Mirror Therapy Stroke Recovery

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     Most recovery from stroke requires neuroplastic "rewiring" of the brain. Forging neuroplastic change in the cortex, the outer shell of the brain where much of neuroplastic action takes place, involves an incredible amount of effort on the part of the stroke survivor. 

It also takes time and resources dedicated to that effort. There are, however, recovery options that stroke survivors can use that to not burn through a lot of resources.  These recovery options can be added as a simple and effective adjunct to traditional therapy.

One example of such a recovery option is mirror therapy. Much research remains to be done to fully prove efficacy of mirror therapy. But for some stroke survivors mirror therapy appears to be a promising and effective option for reestablishing cortical control over wayward limbs.

Mirror therapy

·        requires very little training

·        is easy to set up

·        requires inexpensive equipment

·        is not taxing to the patient.

Mirror therapy for the upper extremity.

The stroke survivor is seated. A mirror is aligned to intersect with the patient's body in the sagittal plane at chest level. This is usually done by placing the mirror on a table with the hands resting on the table on either side of the mirror. The reflective part of the mirror faces the unaffected side. As the patient looks into the mirror, all they see is the unaffected side. The mirror blocks the view of the unaffected side of the body. The patient gazes into the mirror reflecting the "good" hand. When the "good" hand is moved the mirror gives the illusion that the "bad" hand is moving perfectly well.

Often, a "mirror box"—usually about twice the size of a shoebox—is used.  On one outside surface of the box is a mirror, which faces the unaffected side. The patient places the affected hand in the box so it is covered on all sides. The stroke survivor attempts to copy the movement of the “good” arm and hand with the hemiparetic arm. In other words, the movements are done symmetrically, like conducting an orchestra. However, the stroke survivor only sees the reflection of the good hand.

Mirror therapy for the lower extremity.

The stroke survivor can be either in long sitting on a plinth or seated on a chair. The advantage of the plinth is that the lower extremity is more easily viewed. The advantage of the chair is that it may be more comfortable for some patients. In either case, a mirror is placed the between the patient's legs to intersect patient's body in the sagittal plane. As with the upper extremity, the mirror is facing the unaffected side. The patient is instructed to plantar and dorsiflex the unaffected side ankle, and at the same time attempting to do the same movement with the unaffected side. The speed of the movement is self-selected.

Dosage.

For both the upper and lower extremity the dosage is 30 minutes a day, five days a week for four weeks.

How and why does it work?

There are two explanations for why mirror therapy seems to show efficacy in clinical research. The first is technical. The second explanation is better suited for patients who are less interested in the science and more interested in efficacy.

The scientific basis seems to be in what is activated when we are presented with the illusion of seeing both limbs when, in reality, we are only seeing one. Transcranial magnetic stimulation studies with mirror therapy reveal something remarkable; when the left hand is moving the left motor cortex is excited, and vice versa. Normally, of course, when the left hand moves, the motor cortex on the right side is activated. So if the stroke survivor has right-sided hemiparesis, viewing the "false” right hand in the mirror will activate the portion of the brain that controls the hemiparetic hand. If the stroke survivor is trying to activate the motor cortex for the affected side limb, research suggests that mirror therapy can be used to initiate that activation.

The simple explanation. But just like any other neuroplasticity-driving treatment option, it is primarily through the effort of the stroke survivor that rewiring takes place. For that reason it is essential that stroke survivors are educated on what works and how it works. Stroke survivors need to know why they're doing what they're doing in order to have them on board for the process. The challenge of making things scientifically accurate and easy-to-understand is essential to any patient education. Mirror therapy is no exception. The following can be used to describe the essence of mirror therapy to patients considering this option:

·        The reflection of the good arm superimposes normal sensory signals on the brain.

·        Mirror therapy provides proper visual input because the reflection helps them think that their affected arm is moving correctly.

·        The reflection, perceived to be accurate movement is thought to reorganize the way the brain is wired.

·       This fooling of the brain stimulates the brain to help with control of limb movement.

