Health, 2016, 8, 1442-1452

http://www.scirp.org/journal/health
ISSN Online: 1949-5005
ISSN Print: 1949-4998

Effects of Mirror Therapy on the Lower Limb

Functionality Hemiparesis after Stroke

Bruno Vieira Cortez1, Constância Karyne da Silva Coêlho1, Danylo Rafhael Costa Silva2,
Maria da Conceição Barros Oliveira2, Giselle Borges Vieira Pires de Oliveira3,
Francisco Mayron de Sousa e Silva1, Éric Heleno Freire Ferreira Frederico4,
Danúbia da Cunha de Sá-Caputo4, Mario Bernardo-Filho4, Janaína de Moraes Silva3
1
Departamento de Fisioterapia, Faculdade Maurício de Nassau, Teresina, Brasil
2
Pós-graduação da Rede Nordeste de Biotecnologia da Universidade Federal do Piauí, Universidade Federal do Piauí, Teresina, Brasil
3
Departamento de Fisioterapia, Universidade Estadual do Piauí, Teresina, Brasil
4
Laboratório de Vibrações Mecânicas e Práticas Integrativas e Complementares, Universidade do Estado do Rio de Janeiro, Rio de Janeiro,
Brasil

How to cite this paper: Cortez, B.V., Coêlho, Abstract

C.K.S., Silva, D.R.C., Oliveira, M.C.B., Olivei-
ra, G.B.V.P., Sousa e Silva, F.M., Frederico, Introduction: Mental exercise using the mirror therapy (MT) improves the reten-
É.H.F.F., Sá-Caputo, D.C., Bernardo-Filho, tion of newly acquired skills and the performance of sequential motor skills in sub-
M. and Silva, J.M. (2016) Effects of Mirror
jects with post-stroke hemiparesis. Objectives: The study aimed to analyze the mir-
Therapy on the Lower Limb Functionality
Hemiparesis after Stroke. Health, 8, 1442- ror therapy effect on the range of motion and the lower limb functionality in post-
1452. stroke hemiparesis subjects. Materials and Methods: Eleven participants with he-
http://dx.doi.org/10.4236/health.2016.814144 miparesis in the lower limb were subjected to the 10 sessions of a MT protocol. The
interventions were three times per week per 30 minutes each day. Evaluation of ac-
Received: October 1, 2016
Accepted: November 7, 2016 tive and passive ankle goniometry (dorsiflexion and eversion movements); Ascent
Published: November 10, 2016 and Descent Ladder Rate (ADLR); Time Up and Go test (TUG test); EFEI scale; and
FAAM scale were performed. The data were collected before and after the interven-
Copyright © 2016 by authors and
Scientific Research Publishing Inc.
tion using MT, and then statistically compared. Results: The MT improved signifi-
This work is licensed under the Creative cantly (p < 0.01) the range of motion of the paretic lower limb both evaluated by ac-
Commons Attribution International tive and passive ankle goniometry. An increase in the speed of gait and other func-
License (CC BY 4.0).
tional tasks related to the paretic lower limbs were found through the TUG and
http://creativecommons.org/licenses/by/4.0/
Open Access
ADLR tests. It also demonstrated a positive influence on the functionality of the pa-
retic lower limb motor control through the analysis of the scores in the FAAM and
EFEI scales. Conclusion: It is concluded that the MT therapy can help the patients
with post-stroke hemiparesis in the improvement of several functions. Probably, the
mirror therapy would aid in the repair of the injuries in the cortical areas.

