How mirror box therapy can support stroke rehabilitation

Mirrors are said to have mysterious powers in fairy tales. What’s also mysterious is how it is possible for people who have suffered a stroke to suddenly be able to see their hand or leg move after weeks of paralysis.

In this article, you can find out how a mirror can help a patient learn how to move again and what you need to build your own therapy mirror.

What is mirror box therapy?

In occupational therapy, mirror box therapy is used when limbs are affected by an impairment, such as after a stroke.

The patient sits in front of a mirror which is placed between the arms or legs. The reflecting side is aimed at the healthy or less-affected limb.

The brain gets tricked by using the mirror image of the less-affected arm or leg. This illusion creates the impression that the affected side, located behind the mirror, can also perform the movement without problems or limitations.

Practicing correctly with your arm

Before mirror therapy is started, please check with your respective physician or occupational therapist.

The mirror is placed centrally between the affected limbs – in this case between the two arms. Start by moving your fingers and joints on the less-affected side. You can, for example, rotate your forearm and bend and extend your wrist.

Then move your hand to the side and then back toward your body or rotate your wrist, spread your fingers, or form a fist.

Watch your less-affected hand in the mirror and move the hand behind the mirror, as well as you can, at the same time.

In the next step you carry out more complex movements with your healthy hand. You can, for example, work with a small ball or flip over cards. Pouring rice from one cup into another or drawing with felt-tip pens or a paintbrush would also work.

If your occupational therapist or physiotherapist uses mirror box therapy, the movements of your healthy hand may be guided, and you would be more focused on how the joint feels vs how the movement looks. Whether you see or feel the movement, you should try to move your affected hand the same way it looks in the mirror.

Practicing correctly with your leg

A rolling mirror that you roll between your legs is provided for practicing with your leg.

You should sit in a slightly elevated position so that you can move your legs and feet freely.

Carry out the movements with your less-affected leg and watch it in the mirror. Start by bending and stretching the knee. Remember that you can move your ankle, knee, and hip in every possible direction in isolation.

You should actively move the leg behind the mirror. Your therapist may even help with the movements if you cannot perform them fully.

Occupational therapists and physiotherapists coordinate the exercises very precisely to your abilities. Should you be severely affected, simpler exercises like isolated joint movements will be selected, and the training intensity will be kept low.

Examples of complex movements with your leg or foot are picking up clothes from the ground or rolling a ball beneath your less-affected foot.

The correct training intensity

The correct training intensity is always a topic to discuss with your respective physician or occupational therapist first.

In general, mirror box therapy works particularly well if it is performed over a period of 3-4 weeks. Over that period, you should train in front of a mirror for 20 to 50 minutes and at least five times a week.

The exercises can also be divided into two sessions. Each movement should be repeated up to 30 times. Take a break for a minute before starting the next movement.

The more complex the movements are, the longer they should be practiced.

Most studies suggest that mirror box therapy should always be carried out in addition to physiotherapy or occupational therapy.

Mirror box therapy can easily be done at home as additional therapy. Ask your therapist for exercises that are suitable for you.

The role of mirror neurons in mirror therapy

Mirror neurons are also thought to be related to the mechanism behind mirror therapy. Mirror neurons are activated in small children when they watch adults and imitate their movements.

When we imagine and observe movements, mirror neurons in the motor regions of the brain are stimulated. As a result, this stimulation encourages increased active movement.

During mirror therapy, patients watch their own movement and, in doing so, potentially activate their own mirror neurons.

The psychoneuromuscular theory

This theory assumes that specific patterns of movements (e.g. walking patterns) are retained after a stroke, despite the resulting impaired movement.

The theory further assumes that, by imagining a movement, this pattern is activated and consolidated to the same extent as when actively carrying out the movement. As a result, this can accelerate the process of re-learning to move. Visualizations used by top athletes work according to a similar principle.

Mirror therapy is still something of a mystery. Why using a mirror can result in improved movement after a stroke hasn´t been fully explained, but there is evidence to show it can be an effective treatment technique. Rehabilitation after a stroke is individual, ask your therapist whether you could also benefit from mirror therapy.

Build your own therapy mirror

f you want to practice mirror box therapy at home, you’ll need a suitable mirror.

Do you have relatives or friends who like crafting? Here are some brief instructions on how you can build your own therapy mirror to use with your arms and hands.

You’ll need:

• A solid wooden baseplate (approx. 40cm x 30cm)
• Two wooden strips (approx. 4cm high)
• Glue
• A mirror the same size as the baseplate (furniture or specialist shop)
  The mirror edges should be smoothed and rounded, and the glass should be shatterproof.

