Mirror therapy in upper limb motor recovery and activities of daily living, and its neural correlates in stroke individuals: A systematic review and meta-analysis

Alternating Hot-Cold Water Immersion Facilitates Motor Function Recovery in the Paretic Upper Limb After Stroke: A Pilot Randomized Controlled Trial

OBJECTIVE

To assess the effectiveness of alternating hot-cold water immersion (AHCWI) in patients with acute stroke.

DESIGN

A single-blind pilot randomized controlled trial.

SETTING

Department of Rehabilitation Medicine of a medical center.

PARTICIPANTS

Early stroke survivors (N=24) with moderate-to-severe arm paresis.

INTERVENTIONS

In addition to conventional rehabilitation, eligible patients were randomly assigned to an AHCWI group (n=12, for AHCWI) or a control group (n=12, for upper limb [UL] cycling exercises) 5 times per week for 6 weeks.

MAIN OUTCOME MEASURES

The Fugl-Meyer Assessment motor-UL (FMA-UL) score, Motricity Index-UL (MI-UL) score, modified Motor Assessment Scale (MMAS; including its UL sections, MMAS-UL) score, Berg Balance Scale score, Barthel Index (BI), and modified Ashworth Scale score were assessed by the same uninvolved physical therapist at baseline and after 4 and 6 weeks of intervention.

RESULTS

Compared with the control group, the AHCWI group performed better, with significant group effects (P<.05), and exhibited significant improvements in FMA-UL, MI-UL, and MMAS-UL scores at 4 and 6 weeks (P<.05). Although the remaining outcomes were not significantly different, they favored the AHCWI group. Notably, a significant difference was observed in the BI at 4 weeks (P=.032). Significant changes in the muscle tone or adverse effects were not observed in either group after the intervention.

CONCLUSIONS

AHCWI with stroke rehabilitation is feasible and may facilitate motor function recovery of the paretic UL after a stroke.

Using mechanistic knowledge to appraise contemporary approaches to the rehabilitation of upper limb function following stroke

It is a paradox of neurological rehabilitation that, in an era in which preclinical models have produced significant advances in our mechanistic understanding of neural plasticity, there is inadequate support for many therapies recommended for use in clinical practice. When the goal is to estimate the probability that a specific form of therapy will have a positive clinical effect, the integration of mechanistic knowledge (concerning 'the structure or way of working of the parts in a natural system') may improve the quality of inference. This is illustrated by analysis of three contemporary approaches to the rehabilitation of lateralized dysfunction affecting people living with stroke: constraint-induced movement therapy; mental practice; and mirror therapy. Damage to 'cross-road' regions of the structural (white matter) brain connectome generates deficits that span multiple domains (motor, language, attention and verbal/spatial memory). The structural integrity of these regions determines not only the initial functional status, but also the response to therapy. As structural disconnection constrains the recovery of functional capability, 'disconnectome' modelling provides a basis for personalized prognosis and precision rehabilitation. It is now feasible to refer a lesion delineated using a standard clinical scan to a (dis)connectivity atlas derived from the brains of other stroke survivors. As the individual disconnection pattern thus obtained suggests the functional domains most likely be compromised, a therapeutic regimen can be tailored accordingly. Stroke is a complex disorder that burdens individuals with distinct constellations of brain damage. Mechanistic knowledge is indispensable when seeking to ameliorate the behavioural impairments to which such damage gives rise.

How does combining physical therapy with transcranial direct stimulation improve upper-limb motor functions in patients with stroke? A theory perspective

