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Table of Contents    
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 570-576

Neural interface of mirror therapy in chronic stroke patients: A functional magnetic resonance imaging study

1 Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
2 N. M. R, All India Institute of Medical Sciences, New Delhi, India
3 N. M. R and Stem Cell Facility, All India Institute of Medical Sciences, New Delhi, India

Date of Submission26-Jun-2012
Date of Decision07-Sep-2012
Date of Acceptance11-Oct-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
Ashu Bhasin
Department of Neurology, All India Institute of Medical Sciences, New Delhi -110 029
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Source of Support: The research was funded by Department of Science and Technology (DST), Government of India, Conflict of Interest: None

DOI: 10.4103/0028-3886.105188

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 » Abstract 

Background: Recovery in stroke is mediated by neural plasticity. Neuro-restorative therapies improve recovery after stroke by promoting repair and function. Mirror neuron system (MNS) has been studied widely in humans in stroke and phantom sensations. Materials and Methods: Study subjects included 20 patients with chronic stroke and 10 healthy controls. Patients had clinical disease-severity scores, functional magnetic resonance imaging (fMRI) and diffuse tensor imaging (DTI) at baseline, 8 and at 24 weeks. Block design with alternate baseline and activation cycles was used with a total of 90 whole brain echo planar imaging (EPI) measurements (timed repetition (TR) = 4520 ms, timed echo (TE) = 44 ms, slices = 31, slice thickness = 4 mm, EPI factor 127, matrix = 128 × 128, FOV = 230 mm). Whole brain T1-weighted images were acquired using 3D sequence (MPRage) with 120 contiguous slices of 1.0 mm thickness. The mirror therapy was aimed via laptop system integrated with web camera, mirroring the movement of the unaffected hand. This therapy was administered for 5 days in a week for 60-90 min for 8 weeks. Results: All the patients showed statistical significant improvement in Fugl Meyer and modified Barthel Index (P < 0.05) whereas the change in Medical Research Council (MRC) power grade was not significant post-therapy (8 weeks). There was an increase in the laterality index (LI) of ipsilesional BA 4 and BA 6 at 8 weeks exhibiting recruitment and focusing principles of neural plasticity. Conclusions: Mirror therapy simulated the "action-observation" hypothesis exhibiting recovery in patients with chronic stroke. Therapy induced cortical reorganization was also observed from our study.

Keywords: Functional neuroimaging, motor learning, neural plasticity, visuomotor system

How to cite this article:
Bhasin A, Padma Srivastava M V, Kumaran SS, Bhatia R, Mohanty S. Neural interface of mirror therapy in chronic stroke patients: A functional magnetic resonance imaging study. Neurol India 2012;60:570-6

How to cite this URL:
Bhasin A, Padma Srivastava M V, Kumaran SS, Bhatia R, Mohanty S. Neural interface of mirror therapy in chronic stroke patients: A functional magnetic resonance imaging study. Neurol India [serial online] 2012 [cited 2023 Dec 8];60:570-6. Available from:

 » Introduction Top

Stroke is second leading cause of mortality in developing countries. The estimated prevalence of stroke in Asian countries is about 250-300 per 100,000 with a death rate of 1.2%. [1],[2] Various therapies, aim to improve patient outcomes by promoting repair and restoration of function in the sub-acute or chronic phase, eg. cell and gene therapy, physiotherapy techniques like electromagnetic stimulation, and task-oriented training have been evaluated. [3],[4] Longitudinal studies suggest that approximately 50% of patients with significant arm paresis recover useful arm function within the first 3 years of stroke. [5],[6]

Mirror therapy was first introduced by Ramachandran and co-workers to alleviate phantom limb pain in amputees. [7] Imagination and observation of a movement forms a source of information that could be useful for motor rehabilitation after stroke with the rationale that brain areas that are normally involved in movement planning and execution are also active during the imagination of a movement. [8] Mirror therapy is based on the concept of mirror neuron system (MNS). It was first described in monkey ventral pre-motor cortex (Brodmann area 5) and it has been observed that MNS discharges when an animal performs a goal-directed hand action and also when it observes someone else performing a similar action. Their activation leads to recruitment of functionally interconnected cortical structures coupling action execution and observation. [9],[10] Motor imagery has been proven to be effective in stroke patients with mirror induced-visual feedback facilitating recovery. [11] It may thus be possible for a system capable of appropriately stimulating the action observation system to encourage plasticity and repair. Since task-oriented rehabilitation is known to be beneficial, it thus suggests that mirror therapy based motor imagery may induce cortical plasticity and promote recovery using goal-directed arm and/or hand movements. [12] The aim of the study is to evaluate the effectiveness of mirror therapy by a computer-assisted (laptop) webcam system in rehabilitating stroke patients. It also studies cortical reorganization when the patients were subjected to physiotherapy regime.

