Hemiparesis is one of the common syndromes caused by stroke, which leads to limitations of basic activities of daily living (ADL) and to disability. Older adult stroke patients are most at risk of independence loss because of many factors, such as pain, edema, weakness, medicines, or mental state (depressive mood). Such problems underline the need to combine various types of therapies to obtain the greatest benefits. The optimal therapy strategy should be focused on encouraging patients to repeat task-oriented training with feedback on performance (Langhorne et al., 2009).
To solve these problems, many visual feedback ideas have been used in a treatment. Ramachandran and Altshuler (2009) introduced a treatment (1998) for phantom limb pain. They named the treatment Mirror Visual Feedback (MVF). The current evidence suggests that MVF might also facilitate motor output in patients with hemiparesis (Lamont et al., 2011). Mirror Visual Feedback has been demonstrated to be an intervention inducing neuroplasticity changes in the primary motor cortex (M1; Nojima et al., 2012; Touzalin-Chreiten et al., 2010) and might activate areas within the premotor and somatosensory cortex and/or the mirror neuron system (Fukumura et al., 2007; Garry et al., 2005; Small et al., 2012). This topic is of great relevance when MVF is applied in stroke rehabilitation.
Mirror therapy (MT) is one of the MVF-based therapies. In MT, people with hemiparesis can experience a visual reaction to a successfully completed task using their affected limb (Ramachandran & Altshuler, 2009). During the MT, the patient sits at a table. A mirror is positioned in front of the patient’s midline. The impaired limb is positioned behind the mirror and the healthy one in front of the mirror. The subject tries to make symmetrical movements of both arms on the command of a therapist, and they try to focus only on the observation of the reflected image of the intact limb (this makes the mirror image perceived as the affected limb).
The literature studies of MT’s effects on the recovery of motor function have demonstrated beneficial effects within 2 months poststroke and 6 months poststroke (Altschuler et al., 1999; Dohle et al., 2009; Lin et al., 2014; Radajewska et al., 2013; Sathian et al., 2000; Stevens & Stoykov, 2003; Sutbeyaz et al., 2007; Yavuzer et al., 2008). They have demonstrated a positive influence on the motor function of the paretic hand. However, more research is needed for optimal patient selection, application programs, and duration and intensity of MT (Thieme et al., 2012).
From the systematic review of clinical trials on the effect of specific rehabilitation methods on arm function, it was shown that among many reports regarding the efficacy of MT the clinical significance remains unclear (Langhorne et al., 2011), and the quality of the methodology used for individual studies was considered as a variable (Rothgangel et al., 2011).
In the Cochrane Database review, Thieme et al. included 14 studies with a total of 567 participants that compared MT with other interventions. When compared with all other interventions, MT may have a significant effect on motor function (postintervention data: SMD 0.61, 95% confidence interval [CI] 0.22–1.0, p = .002; change scores: SMD 1.04, 95% CI 0.57–1.51, p < .0001). However, effects on motor function are influenced by the type of control intervention. In addition, MT may improve ADL (SMD 0.33, 95% CI 0.05–0.60, p = .02). They found a significant positive effect on pain (SMD – 1.10, 95% CI – 2.10 to – 0.09, p = .03), which is influenced by the patient population. They also found limited evidence for improving visuospatial neglect (SMD 1.22, 95% CI 0.24–2.19, p = .01). The effects on motor function were stable at follow-up assessment after 6 months. Authors’ conclusions: The results indicate evidence for the effectiveness of MT in improving upper extremity motor function, ADL, and pain, at least as an adjunct to normal rehabilitation for patients after stroke. Limitations are due to the small sample sizes of most included studies, control interventions that are not used routinely in stroke rehabilitation, and some methodological limitations of the studies (Thieme et al., 2012).
The factors that significantly influence the independence achieved in mirror conditions have not yet been explained. It is known that not all patients respond to the treatment with MVF, and the reason for this remains unknown. This study presents a report on research findings and their specific practice implications in the older adult population.
