Mirror therapy has been gradually adopted for lower limb rehabilitation, but its efficacy and neural mechanism are not well understood.
OBJECTIVE:
This study aims to investigate the effect and neural mechanism of mirror therapy on lower limb rehabilitation after ischemic stroke by using resting state functional magnetic resonance imaging (rs-fMRI).
METHODS:
A single-blind and randomized controlled pilot study was conducted. 32 patients with ischemic stroke were included in this study and randomly divided into two groups – the control group (CT, n = 16) and the mirror therapy group (MT, n = 16). Both the CT and MT groups received medication and routine rehabilitation training. In addition, mirror therapy was added to the MT group 5 times a week for 30 minutes each time over a period of 3 weeks. Patients’ motor functions, functional connectivity (FC), regional homogeneity (ReHo), and fractional amplitude of low-frequency fluctuations (fALFF) were analyzed both before and immediately after the treatment.
RESULTS:
Patients’ motor functions showed significant improvement in both groups compared to those before treatment (p < 0.01). Moreover, the MT group showed significantly better improvement than the CT group after the treatment (p < 0.05). FC, ReHo and fALFF indicated enhanced neuronal activities in motor function-related brain regions in the MT group compared to the CT group.
CONCLUSION:
Mirror therapy promotes the recovery of lower limb motor functions in patients with ischemic stroke. Through the comparative rs-fMRI analysis, it is found that the mirror therapy promotes the functional reorganization of the injured brain.
A, G. L., & A, G. D. (2018) The cross education of strength and skill following unilateral strength training in the upper and lower limbs, Journal of Neurophysiology120(2).
2.
A, S. J., & Phillips,S. M. E. (2003) Using motor imagery in the rehabilitation of hemiparesis, Archives of Physical Medicine and Rehabilitation84(7).
3.
Aliyeh,D., Mokhtar,A., & Gholamreza,A. (2018) Effect of different designs of ankle-foot orthoses on gait in patients with stroke: A systematic review, Gait & Posture62.
4.
Altschuler,E. L., Wisdom,S. B., Stone,L., Foster,C., Galasko,D., Llewellyn,D. M. E., & Ramachandran,V. (1999) Rehabilitation of hemiparesis after stroke with a mirror, The Lancet353(9169).
5.
Arya,K. N., Pandian,S., & Kumar,V. (2019) Effect of activity-based mirror therapy on lower limb motor-recovery and gait in stroke: A randomised controlled trial, Neuropsychological Rehabilitation29(8), 1193–1210.
6.
Chao-Gan,Y., & Yu-Feng,Z. (2010) DPARSF: A MATLAB Toolbox for “Pipeline” Data Analysis of Resting-State fMRI, frontiers in Systems Neuroscience4, 13–13. doi: 10.3389/FNSYS.2010.00013.
7.
Dani, euml, Ezendam,l., Bongers,R. M., & Jannink,M. J. A. (2009) Systematic review of the effectiveness of mirror therapy in upper extremity function, Disability & Rehabilitation31(26).
8.
Dohle,C. (2009) Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial, Neurorehabilitation and Neural Repair23(3).
9.
Downs,S., Marquez,J., & Chiarelli,P. (2013) The Berg Balance Scale has high intra- and inter-rater reliability but absolute reliability varies across the scale: a systematic review, Journal of Physiotherapy59(2), 93–99. doi: 10.1016/S1836-9553(13)70161-9.
10.
E,M.M.,Marion, S.,M, R. G., J, S. H., N, v. d. G. J., J, B. J. B., & W, S. R. (2011) The neuronal correlates of mirror therapy: an fMRI study on mirror induced visual illusions in patients with stroke, Journal of Neurology, Neurosurgery, and Psychiatry82(4).
11.
E, M. M., W, S. R., N, v. d. G. J., Martine, E., Gunes, Y., J, S. H.,... J, B. J. B. (2011) Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial, Neurorehabilitation and Neural Repair25(3).
12.
Farsin,H., Henning,L. C., Volkmar,G., Irina,M., Michel,R., & Cornelius,W. (2012) Functional plasticity induced by mirror training: the mirror as the element connecting both hands to one hemisphere, Neurorehabilitation and Neural Repair26(5).
13.
Fritzsch,C., Wang,J., Santos,L. F. d., Mauritz,K.-H., Brunetti,M., & Dohle,C. (2014) Different effects of the mirror illusion on motor and somatosensory processing, Restorative Neurology and Neuroscience32(2).
14.
Ghadir,S., Rifaii,S. A., & Soha,S. (2016) Mirror therapy combined with functional electrical stimulation for rehabilitation of stroke survivors’ ankle dorsiflexion, Conference proceedings: IEEE Engineering in Medicine and Biology Society2016.
15.
Giovanni,B., Ana,S., & L, S. S. (2006) Functions of the mirror neuron system: implications for neurorehabilitation, Cognitive and Behavioral Neurology: Official Journal of the Society for Behavioral and Cognitive Neurology19(1).
16.
Gunes,Y., Ruud,S., Nebahat,S., Serap,S., B, B. J., Füsun,K., ...J, S. H. (2008) Mirror therapy improves hand function in subacute stroke: a randomized controlled trial, Archives of Physical Medicine and Rehabilitation89(3).
