Combining Afferent Stimulation and Mirror Therapy for Improving Muscular, Sensorimotor, and Daily Functions After Chronic Stroke: A Randomized, Placebo-Controlled Study

Sensory Stimulation and Robot-Assisted Arm Training after Stroke: A Randomized Controlled Trial

BACKGROUND AND PURPOSE

Functional recovery after stroke is often limited, despite various treatment methods such as robot-assisted therapy. Repetitive sensory stimulation (RSS) might be a promising add-on therapy that is thought to directly drive plasticity processes. First positive effects on sensorimotor function have been shown. However, clinical studies are scarce, and the effect of RSS combined with robot-assisted training has not been evaluated yet. Therefore, our objective was to investigate the feasibility and sensorimotor effects of RSS (compared to a control group receiving sham stimulation) followed by robot-assisted arm therapy.

METHODS

Forty participants in the subacute phase (4.4-23.9 weeks) after stroke with a moderate to severe arm paresis were randomized to RSS or control group. Participants received 12 sessions of (sham-) stimulation within 3 weeks. Stimulation of the fingertips and the robot-assisted therapy were each applied in 45-min sessions. Motor and sensory outcome assessments (e.g. Fugl-Meyer-Assessment, grip strength) were measured at baseline, post intervention and at a 3-week follow-up.

RESULTS

Participants in both groups improved their sensorimotor function from baseline to post and follow-up measurements, as illustrated by most motor and sensory outcome assessments. However, no significant group effects were found for any measures at any time (P > 0.058). Stimulations were well accepted, no safety issues arose.

DISCUSSION AND CONCLUSIONS

Feasibility of robot-assisted therapy with preceding RSS in persons with moderate to severe paresis was demonstrated. However, RSS preceding robot-assisted training failed to show a preliminary effect compared to the control intervention. Participants might have been too severely affected to identify changes driven by the RSS, or these might have been diluted or more difficult to identify because of the additional robotic training and neurorehabilitation.

VIDEO ABSTRACT AVAILABLE

for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A478).

Indirect causal path from motor function to quality of life through daily use of the affected arm poststroke after task-specific training: a longitudinal mediation analysis

PURPOSE

Task-specific training generally targets motor function, with the ultimate goal of improving quality of life (QoL). This study aimed to determine whether motor function indirectly affects QoL through daily use of the affected arm and activities of daily living (ADL) in patients with chronic stroke.

METHODS

This was a retrospective cohort study of 155 patients who received training for 90-120 min/session, 3-5 sessions/week, for 4-6 weeks. The training involved specific mirror or robot-assisted therapy, followed by functional task practice for 15-30 min in each session. Patients were assessed before and after the intervention.

RESULTS

At both pre-test and post-test, significant indirect effects of motor function on QoL through daily use of the affect arm and ADL were observed (β = 0.087-0.124). When the change scores of the measures between the pre-test and post-test were used, significant mediating effects of daily arm use on the relationship between motor function and QoL were identified (β = 0.094-0.103).

CONCLUSIONS

Enhanced motor function after intervention may lead to an increase in arm use for daily activities and subsequently result in an improvement in QoL. These results highlight the critical role of daily arm use in task-specific training aimed at improving QoL.

Effects of mirror therapy with electrical stimulation for upper limb recovery in people with stroke: a systematic review and meta-analysis

PURPOSE

To provide updated evidence about the effects of MT with ES for recovering upper extremities motor function in people with stroke.

METHODS

Systematic review and meta-analysis were completed. Methodological quality was assessed using the version 2 of the Cochrane risk-of-bias tool. The GRADE approach was employed to assess the certainty of evidence.

RESULTS

A total of 16 trials with 773 participants were included in this review. The results demonstrated that MT with ES was more effective than sham (standardized mean difference [SMD], 1.89 [1.52-2.26]) and ES alone (SMD, 0.42 [0.11-0.73]) with low quality of evidence, or MT alone (SMD, 0.47[0.04-0.89]) with low quality of evidence for improving upper extremity motor control assessed using Fugl-Meyer Assessment. MT with ES had significant improvement of (MD, 6.47 [1.92-11.01]) the upper extremity gross gripping function assessed using the Action Research Arm Test compared with MT alone with low quality of evidence. MT combined with ES was more effective than sham group (SMD, 1.17 [0.42-1.93) for improving the ability to perform activities of daily living with low quality of evidence assessed using Motor Activity Log.

CONCLUSION

MT with ES may be effective in improving upper limb motor recovery in people with stroke.