The aim of this study was to determine the effectiveness of MT as an adjunct to comprehensive treatment using functional scales (FIR, FAT) and to investigate the possible relationship between functional state score ([INCREMENT]FIR—differences in change in pre- and postparameters) and selected factors, such as age and affected side (dominant or nondominant hand paresis).
Materials and Methods
Sixty right-handed subjects who had experienced unilateral stroke participated (24 women and 36 men; mean age, 60.8 years, range of age 39–75). The inclusion criteria were as follows: more than 2 months after the onset of the first ever stroke, no severe cognitive deficits (Mini-Mental State Examination [MMSE] score >25), and no severe motor impairment of the hand (Frenchay Arm Test [FAT] >1). The exclusion criteria were as follows: second or further strokes, severe cognitive deficit—less than 25 in the MMSE (Folstein et al., 1975)—or severe aphasia. The study was approved by the local ethics committee. All patients gave written informed consent before the study.
Patients were selected for the study in a targeted manner (according to study selection criteria), whereas assignment to the Mirror group (n = 30) or Control group (n = 30) was based on simple randomization (alternative allocation). Patients were allocated to their study group before baseline measurements were performed. All subjects were tested twice: immediately after admission to rehabilitation (FIR1, FAT1) and 21 days later—at the end of the intervention (FIR2, FAT2). Pre- and posttest clinical evaluations were conducted by one investigator, blinded to the participant group.
Both Mirror and Control study groups participated in a comprehensive rehabilitation program conducted as inpatient rehabilitation in the Rehabilitation Centre (see Table 1). Both groups received the comprehensive rehabilitation program 5 days/week, for 21 days.
The mirror group was additionally involved in an MT training program according to the basic principles (Rothgangel et al., 2011). They received MT training for 5 days/week, 2 sessions/day, for 21 days. Every session lasted for 15 minutes—which resulted in 30 minutes per day of additional training.
Mirror therapy training was performed by the subjects under the supervision of a physical therapist, and was focused on specific hand activities (see Table 2).
Independence in performing daily activities was assessed using the Functional Index “Repty” (FIR) scale (see Table 3), a modification of the American Functional Independence Measure (FIM). FIR consists of 15 items and is shorter and simpler than the FIM. In scoring subjects by the FIR scale, they can gain 7 points for full independence (timely, safety), 5 points for modified dependence (supervision, using devices), 3 points for moderate assistance (help needed), and 1 point for total dependence. The minimum and maximum scores range from 15 to 105 points. Functional skills of the upper limb were assessed using the FAT (Wade et al., 1983). The FAT consists of seven items; the final result can be from 0 to 7.
To identify if there were any significant differences in hand function ([INCREMENT]FAT rate) and subjects’ performance in ADL ([INCREMENT]FIR rate) between the mirror condition and without the mirror condition, the subjects were divided into two groups: the Mirror group (n = 30) and the Control group (n = 30); see Tables 4 and 5. Both analyses focused on evaluation of subjects’ functional level score in relation to the type of rehabilitation they were assigned to.
Further analyses were focused on an evaluation of whether there were any differences between subjects’ performance in ADL score ([INCREMENT]FIR rate) and selected factors. The analyses were as follows.
To see if there were any changes in subjects’ performance in ADL rate ([INCREMENT]FIR) in relation to the age factor between groups, both study groups (Mirror and Control) were divided into two groups according to the critical value of age: the older adults (≥61 years) and the younger adults (≤60 years). The cut-off point was the value close to the mean age of all subjects—60.8 years. See Table 5.
The next analysis focused on the evaluation of subjects’ performance in ADL in relation to their affected side between groups. Therefore, both study groups (Mirror and Control) were divided into two groups according to affected side: nondominant (the left hand paresis group) and dominant (the right hand paresis group). See Table 5.
Results and Description of Results
Before data analysis, the Shapiro–Wilk test was used for the assessment of normal distribution of variables.
Statistical analyses were performed using statistical software (Statistica Ver. 6.1). A parametric test (Student’s t test) and nonparametric tests (Wilcoxon’s test and Mann–Whitney’s U-test) were used, with the critical value p ≤ .05 considered significant.