Here is a vid that will give you a general idea of how it works. I would suggest that the skill this therapist is suggesting (handwriting) may not be the best for this patient for 2 reasons:
1. Handwriting is a skill usually only done by the dominant hand. This patient cannot adequately perform handwriting with his non-dominant hand. So his left hand may not be the best teacher. This patient would probably be better served by working on something that the left hand can do flawlessly and that the right hand can learn from.
2. What movement should be chosen? I would suggest working on whatever movement the "bad" hand is on the cusp of doing. So if the survivor is on the cusp of opening the hand, work on that. Simple, basic movements seem to work best.

The politics of stroke recovery

An extraordinarily interesting conversation broke out in my last seminar. Usually, I try to keep the conversations short and tight. We have a schedule, and I try to stick to it. But this involved about 10 therapists. And it was brilliant. It went like this...

We were talking about the acute phase after stroke. The acute phase is defined in different ways by different disciplines. For instance doctors will define it one way, therapists another way, radiologists another way, etc. The way that these different disciplines define the phases (from hyperacute to chronic) are important. All those definitions have different valuable uses. (Please note that the second edition of stronger after stroke has all the definitions of all the phases, along with suggestions about how to rehab during those phases.)

In any case, we were talking about the acute phase. I'll paraphrase what I was saying by taking a quote from the book...

"The brain remains in a very delicate state during the acute phase. The neurons of penumbra are especially vulnerable. Consider the studies of animals that have been given a stroke. Animals forced to do too much too soon increase the damage to their brain. In human studies the results of intensive rehab (too much, too soon) has been mixed at best."

The acute therapist then chimed in. They said that often survivors are sent home after their hospital stay. Once home they get a therapist to come to their house. But that kind of therapy, usually called "home therapy," is not generally as aggressive as what survivor swould receive from a rehabilitation hospital. Therapists who come to he home don't have many of the tools that they'd have in a therapy gym. 

So why are survivors often sent straight home? Managed care demands that they go home if they are not making progress. But if you take my suggestion (too much too soon is a bad thing) survivors won't make much progress, because therapy has to be -- for lack of a better word -- gentle. 

The time to make progress is not during the acute phase. (More about how therapy is "upside down" for stroke survivors here.) The time to make progress is during the subacute phase. But if survivors are discharged to home rather than to a rehab hospital, or outpatient therapy, they're not going to get aggressive therapy when they need it: during the subacute phase. Classic Catch-22.

One of the suggestions was that instead of sending people home, from the hospital they be sent to skilled nursing facilities (SNFs). But there is a problem with SNFs. It's the "N." N=Nursing. And people hear that and they think "nursing home." And so they refuse. They don't want to go to a nursing home.

But survivors may want to rethink this position. Skilled nursing facilities provide skilled therapy. Physical therapy, occupational therapy, speech therapy -- it's all there. It allows the survivor to get the most out of the subacute phase. It may also allow them to get good enough to go to a rehabilitation hospital, or an outpatient clinic that's very aggressive. 

SNFs can be used as stepping stones to more and better therapy. BUT: If the discussion is "We're going to park you at the nursing home FOREVER" that's not a good thing. SNFs are a nice place to visit, but you may not want to live there (although some are very nice!)

There so many ways that managed care works against the best interest of stroke survivors. This (too much too soon is bad, but if you don't show progress your discharged home) is just one example of how managed care drops the rehab ball.

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DIY Stroke Recovery

There is a common suggestion among many in the "alternative medicine" industry expressed in the question: "If it means less business, why would your doctor want you to be healthy?" A strict emphasis on healthy lifestyle including diet and exercise would be like the proverbial "apple a day" - keeping the doctor away.

Doctors who do this - who keep themselves away as much as they can - are the best doctors. And therapists who "keep themselves away" are the best therapists.

Many pathologies allow for a definitive discharge point. The patient who has had a knee replacement gets therapy, and then goes home to live the rest of his life. But neurological disorders are different. Many, from Parkinson's disease to multiple sclerosis, are progressive. But what of non-progressive neurological disorders like stroke and traumatic brain injury? Does this "apple a day" philosophy work? Is there a point at which these populations no longer need therapists?

Many patients with brain injury (including stroke) believe that they will always need therapists. Most see therapists as essential to the recovery process, no matter how long (months, years, decades) it takes for them to achieve their highest level of potential recovery. But this view is incorrect.

