Maximum tolerable daily dose of mirror movement therapy ankle exercises after stroke: an early phase dose screening study

BACKGROUND

Mirror movement therapy may reduce lower limb motor impairment after stroke. The dose is unknown.

OBJECTIVE

identify the maximum tolerable dose a day (MTD) of lower limb mirror movement therapy DESIGN: 3 + 3 cohort rule-based, dose escalation/de-escalation study. After undertaking baseline measures participants performed mirror movement therapy for 14 consecutive days. Participants then undertook outcome measures. Cohort One trained for 15 minutes daily. Subsequent cohorts exercised at a dose set according to pre-set rules and the modified Fibonacci sequence. The study stopped when the difference between set doses for consecutive cohorts was 10% or less.

SETTING

Participants' homes (intervention) and a movement analysis laboratory (measures).

PARTICIPANTS

Adults discharged from statutory stroke rehabilitation services.

INTERVENTION

Mirror movement therapy ankle exercises.

OUTCOME MEASURES

Motricity Index (primary) and bilateral time symmetry from movement onset to peak activation of Tibialis Anterior muscles during standardised sit-to-stand (secondary).

RESULTS

Five cohorts of three participants were included (n = 15). Mean (SD) age and time after stroke were 61 (9) years and 35 (42) months respectively. Set daily doses for the five cohorts were: 15, 30, 50, 40 then 35 minutes. The set dose for a subsequent cohort (six) would have been 38 minutes thus the difference from cohort five would have been three minutes i.e., 9% different. Therefore, the study stopped CONCLUSION: The identified MTD of lower limb mirror therapy was 35 minutes daily when frequency was set at seven days a week and duration as two weeks.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04339803 (ClinicalTrials.gov) CONTRIBUTION OF THE PAPER: This early phase study found that the maximum tolerable dose per day (MTD) of mirror movement therapy ankle exercises was 35 minutes when frequency was set at seven days a week and duration as two weeks. The optimal therapeutic dose will therefore be somewhere in the range of 15 (starting dose) to 35 minutes per day. Further dose articulation studies are required to identify the optimal therapeutic dose before use of findings in clinical practice. This study is the first step in that research process.

Mirror therapy combined with neuromuscular electrical stimulation for poststroke lower extremity motor function recovery: a systematic review and meta-analysis

The combination of mirror therapy (MT) and neuromuscular electrical stimulation (NMES) has been devised as an intervention method in stroke rehabilitation; however, few studies have investigated its efficacy in lower extremity motor function recovery. In this systematic review and meta-analysis, we examined the effectiveness of combined MT and NMES therapy in improving poststroke walking speed, spasticity, balance and other gait parameters. Randomized controlled trials (RCTs) were selected from PubMed, Cochrane Library, EMBASE, and Scopus databases. In total, six RCTs which involving 181 participants were included. Our findings indicate that MT combined with NMES elicits greater improvement relative to control group in walking speed (SMD = 0.67, 95% confidence interval [CI] 0.26-1.07, P = 0.001), Berg Balance Scale (SMD = 0.72; 95% CI 0.31-1.13; P = 0.0007), cadence (SMD = 0.59, 95% CI 0.02-1.16, P = 0.04), step length (SMD = 0.94, 95% CI 0.35-1.53, P = 0.002), and stride length (SMD = 0.95, 95% CI 0.36-1.54, P = 0.002) but not in modified Ashworth scale (SMD =  - 0.40, 95% CI - 1.05 to 0.26, P = 0.23). Our findings suggest that MT combined with NMES may be a suitable supplemental intervention to conventional therapy in stroke survivors.

Treatment effects of low-frequency repetitive transcranial magnetic stimulation combined with motor relearning procedure on spasticity and limb motor function in stroke patients

Objective

Limb paralysis, which is a sequela of stroke, limits patients' activities of daily living and lowers their quality of life. The purpose of this study was to investigate the effects of repetitive transcranial magnetic stimulation (rTMS) combined with a motor relearning procedure (MRP) on motor function and limb spasticity in stroke patients.

Methods

Stroke patients were randomly divided into a combined treatment group (rTMS + MRP) and a control group (MRP) (n = 30 per group). The control group was given MRP in addition to conventional rehabilitation, and the combined treatment group was given 1 Hz rTMS combined with MRP. The treatment efficacy was assessed by the modified Ashworth scale (MAS), Fugl-Meyer motor function scale, and motor evoked potential (MEP) testing.

Results

After 4 weeks of treatment, the Brunnstrom score, Fugl-Meyer lower extremity motor function, and Fugl-Meyer balance function were significantly higher in the combination treatment group compared to the control group, while the MAS score was lower in the combination treatment group compared to the control group. The MEP extraction rate was higher in the combined treatment group compared to the control group, while the threshold and central motor conduction time (CMCT) were lower in the combined treatment group compared to the control group.

