Original Article
EFFECTIVENESS OF M IRROR THERAPY AS A HOM E PROGRAM IN
REHABILITATION OF HAND FUNCTION IN SUB-ACUTE STROKE
Femy M ol Baby
1, Vinod Babu. K
2, Sai Kumar. N
3, Akshata Akalwadi
4.
K.T.G. College of Physiot herapy and K.T.G. Hospital. Bangalore. India.
Background and introduction: Purpose is t o st udy t he ef fect iveness of M irr or Therapy as a hom e pr ogram in rehabilit at ion of hand funct ion in sub-acut e st r oke
M ethod: An experim ent al study design, 30 subject s w it h sub-acut e st roke w it h im paired hand funct ion random ly allocat ed 15 subject s int o each M irror t herapy and Sham m irror t herapy group. Sham m ir ror t herapy gr oup received sham m irr or t herapy w it h convent ional exercises w hile M ir ror t herapy group received hom e based M ir ror t herapy w it h convent ional exer cises. Subject s w er e asked t o review once in a w eek and follow t he t reatm ent at hom e for 4 w eeks. Hand funct ions w ere m easured using Chedoke Arm and Hand Act ivities Invent ory-9 (CAHAI-ory-9) Scale befor e and aft er 4 w eeks of int er vent ion.
Results: When m eans of post int ervent ion com pared using Independent ‘t ’ t est bet w een t he groups found t here is a st at ist ically significant differ ence (p<0.05) in m eans of CAHAI-9 score for hand funct ions. When analyzed w it hin groups using Paired ‘t ’ t est and W ilcoxon signed rank t est t here is a st at ist ically signif icant im provem ent in m eans of CAHAI-9 scor e in bot h t he groups.
Conclusion: It is concluded t hat t he M irror t herapy as a hom e program w it h convent ional exer cises signif icant ly found ef fect ive t han Sham m irror t her apy in im proving hand funct ions in sub-acut e st roke.
KEYW ORDS:Sub-acut e st roke; M irr or t herapy; Sham m irror t herapy; Convent ional exercise; Hand Funct ion; M ot or im agery; Hem iplegia.
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International Journal of Physiotherapy and Research
ISSN 2321- 1822
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Received: 04-01-2014 Accept ed: 17-01-2014
Published: 11-02-2014
ABSTRACT
INTRODUCTION
Address for correspondence: Dr. Vinod Babu. K, Assistant Professor, K.T.G. College of Physiotherapy and K.T.G. Hospital, Bangalore-560 091, India.
E-M ail: vinodbabupublicat ions@gmail.com; femyajish@gmail.com
Peer Review : 04-01-2014
1 M PT St udent 2012-2014, *2 Assistant Professor in Physiot herapy,
3 Principal & Professor in Physiot herapy, 4 AssociateProfessor.
St roke is defined as a rapidly developing clinical sign of focal or global dist urbance of cerebral funct ion, last ing more t han 24 hours or leading t o deat h, w it h no apparent cause ot her t han vascular orgin.1 St roke pat ient ’s incidence
rate ranges from 0.2 to 2.5 per 1000 populat ions per year in India. Prevalence rat e in sout h India w as report ed t o be 56.9 per 100000.1Up t o 85%
st ro ke su r vi v o rs exp er i en ce h em ip ar esi s result ing in impairment of an upper ext remit y immediately after st roke. 2
M irror t herapy is a relat ively new approach in
rehabilit at ion used in different neurological disorders including st roke.3 In mirror t herapy,
pat ient s bei ng in f r on t of a m i r r or t hat is oriented parallel t o person’s mid line blocking t he view of t he affect ed limb posit ioned behind t he mirror. W hen looking int o t he mirror t he person sees t he reflection of the unaffected limb. This creat es a visual illusion by movement or t ouch t o t he int act limb may be perceived as affect ing t he paret ic or painful limb.4
M ATERIALS AND M ETHODS
Ram achandr an or iginally hypot hesized t hat p ar al ysi s f o l lo w i ng m igh t h av e a ‘ l ear n t ’ component , w hich could possibly be ‘unlearnt ’ b y m ean s of t he m ir r o r i l lu si on .5 Ot h er s
suggest ed t hat mirror t herapy might be a form of visually guided m ot or im ager y.4,6,7 M irror
illusion increases act ivit y in precuneus and post erior cingulat ed cort ex areas associat ed w it h aw areness of self and spat ial at t ent ion.8
It is suggest t hat mirror t herapy st imulat e t he mirror neuron. M irror neuron provides visual input t o review mot or neurons9 again m ight
t rigger t he mirror neuron syst em4.
