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What is Mirror Therapy (MT)?

Informally known as mirror box therapy.
It’s the use of a mirror to create a reflective illusion of an affected limb in order to trick the brain into thinking movement has occurred without pain.

The box has one mirror in the center, on each side the arms/legs are placed in a manner that the affected limb is kept covered and the unaffected limb is kept on the side whose reflection can be seen on the mirror.

This sends a visual stimulus to the brain to promote movement in the affected limb.

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What happens to the body during a stroke?�

A stroke is a disease that affects the arteries leading to and within the brain.
Occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or ruptures. When this happens, part of the brain cannot get the blood and oxygen it needs and brain tissues begin to die off.
Ischemic Stroke - a stroke caused by a clot obstructing the flow of blood to the brain (most common, about 87% of cases).
Hemorrhagic Stroke - a blood vessel ruptures and prevents blood flow to the brain (15% of cases).
If a stroke occurs and blood flow can't reach the region that controls a particular body function, that part of the body will not respond as normal.

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Ischemic Stroke vs. Hemorrhagic Stroke�

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Common Post-Stroke Complications�

Loss of motor function in skeletal muscle causes the individual to lose independent motility.
Depressive symptoms can develop due to loss of tissue & neuron connections.
Loss of cognition includes speech loss, emotional distress, impaired perception, loss of senses, and memory loss.
Worsened quality of life overall.
Rehabilitation is necessary in most cases to gain lost functions. Some can be recovered in less than 12 months but more severe function loss may take many years to recover.

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How MT for stroke rehabilitation works�

During mirror therapy, the patient performs various stroke recovery exercises with the non-affected side.
The mirror image ‘tricks’ the brain into thinking the affected side is moving like the unaffected side.
If a specific area of the brain is damaged (from a stroke) that area of the brain can no longer send specific commands to the body.
However, neuroplasticity allows the brain to modify its organization through the creation of new connections between neurons.
Some of the success can be attributed to the mirror neurons in the brain.
Mirror Neurons are activated if someone is imitating or manipulating an action or object. Imitating is important for learning and planning actions.
Mirror neurons are only activated if someone watches an action that they can do them self.

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MT Used to Rehabilitate Daily Living Activities�

The objective of the study was to compare improved motor function of the upper extremities of stroke patients receiving mirror therapy versus stroke patients receiving conventional therapy 6 months post stroke diagnosis.
Function of UE was tested using ARAT: Action Reach Arm Test; FMA: Fugl-Meyer Assessment; BBT: Box and Block Test as well as activities of daily living through a FIM: Functional Independence Measure.
25 participants took pre-tests 1 week before the respective therapy and a post-test after the completion of therapy.
Each group participated in therapy for 30 minutes a day, 5 x week, for 4 weeks.
Exercises were performed individually 10 x each. Exercises included reaching, grasping, manipulation, towel folding, table wiping, sponge squeezing, pegboard, card turnover, and typing

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MT Used to Rehabilitate Daily Living Activities�

Both the mirror therapy group and conventional therapy group showed improvement in function and daily living activities between the pre and post-tests.
MT group showed a statistically significant increase and greater improvement in both function and daily living activities.
As compared to other studies, it is suggested that mirror therapy activates the premotor area of the brain damaged by stroke complications stimulating neuroplasticity throughout the primary motor area. Therefore motor function is partially restored throughout the skeletal muscle¹.

Kantak SS, Stinear JW, Buch ER, et al.: Rewiring the brain: potential role of the premotor cortex in motor control, learning, and recovery of function following brain injury. Neurorehabil Neural Repair, 2012, 26: 282–292. [Medline][CrossRef]

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Mirror therapy on rehabilitation of lower limb motor function in patients with stroke hemiplegia�

Over the course of three months 36 hemiplegia patients were placed in either a mirror therapy group or general rehabilitation group (18 each).
Both groups received general rehabilitation, however the MT group was given additional rehabilitation through mirror therapy

The Gen. rehab. Group Performed the same movements but were allowed no visual aids or imagery.

