Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contact us Login 
  • Users Online:298
  • Home
  • Print this page
  • Email this page


 
 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 262-265

Role of mirror therapy in management of stroke – Current and future perspectives


1 Department of Medical Surgical Nursing, Vinayaka Missions Annapoorana College of Nursing, Vinayaka Mission's Research Foundation - Deemed to be University, Salem, Tamil Nadu, India
2 Department of Obstetrics and Gynaecological Nursing, Vinayaka Missions Annapoorana College of Nursing, Vinayaka Mission's Research Foundation - Deemed to be University, Salem, Tamil Nadu, India

Date of Submission01-Aug-2022
Date of Acceptance01-Dec-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Ms. Deepa Ramaswamy
Department of Medical Surgical Nursing, Nursing Research Scholar, Vinayaka Missions Annapoorana College of Nursing, Vinayaka Mission's Research Foundation - Deemed to be University, Salem, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_182_22

Rights and Permissions
  Abstract 


Mirror therapy (MT) is a sort of therapy that makes use of vision for managing pain in persons with amputated limbs or weakness in stroke patients. Mirror treatment works by deceiving the brain by making it appear as though the missing limb or weaker limb is moving while the patient looks at the actual, functional limb in a mirror. By doing this, the brain conceals the fact that the amputated limb itself does not provide any signals of movement. Although very encouraging, MT has notable drawbacks that researchers are desiring and working hard to resolve so that it could be applied in treating more composite movements or pain of several types. Stroke has been the third biggest cause worldwide for the years of life lost (YLL); the age-standardized YLL grew by 12.9% (10.6–15.2) between 1990 and 2007 and by 12.1% (9.9–14.1) between 2007 and 2017. MT is a kind of rehabilitation method where the movement of an unaffected limb creates the illusion that the affected limb is also moving, for which a mirror is positioned amidst the legs or arms.

Keywords: Amputation, mirror therapy, pain, stroke


How to cite this article:
Ramaswamy D, Parimala S. Role of mirror therapy in management of stroke – Current and future perspectives. Arch Med Health Sci 2022;10:262-5

How to cite this URL:
Ramaswamy D, Parimala S. Role of mirror therapy in management of stroke – Current and future perspectives. Arch Med Health Sci [serial online] 2022 [cited 2023 Jan 31];10:262-5. Available from: https://www.amhsjournal.org/text.asp?2022/10/2/262/364957




  Introduction Top


Mirror therapy (MT) is a sort of therapy that makes use of vision for managing pain in persons with amputated limbs or weakness in stroke patients. Mirror treatment works by deceiving the brain by making it appear as although the missing limb or weaker limb is moving while the patient looks at the actual, functional limb in a mirror.[1] By doing this, the brain conceals the fact that the amputated limb itself does not provide any signals of movement. Although very encouraging, MT has notable drawbacks that researchers are desiring and working hard to resolve so that it could be applied in treating more composite movements or pain of several types.[2] Stroke has been the third biggest cause worldwide for the years of life lost (YLL); the age-standardized YLL grew by 12.9% (10.6–15.2) between 1990 and 2007 and by 12.1% (9.9–14.1) between 2007 and 2017. Between 2007 and 2017, the number of stroke-related deaths worldwide rose from 5.29 million (5.22–5.40) to 6.17 million (6.04–6.33).[3] In consequence, the “disability-adjusted life years” resulting from stroke grew from 3.54% to 9.66% between 1990 and 2013, and there were roughly 25.7 million stroke survivors worldwide by 2013.[4] Over the past 40 years, stroke rates have increased by 100% in low income and middle-income countries (LMIC)and decreased by 42% in high-income countries.[5] About 60%–80% of survivors show upper or lower limb motor deficits during the acute poststroke phase. In contrast to 80% of mildly paretic stroke patients, only 20% of severely paretic survivors regain complete function of the upper limb. Of stroke victims who initially presented with paralyzed upper and lower limbs, 50% eventually get back some motor function.[6] About 50% of stroke patients report painful upper limbs in the 1st year after their stroke, especially in the shoulder region, and “complex regional pain syndrome type I”, which interferes with their everyday activities (activities of daily living [ADL]). Neuroplasticity must produce recovery through repetitive, rigorous, and task-specific rehabilitation techniques. According to reports, when the intervention starts within 16 h to 6 months after a stroke, ADL performance significantly improves with added exercise therapy.[7] MT, which uses visual rather than somatosensory inputs for producing the required response in the damaged limb, can be employed even by fully plegic, stroke survivors with severe weakness, in comparison to several therapy modalities which require several degrees of movement voluntarily.[8] The objective of this review is to summarize the role and effectiveness of MT in the management of stroke and its impact on improving the outcomes of stroke. This review can also serve to map the existing evidence and knowledge gaps related to MT.