The two wooden strips are to be cut to a length of 40 cm and glued parallel to each other in the middle of the base plate; the mirror can be wedged in between the wooden strips.

You can also buy therapy mirrors online or from orthopaedic shops.

Author: Hannes Aftenberger

Sources:

The effectiveness of different treatment modalities for the rehabilitation of unilateral neglect in stroke patients: a systematic review (2013)

The Effects of Mirror Therapy on Clinical Improvement in Hemiplegic Lower Extremity Rehabilitation in Subjects with Chronic Stroke (2015)

Mirror Therapy Enhances Motor Performance in the Paretic Upper Limb After Stroke: A Pilot Randomized Controlled Trial (2014)

Advanced Rehabilitation Technology: Improving Life After Stroke

It’s human nature to lose interest in monotonous tasks or procrastinate on challenging ones. For millions of stroke survivors, repetitious motions are challenging. You know you need to do those to get better, but it’s simply hard to stay focused. Advanced technology and Gamification may help.

Once a stroke patient leaves the hospital, therapists often struggle to motivate them to return for therapy. Older stroke patients, in particular, can have trouble self-motivating and encounter more roadblocks throughout the rehabilitation process. However, research shows that treatment timelines matter. And the sooner a patient starts rehabilitating their body, the better the outcomes.

Advanced rehabilitation technology addresses the lack of motivation that can stand in the way of recovery. Using robot-assisted therapies, virtual reality (VR), and Gamification, therapists leverage the latest technologies to help patients rehabilitate their extremities.

Upping the Game for Upper Extremity Rehabilitation

Neurological damage can lead to spasticity or muscle atrophy. Spastic paralysis can affect individual muscles or entire areas of the body. The extent of the paralysis depends on which areas of the brain or spinal cord are damaged. Impaired motor function prevents people from performing activities essential to their independence. Writing, typing, or cooking may be difficult.

A fundamental goal of post-stroke rehabilitation is to optimize the functional use of the upper extremities. PT and OT exercises can help to decrease symptoms like tight and stiff muscles. Robot-assisted and VR-enabled devices also can help to reduce symptoms and are motivating.

With a Little Help from My Friends

Robot-assisted devices take a playful approach to upper extremity rehabilitation therapy that is both motivating and results-driven. Benefits include:

• Data-informed treatment plans. Robotic-assisted devices provide objective data that occupational and physical therapists analyze and use to shape their interventions. With data-informed treatment plans, therapists can prescribe more meaningful, goal-oriented tasks that accelerate and enhance recovery.
• Increased intensity and accuracy of exercises. With robotic-assisted devices, therapists can increase the frequency, dose, and intensity of therapeutic exercises. These devices also help ensure the accuracy of exercises by decreasing the chances of improper patient performance.
• Access to data. As patients continue to progress, robotic-assisted devices provide instant and concrete evidence of their continued progress. This information also helps demonstrate global improvements that can show patients how far they have come.

It’s Not All Fun and Games

A study has found that when a patient enjoys an activity, the burden of recovery can be temporarily forgotten. Instead of simple sets of exercises, gamified devices engage and distract patients from the pain and hard work of rehabilitation.

VR-enabled devices present patients with virtual tasks, such as picking fruit or hanging laundry. The movements mimic their actual life. VR applications are not only engaging, but they are also helpful in reengaging the muscles and joints needed to perform such tasks.

Building the Foundation Through Stability and Coordination

A majority of stroke survivors endure some functional disability that increases their likelihood of falling. A combination of muscle weakness, unbalanced weight distribution and lack of equilibrium contribute to instability leading to post-stroke falls. For example, patients who are unstable and uncoordinated experience problems with transitions from sitting to standing.

Computer-assisted tools can help retrain the brain and help patients regain stability and coordination. With Tymo, for example, therapists gain a better understanding where the visual, vestibular, and somatosensory systems deficiencies lie. Then, they can fine tune prescribed therapies to target specific functions.

Advanced rehabilitation technologies use attention-grabbing games that facilitate the repetitive exercises required to relearn lost movements. These therapeutic games can boost self-esteem and self-confidence, enhancing the trajectory of patient recovery.

Recovery is Different for Every Patient

While some stroke survivors overcome obstacles with more ease than others, the healing journey is almost always challenging. That’s why seeking the right type of care makes all the difference. With its personalized, motivational approach, advanced rehabilitation technology has revolutionized post-stroke therapy. Still, a therapist will always be by your side to adapt technologies according to the patient´s needs. Technology will never be able to replace humans in rehabilitation, but it can make certain tasks easier for the therapist and the patient.