There is a point at which therapists are no longer the fulcrum for recovery. Nor should they be, for reasons that range from financial to practical. At discharge stroke survivors are, and should be, in complete control of their own recovery. During the chronic phase of recovery from stroke, the speed of recovery slows. The physiological action of recovery is based on a lot of self-directed hard work. Much of what is required is relatively simple, and revolves around the broad concept of repetitive practice. In order to take charge, stroke survivors need to be given the tools to initiate and follow an "upward spiral of recovery." This term is used to describe the path to the highest level of potential recovery. The "upward spiral of recovery" is driven by real-life demands for everything from coordination to cardiovascular strength.

Herding Spastic Cats: electrical stimulation

There's a lot of great things to be said about e-stim after stroke. E-stim can be used to do a number of things to help survivors recover. But let me review one: Stretching.

About 30% of the time stroke survivors have "severe" spasticity. How is "severe" defined? Severe is considered "≥ to 3 in the modified Ashworth scale." What does that mean? It means that if you move the joint through its range of motion it is tough to move. The force that used is an outside force; someone other than the survivor moves it (passively).

Severe spasticity in the upper extremity can lead to a fisted hand. In the lower extremity it leads to the foot pointing down at the ankle (plantarflexion). 

So how should you stretch spastic muscles? One way is manually. In the ankle is pretty easy. Stand up. This is called a "weigtbearing" stretch. But in the upper extremity... ah, it can be difficult to stretch a fisted hand. It's not just that you're dealing with stretching over all of the joints of the fingers (12 in all). If that you can't fully stretch the fingers without also stretching the wrist. The reason they have to do both gets technical. The muscles that control the fingers, also control the wrist. So to get everything fully stretched you have to extend both the wrist and fingers. "Extend" means that the fingers would be perfectly straight, and the wrist would be pushed back as far as possible.

There was a very influential neuroscientists and Nobel laureate named Sir Charles Sherrington. Sherrington made many discoveries about the nervous system. One of the things that he discovered is that for one set of muscles to contract, the other set of muscles would have to relax. Let's use that hand as an example. For the muscles to open the hand to work properly the muscles that close the hand after relax. Otherwise those muscles would be fighting themselves. Which Sherrington discovered was that in a healthy (non-stroke) situation, when there was an attempt to open the hand the muscles that close the hand would relax. If you want to get technical, it's called reciprocal inhibition.

Trying to stretch the fingers into an open position, while also extending the wrist with a spastic stroke survivor is a bit like herding cats. It's tough to get all of those joints (were up to 13 now) going in the right direction. This is where e-stim can come in.

Because e-stim makes the finger extensors and the wrist extensors fire, it also forces the wrist and finger flexors to relax (reciprocal inhibition). In this case, the electrodes would be put on the back of the forearm with the muscles that open the hand and wrist are. Again, the e-stim would go through the electrodes into the back of the forearm fire the muscles that extend the fingers and wrist. And... at the same time... relax the muscles that close the fingers and wrist.

Talk to your therapist. If you have a lot of spasticity this is something that you can do at home, once trained. The technology tends to be relatively inexpensive, and can be used for an extended period of time. But again, talk to a therapist, and get them to figure out what the right settings and dosage or for you, and then e-stim away!

Why a little means a lot

10°. 

10° is all you need to qualify for constraint induced therapy. Just a tiny bit of movement. Just a little bit of movement in the fingers and a little bit of movement in the wrist. This would be movement that many clinicians would call "nonfunctional" movement. That is, many clinicians make the unfortunate mistake of thinking that a small amount of movement is not helpful. The thinking is, small amounts of movement won't help you live your life, so who cares?

But every bit of neuroscience is very clear about this: a little bit movement can lead to more movement through repetitive and demanding practice. Move as much as you can. It may be ugly, it may be "incorrect," it may be "nonfunctional," and it may be "useless." But this is probably more true: Small amounts of movement may turn into something beautiful, something correct, something functional, and something useful. If someone is telling you that your movement is unimportant, or harmful, or irrelevant, politely don't listen.

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