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Inservice Presentation on Mirror Therapy

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Tony Chou

on 30 July 2013

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Transcript of Inservice Presentation on Mirror Therapy

In-Service Presentation
by Tony Chou, S/OT
Mirror Therapy
for Subacute Stroke Patients

Working Mechanism

What is Mirror Therapy?
Putative human MNS = frontal and parietal motor regions
Frontal MNS:
Pars opercularis of the Inferior frontal gyrus
Adjacent ventral premotor cortex
Parietal MNS:
Inferior parietal lobule
Working Mechanism -
Mirror Neuron System
Motor imitation
Motor observation
Motor imagery
Motor execution
"When tested individually, both action observation and motor imagery increase the excitability of the corticospinal pathway (Cochin et al., 1999; Hari et al., 1998; Tremblay et al., 2004)
The MNS and Occupational Therapy
Modulated by experience
(Liew et al., 2012)

Literature Review
9 Selected Articles
2 Systematic Reviews
Clinical Question:
Is mirror therapy an effective treatment for subacute stroke patients with UE hemiparesis to improve motor functions and ADLs performance?
Had a first episode of unilateral stroke with hemiparesis
Absence of severe cognitive deficits (< 25 Mini-Mental State Examination)/visualspatial deficits/aphasia
Presence of movements at the three main sites of the UE (shoulder, elbow, and hand)
Had a Brunnstrom score between 1 and 4 for UE
Within 4 wks; 8-10 wks; 3 mos; 6 mos; 12 mos
A mirror box (30cm x 30cm x 3 mm; 50cm x 50 cm; 65x45 cm)
Conventional stroke rehabilitation program: 5 days a week, 2 to 5 hours a day
30 minutes of MT
Movement: Wrist flexion/extension; finger flexion/extension; forearm pronation/supination; elbow flexion/extension; objected related movements (pick up a pencil, a coin, and a needle); with Neuromuscular electrical stimulation/Functional electrical stimulation/bilateral arm training/mental imagery
Outcome measures
Fugl-Meyer test
Action Research Arm test
Frenchay Arm Test
Functional Independence Measure (FIM)
Brunnstrom stages for UE and hand
Manual Function test
Barthel Index for ADLs
Star Cancellation test
Modified Ashworth Scale
Motricity Index
Study limitation
Clinical Bottom line
Simple, inexpensive
Patient-directed treatment that may improve UE functioning
Incorporation of other established treatment approaches
Home therapy program
Effect was difficult to isolate
Small sample size
Lack of follow-up
Dohle, C., Püllen, J., Nakaten, A., Küst, J., Rietz, C., & Karbe, H. (January 01, 2009). Mirror therapy promotes
recovery from severe hemiparesis: a randomized controlled trial. Neurorehabilitation and Neural Repair, 23, 3.)

Ezendam, D., Bongers, R. M., & Jannink, M. J. (January 01, 2009). Systematic review of the effectiveness of mirror
therapy in upper extremity function. Disability and Rehabilitation, 31, 26, 2135-49.

Invernizzi, M., Negrini, S., Carda, S., Lanzotti, L., Cisari, C., & Baricich, A. (January 01, 2013). The value of adding
mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial. European Journal of Physical and Rehabilitation Medicine, 49, 3, 311-7.

Lee, M. M., Cho, H. Y., & Song, C. H. (January 01, 2012). The mirror therapy program enhances upper-limb motor
recovery and motor function in acute stroke patients. American Journal of Physical Medicine & Rehabilitation / Association of Academic Physiatrists, 91, 8, 689-96.

Liew, S.-L., Werner, J., Aziz-Zadeh, L., & Garrison, K. A. (June 01, 2012). The mirror neuron system: Innovations
and implications for occupational therapy. Otjr Occupation, Participation and Health, 32, 3, 79-86.

Radajewska, A., Opara, J. A., Kucio, C., Błaszczyszyn, M., Mehlich, K., & Szczygiel, J. (March 01, 2013). The effects of
mirror therapy on arm and hand function in subacute stroke in patients. International Journal of Rehabilitation Research, 1.

Small, S. L., Buccino, G., & Solodkin, A. (January 01, 2012). The mirror neuron system and treatment of stroke.
Developmental Psychobiology, 54, 3, 293-310.