 » Materials and Methods Top

Twenty chronic stroke (first ever) patients with the following inclusion criteria: Duration 3 months to 2 years; Medical Research Council (MRC) motor power grade at least >2/5 of wrist and hand flexor muscles; Brunnstorm stage between II and IV, National Institute of Health Stroke scale (NIHSS) score between 4 and 15, conscious and able to comprehend, were recruited for the study from the Neurology clinics. The exclusion criteria were: Progressive neurological disorders, unilateral neglect, comorbidities which influence upper extremity usage, contractures, pregnancy, and contraindications to magnetic resonance imaging (MRI). The study was approved by the Institutional Ethics Committee and informed consent was taken from all the subjects. All of them underwent clinical and radiological examination at baseline, 8 and 24 weeks. Ten healthy control subjects also had functional imaging for comparison.


The subjects were examined and assessed by a neurologist and a neurophysiotherapist. Motor function was assessed by NIHSS score, Fugl-Meyer (FM) scale and modified Barthel Index (mBI) at baseline (0 week) and post-physiotherapy (8 weeks). The Edinburgh Handedness Inventory was used to assess the dominance in hand activities. [13],[14]

Functional magnetic resonance imaging studies

Blood oxygenation level dependent (BOLD) data were acquired using the echo planar imaging (EPI) sequence using 1.5T MR scanner (Avanto; Siemens Medical Solutions, Erlangen, Germany) with a standard head coil. Block design with alternate baseline and activation cycles was used with a total of 90 whole brain EPI measurements (timed repetition (TR) = 4520 ms, timed echo (TE) = 44 ms, slices = 31, slice thickness = 4 mm). [15],[16]

Motor paradigm

The subjects were asked to perform the motor task with paretic/affected hand, with self-paced (minimum 0.5 Hz) fist clenching/extension of the wrist joint depending upon the extent of motor damage. For healthy controls, the dominant and non-dominant hand motion was used. To control the consistency of rate of motion, and to reduce movement artefacts, the movement was visually monitored using a remote digital camera.

Physiotherapy regime

All the patients received physiotherapy by the same therapist for the paretic upper and lower limbs. The treatment regime was administered for 5 days in a week for 8 weeks for 60-90 min. [9],[17] The treatment incorporated bilateral hand exercises in such a way that the patient observed his unaffected hand on the laptop screen, imagining it to be the affected hand. The movement of the unaffected hand was captured using a web cam and the mirror image of the same motion was projected on the laptop screen to the subject [Figure 1]. This resulted in the facilitation and movement of the paretic hand. [18] The difficulty of the exercise was dependent on the patient's individual level of functioning. Two similar objects were used for the treatment. For example, two yellow colored soft balls for squeezing, two identical pens to have a prehensile grasp wood blocks to hold in hands.
Figure 1: Mirror therapy using web cam. Patient is right hemiparetic. The camera captures the motion of the unaffected upper limb (left) in a right hemiparetic subject. The left hand is observed as a mirror image as right hand (affected) on the laptop screen. The subject performs bilateral task with the visual feedback

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Statistical analysis

For clinical data, the results were analysed using Statistical Package for the Social Sciences (SPSS Inc. SPSS for Windows, Version 11.5. Chicago, USA). Parametric and non-parametric t-tests were used for analysis between baseline, 8 and 24 weeks. fMRI data were analysed using SPM2 software (Wellcome Department of Cognitive Neurology, London, UK) running under the MATLAB environment (Mathworks). The functional images were realigned, normalized and then smoothed by a 6-mm Gaussian filter before statistical analysis. Montreal Neurological Institute (MNI) co-ordinates were co-related with Talairach's  Atlas More Details for the gray and white matter areas of the brain. The volume of the lesion was analyzed by IMAGEJ (Version 1.42q, Wayne Rasband, National Institute of Health, USA) software.