St udi es h ave been f oun d ef f ect i veness of i nt ense m ir r or t h erap y i n st r oke p at i ent s result ed in significant recovery of grip st rengt h, hand m ovem ent of par et ic arm , st eady and accuracy of arm movement s4, increase in Fugl
M eyer assessm ent s score, im pr ovem ent in speed and hand dext erit y,10 improvem ent s in
hand funct ions in sub-acute st roke pat ient s w it h sensory and at t ent ion deficit s, improvement s in motor recovery in dist al plegic,11 improvement
in Ashw ort h scale, self-care it ems of t he FIM inst rument 4 and mirror t herapy combined w it h
convent ional st roke rehabi lit at ion program enhanced low er-ext remit y mot or recovery and mot or functioning in sub-acute stroke pat ient s.12
St udies h ave sho w n t hat dur ing inp at ient rehabilit at ion mirror t herapy program w it h con-vent ional rehabilitation improved hand funct ions compared wit h a cont rol t reatment immediat ely aft er 4 w eeks of t reat ment and at t he 6 mont hs follow -up.4 Convent ionally t reat ing subject s for
long t erm as inpat ient s or out pat ient s rehabili-t arehabili-t ion is cosrehabili-t effecrehabili-t ive and rehabili-t ime consuming. The previous st udies w ere lim it ed t o st udy t he effect iveness of supervised mirror t herapy as a hom e program w it h out pat ient convent ional rehabilit at ion exercises in hemiplegics. In post st roke w ho are hemiplegic loss of hand funct ion is a m ajor source of im pairm ent , frequent ly prevent ing effect ive occupat ional performance and an independent part icipat ion in daily life.2
Th er ef or e t h i s st u dy w as w it h r esear ch quest ion w het her t he mirror t herapy as a home program does have an effect on funct ional hand recovery in rehabilit at ion of hand funct ion in subj ect s w it h sub-acut e st roke. Hence t he purpose is t o find t he effect of mirror t herapy as
a home program w it h out pat ient convent ional rehabilit ation program on funct ional recovery of hand in subject s w it h sub-acute st roke. It was hypot hesized t hat t here w ill be a significant ef-fect of mirror t herapy as a home program on funct ional hand recovery in rehabilit at ion of hand funct ion in sub-acute st roke.
Pre t o Post t est Experiment al st udy design. As t he st udy included hum an subj ect s et hical clearance was obt ained from et hical commit t ee of K.T.G. College of Physiot herapy and K.T.G. Hospit al, Bangalore. The st udy w as regist ered w it h Universit y no.09_T031_39084. Subject s w er e r ecr uit ed f rom var ious Rehabilit at ion cent ers in Bangalore and st udy conduct ed in K.T.G. Hospital, Bangalore. Subject s included w it h sub-acute st roke w ho w ere diagnosed by Neurologist aft er confirm ed by CT/ M RI and referred t o Physiot herapy t reat ment , age group bet w een 40 t o 65 years, bot h male and female, hist ory of first episode of right hemiplegia w it hin t he durat ion of 4 w eeks w ho w ere in t he st age III t o IV on Brunnstrom stage16 of motor recovery
of upper ext rem it y w it h M odified Ashw ort h scale17 score bet w een 1 t o 3 and w it h no severe
cognit ive disorders (M M SE score >24). Subject s excl u ded w h o w er e associ at ed w i t h p sych o lo gi cal an d per cept u al d i so r d er s, significant visual and audit ory impairment . 30 subject s w ho fulfilled t he inclusion crit eria w ere informed about t he st udy and a w rit t en consent was taken. Subject s w ere randomly allocated 15 int o M irror Therapy Group and 15 int o Sham M irror Therapy Group using pieces of paper t ight ly folded and placed in a box. Aft er shaking t he box each piece of paper w as w it hdraw n individually and t he group name w as w rit t en on a paper t hat cor r esponds w it h t he pat ient numbers from 1 t o 30. Bot h group t rained once a w eek under super vi sion at Hospit al and advised t o pract iced mirror t herapy at home for 30 minutes daily, 5 t imes a w eek for 4 w eeks and record w as m aint ained t o m onit or t he exercises performed at home.