  Mechanisms of Mirror Therapy Top


Numerous theories have been put forth regarding the neurophysiological underpinnings of MT. According to one theory, the superior temporal gyrus (STG) and frontotemporal region contain a mirror neuron system that fires when a hand motion is directed toward a goal or when someone else performs a motion that is comparable to it.[9] The corticospinal pathway is promoted by action observation, which enhances the function of the motor system by evoking mental imagery and fostering motor learning. The STG is hypothesized to be activated by observation of biological motion, which helps the body recover from neglect. According to another theory, activation of the STG, precuneus, and posterior cingulate cortex may promote self-awareness and spatial attention.[10] The effects of MT include improved attention, conscious awareness of sensory feedback, and avoidance of learned nonuse of the injured limb. MT enhances activity in primary and secondary visual and somatosensory areas. Another theory explains how MT affects the ipsilateral and ordinarily dormant pathways of the motor system that originate in the hemisphere affected and project to the paretic side of the body ipsilaterally to activate and recruit them. It has also been proposed that by regulating the excitability of the primary motor cortex (M1), MT may help the hemispheres' balance return to normal following a stroke.[11] During MT, the excitability of M1 is affected by both active movement of the limb affected and passively watching the unaffected limb move while being reflected in a mirror. Brodmann area 4 (primary motor area) showed more activity following MT, according to Pandian JD et al. (restitution principle of neuroplasticity).[12] According to the theory behind MT, the visual input from the mirror prompts the mirror-neural system to divert motor impulses from the injured motor neurons and send them to the motor cortex instead. Hence, this rerouting trickles the brain to cause stimulation in the injured limb.[9] Another theory states that by utilizing the visual feedback mechanism, MT makes use of the neuroplasticity of the brain in causing stimulation in the affected limb.[10] According to Chan BL et al. and Pandian et al., the mechanisms underlying MT for stroke management include either the activation of mirror neurons in the contralateral hemisphere or the change of cortical activity by visual feedback of the envisioned action. Other possible theories or mechanisms on working of MT in conditions where there is no obvious peripheral source of pain (like phantom limb pain) include cortical reorganization of the homunculus as a result of the visual illusion of pain-free, normal movement, or the correction of the imbalance between motor control, proprioception, and vision.[11],[12]


  Application in Stroke Rehabilitation Top


MT is a kind of rehabilitation method where the movement of an unaffected limb creates the illusion that the affected limb is also moving, for which a mirror is positioned amidst the legs or arms.[13],[14],[15] According to the findings of the earlier investigations, an improvement in motor function of the upper limb was noted in terms of either gross or fine motor movements, better dexterity, reduced movement time, proximal motor control, and grip force. In one study by Mirela Cristina et al., MT combined with traditional rehabilitation led to improvements on the Ashworth Scale after 6 weeks.[16] After a stroke, sensory deficiencies were addressed at different stages, which enhanced response to tactile sensation and temperature and observed a reduction in poststroke pain.[15],[16] In earlier research, the use of MT led to improved lower extremity function as measured by Brunnstrom stages, increased single-limb stance, walking speed, lengths of steps, dynamic and static balance, and decreased anteroposterior and mediolateral, and sway during standing.[17] A systematic analysis of 33 research papers on MT conducted by Feigin VL et al. revealed that MT activates a widespread network in the brain that includes areas responsible for higher cognitive, motor, and perceptual functions. The results of this analysis point to the possibility that MT may influence perceptuo-motor control functions via various functional networks leading to increased activation of higher-order areas involved with attentional processes. Overall, the evidence from this systematic review suggests that MT may be used as a tool to promote functional recovery in patients.[18] It is being established that people with acute, subacute, and chronic strokes can all benefit from MT. An earlier systematic review by He et al. found that the treatment of swallowing function after stroke was promising when implemented early. This could help to explain why treatment outcomes in the acute and convalescent phases of stroke differ. The substantial heterogeneity between the subgroups may be the cause of the discrepancies between the pooled and subgroup analyses. In addition, because only a few trials were included in each category, it is probable that the subgroup analysis was unreliable. Multiple subgroup analyses can also produce erroneous results. To further understand these aspects, further extension is necessary.[19] MT (combined or not with other treatments) was more effective in improving neglect as compared to sham MT or no treatment (combined or not with the other therapies), according to a systematic review by Zhang et al. that included five randomized control trials (RCTs) in the data synthesis. MT (combined or not with other treatments) was also more effective in improving daily living activities as compared to the people with no treatment given.[20] The combination therapy of MT and noninvasive brain stimulation (NIBS) on the restoration of upper extremity motor function in stroke patients was analyzed through a systematic review by Zhao et al. According to this systematic study, NIBS and MT combination therapy is superior to either therapy alone for the recovery of upper extremity motor function following stroke.[21] Luo et al. also reported similar outcomes.[22] In addition, MT is a therapeutic approach that combines observation, imitation, and imagination. As a result, the technique is dependent on the vision and cognition of the patients being examined, which restricts its potential applications.