More than half of stroke survivors suffer from upper-limb dysfunction that persists years after stroke, negatively impacting patients' independence and, therefore, affecting their quality of life. Intense motor rehabilitation is required after a stroke to facilitate motor recovery. More importantly, finding new ways to maximize patients' motor recovery is a core goal of stroke rehabilitation. Thus, researchers have explored the potential benefits of combining the effects of non-invasive brain stimulation with physical therapy rehabilitation. Specifically, combining transcranial direct stimulation (tDCS) with neurorehabilitation interventions can boost the brain's responses to interventions and maximize the effects of rehabilitation to improve upper-limb recovery post-stroke. However, it is still unclear which modes of tDCS are optimal for upper-limb motor recovery in patients with stroke when combined with physical therapy interventions. Here, the authors review the existing literature suggesting combining physical therapy rehabilitation with tDCS can maximize patients' motor recovery using the Interhemispheric Competition Model in Stroke. The authors focus on two main rehabilitation paradigms, which are constraint-induced movement therapy (CIMT) and Mirror therapy with and without tDCS. The authors also discuss potential studies to elucidate further the benefit of using tDCS adjunct with these upper-limb rehabilitation paradigms and its effectiveness in patients with stroke, with the ultimate goal of maximizing patients' motor recovery.

Feasibility and efficacy of virtual reality rehabilitation compared with conventional physiotherapy for upper extremity impairment due to ischaemic stroke: protocol for a randomised controlled trial

INTRODUCTION

Approximately half of all stroke survivors have persistent upper extremity functional impairment, leading to reduced self-care, independence and quality of life. High-intensity, task-oriented virtual reality rehabilitation improves motor recovery. However, its clinical efficacy over standard rehabilitation remains uncertain. This study aims to evaluate the feasibility and efficacy of a virtual reality-based comprehensive rehabilitation gaming system (VR-cRGS) in stroke survivors with upper extremity impairment and to characterise the structural and functional plasticity of the affected regions in the brain due to the proposed rehabilitation.

METHODS AND ANALYSIS

This study is a multicentric, open-label, randomised controlled trial with an intention-to-treat analysis. A total of 162 patients will be enrolled in two academic institutes in India that specialise in stroke care. Patients with a first-ever ischaemic stroke (18-70 years and 1-6 months of stroke onset) with upper extremity impairment with 1 and 1+ grades of spasticity as per the modified Ashworth Scale and 3, 4 or 5 stages on Brunnstrom recovery staging will be enrolled. They will be randomised (1:1) into two treatment groups to receive 12 weeks of training either on VR-cRGS or on conventional physiotherapy. The primary feasibility outcome is compliance with the treatment. The primary efficacy outcome is the functional recovery of the upper extremity assessed by the Fugl-Meyer Assessment-Upper Extremity and Wolf Motor Function Test. The secondary outcomes are the Barthel Index and the 36-item Short-Form Health Survey. Multimodal brain imaging will be done in all enrolled patients at baseline and post-treatment to evaluate the structural and functional connectivity changes. The outcome measures will be analysed using paired t-tests or non-parametric tests.

ETHICS AND DISSEMINATION

The study has been approved by the Institutional Ethics Review Board of the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India (SCT/IEC/1415/AUGUST-2019) and the National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India (NIMHANS/IEC (BS and NS DIV.)/32nd Meeting/21). All participants will sign an informed consent form prior to participation. The study results will be disseminated through scholarly publication.

TRIAL REGISTRATION NUMBER

CTRI/2021/11/038339.

Mirror therapy combined with contralaterally controlled functional electrical stimulation for the upper limb motor function after stroke: a randomized controlled trial

PURPOSE

In this study, we investigated the effects of mirror therapy (MT) combined with contralaterally controlled functional electrical stimulation (CCFES) on upper limb motor function, activities of daily life, and corticospinal excitability in post-stroke patients.

METHODS

Sixty post-stroke patients were randomly divided into four groups: CCFES, MT, MT combined with CCFES, and control. All the patients underwent routine rehabilitation. Those in the MT, CCFES, MT combined with CCFES, and control groups received MT, CCFES, MT combined with CCFES, and routine rehabilitation alone, respectively. Upper limb motor function, activities of daily living, and corticospinal excitability were evaluated before and after a 3-week intervention period.

RESULTS

MT combined with CCFES demonstrated a significantly greater therapeutic effect on motor function of the paretic wrist than CCFES, MT, or routine rehabilitation alone. However, there was no significant difference in the overall motor function of the affected upper limb, activities of daily life, or corticospinal excitability between the MT combined with CCFES group and the other three groups.

CONCLUSION

MT combined with CCFES may be a potential adjuvant therapy to promote motor function in paretic wrist after stroke.