Procedure of Intervention for M irror Therapy group:
m ovem ent t hrough nonreflect ing side of t he mirror4. Subjects were advised to pract ice mirror
t herapy at home for 30 minutes daily, 5 t imes a w eek for 4 w eeks. Convent ional t herapy w as given for one hour and t hirt y minut es same as M irror Therapy Group.
Outcome M easure:
Chedoke Arm and Hand Act ivit ies Invent ory Scale.13,14,15 Version – 9 (CAHAI-9) was used t o
measure t he funct ional hand recovery before and aft er 4 w eeks of int ervent ion in bot h t he gr o u p s. CAHAI-9 i s an act iv i t y- b ased assessm ent developed t o include r elevant funct ional t asks and t o be sensit ive t o clinically im port ant changes in upper lim b funct ion.13
CAHAI has a high inter rater reliabilit y, more sensit ive and high const ruct validat ion. The performance of each t ask of t he affect ed upper limb is rat ed using t he 7 point act ivit y scale. The scores on individual it ems are added yielding an overall sum score, t he maximum obt ainable sum score is 63 point s.
M irror Therapy: During mirror pract ices subject seat ed on a chair close t o t he t able on w hich a mirror w as placed vert ically and advised t o place bot h t he hands on t he t able. The involved hand w as p laced b ehi n d t h e m i r r o r an d t h e noninvolved hand in front of t he m irror. The subject s were advised not to look on t he affect ed h and and f ocu s o n t h e m i r r or. Keep t h e unaffect ed hand flat on t he t able. The pract ice consist ed of Non Paret ic side w rist flexion and ext ension finger flexion and ext ension fanning out the hand, finger and thumb abduction, makes a fist and release, Lat eral prehension, pad t o pad, pad t o side, pad t o pad gr ip, grasping o b j ect s, sin gl e f i nger m o v em en t , t hu m b opposit ion w hile subject looked int o t he mirror, w at ching t he image of t heir noninvolved hand.4
During t he session, subject s w ere asked t o t ry t o do t he same movement s in t he paret ic hand w hile t hey w ere moving t he non-paret ic hand. Subject s w ere advised to practice mirror therapy at home for 30 minutes daily, 5 t imes a w eek for 4 w eeks.
Conventional therapy: Convent ional exercises involved w ere range of mot ion exercises and st retching t o shoulder, elbow, w rist , fingers, hip and ankle. Bed m obilit y t asks such as rolling, moving from supine t o sit t ing by coming over t he involved Side and using t he involved arm for suppor t , and br idging. Weight shift ing w as performed in sitting and st anding with cont rolled shift ing over t he involved leg. Sit t o st and and t r ansf er s t ow ar d t he involved side w it hout pushing up w it h t he uninvolved Leg. Cont rol of t he hemiplegic arm performed in weight bearing and functional non-weight bearing patt erns. Gait t r aining and balance act ivit ies t o incr ease cont rol of t he involved leg. Act ivit ies of daily living, vocat ional and recr eat ional act ivit ies performed w it h t he use of involved arm and avo iding pat t er ns t hat i ncrease spast ici t y. Weight bearing t hrough hand performed t o help & st abilize object s. Fanning out t he hand on t he t able, m anual dext erit y exercises and aft er convent ional therapy patient is asked t o take rest for some t ime.18,19 All exercises w ere performed
for 1 hour and 30 minut es.
