Posts Tagged Mirror therapy

[ARTICLE] Effects of action observation therapy and mirror therapy after stroke on rehabilitation outcomes and neural mechanisms by MEG: study protocol for a randomized controlled trial – Full Text

Abstract

Background

Loss of upper-extremity motor function is one of the most debilitating deficits following stroke. Two promising treatment approaches, action observation therapy (AOT) and mirror therapy (MT), aim to enhance motor learning and promote neural reorganization in patients through different afferent inputs and patterns of visual feedback. Both approaches involve different patterns of motor observation, imitation, and execution but share some similar neural bases of the mirror neuron system. AOT and MT used in stroke rehabilitation may confer differential benefits and neural activities that remain to be determined. This clinical trial aims to investigate and compare treatment effects and neural activity changes of AOT and MT with those of the control intervention in patients with subacute stroke.

Methods/design

An estimated total of 90 patients with subacute stroke will be recruited for this study. All participants will be randomly assigned to receive AOT, MT, or control intervention for a 3-week training period (15 sessions). Outcome measurements will be taken at baseline, immediately after treatment, and at the 3-month follow-up. For the magnetoencephalography (MEG) study, we anticipate that we will recruit 12 to 15 patients per group. The primary outcome will be the Fugl-Meyer Assessment score. Secondary outcomes will include the modified Rankin Scale, the Box and Block Test, the ABILHAND questionnaire, the Questionnaire Upon Mental Imagery, the Functional Independence Measure, activity monitors, the Stroke Impact Scale version 3.0, and MEG signals.

Discussion

This clinical trial will provide scientific evidence of treatment effects on motor, functional outcomes, and neural activity mechanisms after AOT and MT in patients with subacute stroke. Further application and use of AOT and MT may include telerehabilitation or home-based rehabilitation through web-based or video teaching.

Background

Stroke is the leading cause of long-term adult disability worldwide [1]. Most patients with stroke experience upper-extremity (UE) motor impairment [2] and show minimal recovery of the affected arm even 6 months after stroke [3]. Due to the potentially severe adverse effects after stroke, it is critical in clinical practice to develop effective and specific stroke interventions to improve arm function and to explore the neural mechanisms involved [45]. Action observation therapy (AOT) and mirror therapy (MT) are two examples of novel approaches concerning stroke motor recovery that are supported by neuroscientific foundations [67]. However, the relative efficacy of AOT versus MT has not been validated in patients with stroke.

AOT is a promising approach grounded in basic neuroscience and the recent discovery of the mirror neuron system (MNS) [6]. AOT commonly includes action observation and action execution and allows patients to safely practice movements and motor tasks. AOT is recommended to help patients with stroke to form accurate images of motor actions [8] and to mediate their motor relearning process after stroke [6]. Researchers have found that AOT can induce stronger cognitive activity than motor imagery in patients with stroke and have suggested that AOT could be an effective approach for patients who have difficulty with motor representation [9]. AOT is a new approach in stroke rehabilitation; therefore, only a few studies have targeted enhancement of UE motor recovery and investigated the effects of AOT in patients with stroke [81011121314]. Based on these studies, AOT has been shown to be a beneficial and effective approach to improve patient motor function. However, the heterogeneity of study designs and small sample sizes of the studies lead to no clear conclusions about the efficacy of AOT in stroke rehabilitation.

MT has emerged as another novel stroke-rehabilitation approach during the last decade [151617]. In this treatment, participants are instructed to move their arms and watch the action reflection of the non-affected arm in the mirror, as if it were the affected one. The process creates the visual illusion of the non-affected arm as the affected arm is normally moving. MT focuses on visual and proprioceptive feedback of the non-affected limb, which may provide substitute inputs for absent or reduced proprioceptive feedback from the affected side of the body [18]. A growing amount of academic literature has demonstrated that patients with stroke gain improvements in motor and daily function, movement control strategies, and activities of daily living [1617] after treatment with MT, which supports its use in stroke rehabilitation. In short, MT is potentially a simpler, less expensive, and effective stroke-rehabilitation approach for practical implementation in clinical settings.

