- •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.
Posts Tagged Mirror therapy
[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. […]
Vilayanur Ramachandran tells us what brain damage can reveal about the connection between celebral tissue and the mind, using three startling delusions as examples.
Neurologist V.S. Ramachandran looks deep into the brain’s most basic mechanisms. By working with those who have very specific mental disabilities caused by brain injury or stroke, he can map functions of the mind to physical structures of the brain.
[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.
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).
via 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 – Qun Xu, Feng Guo, Hassan M Abo Salem, Hong Chen, Xiaolin Huang, 2017
Objectives: Mirror therapy is a unique treatment with a touch of modality that is purported to improve the motor function of the affected limb in individuals with hemiplegia. Previous studies have focused on the neuro-physiological factors underlying the mechanism of the clinical effect of this technique. The present study aims to understand the mechanism using the rehabilitation method and neuro-occupation model as well as analyze the effects of mirror therapy on the upper limb function of subjects with spastic hemiplegic cerebral palsy.
Methods: Single subject design known as withdrawal design was used by a convenience sample of four subjects. The study involved three observational phases known as baseline, treatment, and withdrawal phases that took place during a 10 week period. The study contained a home-based mirror therapy protocol whereby the participants were instructed to do some exercises on a daily basis. The improvement of the hand function of the hemiplegic side was examined by Box and Block test along with two more activities including Threading Beads and Stacking Rings.
Results: The ability to perform the Box and Block test, Threading Beads, and Stacking Rings tended to remain steady in the baseline phase, whereas there was a noticeable improvement during the treatment phase and a decline in the withdrawal phase.
Discussion: From the perspective of visual feedback neuro-occupation model, it could be hypothesized that alterations to the sensory system caused by the mirror reflection of non affected hand may have led to the destabilization of the sensory cortices that changed the participants’ intention, meaning, and perception, thereby improving the subject’s motor control.
The Mirror Therapy
Mirror Therapy, or mirror box therapy, is a physiotherapy (or physical therapy) and occupational therapy technique used to help increase movement and decrease pain in limbs. It is suitable to treat conditions such as complex regional pain syndrome (CRPS), phantom limb pain, stroke and other chronic pain conditions. In many of these conditions the affected limb may not move well and it might be very painful when you try to move it. With adequate practise using mirror therapy, both patients and therapists have reported positive outcomes.
Background Of Mirror Therapy
Mirror therapy was first theorized by V. S. Ramachandran, Director of the Centre for Brain and Cognition, and Distinguished Professor with the Psychology Department and the Neurosciences Program at the University of California, San Diego. He is trained as a doctor and then obtained a Ph.D. from Trinity College at the University of Cambridge.
Ramachandran is credited with the invention of the mirror box and the introduction of mirror visual feedback as a treatment for phantom limb paralysis. This is known as mirror therapy.
V. S. Ramachandran has published over 180 papers in scientific journals and is referred to as “The Marco Polo of neuroscience” by Richard Dawkins and “The modern Paul Broca” by Eric Kandel.
To read more about the background and invention of mirror therapy, click here.
Mirror Therapy & The Brain
The brain is known to be “plastic”. The activity you perform daily, change the way the limb is represented in the brain. For example, if you are a pianist, both of your hands have a bigger representation in your brain. After any injury, the representation of the affected limb in the brain may be smaller or associated with pain.
Mirror therapy uses the brain’s prioritization of visual feedback over the sensation of the limb. In other words, mirror therapy involves using a mirror to “trick” the brain into thinking the affected limb is okay. During mirror therapy treatment exercises, the affected limb is covered and hidden behind a mirror. The movement of the good limb will thus be reflected in the mirror, allowing the brain to think that the affected limb is moving freely.
Evidence has shown that the areas of the brain are active during observation of the movement which are involved in the performance of movements. In simple terms, even though the brain can feel the affected limb is not moving, it forgets this and chooses to believe what it can see reflected in the mirror. With regular use of mirror therapy, the representation of the affected limb in the brain will change again. The brain will start to “learn” that this limb is okay and therefore will start to move it more easily.
How To Begin With Mirror Therapy Treatment & Exercises
Mirror therapy equipment can either be purchased and put together independently or can be bought online as a set. There are a variety of types of mirror boxes. However, as long as the main principles are followed, the shape and design of the box should not matter. The most important thing is that the affected limb is hidden and that the mirror is big enough to see all movements carried out with the opposite limb. The recommended size is a mirror of 25 x 20 inches for the upper limb, and at least 35 x 25 inches for the lower limb.
The choice of material for the mirror is also important. Perspex mirrors with smooth edges can be used to avoid injuries but it is important that the mirror does not buckle as this would distort the image. The “box” part of the mirror box should be made from a neutral colour so that it does not draw attention away from the patient, and the mirror should be large enough to cover the whole of the affected limb. If making a mirror box is too difficult, you can purchase a ready-made mirror box therapy equipment from us here.
Find out more about Mirror Box Therapy Exercises for Hands & Legs here.
Grezes, J. & Decety, J. (2001).Functional anatomy of execution, mental simulation, observation and verb generation of actions: a meta-analysis. Human Brain Mapping, 12 (1), 1-19.
Neuro Orthopaedic Institute (NOI) http://www.noigroup.com/documents/noi-mirror-box-instructions.pdf accessed 29/9/17
Rothgangel AS, Braun SM. (2013). Mirror therapy: Practical protocol for stroke rehabilitation. Munich: Pflaum Verlag. doi: 10.12855/ar.sb.mirrortherapy.e2013
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.
[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
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.
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.
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.
Stroke is the leading cause of long-term adult disability worldwide . Most patients with stroke experience upper-extremity (UE) motor impairment  and show minimal recovery of the affected arm even 6 months after stroke . 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 [4, 5]. Action observation therapy (AOT) and mirror therapy (MT) are two examples of novel approaches concerning stroke motor recovery that are supported by neuroscientific foundations [6, 7]. 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) . 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  and to mediate their motor relearning process after stroke . 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 . 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 [8, 10, 11, 12, 13, 14]. 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 [15, 16, 17]. 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 . 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 [16, 17] 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 . 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 . 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 [21, 22, 23]. In addition, although positive effects of MT have been demonstrated in patients with stroke , 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 . Accordingly, MT may affect perceptual motor processes via three functional neural networks: (1) activation of brain regions associated with MNS [25, 26], (2) recruitment of ipsilateral motor pathways , and (3) substitution of abnormal proprioception from the affected limb with feedback from the non-affected limb [15, 18]. 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.
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
[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
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.
- Essential knowledge in neurological rehabilitation includes an understanding of normal motor behaviour, muscle biology and skill acquisition.
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.
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.
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.
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.
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.[…]