Sham M irror Therapy Group: In t his group, t he subject performed same exercises for t he same duration but t hey were instructed to observe t he
Fig. 1: M irror t herapy
Fig. 2: Sham M irror Therapy
Statistical M ethods:
non-paramet ric t est have been used t o analysis t h e v ar i ab les pr ein t er ven t io n t o p ost -int ervent ion w it h calculat ion of percent age of change. Independent ‘t ’ test as a param et ric and M ann Whit ney U t est as a non-paramet ric t est have been used t o compare t he means of variables bet w een groups w it h calculat ion of percent age of difference bet w een t he means. The St at ist ical soft ware namely SPSS 16.0 , St at a 8.0, M edCalc 9.0.1 and Syst at 11.0 w ere used for t he analysis of t he dat a and M icrosoft w ord and Excel have been used t o generat e graphs, t ables et c.
RESULTS
In Sham M irror Therapy Group t here w ere 15 subject s w it h mean age 50.80 years and w ere 9 m ales 6 females w ere included in t he st udy. There is no significant difference in mean ages bet w een t he groups. When means of CAHAI-9 scores analyzed from pre t o post int ervent ion w it h in M irror Therapy Group and Sham M irror Therapy Group t here is a st at ist ically significant improvement in Post means with p<0.000. When p r e-i nt er ven t io n m ean s w er e com p ar ed bet w een t he groups found t hat t here is no st at ist ically significant difference in means of CAHAI-9 scores. M eans of post int ervent ion compared t here is a st at ist ically significant dif-ference in means of CAHAI-9 scores bet w een t he groups.
In st udy group there were 15 subject s with mean age of 49.87 years and t here w ere 9 males and 6 females w ere included in t he st udy.
M irror Therapy Group
Sham M irror Therapy Group
Bet w een t he groups Significancea
15 15
--M ales 9 9
Females 6 6
15 15 30
Basic Characterist ics of the subject s d studied
Number of subject s studied (n)
P= 0.861 (NS)
Gender P=0.100*
Total number of subject s Age in years (M ean± SD)
49.87± 7.01 (40-63)
50.80± 6.83 (41-61)
t value a Significance
Lower Upper
-3.415
-3.411
(2-tailed) P value
-34.545 P <0.000* *
Sham M irror
Therapy Group 36.18% -14.56 -9.92 -11.328 P <0.000* *
CAHAI Score Perecntage of
change
95%Confidence interval of the difference
M irror Therapy
Group 79.29% -29.57 -26.12
Pre intervention
(M ean±SD) min-max
Post intervention (M ean±SD)
min-max
Effect Size r
( Parametric)
P =0.001* * Z valueb
( Non parametric) 35.12 ± 4.97
(28.57 - 49.20)
62.97 ± 5.66 (57.14 - 77.77)
0.93 (Large)
0.86 (Large) 33.85 ± 4.09
(28.57 - 39.68)
46.10 ± 2.76
(42.85 - 50.79) P =0.001* *
Z valueb Effect Size t value a Significance
Lower Upper
-0.46
-4.686
Pre intervention comparison
-3.68% -2.14 4.67
M irror Therapy Group (M ean±SD)
min-max
Sham M irror Therapy Group (M ean±SD)
min-max
Perecntage of difference
95%Confidence interval of the difference
Post intervention comparison
62.97 ± 5.66 (57.14 -
77.77) -24.80% 13.53 20.2
46.10 ± 2.76 (42.85 - 50.79) 35.12 ± 4.97 (28.57 -
49.20)
(Non-parametric) r ( Parametric)
0.762 33.85 ± 4.09
(28.57 - 39.68)
0.14 (Small)
0.88 (Large)
P value a (2-tailed)
P=0 .646 (NS)
P=0 .000* *
P =0 .453 (NS)
10.371 P=0 .000 * *
Table 1: Basic Charact erist ics of t he subject s st udied.
a- Pear son Ch i-Squar e
Table 2: Analysis of CAHAI-9 score m eans w it hin M irror Therapy Group and Sham M irror Therapy Group.
* * St at ist ically Signif icant dif fer ence p<0.05 a. Par ed t t est . b. W ilcoxon Signed Ranks Test ; NS- Not significant
Table 3: Com parison of m eans of CAHAI-9 scorem eans bet w een M irror Therapy Group and Sham M irror Therapy Group.
