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Neural Plasticity and Stroke Rehabilitation

The purpose of this study was to conduct a review of the literature on mirror therapy and to analyse the scientific evidence about the effectiveness of using mirror therapy to enhance motor and functional results in patients who have suffered a stroke.

Stroke is one of the most common causes of disability around the world. Despite advancements in acute stroke care, stroke continues to be a leading cause of disability around the world. Several neurological functions are compromised as a result of a stroke, the most frequent of which is a motor impairment on the side of the body opposite the stroke lesion(Hatem et al., 2016). So many rehabilitation strategies built on motor learning paradigms have been created to aid in the recovery of impaired mobility in those who have suffered a stroke as a result.

The ability of the central nervous system to modify its structure and/or function is known as neural plasticity. Increased knowledge of neuronal plasticity and its relevance to stroke recovery has recently been aided by technological advancements that allow noninvasive investigation of the human brain. Different unique stroke rehabilitative strategies for motor recovery have been created on the basis of fundamental research and clinical investigations defining brain remodelling as a result of neural plasticity. These treatments include: Motor function deficiencies caused by a stroke have an impact on the patient's mobility, their ability to participate in daily living activities, their ability to participate in society, and their likelihood of returning to their previous career. All of these problems contribute to the overall poor level of quality of life in the population. The most effective method of reducing motor deficits in stroke patients is through rehabilitation training and exercise.

Experimental evidence is mounting that some motor brain regions are activated not only during the execution of actions but also during the observation of another person's activities. The mirror neurons, which have been discovered in nonhuman primates as the neurophysiological foundation for this recruitment, are thought to be responsible for this recruitment. There has also been evidence of a "mirror neuron system" in humans, which has been implicated in movement comprehension, imitation, motor learning, and moderating training effects. Actuation observation, according to the mirror neuron paradigm, appears to stimulate the motor system in a manner similar to execution by establishing an internal representation of an action that may be targeted for motor learning. It was discovered in a prior study conducted on healthy people that seeing another person master a novel task increases one's own performance on the same activity later on. Data from recent virtual lesion research conducted with transcranial magnetic stimulation (TMS) lends more support to the concept that action observation combined with physical exercise may increase use-dependent plasticity through the mirror neuron system in healthy individuals.

The primary aim of the present study is to evaluate the role of mirror therapy in the Rehabilitation of Stroke patients for improvement of motor function.  

  • To evaluate the scientific literature regarding the effectiveness of mirror therapy.
  • To evaluate the evidence presented in the literature regarding the application of mirror therapy in stroke patients.
  • To compare the effectiveness of mirror therapy in comparison to traditional therapy for the motor function of stroke patients.

The PICO approach was used to develop the research question and the criteria for conducting a literature search that followed as indicted in Appendix 1 . Patients suffering from motor function impairment as a result of a stroke were the focus of the study. The application of mirror therapy was used to help people restore motor function after they had lost it. The researchers did a comparison between their technique and the usual therapeutic strategy for restoring motor function in stroke patients. Obtaining an understanding of the effectiveness of enhanced motor function outcomes in the patient was the goal of this study.

Mirror Neurons and Action Observation Therapy

Using a set of search phrases such as "mirror therapy", "motor function", "stroke patient", and"traditional therapy" to search the Google Search and PUBMED databases, the researchers discovered a number of promising results. It was necessary to apply boolean operators in order to construct the search query "And." The following search terms were used to locate the databases: "Mirror therapy and stroke patient," "Mirror therapy and motor function," and "Traditional treatment and stroke patients." Study after study that investigated the impact of mirror therapy on the results of a motor function intervention for stroke patients was included in the review for further consideration. Studies that did not include patients with stroke, studies that did not use a mirror or conventional treatment, and studies that did not examine the efficacy of the intervention on motor function outcomes were eliminated. Relevant studies were evaluated using a variety of critical appraisal skills programme (CASP) techniques, which varied based on the study's design and findings as indicated in Appendix 2.

