1. Allama Iqbal Medical College, Lahore, Pakistan; wardaanam@gmail.com
2. Allama Iqbal Medical College, Lahore, Pakistan; supergirl2021@gmail.com
3. Kinnaird College for Women University, Lahore; muhammadanas@gmail.com

*             Correspondence: wardaanam@gmail.com

Keywords: effectiveness, mirror therapy, conventional therapy, patients, stroke

1. INTRODUCTION

Over 730,000 Americans have a new or recurrent stroke each year, accounting for $35 billion in direct and $21.8 billion in indirect health care expenses. Approximately 566 000 stroke survivors experience hemiparesis, which impairs one or more upper extremities immediately following the stroke. Three to six months later, between five and seventy-five percent of survivors still have functional limitations in their upper extremities, which are linked to a lower quality of life related to health. More recent approaches that involve constant exercise of the paretic upper extremities on task-oriented activities show indications of effectiveness among survivors of stroke who retain some ability to actively extend the thumbs and forearms of their paretic upper extremity [1]. Traditional methods for rehabilitation among patients with limited upper extremity function after stroke, such as neurodevelopmental techniques, have not been shown to be effective in controlled studies. Stroke is the most common cause of disability among adults and is often associated with a significant loss of motor function. According to public health statistics, there has been a rise in stroke cases in Thailand. While most stroke patients who receive rehabilitation have some improvement in their function, each patient’s progress varies greatly. Eighty percent of stroke patients make it through the acute phase. Thirty to sixty-six percent of survivors are unable to use the damaged arm, even though the majority of patients are able to walk again [2]. Compared to the lower extremities, the upper extremities frequently heal from injury more slowly. The hypothesis of “learned nonuse” states that frequent setbacks when attempting to use the affected arm throughout the acute and subacute phases can result in the affected arm being negatively reinforced. Even though spontaneous recovery and rehabilitation may eventually lead to a progressive return of motor function, actual use frequently appears to be far less than potential use. After a stroke, very few, if any, rehabilitation techniques have been shown to improve learned nonuse or restore function in the afflicted upper extremity. Today’s demanding society and the healthcare environment frequently demand that the highest functioning level be attained in the shortest amount of time. Because of this, a patient’s option for therapy frequently focuses on compensating for lost movement by performing activities of daily living (ADL) predominantly on the side unaffected by the stroke. Even with one arm, the person’s abilities may still be restricted when performing ADL duties. Consequences from overusing one side of the body excessively include discomfort, frustration, embarrassment, and overuse syndromes [2]. One typical and unwanted after effect of stroke that increases activity limitation is the paretic upper limb. According to reports, between 55% and 75% of stroke survivors still have impairments with upper-extremity functioning, and up to 85% of stroke patients develop hemiparesis [3]. Numerous interventions, including paretic arm exercise training, impairment-oriented arm training, functional electric stimulation, robotic-assisted rehabilitation, and bilateral arm training, have been published assessing the effectiveness of rehabilitation techniques in enhancing upper-extremity motor control and functioning [4–6]. It is challenging to provide intense treatment for every patient, nevertheless, because the majority of treatment protocols for the paretic upper extremity are labor-intensive and call for one-on-one manual engagement with therapists for several weeks [7]. Mirror therapy has been proposed as a straightforward, low-cost, and most crucially, patient-directed treatment that may enhance upper-extremity function. Mirror therapy (MT) has been suggested as a possible alternative that may be advantageous. With this method, the patient is shown the mirror image of their unaffected arm as though it were the diseased one by placing a mirror in the midsagittal plane. For arm amputees, Ramachandran and colleagues first proposed this method, which involved simulating the amputated arm using the mirror image of the intact arm. This process created false impressions and frequently eased phantom pain in the “virtual” limb [8]. After a stroke, MT was also suggested to relieve chronic hemiparesis [9]. The neurophysiological basis of MT has been further supported. An imaging experiment revealed that lateralized cortical activations can be elicited by inverting the visual picture of a hand [10]. Stated differently, using the right hand but thinking of it as a left hand causes the right hemisphere to get activated extra (and vice versa). Given that the first three months following a stroke are when recovery mechanisms are known to be most prominent [11], it makes sense to believe that MT would be most beneficial at this period. In conclusion, MT may be a more successful treatment for severe hemiparesis recovery than more traditional rehabilitation techniques that rely on active or passive movement execution. This is supported by mounting data. It’s still unknown, though, which symptoms are improveable. In order to assess the possible advantages of showing patients with severe hemiparesis the mirror image of their unaffected upper limb early on after a stroke, a single-blind, randomized trial was planned.  In order to provide the visual illusion of increased movement capabilities of the affected limb, mirror therapy for stroke patients entails moving the unimpaired limb while observing its mirror image superimposed over the (unseen) impaired limb [12]. Viewing a mirror image of the moving hand appears to promote excitability of the primary motor cortex ipsilateral to a unilateral hand movement, according to functional brain imaging studies conducted on healthy people [13]. In motor recovery following a stroke, ipsilesional reorganization of motor processes is likely to be crucial, and other brain regions in the afflicted hemisphere may also play a role [14]. The premotor cortex, the supplementary motor region, and the bilateral inferior parietal area can all become activated during motor task performance [15, 16].  Furthermore, after a stroke, Luft and colleagues showed that central changes take place in networks controlling both the paretic and nonparetic lower limb. The neuronal network involved in motor imagery and motor execution overlaps, especially in the premotor and parietal regions, basal ganglia, and cerebellum. Actions generated by motor imagery follow the same movement rules and limitations that physical motions follow [17–19]. The purpose of this study was to test the hypothesis that functional restoration of the damaged lower extremity may be achieved through the use of a mirror to provide congruent visual feedback and motor imagery from the moving, nonparetic lower extremity.