Thieme, H., Bayn, M., Wurg, M., Zange, C., Pohl, M., & Behrens, J. (January 01, 2013). Mirror therapy for patients
with severe arm paresis after stroke--a randomized controlled trial. Clinical Rehabilitation, 27, 4, 314-24.

Thieme, H., Mehrholz, J., Pohl, M., Behrens, J., & Dohle, C. (January 01, 2013). Mirror therapy for improving motor
function after stroke. Stroke; a Journal of Cerebral Circulation, 44, 1, 1-2.

Yavuzer, G., Selles, R., Sezer, N., Sütbeyaz, S., Bussmann, J. B., Köseoğlu, F., Atay, M. B., ... Stam, H. J. (January 01,
2008). Mirror therapy improves hand function in subacute stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 89, 3, 393-8.

Yun, G. J., Chun, M. H., Park, J. Y., & Kim, B. R. (January 01, 2011). The synergic effects of mirror therapy and
neuromuscular electrical stimulation for hand function in stroke patients. Annals of Rehabilitation Medicine, 35, 3, 316-21.

Focuses for future studies
Address specific questions due to the optimal dose, frequency and duration of mirror therapy
Should focus on outcomes in ADLs
Should also focus on patients with impairments other than motor impairments after stroke, such as pain and visuospatial neglect
Compare mirror therapy with other conventionally applied or newly developed and effective therapies.
1. Yavuzer et al., 2008: the scores of the Brunnstrom stages for the hand and UE and the FIM self-care score improved more in the mirror group than in the control group after 4 weeks of treatment and at the 6-month follow-up.

2. Dohle et al., 2009: in the subgroup of 25 patients with distal plegia at the beginning of the therapy, MT patients regained more distal function than CT patients.

3. Ezendam et al., 2009: the current systematic literature review has shown that the use of mirror therapy in rehabilitation seems promising, especially for CRPS1 patients, when combined with motor imagery, and for stroke patients, while the effectiveness in other patient groups has yet to be determined.

4. Yun et al., 2010: The mirror and NMES group showed significant improvements in the Fugl-Meyer scores of hand, wrist, coordination and power of hand extension compared to the other groups. However, the power of hand flexion, wrist flexion, and wrist exetnsion showed no sinificant differences amoung the groups.

5. Invernizzi et al., 2012: after one month of treatment patients of MT group had greater improvements in the ARAT, MI, and FIM values compared to CT group that received sham therapy.

Inclusion criteria:
Result cont.
6. Thieme et al., 2012: after five 5 weeks, no significant group differences for motor function were found. However, a significant effect on visuospatial neglect for patients in the individual mirror therapy compared to control group could be shown.

7. Thieme et al., 2012: there is evidence for the effectiveness of mirror therapy for improving motor function for patients after stroke. the effects were more prominent and with a clear statistical significance when mirror therapy was compared with sham intervention. Compared with bilateral arm training with unrestricted view, the effects for mirror therapy only just reached significance.

8. Lee et al., 2012: in upper-limb recovery, the scores of Fugl-Meyer Assessment and Brunnstrom stages for upper limb and hand were improved more in the MT group than the CT group.

9. Radajewska et al., 2013: no significant improvement in hand and arm function in both subgroups in Frenchay Arm Test and Motor Status Score scales was observed. however, there was a significant improvement in self-care of activities of daily living in the right arm paresis subgroup in the mirror group measured using the Functional Index 'Repty'.
- "Mirror therapy is defined as an intervention that uses a mirror to create a reflection of the non-paretic upper or lower limb, thus giving the patient visual feedback of normal movement of the paretic limb" (Thieme, Mehrholz, Pohl, Behrens, and Dohle, 2012)
Brunnstrom Stages
I. Flaccidity: no voluntary movement or stretch reflexes
II. Synergies can be elicited reflexively; flexion develops before extension; spasticity developing
III. Beginning voluntary movement, but only in synergy; increased spasticity, which may become marked
IV. Some movements deviating from synergy:
a. Hand behind back
b. Arm to forward horizontal position
c. Pronation and supination with the elbow flexed to 90 degrees; spasticity decreasing

Posterior cingulate cortex
Mirror Neuron System
I. Flaccidity
II. Little or no active finger flexion
III. Mass grasp or hook grasp; no voluntary finger extension or release
IV. Semi-voluntary finger extension in a small range of motion; lateral prehension with release by thumb movement
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