Mirror therapy improves hand function in subacute stroke: a randomized controlled trial.
Methods: Randomised controlled trial of four weeks duration. Forty inpatients with severe hemiparesis within one year of having suffered their first stroke, and without neglect, apraxia or severe cognitive deficits, were recruited. Participants were randomly allocated into either the mirror group or the control group. Those in the mirror group received 30 minutes of mirror therapy in addition to their conventional therapy (physiotherapy, occupational therapy, and if necessary speech therapy, for two to five hours per day), five days per week. During the mirror therapy sessions participants were asked to perform wrist and finger flexion and extension exercises and could only see the reflection of their non-paretic hand. At the same time as performing these exercises, they were also asked to try and do the same movements with their obscured paretic hand. In addition to the conventional therapy, the control group received a sham treatment (using the non-reflecting side of the same mirror) of identical exercises, performed for the same duration as the mirror group. The same therapist delivered both the mirror and sham interventions. Motor recovery was measured using the Brunnstrom stages, spasticity by the Modified Ashworth Scale (MAS), and activity by the self care items of the Functional Independence Measure (FIM). Measures were taken at baseline, four weeks (post treatment) and six months (follow-up). Assessor blinding was achieved however participant and therapist blinding was not possible.
Results: The mirror therapy group showed a statistically significant improvement in motor recovery as measured by the Brunnstrom stages, and in functional activity as measured by the FIM self-care score, both post-treatment and at follow-up. The mean change of Brunnstrom stages for the hand at six months from baseline was 1.5 (95% confidence interval 1.1 -1.9) compared to 0.4 (95%confidence interval 0.1-0.8) change in the control group (P=0.001). The mean change in Brunnstrom stages for the upper extremity at six months from baseline was 1.6 (95% confidence interval 1.3-1.9) compared to 0.3 (95% confidence interval 0.1-0.6) change in the control group (P=0.001). The mean change in FIM self care score at six months from baseline was 8.3 (95% confidence interval 6.5-10.1) compared to 1.8 (95% confidence interval 0.3-3.2) change in the control group (P=0.001). There was no statistical difference in the MAS scores either post-treatment or at follow-up.
Conclusion: Mirror therapy, in addition to conventional therapy, improved hand function in patients with severe hemiparesis both post-treatment and at six month follow-up.
Stroke Foundation of New Zealand Inc. (2003) Life After Stroke, New Zealand Guideline for Management of Stroke. Wellington, New Zealand.
Rizzolatti G, Fabbri-Destro M, Cattaneo L (2009) Mirror neurons and their clinical relevance. Nature Clinical Practise. Neurology 5(1):24-34.
Sharma N, Pomeroy VM, Baron J-C (2006) Motor Imagery. A Backdoor to the Motor System After Stroke? Stroke 37:19411952.
Each year in New Zealand approximately 5640 people suffer their first ever stroke and at one year following a stroke 50% of those that survive will still have a motor deficit (Life After Stroke, New Zealand Guideline for Management of Stroke, 2003). Recovery of hand function is essential for participation in activities of daily living and is often necessary to achieve patient goals. Mirror therapy is an emerging area of research which shows potential for application in neurorehabilitation (Rizzolatti et al, 2009). It offers an inexpensive and simple intervention that is able to be applied independently of the degree of motor return, yet it requires active patient involvement (Sharma et al, 2006; Yavuzer et al, 2008).
The results of the above clinical trial show promise for applying this intervention to patients in rehabilitation settings. The participants in this trial had no greater motor return than Brunnstrom stage four (lateral prehension, release by thumb movement, semi voluntary finger extension with small range) which is a patient group that physiotherapists frequently treat in an inpatient setting. However, these types of patients are often excluded from upper limb rehabilitation interventions due to insufficient voluntary motor control. Not only did this study have the advantage of obtaining clinically relevant results that were retained at follow-up, it achieved these by implementing a clinically feasible intervention. Thirty minutes per day of additional intervention, which requires only a 35cm x 35cm mirror, would be well justified considering the long term improvements that were made in the FIM self-care subscale. These improvements directly relate to improved independence and the potential to reduce carer burden, and therefore long term Ministry of Health costs. The lack of change to the MAS score from this intervention is unsurprising given that the MAS measures resistance to stretch, and the exercises performed were not designed to increase flexibility but rather to improve active movement. It is heartening to note that the authors report there were no adverse effects associated with mirror therapy.
Further trials are necessary to determine whether this intervention can be applied to broader populations or as a home-based exercise intervention. However, clinicians can be encouraged that their patients with severe hemiparesis within one year of having suffered their first stroke, who do not have neglect, apraxia or severe cognitive deficits, may show increased upper limb motor and functional return with the addition of mirror therapy such as that described in this trial.
Justine Grieve, BPhty, PGCert Neurorehabilitation
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|Title Annotation:||Clinically Applicable Papers|
|Author:||Yavuzer, G.; Selles, R.; Sezer, N.; Sutbeyaz, S.; Bussmann, J.B.; Koseoglu, F.; Atay, M.; Stam, H.|
|Publication:||New Zealand Journal of Physiotherapy|
|Date:||Mar 1, 2009|
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