|Ahead of print publication
A study to compare the effectiveness of mirror therapy and neuromuscular electrical stimulation on upper-extremity motor recovery, motor function, and quality of life in subacute stroke subjects: A randomized controlled trial
Manoj Kharka, Priyanka Singh
Department of Physiotherapy, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, Sikkim, India
|Date of Submission||15-Jul-2019|
|Date of Decision||29-Feb-2020|
|Date of Acceptance||25-Jun-2020|
Associate Professor Sikkim Manipal College of Physiotherapy, Sikkim Manipal university, 5th Mile, Tadong, Gangtok 737 102, Sikkim
Source of Support: None, Conflict of Interest: None
Objective: Mirror therapy (MT) and neuromuscular electrical stimulation (NMES) are both effective treatments for impaired upper limbs following stroke. The purpose of this study was to compare the effects of the MT and NMES on upper-limb motor recovery, motor function, and quality of life in subacute stroke patients. Materials and Method: Forty poststroke patients within 1 month of duration were assigned to the MT group (n = 20) or the NMES group (n = 20). Both the MT group and NMES group received the same conventional rehabilitation programs and additionally had each of their own therapies for 30 min, 5 days a week for 3 weeks. The action research arm test (ARAT), Fugl-Meyer assessment (FMA), Modified Ashworth scale (MAS), and Modified Barthel index (MBI) were used as an outcome measure to assess changes in upper-limb motor recovery and motor function at pre- and postintervention. Health-related quality of life was assessed by stroke-specific quality of life (SS-QOL) questionnaire at pre- and postintervention. Results: At the baseline, patients of both the groups showed no significant differences regarding ARAT, FMA, MAS, MBI, and SS-QOL scores, but after 3 weeks of intervention, patients of both the group showed statistically significant improvements in all the variables measured (P < 0.05). Conclusion: The present study confirms that MT and NMES are both effective treatment techniques to improve upper-extremity motor recovery, motor functioning, and quality of life in subacute stroke patients except for improvement in spasticity. However, MT is cost-effective, easy, and safe method for rehabilitation and most important can be easily administered at home by the patients.
Keywords: Electrical stimulation, imagery, motor function, stroke, upper extremity
|How to cite this URL:|
Kharka M, Singh P. A study to compare the effectiveness of mirror therapy and neuromuscular electrical stimulation on upper-extremity motor recovery, motor function, and quality of life in subacute stroke subjects: A randomized controlled trial. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Mar 5]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=309178
| Introduction|| |
The WHO clinically defines stroke as “the rapid development of clinical signs and symptoms of a focal neurological disturbance lasting more than 24 h or leading to death with no apparent cause other than vascular origin” WHO 2005. The paretic upper limb is a common and undesirable consequence of stroke that increases activity limitation. It has been reported that up to 85% of stroke survivors experience hemiparesis and 55%–75% of stroke survivors have continued to have limitations in upper-extremity functioning. It has been shown that intensive stroke unit care and functional exercises are beneficial in the acute rehabilitation of stroke patients. Immediately after stroke onset, approximately 80% of survivors have an upper-or lower-limb motor impairment. Full upper-limb function is achieved by nearly 80% of the patients with mild paresis but only by 20% of the patients with severe paresis of the upper limb. Functional recovery of the upper extremity on average is quite poor, with 55%–75% of the patients having significant permanent deficits in performing activities of daily living.
A number of interventions have been published evaluating the effect of various rehabilitation methods in improving upper-extremity motor control and functioning. As an alternative treatment approach, mirror therapy (MT) and neuromuscular electrical stimulation (NMES) has been proposed as potentially beneficial. MT was first introduced by Ramachandran and Roger-Ramachandran to treat phantom pain after amputation. The use of MT has also been reported in other conditions such as complex regional pain syndrome, and in sensory re-education of severe anesthesia after hand injuries. It is based on visual stimulation in which a mirror is placed in the patient's mid-sagittal plane, thus reflecting the nonparetic side as if it was the affected side. By this setup, movements of the nonparetic limb create the illusion of normal movements of the paretic limb.
Many mechanisms have been proposed for the effect of MT in motor recovery in stroke patients. Altschuler et al. found that the mirror provides proper visual input and substitutes for the decreased or absent proprioceptive input. Similarly, evidence also suggests that congruent visual feedback and motor imagery as provided by the mirror would help to restore the integrity of cortical processing and thereby restore the functions. Mirror neuron seems to be involved in the mechanism underlying MT. This particular type of neuron also presents in human brain which is active when an action is in progress and when the action is observed being performed by others.