 » Results Top

Of the 20 stroke patients (mean age 45.45 ± 6.6 years, M: F: 18:2) included with the pre-defined inclusion criteria, 13 patients had cortical lesions and 7 had subcortical lesions. The mean time of stroke onset was 8.5 months. The clinical scores at baseline (0 week) and at 8 weeks are given in [Table 1]. The mean FM scale score at baseline was 18.90 ± 7.60 and at 8 weeks 29.45 ± 9.07 (t = −14.36, P = 0.0001). The mean FM scale score at 24 weeks was 35.65 ± 8.5 with statistical significant improvement between 8 and 24 weeks ( t = -8.929, P = 0.0001) and between baseline and 24 weeks ( t = −16.37, P = 0.0001). The mean mBI at baseline, 8 and 24 weeks was 46.95 ± 10.04 and 58 ± 9.3, respectively ( P < 0.05) [Table 1]. The mean mBI score at 24 weeks was 68.4 ± 9.2 showing statistical significant improvement between baseline and 24 weeks' scores. No significant difference was observed in MRC grade scale for power and Brunnstrom stage of stroke recovery. Repeated measures of ANOVA were applied to calculate the difference between 0 (baseline), 8 and 24 weeks which was found to be statistically significant.
Table 1: Demographic and clinical data in stroke patients at baseline (0 week), 8 and 24 weeks

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We found a significant improvement in the laterality index (LI) of ipsilesional BA 4 and BA 6 in all patients with P value < 0.05 on Wilcoxon sign rank test. [Table 2] shows the number of cluster activation in the ipsilesional and the contra-lesional hemisphere. There was a consistent increase in the cluster activation of the motor and pre-motor Brodmann areas post-therapy (P < 0.05). Ipsilateral or contra-lateral cerebellum was also found to be active in our patients. There was a shift of LI from negative (patient id 4, 9, and 12) to positive at 8 weeks. The inter-rater reliability for all the clinical outcome measures was 0.89 and for the functional imaging parameters was 0.87.
Table 2: Blood oxygenation level dependent brain activation pattern and voxel counts in BA 4, BA 6 and cerebellum in stroke patients

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The group analysis of BOLD activation in the right hemispheric stroke at 24 weeks showed right BA 6 activation with cluster counts of 91 voxels, inferior parietal lobule with 90 voxels and at 8 weeks showed a cluster activation of 155 voxels in right BA 4 [Table 3]. During BOLD activation of the left hemispheric stroke at 24 weeks, it was found that right and left cerebellum were active with 430 and 85 voxels, respectively, right BA 6 with cluster counts of 118 voxels and left BA 6 with cluster counts of 180 voxels. At 8 weeks, it was observed that right BA 6 had cluster counts of 90 voxels, left BA 6 with 120 voxels.
Table 3: Group analysis of blood oxygenation level dependent activation in patients at 8 weeks (post‑physiotherapy) and at 24 weeks (left hand movement)

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BOLD activation results in healthy controls

The mean age of healthy controls (M: F: 7:3) was 44.6 ± 7.8 years. All of them were right handed. A larger activation of the pre-central sulcus or primary motor areas (BA 4) was observed when the dominant hand was active.

Comparison between stroke subjects and healthy controls

One way ANOVA was done to compare controls and patients. [Table 4] shows the number of cluster activated in the right hemispheric in stroke patients and healthy controls. We observed a cluster activation of 26 voxels in right BA 6, 18 voxels in right BA 40 and 17 voxels in left BA 24 in comparison between the two groups. Similar results were observed in the left hemispheric stroke patients and healthy controls [Figure 2].
Table 4: Blood oxygenation level dependent activation pattern between healthy controls and patients with left hemispheric stroke

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Figure 2: Blood oxygenation level dependent activation comparison between healthy volunteers and stroke patients

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 » Discussion Top

The first objective in this study was to assess the efficacy of 8 weeks physiotherapy regime in chronic stroke patients. There was significant change in the clinical, FM, and mBI parameters at 8 weeks, suggesting improvement in the motor recovery. The impairment in the Ashworth tone grade and motor power by MRC grading for wrist and hand did not show statistically significant improvement when measured at 8 and 24 weeks. The percentage change in the mean FM score and mBI from baseline to 8 weeks were 55.08% and 23%, respectively. This suggests that a structured exercise regime leads to considerable improvement in the clinical and functional recovery.

