Reflections on effective use of mirror therapy after stroke: theory and practice

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1 Reflections on effective use of mirror therapy after stroke: theory and practice Tara Packham, OTReg(Ont), PhD Post-doctoral fellow, DeGroote Institute for Pain Research and Care

2 Overview Questions Definitions Theory Practice Discussion

3 What do you hope to learn?

4 Definitions Mirror (box) therapy or mirror visual feedback: may include simply looking at the image, unilateral movement reflected in the mirror, or bilateral movements with the target limb behind the mirror (McCabe, 2011) Graded motor imagery: a formal, sequential program of laterality judgements [distinguishing images as left or right], mental imagery and mirror visual feedback used for pain syndromes (Moseley, 2004)

5 Definitions Motor imagery mental rehearsal or simulation of an action or activity without any body movement (Harris & Hebert, 2015) also known as imagined movements inherent focus is on the kinesthetic sense of movement

Definitions Mental imagery a perceptual experience in the absence of external stimuli can include multiple forms of sensory representation: touch, sight,

6 Definitions Mental imagery a perceptual experience in the absence of external stimuli can include multiple forms of sensory representation: touch, sight, smell, and sounds (Schmaltzl et al, 2013) Imagined movements are a subset of mental imagery; other forms of mental imagery include guided visualization and hypnosis

7 Definitions Functional equivalence careful matching of motor imagery elements to desired motor action to stimulate the same brain areas and strengthen the memory trace of the task. Bodily illusions a deliberate manipulation of perception of physical aspects of body size, shape or position, tactile and visual representation (Boesch et al, 2016; Moseley & Weich, 2009) Cortical reorganization alterations in the function of the somatosensory cortex leading to OR resulting from distorted or altered perceptual feedback

8 Theoretical underpinnings Neuroplasticity concepts Sensorimotor incongruence while visual and motor networks are separate in the brain, and activated differentially by imagery, they are nonetheless tied to each other and often activated simultaneously Body perception, perceived ownership Illusion of two normal moving arms? Unlearning of learned paralysis? Mechanism of MT possible related to:? Effective form of motor imagery? Mirror neuron system? Bilateral coupling of both arm movements? Activation of visual-motor cortex pre-motor cortex somatosensory and motor cortices cerebellum and crosshemisphere communication?

9 Proposed neural mechanisms for mirror visualization post-stroke (Arya, 2016) This illustrates imagined movements of the left hemiparetic arm in a subject visualizing and moving the rightunaffected upper limb and perceiving it as the left side. The brain areas/network (directeddotted line) involved during MT and/or responsible for the associated motor recovery are represented

patients. It may help to improve upper extremity motor function and ADLs.

10 Canadian Best Practice Guidelines for Stroke Care Recommendations for U/E care: Mirror therapy should be considered as an adjunct to motor therapy for select patients. It may help to improve upper extremity motor function and ADLs. (Evidence Level: Early-Level A; Late-Level A). No reference to mirror therapy in the L/E recommendations

11 Current evidence Cochrane reviews Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II Smart et al, 2016 Interventions to improve arm and hand function in people after stroke Pollock et al, 2014 Which treatments are effective for the treatment of complex regional pain syndrome in adults? O Connell et al, 2013 Mirror therapy for improving motor function after stroke Theime et al, 2012

12 Rothgangel et al, 2011 Clinical aspects of mirror therapy in rehabilitation: a systematic review For stroke (7 studies total): moderate quality evidence MT + usual care = recovery low quality of evidence regarding lower limb function low quality evidence for improving post-stroke pain RCTs by Yavuzer et al, 2008 (U/E) and Sutbeyaz et al, 2007 (L/E) were deemed highest quality 3 different intervention approaches: patient encouraged to move the affected limb as much as they could (Altschuler et al 1999; Yavuzer et al 2008; Dohle et al 2009) movements were only performed by the unaffected limb (Sutbeyaz et al 2007; Cacchio et al 2009) movements of the affected limb were facilitated by the therapist (Rothgangel et al 2004).

