Effects of mirror therapy on the motor and functional recovery of post-stroke paretic upper limbs: a systematic review

Valton da Silva Costa Júlio César Cunha da Silveira Tatiana Catarina Albuquerque Clementino Lorenna Raquel Dantas de Macedo Borges Luciana Protásio de Melo About the authors

RESUMO

Após um acidente vascular cerebral (AVC), o membro superior pode apresentar déficits motores que podem levar a incapacidades funcionais. A terapia espelho (TE) é uma possibilidade terapêutica na reabilitação do membro superior (MS). Este estudo objetivou reunir evidências que pudessem mostrar quais são os efeitos da TE na recuperação motora e funcional do MS com paresia pós-AVC. Foi realizada uma busca eletrônica nas bases de dados SciELO, LILACS, PubMed, PEDro e ScienceDirect, utilizando como critérios de inclusão: ensaios clínicos, nos quais os indivíduos acima de 18 anos apresentassem AVC de qualquer etiologia e em qualquer tempo após a lesão encefálica, com sequela no MS; estudos publicados na íntegra em revistas indexadas nas bases supracitadas entre 2010 e 2015, nos idiomas inglês e português, que utilizassem a TE para reabilitação do MS de pacientes com AVC, apresentando como desfechos função motora e independência funcional. Os artigos resultantes foram avaliados pela escala PEDro quanto à qualidade metodológica. Treze ensaios clínicos avaliaram efeitos da TE no MS parético. Os testes mais utilizados foram escala de Fugl-Meyer e Medida de Independência Funcional. Nesses estudos, a TE foi eficaz na recuperação motora do MS e na independência funcional dos pacientes, especialmente nos quesitos transferências e autocuidados. Os artigos foram considerados de moderada a alta qualidade metodológica. Conclui-se que a TE promoveu melhora significativa da função motora e da independência funcional do MS parético pós-AVC independente do tempo decorrido após a lesão encefálica.

Descritores
Acidente Vascular Cerebral; Extremidade Superior; Destreza Motora; Modalidades de Fisioterapia; Retroalimentação Sensorial

RESUMEN

Debido al accidente cerebrovascular (ACV), los miembros superiores pueden presentar problemas motores, que pueden llevar a incapacidades funcionales. La terapia del espejo (TE) presenta una posibilidad terapéutica de rehabilitar los miembros superiores (MS). El propósito de este estudio es reunir evidencias que muestran cuáles son los efectos de la TE en la rehabilitación motora y funcional de MS con paresia pos-ACV. Se buscó en las bases de datos SciELO, LILACS, PubMed, PEDro y ScienceDirect, empleando los siguientes criterios de inclusión: estudios clínicos, en los cuales los sujetos de más de 18 años presentaron ACV de cualquier etiología y de cualquier tiempo tras la lesión cerebral, con secuela en MS; textos publicados integralmente entre 2010 y 2015 en revistas científicas de las citadas bases de datos, en lengua inglesa y en portugués brasileño, que empleasen la TE en la rehabilitación de MS de pacientes con ACV y presentasen como resultados función motora e independencia funcional. Los textos recolectados fueron evaluados por la escala PEDro en función de la calidad metodológica. Trece estudios clínicos evaluaron los efectos de la TE en MS parético. Las pruebas más empleadas fueron la escala Fugl-Meyer y la Medida de Independencia Funcional. En estos estudios se comprobó la eficacia de la TE en la rehabilitación motora de MS y en la independencia funcional de los pacientes, especialmente en los aspectos transferencia y autocuidado. Se evaluaron los textos como de moderada a alta calidad metodológica. Se concluye que la TE mejora significativamente la función motora y la independencia funcional de MS parético pos-ACV independiente del tiempo transcurrido de la lesión cerebral.

Palabras clave
Accidente Cerebrovascular; Extremidad Superior; Destreza Motora; Modalidades de Fisioterapia; Retroalimentación Sensorial

ABSTRACT

After a stroke upper limbs may display motor deficits that could lead to functional disability. Mirror therapy (MT) is a therapeutic tool in the rehabilitation of upper limbs (UL). This study aimed to bring together evidence to show the main effects of MT in the motor recovery of paretic upper limbs after a stroke. An electronic search on the Lilacs, Scielo, PubMed, PEDro and ScienceDirect databases was performed, in accordance with the inclusion criteria: clinical trials, in which individuals should have had a stroke of any etiology and in any stage of recovery, with UL impairment, published in full in journals indexed in those databases, between 2010 and 2015, in English or Portuguese, using MT for the rehabilitation of these patients’ UL, with motor function and functional independence as main outcomes. The remaining articles were evaluated with the PEDro scale to assign their methodological quality a score. Thirteen clinical studies evaluated the effects of MT in the motor function and functional independence of the upper limbs after a stroke. Fugl-Meyer scale and the Functional Independence Measure were frequently used in the studies, which showed that MT is efficient in upper limb motor recovery and functional independence, especially concerning transferring and self-care. Regarding the methodological evaluation, the articles were considered as having moderate or high quality. In conclusion, MT promotes significant improvement of the motor function and functional independence of paretic upper limbs after a stroke, regardless of the time elapsed after the encephalic lesion.