Electromyographic biofeedback therapy for improving limb function after stroke: A systematic review and meta-analysis

BACKGROUND

Upper and lower limb impairment is common after stroke. Electromyographic biofeedback therapy is a non-invasive treatment, and its effectiveness in functional rehabilitation of the limb after stroke still remains uncertain.

OBJECTIVE

The objective of this study was to evaluate whether electromyographic biofeedback can improve upper and lower limb dysfunction in stroke patients.

METHODS

PubMed, Embase, Cochrane Library, and Physiotherapy Evidence Database (PEDro) were searched from inception to 1st May 2022. Inclusion criteria were randomized controlled clinical trials of electromyographic biofeedback therapy interventions reporting changes in upper and lower limb function in post-stroke patients. Data were extracted by two independent reviewers and pooled in random-effects models using Review manager (RevMan) software.

RESULTS

Our analyses included 10 studies enrolling a total of 303 participants. Electromyographic biofeedback therapy can effectively improve limb function after stroke (standardized mean difference [SMD], 0.44; 95% confidence interval [CI], 0.12-0.77; P = 0.008) and in subgroup analyses, the effect sizes of short-term effect (SMD, 0.33; 95% CI, 0.02-0.64; P = 0.04) was significant, but the long-term was not (SMD, 0.61; 95% CI, -0.11-1.33; P = 0.10). In addition, Electromyographic biofeedback therapy can improve the active range of motion of shoulder (SMD, 1.49; 95% CI, 2.22; P<0.0001) and wrist joints (SMD, 0.77; 95% CI, 0.13-1.42; P = 0.02) after stroke.

CONCLUSION

In this meta-analysis, electromyographic biofeedback therapy intervention can improve upper and lower limb function in patients with stroke. Short-term (less than one month) improvement after electromyographic biofeedback therapy was supported, while evidence for long-term (more than one month) benefits was lacking. Range of motion in the glenohumeral and wrist joints were improved. Stronger evidence for individualized parameters, such as optimal treatment parameters and intervention period, is needed in the future.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/display_record.php?recordID=267596], identifier [CRD42022354363].

Effects of robotic priming of bilateral arm training, mirror therapy, and impairment-oriented training on sensorimotor and daily functions in patients with chronic stroke: study protocol of a single-blind, randomized controlled trial

BACKGROUND

Combining robotic therapy (RT) with task-oriented therapy is an emerging strategy to facilitate motor relearning in stroke rehabilitation. This study protocol will compare novel rehabilitation regimens that use bilateral RT as a priming technique to augment two task-oriented therapies: mirror therapy (MT) and bilateral arm training (BAT) with a control intervention: RT combined with impairment-oriented training (IOT).

METHODS

This single-blind, randomized, comparative efficacy study will involve 96 participants with chronic stroke. Participants will be randomized into bilateral RT+MT, bilateral RT+BAT, and bilateral RT+IOT groups and receive 18 intervention sessions (90 min/day, 3 d/week for 6 weeks). The outcomes will include the Fugl-Meyer Assessment, Stroke Impact Scale version 3.0, Medical Research Council scale, Revised Nottingham Sensory Assessment, ABILHAND Questionnaire, and accelerometer and will be assessed at baseline, after treatment, and at the 3-month follow-up. Analysis of covariance and the chi-square automatic interaction detector method will be used to examine the comparative efficacy and predictors of outcome, respectively, after bilateral RT+MT, bilateral RT+BAT, and bilateral RT+IOT.

DISCUSSION

The findings are expected to contribute to the research and development of robotic devices, to update the evidence-based protocols in postacute stroke care programs, and to investigate the use of accelerometers for monitoring activity level in real-life situations, which may in turn promote home-based practice by the patients and their caregivers. Directions for further studies and empirical implications for clinical practice will be further discussed in upper-extremity rehabilitation after stroke.

TRIAL REGISTRATION

This trial was registered December 12, 2018, at www.

CLINICALTRIALS

gov ( NCT03773653 ).

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.

Mirror Therapy Rehabilitation in Stroke: A Scoping Review of Upper Limb Recovery and Brain Activities

Background

Mirror therapy (MT) has been used as a treatment for various neurological disorders. Recent application of electroencephalogram (EEG) to the MT study allows researchers to gain insight into the changes in brain activity during the therapy.

Objective

This scoping review is aimed at mapping existing evidence and identifying knowledge gaps about the effects of MT on upper limb recovery and its application for individuals with chronic stroke.

