Effects of Task-Based Mirror Therapy for Post-stroke Shoulder-Hand Syndrome

Stroke is a sudden neurological loss caused by cerebral vascular damage. Upper extremity paralysis is the most prevalent symptom in stroke patients. Stroke-related paralysis is typically caused by internal capsule injury. Neuroplasticity, which involves multiple sections of the brain, is necessary to heal from this damage.Upper extremity function makes up 60% of total body function, with hand function accounting for 90% of that. Shoulder-hand syndrome (SHS), a chronic neurological condition that can develop after a stroke, is defined by excruciating discomfort, edema, vasomotor instability, and impaired motor performance. SHS is often referred to as reflex sympathetic dystrophy of the upper limb or poststroke complicated regional pain syndrome (CRPS). The development of upper limb discomfort and edema observed in SHS was attributed to hemiparetic arms. After a stroke autonomic and motor dysfunction, as well as upper limb pain, can be symptoms of SHS. Pathophysiologic mechanisms may include somatosensory and central autonomic system in brain, peripheral sensitization as hyperexcitability of the afferent fibers and inflammation of peripheral nerves and central mechanism as maladaptive neuroplasticity of motor cortex.

Mirror therapy is an attractive treatment option for clinical practice because it is simple to implement, relatively inexpensive, less intimidating for patients, and often equally or more effective than many alternative treatments. However, not all mirror therapy studies involving stroke victims have yielded such encouraging results. One study observed that the positive effects of mirror therapy decreased over time, and that mirror therapy involving the repetition of simple movements produced improvements during the start of treatment but were followed by a gradual decrease in function as the patients became bored with the movements and began resisting therapy. Based on this observation, mirror therapy programs that incorporate a variety of functional tasks were proposed to be more effective than those involving only simple movements designed to mimic tasks. It was also suggested the use more functional and task-oriented programs that involved picking up a coin because simple movements restrict the functional recovery of more complicated movements performed using the upper extremity. It was observed that treatment was more effective when an actual coin was used rather than when the same motion was performed without a coin.

Traditional rehabilitation methods often inadequately address the specific symptoms of SHS, creating a compelling case for innovative approaches like TBMT. This method uses visual feedback to improve motor function while engaging patients in purposeful, task-oriented exercises. Mirror treatment improves brain plasticity and motor recovery. This study will help us understand the effects of this treatment method and will pay ways for upgraded treatment strategies to improve symptoms and may have better outcomes and prognosis.

• Task based mirror therapy (Other): Group A will undergo treatment for 30 minutes a day, five days a week, over four weeks. Each task will be performed by repeating each movement 20 times per set for three sets, with a 2-minute break between sets. There will also be 2-minute intervals between each completed task
• Conventional exercises (Other): Group B will undergo treatment for 30 minutes a day, five days a week, over four weeks. Each task will be performed by repeating each movement 20 times per set for three sets, with a 2-minute break between sets. There will also be 2-minute intervals between each completed task

Primary outcomes

• Numeric pain rating scale (NPRS) [Baseline]: The Numeric Pain Rating Scale (NPRS) is an effective tool for assessing pain intensity in stroke patients, utilizing a scale from 0 to 10, where 0 indicates "no pain" and 10 represents "the worst pain imaginable." This scale is particularly valuable in stroke populations due to its simplicity and quick administration, allowing for effective communication of pain levels even in individuals with cognitive or physical impairments.
• Numeric Pain Rating Scale (NPRS) [4 weeks]: The Numeric Pain Rating Scale (NPRS) is an effective tool for assessing pain intensity in stroke patients, utilizing a scale from 0 to 10, where 0 indicates "no pain" and 10 represents "the worst pain imaginable." This scale is particularly valuable in stroke populations due to its simplicity and quick administration, allowing for effective communication of pain levels even in individuals with cognitive or physical impairments.

Secondary outcomes

• Figure of 8 measurement method [Baseline]: Figure 8 measurement method is a practical technique used to assess edema in the hand, particularly following a stroke. This method involves wrapping a flexible measuring tape around the hand and wrist in a figure-eight pattern, allowing for consistent measurements at specific anatomical points. It begins by placing the tape at the ulnar aspect of the wrist, passing it across the palm and around the fingers, and then returning to the starting point. Abnormal values indicating edema may be defined as an increase of more than 1-2 cm compared to the unaffected hand, signifying potential swelling due to conditions such as stroke, trauma, or inflammation
• Figure of 8 measurement method [4 weeks]: Figure 8 measurement method is a practical technique used to assess edema in the hand, particularly following a stroke. This method involves wrapping a flexible measuring tape around the hand and wrist in a figure-eight pattern, allowing for consistent measurements at specific anatomical points. It begins by placing the tape at the ulnar aspect of the wrist, passing it across the palm and around the fingers, and then returning to the starting point. Abnormal values indicating edema may be defined as an increase of more than 1-2 cm compared to the unaffected hand, signifying potential swelling due to conditions such as stroke, trauma, or inflammation
• Functional independence measure [FIM] [Baseline]: The Functional Independence Measure (FIM) assesses a patient's level of independence in daily activities following a stroke. It includes various domains such as self-care, mobility, and social cognition. An admission FIM score > 70 has been associated with achieving non-dependence by discharge whereas those with an admission score < 50 remained dependent
• Functional Independence Measure (FIM) [4 weeks]: The Functional Independence Measure (FIM) assesses a patient's level of independence in daily activities following a stroke. It includes various domains such as self-care, mobility, and social cognition. An admission FIM score > 70 has been associated with achieving non-dependence by discharge whereas those with an admission score < 50 remained dependent

Sex: All, ages: 45 Years to 75 Years

Inclusion Criteria: Age 45 to 75 years.

* Both male and female patients are included in the study.
* Subacute stroke patients having stroke less than 6 months are included in this study.
* Stable participants having a stroke severity score > 6 on National Institute of Health Stroke Scale (NIHSS).
* Modified Ashworth scale score ≤ 2 of the affected upper extremity.
* Montreal Cognitive Assessment (MoCA) score ≥ 24.
* Patients who can sit with or without support.
* No contractures of the affected shoulder, elbow, wrist and fingers.
* Participants who have no history of peripheral nerve injury or musculoskeletal disease

Exclusion Criteria:

* • Participants who have medical problems or co-morbidities that interdict their participation in the study.

  * Patients with severe apraxia, somatosensory problems.
  * Unilateral neglect
  * Severe contractures of the affected shoulder, elbow, wrist and finger.
  * Participants who show the symptoms of global or receptive aphasia.

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• Binash Afzal, PHD, Principal investigator, Riphah International University