Simple and Task-oriented Mirror Therapy for Upper Extremity Function in Stroke Patients: A Pilot Study

Conjunct Effects of Transcranial Direct Current Stimulation with Mirror Therapy on Motor Control and Muscle Performance in Spastic Quadriplegic Cerebral Palsy Children: A Randomized Clinical Trial

Background

Cerebral palsy (CP) is a birth-related non-progressive neuromotor brain disorder characterized by abnormalities of muscular tonicity, gross and fine motor skills, gait, and posture. It impacts motor control and muscle performance, which are emergent rehabilitation challenges in cerebral palsy children. Mirror therapy (MT) and transcranial direct current stimulation (tDCS) are novel treatment strategies to enhance muscle performance and motor control.

Methods

A randomized clinical trial was conducted at Ghurki Hospital Lahore, Pakistan. One hundred and five spastic quadriplegic CP (SQCP) children aged three to seven years were included. Randomization was carried out using Version 1.0 of Randomized Allocation Software. Allocation was done to three groups (35 in each group) with a 1:1:1 ratio with a unique identity number. Group I (tDCS+MT+Routine Physical Therapy (RPT), Group II (MT+RPT), and Group III (tDCS + RPT). Each patient received ten sessions of tDCS and MT, lasting for 15 minutes per side along with 20 minutes of RPT five days a week for ten weeks. Motor control was assessed by the Fugl-Meyer assessment tool, and muscle performance was measured using an isokinetic dynamometer and assessed at baseline, the 2nd, and the 10th week of follow-up and was analyzed using SPSS version 26.

Results

The results indicated a significant improvement after 10 weeks in the mean scores of motor control upper extremities, lower extremities, and trunk) with P-values of <0.000, <0.001, and <0.001, respectively. The mean scores of muscle performance (isokinetic strength) for right and left-sided elbow and knee flexors and extensors showed significant changes with P-values of 0.04, 0.01, 0.02, 0.02, 0.03, 0.05, 0.05, and 0.02, respectively. Similarly, muscle performance (isokinetic power) for these muscle groups also demonstrated significant changes, with P-values of 0.04, 0.01, 0.04, 0.02, 0.03, 0.05, 0.05, and 0.02, respectively.

Conclusion

tDCS and MT in combination significantly impacted motor control and muscle performance, enhancing elbow and knee musculature strength and power among SQCP patients.

Trial Registration

IRCT20231227060542N1 on 26-01-2024 https://irct.behdasht.gov.ir/.

The Role of Mirror Therapy in the Rehabilitation of the Upper Limb's Motor Deficits After Stroke: Narrative Review

Stroke is one of the leading causes of death and disability worldwide and poses a tremendous socioeconomic burden upon individuals, countries and healthcare systems. It causes debilitating symptoms and thus interferes with many aspects of the patient's life, including physical functioning, cognition, emotional status, activities of daily living, social reintegration and quality of life. Post-stroke patients frequently experience functional motor disabilities of the upper limb, which restrict autonomy and self-efficacy and cause limitations in engagement with activities and social participation, as well as difficulties in performing important occupations. It is therefore not surprising that motor impairment or loss of motor function of the upper limb is one of the most devastating sequelae of stroke. On these grounds, achieving optimal functioning of the upper limb after stroke remains a fundamental goal of stroke rehabilitation. Mirror therapy (MT) represents one of the several rehabilitation techniques used for restoring the upper limb's motor function after a stroke. However, conflicting results about the role of MT in the rehabilitation of the upper limb's motor deficits have been reported in the literature. Accordingly, the aim of this narrative review is to summarize existing evidence regarding the effects of MT on the upper limb's motor function in post-stroke patients and to further explore its role when applied in different phases of stroke.

Impact of task-oriented training based on acupuncture rehabilitation on upper extremity function and quality of life of patients with early stroke

BACKGROUND

Eighty percent of stroke patients develop upper limb dysfunction, especially hand dysfunction, which has a very slow recovery, resulting in economic burden to families and society.

AIM

To investigate the impact of task-oriented training based on acupuncture therapy on upper extremity function in patients with early stroke.

METHODS

Patients with early stroke hemiplegia who visited our hospital between January 2021 and October 2022 were divided into a control group and an observation group, each with 50 cases. The control group underwent head acupuncture plus routine upper limb rehabilitation training (acupuncture therapy). In addition to acupuncture and rehabilitation, the observation group underwent upper limb task-oriented training (30 min). Each group underwent treatment 5 d/wk for 4 wk. Upper extremity function was assessed in both groups using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Wolf Motor Function Rating Scale (WMFT), modified Barthel Index (MBI), and Canadian Occupational Performance Measure (COPM). Quality of life was evaluated using the Short-Form 36-Item Health Survey (SF-36). Clinical efficacy of the interventions was also evaluated.