DOI: 10.4236/health.2016.814144 November 10, 2016

 B. V. Cortez et al.

Keywords
Mirror Therapy, Stroke, Hemiparesis, Visual Feedback, Functionality

1. Introduction
Stroke is defined as a focal and acute neurological deficit, lasting more than 24 hours,
due to a vascular injury. The consequences are related to its location and extension.
Among the causes, there is the obstruction or rupture of a cerebral artery, leading to the
ischemic or hemorrhagic strokes, respectively [1] [2] [3].
As consequences of the stroke, there are several deficits, such as cognitive, sensory,
perception, language and motor. They can be temporary or permanent, according to
the affected region, level of injury and the individual capability. They can interfere di-
rectly on the functional capacity of the affected individuals [4] [5] [6] [7].
The chance of a person to have a stroke approximately doubles for each decade of life
after 55 years old and it occupies an important position among the elderly. The world-
wide prevalence of stroke in the general population is estimated from 0.5% to 0.7% [8].
It is suggested that, without appropriated intervention, the number of deaths due to the
stroke will increase to 6.3 million by 2015 and 7.8 million in 2030 [9].
Neurological rehabilitation programs based on suitable motor control models and on
motor learning theories have shown positive responses in the functional recovery of the
affected lower limb [10]. Trevisan et al. [11] have suggested a procedure based on the
mirror therapy (MT). This technique aims to accelerate the motor recovery of the lower
paretic member, integrating sensory stimuli to motor responses, remodeling cortical
connections and promoting changes in areas with cortical representation.
The general principles of the MT consist of a strategy involving “motor copy”, with
an induction of the use of the paretic limb through the mobilization of the healthy limb
using an external feedback using the mirror, and an internal feedback through the
mental practice of functional activities [11] [12].
Mirror therapy is an inexpensive, safe and useful feature. It is currently used for the
treatment of post-stroke hemiparesis in order to mitigate the sensorimotor deficits and
to accelerate the functional rehabilitation of the affected limb [13]-[18]. Amasyali and
Yaliman [19] have reported improvements of functions of the upper extremity (hand
skills) in patients with ischemic stroke.
Due to the relevance of the rehabilitaion of the patients with stroke, this study aimed
to evaluate the mirror therapy on the range of motion and functionality of the lower
limb in subjects with post-stroke hemiparesis.

2. Materials and Methods

2.1. Ethics Approach and the Selection of Subjects
Eleven subjects with post-stroke hemiparesis were included in the study and they were

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outpatients of the Clínica Escola de Fisioterapia, Faculdade Maurício de Nassau, Tere-

sina city, Piauí, Brazil. They were informed about the study and they decided to partic-
ipate in it. All subjects signed a consent and informed form to participate in the study
before to start the evaluation.
This study was approved by the Ethics Committee of the Hospital São Marcos Tere-
sina city, Piauí, Brazil under the number 973598.

2.2. Inclusion and Exclusion Criteria

Considering the inclusion criteria, the study included individuals (i) with both sexes,
(ii) with age over 55 years old, (iii) spasticity ranked 1, 1+ and 2 according to the Mod-
ified Ashworth Scale [20], (iv) absence of cognitive impairment, (v) stroke episode
(hemorrhagic or ischemic) for at least 6 months and (vi) that can walk without orthes-
es.
Considering the exclusion criteria, subjects were excluded if they had (a) more than
80 years old, (b) signals of visual impairment, (c) clinical evaluation revealed existence
of multiple brain lesions and cardiorespiratory changes, (d) previous lesions in the af-
fected limb before the stroke and (e) refused to sign the consent and informed form.

2.3. Intervention
All the participants were in a single intervention group. The intervention and data col-
lection were carried out by a single evaluator and according to the availability of the pa-
tients, according to a sequence of three sessions per week, in a total of ten sessions.
In the intervention, the subject was asked to use of the paretic limb through the mo-
bilization of the healthy limb in front of a mirror, and an internal feedback through the
mental practice of functional activities [11] [12]. In the protocol of the MT involving
the lower limbs, there were three sets of ten repetitions for each movement of dorsif-
lexion and eversion ankle in the sitting position. A rectangular mirror (50 cm of wide
and 91 cm of length) was positioned with reference to the sagittal subject’s line. In this
condition, the healthy lower limb remained in visual field of the subject and the affected
lower limb covered by the reflecting object. Subjects were instructed to observe the
healthy limb through the reflection of the mirror and perform the same activities with
the paretic limb.

