effects could also be enhanced by applying simultaneous neuromodulation with tDCS. This small sample trial was conducted to evaluate the feasibility and tolerance of an IVS3 motor training combined with simultaneous bi-hemispheric tDCS.
Material and method
Four patients with right or left hemiparesis following stroke were included in this trial. They received 20 sessions of computerized MT (IVS3 ™, Dessintey; 5 sessions/week; 1 hour and 200 movements/session) combined with bi-hemispheric tDCS over the hand motor cortex (2 mA, 20 minutes). The primary endpoint was adherence to the therapeutic program. The secondary judgment criteria were the safety assessmentand the evolution of the tolerance of repeated tDCS stimulation coupled with IVS3.
The synergy of these two therapies is well tolerated by patients with a compliance rate of 99% ± 0.025. There have been no serious adverse reactions or unknown side effects. The upper limb motor function of the 4 patients improved, but this small sample non-controlled trial do not allow to conclude on a significant effect.
In this feasibility small sample study, the 4 patients well tolerated and perfectly complied with the computerized mirror therapy associated with bi-hemispheric tDCS. This finding calls for clinical controlled study to evaluate the efficacy of this combined IVS3-tDCS program in stroke patients.
[Abstract] Comparative hybrid effects of combining botulinum toxin A injection with bilateral robot-assisted, mirror or task-oriented therapy for upper extremity spasticity in patients with chronic stroke
Spasticity, a common impairment after stroke, has profound negative impact on outcomes in patients with stroke. Botulinum toxin type A (BoNT-A) injection combined with rehabilitation training is suggested for spasticity treatment. However, there is no recommendation about what kind of rehabilitation training is more appropriate than others following BoNT-A injection. The purpose of this study was to compare the effects of combining BoNT-A injection with bilateral robot-assisted (RT) or mirror (MT) or task-oriented (TT) therapy for upper extremity (UE) spasticity in patients with chronic stroke.
Material and method
Participants were randomly assigned to RT, or MT, or TT group after BoNT-A injection. The participants received 45 minutes of intervention per day, 3 days/week, for 8 weeks according the allocated results. In addition, all participants received 30 minutes of functional practice training. At pre-intervention, post-intervention and 3-month follow-up a blinded research assistant did outcome measures, including body function and structures by Fugl-Meyer Assessment (FMA), and Modified Ashworth Scale (MAS); activity and participation measures by Motor Activity Log (MAL), and Nottingham Extended Activities of Daily Living Scale (EADLS).
Thirty-seven subjects met the inclusion criteria and underwent randomization, 13 were assigned to the RT; 12 to MT; and 12 to TT group. The 3 groups were well matched with regard to baseline characteristics and functional status. All groups had significant improvement in FMA, MAS and MAL post-intervention. There were no group differences in FMA, MAS, EADLs either post-intervention or at follow-up. There was a trend that TT group had higher quality of movement (QOM) in MAL post intervention than the other 2 groups (P = 0.07), at follow-up TT group had significantly higher QOM in MAL than the other 2 groups (P = 0.03).
Combining BoNT-A injection with TT resulted in better quality of UE movement in patients with spastic stroke than with RT or MT.
via Comparative hybrid effects of combining botulinum toxin A injection with bilateral robot-assisted, mirror or task-oriented therapy for upper extremity spasticity in patients with chronic stroke – ScienceDirect
[Abstract] Recovery in the Severely Impaired Arm Post-stroke after Mirror Therapy – a Randomized Controlled Study
This study aimed to examine the effectiveness of mirror therapy (MT) on recovery in the severely impaired arm after stroke.
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.
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).
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] Effect of mirror use on lower extremity muscle strength of patients with chronic stroke – Full Text
[Purpose] This study examines the effect on muscle strength of lower extremity muscle strength exercise while using a mirror on the non-paretic side in patients with chronic stroke. [Subjects and Methods] Subjects were randomly assigned to a non-mirror lower extremity exercise group (n=10), a mirror lower extremity exercise group (n=10), or a mirror lower extremity muscle strength exercise group (n=10). Subjects were asked to do the exercise assigned to their group (5 sets 30 times a day, 5 times weekly for 4 weeks) with general physical therapy in the hospital. Muscle strength in the knee extensor and flexor of paretic and non-paretic side were measured using electrical muscle testing device before and after the intervention. [Results] Muscle strength significantly increased within each group after intervention. No significant differences were found among the three groups. [Conclusion] This study showed that the lower extremity muscle strength exercise of the non-paretic side using a mirror has a positive effect on muscle strength in patient with chronic stroke.