13 Perez-Cruzado et al, 2017 Systematic review of mirror therapy compared with conventional rehabilitation in upper extremity function in stroke survivors 15 studied included (cut score 6/11 on PEDro) MT better than CR (d= ) for U/E motor recovery MT + CR better than CR alone for U/E motor recovery (5 studies), even if corrected for dosage MT > MT + CR (2 studies) 4/5 studies reporting function outcomes had d>0.80 favoring MT Better results if MT sessions were min vs 90 min; also noted typical CR sessions were 1 hour

14 Pervane Vural et al, 2016 The effects of mirror therapy in stroke patients with CRPS1: a randomized controlled study N=30, 4 weeks of rehabilitation 5d/week, 2-4 hrs/day + MT 30 min/day **38/150 were dx with CRPS during study period 35x35cm mirror, instructed to watch and try bilaterally both groups had significant improvements in FIM-motor and VAS pain scores; MT group improved more (p<0.001 FIM, p=0.03 pain) patients in the MT group also showed significant improvement in Brunstromm staging and Fugl-Meyer scores (p<0.05). No significant difference was found for MAS scores in either group.

15 Sütbeyaz et al, 2007 Mirror therapy enhances lower-extremity motor recovery and motor functioning after stroke RCT: N= 40, sub-acute stroke (less than 1 yr. post) 30 min/day of the mirror therapy program, consisting of nonparetic ankle dorsiflexion movements or sham therapy, + usual stroke rehab 5 days a week, 2 to 5 hours a day, for 4 weeks Subjects were in a semi-seated position on a bed, while the mirror board (40 X 70cm) was positioned between the legs perpendicular to midline. Subjects observed the reflection of the nonparetic leg while flexing and extending the ankle at a self-selected speed under supervision but without additional verbal feedback. Improvements in FIM scores twice as big in MT group; MT group improved 2 Brunstromm stages while controls improved by 1; no differences between groups in spasticity

16 Xu et al, 2017 Effects of MT combined with NMES on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled study N=69: control, MT, and MT +NMES; 4 weeks at 30 min/day MT> control: Brunnstrom stage (P = 0.04), 10-meter walk test (P < 0.05), and passive range of motion (P < 0.05) MT + NMES > MT: 10-meter walk test (P < 0.05). MT == MT + NMES for spasticity MT + NMES > control for spasticity (P < 0.001)

17 Selles et al, 2014 Effects of a Mirror-Induced Visual Illusion on a Reaching Task in Stroke Patients: Implications for Mirror Therapy Training Mirror reflection facilitates motor learning large effect of the mirror when moving only the unaffected hand so good for those at low CMSA stages BUT mirror training alone == direct training of the involved hand Bilateral movements with a mirror not as useful because of fatigue? Incongruence? May be more effective to combine mirror training with training of only the affected arm or with other training regimens such as mcimt

18 Yun et al, 2011 The synergic effects of mirror therapy and neuromuscular electrical stimulation for hand function in stroke patients. N=60, 3 weeks Rx. MT + NMES > MT or control Fugl-Meyer scores of hand, wrist, coordination and power of hand extension. MT + NMES==MT==control on power of hand fl, wrist fl, wrist ext, or tone Yoon et al, Effect of constraint-induced movement therapy and mirror therapy for patients with subacute stroke. N=26, 2 weeks Rx, CIMT + MT==CIMT>control functional improvements. CIMT + MT > CIMT for grip and fine motor Lee D et al, Mirror therapy with NMES for improving motor function of stroke survivors. Improvements in grip strength, balance, spasticity, TUG Lundquist & Nielsen, Left/right judgement does not influence the effect of mirror therapy after stroke. GMI not necessary, just MT **NB 5/36 dropped out from pain unaffected arm (3) or failure to engage (2)

stroke patients J Physical Therapy Sci N=30, all 8

19 Park et al, 2014 The effects of mirror therapy with tasks on upper extremity function and self-care in stroke patients J Physical Therapy Sci N=30, all 8 tasks each session 5d/week x 6 week s= improved FIM