Conclusion

Low-frequency rTMS combined with MRP had better efficacy on spasticity and motor function in stroke patients with hemiparesis than MRP alone.

Synergic effect of the combination of mirror therapy and electrical stimulation for lower extremity motor function recovery in stroke survivors: a meta-analysis of randomized controlled trials

OBJECTIVES

To explore the synergic effect of the combination of mirror therapy and electrical stimulation on lower limb motor function recovery in stroke survivors.

MATERIALS AND METHODS

PubMed, Web of Science, Embase, Cochrane Library, CINAHL, CNKI, Wan Fang, CBM were searched from inception to December 2020. Randomized controlled trials that compared the combined therapy with another single therapy were included. A pre-determined data collection form was used to extract data. Two authors independently extracted data and used the Cochrane Handbook criteria to assess the quality of included studies.

RESULTS

Six studies, with a total of 437 patients were included. There was an overall positive effect on lower limb motor function recovery, according to Fugl-Meyer Assessment for the Lower Extremity [all: WMD in fixed effects model: 5.63, 95% CI 4.86, 6.39] and Brunnstrom stage [all: WMD in fixed effects model: 0.49, 95% CI 0.32, 0.66].

CONCLUSIONS

The results indicate that the combination of mirror therapy and electrical stimulation for lower extremity motor function recovery in stroke survivors may have a positive effect.

The Development of Hindlimb Postural Asymmetry Induced by Focal Traumatic Brain Injury Is Not Related to Serotonin 2A/C Receptor Expression in the Spinal Cord

Brain injury and stroke are leading causes of adult disability. Motor deficits are common problems, and their underlying pathological mechanisms remain poorly understood. The serotoninergic system is implicated in both functional recovery from and the occurrence of spasticity after injuries to the central nervous system. This study, which was conducted on rats, investigated the development of limb postural changes and their relationship to the expression of serotonin (5-HT) 2A and 2C receptors in the spinal cord in the 4 weeks after focal traumatic brain injury (TBI) to the right hindlimb sensorimotor cortex. The limb motor deficits were assessed by measuring gait pattern changes during walking and hindlimb postural asymmetry at different time intervals (3−28 days) after surgery. The expressions of the 5-HT2A and 2C receptors in the lumbar spinal cord were investigated using immunohistochemistry. The results showed that all the rats with TBI, independently of the duration of the interval, displayed postural asymmetry with flexion on the contralateral (left) side (>2 mm), while the sham-operated rats showed no apparent postural asymmetry. The TBI rats also had longer stride lengths during walking in both their hindlimbs and their forelimbs compared with the sham rats. For both the TBI and the sham rats, the hind-paw placement angles were larger on the contralateral side in some of the groups. Compared to the sham-operated rats, the 5-HT2A and 2C receptor expression did not significantly change on either side of the lumbar spinal cords of the TBI rats in any of the groups. These results suggest that focal TBI can induce motor deficits lasting a relatively long time, and that these deficits are not related to the expression of the 5-HT2A and 2C receptors in the spinal cord.

Effect and mechanism of mirror therapy on lower limb rehabilitation after ischemic stroke: A fMRI study

BACKGROUND

Mirror therapy has been gradually adopted for lower limb rehabilitation, but its efficacy and neural mechanism are not well understood.

OBJECTIVE

This study aims to investigate the effect and neural mechanism of mirror therapy on lower limb rehabilitation after ischemic stroke by using resting state functional magnetic resonance imaging (rs-fMRI).

METHODS

A single-blind and randomized controlled pilot study was conducted. 32 patients with ischemic stroke were included in this study and randomly divided into two groups - the control group (CT, n = 16) and the mirror therapy group (MT, n = 16). Both the CT and MT groups received medication and routine rehabilitation training. In addition, mirror therapy was added to the MT group 5 times a week for 30 minutes each time over a period of 3 weeks. Patients' motor functions, functional connectivity (FC), regional homogeneity (ReHo), and fractional amplitude of low-frequency fluctuations (fALFF) were analyzed both before and immediately after the treatment.

RESULTS

Patients' motor functions showed significant improvement in both groups compared to those before treatment (p <  0.01). Moreover, the MT group showed significantly better improvement than the CT group after the treatment (p <  0.05). FC, ReHo and fALFF indicated enhanced neuronal activities in motor function-related brain regions in the MT group compared to the CT group.

CONCLUSION

Mirror therapy promotes the recovery of lower limb motor functions in patients with ischemic stroke. Through the comparative rs-fMRI analysis, it is found that the mirror therapy promotes the functional reorganization of the injured brain.