Stroke is a major problem causing disability in adults1). Most survivors experience decreased motor function and do not fully recover2). After a stroke, patients have physical therapy such as neuromuscular re-education and functional tasks including weight-bearing training in a standing position3).
Since it is related to independent functional activity, treatments for patients focus on muscle strengthening of extremities on the paretic side4). Muscle strengthening exercise of the paretic side is important to increase motor function and quality of daily activities5). However, patients who have severe paralysis often dislike a treatment approach focusing on paretic side recovery6). Instead, a treatment method using the non-paretic side has potential. Carroll et al.7) showed that elbow flexor muscle exercise increased activity of the elbow flexor muscle, which performs the same function on the opposite side.
Visual feedback through motion in the mirror enables bilateral exercise training and helps improve brain function in subacute stroke8). Mirror therapy using activation of the mirror neuron system is a cognitive training method used to increase motor function and motor learning9, 10). Mirror therapy is task-oriented therapy based on imagery therapy in which patients see their non-paretic side with imaging as their paretic side11).
Therefore, the purpose of this study is to assess the effect of muscle strengthening exercise using a mirror for muscle strength treatment in chronic stroke patients.[…]
[Abstract] Effects of mirror therapy on walking ability, balance and lower limb motor recovery after stroke: a systematic review and meta-analysis of randomized controlled trials
To investigate the effects of mirror therapy on walking ability, balance and lower limb motor recovery in patients with stroke.
MEDLINE, EMBASE, Web of Science, CENTRAL, PEDro Database, CNKI, VIP, Wan Fang, ClinicalTrials.gov, Current controlled trials and Open Grey were searched for randomized controlled trials that investigated the effects of mirror therapy on lower limb function through January 2018. The primary outcomes included were walking speed, mobility and balance function. Secondary outcomes included lower limb motor recovery, spasticity and range of motion. Quality assessments were performed with the PEDro scale.
A total of 13 studies (n = 572) met the inclusion criteria. A meta-analysis demonstrated a significant effect of mirror therapy on walking speed (mean difference (MD) 0.1 m/s, 95% confidence interval (CI): 0.08 to 0.12, P < 0.00001), balance function (standard mean difference (SMD) 0.66, 95% CI: 0.43 to 0.88, P < 0.00001), lower limb motor recovery (SMD 0.83, 95% CI: 0.62 to 1.05, P < 0.00001) and passive range of motion of ankle dorsiflexion (MD 2.07°, 95% CI: 082 to 3.32, P = 0.001), without improving mobility (SMD 0.43, 95% CI: −0.12 to 0.98, P = 0.12) or spasticity of ankle muscles (MD −0.14, 95% CI: −0.43 to 0.15, P = 0.35).
via Effects of mirror therapy on walking ability, balance and lower limb motor recovery after stroke: a systematic review and meta-analysis of randomized controlled trials – Yi Li, Qingchuan Wei, Wei Gou, Chengqi He, 2018
[Abstract] Mirror therapy for motor function of the upper extremity in patients with stroke: A meta-analysis.
To evaluate the mean treatment effect of mirror therapy on motor function of the upper extremity in patients with stroke.
Electronic databases, including the Cochrane Library, PubMed, MEDLINE, Embase and CNKSystematic, were searched for relevant studies published in English between 1 January 2007 and 22 June 2017.
Randomized controlled trials and pilot randomized controlled trials that compared mirror therapy/mirror box therapy with other rehabilitation approaches were selected.
Two authors independently evaluated the searched studies based on the inclusion/exclusion criteria and appraised the quality of included studies according to the criteria of the updated version 5.1.0 of the Cochrane Handbook for Systematic Review of Interventions.
Eleven trials, with a total of 347 patients, were included in the meta-analysis. A moderate effect of mirror therapy (standardized mean difference 0.51, 95% confidence interval (CI) 0.29, 0.73) on motor function of the upper extremity was found. However, a high degree of heterogeneity (χ2 = 25.65, p = 0.004; I2 = 61%) was observed. The heterogeneity decreased a great deal (χ2 = 6.26, p = 0.62; I2 = 0%) after 2 trials were excluded though sensitivity analysis.
