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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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[Abstract] A Wearable Hand Rehabilitation System with Soft Gloves

Abstract

Hand paralysis is one of the most common complications in stroke patients, which severely impacts their daily lives. This paper presents a wearable hand rehabilitation system that supports both mirror therapy and task-oriented therapy. A pair of gloves, i.e., a sensory glove and a motor glove, was designed and fabricated with a soft, flexible material, providing greater comfort and safety than conventional rigid rehabilitation devices. The sensory glove worn on the non-affected hand, which contains the force and flex sensors, is used to measure the gripping force and bending angle of each finger joint for motion detection. The motor glove, driven by micromotors, provides the affected hand with assisted driving-force to perform training tasks. Machine learning is employed to recognize the gestures from the sensory glove and to facilitate the rehabilitation tasks for the affected hand. The proposed system offers 16 kinds of finger gestures with an accuracy of 93.32%, allowing patients to conduct mirror therapy using fine-grained gestures for training a single finger and multiple fingers in coordination. A more sophisticated task-oriented rehabilitation with mirror therapy is also presented, which offers six types of training tasks with an average accuracy of 89.4% in real-time.

via A Wearable Hand Rehabilitation System with Soft Gloves – IEEE Journals & Magazine

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[Abstract + References] Unilateral Dorsiflexor Strengthening With Mirror Therapy to Improve Motor Function After Stroke: A Pilot Randomized Study

Abstract

Background: Independently, cross-education, the performance improvement of the untrained limb following unilateral training, and mirror therapy have shown to improve lower limb functioning poststroke. Mirror therapy has shown to augment the cross-education effect in healthy populations. However, this concept has not yet been explored in a clinical setting.

Objectives: This study set out to investigate the feasibility and potential efficacy of applying cross-education combined with mirror therapy compared with cross-education alone for lower limb recovery poststroke.

Methods: Thirty-one chronic stroke participants (age 61.7 ± 13.3) completed either a unilateral strength training (ST; n = 15) or unilateral strength training with mirror-therapy (MST; n = 16) intervention. Both groups isometrically strength trained the less-affected ankle dorsiflexors three times per week for 4 weeks. Only the MST group observed the mirror reflection of the training limb. Patient eligibility, compliance, treatment reliability, and outcome measures were assessed for feasibility. Maximal voluntary contraction (MVC; peak torque, rate of torque development, and average torque), 10-m walk test, timed up and go (TUG), Modified Ashworth Scale (MAS), and the London Handicap Scale (LHS) were assessed at pretraining and posttraining.

Results: Treatment and assessments were well tolerated without adverse effects. No between group differences were identified for improvement in MVC, MAS, TUG, or LHS. Only the combined treatment was associated with functional improvements with the MST group showing an increase in walking velocity.

Conclusion: Cross-education plus mirror therapy may have potential for improving motor function after stroke. This study demonstrates the feasibility of the combination treatment and the need for future studies with larger sample sizes to investigate the effectiveness of the treatment.

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via Unilateral Dorsiflexor Strengthening With Mirror Therapy to Improve Motor Function After Stroke: A Pilot Randomized Study – PubMed

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[Abstract + References] A Mechatronic Mirror-Image Motion Device for Symmetric Upper-Limb Rehabilitation

Abstract

This paper presents an upper-limb rehabilitation device that provides symmetric bilateral movements with motion measurements using inertial sensors. Mirror therapy is one of widely used methods for rehabilitation of impaired side movements because voluntary movement of the unimpaired side facilitates reorganizational changes in the motor cortex. The developed upper-limb exoskeleton was equipped with two brushless DC motors that helped generate three axes of upper-limb movements corresponding to other arm movements that were measured using inertial sensors. In this study, inertial sensors were used to estimate the joint angles for three target upper-limb movements: elbow flexion and extension (flex/ext), wrist flex/ext, and forearm pronation and supination (pro/sup). Elbow flex/ext was performed by the actuator that was directly attached to the elbow joint. The actuation of the forearm pro/sup and wrist flex/ext shared one motor using a developed cable-driven mechanism, and two types of motion were selectively performed. We assessed the feasibility of the proposed mirror-image device with the accuracy and precision of the motion estimation and the actuation of joint movements. An individual could perform most upper-limb movements for activities of daily living using the proposed device.