  Future Perspectives Top


The identification of MT's relationship to the different stroke presentations in men and women would be a future area of focus. Given the stroke severity, different risk factors, and neurological outcomes among males and females, MT for rehabilitation may need to be used differently depending on the gender. Research is also required to determine how MT affects different subtypes of stroke, including those with sensory and other components as well as pure motor strokes.[23] To set the stage, it is possible to look into the uses of MT in the rehabilitation of chronic and acute lacunar strokes, the increase in quality of life (QOL) resultingly and its long-term consequences. The majority of the scientific evidence that is currently available comes from studies of healthy adult participants, and the few research that has looked at patient populations primarily took stroke survivors into account. The applicability of these concepts to additional clinical disorders for which MT has been proposed as an adjuvant to standard therapy is still unknown. The effectiveness and underlying processes of MT in various groups, as well as any potential differences between them, will be examined in large-scale clinical trials that incorporate measurements of brain function and structure. Hence, high-quality clinical trials are required to completely comprehend and utilize the potential of MT in neurorehabilitation.


  Conclusion Top


Training the impairments in terms of sensory, motor, and perceptual deficits among poststroke patients in various phases such as chronic, subacute, and acute is practicable using MT. The addition of training on the bilateral arm enhances the reaction of the patients toward MT. It is necessary to do in-depth analyses in larger populations of the required MT dosage, influence on QOL and ADL, and long-term effects concerning different subtypes of stroke. The effectiveness of a suitable MT regimen for both short- and long-term has to be determined in future high-quality RCTs with fair methodological quality and larger sample sizes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Thieme H, Morkisch N, Mehrholz J, Pohl M, Behrens J, Borgetto B, et al. Mirror therapy for improving motor function after stroke. Cochrane Database Syst Rev 2018;7:CD008449.  Back to cited text no. 1
    
2.
Gandhi DB, Sterba A, Khatter H, Pandian JD. Mirror therapy in stroke rehabilitation: Current perspectives. Ther Clin Risk Manag 2020;16:75-85.  Back to cited text no. 2
    
3.
GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: A systematic analysis for the global burden of disease study 2017. Lancet 2018;392:1736-88.  Back to cited text no. 3
    
4.
Feigin VL, Krishnamurthi RV, Parmar P, Norrving B, Mensah GA, Bennett DA, et al. Update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: The GBD 2013 study. Neuroepidemiology 2015;45:161-76.  Back to cited text no. 4
    
5.
Ferri CP, Schoenborn C, Kalra L, Acosta D, Guerra M, Huang Y, et al. Prevalence of stroke and related burden among older people living in Latin America, India and China. J Neurol Neurosurg Psychiatry 2011;82:1074-82.  Back to cited text no. 5
    
6.
Hata J, Kiyohara Y. Epidemiology of stroke and coronary artery disease in Asia. Circ J 2013;77:1923-32.  Back to cited text no. 6
    
7.
Feigin VL, Roth GA, Naghavi M, Parmar P, Krishnamurthi R, Chugh S, et al. Global burden of stroke and risk factors in 188 countries, during 1990-2013: A systematic analysis for the global burden of disease study 2013. Lancet Neurol 2016;15:913-24.  Back to cited text no. 7
    
