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THE EFFECTS OF MIRROR THERAPY ON UPPER EXTREMITY FUNCTION POST-STROKE: A SYSTEMATIC REVIEW.

INTRODUCTION

Stroke is caused by damage to the brain and can lead to a variety of impairments including motor, sensory, perception, and language disorders [1]. Hemiplegia is a consequence in 85% of patients who survive a stroke. Upper extremity (UE) function is impaired in approximately 69% of these individuals. Upper extremity impairment after stroke can be due to paresis and/or spasticity and can be detrimental to independence in activities of daily living [2]. Basic activities of daily living include but are not limited to: personal hygiene, dressing, eating, transferring from sitting to standing, getting in and out of bed, and walking. If unable to perform the basic activities of daily living, stroke survivors may not be able to live independently. Most evidence-based rehabilitation treatments for the hemiplegic UE require direct interaction with a therapist for many weeks. Mirror therapy is inexpensive, easy to construct, and is directed by the patient. During MT, the individual watches the movement of the unaffected hand in a mirror that is placed in the mid-sagittal plane between the patient's two upper extremities. The reflecting side of the mirror blocks the patient's view of the affected extremity while the patient watches the mirror image of the unaffected extremity. This gives the patient the illusion of correctly moving the paretic hand [3]. Mirror therapy effects "motor image and motor execution overlap particularly in the premotor and parietal areas, basal ganglia and the cerebellum." [4 p. 576] The theory is that MT promotes neuroplasticity of the brain while having effects in the motor and somatosensory cortices [4]. Functional magnetic resonance imaging has given credence to this theory [5].

METHODS

An electronic search of the PubMed Database was conducted through November 15, 2017, which resulted in 116 articles related to this topic. Specific search terms included those related to cerebral vascular accident and upper extremity and mirror therapy. These articles were screened according to title, which eliminated 101 articles and left 15 for continued screen. Following the abstract screen, nine articles remained for consideration. Two of these were eliminated according to the inclusion/exclusion criteria. Inclusion criteria were; randomized control trials comparing conventional treatment and/or sham treatment to MT, (UE) weakness/paresis, and the use of the Functional Independence Measure (FIM) as an outcome measure. Exclusion criteria consisted of the use of Mirror Image Movement Enabler, or robotics, and the use of MT as the control group.

The seven articles included in the review were scored using the PEDro scale, a 10-point scale developed to assess internal validity and the quality of methodology of clinical trials in physical therapy research. Higher PEDro scores suggest higher quality clinical trials. PEDro scores for this review ranged from 5 to 8 with a mean of 6.7. The level of evidence was also assessed using the 2011 Centre of Evidence Based Medicine (CEBM) scale which is a 5point scale with a lower score indicating a higher level of evidence. CEBM is based primarily on study design. The CEBM levels of evidence included five level II studies and two level III studies.

RESULTS

In a recent study by Kim, et al., [1] 25 adults with hemiplegia post-stroke were randomly assigned to one of two groups. The intervention group received four weeks of MT for 30 minutes per day five days a week. The control group received four weeks of conventional therapy for 30 min per day five days a week. Upper extremity function and activities of daily living were measured using the Action Research Arm Test (ARAT), Fugl-Meyer Assessment (FMA), Box and Block Test (BBT), and the Functional Independence Measure (FIM) total. The within group comparisons demonstrated that both the intervention and control groups showed statistically significant improvements (p < 0.05) after therapy in the ARAT, FMA, BBT, and FIMtotal. The MT group showed greater improvements than the control group. The post intervention mean score improvements were as follows: ARAT- MT group increased by 5.7 while the control increased by 2.8; FMA- MT increased by 5.9 while the control increased by 3.4; BBT-MT increased by 4.2 while the control increased by 2.8; FIMtotal- MT increased by 6.8 while the control increased by 3.7. The between group comparison demonstrated that the intervention group (MT) showed statistically significant improvements (p < 0.05) in mean scores when compared to the control group in all outcome measures.

In a study by Park, et al. [2], 30 adult participants with hemiplegia post-stroke were randomly assigned to one of two groups. The intervention group participated in four weeks of MT five times each week for 30 minutes in addition to conventional therapy. The control group participated in four weeks of sham therapy using a nonreflecting mirror five times each week for 30 minutes in addition to conventional therapy. Outcome measures included the FIMtotal, FIMself-care, FMA, and the BBT. Results of the between group comparison revealed a significant difference in mean scores in favor of the intervention group (MT) for UE function in FMA (p = 0.000), coordination in BBT (p = 0.002), self-care in FIMself-care (p = 0.001), and activities of daily living in FIM total (p = 0.008) (see Figure 1).