35.12 62.97
33.85 46.10
0 10 20 30 40 50 60 70 80 90 100
M
e
a
n
s
o
f
C
A
H
A
I-9
s
c
o
r
e
s
M irror Therapy Group Sham Therapy Group
Preint er vent ion Postintervention
Chart 1: Analysis of CAHAI-9 score m eans w it hin Groups.
The above gr aph show s t hat w hen m eans of CAHAI-9 scores analyzed fr om pr e t o post int ervent ion in M ir ror Therapy Group and Sham M irror Therapy Group t here is a st at ist ically signif icant im pr ovem ent in Post m eans w it h p<0.000.
Chart 2: Com parison of m eans of CAHAI-9 score bet ween t he Groups.
35.1 2 33.8 5
62.97
46.1 0
0 10 20 30 40 50 60 70 80 90 100
M
e
a
n
s
o
f
C
A
H
A
I-9
s
c
o
re
s
Preinte rvent ion Postinterve ntion
M irror Therapy Group Sham Therapy Group
The above gr aph show s t hat w hen pr e-int er vent ion m eans w ere com par ed bet w een t he groups found t hat t here is no st at ist ically significant difference in m eans of CAHAI-9 scores. When m eans of post int ervent ion com pared t here is a st at ist ically significant dif ference in m eans of CAHAI-9 scores bet w een t he groups.
DISCUSSION
Jill W hit all et al20 suggest ed t hat r epet it ive
bilat eral arm t raining improves funct ional motor perform ance of t he paret ic upper ext rem it y. Im ager y hand m ovem ent s could st im ulat e rest it ut ion and redist ribut ion of brain act ivit y w hich accompanies recovery of hand funct ion t hus result ing in a reduced mot or deficit . Decet y and colleagues have show n t hat im agery of m ovement s act ivat es largely t he same brain areas t hat are act ivat ed w hen movement s are act ually execut ed. Furt hermore, even passive observat ion of movement has been show n t o act ivat e cor t ical m ot or areas. Sj oer d et al suggest ed t hat t he mot or syst em can also be act ivated “ offline” by imagining (mot or imagery) or observing movement s.21
In mirror t herapy group, improvement in means of CAHAI-9 could be because of effect s of home based mirror feedback t herapy, bimanual act ivit y for bot h hands, and convent ional exercises. Dur i n g m i r r o r p r act ices su b j ect s p r act ice consist ed of non-paret ic side movement s w hile subject looked int o t he m irror w at ching t he im age o f t hei r n on inv olv ed hand. Sever al underlying mechanisms for t he effect of mirror therapy on motor recovery after stroke have been proposed. Alt schuler et al22 suggest ed t hat t he
m irror illusion of a norm al m ovement of t he affect ed hand m ay subst it ut e for decreased propriocept ive informat ion, t hereby helping t o r ecr u it t he pr em o t or cor t ex an d assi st i ng rehabilit at ion t hrough an int imat e connect ion bet w een visual input and pr em ot or areas. St evens and St oykov suggest ed t hat m irror t herapy relat ed t o mot or imagery and t hat t he m irror creat es visual feedback of successful performance of t he imagined act ion w it h t he impaired limb. M ot or imagery it self, t he mental perform ance of a m ovem ent w it hout overt execut ion of t his movement , has proven t o be pot ent ially beneficial in t he rehabilit at ion of hemiparesis.6
In m irror t herapy, t he effect of m irror visual illusions on brain act ivit y has been invest igat ed in a number of st udies. Garry et . al performed t ranscranial magnet ic st imulat ion during mirror i l lu si on i n h eal t h y su b j ect s an d sh ow ed increased excit abilit y of primary mot or cort ex (M 1) of t he hand behind t he m ir ror. M ir ror neurons are bimodal visuomot or neurons t hat The st udy found t hat t here is st at ist ically and
cli nically sign if icant im pr ovem ent in h and funct ions in subject s w ho received home based mirror t herapy w it h convent ional t herapy t han t he subject s w ho received sham mirror t herapy w it h convent ional t herapy for a period of 4 w eeks.