The Brainstorm stage of lower limb motor function (Brunnstrom scale), Berg Balance scale, Functional Ambulation Category scale (FAC) and Functional Independence Measurement (FIM) test were all utilize in this study

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General overview of test performed �

Balance scale: 14 stages of recovery including sitting balance, standing balance (i.e. standing on one foot) & dynamic balance (i.e. sitting to standing)
Functional ambulation scale: 5 category scale ranging from “lyer” to “outdoor walker”
Functional independence measurement scale: 18 scale system based on physical, psychological and social function. Assess disability

Brunnstrom scale: six classified stages of recovery

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Results: Mirror therapy on rehabilitation of lower limb motor function in patients with stroke hemiplegia �

Both groups of being MT and Gen. Rehab. Had a statistically significant increase in mobility after treatment
Results of MT group concluded that there was a more prevalent increase than that of Gen. Rehab.
fMRI scans concluded that MT patients had more activation of the M1 (primary motor cortex) area opposite to the stroke side in the brain when contrasted, Gen. Rehab showed no obvious change

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The Effect of MT on the balance ability of subacute stroke patients

The experiment was performed 5 days a week for 4 weeks
A group of 34 patients were split into two groups:
Experimental group: Mirror Therapy (n=17)
Control group: Sham therapy (n=17)
Mirror therapy group: Patients received 30 minutes of conventional rehabilitation therapy and 30 minutes of mirror therapy per day, including a 10 minute break between sessions.
Sham therapy group: Patients received 30 minutes of conventional rehabilitation therapy and 30 minutes of sham therapy per day, including a 10 minute break between sessions.

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What is being measured?

The study is measuring for the Balance Index (BI) of each patient in the group. The balance measuring system (Balance System SD, Biodex, NY, USA) is used, which incorporates a specific monitor and a moveable force platform, that has a feedback system that delivers the overall stability index, the anterior/posterior stability index, and the medial/lateral stability index.
The lower the BI index the greater your balance ability.

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First Method (modified version by Sütbeyazet al.)

Starts out with a mirror mounted on a stand tilted toward the paretic side of the body. Both groups were in a semi-seated position and completed these exercises:
Hip-knee ankle flexion
Knee extension with ankle dorsiflexion
Knee flexion beyond 90 degrees
Experimental group: The reflective surface was facing the non-paretic leg, preventing from seeing the paretic leg.
Control group: The reflective surface was covered with white fabric

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Second method: Balance training (modified method by Valliant et al)

Patients placed a chair in front of a full length mirror
Exercise consisted of sitting and standing up from the chair while keeping the feet parallel.
Experimental group: Conducted the exercises in front of the full length mirror
Control group: Conducted the exercise without the full length mirror

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Results

Initially, there were no significant differences in the baseline BI for patients. However, after performing both methods on each group, The BI index of patients significantly decreased.
This means that there was an increase in the balancing ability of the patients.
In conclusion, mirror therapy may in fact help with the overall stability and balance of a subacute stroke patient. Further studies should be performed with larger samples to get a more accurate results.

	EG (n = 17)			CG (n = 16)			t	p
	Pre	Post	CWG	Pre	Post	CWG	t	p
Overalla	5.29 (0.79)	4.32 (1.12)	0.97 (0.59–1.34)*	5.31 (0.87)	5.08 (0.88)	0.23 (0.19–0.45)*	−2.155	0.038
A/P	4.42 (0.43)	4.10 (0.51)	0.32 (0.10–0.54)*	4.43 (0.45)	4.27 (0.51)	0.16 (0.01–0.31)*	−0.983	0.333
M/La	4.27 (0.42)	3.33 (0.67)	0.94 (0.67–1.21)*	4.06 (0.44)	3.89 (0.45)	0.17 (0.37–0.30)*	−2.816	0.008

Table 2. Comparison of balance within and between groups (n = 33) (unit: degree).

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References

Kim, M.- K., Ji, S.- G., & Cha, H.- G. (2016). The effect of mirror therapy on balance ability of subacute stroke patients. Hong Kong Physiotherapy Journal, 34, 27–32. doi: 10.1016/s1013-7025(16)30025-2.

Kyunghoon Kim, Sukmin Lee, Donghoon Kim, Kyoungbo Lee, & Youlim Kim. (2016). Effects of mirror therapy combined with motor tasks on upper extremity function and activities daily living of stroke patients. Journal of Physical Therapy Science, 28(2), 483–487. Retrieved from https://search-ebscohost.com.libez.lib.georgiasouthern.edu/login.aspx?direct=true&db=cc m&AN=113643216.

Li, S. Francisco, G., (2015). New insights into the pathophysiology of post stroke spasticity. Frontiers in Human Neuroscience. 9(129) Retrieved fromhttps://www.researchgate.net/publication/275526688_New_insights_into_the_pathophysiology_ of_post-stroke_spasticity/link/5547895f0cf2e2031b36ef60/download

Mamoru Yoshida, H., Barreira, J., & Teixeira Fernandes, P. (2019). Motor skills, depressive symptoms and cognitive functions in post-stroke patients. Fisioterapia e Pesquisa, 26(1), 9–14. https://doi-org.libez.lib.georgiasouthern.edu/10.1590/1809-2950/17001026012019.

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