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

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

doi:10.1590/1809-2950/15809523042016

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SYSTEMATIC REVIEW • Fisioter. Pesqui. 23 (4) • Dec 2016 • https://doi.org/10.1590/1809-2950/15809523042016 copy

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

Authorship SCIMAGO INSTITUTIONS RANKINGS

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

Author/Year	Sample	Main Evaluations	Interventions	Main Results
Michielsen et al., 2011¹⁰10. 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...	40 patients Chronic phase	fMRI	1 hour per day, 1x week in the Rehabilitation Center and 5x week at home, during 6 weeks	There was statistically significant improvements in motor function in the EG. In both groups there was cortical reorganization, but there was no statistically significant correlation with the therapy. There were no significant results after follow-up (6 months).
	EG=20	FMS	EG = MT
	CG=20		CG = bilateral movements without a mirror
Lee; Cho; Song, 2012¹⁵15. 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...	26 patients Acute phase	FMS	25 min per session, 2x day, 5x week, for 4 weeks	There was statistically significant improvement in the EG regarding motor function. There was no statistically significant difference in coordination according to the FSM.
	EG = 13	BMRS	EG = conventional rehabilitation + MT
	CG = 13	MFT	CG = conventional rehabilitation
Thieme etal., 2012¹⁶16. 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...	60 patients Acute phase	FMS	30 min per session, 20 sessions, during 5 weeks	There was no statistically significant difference between the groups regarding motor function. There was statistically significant increase of the degree of spasticity in the finger flexors comparing the IG with the GG. There was statistically significant improvement comparing the IG with the CG in what concerns visuospatial neglect.
	IG = 18	ARAT	IG = first week with isolated movements up to 4X50 for each direction. 2nd and 3rd week with functional tasks added
	GG = 21	BI	GG = 2 to 6 patients in a group using the same protocol
	CG = 21	SIS	CG = same protocol, but without a mirror
		SCT
Invernizzi et al., 2013¹⁷17. 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.	26 patients Acute phase EG = 13	ARAT	1h per session, 5x week, for 4 weeks	There was statistically significant improvement in both groups regarding motor function and functional independence, greater significance having been found in the EG.
	GC = 13	FIM	EG = conventional rehabilitation + 30 min of MT in the first 2 weeks and 1h in the last 2 weeks
		IM	CG = conventional rehabilitation + FES + therapy with a covered mirror
Wu et al., 2013¹⁸18. 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...	33 patients Chronic phase	FMS	1,5h per day, 5x week, for 4 weeks	There was statistically significant improvement in the motor (distal and total), kinematic and thermal sensory function, there being no significance in the tactile scores. There were no significant results after follow-up (6 months).
	EG = 16	RNSA	EG = MT
	CG = 17	ABILHAND-q	CG = bilateral movements without a mirror
		MAL
		KA
Kim; Lee; Song, 2014¹⁹19. 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...	27 patients Acute phase	FMS	30 min per session, 5x week, for 4 weeks	There was statistically significant improvement in the motor function (FSM) for both groups, in hand motor function (BMRS) for both groups with the highest result belonging to the EG and in the motor function of shoulder and hands (MFT) for both groups with greater significance of the hand motor function in the EG. There was satistically significant improvement of manual dexterity (BBT) in both groups.
	EG = 14	BMRS	EG = MT + FES + conventional rehabilitation
	CG = 13	MFT	CG = therapy with non-reflective side of the mirror + FES + conventional rehabilitation
		BBT
Lin et al., 2014²⁰20. 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...	16 patients Chronic phase	MAS	1,5h per day, 5x week, for 4 weeks	There was improvement in the spasticity of the distal region (MAS) and in manual dexterity (BBT) in the EG. There was statistically significant improvement in motor function (ARAT) in the total score for both groups and improvement in the sub-tests in the CG. There was statistically significant improvement of functional independence (FIM) in what concerns transfer and no significant improvement in the motor sub-scale in the EG.
	CG=8	BBT	EG = Electro-MeshGlove (somatosensorial electrical stimulation) + MT + conventional rehabilitation
	EG=8	ARAT	CG = MT + conventional rehabilitation
		FIM
Medeiros et al., 2014²¹21. 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...	6 patients Chronic phase	FMS	50 min per session, the 10 initial minutes being of IM and stretching + 30 min of MT with 1-2 minutes of rest between activities, 3x week, 15 sessions, during 5 weeks	There was statistically significant improvement in functional independence (FIM) in the cognitive domain and in total in both groups.
	IMG = 3	MAS	IMG: MT with isolated movements
	FTG = 3	FIM	FTG MT with functional tasks
Paik et al., 2014²²22. 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....	4 patients Chronic phase	FMS	30 min per session, 15 sessions, during 15 days	There was improvement of functional manual tasks with respect to the increasing of the speed of execution of finger and wrist movements in both groups (CTT). There was improvement of the motor function (FSM) in both groups.
	IMG = 2	BBT	IMG: MT with isolated movements (10 repetitions for each movement)
	FTG = 2	BMRS	FTG: MT with functional tasks
		MFT
		CCT
		CTT
Samuelkamaleshkumar et al., 2014²³23. 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...	20 patients Chronic phase	FMS	1h per day divided into 2X30min being the first 15 min of isolated bilateral movements and the last 15 min of functional tasks, 5x week for 3 weeks	There was statistically significant improvement of manual dexterity (BBT) in the EG. As for the motor function (FSM) and hand and arm motor recovery scores (BMRS) there was statistically significant improvement in both groups with the highest result in the EG. No significant difference was found for spasticity (MAS) between the groups.
	EG=10	BMRS	EG = conventional rehabilitation + MT
	CG=10	BBT	CG = conventional rehabilitation
		MAS
Arya et al., 2015²⁴24. 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...	33 patients Acute phase	BMRS	90 min per session, 5x week, 40 sessions, during 8 weeks	There was statistically significant improvement in the motor function of the wrist, hand and arm in the EG, but this improvement was not seen in the shoulder. As for motor recovery, statistically significant improvement was observed in the EG.
	EG=17	FMS	EG = Occupational Therapy + MT
	CG=16		CG = Occupational Therapy
Cho; Cha, 2015²⁵25. 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...	27 patients Acute phase	BBT	20 min per session, 3x week for 6 weeks	There was statistically significant improvement in grip strength (HD) and in the performance of functional manual tasks (JTT) in both groups. As for motor function and manual dexterity (BBT), there was statistically significant improvement only in the EG. There were more significant increases of BBT and HD in the EG.
	EG=14	HD	EG = MT
	CG=13	JTT	CG = therapy with the non-reflective side of a mirror
		FMS
		tDCS
Park et al., 2015²⁶26. 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...	30 patients Chronic phase	FIM	5x week for 6 weeks	There was statistically significant improvement in the scales in both groups, with greater significance in the EG in the self-care domain of the FIM and MFT.
	EG=15	MFT	EG = MT
	CG=15		CG = therapy with the non-reflective side of a mirror