2. LITERATURE REVIEW

Mirror therapy concentrates on visual input as opposed to most interventions that involve sensorimotor training techniques. A mirror placed between the two arms creates an inverse reflection when the unimpaired arm is moved. The injured arm appears to have greater movement capability due to the reflection of the unimpaired arm. Mirror treatment after a stroke is beneficial in improving short- and middle-term motor function, activities of daily living, and pain reduction, particularly in patients with complicated regional pain syndrome, according to a systematic Cochrane Review [20]. Mirror therapy has been shown in one research to improve visuospatial neglect following a stroke [21]. Regarding the effectiveness of mirror therapy in relation to the degree of motor impairment or the duration since the stroke began, no firm findings could be made. Mirror treatment was reported to be beneficial in one research, but only in patients who were paralyzed in the early stages following a stroke [22]. Other research, on the other hand, recruited individuals with moderate motor impairment and discovered noteworthy outcomes for these individuals. Studies conducted during the subacute phase following a stroke are also uncommon and equivocal. Research on the benefits of mirror therapy for the upper limbs has shown that individuals with chronic strokes benefit from greater squeezing strength, improved range of motion, improved speed and accuracy of movement, and improved motor function and motor recovery [23]. In patients with subacute stroke, mirror treatment has also been shown to improve upper limb motor recovery and self-care skills. Furthermore, it has been documented that mirror therapy improved the distal upper limb motor function in stroke patients.  However, further study is required to determine the best patient selection, application strategies, and mirror therapy’s duration and intensity. Moreover, relatively little research has been done on individuals who are more likely to benefit from mirror therapy—those who had an acute or subacute stroke within six months of its start [24]. The ability of the brain to heal itself is known as neuroplasticity, and it is a process that occurs in the brain. One of the most common neurological disorders in the world, particularly among the elderly, is stroke. This type of cerebrovascular illness can result in a range of symptoms and, in extreme situations, even death. One of the primary disabilities following a stroke is motor impairment. When a patient’s environment is not adjusted to meet their functional limitations—for instance, by not having assistive devices to help with everyday activities—their physical disability can have a significant negative impact on their quality of life. It has long been recognized that exercise and training can help improve motor function following a brain injury [25]. Rehabilitation and especially neurorehabilitation have become recognized as clinical specialties as a result of this fact. Substantial improvements in motor function following a stroke are largely attributed to innate physiological and anatomical plasticity; task-specific training combined with general aerobic exercise remains the gold standard for post-stroke rehabilitation. However, 15–30% of stroke patients remain permanently impaired after receiving intense task-specific training and engaging in physical exercise [26]. Therefore, in order to enable the rehabilitation of these individuals, research is currently being performed with the goal of developing novel therapies that improve neuroplasticity. Three distinct research arms that are all still in the early phases of development make up this field of study. The first research arm focuses on the pathophysiological causes of post-stroke paresis as well as the molecular and cellular mechanics of normal movement. A thorough comprehension of the pathophysiological mechanisms behind stroke-related paresis should result in better prognostic markers of functional recovery as well as more potent therapies than those that are now in use to enhance the relearning of lost motor function. The creation of pharmacological, biological, and electrophysiological methods that can strengthen training-induced plasticity is the focus of the second research arm [27]. The goals of these two study areas are to better understand and develop the adult central nervous system’s intrinsic plasticity in order to use this neurological mechanism to support post-stroke rehabilitation. However, the extent to which the adult brain is neuroplastic remains unclear, and the profound neuronal reconfiguration following hemispherectomy that is seen in children may not be intrinsically achievable in adults [28]. Therefore, the third research arm seeks to support functional recovery in the brain by applying developments in biomedicine and tissue engineering. Human ipsilesional and contralesional primary motor cortices, as well as the dorsal premotor cortex, have been identified as regions capable of significant post-stroke neuroplasticity. These findings are supported by structural and metabolic brain imaging, as well as electrophysiological recording of the primary motor cortices. Because of the evidence for this brain activity, scientists are looking into potential post-stroke recovery prediction methods. These studies have led to the hypothesis that stroke patients who show evidence of ipsilesional motor cortex evoked potentials to transcranial magnetic stimulation and low contralesional primary motor cortex activity may be better able to recover from stroke-related motor deficits than those who do not [29, 30]. The study was recommended to stroke patients by