Recommended Mirror Therapy Protocol Based on Supportive Existing Research in CVA Rehabilitation: A Systematic Review

Öz

The purpose of this systematic review was to use existing research to extract a recommended protocol for mirror therapy during CVA rehabilitation. Articles included were published within the last 5 years, in English, had accessible full text versions of the articles, and involved an adult population of individuals 18 years and older. Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were used by two certified occupational therapists to identify and screen studies to be included in the review. Individual searches were conducted in PubMed, CINAHL, APA PsycInfo, and ProQuest databases on December 18, 2024, through January 5, 2025. The following search terms were used by both authors: “mirror therapy,” “intervention,” “occupational therapy,” “stroke OR CVA,” and “adults.” A total of 655 studies were identified, and after sorting for relevance/inclusion criteria, 23 were included. A total of 853 participants were in the included studies, mostly men with a mean age of 55.3. It was found that a minimum protocol of 72 minutes per week for 4 weeks with 15 sessions was an effective use of mirror therapy during CVA rehabilitation. The Fugl-Meyer was the most frequently used outcome measure used by the included studies. This review found moderate evidence to support the establishment of a minimum mirror therapy protocol to be utilized in CVA rehabilitation. However, mirror therapy is most effective when combined with other interventions such as cognitive therapeutic exercise, BoNT-A injections, electric stimulation, task-based mirror therapy, and video-augmented therapy.

Anahtar Kelimeler

• upper extremity
• stroke
• therapy

Destekleyen Kurum

Gannon University

Etik Beyan

We expose that the manuscript represents the results of original work submitted solely to your journal and will not be submitted for publication elsewhere until a decision is made regarding its acceptability. APA ethical standards were followed during the study. All authors acknowledge ethical responsibility for the content of the manuscript and will accept the consequences of any ethical violation. This research is not part of a larger study.

Serebrovasküler Olay Rehabilitasyonunda Mevcut Destekleyici Araştırmalara Dayalı Önerilen Ayna Terapisi Protokolü: Sistematik Bir Derleme

Öz

Bu sistematik derlemenin amacı, mevcut araştırmaları kullanarak CVA rehabilitasyonu sırasında ayna terapisi için önerilen bir protokol çıkarmaktı. Dahil edilen makaleler son 5 yıl içinde yayımlanmış, İngilizce, makalelerin tam metinlerine erişilebilir durumda olan ve 18 yaş ve üzeri yetişkinleri içeren çalışmalardı. Sistematik Derleme ve Meta-Analiz için Tercih Edilen Raporlama Ögeleri (PRISMA) yönergeleri, derlemeye dahil edilecek çalışmaları belirlemek ve taramak için iki sertifikalı ergoterapist tarafından kullanıldı. Bireysel aramalar 18 Aralık 2024 ile 5 Ocak 2025 tarihleri arasında PubMed, CINAHL, APA PsycInfo ve ProQuest veri tabanlarında yapıldı. Her iki yazar tarafından şu arama terimleri kullanıldı: "ayna terapisi," "müdahale," "ergoterapi," "inme YA DA CVA," ve "yetişkinler." Toplamda 655 çalışma belirlendi ve uygunluk/dahil etme kriterlerine göre sıralandıktan sonra 23 çalışma dahil edildi. Dahil edilen çalışmalarda toplam 853 katılımcı bulunmaktaydı, bunların çoğu ortalama yaşı 55,3 olan erkeklerdi. CVA rehabilitasyonu sırasında aynalı terapi için 4 hafta boyunca haftada 3-4 kez, en az 72 dakika toplam 15 seans bir protokolün etkili bir kullanım olduğu bulunmuştur. Dahil edilen çalışmalarda en sık kullanılan sonuç ölçütü Fugl-Meyer idi. Bu derleme, CVA rehabilitasyonunda kullanılacak minimum bir aynalı terapi protokolünün oluşturulmasını desteklemek için orta düzeyde kanıt bulmuştur. Bununla birlikte, aynalı terapi, bilişsel terapötik egzersiz, BoNT-A enjeksiyonları, elektriksel uyarım, görev tabanlı aynalı terapi ve video destekli terapi gibi diğer müdahalelerle birleştirildiğinde en etkili olanıdır.

Anahtar Kelimeler

• üst ekstremite
• inme
• terapi

Destekleyen Kurum

Gannon University

Etik Beyan

Elimizdeki makalenin, yalnızca derginize sunulan özgün çalışmaların sonuçlarını temsil ettiğini ve kabul edilebilirliğiyle ilgili bir karar verilene kadar başka bir yerde yayınlanmak üzere sunulmayacağını beyan ederiz. Çalışma sırasında APA etik standartlarına uyulmuştur. Tüm yazarlar, makalenin içeriği ile ilgili etik sorumluluğu kabul eder ve herhangi bir etik ihlalin sonuçlarını kabullenir. Bu araştırma, daha geniş bir çalışmanın parçası değildir.