20 Lim et al, 2016 Efficacy of Mirror Therapy Containing Functional Tasks in Poststroke Patients Week Concept Activities 1 Simple movement Visualization Pro/Sup, Wrist E/F 2 Simple movement Finger E/F, finger tapping Counting on fingers Thumb opposition 3 Simple tasks Pick up a coin or bean Flip a card Block in a bucket 4 Complex tasks Pegboard Copying shapes, colouring N=60, at least Brunstromm stage 3, 20 min/day bilateral exs. More gains in Fugl-Meyer and Barthel with tasks, similar in Brunstromm

21 Targeted outcomes post stroke Motor function Reducing pain Reducing spasticity (when used with NMES or tasks) Improving function Sensation or neglect???? Consider what evaluations will help to gauge progress for your primary outcomes of interest

22 Play time! Please try. getting a visual illusion just moving the hand in front of the mirror moving hands together, then separately if you dare interacting with 2 identical objects experiencing synchiria (with help from a friend) stimulating ONLY the hand behind the mirror play a localization game

23 Let s discuss What have you tried with clients? Visualizing, movements, tasks or all? What clients would you want to use MT with? Hospital/clinic or home program? Combined with NMES? Motor imagery? Would you use this for the lower extremity? What would you do differently? Who would you avoid this with? What concerns do you still have?

24 Grading and progressing PETTLEP model from sports (see Harris & Hebert, 2015) Physical - practice, positioning, NMES Environment reduce distractions, visual /auditory cues and feedback (vanvliet & Wulf, 2006), promote relaxation? Task object interactions, multisensory inputs, isolated movements vs. functional activities

25 Grading and progressing Timing before or after physical practice? Increasing the dose, duration, & intensity Learning grading the task relative to mastery Emotion meaningful tasks, client choice/preference Perspective - internal focus on bodily movement and limb position vs external focus on control/manipulation of objects (Harris & Hebert, 2015; vanvliet & Wulf, 2006)

26 Vision? Indications and contraindications Reports of nausea or vestibular responses (i.e. balance perturbation, falls), negative changes in limb temperature or weight, pain invoked or increased Profound hemi-neglect Be aware of creating or reinforcing distortions with poor quality materials or set-up

27 Complimentary modalities Motor imagery Mental imagery Relaxation Virtual reality reflection therapy (e.g. ipad camera) NEMS: combined therapy (Yun et al, 2011 for U/E, Xu et al, 2017 for L/E) Augmented tactile feedback if sensation is not impaired Synchiria - Localization Bilateral sensory stimulation - Tactile discrimination

28 Summary of evidence-informed recommendations Mirror therapy is helpful for both upper and lower extremity training Mirror visualization good for low functioning arm/leg OR as adjunct to bilateral task training Mirror augmented bilateral training most effective when used with NMES Can be used in conjunction with mcimt May consider as an alternative to conventional rehab if pain is a barrier Sessions should be between minutes; shorter repeated sessions may be better for a painful limb

29 Patient education and home programs Patient education is key to achieving an effective dose and duration of MVF; may need to engage family members as well Will need to understand some basic neurophysiology to get buy in Pick the examples and stories that work for you, and rehearse them, construct educational materials that utilize them, and reinforce regularly Be strategic about inclusivity for persons with aphasia, both in your education and MVF activities

30 More reading The Brain that Changes Itself Norman Doidge The Brain s Way of Healing Norman Doidge Phantoms in the Brain V.S. Ramachandran Highlighted readings in reference list