their doctors or physical therapists. The following criteria were used to screen and invite patients to the study: (a) they had to be between the ages of 18 and 80 years old, (b) have a clinical diagnosis of severe distal hemiparesis of the arm [31] (grading of 0 or 1 for wrist and finger extensors), and (c) have had their first supratentorial stroke within the previous three months, as confirmed by the primary care hospital’s diagnosis. Patients were excluded if they had any of the following conditions: (a) severe cognitive and/or language deficits that could make it difficult for them to follow instructions; (b) severe visual impairments that might limit their participation in mirror therapy; (c) other neurological or musculoskeletal impairments of the upper extremities unrelated to stroke; or (d) severe visuospatial neglect (clinically evaluated as not turning their face to an examiner on their contralesional side when asked to do so). Patients provided their informed written consent to participate in the trial after being informed about its purpose and design prior to enrollment. Following that, patients were assigned at random to one of three intervention groups. A computer-generated random number sequence was used to carry out the randomization process. A phone call was made to an individual who was not otherwise involved in the trial to assign patients to one of the three therapeutic groups. A computer-generated random number sequence was used to carry out the randomization process. A telephone call was made to an individual who was not otherwise involved in the experiment to assign patients to their groups. The effects of the mirror therapy program on upper-limb motor recovery and motor function in patients with acute stroke were reported by Lee MM, Cho H, and Song CH in their study. Design: Twenty-six individuals were randomized to either the experimental or control groups if they experienced an acute stroke within six months of the study’s start. Participants in both the experimental and control groups underwent a regular rehabilitation program; however, only the experimental group underwent an additional four weeks of 25 minutes a day, five times a week, of mirror treatment. Changes in upper-limb motor recovery and motor function following intervention were evaluated using the Fugl-Meyer Assessment, the Brunnstrom motor recovery stage, and the Manual Function Test. The experimental group’s Fugl-Meyer Assessment scores improved more in upper-limb motor recovery than did the control group’s. The experimental group’s Manual Function Test score for upper-limb motor function was significantly higher than the control group’s. For the coordination tasks in the Fugl Meyer Assessment, there were no significant differences observed between the groups [32]. In his research, Christian Dohleim assesses the impact of a therapy that involves simulating the damaged upper extremity with the unaffected upper extremity in the early stages following a stroke. No more than eight weeks following the initial ischemic stroke in the region of the middle cerebral artery, thirty-six patients with severe hemiparesis as a result were enrolled. They finished a six-week program that involved being randomly assigned to receive either mirror treatment (MT) or an equivalent control therapy (CT). The primary outcome measures were the upper extremity Fugl-Meyer subscores, which were assessed by third-party raters using videotape. Neuropsychological and functional testing was also performed on the patients. In terms of motor function, none of the three motor subscores for any patient showed a significant therapeutic effect. The only one to show a tendency that fell short of significance was the finger motor score. A notable variation in the subgroup of those 25 individuals who were initially distal plegic was the reason of this trend. There was no discernible difference between the two therapy groups [33].  M. Invernizz et al. found that mirror treatment is beneficial for patients recovering from subacute strokes in terms of upper limb motor function. Patients were randomized to either the CT or MT groups. Both had extensive rehabilitation therapy. Furthermore, the CT group received 30 minutes of sham therapy and the MT group received 30 minutes of MT. The main outcome measure used was the Action Research Arm Test (ARAT). The secondary outcome measures were the Functional Independence Measure (FIM) and the Motricity Index (MI). Additionally, compared to the CT group, patients in the MT group showed higher improvements in the ARAT, MI, and FIM scores. During the investigation, no pertinent adverse event was discovered. For individuals suffering from subacute strokes, MT is a simple and effective way to enhance upper limb motor recovery [34]. The goal of this study, according to Jin-Young Park, was to look at how mirror treatment affected daily living activities and upper-extremity function in patients with chronic stroke. A sham therapy group and a mirror therapy group were each allocated to fifteen subjects. The Box and Block Test and the Fugl-Meyer Motor Function Assessment were used to compare hand coordination and paretic upper-extremity function. The purpose of the functional independence assessment was to compare people’s capacities for carrying out everyday tasks. The mirror therapy and sham therapy groups differed considerably in paretic upper-extremity function and hand coordination skills. When it came to enhancing the capacity to carry out activities of daily life, the intervention in the mirror treatment group proved more successful than in the sham therapy group. Mirror therapy works well in helping chronic stroke patients with paretic