Keywords
Stroke; Upper Extremity; Motor Skills; Physical Therapy Modalities; Sensory Feedback

INTRODUCTION

The Cerebral Vascular Accident (CVA) is defined as a hemorrhagic or ischemic vascular dysfunction that can reach different regions of the brain and result in neurological damage and sensorimotor deficits. The most frequent consequences are hemiparesis or hemiplegia and sensitivity and coordination disorders11. Martin ST, Kessler M. Neurologic interventions for physical therapy. 2. ed. Missoure: Saunders; 2007.. The upper limbs (UL) are compromised due to weakness and/or spasticity22. Bhakta BB. Management of spasticity in stroke. Br Med Bull. 2000;56(2):476-85.. Such deficits may lead to the restriction of activities of daily living (ADL) and to functional disabilities, restricting the patient’s social participation33. World-Health-Organization. ICF: International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001..

The neurorehabilitation of the UL with paresis after a stroke includes methods and techniques aimed at the reduction of functional impairments and recovery of the individual’s abilities so that he can achieve the highest degree of functional independence possible. Mirror Therapy (MT), one of these methods, uses visual feedback to stimulate neuronal plasticity in the primary motor area and cortical reorganization, the mechanisms responsible for the therapeutic results obtained by this therapy44. Tominaga W, Matsubayashi J, Deguchi Y, Minami C, Kinai T, Nakamura M, et al. A mirror reflection of a hand modulates stimulus-induced 20-Hz activity. Neuroimage. 2009;46(2):500-4. doi: 10.1016/j.neuroimage.2009.02.021
https://doi.org/10.1016/j.neuroimage.200...
),(55. Rossiter HE, Borrelli MR, Borchert RJ, Bradbury D, Ward NS. Cortical mechanisms of mirror therapy after stroke. Neurorehabil Neural Repair. 2015;29(5):444-52. doi: 10.1177/1545968314554622
https://doi.org/10.1177/1545968314554622...
. In addition, other mechanisms have been suggested, such as the stimulating of certain areas of the primary motor cortex and the activation of mirror neurons, induced by the MT66. Pomeroy VM, Clark CA, Miller JS, Baron JC, Markus HS, Tallis RC. The potential for utilizing the "mirror neurone system" to enhance recovery of the severely affected upper limb early after stroke: a review and hypothesis. Neurorehabil Neural Repair. 2005;19(1):4-13. doi: 10.1177/1545968304274351
https://doi.org/10.1177/1545968304274351...
),(77. Kho AY, Liu KPY, Chung RC. Meta-analysis on the effect of mental imagery on motor recovery of the hemiplegic upper extremity function. Aust Occup Ther J. 2014; 61(2):38-48..

The technique consists in the performing of bimanual activities with the use of a box with an one-sided mirror placed in the sagittal plane (in relation to the patient). This way, the patient visualizes the reflection of his healthy upper limb as if it were the impaired member88. Dohle C, Püllen J, Nakaten A, Küst J, Rietz C, Karbe H. Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial. Neurorehabil Neural Repair. 2009;23(3):209-17. doi: 10.1177/1545968308324786
https://doi.org/10.1177/1545968308324786...
. For the application of the technique, two protocols are proposed, namely, the performing of isolated movements of the shoulders, elbows, wrists and fingers, or functional tasks of the upper limbs99. Cacchio A, De Blasis E, De Blasis V, Santilli V, Spacca G. Mirror therapy in complex regional pain syndrome type 1 of the upper limb in stroke patients. Neurorehabil Neural Repair. 2009;23(8):792-99. doi: 10.1177/1545968309335977
https://doi.org/10.1177/1545968309335977...
),(1010. Michielsen ME, Selles RW, van der Geest JN, Eckhardt M, Yavuzer G, Stam HJ, et al. Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial. Neurorehabil Neural Repair. 2011;25(3):223-33.doi: 10.1177/1545968310385127
https://doi.org/10.1177/1545968310385127...
.

Although there are a few studies which assess the effects of MT, as indicated by the reviews of Toh and Fong1111. Toh SF, Fong KN. Systematic review on the effectiveness of mirror therapy in training upper limb hemiparesis after stroke. Hong Kong J Occup Ther. 2012;22(2):84-95. doi: dx.doi.org/10.1016/j.hkjot.2012.12.009
https://doi.org/10.1016/j.hkjot.2012.12....
and Thieme et al. (1212. Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. Mirror therapy for improving motor function after stroke. Cochrane Database Syst Rev. 2012;14(3):CD008449. doi: 10.1002/14651858.CD008449.pub2
https://doi.org/10.1002/14651858.CD00844...
, more homogenous clinical studies with larger samples and with improved methodological quality have been carried out in recent years. These studies have more robust results, which can support the use of the technique in the functional recovery of patients with stroke sequelae. The aim of this study was to gather evidence that could show the effects of MT on the motor and functional recovery of upper limbs with post-stroke paresis.

METHODOLOGY

The present study is a systematic review of the literature. A search in the Scielo, Lilacs, Pubmed, PEDro and ScienceDirect electronic databases was held in the period from September to October 2015, using an advanced integrative search strategy, with the combination of the four terms connected by the Boolean operator “and”. The following search terms were used, in Portuguese: Terapia Espelho, Reabilitação, Membro Superior, Acidente Vascular Cerebral and in English: Mirror Therapy, Rehabilitation, Upper Limb, Stroke.