Action observation is based on activities of the MNS and mainly involves brain areas of the inferior parietal lobe, inferior frontal gyrus, and ventral premotor cortex [19]. Mirror neurons discharge both during the execution of motor acts or goal-directed actions and during the observation of other people performing the same or similar actions [20]. Experimental studies in healthy adults have demonstrated that the MNS was activated during both the observation and execution of movements, which helped to form new motor patterns during action observation [212223]. In addition, although positive effects of MT have been demonstrated in patients with stroke [24], there is no consensus about the underlying neural mechanisms of MT. Three hypotheses have been recently proposed to explain the beneficial effects of MT on motor recovery [7]. Accordingly, MT may affect perceptual motor processes via three functional neural networks: (1) activation of brain regions associated with MNS [2526], (2) recruitment of ipsilateral motor pathways [27], and (3) substitution of abnormal proprioception from the affected limb with feedback from the non-affected limb [1518]. Few AOT and MT neurophysiological or imaging studies have been conducted in patients with stroke. No studies have directly compared and unraveled the similarities or differences in neural plastic changes between AOT and MT in these patients. It is crucial to compare neuroplasticity mechanisms between these intervention regimens to optimize rehabilitative outcomes.

Objectives

The main purposes of this clinical trial are to (1) compare the immediate and retention treatment effects of AOT and MT on different outcomes with those of a dose-matched control group and (2) explore and compare the neural mechanisms and changes in cortical neural activity associated with the effects of AOT and MT in stroke patients, using magnetoencephalography (MEG).[…]

Continue —> Effects of action observation therapy and mirror therapy after stroke on rehabilitation outcomes and neural mechanisms by MEG: study protocol for a randomized controlled trial | Trials | Full Text

Fig. 2 Action observation therapy. a Observation of task. b Execution of task

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[Abstract] Robot-assisted mirroring exercise as a physical therapy for hemiparesis rehabilitation

Abstract:

The paper suggests a therapeutic device for hemiparesis that combines robot-assisted rehabilitation and mirror therapy. The robot, which consists of a motor, a position sensor, and a torque sensor, is provided not only to the paralyzed wrist, but also to the unaffected wrist to induce a symmetric movement between the joints. As a user rotates his healthy wrist to the direction of either flexion or extension, the motor on the damaged side rotates and reflects the motion of the normal side to the symmetric angular position. To verify performance of the device, five stroke patients joined a clinical experiment to practice a 10-minute mirroring exercise. Subjects on Brunnstrom stage 3 had shown relatively high repulsive torques due to severe spasticity toward their neutral wrist positions with a maximum magnitude of 0.300kgfm, which was reduced to 0.161kgfm after the exercise. Subjects on stage 5 practiced active bilateral exercises using both wrists with a small repulsive torque of 0.052kgfm only at the extreme extensional angle. The range of motion of affected wrist increased as a result of decrease in spasticity. The therapeutic device not only guided a voluntary exercise to loose spasticity and increase ROM of affected wrist, but also helped distinguish patients with different Brunnstrom stages according to the size of repulsive torque and phase difference between the torque and the wrist position.

Source: Robot-assisted mirroring exercise as a physical therapy for hemiparesis rehabilitation – IEEE Conference Publication

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[Workshop] Evidence-Based Upper Limb Retraining after Stroke 2017 – Pre-Reading and Workshop Tasks – PDF

CHAPTER 40: Optimizing motor performance and sensation after brain impairment

ABSTRACT

This chapter provides a framework for optimizing motor performance and sensation in adults with brain impairment. Conditions such as stroke and traumatic brain injury are the main focus, however, the chapter content can apply to adults with other neurological conditions. The tasks of eating and drinking are used as examples throughout the chapter. Skills and knowledge required by graduates are identified, including knowledge of motor behaviour, the essential components of reaching to grasp and reaching in sitting, and how to identify compensatory strategies, develop and test movement hypotheses. Factors that enhance skill acquisition are discussed, including task specificity, practice intensity and timely feedback, with implications for therapists’ teaching skills. Finally, a summary is provided of evidence-based interventions to improve motor performance and sensation, including high intensity, task-specific training, mirror therapy, mental practice, electrical stimulation and constraint therapy.

Key Points:

  1. Essential knowledge in neurological rehabilitation includes an understanding of normal motor behaviour, muscle biology and skill acquisition.
  2. Abnormal motor performance can be observed during a task such as reaching for a cup, and compared with expected performance. Hypotheses about the cause(s) of observed movement differences can then be made and tested.

  3. Paralysis, weakness and loss of co-ordination affect upper limb motor performance. To improve performance after brain impairment, therapists should primarily focus on improving strength and co-ordination.

  4. Many people with brain impairment have difficulty understanding instructions, goals and feedback, and consequently may not practice well. To teach people to practice well and learn skills, therapists need to be good coaches.

