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Byline: Rabia Rauf, Abdul Rashad, Alisha Noreen, Rabia Intikhab, Tehreem Anis Suleman and Seemab Mughal

Keywords: Motor function, Stroke, Upper extremity.


Stroke is a clinical syndrome which is defined as quickly developed signs of focal or global disruption of functions of cerebrum, lasting for greater than 24 hours. It may lead to death, with none obvious causes other than vascular origin 1. Most common signs and symptoms associated with stroke are weakness on one side of body and speech problems 2.

Globally stroke is considered as second most leading cause of death and disability 3. According to the global burden of disease in 2013 men have continuously greater frequency of ischemic stroke than women 4. In Pakistan the true incidence of stroke is not reported as there is no specific population based study conducted yet. The anticipated stroke cases in Pakistan are 250/100,0005 Arm and hands help in various activities of daily living including manipulation of objects, special type of grasping and control of proximal and distal joints to perform different goals. The patients who experienced upper limb impairment due to stroke lost their ability to perform these specific tasks of grasping and manipulation. To treat the stroke related movement impairments it is important to identify underlying causes and further proper investigation of the effective treatment option 6. Numerous patients (41-45%) endure chronic motor disabilities and restrictions in activities of everydayliving indeed after broad neurological recovery.

There are different researches which have used different interventions with variations in treatment duration and protocols to evaluate the best effective treatment for stroke. For the stroke Rehabilitation concern the main therapeutic methods for patients are Brunnstrom, Bobath therapy proprioceptive neuromuscular facilitation (PNF), motor relearning program (MRP), Mirror therapy as well as constrained induced movement therapy (CIMT) 7. In the beginning the purpose of Mirror Therapy was to reduce the pain of phantom limb in persons with amputations.The mirror reflection of sound limb gave the patients a sensation of moving both arms which results in reduction of pain sensation. Ramachandran explained the mechanism of relearning process in the brain which is being unlearned 8. The motor relearning program (MRP) was devised by Janet Carr and Roberta Shepherd who was the Australian physiotherapists by profession. To improve motor control it is a type of task-oriented approach, which focuses on the relearning of daily activities. MRP powerfully based on concepts in kinesiology that stresses on distributed motor control model.

Motor relearning program consists of four steps including Analysis of the task, Practice of missing component, and Practice of task and last one is about Transference of training 9. The Fugl Meyer is a properly designed, convenient and productive clinical examination tool that has been tried broadly within the stroke populace. It has excellent intra-rater, inter-rater and construct validity 10. The study was aimed to compare the effectiveness of motor relearning program and mirror therapy in stroke patients. There is a need to incorporate easy, simple, economic, patient directed and effective treatment techniques to enhance recovery following stroke. There is less data available on comparison between motor relearning and mirror therapy in the upper limb in the past. Researches on either the effects of MRP or the effects of mirror therapy can be found. That is why this particular kind of research will contribute in stroke rehabilitation.


This single blind (assessor) randomized trial was conducted from January 2020 to July 2020 after ethics approval from Isra University ASRC-055/2020). The datawas collected from Al Noor ospital and Al Jannat Medicare Rahim Yar Khan. Sample was calculated by an online calculator OpenEpi tool and consisted of 30 patients; previous study's prevalence was used for sample calculation 11. Sampling technique was non-probability convenient sampling After informed consent Patients withischemic and hemorrhagic stroke, in age range of 40-65 years, having unaffected extremity were included in the study. Patients who were not mentally-stable, having any musculoskeletal impairment and patients with Mini Mental State Examination less than 23 were excluded. All assessments before and after the intervention were performed by Independent assessor and only eligible subjects were enrolled. Randomization was computerized with concealed allocation sequence carried out at an external sitethrough blind acessor. Treatment protocol included 5 sessions a week for 6 weeks and the session duration was 40 minutes.

Group A of this study received MRP (Motor relearning program) treatment which included different types of task specific exercises, reaching and manipulation. Practice of wrist flexion and Extension with holding different objects, pronation/supination, and opposition of thumb for paretic upper limb. Activities were started with simple tasks and less repetitions and were progressed to more complex tasks andrepetitions. The group B was treated with Mirror Therapy. The activities performed in this group were in front of mirror and with the non-paretic limb. The mirror size was 20 x 25. Visual or verbal instructions were given about the movement. The mirror was placedin the midline ofpatient 12. The unaffected limb was positioned similar to that of the affected limb. Next, patients were instructed to observe the mirror reflection for one to two minutes, trying to visualize the mirror image as the affected limb. Unilateral motor exercises with the non-affected limb were performed. All the patients were assessed before treatment (pre assessment), at 3 rd week (mid assessment) and after 6 th week (post assessment) with the outcome measure Modified Fugl Meyer Assessment scale.