The improvement of motor function has been demonstrated that observation of mirrored distal movements enhances corticospinal excitability, similar to actual movement execution. Apparently, this modulation of excitability contributes to motor recovery, even in an initially plegic limb. Mirror neurons are now generally understood to be the system underlying the learning of new skills by visual inspection of the skill. In addition to previously reported “observation with intent to initiate” or “stimulation through simulation” mechanisms based on increased visual or mental imagery feedback, another possible mechanism for the effectiveness of the MT might be bilateral arm training. The same cortical motor areas that are active during observation of movements are involved in the performance of the observed actions. However, the precise mechanisms of the effect of MT in stroke patients remain speculative.
Previous studies have shown that MT is effective for functional recovery of upper extremity when it was compared with sham intervention after stroke, but they are undersized with different outcome measures and protocol. Most of the studies have been conducted in chronic stroke patients. A Cochrane review has suggested the need for well-designed good-quality randomized controlled studies to evaluate the effects of MT after stroke and also to compare MT with other conventionally applied or newly developed and effective therapies in stroke patients.
In NMES, a muscle is repetitively electrically stimulated at near-maximum contraction with the aim of strengthening that muscle. It enhances motor recovery after stroke can reduce spasticity, strengthen muscles, and increase the range of movement of joints with prevention or correction of contractures. The Cochrane and systematic reviews have also found the beneficial effect of NMES on muscle strength and function after stroke. They also suggested to investigate whether NMES is more effective than other intervention. To our knowledge, this study is among the first to compare the effect of MT and NEMS in stroke patients and also to report their effect on quality of life. This study if proven to be beneficial can be consider as one of the strategies to improve upper-extremity function in stroke patients. Hence, our aim was to compare the short-term (at 3 weeks) effect of MT and NMES on upper-extremity motor recovery, motor functioning, and quality of life in subacute stroke patients.
| Materials and Methods|| |
Stroke patients were recruited from Central Referral Hospital in Sikkim, India, by a simple random sampling method. SMIMS Institutional Ethics Committee approved the study on October 23, 2013, with registration no IEC/175/13-53. It was not registered in clinical trial registry of India. Stroke was defined as an acute event of cerebrovascular origin causing focal or global neurologic dysfunction lasting more than 24 h, as diagnosed by a neurologist and confirmed by computed tomography or magnetic resonance imaging. Patients were included in the study if they (1) had a first episode of unilateral stroke with hemiparesis from 8 days to 1 month, (2) had a Brunnstrom score between stages I and III for the upper extremity, (3) both gender of any age, and (4) Mini-Mental State Examination (MMSE) score ≥24 (21 for illiterate). We also applied the following exclusion criteria: patients with severe aphasia, severe shoulder pain affecting therapy or any comorbid condition that could limit upper-extremity function, unable to sit <30 min, and visual or hearing impairment.
We used a randomized controlled design in which the assessor was blinded to the group allocation of each patient. All assessments were performed by the same investigator who was blinded to the treatment assignment. The baseline data regarding name, age, sex, hospital number, poststroke duration, the side of involvement, MMSE, and Brunnstrom recovery stage were collected after obtaining informed consent from all patients. Patients were individually randomized into MT and NMES groups using a lottery method. There were a total number of 20 patients in each group. The intervention was given for 3 weeks. there were no drop outs during the study.
Both the MT group and NMES group received the same conventional rehabilitation programs and additionally had each of their own therapies for 30 min, 5 days a week for three weeks [Figure 1]. The conventional program was patient specific and consists of neurodevelopmental facilitation techniques, physiotherapy, occupational therapy, and speech therapy (if needed). The MT group received an additional 30 min a day of a MT program consisting of nonparetic upper-extremity transitive and intransitive movements for gross and fine motor activity. During the mirror practices, patients were seated close to a table on which a mirror (65 cm × 45 cm) was placed vertically. The involved hand was placed behind the mirror and the noninvolved hand in front of the mirror. The practice consisted of nonparetic-side flexion and extension of the elbow, wrist, and finger and prone-supination of the forearm (intransitive movement) and stacking blocks, flipping the card, etc., (transitive movement) while patients looked into the mirror, watching the image of their noninvolved hand, thus seeing the reflection of the hand movement projected over the involved hand. Patients could see only the noninvolved hand in the mirror; otherwise, the noninvolved hand was hidden from sight. During the session, patients were asked to try to do the same movements with the paretic hand while they were moving the nonparetic hand. The speed of the movement was self-selected and no verbal feedback was offered. The progression was made by progressively increased number of repetition of upper-extremity movements. In NMES group, electrical stimulation was applied at 30–70 mA intensity, 250 μ s amplitude, and 35 Hz frequency. It lasted for 8 s and then stopped for 8 s. The intensity of stimulation was determined so that the patients could feel muscle contraction while not feeling tired. It was applied to the common extensor digitorum, extensor pollics brevis, pronator teres, and biceps brachii muscle of the paretic arm with an aim at hand extension, elbow flexion, and forearm supination/pronation movements. At the same time, patients actively practiced all movements to electrical stimuli. The progression was made by progressively increased duration of contractions of each muscle. The same therapist delivered the mirror or NMES to the patients.