Cognitive approaches in the rehabilitation of upper limbs function in children with cerebral palsy: a systematic review and meta-analysis

INTRODUCTION

Cerebral palsy (CP) is the predominant cause of children disability. It is characterized by motor, sensory, and postural deficits due to a non-progressive injury to the developing central nervous system. In recent years, new rehabilitation techniques targeting the central representations of motor patterns have been introduced: the most used are action observation therapy (AOT), motor imagery (MI), and mirror therapy (MT). Aim of this study is to assess the effectiveness of these cognitive strategies on the recovery of upper limb motor functions in children with CP.

EVIDENCE ACQUISITION

This study was designed as a systematic review and meta-analysis, registered in PROSPERO (CRD42023403794). For the report and methodological definitions of this study, the recommendations of the PRISMA protocol and the Cochrane collaboration, were followed. A total of 3 electronic databases (PubMed, Scopus, and Web of Science) were searched for relevant Randomized Control Trials (RCT) using the combinations of terms "cerebral palsy" AND "action observation" OR "motor imagery" OR "mirror therapy" OR "cognitive therapy." A meta-analysis was carried out to compare cognitive and conventional approaches and combine direct and indirect effects. A random-effects meta-analysis model was used to derive pooled effect estimates.

EVIDENCE SYNTHESIS

Out of 328 records, 12 RCTs were analyzed in this systematic review published from 2012 to 2022, and included 375 children, of whom 195 received cognitive therapies, and 180 underwent conventional rehabilitation. AOT was the most investigated (RCTs N.=7), and showed significant results in the recovery of upper limb motor functions, albeit the meta-analysis demonstrated a non-significant difference in Melbourne Unilateral Upper limb Scale (MUUL) (95% CI: -7.34, 12); in Assisting Hand Assessment (AHA) (95% CI: -4.84, 10.74), and in AbilHand-Kids Questionnaire (95% CI: -1.12, 1.45). Five RCTs investigated MT showing significant improvements in grip and dexterity; none used MI as intervention therapy.

CONCLUSIONS

Cognitive therapies provided with encouraging results in the recovery of upper limb motor functions, although not a clinical effect in bimanual or unimanual performance; they could represent a valid therapeutic solution integrated to conventional rehabilitation in the treatment of upper limb motor impairment in children with CP.

Effects of mirror neuron activation therapies on functionality in older adults: Systematic review and meta-analysis

PURPOSE

To identify the effects of mirror neuron activation (MNAT) combined or not with physical exercise (PE) in healthy older adults, on functionality, balance, gait velocity and risk of falls.

METHODS

A systematic electronic search was performed in PubMed/MEDLINE, Cochrane, and Embase databases.

RESULTS

Thirteen randomized controlled trials were included in the qualitative analysis, and eleven in the quantitative analysis. All studies showed fair to high quality and the most frequent high-risk bias was "Blinding of participants and personnel". Compared to the control condition, higher improvement was shown in older people who received MNAT, on functionality (1.57 [0.57, 2.62], balance (1.95 [1.32, 2.572]), and gait velocity (1.20 [0.30, 2.11]). Compared to PE, MNAT combined with PE does not improve functionality. More studies are needed to assess MNAT effectiveness in the rest of the outcomes.

CONCLUSIONS

Neuron system activation through MNAT improves relevant abilities in older adults, with better results when including functional activities. However, the beneficial effects on these variables of adding MNAT to a PE program are controversial.

Effects of mirror therapy on spasticity and sensory impairment after stroke: Systematic review and meta-analysis

OBJECTIVE

To review and synthesize existing evidence on the effectiveness of mirror therapy (MT) compared to active exercise-based interventions (ie, cross-training and conventional exercise) for reducing spasticity and sensory impairment in stroke survivors. TYPE: Systematic Review and Metanalysis.

LITERATURE SURVEY

Pubmed/MEDLINE, Cochrane, Embase, CINAHL, and Physiotherapy Evidence Database (PEDro), were searched.

METHODOLOGY

Randomized controlled trials (RCTs) that investigated MT effectiveness in improving spasticity and sensory impairment in stroke survivors compared to a control group.