The search for and selection of the articles was performed by four researchers and held according to the following inclusion criteria: randomized controlled trials, in which individuals above 18 years old were assigned a clinical diagnosis of stroke of any etiology and at any stage, and with sequelae in the upper limbs; studies published in full in scientific journals indexed in the aforementioned databases, in English and Portuguese, with publication date between 2010 and 2015 and which used MT for the rehabilitation of the UL of these patients, having as outcomes motor function and functional independence. Articles identified as duplicates were excluded. The proceedings of this research were summarized in accordance with the PRISMA criteria13 and can be seen in Figure 1.

Figure 1
Flowchart of search procedures in the databases, based on the PRISMA group (2009) (1313. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi: 10.1371/journal.pmed.1000097
https://doi.org/10.1371/journal.pmed.100...

Thus, the final sample of this review consisted of 13 articles, which had their methodological quality evaluated in accordance with the PEDro scale1414. Physiotherapy Evidence Database. Escala PEDro em português. [Internet]. [acesso em 15 set. 2015]. Disponível em: http://www.pedro.org.au/portuguese/downloads/pedro-scale/
http://www.pedro.org.au/portuguese/downl...
and were assessed independently by two researchers. In the absence of consensus, a new evaluation was carried out by a third party. This scale is made up of eleven items, each item is equivalent to one point when the criterion is obeyed, except item one, which should not be assigned a score. Thus, the score ranges from zero to ten. The items are: eligibility criteria, random allocation, secret allocation, homogeneity of the sample, blind sample, blind therapist, blind appraiser, outcome in 85% of the subjects initially distributed among the groups, treatment or control according to allocation, statistical comparison between the groups for at least one key outcome and precision and variability measures for at least one key outcome.

RESULTS

Thirteen clinical studies with a total sample of 368 individuals were part of this research. These studies were characterized according to the analyzed variables, type of intervention and main results, as shown in Table 1.

Table 1
Characterization of the studies regarding the sample, main evaluations, interventions and main results

Generally these studies evaluate motor function, sensory function and functional independence. A few of them included some method for measuring strength, muscle spasticity and kinematics, in addition to electroencephalographic and functional magnetic resonance analyses. The variables which were most studied were the motor function of paretic UL, through the Fugl-Meyer (FMS) (eight studies), Brunnstrom Motor Recovery Stage (BMRS) (four studies), Manual Function Test (MFT) (three studies) and Box and Block Test (BBT) (four studies) scales. Functional independence was evaluated through the Functional Independence Measure (FIM) (four studies). Most of these studies demonstrated the effectiveness of MT on the motor recovery of UL, compared to the control therapy.

In general terms, it was observed that MT significantly improves the gross and fine motor function of the paretic UL. With regard to functional independence, it was observed that the MT provided significant changes especially concerning the transfer and self-care items of the FIM. The articles were grouped according to their methodological quality, analyzed through the PEDro scale. The results of this analysis can be seen in Table 2.

Table 2
Methodological evaluation of the studies in accordance with the PEDro scale.

DISCUSSION

The literature includes some studies that support the use of MT in post-stroke rehabilitation, although many of them are inconclusive1111. Toh SF, Fong KN. Systematic review on the effectiveness of mirror therapy in training upper limb hemiparesis after stroke. Hong Kong J Occup Ther. 2012;22(2):84-95. doi: dx.doi.org/10.1016/j.hkjot.2012.12.009
https://doi.org/10.1016/j.hkjot.2012.12....
),(1212. Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. Mirror therapy for improving motor function after stroke. Cochrane Database Syst Rev. 2012;14(3):CD008449. doi: 10.1002/14651858.CD008449.pub2
https://doi.org/10.1002/14651858.CD00844...
. However, researches involving MT have evolved over the past years, acquiring better methodological quality.

The studies found in this review assessed individuals in the acute and chronic phases post-stroke and showed similar effects concerning the effectiveness of MT on the recovery of the motor function (the acute phase being understood as the period of up to six months after a stroke and the chronic phase the period that follows). Two of these studies1616. Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. Mirror therapy for patients with severe arm paresis after stroke: a randomized controlled trial. Clin Rehabil. 2013;27(4):314-24. doi: 10.1177/0269215512455651
https://doi.org/10.1177/0269215512455651...
),(2121. Medeiros CSP, Fernandes SGG, Lopes JM, Cacho EWA, Cacho RO. Effects of mirror therapy through functional activities and motor standards in motor function of the upper limb after stroke. Fisioter Pesqui. 2014;21(3):264-70. doi: 10.590/1809-2950/87821032014
https://doi.org/10.590/1809-2950/8782103...
did not present significant results, when compared to the control therapy. However, in the study by Medeiros et al. (2121. Medeiros CSP, Fernandes SGG, Lopes JM, Cacho EWA, Cacho RO. Effects of mirror therapy through functional activities and motor standards in motor function of the upper limb after stroke. Fisioter Pesqui. 2014;21(3):264-70. doi: 10.590/1809-2950/87821032014
https://doi.org/10.590/1809-2950/8782103...
the absence of effects can be attributed to the small sample of only six patients, not being thus possible to generalize their results, and to the fact that these researchers compared two groups that used different MT protocols. On the other hand, the study by Thieme et al. (1616. Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. Mirror therapy for patients with severe arm paresis after stroke: a randomized controlled trial. Clin Rehabil. 2013;27(4):314-24. doi: 10.1177/0269215512455651
https://doi.org/10.1177/0269215512455651...
used relatively low frequency and intensity, with less than 10 total hours of MT.