Longitudinal Changes in Temporospatial Gait Characteristics during the First Year Post-Stroke

Given the paucity of longitudinal data in gait recovery after stroke, we compared temporospatial gait characteristics of stroke patients during subacute (<2 months post-onset, T0) and at approximately 6 and 12 months post-onset (T1 and T2, respectively) and explored the relationship between gait characteristics at T0 and the changes in gait speed from T0 to T1. Forty-six participants were assessed at T0 and a subsample of twenty-four participants were assessed at T2. Outcome measures included Fugl-Meyer lower-extremity motor score, 14 temporospatial gait parameters, and symmetry indices of 5 step parameters. Except for step width, all temporospatial parameters improved from T0 to T1 (p ≤ 0.0001). Additionally, significant improvements in symmetry were found for the initial double-support time and single-support time (p ≤ 0.0001). As a group, no significant differences were found between T1 and T2 in any of the temporospatial measures. However, the individual analysis revealed that 42% (10/24) of the subsample showed a significant increase in gait speed (Welch’s t-test, p ≤ 0.002). Yet, only 5/24 (21%) of the participants improved speed from T1 to T2 according to speed-based minimum detectable change criteria. The increase in gait speed from T0 to T1 was negatively correlated with gait speed and stride length and positively correlated with the symmetry indices of stance and single-support times at T0 (p ≤ 0.002). Temporospatial gait parameters and stance time symmetry improved over the first 6 months after stroke with an apparent plateau thereafter. A greater increase in gait speed during the first 6 months post-stroke is associated with initially slower walking, shorter stride length, and more pronounced asymmetry in stance and single-support times. The improvement in lower-extremity motor function and bilateral improvements in step parameters collectively suggest that gait changes over the first 6 months after stroke are likely due to a combination of neurological recovery, compensatory strategies, and physical therapy received during that time.

The efficiency of mirror therapy on drop foot in Multiple Sclerosis Patients

INTRODUCTION

Although the effectiveness of mirror therapy (MT) has been proved in stroke persons, there is no scientific evidence about the results in people with multiple sclerosis. The aim was to investigate whether adding MT to exercise training and neuromuscular electrical stimulation (NMES) has any effect on clinical measurements, mobility, and functionality in people with multiple sclerosis (MS).

METHODS

Ambulatory people with MS, with unilateral drop foot, were included. MT group (n = 13) applied bilateral ankle exercise program with mirror following NMES for 3 days a week at hospital and exercise program for 2 days a week at home. Control group (n = 13) performed same treatment without mirror box (6 weeks). The later 6 weeks both groups performed only exercise program. Clinical measurements included proprioception, muscle tone of plantar flexor muscles (MAS), muscle strength of dorsiflexor, ankle angular velocity, and range of motion (ROM) of ankle. Functionality (Functional Independence Measurement-FIM), mobility (Rivermead Mobility Index-RMI), ambulation (Functional Ambulation Scale-FAS), duration of stair climb test, and 25-foot walking velocity were assessed at the beginning, in 6th and 12th weeks.

RESULTS

More positive improvements were obtained in MT group than control group in terms of range of motion (0.012), muscle strength (0.008), proprioception (0.001), 25 feet walking duration (0.015), step test duration (0.001), FAS (0.005), RMI (0.001), and FIM (0.001) after 6 weeks treatment. It was seen that this improvement maintained to 12th week on all clinical and functional measurements (p < .05).

CONCLUSION

The trial revealed that adding MT to exercise training and NMES has more beneficial effects on clinical measurements, mobility, and functionality in people with multiple sclerosis with unilateral drop foot.

Effects of Mirror Therapy Combined with EMG-Triggered Functional Electrical Stimulation to Improve on Standing Balance and Gait Ability in Patient with Chronic Stroke

This study was performed to evaluate the effects of EMG-triggered functional electrical stimulation on balance and gait ability on patient with Chronic Stroke. A total of 60 chronic stroke patients were divided into mirror treatment and functional electrical (MT-EF) Group, MT group, CON group. Each group performed 60 min a day five times a week for eight weeks. MT-FE group was performed 30 min five times a week for eight weeks in mirror therapy process with EMG-FES. MT group performed 30 min five times a week for eight weeks in mirror therapy process. CON group was performed 30 min five times a week for eight weeks in conservative treatment. To measure the balance ability, Biorescue (COP, LOS), Berg balance scale (BBS) and FRT, and the gait ability test was performed by 10 m walk test. MT-FE group revealed significant differences in COP, LOS, BBS, FRT and 10 m walk test as compared to the MT and CON groups (p < 0.05). Our results showed that MT-FE was more effective on COP, LOS, BBS, FRT and 10 m walk test in patients with chronic stroke. Our results also showed that MT-EF group was more effective on balance and gait ability in patients with chronic stroke. We suggest that this study can be used for intervention data for recovering balance and gait ability in chronic stroke patients.

Motor imagery for gait rehabilitation after stroke

BACKGROUND

Motor imagery (MI) is defined as a mentally rehearsed task in which movement is imagined but is not performed. The approach includes repetitive imagined body movements or rehearsing imagined acts to improve motor performance.