SYNTHESIS

Fifteen RCTs (653 volunteers) were included. Spasticity improvements achieved with MT were similar to those obtained with cross-training (standard mean difference [SMD]: 0.12, 95% confidence interval [CI]: -0.43 to 0.68). In addition, when further combined with conventional exercise, spasticity improved similarly in both groups (SMD: 0.10, 95% CI: -0.16, 0.36). Lastly, when MT plus exercise was compared to exercise alone, spasticity decreased in both groups (SMD: 0.16, 95% CI: -0.16 to 0.48). Nevertheless, none of the Interventions seem effective on sensory impairment (SMD: 0.27, 95% CI: -0.28 to 0.81).

CONCLUSIONS

MT is equally effective as other exercise therapies, such as cross-training and conventional exercise, for improving spasticity in stroke survivors, whereas none of the explored interventions yielded beneficial effects on sensory impairment. Further well-designed RCTs are needed to confirm the results.

Validating the measurement of upper limb sensorimotor behavior utilizing a tablet in neurologically intact controls and individuals with chronic stroke

BACKGROUND

Intact sensorimotor function of the upper extremity is essential for successfully performing activities of daily living. After a stroke, upper limb function is often compromised and requires rehabilitation. To develop appropriate rehabilitation interventions, sensitive and objective assessments are required. Current clinical measures often lack precision and technological devices (e.g. robotics) that are objective and sensitive to small changes in sensorimotor function are often unsuitable and impractical for performing home-based assessments. Here we developed a portable, tablet-based application capable of quantifying upper limb sensorimotor function after stroke. Our goal was to validate the developed application and accompanying data analysis against previously validated robotic measures of upper limb function in stroke.

METHODS

Twenty individuals with stroke, twenty age-matched older controls, and twenty younger controls completed an eight-target Visually Guided Reaching (VGR) task using a Kinarm Robotic Exoskeleton and a Samsung Galaxy Tablet. Participants completed eighty trials of the VGR task on each device, where each trial consisted of making a reaching movement to one of eight pseudorandomly appearing targets. We calculated several outcome parameters capturing various aspects of sensorimotor behavior (e.g., Reaction Time, Initial Direction Error, Max Speed, and Movement Time) from each reaching movement, and our analyses compared metric consistency between devices. We used the previously validated Kinarm Standard Analysis (KSA) and a custom in-house analysis to calculate each outcome parameter.

RESULTS

We observed strong correlations between the KSA and our custom analysis for all outcome parameters within each participant group, indicating our custom analysis accurately replicates the KSA. Minimal differences were observed for between-device comparisons (tablet vs. robot) in our outcome parameters. Additionally, we observed similar correlations for each device when comparing the Fugl-Meyer Assessment (FMA) scores of individuals with stroke to tablet-derived metrics, demonstrating that the tablet can capture clinically-based elements of upper limb impairment.

CONCLUSIONS

Tablet devices can accurately assess upper limb sensorimotor function in neurologically intact individuals and individuals with stroke. Our findings validate the use of tablets as a cost-effective and efficient assessment tool for upper-limb function after stroke.

The Effect of Kinesio Taping Combined with Virtual-Reality-Based Upper Extremity Training on Upper Extremity Function and Self-Esteem in Stroke Patients