The studies involving functional independence assessed patients predominantly in the chronic phase. As an exception, the study by Thieme et al. (1616. Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. Mirror therapy for patients with severe arm paresis after stroke: a randomized controlled trial. Clin Rehabil. 2013;27(4):314-24. doi: 10.1177/0269215512455651
https://doi.org/10.1177/0269215512455651...
) evaluated patients in the acute phase, with the Barthel Index (BI), but showed no significant result. On the other hand, Invernizzi et al. (1717. Invernizzi M, Negrini S, Carda S, Lanzotti L, Cisari C, Baricich A. The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial. Eur J Phys Rehabil Med. 2013;49(3):311-7. assessed functional independence with FIM and showed statistically significant results in the acute phase. The studies that evaluated functional independence in patients in the chronic phase, with FIM2020. Lin KC, Chen YT, Huang PC, Wu CY, Huang WL, Yang HW, et al. Effect of mirror therapy combined with somatosensory stimulation on motor recovery and daily function in stroke patients: a pilot study. J Formos Med Assoc. 2014;113(7):422-8. doi: 10.1016/j.jfma.2012.08.008
https://doi.org/10.1016/j.jfma.2012.08.0...
),(2121. Medeiros CSP, Fernandes SGG, Lopes JM, Cacho EWA, Cacho RO. Effects of mirror therapy through functional activities and motor standards in motor function of the upper limb after stroke. Fisioter Pesqui. 2014;21(3):264-70. doi: 10.590/1809-2950/87821032014
https://doi.org/10.590/1809-2950/8782103...
),(2626. Park Y, Chang M, Kim KM, An DH. The effects of mirror therapy with tasks on upper extremity function and self-care in stroke patients. J Phys Ther Sci. 2015;27(5):1499-501. doi: 10.1589/jpts.27.1499
https://doi.org/10.1589/jpts.27.1499...
, observed statistically significant improvement of functional independence after the intervention.

The studies that used FIM observed statistically significant improvement especially in the categories of transfer and self-care1717. Invernizzi M, Negrini S, Carda S, Lanzotti L, Cisari C, Baricich A. The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial. Eur J Phys Rehabil Med. 2013;49(3):311-7.),(2020. Lin KC, Chen YT, Huang PC, Wu CY, Huang WL, Yang HW, et al. Effect of mirror therapy combined with somatosensory stimulation on motor recovery and daily function in stroke patients: a pilot study. J Formos Med Assoc. 2014;113(7):422-8. doi: 10.1016/j.jfma.2012.08.008
https://doi.org/10.1016/j.jfma.2012.08.0...
),(2121. Medeiros CSP, Fernandes SGG, Lopes JM, Cacho EWA, Cacho RO. Effects of mirror therapy through functional activities and motor standards in motor function of the upper limb after stroke. Fisioter Pesqui. 2014;21(3):264-70. doi: 10.590/1809-2950/87821032014
https://doi.org/10.590/1809-2950/8782103...
),(2626. Park Y, Chang M, Kim KM, An DH. The effects of mirror therapy with tasks on upper extremity function and self-care in stroke patients. J Phys Ther Sci. 2015;27(5):1499-501. doi: 10.1589/jpts.27.1499
https://doi.org/10.1589/jpts.27.1499...
. Two studies evaluated functional independence with the BI and ABILHAND1616. Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. Mirror therapy for patients with severe arm paresis after stroke: a randomized controlled trial. Clin Rehabil. 2013;27(4):314-24. doi: 10.1177/0269215512455651
https://doi.org/10.1177/0269215512455651...
),(1818. 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(6):1023-30. doi: 10.1016/j.apmr.2013.02.007
https://doi.org/10.1016/j.apmr.2013.02.0...
, however they did not report significant difference between the experimental and control groups. Some methodological limitations may explain this absence of difference. Firstly, the sample size was relatively small to detect the size of the effect, with a high rate of loss of the sample in one of them1616. Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. Mirror therapy for patients with severe arm paresis after stroke: a randomized controlled trial. Clin Rehabil. 2013;27(4):314-24. doi: 10.1177/0269215512455651
https://doi.org/10.1177/0269215512455651...
. Secondly, the first study did not use blinding in the evaluation through the BI, which may have lead to some bias; also, it used patients in the subacute phase in the sample, with severe distal impairment, and admittedly poor prognosis for recovery1616. Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. Mirror therapy for patients with severe arm paresis after stroke: a randomized controlled trial. Clin Rehabil. 2013;27(4):314-24. doi: 10.1177/0269215512455651
https://doi.org/10.1177/0269215512455651...
. Additionally, the ABILHAND questionnaire evaluates the patient’s difficulty in performing ADL2323. Samuelkamaleshkumar S, Reethajanetsureka S, Pauljebaraj P, Benshamir B, Padankatti SM, David JA. Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial. Arch Phys Med Rehabil. 2014;95(11):2000-5. doi: 10.1016/j.apmr.2014.06.020
https://doi.org/10.1016/j.apmr.2014.06.0...
which require bimanual manipulation, thus it is possible that the effects on the motor and kinematic functions observed in that same study1818. 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(6):1023-30. doi: 10.1016/j.apmr.2013.02.007
https://doi.org/10.1016/j.apmr.2013.02.0...
were not reflected in activities that require simultaneous and joint use of the hands and therefore require specific training.