8.
Madhoun HY, Tan B, Feng Y, Zhou Y, Zhou C, Yu L. Task-based mirror therapy enhances the upper limb motor function in subacute stroke patients: A randomized control trial. Eur J Phys Rehabil Med 2020;56:265-71.  Back to cited text no. 8
    
9.
Lamont K, Chin M, Kogan M. Mirror box therapy: Seeing is believing. Explore (NY) 2011;7:369-72.  Back to cited text no. 9
    
10.
Buccino G, Solodkin A, Small SL. Functions of the mirror neuron system: Implications for neurorehabilitation. Cogn Behav Neurol 2006;19:55-63.  Back to cited text no. 10
    
11.
Chan BL, Witt R, Charrow AP, Magee A, Howard R, Pasquina PF, et al. Mirror therapy for phantom limb pain. N Engl J Med 2007;357:2206-7.  Back to cited text no. 11
    
12.
Pandian JD, Arora R, Kaur P, Sharma D, Vishwambaran DK, Arima H. Mirror therapy in unilateral neglect after stroke (MUST trial): A randomized controlled trial. Neurology 2014;83:1012-7.  Back to cited text no. 12
    
13.
Ezendam D, Bongers RM, Jannink MJ. Systematic review of the effectiveness of mirror therapy in upper extremity function. Disabil Rehabil 2009;31:2135-49.  Back to cited text no. 13
    
14.
Bhasin A, Padma Srivastava MV, Kumaran SS, Bhatia R, Mohanty S. Neural interface of mirror therapy in chronic stroke patients: A functional magnetic resonance imaging study. Neurol India 2012;60:570-6.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Schwerin S, Dewald JP, Haztl M, Jovanovich S, Nickeas M, MacKinnon C. Ipsilateral versus contralateral cortical motor projections to a shoulder adductor in chronic hemiparetic stroke: Implications for the expression of arm synergies. Exp Brain Res 2008;185:509-19.  Back to cited text no. 15
    
16.
Mirela Cristina L, Matei D, Ignat B, Popescu CD. Mirror therapy enhances upper extremity motor recovery in stroke patients. Acta Neurol Belg 2015;115:597-603.  Back to cited text no. 16
    
17.
Tyson S, Wilkinson J, Thomas N, Selles R, McCabe C, Tyrrell P, et al. Phase II pragmatic randomized controlled trial of patient-led therapies (Mirror Therapy and Lower-Limb Exercises) during inpatient stroke rehabilitation. Neurorehabil Neural Repair 2015;29:818-26.  Back to cited text no. 17
    
18.
Deconinck FJ, Smorenburg AR, Benham A, Ledebt A, Feltham MG, Savelsbergh GJ. Reflections on mirror therapy: A systematic review of the effect of mirror visual feedback on the brain. Neurorehabil Neural Repair 2015;29:349-61.  Back to cited text no. 18
    
19.
He K, Wu L, Ni F, Li X, Liang K, Ma R. Efficacy and safety of mirror therapy for post-stroke dysphagia: A systematic review and meta-analysis. Front Neurol 2022;13:874994.  Back to cited text no. 19
    
20.
Zhang Y, Xing Y, Li C, Hua Y, Hu J, Wang Y, et al. Mirror therapy for unilateral neglect after stroke: A systematic review. Eur J Neurol 2022;29:358-71.  Back to cited text no. 20
    
21.
Zhao Q, Li H, Liu Y, Mei H, Guo L, Liu X, et al. Non-invasive brain stimulation associated mirror therapy for upper-limb rehabilitation after stroke: Systematic review and meta-analysis of randomized clinical trials. Front Neurol 2022;13:918956.  Back to cited text no. 21
    
22.
Luo Z, Zhou Y, He H, Lin S, Zhu R, Liu Z, et al. Synergistic effect of combined mirror therapy on upper extremity in patients with stroke: A systematic review and meta-analysis. Front Neurol 2020;11:155.  Back to cited text no. 22
    
23.
Wu CY, Huang PC, Chen YT, Lin KC, Yang HW. Effects of mirror therapy on motor and sensory recovery in chronic stroke: A randomized controlled trial. Arch Phys Med Rehabil 2013;94:1023-30.  Back to cited text no. 23
    




 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Mechanisms of Mi...
Application in S...
Future Perspectives
Conclusion
References

 Article Access Statistics
    Viewed222    
    Printed10    
    Emailed0    
    PDF Downloaded32    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]