2.4. Evaluations
All the subjects were evaluated before and after the intervention, as (i) active and pas-
sive Goniometry ankle (dorsiflexion and eversion movements) [21], (ii) time up and go
test [22], (iii) cadence test in climbing up and down a stair [23], (iv) filling the ques-
tionnaire Foot and Ankle Ability Measure (FAAM) [24] and Lower Extremity Func-
tional scale (EFEI) [25].
The FAAM questionnaire is an instrument composed of items for assessing the
physical performance of individuals with musculoskeletal disorders of the leg, ankle
and foot. The original version of the FAAM is divided into two areas, one subscale of

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Activities of Daily Living (ADLs), consisting of 21 items and other Sport subscale con-
sisting of 8 items. These scales are scored separately and generated three scores, one for
each scale and the total score of the instrument. Each item is scored on a Likert scale,
ranging from 0 (unable to do) to 4 (any difficulty). Therefore, the maximum score on
ADL subscale are 84 points and subscale Sport are 32. For each item there is the option
called “Not applicable (N/A)”. This option is not scored and thus is not considered in
the final calculation of the score. The values obtained are transformed into percentage,
and 100% indicates the highest level of functionality [26]. The FAAM is valid, reliable
and responsive to changes in the health status of individuals [27]. In this experimental
study, it will be considered only the sub-scale of activities of daily living (ADL), as a
criterion for specific functional assessment of the ankle and foot complex.
The EFEI was developed based on the criteria established by the function model and
disability prepared by the World Health Organization (WHO). It is used in individuals
with orthopedic disorders in the lower limbs, especially knee and ankle, and it is consi-
dered a specific instrument for these body segments. It consists of 20 items, each with a
maximum score of four points, with a maximum score of 80 points, which means a
normal functional state, and a minimum of nine points. The questionnaire can be
self-administered, with an approximate time of 2 minutes to complete all the items
[28].

2.5. Statistical Analysis

Data processing and statistical analysis were performed using SPSS software, version
19.0. Data were statistically analyzed by Pearson’s test, with statistical significance level
of 95% (p < 0.05).

3. Results
Eleven participants (four female and seven male) with 64 ± 9.74 years old participated
in this study.
Figure 1 shows the comparative data related to the active and passive goniometry
[21] of the dorsiflexion and eversion movements of the hemiparetic ankle before and
after the interventions with mirror therapy. It is possible to verify a significant differ-
ence in the data before and after the intervention. The MT seems to generate a better
improvement to the active goniometry (p < 0.01).
Figure 2 shows the comparative data of the Time Up and Go Test [22] before and
after the intervention of the MT. It is verified a significant (p < 0.01) improvement (re-
duction) of the time to perform the Time Up and Go Test after the MT.
Figure 3 shows the comparative data of the test in climbing up and down a stair [23]
before and after the MT. It is found a significant difference (p < 0.01) after the MT with
a reduction of the time to perform the evaluation.
Figure 4 shows the comparative data of the FAAM scale [24] before and after the
MT. It is found a significant improvement (p < 0.01) in the score of the questionnaire
Foot and Ankle Ability Measure after the MT.

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B. V. Cortez et al.

Figure 1. Active and passive goniometry of the dorsiflexion and eversion movements of the he-
miparetic ankle before and after the interventions with mirror therapy.

Figure 2. Comparative data of the time up and go test before and after the intervention of the
mirror test.

Figure 5 shows the comparative data of the EFEI scale [25] before and after the MT.
It is found a significant improvement (p < 0.01) in the Lower Extremity Functional
scale after the MT.

4. Discussion
As the results of measurements of the range of motion, mirror therapy provided signif-
icantly increase the amplitude of the lower limb movements paretic, dorsiflexion and
eversion (Figure 1). This finding could be associated with the increase of the muscle
strength, as described in a case study of Ramachandran; Altschuler [29] found satisfactory

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Figure 3. Comparative data of the test in climbing up and down a stair before and after the mir-
ror test.