The data analysis was made through SPSS-20. Data was not normally distributed so non-parametric tests were used. For pre-mid and post intra group comparison, Friedman test was used.While for inter group comparison of both groups was made using KaruskalWallis test.

Table-I: Gender and affected side distribution of study participants.

Demographics###Group-A with###Group-B with




Left Hemiplegia###10(66.7%)###12(80%)

Right Hemiplegia###5(33.3%)###3(20%)

Table-II: Within group comparison of fugl meyer score using non-parametric friedman test.




Group A###5(3)###15(4)###25(6)###<0.001

Group B###5(4)###14(9)###17(13)###<0.001

Table-III: Post hoc analysis of both groups by wilcoxon test.

###PRE vs.###MID vs.###POST vs.


Group A###0.001###0.001###0.001

Group B###0.001###0.001###0.001

Table-IV: Between group comparison of fugl meyer score using karuskal-wallis test.

###Group A###Group B###p-






Out of the total 30 participants male and femalein both groups were 21 (70%) and 9 (30%) respectively. The total participants who suffer from left hemiplegia were 22 (73.33%) where as the number of patients having right hemiplegia was 8 (26.66%). The mean age of participants in both groups was 53.80 +- 7.6 (table-I).

The results showed statistically significant improvement in motor function of stroke patients from baseline to post assessment in both groups (p 0.005) (table-III).


The purpose of this RCT was to compare the effects of two different therapeutic interventions which can be used to enhance themotor function after stroke. Motor relearning program and Mirror therapy were compared for 6 weeks in 30 stroke patients. The mean age of subjects in this study was 53.80 +- 7.66. Stroke is a major source of severe long-term disability. More The results of current study were non-significant (p>0.05) comparing the both techniques. There was no significant difference present between two interventions in terms of improving the upper limb motor function of stroke patients. Both interventions improved the upper limb function from baseline to 6 th week as median improved in all three assessments. The results of present study are supported by another study which was conducted in India in 2015 The results of that study were in line with current studystated both MRP and Mirror Therapy are effective in improving the motor function afterstroke 9. One of such study supported the results of current study which compared the effectiveness of task specific exercises and MT, further they evaluated the combine effectiveness of both task specific exercises and MT.

The treatments protocol included 30 mints of exercise for 5 days a week for 4 weeks. The significant improvement was seen in all 3 groups. While 3 rd group who received combined treatment showed more improvement 14. Another study related to present study was conducted in Peshawar which compared the effects of MT and MRP for improvement of upper limb motor function in stroke patients. A total of 66 subjects were included in the study and motor assessment scale was used as an outcome measure. This study did not support the present study, their study stated that both Motor relearning program and Mirror therapy are effective in improving the upper limb motor function but MRP is slightly more effective 10. The differences in results might be due to difference in treatment protocol and geographical changes. The results of our study showed that Motor Relearning program iseffective in improving the upper limb motor function of stroke patients; it is supported by a study conducted in 2017. According to that study early administration of motor relearning program training improves the motor function of patients with stroke 15.

Further the results of present study states that Mirror therapy found to be more effective in enhancing the Upper limb motor function. A similar study supported the current study, which followed MT treatment protocol for 6 weeks, 5 times a week. They included sub-acute stroke patients; the study results showed that early administration of Mirror therapy after stroke supports the motor function recovery 16. The results of our study are supported by another study conducted in Malaysiain 2020. That study stated that Mirror therapy along with conventional treatment is effective to restore the upper limb motor function 17. Current study is supported by a study conducted in Hong Kong, according to that study mirror therapy is more effective than bilateral arm training in improving the motor function of stroke patients 18.

Both motor relearning program and mirror therapy are effective in the treatment of upper limb motor function of stroke patients. There is no significant difference present in the effectiveness of these techniques.


The study was limited to only motor assessment. The data was collected form two settings.


Both interventions are effective in stroke rehabilitation and thereis no significant difference present between the effectiveness of mirror therapy and motor relearning program in improving the upper limb motor function of patients with stroke.


This study has no conflict of interest to be declared by any author.


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Author:Rabia Rauf, Abdul Rashad, Alisha Noreen, Rabia Intikhab, Tehreem Anis Suleman and Seemab Mughal
Publication:Pakistan Armed Forces Medical Journal
Date:Aug 31, 2021

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