Although the included studies had high heterogeneity, meta-analysis provided some evidence that mirror therapy may significantly improve motor function of the upper limb in patients with stroke. Further well-designed studies are needed.
- PMID: 29077129
- DOI: 10.2340/16501977-2287
[Abstract] Outcome measurement of hand function following mirror therapy for stroke rehabilitation: A systematic review
Mirror therapy is a treatment used to address hand function following a stroke. Measurement of outcomes using appropriate assessment tools is crucial; however, many assessment options exist.
Purpose of the Study
The purpose of this study is to systematically review outcome measures that are used to assess hand function following mirror therapy after stroke and, in addition, to identify the psychometric and descriptive properties of the included measures and through the linking process determine if the outcome measures are representative of the International Classification of Functioning, Disability and Health (ICF).
Following a comprehensive literature search, outcome measures used in the included studies were linked to the ICF and analyzed based on descriptive information and psychometric properties.
Eleven studies met inclusion criteria and included 24 different assessment tools to measure hand or upper limb function. Most outcome measures used in the selected studies (63%) were rated by the evaluating therapist. Thirteen outcome measures (54%) linked to the ICF body function category and 10 measures (42%) linked to activities and participation. One outcome measure was linked to not defined, and all other ICF categories were not represented. A majority of outcome measures have been assessed for validity, reliability, and responsiveness, but responsiveness was the least investigated psychometric property.
Current studies on mirror therapy after stroke are not consistent in the assessment tools used to determine hand function. Understanding of study outcomes requires analysis of the assessment tools. The outcome measures used in the included studies are not representative of personal and environmental factors, but tools linking to body functions and activities and participations provide important information on functional outcome.
Integrating a combination of measures that are psychometrically sound and reflective of the ICF should be considered for assessment of hand function after mirror therapy after stroke.
[ARTICLE] Effectiveness of Mirror Therapy in Rehabilitation of Hand Function in Sub-Acute Stroke – Full Text
Methodology: An experimental study design, 30 subjects with sub-acute stroke with impaired hand function randomly allocated 15 subjects into each experimental group and conventional group. Both groups received conventional physiotherapy. The experimental group in addition, received Mirror Therapy program of 30 repetition of each exercises per day for 5 days in a week for 4 weeks (total = 20 sessions). Hand functions were measured using Upper extremity motor activity log (UE MAL) and Action research arm test (ARAT) before and after 4 week of intervention.
Results: Results of the study suggested that both the experimental and conventional group had a significant improvement in hand function (AROM, functional task with objects, object manipulation), however experimental group showed significantly more improvement than conventional group, providing Mirror Therapy with conventional treatment is more effective than conventional treatment alone.
Conclusion: Mirror therapy with conventional physiotherapy brings more improvement in hand function than conventional physiotherapy alone.
Prevalence rates reported for stroke or CerebroVascular Accident (CVA) worldwide vary between 500 to 800 per 100,000 population [N.K. Sehi et al 2007] with about 20 million people suffer from stroke each year; out of that 5 million will die as a consequences and 15 million will survive with long term disabilities of varied spectrum. Many surviving stroke patients will often depends on other people‘s continuous support to survive.
Stroke is the most common cause of chronic disability . Of survivors, an estimated one third will be functionally dependent after 1 year experiencing difficulty with activities of daily living (ADL), ambulation, speech, and so forth . Cognitive impairment occurs frequently after stroke, commonly involving memory, orientation, language, and attention. The presence of cognitive impairment in patients with stroke has important functional consequences, independent of the effects of physical impairment (T K Tatemichi et al 1994).
Recovery of function after stroke may occur, but it is unclear whether interventions can improve function beyond the spontaneous process. In particular, recovery of hand function plateaus in about 1 year, and common knowledge is that the patient will remain at that level for the rest of his or her life [3,4]. Typically in such situations, upper arm function is better than that in the hand . An emerging concept in neural plasticity is that there is competition among body parts for territory in the brain [6-11].