OBJECTIVES

To assess the treatment effects of MI for enhancing ability to walk among people following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group registry, CENTRAL, MEDLINE, Embase and seven other databases. We also searched trial registries and reference lists. The last searches were conducted on 24 February 2020.

SELECTION CRITERIA

Randomized controlled trials (RCTs) using MI alone or associated with action observation or physical practice to improve gait in individuals after stroke. The critical outcome was the ability to walk, assessed using either a continuous variable (walking speed) or a dichotomous variable (dependence on personal assistance). Important outcomes included walking endurance, motor function, functional mobility, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials according to pre-defined inclusion criteria, extracted the data, assessed the risk of bias, and applied the GRADE approach to evaluate the certainty of the evidence. The review authors contacted the study authors for clarification and missing data.

MAIN RESULTS

We included 21 studies, involving a total of 762 participants. Participants were in the acute, subacute, or chronic stages of stroke, and had a mean age ranging from 50 to 78 years. All participants presented at least some gait deficit. All studies compared MI training versus other therapies. Most of the included studies used MI associated with physical practice in the experimental groups. The treatment time for the experimental groups ranged from two to eight weeks. There was a high risk of bias for at least one assessed domain in 20 of the 21 included studies. Regarding our critical outcome, there was very low-certainty evidence that MI was more beneficial for improving gait (walking speed) compared to other therapies at the end of the treatment (pooled standardized mean difference (SMD) 0.44; 95% confidence interval (CI) 0.06 to 0.81; P = 0.02; six studies; 191 participants; I² = 38%). We did not include the outcome of dependence on personal assistance in the meta-analysis, because only one study provided information regarding the number of participants that became dependent or independent after interventions. For our important outcomes, there was very low-certainty evidence that MI was no more beneficial than other interventions for improving motor function (pooled mean difference (MD) 2.24, 95% CI -1.20 to 5.69; P = 0.20; three studies; 130 participants; I² = 87%) and functional mobility at the end of the treatment (pooled SMD 0.55, 95% CI -0.45 to 1.56; P = 0.09; four studies; 116 participants; I² = 64.2%). No adverse events were observed in those studies that reported this outcome (seven studies). We were unable to pool data regarding walking endurance and all other outcomes at follow-up.

AUTHORS' CONCLUSIONS

We found very low-certainty evidence regarding the short-term benefits of MI on walking speed in individuals who have had a stroke, compared to other therapies. Evidence was insufficient to estimate the effect of MI on the dependence on personal assistance and walking endurance. Compared with other therapies, the evidence indicates that MI does not improve motor function and functional mobility after stroke (very low-certainty evidence). Evidence was also insufficient to estimate the effect of MI on gait, motor function, and functional mobility after stroke compared to placebo or no intervention. Motor Imagery and other therapies used for gait rehabilitation after stroke do not appear to cause significant adverse events.

Effectiveness of a home-based exercise program among patients with lower limb spasticity post-stroke: A randomized controlled trial

PURPOSE

To evaluate the effectiveness of advanced practice nurse-guided home-based rehabilitation exercise program (HREPro) among patients with lower limb spasticity post-stroke.

METHODS

This randomized controlled study recruited 121 patients with lower limb spasticity post-stroke. Intervention (n = 59) and control (n = 62) groups underwent 12-month HREPro and conventional rehabilitation, respectively, after discharge. The Fugl-Meyer assessment of spasticity measurement, modified Ashworth scale of motor function, 10-Meter Walk Test of walking ability, and Barthel index of activities of daily living (ADL) were evaluated at 0, 3, 6, and 12 months after discharge.

RESULTS

Significant differences were found in spasticity degree, motor function, walking ability, and ADL at 6 and 12 months after discharge between the control and intervention groups. Lower limb spasticity and ADL in the intervention group were significantly improved.

CONCLUSION

HREPro is effective for rehabilitation of patients with lower limb spasticity post-stroke and has favorable home application.

Mirror Therapy in Stroke Rehabilitation: Current Perspectives

In contrast to varied therapy approaches, mirror therapy (MT) can be used even in completely plegic stroke survivors, as it uses visual stimuli for producing a desired response in the affected limb. MT has been studied to have effects not just on motor impairments but also on sensations, visuospatial neglect, and pain after stroke. This paper attempts to systematically review and present the current perspectives on mirror therapy and its application in stroke rehabilitation, and dosage, feasibility and acceptability in stroke rehabilitation. An electronic database search across Google, PubMed, Web of Science, etc., generated 3871 results. After screening them based on the inclusion and exclusion criteria, we included 28 studies in this review. The data collected were divided on the basis of application in stroke rehabilitation, modes of intervention delivery, and types of control and outcome assessment. We found that most studies intervened for upper limb motor impairments post stroke. Studies were equally distributed between intervention in chronic and acute phases post stroke with therapy durations lasting between 1 and 8 weeks. MT showed definitive motor and sensory improvements although the extent of improvements in sensory impairments and hemineglect is limited. MT proves to be an effective and feasible approach to rehabilitate post-stroke survivors in the acute, sub-acute, and chronic phases of stroke, although its long-term effects and impact on activities of daily living need to be analysed extensively.