  5. Motor performance and sensation can be improved using low-cost evidence-based strategies such as high intensity, repetitive, task-specific training, mirror therapy, mental practice, electrical stimulation and constraint-induced movement therapy.

1. Introduction

Upper motor neuron lesions typically cause impairments such as paralysis, muscle weakness and loss of sensation. These impairments can limit participation in everyday tasks such as eating a meal. Motor control is a term commonly used in rehabilitation (Shumway-Cook, 2012; van Vliet et al 2013) and refers to control of movements such as reaching to grasp a cup and standing up. Occupational therapists and physiotherapists retrain motor and sensory impairments that interfere with tasks such as grasping a cup and sitting safely on the toilet.

The aim of this chapter is to provide a framework that helps therapists to systematically observe, analyse and measure motor and sensory impairments. Targeted evidence-based interventions will be described that can drive neuroplasticity. Therapists need to proactively seek muscle activity and sensation. It is not enough to teach a person how to compensate using one-handed techniques, or to wait for recovery to possibly occur.[…]

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[Abstract] Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled study 

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.

Randomized controlled study.

Inpatient rehabilitation center of a teaching hospital.

Sixty-nine patients with foot drop.

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.

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.

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).

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Source: Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled studyClinical Rehabilitation – Qun Xu, Feng Guo, Hassan M Abo Salem, Hong Chen, Xiaolin Huang, 2017

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[ARTICLE] Effects of observation of hand movements reflected in a mirror on cortical activation in patients with stroke – Full Text PDF

Abstract.

[Purpose] The purpose of this study was to examine what changes occur in brain waves when patients with stroke receive mirror therapy intervention.

[Subjects and Methods] The subjects of this study were 14 patients with stroke (6 females and 8 males). The subjects were assessed by measuring the alpha and beta waves of the EEG (QEEG-32 system CANS 3000). The mirror therapy intervention was delivered over the course of four weeks (a total of 20 sessions).

[Results] Relative alpha power showed statistically significant differences in the F3, F4, O1, and O2 channels in the situation comparison and higher for hand observation than for mirror observation. Relative beta power showed statistically significant differences in the F3, F4, C3, and C4 channels.

[Conclusion] This study analyzed activity of the brain in each area when patients with stroke observed movements reflected in a mirror, and future research on diverse tasks and stimuli to heighten activity of the brain should be carried out.

INTRODUCTION

Dysfunction from upper extremity hemiparesis impairs performance of many activities of daily living (ADL)1) . Individuals affected by stroke will learn or relearn competencies necessary to perform ADL. Traditionally, the practice of skills provided in neurologic rehabilitation has focused on reducing motor impairment and minimizing physical disability2, 3) . Since 2000, various studies of upper extremity function recovery using interventions such as constraint-induced movement therapy, functional electric stimulation, robotic-assisted rehabilitation, and bilateral arm training have been carried out4) . Such interventions were effective in increasing upper extremity functions in patients with stroke and are continually utilized in the clinical field5–7) .

However, most of the treatment protocols for the paretic upper extremity are labor intensive and require one on one manual interaction with therapists for several weeks, which makes the provision of intensive treatment for all patients difficult8) . Hence, alternative strategies and therapies are needed to reduce the long-term disability and functional impairment from upper extremity hemiparesis9) .

Mirror therapy may be a suitable alternative because it is simple; inexpensive; and, most importantly, patient-directed treatment that may improve upper extremity function8, 10) . Emerging methods in mirror therapy aim to restore motor control through a change in brain function, i.e. motor relearning11, 12) . Voluntary movements of the paretic upper extremity and hand by referring to a mirror activate the bilateral cortex and cause reorganization for other areas around the damaged brain to replace its function, thereby affecting recovery in motor function13) .

Although such methods are promising, they have failed to restore functional motor control for many patients who have experienced stroke. It is important to explore new methods that may facilitate the recovery of brain function and the restoration of more normal motor control14) . Many studies have addressed the neurophysiological effects of mirror therapy. The EEG study gave diverse stimulations to the thumb with or without a mirror to examine which area of the cortex was activated. They observed common activation areas in the primary motor cortex (M1), cingulate, and prefrontal cortex15) . And the study with healthy adults used mirror therapy with functional MRI (fMRI) and showed no difference between the dominant and non-dominant hand. Excitability of M1 ipsilateral to a unilateral hand movement was facilitated by viewing a mirror reflection of the moving hand16) . This finding provides neurophysiological evidence supporting the application of mirror therapy in stroke rehabilitation. Even though, previous studies concerned healthy subjects and had no interventions, a diversity of studies have shown upper extremity functional improvement through mirror therapy8) .