Clinical and functional recovery is attributed to reorganization processes in the damaged brain. Within-system reorganization may be possible when damage to a system is partial. However, when a functional system is completely damaged, recovery is achieved largely by a process of substitution, that is, other brain areas are recruited to take over the functions of the damaged areas. [19],[20] The observations in this study suggest that there was an increase in the activation of primary motor area BA 4 post-therapy explaining the "restitution" principle of neural plasticity. [21] A shift in the position of the BA 4, 6 was also observed post-therapy, suggesting that physiotherapy in the form of mental imagery promotes a focused activation of the injured brain, augmenting recovery [Figure 3]. [22],[23]
Figure 3: (a) Activation in the right hemisphere (lesioned hemisphere) at baseline (b) BOLD activation showing an increased activation of premotor, primary motor, cerebellar and parieto-occipital areas in the right(lesioned) hemisphere after physiotherapy at 8 weeks

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The role of cerebellum in the recovery and movement generation following stroke is still being investigated and many varied views have been put forth. All patients in the present study showed an increased cerebellar activation (ipsilateral or contra-lateral to the paretic hand movement) during pre-therapy consistent with the hypothesis that blood flow and the cerebello-cortico network enhance at the beginning of the movement or in performing a new task in diseased subjects whereas a decrease in the post-therapy results suggest that patients had achieved skilled motor performance due to the intense physiotherapy regime. [24],[25]

It has been observed that there is an increase in the signal intensity as well an increased change in the LI as measured post-therapy. [26] These results suggest a focused activation of the perilesional cortex, the plasticity. These observations support the hypothesis that a structured physiotherapy regime improves the outcome measures. [27],[28]

The treatment regimens in this study were based on the principles of virtual reality (VR) and motor imagery. [29],[30] Patients observed the moving hand on the laptop screen as the affected hand and imagined it to be the affected hand (mirror image of the unaffected hand captured by a web cam) and tried to imitate the movement in real environment. The brain areas involved are pre-motor cortex, dorsolateral pre-frontal cortex, and the primary hand motor area as evident by the results in this study. In this therapy, the subject uses two different strategies: (a) Producing a visual representation of the moving limb, in which case the subject is a (third-person) spectator of the movement (visual imagery, [VI]) or (b) mentally simulating the movement, associated with a kinesthetic feeling of the movement, in which case the person is a (first-person) performer of the movement (kinetic imagery). [9],[31]

In healthy subjects, ipsilateral cortical activation was more pronounced during left hand motor tasks as compared with the right hand similar to the earlier observations. During the dominant (right) hand movement, pre-central sulcus or the primary motor areas (BA 4) was highly active in healthy subjects. When the BOLD activation pattern were compared with stroke and healthy controls, the ipsilesional hemisphere (left) was active when compared with healthy controls, left BA 6 active with cluster counts of 26 voxels, left BA 40 with 18 voxels. Similar results were observed with the right hemispheric stroke with primary motor cortex active along with the processing areas.

Chemical and anatomic plasticity of the cerebral cortex have been demonstrated in adult animals, suggesting that the neuronal cortical connections can be remodeled by experience, training, and sensory inputs. [32] Animals reared in complex environments with access to various toys and activities developed more dendritic branching and have higher gene expression for trophic factors than those in standard cages. [33],[34]

Both the time of onset of symptoms and the site of cortical lesion play major role in the degree of motor impairment. In the present study, the volume of the lesion varied from a small lacuna (5.8 ml) to a large cortical lesion (45.5 ml). The site and size of the infarct had no correlation with improvement. Patients with <10 ml of lesion showed good recovery as compared with large volume lesion more than 30 ml. Nevertheless a patient with a volume of 21.2 ml had similar clinical scores as compared with a patient with a large volume, 45 ml lesion. It was also observed that lesion at posterior limb of internal capsule (PLIC) had less probability of recovery than the cortical stroke with nearly same volume of lesion. [35] In this study patients were recruited according to their functional potential i.e, MRC motor power grade of at least 2, NIHSS between 4 and 15, which were contrary to the factors like site and side of lesion, stroke topography, premorbid status, clinical status, the time of onset of symptom, frequency of attack, and acute stroke interventions.

Post-stroke, intensive repetition of exercises leads to learning and improves the motor potential of hemiplegic limb. [36],[37] Motor imagery activates the primary and pre-motor areas for a task execution. During observation of a movement, areas in the pre-motor cortex become active when the (same) movement is executed. Our treatment involved the basic principles of learning: Practice and active participation. During bilateral hand movements, when the patient observes the mirror image of the unaffected hand on the laptop screen, thinking it to be the affected hand, the patient gets reinforced to move the affected hand in the real world. This kind of cognition and mental activity stimulates the motor processing areas (BA4 and BA6) and showed improvement in the affected hand clinically and functionally. [38],[39]

A recent phase II randomized trial evaluated clinical effects and cortical reorganization of home-based mirror therapy in chronic stroke patients. It was observed that post-treatment FM scores improved more in the mirror than in the control group. [40] Our results are also similar to this study showing greater improvement in the clinical outcome measures at 8 weeks than at 24 weeks when the therapy was withdrawn. The functional and behavioral recovery still needs to be understood to evolve a definite pattern to help the medical and health care professionals to deal with load of stroke patients in India. Also, the post-stroke rehabilitation services are non-structured and have not yet been standardized.