Investigation of the effects of mirror therapy on the spasticity, motor function and functionality of impaired upper limbs in chronic stroke patients

Background/Aims

Strokes lead to different levels of disability. During the chronic stage, hemiparesis, spasticity and motor deficits may cause loss of functional independence. Mirror therapy aims to reduce deficits and increase functional recovery of the impaired upper limb. This study aimed to evaluate the effects of mirror therapy on upper limb spasticity and motor function, as well as its impact on functional independence in chronic hemiparetic patients.

Methods

In this quasi-experimental study, eight chronic hemiparetic patients (age 55.5 ± 10.8 years) were assessed to determine their degree of spasticity (Modified Ashworth Scale), level of upper limb motor function (Fugl-Meyer Assessment) and functionality (Functional Independence Measure). All participants received 12 sessions of mirror therapy delivered three times per week, over a period of 4 weeks. Participants were re-evaluated post-intervention and these results were compared to their pre-intervention scores to determine the impact of mirror therapy.

Results

A decrease in spasticity was observed, with significant improvements in shoulder extensors (P=0.033) and a significant increase in motor function (P=0.002). The therapeutic protocol adopted did not have a significant effect on functional independence (P=0.105).

Conclusions

Mirror therapy led to improvements in upper limb spasticity and motor function in chronic hemiparetic stroke patients. No effects on functional independence were observed. Further research with a larger number of patients is needed to provide more robust evidence of the benefits of mirror therapy in chronic hemiparetic stroke patients.

Effects of mirror therapy on muscle activity, muscle tone, pain, and function in patients with mutilating injuries: A randomized controlled trial

BACKGROUND

This study assessed the effectiveness of mirror therapy (MT) on muscle elasticity, pain, and function in patients with mutilating injuries.

METHODS

Thirty patients with impaired function due to mutilating injuries were assigned randomly to experimental or control group. The experimental group (n = 15) received MT (30 minutes a day, 3 days a week for 4 weeks) and conventional physical therapy after each MT session while the control group (n = 15) only received conventional physical therapy.

RESULTS

There were significant differences in pain and hand function within each group (pre-intervention vs post-intervention) and between groups (experimental vs control) (P < .05). However, there was no significant difference in muscle elasticity between groups (P > .05).

CONCLUSION

Although MT cannot result in significant changes in muscle elasticity in a clinical setting, it does have positive effects by reducing pain and improving hand function. Thus, MT can be effective for patients with impaired function due to mutilating injuries.

Effect of afferent electrical stimulation with mirror therapy on motor function, balance, and gait in chronic stroke survivors: a randomized controlled trial

BACKGROUND

When solely mirror therapy is applied for a long period of time, spatial perception and attention to the damaged side may decrease, and the effect of mirror therapy may be limited. To overcome this limitation, it has recently been suggested that the combination of mirror therapy with mirror treatment is effective.

AIM

The aim of this study was to investigate the effects of afferent electrical stimulation with mirror therapy on motor function, balance, and gait in chronic stroke survivors.

DESIGN

A randomized controlled trial.

SETTING

Rehabilitation center.

POPULATION

Thirty stroke survivors were randomly assigned to two groups: the experimental group (N.=15) and the control group (N.=15).

METHODS

Participants of the experimental group received afferent electrical stimulation with mirror therapy, and participants of the control group received sham afferent electrical stimulation with sham mirror therapy for 60 minutes per day, 5 days per week, for 4 weeks. Motor function was measured using a handheld dynamometer and the Modified Ashworth Scale, balance was measured using the Berg Balance Scale, and gait was assessed using the GAITRite® (GAITRite, CIR System Inc., Franklin, NJ, USA) pressure-sensitive walkway at baseline and after 4 weeks.

RESULTS

The experimental group showed significant differences in muscle strength, Modified Ashworth Scale, and Berg Balance Scale results, and velocity, cadence, step length, stride length, and double support time of their gait (P<0.05) in the pre-post intervention comparison. Significant differences between the two groups in muscle strength, Berg Balance Scale, gait velocity, step length, and stride length (P<0.05) were found.

CONLCUSIONS

Mirror therapy with afferent electrical stimulation may effectively improve muscle strength and gait and balance abilities in hemiplegic stroke survivors.

CLINICAL REHABILITATION IMPACT

Afferent electrical stimulation combined with mirror therapy can be used as an effective intervention to improve lower limb motor function, balance, and gait in chronic stroke survivors in clinical settings.