upper extremity function and activities of daily living. Self-care revealed statistically significant differences between the two groups. The two groups’ paretic upper-extremity function and coordination levels differed noticeably. When the two groups’ capacities to carry out everyday tasks were compared, statistically significant differences were also found [35]. In his research, Youngju Park, MS examined how mirror therapy with tasks affected stroke patients’ self-care and upper extremity unction. For a period of six weeks, subjects in the experimental group underwent tasks-based mirror therapy, while those in the control group received a sham therapy five times a week. The Manual Function Test for the paralyzed upper limb and the Functional Independence Measure for the performance of self-care were the primary outcome measures. Following the intervention, the experimental group’s change scores increased more significantly than those of the control group. Mirror therapy combined with tasks is what we believe to be a successful form of intervention for stroke patients’ self-care and upper extremity function. Regarding the participants’ clinical features and demographics, there were no appreciable variations between the groups.  baseline, the MFT and FIM self-care scores did not significantly differ between the groups. Following the intervention, there was a noticeable improvement in both groups. When the MFT and FIM self-care ratings were compared between the groups at baseline and after six weeks, the experimental group’s scores significantly improved [36].  In his research, Nigar Gurbuz sought to determine how well mirror therapy paired with a traditional rehabilitation program affected stroke patients’ recovery of upper extremity motor and functional abilities. The non-paralyzed side’s fingers and wrist were periodically extended and flexed as part of the mirror group’s mirror therapy. The identical exercises were done by the patients in the conventional group against the mirror’s non-reflecting face. Both groups’ Brunnstrom stages and FIM self-care scores improved, but the mirror therapy group’s post-treatment FMA score was noticeably greater than that of the conventional treatment group. It has been discovered that adding mirror therapy to a traditional rehabilitation program helps stroke patients recover more in terms of upper extremity motor function [37]. According to Keh-chung Lin’s research, afferent stimulation by mesh gloves (MG) and mirror treatment (MT) may be useful in improving motor dysfunction following a stroke. MT+ MG, MT, or CT were randomly allocated to 43 chronic stroke patients with mild to moderate upper extremity dysfunction for 1.5 hours per day, five days per week, for a duration of four weeks. The Fugl-Meyer Assessment (FMA) and Myoton-3 muscle tone measurement were used as outcome measures for motor impairment, while the Box and Block Test (BBT) and 10-Meter Walk Test (10 MWT) were used to test motor function. MT + MG enhanced walking and hand dexterity. More so than CT, MT + MG and MT decreased motor impairment and synergistic shoulder abduction [38].  In a study, Hyuk-Shin and Colleageus discussed how mirror therapy (MT) combined with transcranial direct current stimulation (tDCS) affected chronic stroke patients’ ability to regain function in their upper extremities. Subjects: Thirteen patients at least six months post-stroke began as part of a random assignment to an experimental group consisting of fourteen patients and a control group consisting of thirteen patients. [Methods] After 20 minutes of tDCS, each patient rested for five minutes. For six weeks, this 45-minute intervention was given to each individual three times a week. Following the intervention, the experimental group demonstrated a substantial drop in the Jebsen-Taylor test and a significant improvement in grip strength, the Fugl-Meyer assessment (FMA), and the box and block test (BBT). Following the intervention, the control group had a significant increase in grip strength and a significant decrease in the Jebsen-Taylor test scores. Following the intervention, a comparison of the results showed that the experimental group had more notable gains in both grip strength and BBT than the control group [39]. Sang Gu Ji looks at how mirror therapy affects subacute stroke patients’ gait. A total of thirty-four stroke patients were randomized into two groups: one for experimental mirror therapy and the other for control. Interventions: Mirror treatment for the lower limbs and full rehabilitation therapy were provided to the stroke patients in the experimental group. The control group’s stroke patients received both comprehensive rehabilitation therapy and sham therapy. For four weeks, each group’s participants received therapy five days a week. Principal measures: Prior to and following the four-week therapy session, measures of temporo-spatial gait parameters, including single stance, stance phase, step length, stride, swing phase, velocity, and cadence, were taken. We draw the conclusion that mirror treatment could help mitigate the impact of stroke on walking abilities [40].

3. CONCLUSION

The review’s findings suggest that mirror treatment may be used to help stroke survivors perform better in their everyday activities and improve their motor function and lower and upper extremity motor impairment. Mirror therapy may be a useful intervention for lowering pain in a subgroup of people with complicated regional pain syndrome, type I following stroke. The motor brain receives positive feedback from the visual illusion of the afflicted limb movement, which may break the pain cycle.

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