Comparison of Goal Specific Functional Tasks With and Without Mirror Therapy
Condition: Stroke
MeSH terms: Stroke
Study type: Interventional

Summary: 
      The hemiparetic arm is one of the most undesirable consequences of stroke. Approximately
      30-66% of patients with stroke are not able to gain motor function of their affected hand
      which prevents them from performing their daily activities for the rest of their lives. It is
      very important in the treatment of stroke patients to improve their upper limb function.
      Mirror therapy has drawn much focus on the rehabilitation of hemiplegic stroke patients in
      the past two decades. Mirror therapy is one of the priming technique that causes neural
      plasticity of the brain. In mirror therapy a mirror is placed in the mid-sagittal plane of
      the patient between his two arms and the patient is given instruction to move his less
      affected or normal limb while looking at its reflection in the mirror which will produce as
      the affected or paretic limb is also moving with a normal movement pattern. This will create
      visual stimulus on the patient's brain known as mirror visual feedback (MVF) and will cause
      cortical reorganization hence it will increase the motor recovery of the affected or paretic
      limb. A type of mirror therapy is task-based mirror therapy in which the participants are
      asked to perform specific motor tasks with their less affected arm. There are very few
      studies regarding mirror therapy combined with functional tasks. It is a randomized
      controlled trial study and its duration is 6 months. Total sample size will be 26; 13
      participants into each group. The subjects will be divided into two groups, Group A
      Experimental group and Group B control group. A 20 minutes session will be performed thrice
      in a week for a total of 6 weeks. The experimental group will perform functional tasks with
      mirror therapy and the control group will perform functional tasks without mirror therapy.
      The Standardized Mini-Mental State Examination scale and Brunnstrom stages of motor recovery
      scale will be used in the inclusion criteria of patients. Outcomes of patients will be
      measured using Brunnstrom stages of motor recovery, Motor Assessment Scale (MAS) upper limb
      component, Fugl Meyer Upper Extremity Assessment Scale (FMA-UE) and Functional Independence
      Measure (FIM) self-care component at baseline, after every 2 weeks and with follow up at 6
      weeks. After this, the data will be analyzed on the Statistical Package for the Social
      Sciences (SPSS) 21 version.
    

Detailed description: 
      The hemi paretic arm is one of the most undesirable consequences of stroke. Approximately
      30-66% of patients with stroke are not able to gain motor function of their affected hand
      which prevents them from performing their daily activities for the rest of their lives.The
      paralysis of upper limb along with increase in muscle spasticity, muscle weakness and loss of
      sensory perception are reasons of disability in stroke patients. It is very important in the
      treatment of stroke patients to make effective treatment strategies to improve their upper
      limb function. Many treatment options are used for the recovery of upper limb motor function
      such as robot-assisted therapy and constraint induced movement therapy. Mirror therapy has
      drawn much focus for the rehabilitation of hemiplegic stroke patients in the past two
      decades. Mirror therapy is one of the priming technique that causes neural plasticity of
      brain.Mirror therapy is also used to address problems like phantom limb pain.In stroke
      patients it is helpful in managing pain and hemi spatial neglect. According to the theory the
      cortical areas of brain that are involved in the motor task execution can be activated by
      observing the actions performed by others, which is the function of the mirror neuron system
      (MNS).The mirror neuron system is composed of mirror neurons that discharge during action
      observation (AO) and action execution. The mirror neuron system is located in the inferior
      frontal gyrus (IFG), including the ventral premotor cortex (PMv), the inferior parietal
      lobule (IPL), and the intraparietal sulcus (IPS). It also extends to other brain areas like
      the primary motor cortex, the primary somatosensory cortex, and the middle frontal cortex. In
      mirror therapy we use the mirror neuron system to perform action observation training (AOT)
      and action execution.

      In mirror therapy a mirror is placed in the mid sagittal plane of a patient between the two
      arms and the patient is given instruction to move his less affected or normal limb while
      looking at its reflection in the mirror which will produce as the affected or paretic limb is
      also moving with a normal movement pattern.This will create visual stimulus on the patient's
      brain known as mirror visual feedback (MVF) and will cause cortical reorganization hence it
      will increase the motor recovery of the affected or paretic limb.