To measure improvement in motor recovery of upper extremity, the Action research arm test (ARAT) and Modified Ashworth scale (MAS), and for motor functioning, Fugl Meyer assessment (FMA) and Modified Barthel index (MBI) were administered. Health-related quality of life (HRQOL) was also assessed by stroke-specific quality of life (SS-QOL). The ARAT, FMA, and MAS were administered as primary outcomes, whereas MBI and SS-QOL as secondary outcomes. Outcome measures were performed at 0 months (pretreatment) and at 3 weeks (posttreatment). The patients in both the groups were made to sit in comfortable position in a calm and well-ventilated room before treatment.
The ARAT is a standardized ordinal scale that measures upper-extremity (arm and hand) function. It is a 19-item measure divided into four basic movements: grasp, grip, pinch, and gross movements of extension and flexion at the elbow and shoulder. It is a reliable and valid measure to assess upper-limb functions in stroke patients. The MAS is 5-point ordinal scale with good inter-rater reliability used in the stroke patients to measure muscle tone. MAS score ranges from 0 to 4: a MAS score of 0 represents no increase in muscle tone and a score of 4 is “limb rigid in flexion and extension.” The FMA is 3-point ordinal scale to measure impairments of volitional movements. Its motor score includes 33 items related to movements of the proximal and distal parts of the upper extremity. The total score ranges from 0 to 66. It has good validity and high reliability. It is having four components: shoulder/elbow/wrist, wrist, hand, and coordination/speed. The MBI is a well-validated tool for the assessment of self-care and mobility skills in stroke which assesses feeding, dressing, personal hygiene, bathing, toileting, bladder and bowel control, transfers, ambulation, and stair climbing. Each category of the MBI is rated on a scale of one to five, with one indicating inability to perform the task and five, full independence. The SS-QOL was developed using standard psychometric techniques from interviews with stroke survivors, and it includes 49 items encompassing 12 domains: energy, family roles, language, mobility, mood, personality, self-care, social roles, thinking, vision, upper-extremity function, and work/productivity. Each item is ranked on a 5-point Likert scale, with higher scores indicating better function.
The data were statistically analyzed using SPSS 19.0 version. All statistical analyses were performed on the final 40 patients, and there were no missing data. The mean and standard deviation of the data were obtained through descriptive statistics. Groups were compared at baseline using the t- test for independent samples for the continuous variables. To investigate whether the mirror group changed by more than the NMES group at posttreatment, we calculated change scores for each group and compared them using an independent sample t- test. Significance was set at 0.05.
| Results|| |
A total 40 patients were recruited, of which 20 were in MT group and 20 in NMES group. Demographic and clinical characteristics of the 40 patients, as well as baseline comparisons of the groups, are presented in [Table 1]. Baseline comparisons revealed that age, gender, time since stroke, type, paretic/dominant side, Brunnstrom recovery stages, and MMSE scores did not differ between the groups. At baseline, patients of both the groups showed no statistically significant differences regarding ARAT, FMA, MAS, MBI, and SS-QOL scores [Table 2] and [Table 3]. After 3 weeks of treatment, patients of both the groups showed statistically significant improvements in all the variables measured [Table 2] and [Table 3]. No relevant adverse event was noted during the study in both the groups. [Table 3] and [Table 4] present the group comparisons of the change score for ARAT, FMA, MAS, MBI, and SS-QOL from baseline to postintervention.
|Table 1: Demographic characteristics of the mirror and control groups and baseline measurements|
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|Table 2: Motor recovery and motor functioning scores of stroke patients at pre- and postintervention in mirror therapy and neuromuscular electrical stimulation group|
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|Table 3: Stroke specific quality of life scores of stroke patients at pre- and postintervention in mirror therapy and neuromuscular electrical stimulation group|
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|Table 4: Between-group differences in change scores for outcome measures|
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| Discussion|| |
The outcome measures used in this study showed improvements, after 3-week intervention period in subacute stroke patients. Hence, the results indicate a significant improvement in terms of motor recovery, motor functioning, and HRQOL in 30 min session of MT and NMES group addition to conventional rehabilitation. However, no effect on spasticity has been obtained in both the groups. HRQOL has been positively improved in both the groups with better result in MT group. No adverse effect was noted at postintervention in both the groups.