The effects of mirror neuron system-based self-observation training on lower limb muscle activity and dynamic balance in patients with chronic stroke

[Purpose] This study aimed to investigate the effects of mirror neuron system-based self-observation training on lower limb muscle activity and dynamic balance in patients with chronic stroke. [Participants and Methods] Twenty patients with chronic stroke were randomly assigned to a self-observation training group (n=10) or a control group (n=10). Both groups followed a routine 30-minute exercise therapy regimen five days a week for four weeks. The self-observation training group additionally watched video clips of their balance and functional gait training and performed physical training twice over a 10-minute time span. Each self-observation training session was performed for 30 minutes, three times a week for four weeks. Muscle activity was evaluated using surface electromyography; dynamic balance was evaluated using timed up and go and 10-meterwalk tests. [Results] Within-group comparisons showed significant differences in muscular activities of the rectus femoris, biceps femoris, tibialis anterior, and gastrocnemius and dynamic balance. Comparing between groups, the muscle activity of the rectus femoris, biceps femoris, tibialis anterior, and gastrocnemius and dynamic balance were significantly different between experimental and control groups. [Conclusion] Self-observation training improved lower limb muscle activity and dynamic balance in patients with chronic stroke.

The Efficacy of Lower Extremity Mirror Therapy for Improving Balance, Gait, and Motor Function Poststroke: A Systematic Review and Meta-Analysis

BACKGROUND

Mirror therapy is less commonly used to target the lower extremity after stroke to improve outcomes but is simple to perform. This review and meta-analysis aimed to evaluate the efficacy of lower extremity mirror therapy in improving balance, gait, and motor function for individuals with stroke.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database, and PsychINFO were searched from inception to May 2018 for randomized controlled trials (RCTs) comparing lower extremity mirror therapy to a control intervention for people with stroke. Pooled effects were determined by separate meta-analyses of gait speed, mobility, balance, and motor recovery.

RESULTS

Seventeen RCTs involving 633 participants were included. Thirteen studies reported a significant between-group difference favoring mirror therapy in at least one lower extremity outcome. In a meta-analysis of 6 trials that reported change in gait speed, a large beneficial effect was observed following mirror therapy training (standardized mean differences [SMD] = 1.04 [95% confidence interval [CI] = .43, 1.66], I² = 73%, and P < .001). Lower extremity mirror therapy also had a positive effect on mobility (5 studies, SMD = .46 [95% CI = .01, .90], I² = 43%, and P = .05) and motor recovery (7 studies, SMD = .47 [95% CI = .21, .74], I² = 0%, and P < .001). A significant pooled effect was not found for balance capacity.

CONCLUSIONS

Mirror therapy for the lower extremity has a large effect for gait speed improvement. This review also found a small positive effect of mirror therapy for mobility and lower extremity motor recovery after stroke.

Mirror therapy for improving lower limb motor function and mobility after stroke: A systematic review and meta-analysis

BACKGROUND

Mirror therapy has been proposed as an effective intervention for lower limb rehabilitation post stroke.

RESEARCH QUESTION

This systematic review with meta-analysis examined if lower limb mirror therapy improved the primary outcome measures of muscle tone and motor function and the secondary outcome measures balance characteristics, functional ambulation, walking velocity, passive range of motion (PROM) for ankle dorsiflexion and gait characteristics in patients with stroke compared to other interventions.

METHODS

Standardised mean differences (SMD) and mean differences (MD) were used to assess the effect of mirror therapy on lower limb functioning.

RESULTS

Nine studies were included in the review. Among the primary outcome measures there was evidence of a significant effect of mirror therapy on motor function compared with sham and non-sham interventions (SMD 0.54; 95% CI 0.24-0.93). Furthermore, among the secondary outcome measures there was evidence of a significant effect of mirror therapy for balance capacity (SMD -0.55; 95% CI -1.01 to -0.10), walking velocity (SMD 0.71; 95% CI 0.35-1.07), PROM for ankle dorsiflexion (SMD 1.20; 95% CI 0.71-1.69) and step length (SMD 0.56; 95% CI -0.00 to 1.12).

SIGNIFICANCE

The results indicate that using mirror therapy for the treatment of certain lower limb deficits in patients with stroke may have a positive effect. Although results are somewhat positive, overly favourable interpretation is cautioned due to methodological issues concerning included studies.

Effects of mirror therapy on walking ability, balance and lower limb motor recovery after stroke: a systematic review and meta-analysis of randomized controlled trials

Objective:

To investigate the effects of mirror therapy on walking ability, balance and lower limb motor recovery in patients with stroke.

Method:

MEDLINE, EMBASE, Web of Science, CENTRAL, PEDro Database, CNKI, VIP, Wan Fang, ClinicalTrials.gov, Current controlled trials and Open Grey were searched for randomized controlled trials that investigated the effects of mirror therapy on lower limb function through January 2018. The primary outcomes included were walking speed, mobility and balance function. Secondary outcomes included lower limb motor recovery, spasticity and range of motion. Quality assessments were performed with the PEDro scale.