(Jan et al., 2019) uncovered that both the engine relearning program and the mirror treatment were valuable in further developing upper appendage engine capacities in stroke patients, with the previous being shown to be more viable than the last option in further developing upper appendage engine capacities in stroke patients. The CASP analysis indicated that the aim that was set for the study was achieved, however the study did not provided any information regarding the inclusion and exclusion criteria that was followed. Moreover, due to the small sample size the study did not provided any conclusive comparison with the previous  studies with the same intervention.     Further developed upper appendage incapacity, which is for the most part brought about by stroke, is as yet one of the most difficult restoration treatment troubles that the recovery local area should manage, as indicated by Madhoun et al. (2020). Despite the fact that task-based reflect treatment (TBMT) has been demonstrated to be helpful in the treatment of subacute stroke patients with moderate to serious upper appendage debilitation, little examination has been done on its viability in the treatment of post-stroke patients with extreme upper appendage handicap. Patients who have had an upper appendage stroke might profit from a blend of standard treatment and TBMT, as per the discoveries of the study. Critical analysis of article indicated that inclusion criteria that was set earlier for the participants was followed in the present study as there were 57 participants selected earlier, but based on the inclusion and exclusion criteria 20 were excluded from the study moreover 5 participants did not completed the study, hence 30 participants were finally analyzed for the results. Following the consummation of an examination by Choi et al. (2019), it was discovered that participants in the gesture recognition (G.R.) mirror treatment group had significantly better upper-extremity function, lower depression, and higher quality of life than participants in a control group, indicating that the intervention was effective. While the decreases in neck discomfort were statistically significant, they were statistically significantly less than the changes in neck discomfort seen with generalised relaxation mirror therapy in both the traditional mirror treatment and control groups. Patient-centered G.R. device-based mirror therapy has been shown to enhance upper-extremity function, neck discomfort, and overall quality of life in people who have had a chronic stroke, according to the findings of the study. In the context of selection of participants the study included participants who suffered stroke within 6 months with a score of 24 or more. The  study conducted by Shih et al. (2017) discovered that the loss of upper-extremity motor function is one of the most debilitating deficits that may occur after a stroke. Afferent inputs and visual feedback patterns from a variety of sources are combined to form two potential therapeutic techniques: action observation therapy (AOT) and mirror therapy (MT). The goal of these two techniques is to improve motor learning and promote brain reconfiguration in people who suffer from movement disorders. In spite of the fact that the two systems employ separate patterns of motor observation, imitation, and execution, they both rely on similar neurological substrates of the mirror neuron system, which are equivalent to one another. In patients with subacute stroke who have received AOT and M.T., this clinical trial will give scientific verification of the effects of these therapies on motor and functional results, as well as on brain activity processes in these individuals. AOT and M.T. applications and use may also involve telerehabilitation, often known as home-based rehabilitation, which is accomplished via the use of web-based or video-based instruction. In the context of results of the study, it was not discussed  in the study as the trail was not completed.

Aim

It has been shown that mirror therapy (M.T.) can be beneficial even in patients who are entirely paralysed following a stroke, as contrasted to other types of rehabilitation methods such as physical therapy. The reason for this is that mirror therapy (M.T.) makes use of visual cues in order to induce a desirable reaction in the wounded limb. In recent research , M.T. has been displayed to have helpful advantages on engine deficiencies as well as on disposition, visuospatial disregard, and torment following a stroke, in addition to other things. If viable measures to forestall strokes and decrease the incapacitating impacts of strokes are not effectively evolved and executed during this time span, as per King et al. (Lord and partners, 2020), the expenses of stroke care in the United Kingdom will rise quickly throughout the following twenty years. Death due to stroke in the United Kingdom are probably going to ascend by 60% over the course of the following 10 years, and the quantity of individuals who endure a stroke will over two times.

Despite the fact that many drugs are available to increase cerebral perfusion after an acute stroke and to prevent recurrent stroke, acute stroke rehabilitation therapies have been found to be effective in improving neurologic recovery in clinical investigations. Although advances in neurorehabilitation have been made in recent years, the great majority of stroke patients who have experienced motor loss do not regain their pre-stroke levels of functioning. It is necessary to develop innovative neurorehabilitation therapies in order to reduce long-term disability while simultaneously improving quality of life and psychosocial outcomes. The development of innovative medications for the restoration of motor function after a stroke has accelerated in recent years, and the development of more experimental therapy has also gained momentum in recent years (Claflin, Krishnan and Khot, 2014). It is the ultimate objective of stroke rehabilitation to improve patients' neurologic recovery, functional independence, and overall quality of life to the greatest extent feasible after having had a stroke. A variety of conventional therapeutic techniques are used to aid in the patient's spontaneous neurologic and functional recovery following a stroke. The multidisciplinary treatment team – which includes physical therapy, occupational therapy, and speech and language pathology – is responsible for the patient's recovery. The development of exciting alternative therapies, pharmaceuticals, and experimental treatments has taken place in recent decades, and some of these treatments are now showing promise in the treatment of post-stroke patients (Gandhi et al., 2020).

