Mirror Therapy in Stroke Rehabilitation: Why, How Early, and Effects: A Meta-analysis

 

Useless. No indication that protocols were created and if they were, where they are located. 

Mirror Therapy in Stroke Rehabilitation: Why, How Early, and Effects: A Meta-analysis

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Dorcas B. C. Gandhi, Albert Sterba, Himani Khatter, ...

First Published December 21, 2020 Research Article 

https://doi.org/10.1177/2516608520974512

Article information

   

Abstract

Background and Aims:

The use of visual stimuli to facilitate a desired response in the affected limb in mirror therapy (MT) makes it an effective treatment modality even in instances of a complete plegic upper extremity poststroke. This article analyzes the effects of MT on impairments, activity limitation, and participation restriction in the acute and chronic phases poststroke.

Methods:

In total, 16 out of 3871 studies were included in the meta-analysis, using PRISMA guidelines. Data were categorized based on application in stroke rehabilitation (acute/chronic, motor/sensory/neglect/activity of daily living, upper limb/lower limb), modes and dosage of intervention delivery, types of control, and outcome assessment. RevMan 5.0 software was used for analysis.

Results:

Studies were equally distributed between chronic and acute phases. Therapy durations lasted between 1 and 8 weeks. Most studies intervened for upper limb motor impairments showing improvement in Brunnstrom motor recovery stages of arm (P value: .04, 95% CI, 0.05-1.54, I² = 59%) and hand (P value: <.001, 95% CI, 0.80-2.01, I² = 0%) during acute phase (0-4 weeks). “Activity/function” measured by functional independence measure showed improvement only in self-care subsection (P value: <.001, 95% CI, 2.05-5.16, I² = 0%). No long-term effects were analyzed in any of the included studies.

Conclusion:

A significant finding of this study is the role of MT in improving arm and hand impairments in acute phase poststroke. Rehabilitation protocols can be improved based on this finding. As MT is effective, affordable, and feasible, we have made suggestions toward its incorporation in physiotherapy protocols for low- and middle-income countries.

Keywords Stroke, rehabilitation, acute stroke, mirror therapy, mirror box therapy

Introduction and Aim

Rehabilitation as defined by the British Society of Rehabilitation Medicine is “a process of active change by which a person who has become disabled acquires the knowledge and skills needed for optimum physical, psychological and social function.”¹ Stroke rehabilitation defined by the World Health Organization (WHO) encompasses the coordinated delivery of intervention(s) provided by two or more disciplines in conjunction with medical professionals.² Rehabilitation, however, differs from recovery in that the latter depicts the mechanism underlying improvement, be it behavioral restitution or compensatory strategies.^{3, 4} Such recovery is driven by neuroplasticity that causes functional changes in both the ipsilesional and contralesional cortices^5-7 leading to recovery in motor and other systems⁸ poststroke.^{9, 10}

Furthermore, spontaneous recovery (SR) reflects the improvement in behavior of motor or other systems, in the absence of a specific and focused treatment. Such SR begins early after stroke, peaks around 4 weeks, tapers off gradually over 6 months, and exists for different time-periods for various systems of the body.^11-20 On the other hand “true recovery” (TR) or behavioral restitution is defined as a return to more normal patterns of motor control that was available before the injury^{21, 22} and requires neural repair.⁸ Recovery could also be achieved via “compensation,” which is the patient’s ability to achieve a goal by substituting prestroke functioning with a new approach.⁸ This requires relearning rather than neural repair. Most rehabilitative strategies are based on this principle, using intact muscles, joints to accomplish a desired task.^{21, 22}

Mirror therapy (MT) is one among few physical rehabilitative approaches that allows for TR through neural reorganization via the mirror neuron system (MNS)²³ unlike most of the others that use compensatory strategies. This advantage along with the possibility of using MT even in complete plegic upper extremity (as it uses visual stimuli to produce a desires response²⁴) makes MT advantageous in stroke rehabilitation. MT, a form of enriched environment, can be applied in various forms as per need, using multisensory inputs like visual, tactile sensations, action-observation strategies to facilitate a desired rehabilitative output.¹⁰ Studies have reported that such an exposure promotes recovery of sensorimotor function in animal models^{25, 26} and healthy human subjects.^{27, 28} A review on the current perspectives of MT revealed that it has positive effects on the improvement of not just motor outcomes but on the sensory system as well as in treating unilateral neglect.²⁴ Investigating the detailed role and effects of MT in poststroke patients in achieving improved recovery and better clinical outcomes is therefore needed to inform better management and rehabilitation practices.

Stroke in Asia accounts for more than two-thirds of the overall stroke incidence across the world²⁹ with almost 60% presenting with upper limb impairments and only 5% to 20% showing complete functional recovery.³⁰ Our findings will direct clinical practice in terms of how early to start MT and what effect it may have in these 2 poststroke phases. MT has a potential for wide application in low- and middle-income countries (LMICs), considering the simplicity of its application, affordability, and feasibility established in our previous review.²⁴

Our aim is to determine the role of MT in improvement of ICIDH-2 (International Classification of Functioning, Disability, and Health) based outcomes of impairment, functional limitation, and participation restriction in the acute and chronic phases poststroke.