Results:

A total of 13 studies ( n = 572) met the inclusion criteria. A meta-analysis demonstrated a significant effect of mirror therapy on walking speed (mean difference (MD) 0.1 m/s, 95% confidence interval (CI): 0.08 to 0.12, P < 0.00001), balance function (standard mean difference (SMD) 0.66, 95% CI: 0.43 to 0.88, P < 0.00001), lower limb motor recovery (SMD 0.83, 95% CI: 0.62 to 1.05, P < 0.00001) and passive range of motion of ankle dorsiflexion (MD 2.07°, 95% CI: 082 to 3.32, P = 0.001), without improving mobility (SMD 0.43, 95% CI: −0.12 to 0.98, P = 0.12) or spasticity of ankle muscles (MD −0.14, 95% CI: −0.43 to 0.15, P = 0.35).

Conclusion:

The systematic review demonstrates that the use of mirror therapy in addition to some form of rehabilitation appears promising for some areas of lower limb function, but there is not enough evidence yet to suggest when and how to approach this therapy.

Mirror therapy and treadmill training for a patient with chronic stroke: A case report

INTRODUCTION

A large proportion of patients with chronic stroke have permanent lower limb functional disability leading to reduced levels of independent mobility. Individually, both mirror therapy and treadmill training have been shown to improve aspects of lower limb functioning in patients with stroke. This case report examined whether a new combination of both interventions would lead to improvements in lower limb functional disability for a patient with chronic stroke.

CASE DESCRIPTION

The participant was a 50-year-old female who had a left middle cerebral artery infarction (47 months' post stroke). Due to hemiparesis, she had lower limb motor impairment and gait deficits.

INTERVENTION

The participant engaged in a combination of mirror therapy and treadmill training for 30 minutes per day, 3 days per week, for 4 weeks.

OUTCOMES

Modified Ashworth Scale, Fugl-Meyer Assessment-Lower Extremity and the 10 m Walk Test demonstrated clinically meaningful change. The 6 Minute Walk Test did not demonstrate meaningful change.

DISCUSSION

The positive outcomes from this new combination therapy for this participant are encouraging given the relatively small dose of training and indicate the potential benefit of mirror therapy as an adjunct to treadmill training for enhancing lower limb muscle tone, motor function and walking velocity in patients with chronic stroke.

Effectiveness of external cues to facilitate task performance in people with neurological disorders: a systematic review and meta-analysis

Purpose: To examine in people with neurological disorders, which method/s of providing external cues to improve task performance are most effective. Methods: Medline, EMBASE, and PsycINFO were systematically searched. Two reviewers independently screened, extracted data, and assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: Twenty six studies were included. Studies examined a wide-range of cues including visual, tactile, auditory, verbal, and multi-component cues. Cueing (any type) improved walking speed when comparing cues to no cues (mean difference (95% confidence interval): 0.08 m/s (0.06-0.10), I² = 68%, low quality of evidence). Remaining evidence was analysed narratively; evidence that cueing improves activity-related outcomes was inconsistent and rated as very low quality. It was not possible to determine which form of cueing may be more effective than others. Conclusion: Providing cues to encourage successful task performance is a core component of rehabilitation, however there is limited evidence on the type of cueing or which tasks benefit most from external cueing. Low-quality evidence suggests there may be a beneficial effect of cueing (any type) on walking speed. Sufficiently powered randomised controlled trials are needed to inform therapists of the most effective cueing strategies to improve activity performance in populations with a neurological disorder. Implications for rehabilitation Providing cues is a core component of rehabilitation and may improve successful task performance and activities in people with neurological conditions including stroke, Parkinson's disease, Alzheimer's disease, traumatic brain injury, and multiple sclerosis, but evidence is limited for most neurological conditions with much research focusing on stroke and Parkinson's disease. Therapists should consider using a range of different types of cues depending on the aims of treatment and the neurological condition. There is currently insufficient evidence to suggest one form of cueing is superior to other forms. Therapists should appreciate that responding optimally to cues may take many sessions to have an effect on activities such as walking. Further studies should be conducted over a longer timeframe to examine the effects of different types of cues towards task performance and activities in people with neurological conditions.

The effects of action observation training and mirror therapy on gait and balance in stroke patients

[Purpose] The aim of this study was to evaluate the effects of action observation training and mirror therapy to improve on balance and gait function of stroke patients. [Subjects and Methods] The participants were randomly allocated to one of three groups: The action observation training with activity group practiced additional action observation training with activity for three 30-minute session for six weeks (n=12). The mirror therapy with activity group practiced additional mirror therapy with activity for three 30-minute sessions for six weeks (n=11). The only action observation training group practiced additional action observation training for three 30-minute sessions for weeks (n=12). All groups received conventional therapy for five 60-minute sessions over a six-week period. [Results] There were significant improvements in balance and gait function. The action observation training with activity group significantly improved subjects’ static balance. The action observation training with activity group and the mirror therapy with activity group significantly improved subjects’ gait ability. [Conclusion] The activation of mirror neurons combined with a conventional stroke physiotherapy program enhances lower-extremity motor recovery and motor functioning in stroke patients.