The most widely used instruments for motor function were FMS1010. Michielsen ME, Selles RW, van der Geest JN, Eckhardt M, Yavuzer G, Stam HJ, et al. Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial. Neurorehabil Neural Repair. 2011;25(3):223-33.doi: 10.1177/1545968310385127
https://doi.org/10.1177/1545968310385127...
),(1515. Lee MM, Cho HY, Song CH. The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients. Am J Phys Med Rehabil. 2012;91(8):689-700. doi: 10.1097/PHM.0b013e31824fa86d
https://doi.org/10.1097/PHM.0b013e31824f...
),(1818. 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(6):1023-30. doi: 10.1016/j.apmr.2013.02.007
https://doi.org/10.1016/j.apmr.2013.02.0...
),(1919. Kim H, Lee G, Song C. Effect of functional electrical stimulation with mirror therapy on upper extremity motor function in poststroke patients. J Stroke Cerebrovasc Dis. 2014;23(4):655-61. doi: 10.1016/j.jstrokecerebrovasdis.2013.06.017
https://doi.org/10.1016/j.jstrokecerebro...
),(2222. Paik YR, Kim SK, Lee JS, Jeon BJ. Simple and task-oriented mirror therapy for upper extremity function in stroke patients: a pilot study. Hong Kong J Occup Ther. 2014;24(1):6-12. doi: dx.doi.org/10.1016/j.hkjot.2014.01.002
https://doi.org/10.1016/j.hkjot.2014.01....
)-(2525. Cho HS, Cha HG. Effect of mirror therapy with tDCS on functional recovery of the upper extremity of stroke patients. J Phys Ther Sci. 2015;27(4):1045-47. doi: 10.1589/jpts.27.1045
https://doi.org/10.1589/jpts.27.1045...
, BMRS1515. Lee MM, Cho HY, Song CH. The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients. Am J Phys Med Rehabil. 2012;91(8):689-700. doi: 10.1097/PHM.0b013e31824fa86d
https://doi.org/10.1097/PHM.0b013e31824f...
),(1919. Kim H, Lee G, Song C. Effect of functional electrical stimulation with mirror therapy on upper extremity motor function in poststroke patients. J Stroke Cerebrovasc Dis. 2014;23(4):655-61. doi: 10.1016/j.jstrokecerebrovasdis.2013.06.017
https://doi.org/10.1016/j.jstrokecerebro...
),(2323. Samuelkamaleshkumar S, Reethajanetsureka S, Pauljebaraj P, Benshamir B, Padankatti SM, David JA. Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial. Arch Phys Med Rehabil. 2014;95(11):2000-5. doi: 10.1016/j.apmr.2014.06.020
https://doi.org/10.1016/j.apmr.2014.06.0...
),(2424. Arya KN, Pandian S, Kumar D, Puri V. Task-based mirror therapy augmenting motor recovery in poststroke hemiparesis: a randomized controlled trial. J Stroke Cerebrovasc Dis. 2015;24(8):1738-48. doi: 10.1016/j.jstrokecerebrovasdis.2015.03.026
https://doi.org/10.1016/j.jstrokecerebro...
, MFT1515. Lee MM, Cho HY, Song CH. The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients. Am J Phys Med Rehabil. 2012;91(8):689-700. doi: 10.1097/PHM.0b013e31824fa86d
https://doi.org/10.1097/PHM.0b013e31824f...
),(1919. Kim H, Lee G, Song C. Effect of functional electrical stimulation with mirror therapy on upper extremity motor function in poststroke patients. J Stroke Cerebrovasc Dis. 2014;23(4):655-61. doi: 10.1016/j.jstrokecerebrovasdis.2013.06.017
https://doi.org/10.1016/j.jstrokecerebro...
),(2626. Park Y, Chang M, Kim KM, An DH. The effects of mirror therapy with tasks on upper extremity function and self-care in stroke patients. J Phys Ther Sci. 2015;27(5):1499-501. doi: 10.1589/jpts.27.1499
https://doi.org/10.1589/jpts.27.1499...
and BBT1919. Kim H, Lee G, Song C. Effect of functional electrical stimulation with mirror therapy on upper extremity motor function in poststroke patients. J Stroke Cerebrovasc Dis. 2014;23(4):655-61. doi: 10.1016/j.jstrokecerebrovasdis.2013.06.017
https://doi.org/10.1016/j.jstrokecerebro...
),(2020. Lin KC, Chen YT, Huang PC, Wu CY, Huang WL, Yang HW, et al. Effect of mirror therapy combined with somatosensory stimulation on motor recovery and daily function in stroke patients: a pilot study. J Formos Med Assoc. 2014;113(7):422-8. doi: 10.1016/j.jfma.2012.08.008
https://doi.org/10.1016/j.jfma.2012.08.0...
),(2323. Samuelkamaleshkumar S, Reethajanetsureka S, Pauljebaraj P, Benshamir B, Padankatti SM, David JA. Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial. Arch Phys Med Rehabil. 2014;95(11):2000-5. doi: 10.1016/j.apmr.2014.06.020
https://doi.org/10.1016/j.apmr.2014.06.0...
),(2525. Cho HS, Cha HG. Effect of mirror therapy with tDCS on functional recovery of the upper extremity of stroke patients. J Phys Ther Sci. 2015;27(4):1045-47. doi: 10.1589/jpts.27.1045
https://doi.org/10.1589/jpts.27.1045...
, which assess the gross and fine motor function of the UL. In general, the studies that used these tests showed statistically significant results, with improvement of the group that received MT, in comparison to the control group. Some studies used the Action Research Arm Test, the Jebsen-Taylor Test and the Motricity Index instruments and also verified improvements in the experimental group, compared to the control group1717. Invernizzi M, Negrini S, Carda S, Lanzotti L, Cisari C, Baricich A. The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial. Eur J Phys Rehabil Med. 2013;49(3):311-7.),(2020. Lin KC, Chen YT, Huang PC, Wu CY, Huang WL, Yang HW, et al. Effect of mirror therapy combined with somatosensory stimulation on motor recovery and daily function in stroke patients: a pilot study. J Formos Med Assoc. 2014;113(7):422-8. doi: 10.1016/j.jfma.2012.08.008
https://doi.org/10.1016/j.jfma.2012.08.0...
),(2222. Paik YR, Kim SK, Lee JS, Jeon BJ. Simple and task-oriented mirror therapy for upper extremity function in stroke patients: a pilot study. Hong Kong J Occup Ther. 2014;24(1):6-12. doi: dx.doi.org/10.1016/j.hkjot.2014.01.002
https://doi.org/10.1016/j.hkjot.2014.01....
),(2323. Samuelkamaleshkumar S, Reethajanetsureka S, Pauljebaraj P, Benshamir B, Padankatti SM, David JA. Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial. Arch Phys Med Rehabil. 2014;95(11):2000-5. doi: 10.1016/j.apmr.2014.06.020
https://doi.org/10.1016/j.apmr.2014.06.0...
.