Thus, the purpose of this study was to examine what changes occur in brain waves when patients with stroke receive mirror therapy intervention.

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[WEB PAGE] How to Regain Movement in a Paralyzed Hand with MusicGlove – Flint Rehabilitation Devices

 

“Can I use MusicGlove if I have no hand movement?”

We hear this question a lot, and we’re obligated to answer with, “Unfortunately MusicGlove requires that you can touch your thumb to at least one of your finger tips and release this grip by a quarter of an inch or more.”

It’s a stiff, clinical response, but it’s the truth about 80% of the time.

Recently we had one woman challenge this notion – and it made us soooo happy!

Margaret, a post rehabilitation exercise specialist, purchased a MusicGlove for her husband, a stroke survivor who had absolutely no movement in his affected hand. He could not lift a single finger.

He was in stage 1 of the Brunnstrom stages of recovery: Flaccidity.

Flaccidity’s Common Misconception

Some stroke survivors are told that there’s no hope for flaccidity, and limiting statements like this should be taken with a grain of salt.

Case in point: Margaret’s husband’s therapist said that he wouldn’t regain any hand movement, and that he would eventually lose all movement and die… What?!?!

We can’t even believe words like that are spoken in the clinic! Obviously this isn’t the norm, but it was still shocking to hear.

Needless to say, Margaret dismissed what the therapist said and started researching her options.

Because the truth is that if you have no movement in your affected hand, it’s still possible to regain movement. You can do whatever you put your mind to, as long as you put in the time and hard work.

And it helps to have a little ingenuity.

A Different Way to Use MusicGlove

Margaret refused to accept that her husband couldn’t regain hand movement, so she took matters into her own hands.

She purchased MusicGlove and used it in combination with mirror therapywith a twist. A huge twist.

Typically, mirror therapy involves using a tabletop mirror to reflect your ‘good’ hand in place of your affected hand. (See this image.)

When performing hand therapy exercises in this manner, it ‘tricks’ your brain into thinking that you’re actually moving your affected hand and helps rewire your brain.

It’s a highly effective method for regaining hand function after stroke. So Margaret used this principle, but ditched the mirror.

She placed the MusicGlove on her husband’s ‘good hand’ and had him use it that way. While he was doing this, she would assist his affected hand to mirror his movements.

She wouldn’t move his hand to the game; she moved his hand to exactly match what his other hand was doing. So if he missed a note, she missed a note.

This bilateral synchronicity helped rewire her husband’s brain, and he went from being completely flaccid to having twitches!

Gratitude for the Little Things

While twitches might not seem like a big deal to you, they were a big deal to this couple – especially when his therapist said it wasn’t possible.

Can you imagine the satisfaction and happiness they felt?

And twitches are just the beginning.

If he continues to use the device passively, then he can continue to improve until he can use the device independently. Then in due time and effort, he might progress into stage 7 of stroke recovery: full muscle control.

It’s a big, hairy goal – one that only a confident post-rehab specialist would think of – but it’s possible.

“The body achieves what the mind believes.”

Power in Believing

If this couple took their therapists’ word as law, they wouldn’t have experienced this progress. They wouldn’t have witnessed his potential.

Whatever you believe becomes your reality. Make the choice to believe in a higher recovery.

Learn to question your therapists and get curious about your potential.

Movement or Not, Is MusicGlove for You?

If you have no hand movement, then you can use MusicGlove – it just requires time, patience, and assistance.

You can use the device passively by using your unaffected hand to move your affected hand, which still helps your brain rewire itself. You can do this until you regain enough hand function to use the device actively without assistance.

There’s no guarantee about what will happen because every recovery is different.

The choice is yours to make.

But no matter what you choose, always believe in a higher recovery.

Challenge the status quo, and believe in progress even when no one else does.

Click here to learn more about MusicGlove. You’ll find our clinical trial results, more information about the device, a few video testimonials, and our contact number in case you’d like to discuss your questions with us.

Source: How to Regain Movement in a Paralyzed Hand with MusicGlove – Flint Rehabilitation Devices

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[Abstract] Systematic review of mirror therapy compared with conventional rehabilitation in upper extremity function in stroke survivors

Abstract

Background/aim

Stroke is a leading cause of disability in developed countries. One of the most widespread techniques in clinical practice is mirror therapy (MT). To determine the effectiveness of MT over other methods of intervention in the recovery of upper limb function in people who have had a stroke.