In a 2015 study by Park, et al., [3] 30 adults with hemiplegia post-stroke were randomly assigned to one of two groups. The intervention group participated in six weeks of MT incorporating eight specific functional tasks five times per week. The control group participated in six weeks of sham therapy utilizing the same functional tasks five times per week but utilizing the nonreflecting side of the mirror. Outcome measures included the Manual Function Test (MFT) and the FIM self-care. Within group comparisons revealed that both the intervention and the control group showed significant improvements in the mean scores on MFT and FIMself-care (p < 0.05).The between group comparisons revealed that the intervention group had statistically significant improvements in the mean scores in MFT and FIMself-care (p < 0.05) (see Figure 1).

In a study comparing the outcomes of 30 adult subjects with hemiplegia post-stroke accompanied by complex regional pain syndrome type 1, Vural, et al. [4], randomly assigned patients into two groups. The intervention group received four weeks of conventional stroke rehabilitation five times per week for two to four hours a day, plus MT five times a week for 30 minutes. The control group received four weeks of conventional stroke rehabilitation five times a week for two to four hours per day. Outcome measures included were the FIMmotor, Brunnstrom Recovery Stages (BRS) hand, BRSarm, Modified Ashworth Scale (MAS), FMAwrist, and FMAhand. Results of the within group comparisons revealed that the intervention group (MT) showed significant improvement in median scores in FIMmotor (p = 0.01), BRShand (p = 0.01), BRSarm (p = 0.02), FMAwrist (p < 0.001), and FMAhand (p < 0.001).The control group showed significant improvement only in the median scores of FIMmotor (p = 0.01). Between group comparisons upon study completion revealed that the intervention group (MT) showed significant improvement over the control group in the median scores in FMAwrist (p < 0.001) and FMAhand (p < 0.001).

Thirty-one adult hemiplegic patients post-stroke were randomly assigned to two groups in a study by Gurbuz, et al. [5]. The intervention group participated in four weeks of conventional stroke rehabilitation consisting of 1-2 hours of neurodevelopmental treatment (NDT) and 20 minutes of MT. The control group participated in four weeks of the same interventions but used the non-reflecting side of the mirror. Outcome measures used were the BRS, FMA upper extremity score, and the FIMself-care score. Within group comparisons revealed that both groups showed statistically significant improvement (p < 0.05) in BRS, FMA upper extremity score, and FIMself-care scores. Between group comparisons showed greater improvement with MT in the BRS and the FIMself-care, however, the improvements were not statistically significant. The FMA upper extremity score was significantly higher (p < 0.05) in the MT group (see Figure 1).

In an earlier study, by Invernizzi, et al. [6], 26 adult subjects with hemiplegia post-stroke were randomly assigned to two groups. The intervention group received four weeks of conventional stroke rehabilitation five times per week for 60 minutes, including 30 minutes of MT for the first two weeks and 60 minutes of MT for the last two weeks. The control group received four weeks of conventional stroke rehabilitation five times per week for 60 minutes. The outcome measures performed included the Action Research Arm Test (ARAT), Motricity Index (MI), and the FIMtotal. Results of the within group comparisons revealed that both the intervention and control group showed significant improvements in mean scores of the ARAT, MI, and FIM total (p < 0.05). Between group comparisons indicated that the intervention group had statistically significant improvements in the mean scores of ARAT, MI, and FIM total (p < 0.001) as compared to the control group.

In the final article in this review, Yavuzer, et al. [7] studied 40 adult subjects with hemiplegia post-stroke. Participants were randomly assigned to one of two groups. The intervention group participated in 4 weeks of conventional stroke rehabilitation five times per week for two to five hours per day plus 30 minutes of MT. The control group participated in four weeks of conventional stroke rehabilitation five times per week for two to five hours per day. The outcome measures utilized were the BRShand, BRSUE, MAS, FIMself-care. Following the intervention, the between group comparison showed significant improvements in mean scores in favor of the intervention group (MT) in motor recovery in BRShand (p = 0.001) and BRSUE (p = 0.001) and functioning in FIMself-care (p = 0.001) at both post-treatment and 6month follow up (see Figure 1).