      The scales that have been used in previous studies to measure motor recovery and improvement
      in daily functions of stroke patients with mirror therapy are Brunnstrom stages of recovery,
      Fugl-Meyer assessment (FMA) and Functional Independence Measure (FIM).The findings of these
      studies has shown positive effects of mirror therapy on decreasing motor impairment.

      Conventional mirror therapy that is most commonly used involves simple movements performed by
      unaffected arm like wrist extension flexion, fingers flexion extension and forearm supination
      and pronation while looking at the visual stimulus created by the mirror placed at their mid
      sagittal plane.

      The functional task-oriented training is mostly used intervention for bringing beneficial
      neural plasticity and improving paretic upper limb functional performance. Functional
      task-oriented training recently applied on stroke patients has proven to be more effective
      than the conventional therapy. A type of mirror therapy is task based mirror therapy in which
      the participants are asked to perform specific motor tasks with their less affected arm.
      Functional tasks may include flipping a card, holding a polystyrene cup, squeezing a sponge.
      A research was carried out in Korea to determine the effects of mirror therapy with
      functional tasks on upper limb function and activities of daily living in patients with
      subacute stroke. The patients were randomly divided into two groups the mirror therapy group
      and the control group.The Fugl-Meyer Motor Function Assessment (FMA), Brunnstrom motor
      recovery stage, and Modified Barthel Index (MBI) were assessed 4 weeks after the treatment
      and the results were significantly greater in the mirror therapy group than the control
      group.

      A study was conducted to determine the effectiveness of mirror therapy in chronic stroke
      patients with severe dysfunction of upper limb and its comparison was done with the control
      group. The results showed significant improvements in mirror therapy group regarding motor
      recovery and tactile stimulation.

      Another study done b to determine if a mirror therapy-based action observation (AO) protocol
      contributes to motor learning of the paretic arm in post stroke patients.The outcome measure
      of this study was movement time of the reaching movement which was measured by accelerometry.
      The results showed that the decrease in movement time was much more in the action observation
      group as compared to the control group. Thus the study showed that a mirror therapy based
      action observation protocol contributes more to motor learning in post stroke patients.

      another study which was the first to achieve delayed mirror visual feedback (MVF) for upper
      extremity mirror therapy training. Their results support the positive effects of mirror
      visual feedback on the cortical activation of brain and hence give additional evidence
      supporting the use of mirror therapy in the future for upper-limb motor training in patients
      with stroke.

      A systematic review was done to evaluate the activation of the mirror neuron system (MNS)
      during the action observation and action execution training with mirror visual feedback (MVF)
      in post stroke patients. The effect of activation of motor cortex of brain in stroke patients
      with mirror therapy was also determined. The results showed that the MVF may cause stroke
      recovery by revising the interhemispheric imbalance caused by stroke and also cause the
      activation of the MNS. Action observation training also promoted motor relearning in stroke
      individuals by the activation of the MNS and the motor cortex.

      Another systematic review was done to conclude the effects of mirror therapy for improving
      motor functions and decreasing motor impairment after stroke. They also assessed the effects
      of mirror therapy on the activities of daily living of stroke patients. The results gave
      evidence on the effectiveness of mirror therapy for increasing upper limb motor function,
      decreasing motor impairment, improving their activities of daily living and decreasing their
      pain as compared to the conventional rehabilitation for stroke patients.
    

Intervention name(s): functional tasks with mirror therapy; functional tasks without mirror therapy
Intervention type(s): Other; Other
Intervention description(s): In this group a mirror will be placed in the sagittal plane of patient. The affected or paretic arm will be placed behind the mirror and the unaffected or normal arm will be placed in front of the mirror. Then the patient will be asked to perform functional tasks; The functional tasks will be explained to patient before the start of treatment. In this group a board instead of a mirror will be placed in the sagittal plane of patient. Then the patient will be asked to perform functional tasks
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Stroke; Functional Tasks; Mirror Therapy