Did your doctor/hospital bring this to your attention even though you are chronic and no longer seeing them? It has been over ten years.
Motor Recovery and Cortical Reorganization After Mirror Therapy in Chronic Stroke Patients: A Phase II Randomized Controlled Trial
Abstract
Objective.
To evaluate for any clinical effects of home-based mirror therapy and subsequent cortical reorganization in patients with chronic stroke with moderate upper extremity paresis.
Methods.
A total of 40 chronic stroke patients (mean time post .onset, 3.9 years) were randomly assigned to the mirror group (n = 20) or the control group (n = 20) and then joined a 6-week training program. Both groups trained once a week under supervision of a physiotherapist at the rehabilitation center and practiced at home 1 hour daily, 5 times a week. The primary outcome measure was the Fugl-Meyer motor assessment (FMA). The grip force, spasticity, pain, dexterity, hand-use in daily life, and quality of life at baseline—posttreatment and at 6 months—were all measured by a blinded assessor. Changes in neural activation patterns were assessed with functional magnetic resonance imaging (fMRI) at baseline and posttreatment in an available subgroup (mirror, 12; control, 9).
Results.
Posttreatment, the FMA improved more in the mirror than in the control group (3.6 ± 1.5, P < .05), but this improvement did not persist at follow-up. No changes were found on the other outcome measures (all Ps >.05). fMRI results showed a shift in activation balance within the primary motor cortex toward the affected hemisphere in the mirror group only (weighted laterality index difference 0.40 ± 0.39, P < .05).
Conclusion.
This phase II trial showed some effectiveness for mirror therapy in chronic stroke patients and is the first to associate mirror therapy with cortical reorganization. Future research has to determine the optimum practice intensity and duration for improvements to persist and generalize to other functional domains.
Introduction
From 55% to 75% of stroke survivors have a paretic arm1 that may improve primarily within 6 months.2 Further intensive training can lead to improved motor function and associated cortical reorganization.3 Yet these training programs often make use of expensive apparatus4 or require an intensive one-on-one interaction with a therapist,5 which hinders implementation on a large scale. Mirror therapy may be a suitable alternative. Designed by Ramachandran et al,6 mirror therapy was originally developed to diminish phantom limb pain in amputees. The reflection of the unimpaired arm in a mirror gave patients the sensation of having 2 moving arms, which led to a reduction in pain. In 1999, Altschuler et al7 introduced mirror therapy for recovery of hemiparesis following stroke. In a crossover design, they showed that motor performance of chronic stroke patients improved. Although several additional studies were small and often not well controlled,8-10 2 recent, high-quality, randomized controlled trials have also reported mirror therapy to improve motor function in patients with subacute11 and acute12 stroke.
Despite the encouraging clinical results, little is known about the underlying mechanisms of mirror therapy. Ramachandran et al6 referred to a “learned paralysis” in the brain, which could possibly be “unlearned” as a result of the mirror illusion.13 Other studies have attributed the positive effects of mirror therapy in stroke to motor imagery8 or the mirror neuron system.11 The prevailing idea is that observing mirrored movements causes additional neural activity in motor areas located in the affected hemisphere, which should eventually result in cortical reorganization and improved function. Research in healthy subjects has provided some evidence of such mechanisms, with the use of either transcranial magnetic stimulation14,15 or functional magnetic resonance imaging (fMRI).16 However, results of these studies are not conclusive, do not give insight into long-term neuronal changes, and do not necessarily apply to stroke patients.
The aim of this phase II study was 2-fold. First, we evaluated the effect of mirror therapy on upper extremity function in a group of chronic stroke patients. As the intervention had to be both effective and efficient, an unsupervised training program to be performed at home was developed and carried out with supervised weekly sessions. Our primary focus was on improvements in motor function, but to get a detailed insight in any effects of mirror therapy, outcomes were also measured at the other International Classification of Functioning, Disability and Health (ICF)17 domains. Second, we used fMRI to examine whether mirror therapy could induce cortical reorganization.
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