31 References Acerra NE, Souvlis T, Moseley GL. Stroke, complex regional pain syndrome and phantom limb pain: Can commonalities direct future management? J Rehabil Med. 2007;39(2): doi: / Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DM, Ramachandran VS. Rehabilitation of hemi- paresis after stroke with a mirror. Lancet. 1999;353: 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: Boesch E, Bellan V, Moseley GL, Stanton TR. The effect of bodily illusions on clinical pain. Pain; 2016 Mar;157(3): Dohle C, Pullen J, Nakaten A, Kust J, Rietz C, Karbe H. Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial. Neurorehabil Neural Repair. 2009; 23: Harris JE, Hebert A. Utilization of motor imagery in upper limb rehabilitation: a systematic scoping review. Clin Rehabil Nov;29(11):

32 Lee D, Lee G, Jeong J. Mirror therapy with NMES for improving motor function of stroke survivors. Technol Health Care 2016; 24(4): Lim KB, Lee HJ, Yoo J, Yun HJ, Hwang HJ. Efficacy of mirror therapy containing functional tasks in poststroke patients. Ann Rehabil Med. 2016;40(4): MacIver K, Lloyd DM, Kelly S, Roberts N, Nurmikko T. Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery. Brain. 2008; 131: McCabe C. Mirror visual feedback therapy. a practical approach. J Hand Ther; 2011;24(2): 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): Moseley GL. Graded motor imagery is effective for long-standing complex regional pain syndrome: A randomised controlled trial. Pain; 2004,108(1-2): Moseley GL, Wiech K. The effect of tactile discrimination training is enhanced when patients watch the reflected image of their unaffected limb during training. Pain Aug;144(3):314 9.

33 Nilsen DM, Gillen G, Gordon AM. Use of mental practice to improve upperlimb recovery after stroke: A systematic review. Am J Occup Ther. 2010;64(5): Perez-Cruzado D, Merchan-Baeza JA, Gonzalez-Sanchez M, Cuesta-Vargas AI. Systematic review of mirror therapy compared with conventional rehabilitation in upper extremity function in stroke survivors. Aust Occup Ther J. 2017;64(2): Pervane Vural S, Nakipoglu Yuzer GF, Sezgin Ozcan D, Demir Ozbudak S, Ozgirgin N. The effects of mirror therapy in stroke patients with CRPS1: a randomized controlled study. Arch Phys Med Rehabil. 2016;97(4): Available from: Rothgangel AS, Braun SM, Beurskens AJ, Seitz RJ, Wade DT. The clinical aspects of mirror therapy in rehabilitation: a systematic review of the literature. Int J Rehabil Res; 2011 Mar;34(1):1 13. Schmalzl L, Ragnö C, Ehrsson HH. An alternative to traditional mirror therapy: illusory touch can reduce phantom pain when illusory movement does not. Clin J Pain 2013;29(10): e10 8. Sutbeyaz S, Yavuzer G, Sezer N, Koseoglu BF. Mirror therapy enhances lowerextremity motor recovery and motor function- ing after stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2007;88:555 9.

34 Valdes K, Naughton N, Algar L. Sensorimotor interventions and assessments for the hand and wrist: A scoping review. J Hand Ther. 2014; 27(4): van Vliet PM, Wulf G. Extrinsic feedback for motor learning after stroke: What is the evidence? Disabil Rehabil. 2006;28(13 14): Available from: Xu Q, Guo F, Salem HMA, Chen H, Huang X. Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled study. Clin Rehabil. 2017;1-9. Available from: Yavuzer G, Selles R, Sezer N, et al. Mirror therapy improves hand function in subacute stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2008;89: Yoon JA, Koo BI, Shin MJ, Shin YB, Ko HY, Shin YI. Effect of constraint-induced movement therapy and mirror therapy for patients with subacute stroke. Ann Rehabil Med 2014;38: Yun GJ, Chun MH, Park JY, Kim BR. The synergic effects of mirror therapy and neuromuscular electrical stimulation for hand function in stroke patients. Ann Rehabil Med 2011;35:

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How Often to Perform Each Exercise: Mirror Box Setup: Make sure you can see the full reflection of your arm in the mirror

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