RESULTS

Before intervention, no significant differences were observed in the FMA-UE, MBI, and WMFT scores between the two groups (P > 0.05). After intervention, the FMA-UE, WMFT, MBI, COPM-Functional Mobility and Satisfaction, and SF-36 scores increased in both groups (P < 0.05), with even higher scores in the observation group (P < 0.05). The observation group also obtained a higher total effective rate than the control group (P < 0.05).

CONCLUSION

Task-oriented training based on acupuncture rehabilitation significantly enhanced upper extremity mobility, quality of life, and clinical efficacy in patients with early stroke.

Augmented Visual Feedback for Complex Motor Skill Acquisition: A Demonstration with Healthy Young Adults

Mirror therapy (MT) is a treatment for improving motor function after stroke. Video therapy (VT) training combines observation and imitation of video clips, and it has been used to conduct efficient occupational therapy. We sought to determine the effects of MT and VT on tool-use with healthy young adults. We assigned participants to three different training groups in which they used their non-dominant left hands to move a ball with chopsticks: (a) a self-paced MT group (N = 14), (b) an MT group who moved the ball while looking at the mirror image of the right hand with a sound cue (4-second intervals) (N = 12), and (c) a group who imitated a video demonstration (4-second intervals) (N = 13). The ball-moving time was significantly reduced after training in all three groups: MT group (p < .001), MT-R group (p = .010), and VT group (p = .014), but the video group showed significantly greater relative improvements in motion variability (p = .030) and object prediction (p = .008).We concluded that MT was as effective as VT in improving movement speed, but, with these healthy young adults, MT was less effective than VT in learning speed control or hand pre-shaping to refine task movements for tool use.

Outcomes of Combined Visual and Auditive Stimulation on Functions of Hand and Grip Strengths in Patients with Hemiplegia

Background Stroke is a major ailment that results from hypoxia, ischemia, blockage, or hemorrhage. The recovery of hand functions is an essential goal in stroke patients' recovery.

Aim This study aimed to analyze the outcomes of rhythmic auditory stimulation (RAS) and mirror therapy on hand functions, as well as grip strength, in stroke patients.

Materials and Methods A quasiexperimental study has been used based on criteria of inclusion, 30 patients were enrolled. The participants were assigned to two groups, 15 patients each. Group A (control group) underwent traditional physiotherapy. Group B (experimental group) underwent RAS and mirror therapy. Both the groups received 20 minutes of treatment, 20 sessions in 1 month. The Action Research Arm Test (ARAT) and hand-held dynamometer were used to evaluate results. Paired t-test has been used to analyze the data with the SPSS software tool.

Results The paired t-test results showed that notable distinctions in ARAT mean pretest scores between two groups were not found. A notable change in ARAT results was present between the two groups with mean posttest score and difference in pretest to posttest. No notable distinctions in grip strength results were seen with mean pretest results. But a notable change was found in grip strength results among two groups with mean posttest scores.

Conclusion Combining RAS and mirror therapy programs has shown beneficial effects on hand functions, as well as grip strength of stroke patients and can be used as adjunct interventions along with conventional physiotherapy to encourage restoration of hand functions in hemiparetic patients.

Effects of a Virtual Reality-Based Mirror Therapy Program on Improving Sensorimotor Function of Hands in Chronic Stroke Patients: A Randomized Controlled Trial

Background. Embedding mirror therapy within a virtual reality (VR) system may have a superior effect on motor remediation for chronic stroke patients. Objective. The objective is to investigate the differences in the effects of using conventional occupational therapy (COT), mirror therapy (MT), and VR-based MT (VR-MT) training on the sensorimotor function of the upper limb in chronic stroke patients. Methods. This was a single-blinded randomized controlled trial. A total of 54 participants, including chronic stroke patients, were randomized into a COT, MT, or VR-MT group. In addition to 20-minute sessions of task-specific training, patients received programs of 30 minutes of VR-MT, 30 minutes of MT, and 30 minutes of COT, respectively, in the VR-MT, MT, and COT groups twice a week for 9 weeks. The Fugl-Meyer motor assessment for the upper extremities (FM-UE; primary outcome), Semmes-Weinstein monofilament, motor activity log, modified Ashworth scale, and the box and block test were recorded at pre-treatment, post-intervention, and 12-week follow-up. Results. Fifty-two participants completed the study. There was no statistically significant group-by-time interaction effects on the FM-UE score (generalized estimating equations, (GEE), P = .075). Meanwhile, there were statistically significant group-by-time interaction effects on the wrist sub-score of the FM-UE (GEE, P = .012) and the result of box and block test (GEE, P = .044). Conclusions. VR-MT seemed to have potential effects on restoring the upper extremity motor function for chronic stroke patients. However, further confirmatory studies are warranted for the rather weak evidence of adding VR to MT on improving primary outcome of this study. Clinical trial registration: NCT03329417.