To our knowledge, this study is among the first to compare the effect of MT and NMES on upper-extremity function and HRQOL in stroke patients. Lang et al. suggested ARAT as an appropriate measure for use in acute upper-extremity rehabilitation trials. Thus, for motor recovery we used ARAT which is a responsive and valid instrument to measure upper-extremity functional limitation and recovery during the 1st week and month post stroke. Our study shows a greater improvement in ARAT which was higher than those previously measured by Dohle et al. where patients with severe paresis at upper extremity showed less improvement. ARAT assesses only distal component, so we also used FMA because the subdivision score of FMA assesses proximal as well as distal function of extremities and it has been used in previous studies to assess motor recovery in stroke patients. FMA shows a significant improvement which was greater in MT group compared with NMES group. FMA is a sensitive most widely used clinical assessment tool for poststroke upper-extremity impairment and showed a very high inter-rater and test–retest reliability (intraclass correlation coefficient >0.95).
Similarly, a significant improvement was also observed in MBI scores which was statistically greater in MT compare to NMES group. Most of the patients were moderately impaired in terms of functional task and only two patients were severely impaired at preintervention in both the groups. After 3 weeks of intervention, most of the patients were mildly impaired, whereas few were moderately impaired [Table 2] in both the groups. However, we found no significant effect on spasticity. This could be because spasticity has a complex pathophysiology so only visual feedback may not be sufficient to influence as for MT group. Our findings are in accord with the previous findings by Sütbeyaz et al.
In this study, we used MT to give visual feedback to the patients to improve upper-extremity motor recovery and functioning. Several underlying mechanisms have been suggested for the effect of MT on motor recovery, but the precise mechanism remains speculative. One of that was the effect of mirror illusion on brain activity, which was suggested by Altschuler et al. that the mirror illusion of a normal movement of the affected hand may substitute for decreased proprioceptive information, thereby helping to recruit the premotor cortex and assisting rehabilitation through an intimate connection between visual input and premotor areas. Stevens and Stoykov hypothesized that congruent visual feedback from the nonparetic hand, as provided by the mirror, would restore the function of the affected hand. They defined MT as a form of visually guided motor imagery, which is the mental performance of a movement without overt execution of that movement.
Previous studies have also investigated the effect of mirror visual illusions on brain activity. Garry et al. performed transcranial magnetic stimulation during mirror illusions in healthy comtrols and showed increased excitability of primary motor cortex of the hand behind the mirror. Various clinical, neurophysiologic, and neuroimaging evidence reported that motor imagery involves the same neural networks as motor execution. Another mechanism could be the involvement of the mirror neuron system. Mirror neurons are bimodal visuomotor neurons that are active during action observation, mental stimulation (imagery), and action execution. For example, it has been shown that passive observation of an action facilitates M1 excitability of the muscles used in that specific action. Mirror neurons are now generally understood to underlie the learning of new skills by visual inspection of the skill.
In this study, we used bilateral training approach which could be the other possible mechanism for effectiveness of MT, in which patient moved the paretic limb as much as they could while moving the nonparetic hand and watching the image in the mirror. Carson also reported in a review that when the nonparetic limb engaged during motor training, crossed facilitatory drive from the intact hemisphere will give rise to increased excitability in the homologous motor pathways of the paretic limb, facilitating recovery of function.
NMES was conducted with the use of specialized equipment that includes a stimulus generator, electrodes, power source, and user control unit (which allows different parameters, such as the frequency, pulse duration, amplitude, duty cycle, and ramping to be altered by the therapist). The principles behind the use of NMES with innervated muscle include strengthening of normal muscle, increasing muscle endurance, strengthening following disuse atrophy, re-education of muscle control, and increasing the range of joint movement. The principle for using NMES with denervated muscle is to reduce or prevent muscle atrophy.