Sources:

Stroke Patients Motivation Influence on the Effectiveness of Occupational Therapy (2018)

The Improvement of Walking Ability Following Stroke (2018)

A Review of Robot-Assisted Lower-Limb Stroke Therapy: Unexplored Paths and Future Directions in Gait Rehabilitation (2020)

Your Competitive Edge: Advanced Rehabilitation Technology

Rehabilitation from stroke or traumatic brain injuries can be a long and difficult journey for patients. People who have endured trauma are often eager to regain their mobility and reclaim their independence after their initial recovery. But the unfortunate reality is that many patients have trouble moving. In fact, 20 – 25 % of stroke patients lose their ability to walk after their health event.

Physical and occupational therapy are the most effective forms of treatment for these patients. Over the past decade, ongoing advancements in rehabilitation technology have taken PT and OT to the next level. As a result, stroke and brain injury patients are making more significant strides than ever before.

From robotics and sensor technology to virtual reality and gamification, therapists utilize these innovative tools to maximize patient rehabilitation. Additional benefits of these technologies include:

1. Cost savings. Investing in the latest technology can help reduce costs for your clinic in the long run.
2. Standing out from your competitors. Offering a new technology can give you a competitive edge over your competition.
3. Improving patient outcomes. Therapists achieve better patient outcomes by increasing treatment intensity, dose and efficiency.
4. Providing hope to patients. Since these new technologies improve patient outcomes, new hope is given to stroke and traumatic brain injury patients.

Keep reading to learn more about these benefits.

Cost-Savings

Combining PT and OT with advanced rehabilitation technology can help contain the cost of operating a clinic in several ways.

Built-in software that gathers data and provides metrics, helps eliminate the need for tedious administrative work. Instead of spending time on documentation, practitioners can deliver more therapy in less time or simultaneously treat more than one patient.

With more efficient and superior outcomes, patients may be discharged sooner. Clinics save on insurance costs, and open their schedules for more patients.

Standing Out from Your Competitors

When dealing with neurological trauma, such as a stroke, patients and their families seek the highest quality care. Families want to give their loved ones the best chance of recovery. People search for indicators which might be the best facility. Hospital quality rankings, innovative therapy means and word-of-mouth referrals from doctors or the public can help them in their decision.

With innovative technology, clinics can gain a competitive edge in the region.

Bringing the latest technologies to the community sends a message to prospective patients and their families that you take advances in care seriously. Advanced rehabilitation technology can supplement your therapists’ work. Patients regain the function they need to perform activities of daily living (ADL).

Providing Hope to Patients

Every therapist aims to improve their patients’ quality of life and help them succeed when they are back in their community. The best reward is to see someone walk out of the clinic when upon beginning therapy they had trouble taking even one small step. New advances in the fields of PT and OT, including innovative technology, push the limits of what’s possible after neurological traumas.

Innovative technology provides hope to patients.

Peter was attending a party when he noticed the world around him was changing. He dropped the knife he was holding. He wanted to say something, but his words came out slurred and unintelligible. He slid sideways and onto the floor, supported by a family member. He was able to register the alarm amongst his friends, who tried to help him. He knew he was having a stroke.

Symptoms, treatment, and rehabilitation after a stroke

The symptoms described by Peter are typical for the sudden onset of a stroke. Common first symptoms of a stroke are a flaccid paralysis of one half of the body and loss of the ability to speak. In addition to paralysis, patients may experience so-called neuropsychological disorders as a result of the stroke. This may include, for example, being able to only perceive one half of a room or being unable to plan sequential actions correctly.

To ensure a good prognosis for the condition, immediate attention is paramount.

Peter’s family did exactly what they were supposed to do. They administered first aid by bringing him into a safe position and calling an ambulance. Twenty minutes later, he was at the hospital and received emergency care.

The chances of surviving a stroke are much higher if the patient receives medical attention within one hour of the stroke happening.

Outpatient rehabilitation

Rehabilitation following a stroke is a long process and many patients will still require care a year later.

Peter is still attending therapy sessions two years after his stroke. His next goal is being able to load and unload the washing machine and the dishwasher by himself. These accomplishments will help him relieve his wife´s workload at home and be more independent.

Like Peter, many stroke patients find new goals they strive to achieve. After a stay in a rehabilitation center, outpatient therapy helps to progress independence, reduce long-term impacts of the stroke, and teach patients to live with permanent limitation.

Therapeutic appliances for everyday life

Today, after two years, Peter is looking forward to going to his favorite café by himself again. He has a trusted companion, a walking stick.