Methods

A systematic review was conducted. The search string was established based on the last systematic review about MT that dated from 2009: “upper extremity” OR “upper limb “AND “mirror therapy” AND stroke. For this search Pubmed, Scopus and SciELO databases were used.

Results

Fifteen studies were included in the systematic review. Recovery of the upper limb, upper limb function and gross manual dexterity were frequently measured in these studies.

Conclusions

In the primary variables in promoting recovery, MT alone showed better results in acute and chronic stroke patients in upper limb functioning than either conventional rehabilitation (CR) or CR plus MT.

 

Source: Systematic review of mirror therapy compared with conventional rehabilitation in upper extremity function in stroke survivors – Pérez-Cruzado – 2016 – Australian Occupational Therapy Journal – Wiley Online Library

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[VIDEO] Mirror Therapy

Your brain can be tricked! 🙂

He thought the rubber hand was his own hand, after getting his real and rubber hand stroked simultaneously.
He pulled his own hand away, when the rubber hand gets hit by a fork! 🙂
Amazing, right?

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[Abstract] Mirror therapy in chronic stroke survivors with severely impaired upper limb function: a randomized controlled trial. – PubMed

Abstract

BACKGROUND:

Mirror therapy (MT) has been proposed to improve the motor function of chronic individuals with stroke with mild to moderate impairment. With regards to severe upper limb paresis, MT has shown to provide limited motor improvement in the acute or sub-acute phase. However, no previous research has described the effects of MT in chronic individuals with stroke with severely impaired upper limb function.

AIM:

The aim of this study was to determine the effectiveness of MT on chronic stroke survivors with severe upper-limb impairment in comparison with passive mobilization.

DESIGN:

A randomized controlled trial.

SETTING:

Rehabilitative outpatient unit.

POPULATION:

A total of 31 chronic subjects poststroke with severely impaired upper limb function were randomly assigned to either an experimental group (N.=15), or a control group (N.=16).

METHODS:

Twenty-four intervention sessions were performed for both groups. Each session included 45-minute period of MT (experimental group) or passive mobilization (control group), administered three days a week. Participants were assessed before and after the intervention with the Wolf Motor Function Test, the Fugl-Meyer Assessment, and the Nottingham Sensory Assessment.

RESULTS:

Improvement in motor function was observed in both groups on the time (P=0.002) and ability (P=0.001) subscales of the Wolf Motor Function Test. No differences were detected in kinesthesis or stereognosis. However, the experimental group showed a significant improvement in tactile sensation that was mainly observed as an increased sensitivity to light touches.

CONCLUSIONS:

In comparison with passive mobilization, MT in chronic stroke survivors with severely impaired upper-limb function may provide a limited but positive effect on light touch sensitivity while providing similar motor improvement.

CLINICAL REHABILITATION IMPACT:

MT is a therapeutic approach that can be used in the rehabilitation of severely impaired upper limb in chronic stroke survivors, specifically to address light touch sensitivity deficits.

Source: Mirror therapy in chronic stroke survivors with severely impaired upper limb function: a randomized controlled trial. – PubMed – NCBI

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[ARTICLE] A novel bilateral lower extremity mirror therapy intervention for individuals with stroke – Full Text

Fig. 1

Fig. 1. The device used for the LE-MT intervention (a). The recording view of the intervention (b).

Abstract

Despite improvements made in stroke rehabilitation, motor impairment and gait deficits persist at discharge. New interventions are needed. Mirror therapy has promise as one element of a rehabilitation program. The primary objectives were to 1) describe a bilateral, lower extremity mirror therapy (LE-MT) device and training protocol and 2) investigate the feasibility of LE-MT. A LE-MT device was constructed to train bilateral LE movements for 30 min, 3 times/week for 4 weeks, as an adjunct to physiotherapy in three individuals post-stroke. Sessions were digitally recorded and reviewed to extract feasibility measures; repetitions, rests and session duration. Pre and post measures of gait and motor impairment were taken. Two participants completed 100% of the sessions and a third completed 83% due to a recurrence of pre-existing back pain. Repetitions increased and session duration was maintained. Number of rests decreased for two participants and increased for one participant. Participants reported fatigue and mild muscle soreness but also that the intervention was tolerable. Positive gait changes included increased velocity and decreased variability. LE motor impairment also improved. A bilateral LE-MT adjunct intervention for stroke is feasible and may have positive effects. A history of low back pain should be a precaution.

Continue —> A novel bilateral lower extremity mirror therapy intervention for individuals with stroke

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