- The priming effect of dual tDCS was important to facilitate motor recovery in combination with mirror therapy in stroke.
Posts Tagged Mirror therapy
You’ve probably heard a lot of recommendations on how to recover hand function after stroke. We sifted through the research for you to explain the top 5 medically proven methods for hand rehabilitation, why they work, and who they work for.
by CLARICE TORREY, 3 JUN 2020 • 8 MIN READ
After a stroke, it’s challenging enough to navigate the medical system to find what services you need, let alone the right treatment approach for you.
You’ve probably heard a lot of recommendations on how to recover hand function after stroke, and everyone seems to give different advice. That’s why we sifted through the research for you. We’ll explain the top 5 evidence-based methods for hand rehabilitation, why they work, and who they work for.
The top 5 evidence-based treatments for improving hand function after stroke:
- Constraint‐induced movement therapy (CIMT)
- Mental practice
- Mirror therapy
- Virtual reality
- High dose repetitive task practice
Constraint-Induced Movement Therapy
What it is:
Constraint-Induced Movement Therapy (CIMT) is a neuro-rehabilitation method where the non-affected hand is constrained or restricted in order to force the brain to use the affected hand, thereby increasing neuroplasticity.
There are two key components: constraint and shaping.
Constraint refers to the way in which the hand is restricted. Therapists have used casts, splints, and mitts to restrict the use of the non-affected hand. None of them have been shown to be more effective than the other.
Shaping involves repetitive movements or activities at the patient’s ability level which become progressively harder. Therapists use shaping techniques to avoid overwhelming the motor system.
Why it works:
Our brain automatically completes a task in the easiest way possible. Our brain is more interested in completing a task than in how it is accomplished.
After a stroke, it’s easier for our brain to do tasks one-handed. This leads to “learned non-use”.
When we constrain our non-affected hand, suddenly our stronger hand becomes the weaker, less functional hand and we’re forced to use our affected hand. Our affected hand might not have much movement, but to our brain any movement is better than no movement, and the brain is highly motivated to figure out how to accomplish a task.
This is where the “shaping” piece is so important. If you are presented with rehab tasks that overwhelm the motor system or are higher level than your affected hand can functionally do, you’ll be more likely to knock the table over than to participate in picking up pennies from the table.
If you knock the table over with your affected hand, your occupational therapist might actually be excited about it; but in practical life finding that balance of not being too easy and not being so hard that you give up is an important lesson for every human being, not just those after stroke.
Who it’s for:
This approach is used for people who have at least 10 degrees of active wrist and finger extension, as well as 10 degrees of thumb abduction (the ability of the thumb to move out of the palm).
It’s been shown to be effective even years after stroke. Lower intensity CIMT is better than higher intensity in the very early stages after stroke.
What it is:
Mental practice, sometimes called motor imagery or mental imagery, is a training method for improving your hand and arm function without moving a muscle!
Mental practice is typically done by listening to pre-recorded audio that describes in detail the motor movement of a specific task. The listener imagines their hand and arm moving in a “typical” way, and the instructor provides cues to extend their arm or open their fingers, as well as the entire sensory experience of the task.
While it’s true that you can do mental practice on its own, it’s best combined with physical practice immediately following.
Why it works:
Brain scans show that similar parts of the brain are activated whether movement is actual, observed or imagined.
It’s a separate area of the brain that’s responsible for actually triggering the muscle movement, but it goes to show that there’s a lot more required of the brain to complete a task than just sending a signal to the muscle.
Who it’s for:
Mental practice has been shown to improve arm movement and functional use in patients after stroke of all levels of abilities and as a treatment approach for people months or years after stroke!
What it is:
Mirror therapy is another voodoo-seeming approach that has a lot of scientific evidence to back it up. It essentially tricks your brain into thinking your affected hand is moving.
You position a mirror to reflect your non-affected hand, while hiding your affected hand. Any movement of your non-affected hand will be reflected in the mirror and make it seem as though you are actually moving your affected hand.
Why it works:
The approach is centered around mirror neurons, which fire in your brain when you see your arm move. Typically, we think about motor neurons being sent from the brain to the muscle, but we don’t realize that mirror neurons are connected to the motor neurons.
After a stroke you lose the ability to access your motor neurons, but not your mirror neurons. By accessing your mirror neurons through seeing your movement (even if the movement is fake), you are tapping into the network between the neurons.
It’s like trying to reconnect with an old friend on Facebook by finding the friends they’re connected with. It might not be the most direct approach in a real life situation, but in stroke rehab that friend of a friend might be your strongest connection.
Who it’s for:
Mirror therapy can be used for people with no movement of the hand or smaller movements of the hand and shoulder, but not functional movement of the hand.
If you have functional movement of your hand, meaning individual finger movement and wrist movement, you have surpassed the benefit that mirror therapy can provide.
It can be used early after stroke, as well as in the chronic stages of stroke.
What it is:
Virtual reality uses a computer interface to simulate a real life objects and events. It’s become an increasingly more prevalent rehabilitation technique to provide motivation and engagement in therapy.
There are two types:
- Immersive: goggles are placed over the eyes and the patient is visually in a different environment than their actual physical one
- Non-immersive: sensors are placed on the body and track the movement of the body and the movements are shown on a screen
Why it works:
Virtual reality works best when paired with traditional therapy. It’s theorized to provide more motivation and engagement for the intensity of therapeutic exercise needed for neuroplasticity. It’s been shown to beneficial in high doses, meaning more than 20 hours.