Robotic Device for Out-of-Clinic Post-Stroke Hand Rehabilitation

Due to the ageing population and an increasing number of stroke patients, we see the potential future of rehabilitation in telerehabilitation, which might alleviate the workload of physiotherapists and occupational therapists. In order to enable the use of telerehabilitation, devices aimed for home and independent use need to be developed. This paper describes the design of a robotic device for post-stroke wrist and finger rehabilitation and evaluates the movement it can perform. Six healthy subjects were tested in three experimental conditions: performing a coupled movement of wrist and fingers from flexion to extension without the device, with a passive device, and with an active device. The kinematics of the hand were captured using three Optotrak Certus motion capture systems and tracking 11 infrared active light-emitting diode (LED) markers. The results are presented in the form of base-line trajectories for all middle finger (MF) joints. In addition, the deviations of trajectories between conditions across all subjects were computed for the metacarpophalangeal (MCP) joint and fingertip of the MF and pinkie (PF) finger. Deviations from the base-line trajectory between measurement protocols and the root-mean-square deviation (RMSD) values indicate that the motion of the hand, imposed by the developed device, is comparable to the unconstrained motion of the healthy subjects, especially when moving into the extension, opening the hand.

Transcranial Direct Current Stimulation and Mirror Therapy for Neuropathic Pain After Brachial Plexus Avulsion: A Randomized, Double-Blind, Controlled Pilot Study

Introduction: Although transcranial direct current stimulation (tDCS) and mirror therapy (MT) have benefits in combating chronic pain, there is still no evidence of the effects of the simultaneous application of these techniques in patients with neuropathic pain. This study aims to assess the efficacy of tDCS paired with MT in neuropathic pain after brachial plexus injury. Methods: In a sham controlled, double-blind, parallel-group design, 16 patients were randomized to receive active or sham tDCS administered during mirror therapy. Each patient received 12 treatment sessions, 30 min each, during a period of 4 weeks over M1 contralateral to the side of the injury. Outcome variables were evaluated at baseline and post-treatment using the McGill questionnaire, Brief Pain Inventory, and Medical Outcomes Study 36-Item Short-Form Health Survey. Long-term effects of treatment were evaluated at a 3-month follow-up. Results: An improvement in pain relief and quality of life were observed in both groups (p ≤ 0.05). However, active tDCS and mirror therapy resulted in greater improvements after the endpoint (p ≤ 0.02). No statistically significant differences in the outcome measures were identified among the groups at follow-up (p ≥ 0.12). A significant relationship was found between baseline pain intensity and outcome measures (p ≤ 0.04). Moreover, the results showed that state anxiety is closely linked to post-treatment pain relief (p ≤ 0.05). Conclusion: Active tDCS combined with mirror therapy has a short-term effect of pain relief, however, levels of pain and anxiety at the baseline should be considered. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04385030.

Effects of home-based mirror therapy and cognitive therapeutic exercise on the improvement of the upper extremity functions in patients with severe hemiparesis after a stroke: a protocol for a pilot randomised clinical trial

INTRODUCTION

Neuroplasticity is defined as the capacity of the brain to reorganise new neuronal pathways. Mirror therapy (MT) and cognitive therapeutic exercise (CTE) are two neurorehabilitation techniques based on neuroplasticity and designed to improve the motor functions of the affected upper extremity in patients with severe hemiparesis after a stroke. Home-based interventions are an appropriate alternative to promote independence and autonomy. The objective of this study is to evaluate which of these techniques, MT and CTE, combined with task-oriented training, is more effective in functional recovery and movement patterns of the upper extremities in patients with severe hemiparesis after a stroke.

METHODS AND ANALYSIS

This is a home-based, single-blind, controlled, randomised clinical trial with three parallel arms, including 154 patients who had a stroke aged above 18 years. The primary outcome will be the functionality of the affected upper extremity measured using the Fugl-Meyer Assessment. Secondary variables will include cognitive performance, emotional state, quality of life and activities of daily living. During 6 weeks, one of the intervention groups will receive a treatment based on MT and the other one on CTE, both combined with task-oriented training. No additional interventions will be provided to the control group. To assess the progress of patients who had a stroke in the subacute phase, all variables will be evaluated at different visits: initial (just before starting treatment and 4 weeks post-stroke), post-intervention (6 weeks after initial) and follow-up (6 months).

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board (CEIm-2.134/2.019) and registered at ClinicalTrials.gov (NCT04163666). The results will be disseminated through open-access peer-reviewed journals, conference presentation, broadcast media and a presentation to stakeholders. These study results will provide relevant and novel information on effective neurorehabilitation strategies and improve the quality of intervention programmes aimed at patients after a stroke.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT04163666).