17.
Hallett,M., Iorio,R. D., Rossini,P. M., Park,J. E., Chen,R., Celnik,P., ...Ugawa, Y. (2017) Contribution of transcranial magnetic stimulation to assessment of brain connectivity and networks, Clinical Neurophysiology128(11).
18.
Holm,T., Nadine,M., Jan,M., Marcus,P., Johann,B., Bernhard,B., & Christian,D. (2018) Mirror therapy for improving motor function after stroke, The Cochrane database of Systematic Reviews7.
19.
Hong,Z., Sui,M., Zhuang,Z., Liu,H., Zheng,X., Cai,C., & Jin,D. (2018) Effectiveness of neuromuscular electrical stimulation on lower limbs of patients with hemiplegia after chronic stroke: a systematic review, Archives of Physical Medicine and Rehabilitation99(5).
20.
Huang,C.-Y., Lin,G.-H., Huang,Y.-J., Song,C.-Y., Lee,Y.-C., How,M.-J., ...Hsieh, C.-L. (2016) Improving the utility of the Brunnstrom recovery stages in patients with stroke: Validation and quantification, Medicine95(31). doi: 10.1097/MD.0000000000004508.
21.
Ji,S. G., & Kim,M. K. (2015) The effects of mirror therapy on the gait of subacute stroke patients: a randomized controlled trial, Clinical Rehabilitation29(4).
22.
Jing,W., Claire,F., Johannes,B., Susanne,H., Karl-Heinz,M., Maddalena,B., & Christian,D. (2013) A comparison of neural mechanisms in mirror therapy and movement observation therapy, Journal of Rehabilitation Medicine45(4).
23.
K, B., S, W.-D., & Ji,W. (1995) The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke, Scandinavian Journal of Rehabilitation Medicine27(1), 27–36.
24.
Kenji,K., Hiroyuki,M., Sayaka,N., Kazuya,H., Yusuke,T., Genichi,T., ...Shigeru, S. (2015) Randomized controlled comparative study on effect of training to improve lower limb motor paralysis in convalescent patients with post-stroke hemiplegia, Journal of Physical Therapy Science27(9).
25.
Kim,K., Lee,S., Kim,D., Lee,K., & Kim,Y. (2016) Effects of mirror therapy combined with motor tasks on upper extremity function and activities daily living of stroke patients, Journal of Physical Therapy Science28(2), 483–487. doi: 10.1589/JPTS.28.483.
26.
Koen,M., Marion,S., N, V. d. G. J., Aad, V. d. L., Ruth, S., J, S. H., & W, S. R. (2009) Mirror-induced visual illusion of hand movements: a functional magnetic resonance imaging study, Archives of Physical Medicine and Rehabilitation90(4).
27.
L, R. K., & G, C. R. (2013) Neural pathways mediating cross education of motor function, Frontiers in Human Neuroscience7.
28.
Langhorne,P., Bernhardt,J., & Kwakkel,G. (2011) Stroke rehabilitation, The Lancet377(9778).
29.
Lee,H. J., Kim,Y. M., & Lee,D. K. (2017) The effects of action observation training and mirror therapy on gait andbalance in stroke patients, The Society of Physical Therapy Science29(3).
30.
Lennon,S., & Johnson,L. (2000) The modified rivermead mobility index: validity and reliability, Disability and Rehabilitation22(18), 833–839. doi: 10.1080/09638280050207884.
31.
Lv,M., Wang,H., & Shao,Z. (2020) Rehabilitation training activity analysis method for motor function in lower limb in elderly patients with hemiplegia after stroke. +, Rehabilitation Medicine30(02), 161. doi: 10.3724.
32.
Mekbib,D. B., Zhao,Z., Wang,J., Xu,B., Zhang,L., Cheng,R., ...Xu, D. (2020) Proactive Motor Functional Recovery Following Immersive Virtual Reality– Based Limb Mirroring Therapy in Patients with Subacute Stroke, Neurotherapeutics17(4), 1919–1930. doi: 10.1007/S13311-020-00882-X.
33.
Minjae,L., & Hyun-mo,K. (2018) The Effects of Mirror Therapy with Functional Electrical Stimulation Therapy for The Stroke Patients. In (Vol. 6, pp. 123-130).
34.
MSc, G. B., MCSP, & Smith,M. (2001) The recovery of walking ability and subclassification of stroke, Physiotherapy Research International6(3).
35.
Narayan,A. K., Shanta,P., Dharmendra,K., & Vinod,P. (2015) Task-based mirror therapy augmenting motor recovery in poststroke hemiparesis: a randomized controlled trial, Journal of Stroke and Cerebrovascular Diseases: The Official Journal of National Stroke Association24(8).
36.
Osumi,M., Sumitani,M., Otake,Y., & Morioka,S. (2019) A hypothetical explanatory sensorimotor model of bilateral limb interference, Medical Hypotheses122.
37.
Rizzolatti,G. (2005) The mirror neuron system and its function in humans, Anatomy and Embryology210(5-6).
38.