According to the findings of their research, Thieme et al. (2018) discovered that mirror therapy might be used to aid individuals who have suffered a stroke in regaining their motor function. Mirror treatment is a technique in which an object such as a mirror is put in the person's midsagittal plane, causing movements of the non-paretic side to appear on the affected side as if they were occurring on the afflicted side. Parkinson's disease is by far the most common ailment for which it is prescribed.. At the very least, using a mirror to treat patients who have suffered from a stroke or another neurological condition has the potential to be beneficial in improving upper extremity motor function and impairment, as well as activities of daily living and pain, at the very least as an adjunct to standard rehabilitation for patients who have suffered from a stroke or another neurological condition. When you have a stroke, it is possible that you will have difficulty doing everyday chores such as walking, dressing, and eating. Because of the paralysis of the arm or limb that normally results from a stroke, which has been mentioned above, this is the case. A type of therapy in which a mirror is placed between the arms or legs in such a way that the image of a moving non-affected limb seems to provide the illusion of normal movement in the afflicted limb is known as mirror therapy. When an arm or leg is moved, a mirror is positioned between them in such a way that the image of the moving non-affected limb gives the illusion of normal movement in the afflicted arm or leg. To do this, a mirror is positioned between the arms or legs in such a manner that the image of a non-affected limb moving creates an illusion of normal movement in the afflicted limb. As a result of this arrangement, it is feasible to engage several brain areas associated with movement, sensation, and pain, which makes them more accessible.

Objectives

Stroke is one of the most widely recognised reasons for extremely durable handicaps all over the planet. In the repercussions of a stroke, hemiplegia (incomplete loss of motion on one side of the body) and hemiparesis (muscle shortcoming on one side of the body) are both ordinary results. It has been assessed that around 85% of stroke survivors would experience the ill effects of hemiplegia and that no less than 69% will encounter an absence of capacity in their upper appendages (Park et al., 2015).

The effortlessness of mirror box treatment recognises it as a genuine development. Other than the mirror treatment box, the patient and a reflection are the actual main parts of this treatment. Albeit the mirror box itself isn't generally a crate, the standards that oversee it are the equivalent no matter what the plan. The mirror is put on a table before the patient and is utilised to recognise the furthest points of the left and right sides. With their hands on the appropriate side of the focal mirror and the harmed appendage concealed by the mirror box itself, the patient might see themselves. It is feasible to overlay the harmed appendage with the impression of the uncovered, unaffected hand and its movements as such outwardly.

Whenever the mind sees this mirror and its connected deception, it is fooled into accepting that the harmed appendage is working typically once more. Thought to reflect neuron enactment has a basic influence on the helpful advantages of mirror treatment, regardless of the way that the hidden interaction isn't completely known as of now.

In view of the mind's capacity to revamp, it is possible for the cerebrum to adjust in the wake of going through an awful mishap like a cerebrum injury. Reflect treatment should initially connect with the neuron reflecting organisation, which is a confounded component including impersonation and human learning before it can start to invigorate neuronal recovery (Carvalho et al., 2013).

It is said that the mirror neuron framework "is set off when an individual knows about an activity performed by someone else." More significantly, its enactment isn't subject to memory; at the end of the day, the mirror neuron framework can perceive activity intricacy and consequently emulates what we see, hear, or experience," as indicated by the International Archives of Medicine (Carvalho et al., 2013).

Therefore, the visual contribution of a typical, unaffected appendage's development, as found in the mirror, animates action in the somatosensory cortex, bringing about the actuation of brain adaptability. This excitement then prompts the tormented side of the mind to move the impacted appendage because of the feeling (Lim et al., 2016).