Author/year	1	2	3	4	5	6	7	8	9	10	11	Total score
Kim; Lee; Song, 2014	-	x	x	x	x	x	x	x	x	X	X	10/10
Wu et al., 2013	-	x	x	x	x		x	x	x	x	X	9/10
Arya et al., 2015	-	x	x	x			x	x	x	x	X	8/10
Lin et al., 2014	-	x	x	x			x	x	x	x	X	8/10
Samuelkamaleshkumar et al., 2014	-	x	x	x			x	x	x	x	X	8/10
Thieme et al., 2012	-	x	x	x			x	x	x	x	X	8/10
Michielsen et al., 2011	-	x	x	x			x	x	x	x	X	8/10
Lee; Cho; Song, 2012	-	x	x	x				x	x	x	X	7/10
Medeiros et al., 2014	-	x		x				x	x	x	X	6/10
Park et al., 2015	-	x		x				x	x	x	X	6/10
Cho; Cha, 2015	-	x		x				x		x	X	5/10
Paik et al., 2014	-			x				x	x	x	X	5/10
Invernizzi et al., 2013	-	x		x				x		x	X	5/10

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[1] Corresponding author: Luciana Protásio de Melo - Rua Dr. Hernani Hugo Gomes, 90, Capim Macio - Natal (RN), Brazil - CEP 59082-270 - E-mail: protasio.melo@yahoo.com.br