Some of the researches also evaluated the sensorial function1616. Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. Mirror therapy for patients with severe arm paresis after stroke: a randomized controlled trial. Clin Rehabil. 2013;27(4):314-24. doi: 10.1177/0269215512455651
https://doi.org/10.1177/0269215512455651...
),(1818. 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(6):1023-30. doi: 10.1016/j.apmr.2013.02.007
https://doi.org/10.1016/j.apmr.2013.02.0...
and aspects such as prehension2525. Cho HS, Cha HG. Effect of mirror therapy with tDCS on functional recovery of the upper extremity of stroke patients. J Phys Ther Sci. 2015;27(4):1045-47. doi: 10.1589/jpts.27.1045
https://doi.org/10.1589/jpts.27.1045...
, kynematics1818. 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(6):1023-30. doi: 10.1016/j.apmr.2013.02.007
https://doi.org/10.1016/j.apmr.2013.02.0...
and spasticy1616. Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. Mirror therapy for patients with severe arm paresis after stroke: a randomized controlled trial. Clin Rehabil. 2013;27(4):314-24. doi: 10.1177/0269215512455651
https://doi.org/10.1177/0269215512455651...
),(2020. Lin KC, Chen YT, Huang PC, Wu CY, Huang WL, Yang HW, et al. Effect of mirror therapy combined with somatosensory stimulation on motor recovery and daily function in stroke patients: a pilot study. J Formos Med Assoc. 2014;113(7):422-8. doi: 10.1016/j.jfma.2012.08.008
https://doi.org/10.1016/j.jfma.2012.08.0...
, with varied instruments. In these studies MT had significant results, with the exception of the studies by Lin et al. (2020. Lin KC, Chen YT, Huang PC, Wu CY, Huang WL, Yang HW, et al. Effect of mirror therapy combined with somatosensory stimulation on motor recovery and daily function in stroke patients: a pilot study. J Formos Med Assoc. 2014;113(7):422-8. doi: 10.1016/j.jfma.2012.08.008
https://doi.org/10.1016/j.jfma.2012.08.0...
and Thieme et al. (1616. Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. Mirror therapy for patients with severe arm paresis after stroke: a randomized controlled trial. Clin Rehabil. 2013;27(4):314-24. doi: 10.1177/0269215512455651
https://doi.org/10.1177/0269215512455651...
, who observed non-significant spasticity improvement and spasticity increase in the finger flexor muscles, respectively, after the intervention. There was disparity in the results of the studies that use different assessment instruments for the same outcome, while some showed significant results, others did not show any statistically significant clinical improvement. This may be explained by the variety of the aspects that are evaluated within each test, mainly in the scales that assess together the gross and fine motor function based on various movements and in different ways.

Only two of the 13 studies evaluated the maintenance of the effects of MT, with a six-month follow-up. Both reported that there was no maintenance of the effects obtained with MT after six months1010. Michielsen ME, Selles RW, van der Geest JN, Eckhardt M, Yavuzer G, Stam HJ, et al. Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial. Neurorehabil Neural Repair. 2011;25(3):223-33.doi: 10.1177/1545968310385127
https://doi.org/10.1177/1545968310385127...
),(1818. 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(6):1023-30. doi: 10.1016/j.apmr.2013.02.007
https://doi.org/10.1016/j.apmr.2013.02.0...
.