Alternative Motor Task-Based Pattern Training With a Digital Mirror Therapy System Enhances Sensorimotor Signal Rhythms Post-stroke

Mirror therapy (MT) facilitates motor learning and induces cortical reorganization and motor recovery from stroke. We applied the new digital mirror therapy (DMT) system to compare the cortical activation under the three visual feedback conditions: (1) no mirror visual feedback (NoMVF), (2) bilateral synchronized task-based mirror visual feedback training (BMVF), and (3) reciprocal task-based mirror visual feedback training (RMVF). During DMT, EEG recordings, including time-dependent event-related desynchronization (ERD) signal amplitude in both mu and beta bands, were obtained from the standard C3 (ispilesional hemisphere, IH), C4 (contralesional hemisphere, CH), and Cz scalp sites (supplementary motor area, SMA). The entire ERD curve was separated into three time-phases: P0 (-2 to 0 s), P1 (0 to 2 s), and P2 (2 to 4 s). Four-way and subsequent repeated-measures analyses of variance were used to examine the effects of group (stroke vs. control group), test condition (NoMVF, BMVF, and RMVF), time-phase (P0, P1, and P2), and brain area (IH, CH, SMA) on the ERD areas (%) in mu and beta bands. For the mu band, generally, ERD areas (%) were larger in the control than in the stroke group. The ERD areas (%) were largest under the RMVF condition, followed by BMVF and NoMVF conditions. Similar results were found in the beta bands. The main effects of group, time-phase, and test condition on the ERD areas (%) were significant for the three brain areas, except the main effect of group in the SMA (Cz) and CH (C4) brain area. The ERD areas (%) were larger in the control than in the stroke group. The ERD area (%) was significantly larger during P1 than during P0 and P2 (ps < 0.02), and during P2 than during P0 (ps < 0.01). The ERD area (%) under the RMVF condition was significantly larger than that under the BMVF condition and NoMVF condition (ps < 0.05). The present study suggests that cortical activation particularly in the SMA (Cz) of the brain increases in the RMVF condition in both healthy subjects and stroke patients. This result supports the hypothesis that stroke patients may benefit from RMVF training.

Mirror Therapy and Task-Oriented Training for People With a Paretic Upper Extremity

OBJECTIVE

This study investigates the effect of mirror therapy and task-oriented training on the paretic upper extremity function and occupational performance of people with stroke.

METHOD

This study used a repeated-measures, case-series design in which 4 participants completed a 4-wk intervention consisting of mirror therapy and task-specific training. The intervention was conducted 2×/wk in the clinic and 4×/wk at home.

RESULTS

All participants displayed clinically meaningful improvements in self-identified goals at the end of the intervention and at follow-up. Three participants showed clinically meaningful changes in motor function. Although only 1 participant improved in his reported amount of use, all participants showed clinically meaningful improvements in perceived movement quality at varying points of assessment.

CONCLUSION

Mirror therapy, when used as priming for task-oriented training, can produce clinical improvements in upper extremity function and occupational performance in people with hemiparesis.

Efeitos da terapia espelho na recuperação motora e funcional do membro superior com paresia pós-AVC: uma revisão sistemática

RESUMO Após um acidente vascular cerebral (AVC), o membro superior pode apresentar déficits motores que podem levar a incapacidades funcionais. A terapia espelho (TE) é uma possibilidade terapêutica na reabilitação do membro superior (MS). Este estudo objetivou reunir evidências que pudessem mostrar quais são os efeitos da TE na recuperação motora e funcional do MS com paresia pós-AVC. Foi realizada uma busca eletrônica nas bases de dados SciELO, LILACS, PubMed, PEDro e ScienceDirect, utilizando como critérios de inclusão: ensaios clínicos, nos quais os indivíduos acima de 18 anos apresentassem AVC de qualquer etiologia e em qualquer tempo após a lesão encefálica, com sequela no MS; estudos publicados na íntegra em revistas indexadas nas bases supracitadas entre 2010 e 2015, nos idiomas inglês e português, que utilizassem a TE para reabilitação do MS de pacientes com AVC, apresentando como desfechos função motora e independência funcional. Os artigos resultantes foram avaliados pela escala PEDro quanto à qualidade metodológica. Treze ensaios clínicos avaliaram efeitos da TE no MS parético. Os testes mais utilizados foram escala de Fugl-Meyer e Medida de Independência Funcional. Nesses estudos, a TE foi eficaz na recuperação motora do MS e na independência funcional dos pacientes, especialmente nos quesitos transferências e autocuidados. Os artigos foram considerados de moderada a alta qualidade metodológica. Conclui-se que a TE promoveu melhora significativa da função motora e da independência funcional do MS parético pós-AVC independente do tempo decorrido após a lesão encefálica.