Methods and Materials

A scoping review through a systematic literature search was conducted using PubMed, CINAHL, PsycINFO, and Scopus databases. Twenty articles published between 2010 and 2020 met the inclusion criteria. The efficacy of MT on upper limb recovery and brain activity during MT were discussed according to the International Classification of Functioning, Disability and Health (ICF).

Results

A majority of the studies indicated positive effects of MT on upper limb recovery from the body structure/functional domain. All studies used EEG to indicate brain activation during MT.

Conclusion

MT is a promising intervention for improving upper limb function for individuals with chronic stroke. This review also highlights the need to incorporate EEG into the MT study to capture brain activity and understand the mechanism underlying the therapy.

Occupational Therapy and the IMPACT Act: Part 2. A Systematic Review of Evidence for Functional Status, Medication Reconciliation, and Skin Integrity Interventions

IMPORTANCE

Interventions that promote function, medication reconciliation, and skin integrity assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing health care costs.

OBJECTIVE

In this systematic review, we focus on three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: functional status, medication reconciliation, and skin integrity.

DATA SOURCES

We conducted a search of the literature published between 2009 and 2019 in CINAHL, Cochrane, MEDLINE, PsycINFO, OTseeker, and Scopus. We also hand searched the systematic reviews and meta-analyses in our search results for articles that met our inclusion criteria. Study Selection and Data Collection: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

FINDINGS

We found 47 articles that address the three outcome areas. Regarding functional status, low strength of evidence is available for cognition and functional mobility interventions to support functional performance, moderate strength of evidence supports interventions for vision, and moderate evidence supports task-oriented and individualized interventions to promote activities of daily living (ADL) outcomes among people with neurological conditions. Strong strength of evidence supports individualized occupational therapy interventions focusing on medication adherence. Low strength of evidence was found for occupational therapy interventions to reduce pressure ulcers and promote skin integrity. Conclusion and Relevance: The evidence supports occupational therapy interventions to improve functional status in ADLs and medication management. Additional research is needed that examines the outcomes of occupational therapy interventions for other areas of function and skin integrity. What This Article Adds: We found evidence to support occupational therapy interventions that align with value-based measures in the three outcome areas of interest. The effectiveness of these interventions highlights the viability of occupational therapy as an essential profession and the worth of occupational therapy to the public, potential clients, and payers.

Sensory-Based Priming for Upper Extremity Hemiparesis After Stroke: A Scoping Review

Sensory priming is a technique to facilitate neuroplasticity and improve motor skills after injury. Common sensory priming modalities include peripheral nerve stimulation/somatosensory electrical stimulation (PNS/SES), transient functional deafferentation (TFD), and vibration. The aim of this study was to determine whether sensory priming with a motor intervention results in improved upper limb motor impairment or function after stroke. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and EMBASE were the databases used to search the literature in July 2020. This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and recommendations for the Cochrane collaboration. In total, 30 studies were included in the analysis: three studies examined TFD, 16 examined PNS/SES, 10 studied vibration, and one combined the three stimulation techniques. Most studies reported significant improvements for participants receiving sensory priming. Given the low risk, it may be advantageous to use sensory-based priming prior to or concurrent with upper limb training after stroke.

Influence of Mirror Therapy (Specular Face Software) on Electromyographic Behavior of the Facial Muscles for Facial Palsy

Introduction: Facial paralysis (FP) is a neuromuscular disorder caused by facial nerve injury. There are two main types of FP (which can be either primary or secondary): central and peripheral; Procedure of cases: This case series presents five patients with facial paralysis with different etiologies. In all cases, we assessed the facial disability index and a clinical test registering the electromyographic activity, with and without biofeedback generated by Specular Face, a new software program; Discussion: After performing the appropriate tests, we checked the patients' ability to change certain expressions when the Specular Face program was added. We can confirm that the mirror visual feedback therapy changes the behavior of synkinesis and the muscle function in these patients; Conclusion: The use of mirror therapy using a computerized treatment system of facial images yields promising results in modulating the muscle activity of patients with FP.

Synergistic Effect of Combined Mirror Therapy on Upper Extremity in Patients With Stroke: A Systematic Review and Meta-Analysis

Background: There is an increasing trend for researchers to combine mirror therapy with another rehabilitation therapy when treating the upper extremity of patients with stroke.