The results in Table 4 indicate that there were significant changes in hand function ([INCREMENT]FAT rate) between groups. The analysis shows a higher level of median (Med = 1) in the [INCREMENT]FAT score in the Mirror group than in the Control group after 3 weeks of rehabilitation. This was supported by the significant level of the Wilcoxon test (p = .005). It is necessary to underline that the subjects of the Mirror group indicated greater therapeutic response beside their lower average of initial hand function score (Mirror FAT1 average vs. Control FAT1 average: 2 points/3.35 points). The FIR test did not indicate any significant level in terms of the type of rehabilitation they were assigned to.
The results in Table 5 indicate that there were significant changes in the patients’ performance of ADL ([INCREMENT]FIR rate) between groups in relation to the age factor. The analysis shows a higher level of median (Med = 8) of [INCREMENT]FIR score reflected in the significance level (p = .005) of older adults than younger adults in the Mirror group (n = 30). The older adult participants in the Control group (n = 30) did not achieve any significant difference of [INCREMENT]FIR level after the applied rehabilitation. A similar tendency was found in older adult subjects with nondominant hand paresis (the left hand paresis group). The analysis indicated that there are significant changes in the patients’ performance of ADL ([INCREMENT]FIR rate) between groups in relation to affected side. The analysis shows a higher level of mean (mean = 13.750) of [INCREMENT]FIR score reflected in the significance level (p = .037) of older adults in the Mirror group (left hand paresis). The analysis of the Mirror group right hand paresis did not achieve any significant difference of [INCREMENT]FIR level after the applied rehabilitation. No significant differences in the Control group were seen.
In relation to affected side, a similar tendency was found in older adults with nondominant hand paresis associated with mirror condition rehabilitation (the Mirror group [left hand paresis], n = 15). We obtained a higher [INCREMENT]FIR score, reflected in the significance level (p = .037), of older adults than younger adult participants in this group, contrary to older adult participants in the Control group (left hand paresis; n = 15; Table 5).
There were no significant differences between the functional status scores of older adult and younger adult participants with dominant hand paresis (the Mirror group [right hand paresis] vs. the Control group [right hand paresis]).
The application of MT combined with comprehensive rehabilitation significantly improved hand function in subacute stoke inpatients without severe hand paresis and without severe cognitive dysfunction.
Among older adult subjects and older adult subjects with nondominant hand paresis, the analysis indicated that a greater score of independence in performing ADL (FIR rate) was particularly associated with adjacent MT rehabilitation. Such results underline that there is a need to apply MT with other treatment also among the older adult stroke population. In practice, physiotherapists and nurses should be aware of the positive therapeutic response in older adult individuals, and they should encourage them to use MT.
The results of this study indicate that MT as an adjunct to comprehensive rehabilitation is effective for increasing ADL in the older adult.
This study showed significant differences both in paretic hand function (FAT rate) and in independence level in daily activities (FIR rate) within groups. The FIR scale is used as a modification of the FIM scale, so the results of this study can be compared to other studies using this outcome measure. There is high correlation between FIR and the Barthel Index (BI; Rycerski & Opara, 2002) and good overall agreement between BI and FIM scores (Turner-Stokes et al., 2013). The BI scale is also helpful in predicting the prognosis for long-term independence in the personal ADL (De Wit et al., 2014; Verheyden et al., 2013). A statistically significant improvement in the FIM scale was observed following the application of MT in randomized controlled studies in 48 subjects after stroke. That effect was also maintained 6 months later (mean improvement +8.3 in the MT group and +1.8 in the control group). However, the intervention used in that study lasted longer than our intervention (4 weeks; 5 days a week; 30 minutes of exercises daily). Similar to our study, exercises were based on wrist and finger flexion and extension movements (Yavuzer et al., 2008). These results are in line with our findings and those reported in the latest study on acute and subacute stroke patients (de Almeida Oliveira et al., 2014), subacute stroke patients (Invernizzi et al., 2013; Park, Chang, Kim, & An, 2015a), and chronic stroke patients (Park, Chang, Kim, & Kim, 2015b). The results of another study (Thieme et al., 2013) indicated that, in stroke patients with severe arm paresis, there was no effect on independence in ADL (BI) in three conditions: individual MT, group MT, and control intervention with restricted view of the affected arm. However, they reported that a positive effect on visuospatial neglect was found. Also, different results have been obtained in other randomized controlled studies in relation to everyday activities. No significant differences have been noted, either between groups of subjects with complete paresis (n = 25) or groups of subjects with unilateral neglect syndrome (n = 20; Dohle et al., 2009). Our study did not take the occurrence of neglect syndrome or complete hand paresis into account.