Planning to draw in neurons in the harmed region of the cerebrum, reflect treatment practices are expected to work on the expertise, exactness, and speed of compromised appendages by utilising neurons reflecting on initiating neurons in the impacted piece of the mind. An accomplished clinical master will initially make sense of the mirror box treatment system to a patient and afterwards take the client through a progression of mirror treatment exercises to kick them off on their organised mirror treatment program. People with engine debilitations have been shown to profit from these exercises regarding recapturing smoothness and strength. These activities are planned to ultimately be performed by the stroke survivor on their own in their own home, taking into consideration proceeding with progress (Nighoghossian, 2018).

Methodology

While rehearsing mirror treatment works out, there are a couple of things to remember. The survivor should spend a couple of moments essentially watching the impression of the mirror box after the mirror enclosure is the place, and the survivor is agreeable to plan for the optical deception to happen. It very well may be advantageous for patients to consider themselves looking through a window as opposed to at a reflection (Hoermann et al., 2017). Since reflect treatment is planned to fix engine brokenness, it is imperative to recall that this treatment depends on "the basic standards of engine learning: countless redundancies blended in with fluctuation in the development execution," as per the National Institutes of Health.

For the initial not many long stretches of treatment, reflect treatment stroke activities will focus on the principal flexion and augmentation movements of the fingers. Thereafter, the patient and the specialist will settle on a satisfactory powerful action that is appropriate for their cutoff points with the harmed appendage. The motivation behind these activities is to step by step work on the scope of movement and the degree of trouble associated with them. The specialist will propose a wide range of approaches, including snatching or maneuvering a thing toward the meeting. The patient will execute these major movements with the unaffected appendage to choose the most fitting treatment decision (Mohanty, 2017). A while later, point by point, one concentrates on the mirror box treatment strategy, "the patient and the specialist select together which exercise best cultivates a distinctive mirror deception."

Basic activities, for example, making a clenched hand or associating the tips of each finger to the thumb, or creeping across the outer layer of the mirror with just the fingers, are instances of what is conceivable. When these activities have been finished, they will progress to additional complex utilitarian exercises utilising things like utilising a washcloth to gradually rub down a level surface, getting various pennies, or reproducing purging the items in a single vessel into one more vessel. The demonstration of penmanship is one more famous action that might be finished with the non-predominant hand, assuming the inability has debilitated the prevailing hand.

Conclusion 

In order to be effective, mirror treatment requires particular physical and cognitive qualities, which might render it ineffective for some individuals. Individuals who have significant impairments as a consequence of a stroke or another medical condition may be unable to perform effective mirror treatment on themselves or others. According to the protocol for mirror therapy, treatment adequacy is determined based on three overall dimensions: the emotional, cognitive, and physical capacities of the patient. Patients will need to be able to follow the therapist's instructions during treatment, as well as provide self-guided mirror therapy in their own homes after treatment. This means that mirror treatment may not be appropriate for those who have significant cognitive problems, as previously stated. As previously said, the non-affected limb is critical in mirror treatment, and as such, it should be able to move freely and comfortably throughout its range of motion. An unaffected limb with severe motor dysfunction on its own may make it difficult to do mirror treatment, and discomfort during movement might be a substantial distraction for the patient throughout the procedure. As a result, patients with significant visual impairments or attention problems may not benefit from mirror therapy since the treatment is dependent on the patient's brain's ability to comprehend the reflected picture. If a person is unable to sit straight without assistance, whether owing to a loss of trunk control or another problem, mirror treatment is not indicated in this situation. Patients should try to keep any identifiable or distinguishing markings on their hands to a minimum in order to get appropriate mirror therapy treatment. It is recommended that patients remove any jewellery before treatment, and those who have tattoos, birthmarks, huge moles, or scars should conceal these areas with cosmetics or wear a glove.

Results

References 

Carvalho, D., Teixeira, S., Lucas, M., Yuan, T.-F., Chaves, F., Peressutti, C., Machado, S., Bittencourt, J., Menéndez-González, M., Nardi, A.E., Velasques, B., Cagy, M., Piedade, R., Ribeiro, P. and Arias-Carrión, O. (2013). The mirror neuron system in post-stroke rehabilitation. International Archives of Medicine, [online] 6, p.41. Available at:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4016580/.