Kaynakça

1. Ağargün, M.Y., Kara, H., & Anlar, O. (1996). Validity and reliability of the Pittsburgh Sleep Quality Index. Turkish Journal of Psychiatry; 7: 107-115.
2. Acharya, S., & Shukla, S. (2012). Mirror neurons: Enigma of the metaphysical modular brain. Journal of Natural Science, Biology, and Medicine, 3(2), 118-124. https://doi.org/10.4103/0976-9668.101878
3. Alkhawaldeh, O. I., Obaid, W., Alshahrani, M., Alnawfal, A., Alobidan, R., Alorf, A., Alateeq, N., & Jaganathan, P. P. (2022). Effect of an early occupational therapy intervention on length of stay in moderate and severe traumatic brain injury patients. Irish Journal of Medical Science, 192(4), 1-7. https://doi.org/10.1007/s11845-022-03226-0
4. American Stroke Association. (2025). Types of stroke and treatment. https://www.stroke.org/en/about-stroke/types-of-stroke#:~:text=Ischemic%20Stroke%20(Clots)%0A%0AOccurs%20when%20a%20blood%20vessel,It%20accounts%20for%2087%25%20of%20all%20strokes
5. Borrowicz, W., Ptaszkowski, K., Murawska-Cialowicz, E., & Rosinczuk, J. (2022). Proprioceptive neuromuscular facilitation and mirror therapy methods are comparable methods of rehabilitation after a first-ever ischemic stroke: A randomized study. Sustainability, 14(22). https://doi.org/10.3390/su142215246
6. Borrowicz, W., Ptaszkowski, K., Ptaszkowski, L., Rosinczuk, J., Murawaska-Cialowicz, E. (2023). Association between serum Vitamin D levels and physical outcomes of patients who underwent rehabilitation following ischemic stroke. International Medical Journal of Experimental and Clinical Research, 29. https://doi.org./10.12659/MSM.940115
7. 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., & Arias-Carrión, O. (2013). The mirror neuron system in post-stroke rehabilitation. International Archives of Medicine, 6(1), 41. https://doi.org/10.1186/1755-7682-6-41
8. Centers for Disease Control and Prevention. (n.d.). Risk factors for stroke. https://www.cdc.gov/stroke/risk-factors/index.html#:~:text=The%20older%20you%20are%2C%20the,4