Nevertheless, not all patients respond to treatment with MVF, and the reasons for this remain unknown. Intersubject variability, such as age, mental state, or primary functional state, might be the factors that enhance response to treatment with MVF—such problems should be supported by further studies. This study demonstrated the significant differences between age variants and ADL rate ([INCREMENT]FIR) associated with mirror condition rehabilitation, and it should be taken into account that MT has a significant relevance in daily functioning, also in older adult stroke patients without severe cognitive deficits. The relatively good therapeutic response in the performance of ADL of older adults having poorer outcomes at baseline stood in contrast to the previous findings that one of the good indicators of motor function return following stroke is the initial level of motor disorders (Foley et al., 2007). There are no findings in the literature concerning the intersubject variability in age in mirror condition rehabilitation. According to the main principles of program training realization for health participants, it is known that those with an initially lower level of functional state can achieve relatively greater change in improvement after intervention than those who are better at baseline (Heyward, 1997). Unlike the previous studies comparing the changes in brain activity or pre- and postintervention outcomes, there is also a report of real-time changes in peripheral muscle activity during observation in young healthy volunteers (n = 24) using Ramachandran’s mirror box therapy. In this study surface electromyography (sEMG) was used to detect the real-time muscle potential, which revealed higher muscle activity in the nondominant hand under the mirror image condition than under the nonwatching condition (Fukurawa et al., 2012).
In the case of affected side analysis, the data available suggest that older adults with nondominant hand paresis obtained greater functional scores then older adults with dominant hand paresis. It may be concluded that the ability to better performance of ADL could be the result of additional MT training and the change score is in favor of the older adult group with left hand paresis. To confirm this finding, there is a need for further study on larger sample population of stroke subjects in terms of side of hand paresis.
In this study, the observation of successfully completed tasks with a paretic arm in conditions of MVF may facilitate self-care in daily activities. Activities such as washing, dressing, and eating are considered the most important of all daily activities (Yavuzer et al., 2008). Patients should not be helped with them but encouraged to complete them independently (Ada et al., 2003). It is believed that the functional recovery of poststroke patients depends on neurological deficit severity, motivation, as well as the patient engaging in any form of physical activity. Mirror training also has a great emotional aspect, encouraging the patient to attempt to use the affected arm in daily activities. MT training may help to prevent activity loss or attention loss in elderly populations. This is important in combating the nonuse syndrome described by Taub et al. (2006), especially in subacute patients.
The limitations of this study are the small number of patients of affected side-related study groups and the longer duration of training in the mirror groups having MT as an adjunct treatment. However, it is both a strength and a limitation that the same person did all the testing of the participants. The next limitation is that there are no interrater and no intrarater reliability checks analysis to generalize the findings. Finally, there is a need for a longitudinal study to determine whether the interventional effects are sustained.
MT is an easy-to-implement, noninvasive training program that can be useful in restoring hand function and performance in ADL and could be offered to suitable patients by practitioners in various medical professions, such as physical therapists, occupational therapists, or nurses.
Key Practice Points
- Mirror therapy training may help to prevent activity loss in elderly stroke populations.
- Mirror therapy is an easy-to-implement, noninvasive training program that could be offered to suitable patients by physical therapists, occupational therapists, or recommended by nurses.
- Among older adult subjects, the analysis indicated greater score of independence in performing ADL in mirror therapy groups.
- There is a benefit influence of MT training associated with comprehensive rehabilitation.
The authors declare no conflict of interest.
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Keywords:© 2017 Association of Rehabilitation Nurses.
Stroke; older adults; mobility