A systematic review of mechanisms of gait speed change post-stroke. Part 1: spatiotemporal parameters and asymmetry ratios

BACKGROUND

In walking rehabilitation trials, self-selected walking speed (SSWS) has emerged as the dominant outcome measure to assess walking ability. However, this measure cannot differentiate between recovery of impaired movement and compensation strategies. Spatiotemporal variables and asymmetry ratios are frequently used to quantify gait deviations and are hypothesized markers of recovery.

OBJECTIVES

The purpose of this review is to investigate spatiotemporal variables and asymmetry ratios as mechanistic recovery measures in physical therapy intervention studies post-stroke.

METHODS

A systematic literature search was performed to identify physical therapy intervention studies with a statistically significant change in SSWS post intervention and concurrently collected spatiotemporal variables. Methodological quality was assessed using the Cochrane Collaboration's tool. Walking speed, spatiotemporal, and intervention data were extracted.

RESULTS

46 studies met the inclusion criteria, 41 of which reported raw spatiotemporal measures and 19 reported asymmetry ratio calculations. Study interventions included: aerobic training (n = 2), functional electrical stimulation (n = 5), hippotherapy (n = 2), motor dual task training (n = 2), multidimensional rehabilitation (n = 4), robotics (n = 4), sensory stimulation training (n = 8), strength/resistance training (n = 4), task specific locomotor rehabilitation (n = 9), and visually guided training (n = 6).

CONCLUSIONS

Spatiotemporal variables help describe gait deviations, but scale to speed, so consequently, may not be an independent factor in describing functional recovery and gains. Therefore, these variables are limited in explaining mechanistic changes involved in improving gait speed. Use of asymmetry measures provides additional information regarding the coordinative requirements for gait and can potentially indicate recovery. Additional laboratory-based mechanistic measures may be required to truly understand how walking speed improves.

Gait deviations associated with plantar heel pain: A systematic review

BACKGROUND

Plantar heel pain is a common foot disorder associated with significant pain and gait-related disability. The aim of this systematic review was to identify gait deviations associated with plantar heel pain.

METHODS

A systematic review of articles with quantitative gait variables in individuals with plantar heel pain was conducted using the CINAHL, MEDLINE, Scopus, and Embase databases. Methodological quality was assessed using the modified Downs and Black criteria and used along with the number of studies per gait variable to determine level of evidence.

FINDINGS

Nineteen articles were included. There was strong evidence that stance phase duration is unchanged. There was moderate to strong evidence of decreased rearfoot center of pressure duration, impulse, and peak vertical ground reaction force at loading response. In compensation there was increased contact time of the midfoot and forefoot, increased midfoot and forefoot impulse, delayed time to the mid-stance vertical ground reaction force valley, and decreased peak force at terminal stance. The only quantitative measure of pronation/supination included limited evidence of increased medial forefoot and rearfoot inversion-eversion total mobility, and medial forefoot plantar flexion.

INTERPRETATION

Studies included in this review identified specific foot and ankle gait deviations in individuals with plantar heel pain compared to asymptomatic cases or limbs. The variables identified in this review may be used to assist in identifying movement-related gait dysfunction for treatment decisions or as outcome measures of recovery. Additional research is needed to increase confidence and clinical relevance of gait variables used to assess and treat individuals with PHP.

Systematic Review: Effectiveness of Mirror Therapy for Lower Extremity Post-Stroke

Background/Objective

This study reviewed the current evidence on the effectiveness of mirror therapy (MT) on improving the motor functions of the hemiplegic lower extremity (LE) in adult clients with stroke.

Methods

A systematic review was conducted of studies published in English in the 10-year period 2005–2015, retrieved from seven electronic databases: Medline, PubMed, CINAHL, Psychlnfo, Science Direct, Cochrane and TBI Rehabilitation. Only articles that focused on the effects of MT on hemiparesis affecting LE function and performance were included. The methodological quality of the studies was appraised using the Physiotherapy Evidence Database Scale (PEDro).

Results

The literature search yielded 14 studies that satisfied the selection criteria, of which five (4 randomised controlled trials and 1 case study) were reviewed after screening. Despite the heterogeneity of the studies, they showed MT to be effective in improving some of the motor functions of the LE at different stages of stroke. However, they offered little evidence on MT's long-term effects and for when is the optimal stage to start MT after stroke onset.

Conclusion

Further research is needed to determine the best treatment regimen and optimal time to initiate MT intervention in terms of the phases of stroke. No firm conclusions can be drawn on the effectiveness of MT on the hemiplegic LE until more evidence is available.