(1) Background: The purpose of this study is to investigate the effect of virtual-reality-based hand motion training (VRT) in parallel with the Kinesio Taping (KT) technique on upper extremity function in stroke patients and to present a more effective therapeutic basis for virtual reality training intervention. (2) Methods: First, 43 stroke patients were randomly assigned to two groups: 21 experimental subjects and 22 controls. The experimental group performed Kinesio Taping (KT) on the dorsal part of the hand along with virtual-reality-based hand motion training, and the control group performed only virtual-reality-based hand motion training. The intervention was conducted for a total of 30 sessions over 6 weeks. To evaluate changes in upper extremity function, the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE), the Wolf Motor Function Test (WMFT), and the Motor Activity Log (MAL) (including amount of use (AOU) and quality of movement (QOM)) were evaluated. In addition, the Self-Efficacy Scale (SEF) was evaluated to examine the change in the self-esteem of the study subjects. (3) Results: The experimental group who participated in the virtual reality training in parallel with the KT technique showed statistically significant improvement (** p < 0.01) in the FMA-UE, WMFT, and MAL evaluations that investigate changes in upper extremity function. SEF evaluation also showed a statistically significant improvement (** p < 0.01). A statistically significant difference between the two groups was observed in the evaluation of FMA-UE, WMFT, MAL-QOM, and SEF (^†p < 0.05), showing that that combined intervention was more effective at improving upper extremity function than the existing VRT intervention. There was no statistical difference between the two groups in the MAL-AOU item, which is an evaluation of upper extremity function (p > 0.05). There was a statistically significant difference between the two groups in the amount of change in upper limb function (^††p < 0.01). (4) Conclusions: It was confirmed that virtual-reality-based hand motion training performed in parallel with the KT technique had a positive effect on the recovery of upper extremity function of stroke patients. The fact that the KT technique provided stability to the wrist by assisting the wrist extensor muscles appears to have improved the upper extremity function more effectively than VRT alone.

Reversed Mirror Therapy (REMIT) after Stroke-A Proof-of-Concept Study

In mirror training (MIT), stroke patients strive to move their hands while looking at the reflected image of the unaffected one. The recruitment of the mirror neurons and visual-proprioceptive conflict are expected to facilitate the paretic voluntary movement. Here, a reversed MIT (REMIT) is presented, which requires moving hands while looking at the reflected image of the paretic one, giving the illusion of being unable to move the unimpaired hand. This study compares MIT and REMIT on post-stroke upper-limb recovery to gain clues on the mechanism of action of mirror therapies. Eight chronic stroke patients underwent two weeks of MIT and REMIT (five sessions each) in a crossover design. Upper-limb Fugl-Meyer, Box and Block and handgrip strength tests were administered at baseline and treatments end. The strength of the mirror illusion was evaluated after each session. MIT induced a larger illusory effect. The Fugl-Meyer score improved to the same extent after both treatments. No changes occurred in the Box and Block and the handgrip tests. REMIT and MIT were equally effective on upper-limb dexterity, challenging the exclusive role of mirror neurons. Contrasting learned nonuse through an intersensory conflict might provide the rationale for both forms of mirror-based rehabilitation after stroke.

Re-evaluation of Mirror Visual Feedback Therapy for a Systematic Evaluation/Meta-analysis of Physical Function Re-education After Stroke

OBJECTIVE

The aim of the study is to re-evaluate the methodological quality and quality of evidence for a systematic evaluation/meta-analysis of the effect of mirror visual feedback therapy on physical function re-education after stroke.

METHODS

Systematic evaluations/meta-analyses of mirror visual feedback therapy on physical function re-education after stroke were searched in the China Knowledge Network database, Wanfang database, Vipers database, China Biomedical Literature database, PubMed, Web of Science, and Embase using a computer, and the search time frame was up to January 2022. Methodological quality and quality of evidence ratings of the included studies were determined using the AMSTAR2 scale and GRADE classification by two authors.

RESULTS

Seventeen publications were included. The evaluation with the AMSTAR2 scale showed that one study had an intermediate quality rating, five had a low-quality rating, and the remaining 11 were all very low quality. The GRADE scale showed 93 outcome indicators, of which 6 were intermediate, 23 were low grades, and the rest were very low grades, with low overall quality.

CONCLUSIONS

Mirror visual feedback therapy is efficacious for physical function re-education after stroke and promotes recovery from physical dysfunction, but the methodological quality and quality of evidence from the related systematic evaluations/meta-analyses are low.