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[Abstract] Comparison of Task Oriented Approach and Mirror Therapy for Poststroke Hand Function Rehabilitation

Abstract

Objective: The purpose of this study was to compare the effectiveness of task-oriented therapy and mirror therapy on improving hand function in post-stroke patients.
Methods: Total subjects 30 were randomly divided into two groups: the task-oriented group (15 patients) and the mirror therapy group (15 patients). The task-oriented group underwent task-oriented training for 45 mins a day for 5 days a week for 4 weeks. The mirror therapy group underwent a mirror therapy program under the same schedule as
task-oriented therapy. The manual dexterity and motor functioning of the hand were evaluated before the intervention and 4 weeks after the intervention by using FMA (Fugl-Meyer assessment) and BBT (Box & Block test).
Results: Hand function of all patients increased significantly after the 4-week intervention program on the evaluation of motor function and manual dexterity by FMA and BBT in both the groups of Task-Oriented approach and Mirror therapy, but Group A Task-oriented approach improved more significantly when compared to Group B Mirror therapy.
Conclusion: The treatment effect was more in patients who received a Task-Oriented approach compared to Mirror therapy. These findings suggest that the Task-Oriented approach was more effective in post stoke hand function rehabilitation.

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[Abstract] Timing-dependent interaction effects of tDCS with mirror therapy on upper extremity motor recovery in patients with chronic stroke: A randomized controlled pilot study

Highlights

  • The priming effect of dual tDCS was important to facilitate motor recovery in combination with mirror therapy in stroke.

Abstract

This study was a randomized, controlled pilot trial to investigate the timing-dependent interaction effects of dual transcranial direct current stimulation (tDCS) in mirror therapy (MT) for hemiplegic upper extremity in patients with chronic stroke. Thirty patients with chronic stroke were randomly assigned to three groups: tDCS applied before MT (prior-tDCS group), tDCS applied during MT (concurrent-tDCS group), and sham tDCS applied randomly prior to or concurrent with MT (sham-tDCS group). Dual tDCS at 1 mA was applied bilaterally over the ipsilesional M1 (anodal electrode) and the contralesional M1 (cathodal electrode) for 30 min. The intervention was delivered five days per week for two weeks. Upper extremity motor performance was measured using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE), the Action Research Arm Test (ARAT), and the Box and Block Test (BBT). Assessments were administered at baseline, post-intervention, and two weeks follow-up. The results indicated that concurrent-tDCS group showed significant improvements in the ARAT in relation to the prior-tDCS group and sham-tDCS group at post-intervention. Besides, a trend toward greater improvement was also found in the FMA-UE for the concurrent-tDCS group. However, no statistically significant difference in the FMA-UE and BBT was identified among the three groups at either post-intervention or follow-up. The concurrent-tDCS seems to be more advantageous and time-efficient in the context of clinical trials combining with MT. The timing-dependent interaction factor of tDCS to facilitate motor recovery should be considered in future clinical application.

via Timing-dependent interaction effects of tDCS with mirror therapy on upper extremity motor recovery in patients with chronic stroke: A randomized controlled pilot study – Journal of the Neurological Sciences

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[VIDEO] Mirror Therapy Combined With Electrical Stimulation Using SaeboStim Micro – YouTube

https://www.saebo.com

Saebo, Inc. is a medical device company primarily engaged in the discovery, development and commercialization of affordable and novel clinical solutions designed to improve mobility and function in individuals suffering from neurological and orthopedic conditions. With a vast network of Saebo-trained clinicians spanning six continents, Saebo has helped over 100,000 clients around the globe achieve a new level of independence.

In 2001, two occupational therapists had one simple, but powerful goal – to provide neurological clients access to transformative and life changing products.

At the time, treatment options for improving arm and hand function were limited. The technology that did exist was expensive and inaccessible for home use. With inadequate therapy options often leading to unfavorable outcomes, health professionals routinely told their clients that they have “reached a plateau” or “no further gains can be made”. The founders believed that it was not the clients who had plateaued, but rather their treatment options had plateaued.

Saebo’s commitment – “No Plateau in Sight” – was inspired by this mentality; and the accessible, revolutionary solutions began.