Three intervention protocols with MT have been identified, namely, isolated bilateral movements (five studies), unilateral or bilateral functional tasks (three studies) or the combination of the two protocols (four studies). In relation to the improvement of motor function and functional independence, there was improvement of these outcomes with each of the protocols. In two studies, two modalities of MT were compared with each other. The study by Paik et al. (2222. Paik YR, Kim SK, Lee JS, Jeon BJ. Simple and task-oriented mirror therapy for upper extremity function in stroke patients: a pilot study. Hong Kong J Occup Ther. 2014;24(1):6-12. doi: dx.doi.org/10.1016/j.hkjot.2014.01.002
https://doi.org/10.1016/j.hkjot.2014.01....
compared MT with isolated movements with MT with functional tasks. Improvement was observed in both groups, with no significant difference regarding motor function. The study by Medeiros et al. (2121. Medeiros CSP, Fernandes SGG, Lopes JM, Cacho EWA, Cacho RO. Effects of mirror therapy through functional activities and motor standards in motor function of the upper limb after stroke. Fisioter Pesqui. 2014;21(3):264-70. doi: 10.590/1809-2950/87821032014
https://doi.org/10.590/1809-2950/8782103...
, who made the same comparison, observed statistically significant improvement in the total FIM and cognition scores, without reporting, however, difference between the groups. In the study by Samuelkamaleshkumar et al. (2323. Samuelkamaleshkumar S, Reethajanetsureka S, Pauljebaraj P, Benshamir B, Padankatti SM, David JA. Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial. Arch Phys Med Rehabil. 2014;95(11):2000-5. doi: 10.1016/j.apmr.2014.06.020
https://doi.org/10.1016/j.apmr.2014.06.0...
MT and conventional rehabilitation were compared. They found that there was significant improvement of manual dexterity (BBT), motor recovery of the hands and arms (assessed through BMRS) and of the motor function (assessed through FSM) compared to the control group.

Most of them used an intervention period of four to six weeks, with a frequency of five times a week, in 30-minute sessions. In what concerns series and repetitions, there was not much homogeneity, with some studies ranging from one to four series of 10 to 100 repetitions for each movement or motor standard used.

In the assessment of methodological quality (through the PEDro scale) seven studies had scores between 8 and 10 (good quality) and six had scores from 5 to 7 (moderate quality). The biggest limitation of the works with moderate quality was the absence of blinding (or information about the blinding) on the part of the appraisers, researchers and participants.

CONCLUSION

It is concluded that MT promotes the clinically significant improvement of the motor function and functional independence of the upper limb with post-stroke paresis, regardless of the recovery phase. Such improvements, highlighted by studies of moderate to high methodological quality, strengthen the indication of MT as therapeutic measure in rehabilitation. The effects of MT on functional independence in the acute phase are not fully established yet, therefore, it becomes necessary to carry out a greater number of studies with good methodological quality, to test this hypothesis. In addition, studies that investigate the duration of the effects of the improvement in the motor function of the UL and in functional independence through the monitoring of these patients after the end of the treatment are necessary. The only two studies that conducted the monitoring after the intervention showed that the effects remained.