Figure 4. Comparative data of the FAAM scale before and after the mirror test.

results within the muscle strength and range of motion of the paretic limb after applica-
tion of the mirror therapy. This would related to the mental performance of motor im-
ages, in which there was increased attention and concentration, providing develop-
ments in the planning and execution of the tasks proposed and information processing
capacity. This would involve greater repetitiveness of training and better improvement
of the motor performance [29].

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B. V. Cortez et al.

Figure 5. Comparative data of the EFEI scale before and after the mirror test.

Rocha, [30] has reported that two participants with post-stroke hemiparesis chronic,
with important difficulty to perform the dorsiflexion movements of the ankle, which
underwent a 10 minutes-intervention with the mirror therapy. The physical evaluation
post-treatment shows that the participants still had gait with hemiparetic characteristics
and with difficulty to perform dorsiflexion movements of the paretic ankle. However,
the evaluation of the images through the software Postural Assessment (SAPO) indi-
cated that that both participants were able to increase the hemiparetic ankle dorsiflex-
ion. In addition, Rocha [30] emphasized that a therapeutic approach to long-term in-
tervention and with greater intensity and frequency of training is necessary.
Regarding the gait functionality, it was verified that after 10 sessions with the mirror
therapy, the average post-treatment time to perform the Time Up and Go Test and Rate
of Climb and Ladder Descent decreased in comparison with the values before the in-
tervention. It was observed that the intervention with the mirror therapy led to an im-
provement of the paretic lower limb function, both in reducing the time to perform the
tests (Figure 2 and Figure 3). These findings are in agreement with Pauline; Shepherd
[31] that have found (i) the reduction of the time to perform the TUG test, (ii) increase
of the speed to do simple and advanced activities involving the functions of the lower
limbs post-stroke paretic. It was suggested that all mental activities were part of a
weekly routine, and kinesthetic information provided by the generation of the images
were more easily processed when the participant was more familiar with the movement,
making it more muscle strength, balance and coordination, as also described by Iest-
waart et al. [32]. However, in a clinical study with 20 participants with lower limb pa-
retic after stroke submitted to the mirror therapy for thirty minutes, five days a week
for four weeks and in combination with conventional physical therapy treatment,

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showed no improvement in the time to the gait performance [33]. Colomer et al. [34]
have also described that the mirror therapy in chronic stroke survivors with severely
impaired upper-limb function provides a limited but positive effect on light touch sen-
sitivity while providing similar motor improvement.
The results of this current study demonstrate positive influence of mirror therapy on
functionality and limb motor control lower post-stroke paretic, through the evaluation
of FAAM (Figure 4) and EFEI (Figure 5) scales. There were significant improvements
in the scores after the intervention related to their daily living activities and functional
capacity of the lower limb. It is suggested that the functional improvement occurs due
to visual stimuli with the mirror that are able to enhance the neural plasticity to repair
functions that were damaged by the stroke [35] [36]. These findings are supported by
Souza; Rangel and Silva [37] that reported the maintenance of the motor and sensory
gains and improvement of the functionality, even over six months after the mirror
therapy in post-stroke paretic limb. Furthermore, study using electromyography ana-
lyzes demonstrate the mirror therapy is capable in promoting activation of cortical
areas responsible for proprioception, vision and motor control, generating activation of
a network mirror neurons and stimulating neuronal plasticity. Putting together all the
findings, it is possible to suggest and to justify the motor recovery and improvement of
the functionality of participants with post-stroke hemiparesis [38]. Gaspar et al. [39]
have suggested that the mirror therapy could be used as a resource for rehabilitation
through mental practice of functional activities. Moreover, it is reported that the mirror
therapy when combined with kinesitherapy is more effective in hemiparetic patients
than is used alone.

5. Conclusion
It is concluded that the mirror therapy can help the patients with post-stroke hemipa-
resis in the improvement of several functions. Probably, the mirror therapy would aid
in the repair of the injuries in the cortical areas.

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