Several studies have been conducted to examine the recovery of the hemiplegic arm in stroke patients. Up to 85% of patients show an initial deficit in the arm. Three to six months later, problems remain in 55% to 75% of patients [12-15]. While recovery of arm function is poor in a significant number of patients. Three quarters of strokes occur in the region supplied by the middle cerebral artery . As a consequence, the upper limb will be affected in a large number of patients. Functional recovery of the arm includes grasping, holding, and manipulating objects, which requires the recruitment and complex integration of muscle activity from shoulder to fingers.
Functional brain imaging studies of healthy subjects suggest that excitability of the primary motor cortex ipsilateral to a unilateral hand movement is facilitated by viewing a mirror reflection of the moving hand . Reorganization of motor functions immediately around the stroke site (ipsilesional) is likely to be important in motor recovery after stroke, and a contribution of other brain areas in the affected hemisphere is also possible. Activation when a subject is doing motor tasks can also occur in the bilateral inferior parietal area, the supplementary motor area, and in the premotor cortex. Furthermore, central adaptations occur in networks controlling the paretic as well as the nonparetic lower limb after stroke .
The aim of this study is to find the effect of mirror therapy in rehabilitation of hand function in sub-acute stroke. […]
Treatment of central post-stroke pain (CPSP) after a thalamic-capsular stroke is generally based on pharmacological approach as it is low responsive to physiotherapy. In this case report, the use of mirror therapy (MT) for the reduction of CPSP in a subject after a stroke involving thalamus is presented.
Five years after a right lenticular-capsular thalamic stroke, despite a good recovery of voluntary movement that guaranteed independence in daily life activities, a 50-year-old woman presented with mild weakness and spasticity, an important sensory loss and a burning pain in the left upper limb. MT for reducing arm pain was administered in 45-min sessions, five days a week, for two consecutive weeks. MT consisted in performing symmetrical movements of both forearms and hands while watching the image of the sound limb reflected by a parasagittal mirror superimposed to the affected limb. Pain severity was assessed using visual analogue scale (VAS) before and after the intervention and at one-year follow-up. After the two weeks of MT, the patient demonstrated 4.5 points reduction in VAS pain score of the hand at rest and 3.9 points during a maximal squeeze left hand contraction. At one-year follow-up, pain reduction was maintained and also extended to the shoulder.
This case report shows the successful application of a motor training with a sensory confounding condition (MT) in reducing CPSP in a patient with a chronic thalamic stroke.
Stroke often causes impairment in movement control but can also affect perception [1, 2]. Alterations of stimulus integration are common after a stroke, with variable reported prevalence ranging from 11 to 85% , and sometimes these alterations of perception result in pain. Pain relates with the site of lesion and it is completely distinct from other painful conditions such as shoulder pain or spasticity . It typically emerges from hemispheric lesions that involve the spinothalamic and thalamocortical pathways, leading patients to complain of sharping, stabbing, or burning through an experience of hyperpathia and allodynia [5, 6]. This association between sensory abnormalities and constant or intermittent central neuropathic pain, arising from damage of the sensory tracts, is known as the central post-stroke pain (CPSP) syndrome [7, 8]. The estimated incidence of CPSP comes up to 1 every 6 patients presenting a vascular lesion in the thalamus [8, 9], but its prevalence is difficult to estimate because of the co-occurrence of other painful conditions, such as spasticity or shoulder pain . The pathophysiological mechanisms underlying the development of CPSP are thought to be related to the hyperexcitability or to the spontaneous discharge of damaged neurons located in the thalamus or in the cortex . The CPSP syndrome is one of the less responsive conditions to physiotherapy treatment and it usually requires a pharmacological approach through the use of Amitriptyline, Gabapentin and Pregabalin .
Mirror therapy (MT), defined as the use of a mirror reflection of unaffected limb movements superimposed on the affected extremity, is often used to treat motor and perception problems [11, 12]. This technique was described for the first time in 1995 in studies reporting the reduction of phantom limb pain in arm amputees ; more recently, its use was described also for recovery of motor function after stroke [14, 15], for the treatment of complex regional pain syndrome type I  and other painful conditions (e.g., brachial plexus avulsion and after surgery) [16, 17].
This case report describes the beneficial effect of MT for the reduction of pain of the upper limb in a subject presenting CPSP in the left body side combined to sensory loss and mild movement disorders after a right haemorrhagic lenticular-capsular, thalamic stroke occurred five years before. To the best of our knowledge, the effect of MT for the treatment of CPSP has never been observed despite it has been defined deserving to be explored .
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