[Modern view on upper limb physical rehabilitation after stroke. Literature review]

Stroke is the world's second leading cause of death and the first cause of disability among all diseases. The most common complication of a stroke is a violation of the motor function of the limbs, which significantly worsens the quality of life and the level of self-care and independence of patients. Restoring the function of the upper limb is one of the priority tasks of rehabilitation after a stroke. A large number of factors, such as the location and size of the primary brain lesion, the presence of complications in the form of spasticity, impaired skin and proprioceptive sensitivity, and comorbidities, determine the patient's rehabilitation potential and the prognosis of ongoing rehabilitation measures. Of particular note are the timing of the start of rehabilitation measures, the duration and regularity of the treatment methods. A number of authors propose scales for assessing the rehabilitation prognosis, as well as algorithms for compiling rehabilitation programs for restoring the function of the upper limb. A fairly large number of rehabilitation methods and their combinations have been proposed, including special methods of kinesitherapy, robotic mechanotherapy with biofeedback, the use of physiotherapeutic factors, manual and reflex effects, as well as ready-made programs that include sequential and combined use of various methods. Dozens of studies have been devoted to comparative analysis and evaluation of the effectiveness of these methods. The purpose of this work is to review current research on a given topic and draw up our own conclusion on the appropriateness of using and combining these methods at various stages of rehabilitation in stroke patients.

Activity of Mirror Neurons and Its Effect on Various Diseases

Ayna nöronların nöroanatomik yapılanması ve işlevselliğinin araştırılması son yıllarda oldukça artmıştır. Özellikle nörolojik ve ortopedik hasta gruplarında uygulanan tedavi yaklaşımlarında pasif uygulamalar yerine hastanın katılımının olduğu aktif uygulamalar tercih edilmektedir. Bunun temel sebeplerinden birisi ayna nöronları ve birincil motor korteksi dâhil ederek tedaviyi kalıcı hale getirmeyi amaçlamaktır. Ayna nöronların fonksiyonel ve disfonksiyonel durumlarını ortaya koymak, tedavi seanslarında hastaların semptomlarını anlamada çok büyük katkı sağlamaktadır. Özellikle ayna nöronları aktive ederek planlanan ayna terapisi ile hastalar nöronal bağlantılarını yeniden yapılandırarak nöroplastik aktivite sağlarlar ve böylece iyileşme süreçlerine katkıda bulunmuş olurlar. Literatür taramalarında ayna nöronların aktivasyonlarının yer aldığı hastalıkların yapısal özellikleri birbirinden farklı olsa da ortak özellik olarak ayna nöronların aktive edilerek tedaviye katkı sağladığını söylemek mümkündür. Yapılan tedavi uygulamalarında, ilgili fonksiyonel hareketin hasta tarafından fiziksel olarak yapılmadığı durumlarda dahi bilişsel olarak hareketin yapıldığının imgelenmesi, ayna nöronları aktive ederek hastanın iyilik halini arttırdığı belirlenmiştir. 

Non-invasive brain stimulation associated mirror therapy for upper-limb rehabilitation after stroke: Systematic review and meta-analysis of randomized clinical trials

Background

Non-invasive brain stimulation (NIBS) techniques and mirror therapy (MT) are promising rehabilitation measures for stroke. While the combination of MT and NIBS has been employed for post-stroke upper limb motor functional rehabilitation, its effectiveness has not been examined.

Objective

This study aimed to evaluate the effectiveness of combined MT and NIBS in the recovery of upper limb motor function in stroke patients.

Methods

The search was carried out in PubMed, EMBASE, Cochrane Library, Web of Science, Science Direct, CNKI, WANFANG and VIP until December 2021. Randomized clinical trials (RCTs) comparing MT or NIBS alone with the combination of NIBS and MT in improving upper extremity motor recovery after stroke were selected. A meta-analysis was performed to calculate the mean differences (MD) or the standard mean differences (SMD) and 95% confidence intervals (CI) with random-effect models. Subgroup analyses were also conducted according to the types of control group, the types of NIBS, stimulation timing and phase poststroke.

Results

A total of 12 articles, including 17 studies with 628 patients, were reviewed in the meta-analysis. In comparison with MT or NIBS alone, the combined group significantly improved body structure and function (MD = 5.97; 95% CI: 5.01–6.93; P < 0.05), activity levels (SMD = 0.82; 95% CI 0.61–1.02; P < 0.05). For cortical excitability, the motor evoked potential cortical latency (SMD = −1.05; 95% CI:−1.57–−0.52; P < 0.05) and the central motor conduction time (SMD=-1.31 95% CI:−2.02-−0.61; P < 0.05) of the combined group were significantly shortened. A non-significant homogeneous summary effect size was found for MEP amplitude (SMD = 0.47; 95%CI = −0.29 to 1.23; P = 0.23). Subgroup analysis showed that there is an interaction between the stimulation sequence and the combined treatment effect.