References

  • 1
    Martin ST, Kessler M. Neurologic interventions for physical therapy. 2. ed. Missoure: Saunders; 2007.
  • 2
    Bhakta BB. Management of spasticity in stroke. Br Med Bull. 2000;56(2):476-85.
  • 3
    World-Health-Organization. ICF: International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001.
  • 4
    Tominaga W, Matsubayashi J, Deguchi Y, Minami C, Kinai T, Nakamura M, et al. A mirror reflection of a hand modulates stimulus-induced 20-Hz activity. Neuroimage. 2009;46(2):500-4. doi: 10.1016/j.neuroimage.2009.02.021
    » https://doi.org/10.1016/j.neuroimage.2009.02.021
  • 5
    Rossiter HE, Borrelli MR, Borchert RJ, Bradbury D, Ward NS. Cortical mechanisms of mirror therapy after stroke. Neurorehabil Neural Repair. 2015;29(5):444-52. doi: 10.1177/1545968314554622
    » https://doi.org/10.1177/1545968314554622
  • 6
    Pomeroy VM, Clark CA, Miller JS, Baron JC, Markus HS, Tallis RC. The potential for utilizing the "mirror neurone system" to enhance recovery of the severely affected upper limb early after stroke: a review and hypothesis. Neurorehabil Neural Repair. 2005;19(1):4-13. doi: 10.1177/1545968304274351
    » https://doi.org/10.1177/1545968304274351
  • 7
    Kho AY, Liu KPY, Chung RC. Meta-analysis on the effect of mental imagery on motor recovery of the hemiplegic upper extremity function. Aust Occup Ther J. 2014; 61(2):38-48.
  • 8
    Dohle C, Püllen J, Nakaten A, Küst J, Rietz C, Karbe H. Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial. Neurorehabil Neural Repair. 2009;23(3):209-17. doi: 10.1177/1545968308324786
    » https://doi.org/10.1177/1545968308324786
  • 9
    Cacchio A, De Blasis E, De Blasis V, Santilli V, Spacca G. Mirror therapy in complex regional pain syndrome type 1 of the upper limb in stroke patients. Neurorehabil Neural Repair. 2009;23(8):792-99. doi: 10.1177/1545968309335977
    » https://doi.org/10.1177/1545968309335977
  • 10
    Michielsen ME, Selles RW, van der Geest JN, Eckhardt M, Yavuzer G, Stam HJ, et al. Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial. Neurorehabil Neural Repair. 2011;25(3):223-33.doi: 10.1177/1545968310385127
    » https://doi.org/10.1177/1545968310385127
  • 11
    Toh SF, Fong KN. Systematic review on the effectiveness of mirror therapy in training upper limb hemiparesis after stroke. Hong Kong J Occup Ther. 2012;22(2):84-95. doi: dx.doi.org/10.1016/j.hkjot.2012.12.009
    » https://doi.org/10.1016/j.hkjot.2012.12.009
  • 12
    Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. Mirror therapy for improving motor function after stroke. Cochrane Database Syst Rev. 2012;14(3):CD008449. doi: 10.1002/14651858.CD008449.pub2
    » https://doi.org/10.1002/14651858.CD008449.pub2
  • 13
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi: 10.1371/journal.pmed.1000097
    » https://doi.org/10.1371/journal.pmed.1000097
  • 14
    Physiotherapy Evidence Database. Escala PEDro em português. [Internet]. [acesso em 15 set. 2015]. Disponível em: http://www.pedro.org.au/portuguese/downloads/pedro-scale/
    » http://www.pedro.org.au/portuguese/downloads/pedro-scale/
  • 15
    Lee MM, Cho HY, Song CH. The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients. Am J Phys Med Rehabil. 2012;91(8):689-700. doi: 10.1097/PHM.0b013e31824fa86d
    » https://doi.org/10.1097/PHM.0b013e31824fa86d
  • 16
    Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. Mirror therapy for patients with severe arm paresis after stroke: a randomized controlled trial. Clin Rehabil. 2013;27(4):314-24. doi: 10.1177/0269215512455651
    » https://doi.org/10.1177/0269215512455651
  • 17
    Invernizzi M, Negrini S, Carda S, Lanzotti L, Cisari C, Baricich A. The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial. Eur J Phys Rehabil Med. 2013;49(3):311-7.
  • 18
    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(6):1023-30. doi: 10.1016/j.apmr.2013.02.007
    » https://doi.org/10.1016/j.apmr.2013.02.007
  • 19
    Kim H, Lee G, Song C. Effect of functional electrical stimulation with mirror therapy on upper extremity motor function in poststroke patients. J Stroke Cerebrovasc Dis. 2014;23(4):655-61. doi: 10.1016/j.jstrokecerebrovasdis.2013.06.017
    » https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.06.017
  • 20
    Lin KC, Chen YT, Huang PC, Wu CY, Huang WL, Yang HW, et al. Effect of mirror therapy combined with somatosensory stimulation on motor recovery and daily function in stroke patients: a pilot study. J Formos Med Assoc. 2014;113(7):422-8. doi: 10.1016/j.jfma.2012.08.008
    » https://doi.org/10.1016/j.jfma.2012.08.008
  • 21
    Medeiros CSP, Fernandes SGG, Lopes JM, Cacho EWA, Cacho RO. Effects of mirror therapy through functional activities and motor standards in motor function of the upper limb after stroke. Fisioter Pesqui. 2014;21(3):264-70. doi: 10.590/1809-2950/87821032014
    » https://doi.org/10.590/1809-2950/87821032014
  • 22
    Paik YR, Kim SK, Lee JS, Jeon BJ. Simple and task-oriented mirror therapy for upper extremity function in stroke patients: a pilot study. Hong Kong J Occup Ther. 2014;24(1):6-12. doi: dx.doi.org/10.1016/j.hkjot.2014.01.002
    » https://doi.org/10.1016/j.hkjot.2014.01.002
  • 23
    Samuelkamaleshkumar S, Reethajanetsureka S, Pauljebaraj P, Benshamir B, Padankatti SM, David JA. Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial. Arch Phys Med Rehabil. 2014;95(11):2000-5. doi: 10.1016/j.apmr.2014.06.020
    » https://doi.org/10.1016/j.apmr.2014.06.020
  • 24
    Arya KN, Pandian S, Kumar D, Puri V. Task-based mirror therapy augmenting motor recovery in poststroke hemiparesis: a randomized controlled trial. J Stroke Cerebrovasc Dis. 2015;24(8):1738-48. doi: 10.1016/j.jstrokecerebrovasdis.2015.03.026
    » https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.03.026
  • 25
    Cho HS, Cha HG. Effect of mirror therapy with tDCS on functional recovery of the upper extremity of stroke patients. J Phys Ther Sci. 2015;27(4):1045-47. doi: 10.1589/jpts.27.1045
    » https://doi.org/10.1589/jpts.27.1045
  • 26
    Park Y, Chang M, Kim KM, An DH. The effects of mirror therapy with tasks on upper extremity function and self-care in stroke patients. J Phys Ther Sci. 2015;27(5):1499-501. doi: 10.1589/jpts.27.1499
    » https://doi.org/10.1589/jpts.27.1499

  • Financing source: CNPq
  • 6
    Approved by Ethics Committee 783.189/2014.

Publication Dates

  • Publication in this collection
    Dec 2016

History

  • Received
    Dec 2015
  • Accepted
    Sept 2016
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E-mail: revfisio@usp.br