There are a variety of possible reasons that our patients who were given NMES showed benefit in motor recovery and functioning after 30 min per session, 5 days/week for 3 week intervention. NMES may have a direct effect leading to increased muscle strength and improve motor control, resulting in reduced upper-limb disability. It has been claimed that improvement in muscle tone or any beneficial effects is short lived. Our results support this hypothesis because patients have shown improvement in motor recovery and functioning. However, tone appeared to be unaffected. The previous evidence showed that NMES activated bilateral motor and sensory cortex on healthy controls and concluded in the meta-analysis that NMES improved motor recovery of upper extremities in stroke patients. The electrical stimulation, however, was reported to induce the most meaningful improvements in patients with mild-to-moderate degree of hand handicap. In stroke, when patients are unable to undertake interventions involving resistance exercises, NMES has the potential to improve strength by increasing the activation of motor unit or cross-sectional area of the muscle. Previous data have reported that it has improved functional activity and was maintained beyond the intervention period with a small-to-moderate effect size. It suggests that the benefits of NMES were incorporated into daily life. Meta-analysis has demonstrated that NMES can be applied effectively in early and subacute stage after stroke as well as chronically, but there are insufficient data to determine whether NMES is better than another intervention. Hence, we compared NMES with MT and found that MT group had better improvement.
In the present study, the effects were observed in the subacute phase after stroke within 10 weeks. It remains speculative whether this result would also be valid for chronic stroke patients (>3 months). Evidences from imaging suggested that there are different area involvements of the ipsilateral and contralateral hemisphere during different phases of stroke recovery. Hence, we assume that basic therapeutic principle of repetitive, effective stimulation of the lesioned hemisphere remains valid, irrespective of the time interval between stroke and rehabilitation. For motor learning to be successful, the desired motor task must be practiced in a pattern that is as close to normal as possible and practiced intensively because it has been demonstrated that the observation of mirrored distal movements enhances corticospinal excitability, similar to actual movement execution. This modulation of excitability contributes to motor recovery, even in an initially plegic limb. Thus, our intervention provides practice of upper-extremity movement pattern that is close to normal and it is believed that repeated task-specific protocols induce brain reorganization that facilitates functional improvements. We found a greater improvement in distal arm muscles compared to proximal arm muscles. This is in accord with previous data where evidence showed that distal movement is organized strictly unilaterally and proximal component rely on bi-hemispheric representations, a different contribution of both hemisphere for proximal and distal motor functions. In the present study, the effect of MT on motor functions appears to be most prominent for those patients who have no distal function at the beginning of the therapy.
To date, none of the study assessed HRQOL following MT or NMES. It is important to incorporate subject-centered outcomes like HRQOL into clinical measures so that the impact of disease on the patient as a whole can be understood and quantified. Clinically, stroke-specific assessments can aid in identifying what is helping or hindering the patient's overall function, allowing the clinician to target interventions that are subject and situation specific. We incorporated disease-specific HRQOL scale, i.e., SS-QOL as an outcome to know whether the intervention really made a difference in patients' HRQOL and found significant improvement in all domains of SS-QOL in both the groups [Table 3]. However, a greater improvement was observed in MT group. Based on our results, systematic application of MT early after stroke might support the motor recovery and functioning and allowing progress to other forms of therapy. We suggest MT even in acute setting because it is very easy to implement and subject can be instructed to train on their own. However, the optimum procedure with regard to frequency, duration, and protocol remains to be established.
According to our inclusion criteria, our findings and conclusions are based on the population of subacute stroke inpatients (all within 3 months post stroke) who survived from first stroke without severe cognitive deficits but with severe motor impairment of the hand and upper extremity. A potential limitation of this study is the generalizability of the results that these findings may not be applicable to chronic stroke patients with severe cognitive deficits. Another limitation could be muscle strength which was not assessed and it is important component because any activity/intervention that involves attempted repetitive effortful muscle contraction can result in increased motor unit activity and strength after stroke. Other possible limitations could be lack of follow-up at postintervention. As a further limitation of our work, we did not use imaging technique to demonstrate brain reorganization after therapy.
Future studies may investigate the effectiveness of MT on other motor impairment such as apraxia and neglect and also address on its duration, intensity, and frequency. To follow up subjects to know its long term effect. MT should also be compared with other stroke rehabilitation technique. Finally, Perform functional brain imaging studies to understand the underlying mechanism of motor recovery after MT in stroke patients.
| Conclusion|| |
This study found impressive positive effects of MT and NMES on motor recovery, especially manual dexterity, grasping performance, functional transfer ability as well as gross motor recoveries and motor functioning in terms of self-care, mobility as well as all daily function and quality of life in subacute stroke patients . Future research should focus on the comparison of MT with other conventional or newly developed technique used for stroke rehabilitation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]