Conclusion

In this meta-analysis of randomized clinical trials, in comparison to the control groups, MT combined with NIBS promoted the recovery of upper extremity motor function after stroke, which was reflected in the analysis of body structure and function, activity levels, and cortical excitability.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022304455.

Update on Stroke Rehabilitation in Motor Impairment

Motor impairment due to stroke limits patients' mobility, activities of daily living, and negatively affects their return to the workplace. It also reduces patients' quality of life and increases the socioeconomic burden of stroke. Therefore, optimizing the recovery of motor impairment after stroke is a very important goal for both individuals and society as a whole. The emergence and improvement of various technologies in the Fourth Industrial Revolution have exerted a major influence on the development of new rehabilitation methods and efficiency enhancements for existing methods. This review categorizes rehabilitation methods that promote the recovery of motor function into upper limb function and lower limb function and summarizes recent advances in stroke rehabilitation. Although debate continues regarding the effects of some rehabilitation therapies, it is hoped that the evidence will be improved through ongoing research so that clinicians can treat patients with a higher level of evidence.

Efficacy and Safety of Vagus Nerve Stimulation on Upper Limb Motor Recovery After Stroke. A Systematic Review and Meta-Analysis

Background

Upper limb motor impairment is one of the main complications of stroke, affecting quality of life both for the patient and their family. The aim of this systematic review was to summarize the scientific evidence on the safety and efficacy of Vagus Nerve Stimulation (VNS) on upper limb motor recovery after stroke.

Methods

A systematic review and meta-analysis of studies that have evaluated the efficacy or safety of VNS in stroke patients was performed. The primary outcome was upper limb motor recovery. A search of articles published on MEDLINE, CENTRAL, EBSCO and LILACS up to December 2021 was performed, and a meta-analysis was developed to calculate the overall effects.

Results

Eight studies evaluating VNS effects on motor function in stroke patients were included, of which 4 used implanted and 4 transcutaneous VNS. It was demonstrated that VNS, together with physical rehabilitation, increased upper limb motor function on average 7.06 points (95%CI 4.96; 9.16) as assessed by the Fugl-Meyer scale. Likewise, this improvement was significantly greater when compared to a control intervention (mean difference 2.48, 95%CI 0.98; 3.98). No deaths or serious adverse events related to the intervention were reported. The most frequent adverse events were dysphonia, dysphagia, nausea, skin redness, dysgeusia and pain related to device implantation.

Conclusion

VNS, together with physical rehabilitation, improves upper limb motor function in stroke patients. Additionally, VNS is a safe intervention.

Comparison of Sensory Observation and Somatosensory Stimulation in Mirror Neurons and the Sensorimotor Network: A Task-Based fMRI Study

Objective

This study aimed to investigate brain plasticity by somatosensory stimulation (SS) and sensory observation (SO) based on mirror neuron and embodied cognition theory. Action observation therapy has been widely adopted for motor function improvement in post-stroke patients. However, it is uncertain whether the SO approach can also contribute to the recovery of sensorimotor function after stroke. In this study, we explored the therapeutic potential of SO for sensorimotor dysfunction and provided new evidence for neurorehabilitation.

Methods

Twenty-six healthy right-handed adults (12 men and 14 women), aged 18–27 (mean, 22.12; SD, 2.12) years were included. All subjects were evaluated with task-based functional magnetic resonance imaging (fMRI) to discover the characteristics and differences in brain activation between SO and SS. We adopted a block design with two conditions during fMRI scanning: observing a sensory video of brushing (task condition A, defined as SO) and brushing subjects' right forearms while they watched a nonsense string (task condition B, defined as SS). One-sample t-tests were performed to identify brain regions and voxels activated for each task condition. A paired-sample t-test and conjunction analysis were performed to explore the differences and similarities between SO and SS.