Another possible factor of why virtual reality works are the same mechanisms that make mirror therapy effective (tapping into the mirror neurons) could be similar.
Virtual reality also creates a biofeedback loop: your brain sends a signal to the muscle, the brain receives a signal back in the form of visual or auditory input. Basically, you get rewarded for your effort.
Who it’s for:
Virtual reality can be used with people who have mild to severe impairments, and from early after stroke to years out.
When deciding what’s right for you, it’s important to look at the adjustability of the device to meet you where you’re at and also to increase in difficulty as you improve.
If you have minimal movements, you’ll want a virtual reality tool specifically for stroke rehabilitation. If you have more movement, it’s possible to use gaming systems not specifically designed for rehab, but make sure you have the support to optimize it for rehab.
High Dose Repetitive Task Practice
What it is:
Repetitive Task Practice is when you practice a task or a part of a task over and over. Task-specific training is a type of repetitive task practice, and refers to the task we complete that is relevant to our daily life.
“Reach to grasp, transport and release” is a type of task-specific training because it is one of the common motor requirements for many functional daily tasks.
The keys for repetitive task practice:
- Task must be meaningful
- Participant must be an active problem-solver
- Real life objects are used
- Difficulty level is not too high and not too low
- Repetition is key
Why it works:
Repetitive Task Practice is based on motor learning theory. Our brains are driven by function. We’re able to achieve neuroplasticity with development of skills, as our brain processes the demands of the task, which have motor and cognitive components.
It’s often used with other treatments, such as virtual reality, to increase the 15 hour dosage that has been shown to be beneficial.
Who it’s for:
Task-specific practice is generally used and is studied in people who have some functional ability of their hand. It’s been shown to be beneficial throughout the rehabilitation process.
Even though the research has been focused on “functional ability” of the hand by practicing reach, grasp, transport, release; there’s potential for recovery by using the same principles of task-specific practice: real life objects, functional tasks, and problem-solving even without the ability to grasp.
Functionally, we can use our affected upper extremity as a stabilizer, an assist, or for manipulation. There are lots of ways to get that side involved to prevent “learned non-use” and to improve your problem-solving skills.
There are two key factors to any hand recovery method: support and meaning.
Neofect aims to support and inspire you to live your best life with virtual reality tools that can be used as part of a constraint-induced movement therapy program or with repetitive task practice.
Our comprehensive recovery and wellness app: Neofect Connect and our YouTube Channel: Find What Works are based on the principles of repetitive task practice and aim to give you the tools to live your best life.
Now the only question is, what are you waiting for?
Pollock A, Farmer SE, Brady MC, Langhorne P, Mead GE, Mehrholz J, van Wijck F. Interventions for improving upper limb function after stroke. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010820. DOI: 10.1002/14651858.CD010820.pub2.
[Abstract] Comparison of Task Oriented Approach and Mirror Therapy for Poststroke Hand Function Rehabilitation
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.
[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
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
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.
[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
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.
[Abstract] Advantages of virtual reality in the rehabilitation of balance and gait: Systematic review
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.
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.
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.
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.
[Abstract + References] Investigation of the effects of mirror therapy on the spasticity, motor function and functionality of impaired upper limbs in chronic stroke patients
Strokes lead to different levels of disability. During the chronic stage, hemiparesis, spasticity and motor deficits may cause loss of functional independence. Mirror therapy aims to reduce deficits and increase functional recovery of the impaired upper limb. This study aimed to evaluate the effects of mirror therapy on upper limb spasticity and motor function, as well as its impact on functional independence in chronic hemiparetic patients.
In this quasi-experimental study, eight chronic hemiparetic patients (age 55.5 ± 10.8 years) were assessed to determine their degree of spasticity (Modified Ashworth Scale), level of upper limb motor function (Fugl-Meyer Assessment) and functionality (Functional Independence Measure). All participants received 12 sessions of mirror therapy delivered three times per week, over a period of 4 weeks. Participants were re-evaluated post-intervention and these results were compared to their pre-intervention scores to determine the impact of mirror therapy.
A decrease in spasticity was observed, with significant improvements in shoulder extensors (P=0.033) and a significant increase in motor function (P=0.002). The therapeutic protocol adopted did not have a significant effect on functional independence (P=0.105).
Mirror therapy led to improvements in upper limb spasticity and motor function in chronic hemiparetic stroke patients. No effects on functional independence were observed. Further research with a larger number of patients is needed to provide more robust evidence of the benefits of mirror therapy in chronic hemiparetic stroke patients.
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via Investigation of the effects of mirror therapy on the spasticity, motor function and functionality of impaired upper limbs in chronic stroke patients | International Journal of Therapy and Rehabilitation
This paper developed a robotics-assisted device for the stroke patients to perform the hand rehabilitation. Not only the system can perform passive range of motion exercises for impaired hand, but also can perform mirror therapy for pinching and hand grasping motions under the guidance of the posture sensing glove worn on patient’s functional hand. Moreover, the framework and operation flow of the developed system has been and delineated in this paper. Practical results with human subjects are shown in this paper to examine the usability of proposed system, trial experiment of advance mirror therapy that use the proposed system to interact with realities is also presented in this paper.
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