Rjosk,V., Lepsien,J., Kaminski,E., Hoff,M., Sehm,B., Steele,C. J., ...Ragert, P. (2017) Neural Correlates of Mirror Visual Feedback-Induced Performance Improvements: A Resting-State fMRI Study, Frontiers in Human Neuroscience11. doi: 10.3389/FNHUM.2017.00054.
39.
Ros,B., eacute, ouml, & Lundborg, r. (2005) Training with a mirror in rehabilitation of the hand, Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery39(2).
40.
S, B. T., P, P. G. E., & Paul,Z. E. (2016) Cross-education of strength and skill: an old idea with applications in the aging nervous system, The Yale Journal of Biology and Medicine89(1).
41.
Safaz,İ., Ylmaz,B., Yaşar,E., & Alaca,R. (2009) Brunnstrom recovery stage and motricity index for the evaluation of upper extremity in stroke: analysis for correlation and responsiveness, International Journal of Rehabilitation Research32(3), 228–231. doi: 10.1097/MRR.0B013E32832A62AD.
42.
Salem,H. M. A., & Huang,X. (2015) The effects of mirror therapy on clinical improvement in hemiplegic lower extremity rehabilitation in subjects with chronic stroke, International Journal of Biomedical and Biological Engineering9(2), 163–166.
43.
Sanford,J., Moreland,J., Swanson,L. R., Stratford,P. W., & Gowland,C. (1993) Reliability of the Fugl-Meyer Assessment for Testing Motor Performance in Patients Following Stroke, Physical Therapy73(7), 447–454. doi: 10.1093/PTJ/73.7.447.
44.
Sutbeyaz,S., Yavuzer,G., Sezer,N., & Koseoglu,B. F. (2007) Mirror therapy enhances lower-extremity motor recovery and motor functioning after stroke: a randomized controlled trial, Archives of Physical Medicine and Rehabilitation88(5), 555–559. doi: 10.1016/j.apmr.2007.02.034.
45.
Thieme,H., Morkisch,N., Mehrholz,J., Pohl,M., Behrens,J., Borgetto,B., & Dohle,C. (2019) Mirror Therapy for Improving Motor Function After Stroke: Update of a Cochrane Review, Stroke50(2). doi: 10.1161/STROKEAHA.118.023092.
46.
Uthra,M., Karthik,B. S., Vijay,K. K., K. K., V, S. B., K, M. Z., & M, C. (2013) Effectiveness of mirror therapy on lower extremity motor recovery, balance and mobility in patients with acute stroke: A randomized sham-controlled pilot trial, Annals of Indian Academy of Neurology16(4).
47.
Vural,S. P., Yuzer,G. F. N., Ozcan,D. S., Ozbudak,S. D., & Ozgirgin,N. (2016) Effects of mirror therapy in stroke patients with complex regional pain syndrome type 1: a randomized controlled study, Archives of Physical Medicine and Rehabilitation97(4), 1.
48.
Wang,J., Fritzsch,C., Bernarding,J., Krause,T., Mauritz,K.-H., Brunetti,M., & Dohle,C. (2013) Cerebral activation evoked by the mirror illusion of the hand in stroke patients compared to normal subjects, Neuro Rehabilitation33(4).
49.
Xiong,J., Parsons,L. M., Gao,J. H., & Fox,P. T. (1999) Interregional connectivity to primary motor cortex revealed using MRI resting state images, Human Brain Mapping8(2-3).
50.
Ya-Long,H., Yan,G., & Bai-Ya,F. (2019) Effectiveness of neuromuscular electrical stimulation combined with rehabilitation training for treatment of post-stroke limb spasticity, Medicine98(39).
51.
Yang,C. M., Wang,Y.-C., Lee,C.-H., Chen,M.-H., & Hsieh,C.-L. (2020) A comparison of test-retest reliability and random measurement error of the Barthel Index and modified Barthel Index in patients with chronic stroke. Disability and Rehabilitation, 1-5. doi:10.1080/09638288.2020.1814429.
52.
Yin,M., Liu,Y., Zhang,L., Zheng,H., Peng,L., Ai,Y., ...Hu, X. (2020) Effects of rTMS Treatment on Cognitive Impairment and Resting-State Brain Activity in Stroke Patients: A Randomized Clinical Trial, Frontiers in Neural Circuits14. doi: 10.3389/FNCIR.2020.563777.
53.
Ying,W., Kai,S., Zhenyu,L., Guanmao,C., Yanbin,J., Shuming,Z., ...Jie, T. (2020) Classification of unmedicated bipolar disorder using whole-brain functional activity and connectivity: a radiomics analysis. Cerebral Cortex (New York, N.Y. : 1991), 30(3).
54.
Yu-Rong,M., Leung,L. W., Qiang,L., Le,L., Xiang,X., Preeti,R., & Dong-Feng,H. (2015) The effect of body weight support treadmill training on gait recovery, proximal lower limb motor pattern, and balance in patients with subacute stroke, BioMed Research International2015.
55.
Zhang,X., Yue,Z., Wang,J., & Kuang,Y. (2017) Robotics in lower-limb rehabilitation after stroke, Behavioural Neurology2017.