Saebo’s revolutionary product offering was based on the latest advances in rehabilitation research. From the SaeboFlex which allows clients to incorporate their hand functionally in therapy or at home, to the SaeboMAS, an unweighting device used to assist the arm during daily living tasks and exercise training, “innovation” and “affordability” can now be used in the same sentence.

Over the last ten years, Saebo has grown into a leading global provider of rehabilitative products created through the unrelenting leadership and the strong network of clinicians around the world. As we celebrate our history and helping more than 100,000 clients regain function, we are growing this commitment to affordability and accessibility even further by making our newest, most innovative products more accessible than ever.

via Mirror Therapy Combined With Electrical Stimulation Using SaeboStim Micro – YouTube

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[Abstract] THE EFFICACY OF MIRROR THERAPY IN ADDITION TO CONVENTIONAL THERAPY VERSUS CT ALONE IN THE ACUTE AND CHRONIC STAGES OF STROKE BASED ON THE ACTION RESEARCH AND ARM TEST: A META-ANALYSIS – Full Text PDF

ABSTRACT

Background: Stroke is one of the leading causes of long term disability for adults and costs the healthcare system 34 billion dollars annually.1-3 Directly after a stroke up to 85% of survivors have an impairment of the upper extremity.4 Previous research has shown mirror therapy (MT) is beneficial for improving function in the upper extremity.5-16

Objective: The objective of this meta-analysis was to determine the efficacy of MT in addition to conventional therapy (CT) versus CT alone in the different stages of stroke rehabilitation including the acute and chronic. 5,7-17

Methods: A literature review was conducted in the fall of 2018 and consisted of the following databases: Pubmed, Medline, and CINAHL. The studies were assessed and reviewed on the specified inclusion/exclusion criteria. A  fixed effect size model of 2 groups was used for the included studies to generate the Q-value, P-value, effect size, and confidence interval.

Results: The results favored MT in addition to CT as compared to CT alone in all stages of stroke rehabilitation. MT in addition to CT used in the acute stage of stroke rehabilitation was favored over MT in addition to CT used in the chronic stage of stroke rehabilitation.

Conclusion: This meta-analysis supports current literature that MT in addition to CT is more effective in improving upper extremity function than CT alone in all stages of stroke rehabilitation. The minimal to moderate effect found in the acute stage of stroke rehabilitation suggests that MT in addition to CT is more beneficial in the acute stage of stroke rehabilitation as compared to use in the chronic stage of stroke rehabilitation. The evidence should, however, be interpreted with caution until further studies are included.

Aaron Larson
May 2019

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[Abstract] Advantages of virtual reality in the rehabilitation of balance and gait: Systematic review

Abstract

BACKGROUND:

Virtual reality (VR) has emerged as a therapeutic tool facilitating motor learning for balance and gait rehabilitation. The evidence, however, has not yet resulted in standardized guidelines. The aim of this study was to systematically review the application of VR-based rehabilitation of balance and gait in 6 neurologic cohorts, describing methodologic quality, intervention programs, and reported efficacy.

METHODS:

This study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. VR-based treatments of Parkinson disease, multiple sclerosis, acute and chronic poststroke, traumatic brain injury, and cerebral palsy were researched in PubMed and Scopus, including earliest available records. Therapeutic validity (CONTENT scale) and risk of bias in randomized controlled trials (RCT) (Cochrane Collaboration tool) and non-RCT (Newcastle-Ottawa scale) were assessed.

RESULTS:

Ninety-seven articles were included, 68 published in 2013 or later. VR improved balance and gait in all cohorts, especially when combined with conventional rehabilitation. Most studies presented poor methodologic quality, lacked a clear rationale for intervention programs, and did not utilize motor learning principles meticulously. RCTs with more robust methodologic designs were widely recommended.

CONCLUSION:

Our results suggest that VR-based rehabilitation is developing rapidly, has the potential to improve balance and gait in neurologic patients, and brings additional benefits when combined with conventional rehabilitation. This systematic review provides detailed information for developing theory-driven protocols that may assist overcoming the observed lack of argued choices for intervention programs and motor learning implementation and serves as a reference for the design and planning of personalized VR-based treatments.

 

via Advantages of virtual reality in the rehabilitation of balance and gait: Systematic review. – PubMed – NCBI

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