Results

The task-based fMRI showed that the bilateral postcentral gyrus, left precentral gyrus, bilateral middle temporal gyrus, right supramarginal gyrus, and left supplementary motor area were significantly activated during SO or SS. In addition to these brain regions, SO could also activate areas containing mirror neurons, like the left inferior parietal gyrus.

Conclusion

SO could activate mirror neurons and sensorimotor network-related brain regions in healthy subjects like SS. Therefore, SO may be a promising novel therapeutic approach for sensorimotor dysfunction recovery in post-stroke patients.

Emerging Limb Rehabilitation Therapy After Post-stroke Motor Recovery

Stroke, including hemorrhagic and ischemic stroke, refers to the blood supply disorder in the local brain tissue for various reasons (aneurysm, occlusion, etc.). It leads to regional brain circulation imbalance, neurological complications, limb motor dysfunction, aphasia, and depression. As the second-leading cause of death worldwide, stroke poses a significant threat to human life characterized by high mortality, disability, and recurrence. Therefore, the clinician has to care about the symptoms of stroke patients in the acute stage and formulate an effective postoperative rehabilitation plan to facilitate the recovery in patients. We summarize a novel application and update of the rehabilitation therapy in limb motor rehabilitation of stroke patients to provide a potential future stroke rehabilitation strategy.

A Novel Approach to Increase Attention during Mirror Therapy among Stroke Patients: A Video-Based Behavioral Analysis

Stroke is a major cause of disability and an evident rehabilitation strategy is crucial. Mirror therapy (MT) is one of the popular rehabilitation methods that is known to be effective as the patients benefit from the mirror illusion. However, the patient’s attention to the mirror illusion during treatment is unclear. Therefore, the present study assesses the duration and frequency of the mirror gaze, distraction, and preparation of sixteen stroke patients during two MT methods using a behavioral coding software. During the 30 min treatment, the total mirror gaze duration during conventional bilateral MT (BMT) was 564.04 s, while it was 1482.45 s in unilateral MT using a screen (UMT). The total distracted time was 945.61 s in BMT, while it was only 162.03 s in UMT. The total preparatory duration was 290.35 s in BMT and 155.53 s in UMT. The total number of distracted bouts were 136.45 in BMT, while it was 73.38 in UMT. The total number of preparatory bouts were 18.42 in BMT and 9.56 in UMT. The average times of gaze duration per bout were 5.52 s in BMT and 21.81 s in UMT. The average times of distraction per bout were 9.22 s in BMT and 3.00 s in UMT. The total number of mirror gaze bouts and average time of preparation per bout did not present a statistical significance in the comparisons of the two methods. This study assesses two methods of MT using observational coding software to evaluate the duration and frequency of the mirror gaze during treatment. The results suggest that UMT may be an alternative option to provide MT for stroke patients to increase their attention towards the mirror.

The addition of mirror therapy improved upper limb motor recovery and level of independence after stroke: a randomized controlled trial

Abstract Introduction In stroke survivors, the prevalence of upper motor disability remains high. There has not been much report on the success of post-stroke mirror therapy, especially in developing countries. Objective The focus of this research is to see how mirror therapy, in addition to standard rehabilitation for hand paresis, affects upper limb motor recovery and level of independence in self-care after stroke at an Indonesian teaching hospital. Method This was a randomized controlled trial with no assessor blinding. The study included 18 subacute stroke patients who did not have cognitive or visual impairment. The mirror group received a 20-minute mirror therapy session in addition to conventional rehabilitation, while the control group received only the standard program for 5 weeks (2 times per week). The Brunnstrom score and self-care level of independence elements of the Functional Independence Measure (FIM) were used as outcome measures. Results Baseline comparisons of lesion type and Brunnstrom score showed significant between-group differences. The ANACOVA test showed the difference had no effect on the FIM change in scores (P > 0.05). One patient (mirror group) was dropped out from the study. After 5 weeks (n=17), the mirror group showed improvement in both the Brunnstrom and FIM scores (P < 0.05) compared to the control group. Conclusions Mirror treatment improves upper limb motor recovery and level of independence in self-care after stroke when combined with standard hand paresis rehabilitation 2 times a week for 5 weeks.