Vural, Invernizzi and Kim are not depicted in Figure 1 because the authors did not separate self-care from motor or total FIM scores. Self-care scores are directly related to UE function; whereas, motor and total FIM scores include lower extremity function.

DISCUSSION

The inclusion of MT as a therapeutic intervention for patients post-stroke has been shown to improve UE function. Evidence in five out of the seven articles demonstrated that MT led to statistically significant improvements in self-care, as demonstrated by increased FIM scores when compared to conventional therapy and/or sham therapy. Longer follow-up studies might further improve these results due to the fact that continued muscle activity is necessary to facilitate neuroplasticity [5]. Further studies that include functional imaging are needed to determine the time frame necessary to produce a change in cortico-motor reorganization. While motor function was evaluated using different clinical outcome measures, the studies reviewed demonstrated good evidence that MT increased motor function in patients post-stroke.

CONCLUSIONS

This systematic review provides evidence to support the use of MT as a therapeutic intervention in patients with chronic or subacute stroke. A mirror therapy box can be constructed for less than ten dollars out of a cardboard box, making this an easily accessible and inexpensive treatment option for this client population. Another attractive aspect of MT is that it can be done by the patient, independent of therapist interaction. It can be easily added to conventional therapy and incorporated into home exercise programs. Depending upon the individual client's motivation to consistently participate in a MT program, this intervention could lead to improved motor control of the affected UE and allow increased independence in basic activities of daily living. Further studies are needed to determine the optimal MT protocol. ACKNOWLEDGMENTS

The authors would like to acknowledge Emily Bright, Allison Dean, Samantha Klein, Kala Ross, Mary Clark Strange, and Carolyn Wellborn for their assistance in gathering the information for this review.

REFERENCES

[1] K. Kim, S. Lee, D. Kim, K. Lee, and Y. Kim, "Effects of mirror therapy combined with motor tasks on upper extremity function and activities daily living of stroke patients," J Phys Ther Sci, vol 28, pp. 483-7, 2016.

[2] J.Y. Park, M. Chang, K. M. Kim, and H.J. Kim, "The effect of mirror therapy on upper-extremity function and activities of daily living in stroke patients," J Phys Ther Sci, vol 27, no 6, pp. 1681-3, 2015.

[3] Y. Park, M. Chang, K. M. Kim, and D.H. An, "The effects of mirror therapy with tasks on upper extremity function and self-care in stroke patients," J Phys Ther Sci, vol 27, no 5, pp. 1499-1501, 2015.

[4] S.P. Vural, G. F. Nakipoglu Yuzer, D. S. Ozcan, S. D. Ozbudak, and N. Ozgirgin, "The effects of mirror therapy in stroke patients with complex regional pain syndrome type 1: a randomized controlled study," Arch Phys Med Rehabil, vol 97, no 4, pp. 575-81. 2016.

[5] N. Gurbuz, S.I. Afsar, S. Ayas, S. N. S. Cosar, "Effect of mirror therapy on upper extremity motor function in stroke patients: a randomized controlled trial, "J Phys Ther Sci, vol 28, pp. 2501-6, 2016.

[6] M. Invernizzi, S. Negrini, S. Carda, L. Lanzotti, C. Cisari, and A. Baricich, "The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized control trial," Eur J Rehabil Med, vol 49, no 3, pp. 311-7, 2013.

[7] G. Yavuzer, R. Sellas, N. Sezer, S. Sutbeyaz, J. B. Bussmann, F. Koseoglu, M.B. Atay, and H.J. Stam, "Mirror therapy improves hand function in subacute stroke: a randomized controlled trial," Arch Phys Med Rehabil, vol 89, no 3, pp. 393-8, 2008.

Janet P. Slaughter and Lisa J. Barnes University of Mississippi Medical Center, School of Health Related Professions, Department of Physical Therapy, Jackson, MS, USA
Figure 1. Comparison of Improved UE Function: Differences in
Mean FIM Self-Care Scores from Pre-Treatment to Post-Treatment

              Mirrot Therapy    Control

Park [3]          7.4              2.7
Park [2]          5.2              1.7
Yavuzer [7]       5.2              0.7
Gurbuz [5]        8.2              3.8

Studies

Note: Table made from bar graph.
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Author:Slaughter, Janet P.; Barnes, Lisa J.
Publication:Journal of the Mississippi Academy of Sciences
Article Type:Report
Date:Apr 1, 2018
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