In the mornings and evenings, he needs his wife to help him with personal hygiene and dressing. Before she heads off for work, she also puts out some tools that help him with daily tasks. His favorite tool is a reacher which gives him greater independence and safety by decreasing the amount that he needs to bend down to reach objects from the floor.

Such tools can make everyday life a lot easier. Therapists and orthopedic technicians can provide advice regarding suitable aids and devices. Occupational therapists can also support independence in daily routines.

Peter’s story is a possible, but fictitious, example of stroke recovery. It is not a linear path to recovery and everyone’s journey is different.

Author: Hannes Aftenberger

Sources:

Neurorestoration after stroke. (2016)

The relationship between Home-time, quality of life and costs after ischemic stroke: The impact of the need for mobility aids, home and car modifications on Home-time (2020)

Causes, symptoms, therapy in the event of hemiplegia after a stroke

Hemiparesis or hemiplegia are the medical terms, for paralysis of one half of the body. Hemiplegia is a symptom of brain or spinal cord damage. For example, paralysis can be a major symptom after a stroke (ischemic or hemorrhagic).

Hemiparesis versus hemiplegia – what is the difference?

The terms hemiplegia and hemiparesis both refer to a limitation of sensorimotor functions of one half of the body or of a body part.

With hemiparesis, individual muscle groups become weaker; the extent of that weakness varies. Hemiparesis is also known as incomplete paralysis. Hemiplegia refers to a complete paralysis. One may have an arm, leg, face, torso, or one entire side of the body affected.

Colloquially, the term hemiplegia is often used to describe both manifestations. The following article will use the term hemiplegia. All causes, symptoms, and treatments discussed below apply to both hemiplegia and hemiparesis.

What else can happen after a stroke?

If damage to the brain is severe, other symptoms may occur:

• Speech and language disturbances: Depending on the location and extent of damage to the brain, individuals may present with disordered speech and/or swallowing difficulties.
• Neuropsychological changes: Cognitive performance, the ability to concentrate, and/or emotional reactions can be affected. Their decreased quality of life often leads patients into depression.
• Difficulties with actions and motor planning (apraxia): Patients may no longer be able to complete routine tasks in the correct order. For example, an undershirt is put on over the shirt. Sometimes objects are no longer used correctly. For example, a comb is no longer recognized as such and is used for other tasks.
• Problems with continence: Adequate retention of urine/stool is often impaired.

Depending on which half of the brain is affected, some disorders are, statistically speaking, more prominent or occur exclusively. Reduced body perception is more common if the right half of the brain is affected. Similarly, it is also possible that the detection of stimuli on the affected side is reduced (neglect, pusher syndrome).

Damage to the left, often dominant half, of the brain is typically associated with speech disorders and a reduced ability to act and plan (apraxia).

Treating hemiplegia

Options to treat hemiplegia with medication depend on its cause. If rapid action is taken when a stroke happens, it is possible to administer medication that will help dissolve the blood clot. If a viral or bacterial infection (e.g. encephalitis) is the cause, suitable medication will be administered. In case of a tumor, radiation therapy or surgery may be necessary.

Different treatment approaches are used during, and especially after the acute phase of hemiplegia:

• Physiotherapy and Occupational therapy address the ability to move and aim to restore control of muscle function and body perception.
• Occupational therapy focuses more on recover of every day function. The patient practices using the regained bodily functions in everyday situations like bathing and dressing. The patient works towards being able to physically and cognitively perform these activities of daily living (ADLs) in a day-to-day life.
• Speech therapy aims to regain or to improve the ability to swallow and speak, as well as cognitive functioning.
• Psychology is often required in cases of extensive perception disorders. Psychological support can also help the patient to come to terms with their new situation. Also, topics like return to work/school or a career change can be addressed during psychological treatment. Mental health is an important topic during stroke recovery.

Doctors and therapists closely coordinate the hemiplegia treatment with their patients. The interdisciplinary approach treats the wide variety of disorders and resulting impairments. Treatment can include forced use of the affected body parts, the help of aids and innovative technology, animals, painting, or other creative activities.

What is the prognosis for hemiplegia?

The extent of the damage and the underlying cause determine the presentation of the hemiplegia.

In the event of a stroke, rapid medical assistance and treatment in a specialized stroke unit are of paramount importance.

In some cases, the paralysis is largely reduced; in rare cases, it is even reversed completely. Most patients must learn to live with some limitations. Continuous therapy and ongoing safe practice allow them to adjust to their new situation or even progress further. There are also various aids, devices, and technology that enable patients to be more independent in everyday tasks.

Author: Saskia Wibner

Source:

Platz, T. (2021). Clinical Pathways in Stroke Rehabilitation. Springer, 1st Edition