are act ive during act ion observat ion, ment al st imulat ion (imagery), and act ion execut ion. It has been show n t hat passive observat ion of an act ion facilit at es M 1 excit abilit y of t he muscles used in t hat specific act ion. Anot her possible m echanism f or t he ef f ect iveness of m irr or t herapy might be bilat eral arm t raining. In t he present st udy t he pat ient s w ere informed t o move t he paret ic hand as much as t hey could w hile moving t he nonparetic hand and wat ching t he image in t he mirror in t he bilat eral t raining approach.10 Sum m ers et al invest igat ed t he
ef f ect iveness of bilat er al ar m t r aining and report ed t hat compared w ith unilat eral training, bilateral training intervention was more effective in f acilit at ing upper lim b m ot or funct ion in chronic st roke pat ient s.4 Carson suggested t hat
w hen the nonparet ic limb engaged during motor t raining, crossed facilit at ory drive from t he int act hemisphere give rise t o increased excit abilit y in t he hom ologous m ot or pat hw ays of t he paret ic limb, facilit at ing recovery of funct ion.4
Bo t h t he gr o u p r ecei v ed h o m e b ased convent ional exercises as common t reat ment prot ocol t hat m ight have also influenced in i m p r o vi n g h and f un ct io n s. Th e ef f ect o f co nv en t i o n al exer cises cau ses co r t ical reorganizat ion, the mechanism probably reflect s eit her an increase in t he excit abilit y of neurons already involved in t he innervat ion of m ore affect ed hand m ovem ent s or an increase in excit ab le neu r on al t i ssu e in t he in f ar ct ed hem isphere.23 M ot or act ivit y in t he affect ed
hand result s in recruit ment of t he cort ical areas along w it h t he infarct rim , secondary mot or ar eas in t he cont r alat eral hem ispher e and ipsilat eral hemisphere mot or areas.
The post int ervent ion com parison of m eans found no significant difference bet w een t he groups in improvement of funct ional act ivit ies, how ever t he subject s in M irror t herapy found great er percent age of im provem ent in hand funct ion by percent age of change 79.29% t han the subject s in sham mirror therapy w ith 36.18%. There is clinical significant improvement in post int ervent ion mean w it h large effect size in bot h groups w it h +0.88.
In t his st udy t he improvement s in hand funct ion was analyzed based on Chedoke Arm and Hand Activit y Inventory Scale t hat has a high inter rat er
reliabilit y and more sensit ive. Even if t he st udy has found improvement in out come, t he st udy w as carried for a period of 4 w eek w herein t he hand funct ion aft er 4 w eeks was not st udied with follow up.
Therefore, based on t he findings t he present st u d y f o u nd t hat t h er e i s a st at i st i cal l y significant effect of mirror t herapy as a home p r ogr am o n f u n ct i o nal han d r ecov er y i n rehabilit at ion of hand funct ion in sub-acut e st roke t han sham t herapy. Hence, t he present reject s null hypot hesis.
Th e st ud y is w it h sev er al li m i t at i on s: Improvement s w ere found based on 4 w eeks of int ervent ion, follow -up w as not done t herefore long t erm effect s w ere not found. Only hand funct ional recovery w as measured. St udy w as carried only on subacute and right dominant side hem iplegeia.
It is recommended for fut ure research t o find t he long t erm effect of m irror t herapy w it h convent ional exercises as a home program w it h follow up , t o find t he effect s of mirror t herapy in st roke pat ient s w it h apraxia or neglect w it h ot her percept ual disorders, t o com pare t he home based mirror t herapy w it h ot her mot or imagery t echniques, t o find the variable durat ion and frequency of home based mirror therapy and exercise paramet ers t o invest igat e t he effect of d i f f er en t exer ci se r egi m es, t o f i n d t h e eff ect iveness of m ir ror t her apy on specific act ivit ies of t raining during mirror t herapy, and t o find t he effect of home based mirror t herapy using ot her out come measure such as sensory and m ot or recover y, and qualit y of life are needed.
CONCLUSION
Acknow ledgem ent:
Aut hors w ere expressing t heir sense of grat it ude’s t o t he p eo pl e w ho h el p ed and en co ur aged t h em f o r t h e com plet ion of t his st udy, Special t hanks t o M r. Ajish Geo r ge, h u sb an d o f Fem y M o l Bab y, w h o h el p ed t hroughout t his st udy.
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Conflicts of interest: None
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