Choi, H.-S., Shin, W.-S. and Bang, D.-H. (2019). Mirror Therapy Using Gesture Recognition for Upper Limb Function, Neck Discomfort, and Quality of Life After Chronic Stroke: A Single-Blind Randomized Controlled Trial. Medical Science Monitor, 25, pp.3271–3278.

Claflin, E.S., Krishnan, C. and Khot, S.P. (2014). Emerging Treatments for Motor Rehabilitation After Stroke. The Neurohospitalist, [online] 5(2), pp.77–88. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4357600/.

Gandhi, D.B., Sterba, A., Khatter, H. and Pandian, J.D. (2020). Mirror Therapy in Stroke Rehabilitation: Current Perspectives. Therapeutics and Clinical Risk Management, Volume 16, pp.75–85.

Hatem, S.M., Saussez, G., della Faille, M., Prist, V., Zhang, X., Dispa, D. and Bleyenheuft, Y. (2016). Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery. Frontiers in Human Neuroscience, [online] 10(442). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5020059/.

Hoermann, S., Ferreira dos Santos, L., Morkisch, N., Jettkowski, K., Sillis, M., Devan, H., Kanagasabai, P.S., Schmidt, H., Krüger, J., Dohle, C., Regenbrecht, H., Hale, L. and Cutfield, N.J. (2017). Computerised mirror therapy with Augmented Reflection Technology for early stroke rehabilitation: clinical feasibility and integration as an adjunct therapy. Disability and Rehabilitation, 39(15), pp.1503–1514.

Jan, S., Arsh, A., Darain, H. and Gul, S. (2019). A randomised control trial comparing the effects of motor relearning programme and mirror therapy for improving upper limb motor functions in stroke patients. JPMA. The Journal of the Pakistan Medical Association, [online] 69(9), pp.1242–1245. Available at: https://pubmed.ncbi.nlm.nih.gov/31511706/ [Accessed 11 Feb. 2021].

King, D., Wittenberg, R., Patel, A., Quayyum, Z., Berdunov, V. and Knapp, M. (2020). The future incidence, prevalence and costs of stroke in the U.K. Age and Ageing, 49(2), pp.277–282.

Lim, K.-B., Lee, H.-J., Yoo, J., Yun, H.-J. and Hwang, H.-J. (2016). Efficacy of Mirror Therapy Containing Functional Tasks in Poststroke Patients. Annals of Rehabilitation Medicine, 40(4), p.629.

Madhoun, H.Y., Tan, B., Feng, Y., Zhou, Y., Zhou, C. and Yu, L. (2020). Task-based mirror therapy enhances the upper limb motor function in subacute stroke patients: a randomised control trial. European Journal of Physical and Rehabilitation Medicine, 56(3).

Mohanty, P. (2017). Effectiveness of Mirror Therapy in Rehabilitation of Hand Function in Sub-Acute Stroke. Palliative Medicine & Care: Open Access, [online] 4(2), pp.1–8. Available at:

https://pdfs.semanticscholar.org/8a96/2544e9f6cfdbf5e2f76706f36d7461bca0a9.pdf.

Nighoghossian, N. (2018). Potential of Mirror Rehabilitation Therapy in Stroke Outcome. Neuroscience, 390, p.317.

Park, J.-Y., Chang, M., Kim, K.-M. and Kim, H.-J. (2015). The effect of mirror therapy on upper-extremity function and activities of daily living in stroke patients. Journal of Physical Therapy Science, [online] 27(6), pp.1681–1683. Available at:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4499960/.

Shih, T., Wu, C., Lin, K., Cheng, C., Hsieh, Y., Chen, C., Lai, C. and Chen, C. (2017). Effects of action observation therapy and mirror therapy after stroke on rehabilitation outcomes and neural mechanisms by MEG: study protocol for a randomised controlled trial. Trials, 18(1).

Thieme, H., Morkisch, N., Mehrholz, J., Pohl, M., Behrens, J., Borgetto, B. and Dohle, C. (2018). Mirror therapy for improving motor function after stroke. Cochrane Database of Systematic Reviews, [online] (7). Available at:

https://www.cochrane.org/CD008449/STROKE_mirror-therapy-improving-movement-after-stroke.

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