9. Centre for Evidence-Based Medicine (n.d.). Explanation of the 2011 OCEBM levels of evidence. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/explanation-of-the-2011-ocebm-levels-of-evidence#:~:text=Introduction,appraisal%20in%20their%20own%20hands
10. Chang, W. K., Lim, H., Park, S. H., Lim, C., Palik, N., Kim, W., & Ku, J. (2023). Effect of immersive virtual mirror visual feedback on mu suppression and coherence in motor and parietal cortex in stroke. Scientific Reports, 13(1). https://doi.org/10.1038/s41598-023-38749-8
11. Chen, Y., Li, K., Lin, C., Hung, P., Lai, H., & Wu, C. (2023). The effect of sequential combination of mirror therapy and robot-assisted therapy on motor function, daily function, and self-efficacy after stroke. Scientific Reports, 13(1). https://doi.org/10.1038/s41598-023-43981-3
12. Cleveland Clinic. (2025). Stroke. https://my.clevelandclinic.org/health/diseases/5601-stroke
13. Donati, D., Boccolari, P., Giorgi, F., Berti, L., Platano, D., & Tedeschi, R. (2024). Breaking the cycle of pain: The role of graded motor imagery and mirror therapy in complex regional pain syndrome. Biomedicines, 12(9), 1-12. https://doi.org/10.3390/biomedicines12092140
14. Fernandez-Solana, J., Alvarez, S. P., Moreno, A. V., Santamaria, M. P., Gonzalez, J. J. B., Velez, R. S., & Gonzalez, J. S. (2024). Efficacy of a rehabilitation program using mirror therapy and cognitive therapeutic exercise on upper limb functionality in patients with acute stroke. Healthcare, 12(5). https://doi.org/10.3390/healthcare12050569
15. Flach, C., Muruet, W., Wolfe, C., Bhalla, A., & Douiri, A. (2020). Risk and secondary prevention of stroke recurrence: A population-base cohort study. American Heart Association Stroke Journal, 51(8). https://doi.org/10.1161/STROKEAHA.120.028992
16. Fong, K. N. K., Ting, K. H., Zhang, X., Yau, C. S. F., & Li, L. S. W. (2023). The effect of mirror visual feedback on spatial neglect for patients after stroke: A preliminary randomized controlled trial. Brain Sciences, 13(1). https://doi.org/10.3390/brainsci13010003
17. Fong, K. N. K., Ting, K. H., Zhang, J. J. Q., Yau, C. S. F., & Li, L. S. W. (2021). Event-related desynchronization during mirror visual feedback: A comparison of older adults and people after stroke. Frontiers in Human Neuroscience. https://doi.org/10.3389/fnhum.2021.629592
18. Freitas-Zanona, A., Romeiro, A. C. S., Rego, A. B. M., Gomes, L. S. N., Bezerra, A. S., Bolognini, N., & Monte-Silva, K. (2022). Somatosensory cortex repetitive transcranial magnetic stimulation and associative sensory stimulation of peripheral nerves could assist motor and sensory recovery after stroke. Frontiers in Human Neuroscience. https://doi.org/10.3389/fnhum.2022.860965
19. Gandhi, B. C. D., Sterba, A., Khatter, H., & Pandian, J. D. (2020). Mirror therapy in stroke rehabilitation: Current perspectives. Therapeutics and Clinical Risk Management, 16(7), 75-85. https://doi.org/10.2147/TCRM.S206883
20. Geller, D., Nilsen, D. M., Quinn, L., Van, S. L., Bayona, C., & Gillen, G. (2022). Home mirror therapy: A randomized controlled pilot study comparing unimanual and bimanual mirror therapy for improved arm and hand function post-stroke. Disability and Rehabilitation, 44(22), 6766-6774. https://doi.org/10.1080/09638288.2021.1973121
21. Hatem, S. M., Saussez, G., Faille, M.D., Prist, V., Zhang, X., Dispa, D., & 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, 442(10). https://doi.org/10.3389/fnhum.2016.00442
22. Heinrich, C., Morkisch, N., Langlotz, T., Regenbrecht, H., & Dohle, C. (2022). Feasibility and psychophysical effects of immersive virtual reality-based mirror therapy. Journal of NeuroEngineering and Rehabilitation, 19, 1-20. https://doi.org/10.1186/s12984-022-01086-4
23. Hsieh, Y., Lee, M., Chih-Chi, C., Hsu, Fu-Lin., & Wu., C. (2022). Development and user experience of an innovative multi-mode stroke rehabilitation system for the arm and hand for patients with stroke. Scientific Reports, 12(1). https://doi.org/10.1038/s41598-022-053114-8
24. Hsieh, Y., Lin, Y., Zhu, J., Wu, C., & Lin, Y. (2020). Treatment effects of upper limb action observation therapy and mirror therapy on rehabilitation outcomes after subacute stroke: A pilot study. Behavioral Neurology, 2020. https://doi.org/10.1155/2020/6250524
25. Hsu, H., Kuo, L., Lin, Y., Su, F., Yang, T., & Lin, C. (2022). Effects of virtual reality-based mirror therapy program on improving sensorimotor function of hands in chronic stroke patients: A randomized controlled trial. Neurorehabilitation and Neural Repair, 36(6), 335-345. https://doi.org/10.1177/15459683221081430
26. Hung, J., Yen, C., Chang, K., Chiang, W., Chuang, I., Pong, Y., Wu, W., & Wu, C. (2022). A pilot randomized controlled trial of botulinum toxin treatment combined with robot-assisted therapy, or active control treatment in patients with spasticity following stroke. Toxins, 14(6), 415. https://doi.org/10.3390/toxins1406415