Objective: To evaluate the synergistic effect of combined mirror therapy (MT) on the upper extremity in patients with stroke and to judge efficacies of four combined mirror therapy subgroups [EMGBF group: electromyographic biofeedback (EMGBF) + MT; MG group: mesh glove (MG) + MT; AT group: acupuncture (AT) + MT; ES group: EMG-triggered electrical stimulation (ES) + MT].

Methods: CNKI, Wan Fang, VIP, Web of Science, ScienceDirect, PubMed, OVID LWW, and Cochrane were used. We searched these databases for randomized controlled trials published from January 2013 to August 2019, which presented results of combining mirror therapy with other rehabilitation therapies. Quality assessments were performed using the Cochrane Handbook criteria in order to accurately review interventions. The primary outcomes were measured by the Fugl–Meyer Assessment—upper extremity (FMA-UE).

Results: Ten trials, with a total of 444 patients whose upper limb functions were damaged after stroke, were included in the meta-analysis. Compared with the control group, a remarkable effect of combined mirror therapy [all: weight mean difference in random effects model (WMD): 8.07, 95% confidence interval (CI) 5.87, 10.26] on functional recovery of the upper limb was detected. However, a high value of heterogeneity (χ2 = 20.09, df = 9; I² = 55%) was found. The subgroup analysis (EMGBF group: WMD = 8.95, 95% CI 6.33, 11.58; ES group: WMD = 10.14, 95% CI: 5.67, 15.01) showed moderate improvement in functional recovery of the upper extremity in patients with stroke when mirror therapy was combined with conventional therapy. Furthermore, no difference in efficacy on upper extremity in patients with stroke was observed between the EMGBF group and the ES group.

Conclusion: Despite the heterogeneity, the results indicate that combining mirror therapy with another rehabilitation therapy on the upper extremity in patients with stroke is better than single rehabilitation therapy. However, more randomized controlled clinical trials and larger sample sizes are required for an in-depth meta-analysis.

The Priming Effects of Mirror Visual Feedback on Bilateral Task Practice: A Randomized Controlled Study

The priming effect of mirror visual feedback can be simply provided by inexpensive mirror therapy (MT), which exhibits beneficial effects on sensorimotor recovery in stroke. The present study was a single-blind pretest-posttest study that examined whether the priming effect of mirror visual feedback on bilateral task practice would render better outcomes. Twenty-three patients with chronic stroke were randomized to receive hospital-based task-oriented MT or bilateral arm training (BAT) for 4 weeks at 90 minutes/day, 3 days/week and a home practice for 30-40 minutes/day, 5 days/week. There was the potential trend for MT to improve temperature sense as measured by the revised Nottingham Sensory Assessment (Cohen's d = 1.00; 95% confidence interval, -0.09 to 2.09), and MT increased the Stroke Impact Scale 3.0 total score (d = 0.89; 0.003 to 1.71). MT also showed a trend for greater improvements in the Motor Activity Log (amount of use: d = 0.62; -0.24 to 1.44; quality of movement: d = 0.50; -0.35 to 1.31). MT involving bilateral movement practice with the priming effect of mirror visual feedback may render beneficial effects. The unilateral approach or MT augmented by extra feedback might be appropriate modifications.

Median nerve stimulation induced motor learning in healthy adults: A study of timing of stimulation and type of learning

Median nerve stimulation (MNS) has been shown to change brain metaplasticity over the somatosensory networks, based on a bottom-up mechanism and may improve motor learning. This exploratory study aimed to test the effects of MNS on implicit and explicit motor learning as measured by the serial reaction time task (SRTT) using a double-blind, sham-controlled, randomized trial, in which participants were allocated to one of three groups: (a) online active MNS during acquisition, (b) offline active MNS during early consolidation and (c) sham MNS. SRTT was performed at baseline, during the training phase (acquisition period), and 30 min after training. We assessed the effects of MNS on explicit and implicit motor learning at the end of the training/acquisition period and at retest. The group receiving online MNS (during acquisition) showed a significantly higher learning index for the explicit sequences compared to the offline group (MNS during early consolidation) and the sham group. The offline group also showed a higher learning index as compared to sham. Additionally, participants receiving online MNS recalled the explicit sentence significantly more than the offline MNS and sham groups. MNS effects on motor learning have a specific effect on type of learning (explicit vs. implicit) and are dependent on timing of stimulation (during acquisition vs. early consolidation). More research is needed to understand and optimize the effects of peripheral electrical stimulation on motor learning. Taken together, our results show that MNS, especially when applied during the acquisition phase, is a promising tool to modulate motor leaning.