27. Hyunjin, K., Junghyun, K., Sungbae, J., Kyeongjin, L., Junesun, K., & Changho S. (2023). Video augmented mirror therapy for upper extremity rehabilitation after stroke: A randomized controlled trial. Journal of Neurology, 270(2), 831-842. https://doi.org/10.1007/s00415-022-11410-6
28. Jaques, E. S., Ineu, A., Aniuska, S., Loss, B. P., Silveira, G. H., Abichequer, S. V., Melo, D. A. S., Xavier, L. L., Sarrogila, P. M., & Gemerasca, M. R. (2023). Stroke Research and Treatment. https://doi.org/10.1155/2023/5080699
29. Lang, C. E., Lohse, K. R., & Birkenmeier, R. L. (2015). Dose and timing in neurorehabilitation: Prescribing motor therapy after a stroke. Current Opinion in Neurology, 28(6), 549-555. https://doi.org/10.1097/WCO.0000000000000256
30. Li, Y., Wu, C., Hsieh, Y., Lin, K., Grace, Y., Chia-Ling, C., & Lee, Y. (2019). The priming effects of mirror visual feedback on bilateral task practice: A randomized controlled trial. Occupational Therapy International, 2019. https://doi.org/10.1155/2019/3180306
31. Mayo Clinic. (2024). Stroke rehabilitation: What to expect as you recover. https://www.mayoclinic.org/diseases-conditions/stroke/in-depth/stroke-rehabilitation/art-20045172#:~:text=Occupational%20therapists.,workplace%20tasks%20and%20overall%20safety
32. Moher, D., Liberati, A, Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PloS Med, 6(6), e1000097. https://doi.org/10.1371/journal.pmed1000097
33. Morris, J. H., van Wijck, F., Joice, S., Ogston, S. A., Cole, I., & MacWalter, R. S. (2008). A comparison of bilateral and unilateral upper-limb task training in early poststroke rehabilitation: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 89(7), 1237-1245. https://doi.org/10.1016/j.apmr.2007.11.039
34. Oxford Center for Evidence-Based Medicine. (2009). Oxford center for evidence-based medicine: Levels of evidence. https://www.cebm.ox.ac.uk/resources/levels-of-evidence-march-2009
35. Patel, J. (2024). Advances in the study of mirror neurons and their impact on neuroscience: An editorial. Cureus, 16(5), e61299. https://doi.org/10.7759/cureus.61299
36. Ruf, S. P., Hetterich, L., Mazurak, N., Rometsch, C., Anna-Maria, J., Ott, S., Herrmann-Werner, A., Zipfel, S., & Stengel, A. (2023). Mirror therapy in patients with somatoform pain disorders: A pilot study. Behavioral Sciences, 13(5). https://doi.org/10.3390/bs13050432
37. Sibila, L. F., Lopez, R., Caris, A., Castro, C., Castillo, R. D., Avello, D., Braulio, B. H. M., Valdes-Badilla, P., Carmine, F., Sandoval, C., & Vasquez, E. (2024). Effectiveness of virtual reality in occupational therapy for post-stroke adults: A systematic review. Journal of Clinical Medicine, 13(16), 1-14. https://doi.org/10.3390/jmc13164615
38. Teasell, R., & Hussein, N. (2013). Clinical consequences of stroke. https://www.strokesolutions.co.uk/wp-content/uploads/2014/07/chapter2_clinical-consequences_final_16ed.pdf
39. Thieme, H., Morkisch, N., Mehrholz, J., Pohl, M., Behrens, J., Borgetto, B., & Dohle, C. (2018). Mirror therapy for improving motor function after stroke. Cochrane Database Systematic Review, 7(7). https://doi.org/10.1002/14651858.CD008449.pub3
40. Wan-wen, L., Wei-chi, C., Keh-chung, L., Ching-yi, W., Chien-ting, L., Yu-wei, H., Yun-chung, L., & Chen, C. (2020). Timing-dependent effects of transcranial direct current stimulation with mirror therapy on daily function and motor control in chronic stroke: A randomized controlled pilot study. Journal of Neuroengineering and Rehabilitation, 17, 1-11. https://doi.org/10.1186/s12984-020-00722-1
41. Wen, X., Li, L., Xuelian, L., Huanghong, Z., Zicai, L., Peng, Y., Xuejin, L., Huiyu, L., Quan, Y., & Jing, W. (2022). Therapeutic role of additional mirror therapy on the recovery of upper extremity motor function after stroke: A single-blind, randomized controlled trial. Neural Plasticity. https://doi.org/10.1155/2022/8966920
42. World Stroke Organization. (2025). Impact of stroke. https://www.world-stroke.org/world-stroke-day-campaign/about-stroke/impact-of-stroke#:~:text=Stroke%20is%20a%20leading%20cause,under%20the%20age%20of%2050
43. Woznowski-Vu, A., Costa, C. D., Turgeon-Provost, F., Dagenais, K., Roy-Mathie, B., Aggban, M., & Preuss, R. (2015). Factors affecting length of stay in adult outpatient physical rehabilitation: A scoping review of the literature. Physiotherapy Canada, 67(4), 329-340. https://doi.org/10.3138/ptc.2024-75
44. Yu, Z., Prado, R., Quinlan, E. B., Cramer, S. C., & Ombao, H. (2017). Understanding the impact of stroke on brain function: A hierarchical Bayesian approach. Journal of the American Statistical Association, 514(111), 549-563. https://doi.org/10.1080/01621459.2015.1133425
45. Zhuang, J., Li, D., Shi, B., Dan, C., & Jie, J. (2021). Associated mirror therapy enhances motor recovery of the upper extremity and daily function after a stroke: A randomized control study. Neural Plasticity. https://doi.org/10.1155/2021/7266263