 » Acknowledgments Top

The first author is the motor rehabilitation scientist who administered physiotherapy with motor imagery to all patients. SSK helped in the BOLD activation results, MVP helped in recruitments of patients. RB helped in analysis of results.

 » References Top

1.Banerjee T, Das S. Epidemiology of stroke in India. Neurol Asia 2006;11:1-4.  Back to cited text no. 1
2.Sethi PK. Stroke - Incidence in India and management of ischemic stroke. Neuroscience 2002;3:202-6.  Back to cited text no. 2
3.Cramer SC. Repairing the human brain after stroke. II. Restorative therapies. Ann Neurol 2008;63:549-60.  Back to cited text no. 3
4.Wade DT, Langton-Hewer R, Wood VA, Skilbeck CE, Ismail HM. The hemiplegic arm after stroke: Measurement and recovery. J Neurol Neurosurg Psychiatry 1983;46:521-4.  Back to cited text no. 4
5.Sunderland A, Tinson D, Bradley L, Hewer RL. Arm function after stroke. An evaluation of grip strength as a measure of recovery and a prognostic indicator. J Neurol Neurosurg Psychiatry 1989;52:1267-72.  Back to cited text no. 5
6.Kwakkel G, Kollen BJ, van der Grond J, Prevo AJ. Probability of regaining dexterity in the flaccid upper limb: Impact of severity of paresis and time since onset in acute stroke. Stroke 2003;34:2181-6.  Back to cited text no. 6
7.Ramachandran VS, Rogers-Ramachandran D, Cobb S. Touching the phantom limb. Nature 1995;377:489-90.  Back to cited text no. 7
8.Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DM, et al. Rehabilitation of hemiparesis after stroke with a mirror. Lancet 1999;353:2035-6.  Back to cited text no. 8
9.Buccino G, Binkofski F, Riggio L. The mirror neuron system and action recognition. Brain Lang 2004;89:370-6.  Back to cited text no. 9
10.Rizzolatti G, Fogassi L, Gallese V. Neurophysiological mechanisms underlying the understanding and imitation of action. Nat Rev Neurosci 2001;2:661-70.  Back to cited text no. 10
11.Stevens JA, Stoykov ME. Using motor imagery in the rehabilitation of hemiparesis. Arch Phys Med Rehabil 2003;84:1090-2.  Back to cited text no. 11
12.You SH, Jang SH, Kim YH, Hallett M, Ahn SH, Kwon YH, et al. Virtual reality-induced cortical reorganization and associated locomotor recovery in chronic stroke: An experimenter-blind randomized study. Stroke 2005;36:1166-71.  Back to cited text no. 12
13.Oldfield RC. The assessment and analysis of handedness: The Edinburgh inventory. Neuropsychologia 1971;9:97-113.  Back to cited text no. 13
14.Loewen SC, Anderson BA. Reliability of the modified motor assessment scale and the barthel index. Phys Ther 1988;68:1077-81.  Back to cited text no. 14
15.Herholz K, Heiss W. Functional imaging correlates of recovery after stroke in humans. J Cereb Blood Flow Metab 2000;20:1619-31.  Back to cited text no. 15
16.Singh LN, Higano S, Takahashi S, Abe Y, Sakamoto M, Kurihara N, et al. Functional MR imaging of cortical activation of the cerebral hemispheres during motor tasks. AJNR Am J Neuroradiol 1998;19:275-80.  Back to cited text no. 16
17.Gallese V, Goldman A. Mirror neurons and the simulation theory of mind-reading. Trends Cogn Sci 1998;2:493-501.  Back to cited text no. 17
18.Ling SS, Fisher BE. Functional improvement using observational movement analysis and task specific training for an individual with chronic severe upper extremity hemiparesis. J Neurol Physiother 2004;28:91-9.  Back to cited text no. 18
19.Marshall RS, Perera GM, Lazar RM, Krakauer JW, Constantine RC, DeLaPaz RL. Evolution of cortical activation during recovery from corticospinal tract infarction. Stroke 2000;31:656-61.  Back to cited text no. 19
20.Ward NS, Brown MM, Thompson AJ, Frackowiak RS. Neural correlates of outcome after stroke: A cross-sectional fMRI study. Brain 2003;126:1430-48.  Back to cited text no. 20
21.Feydy A, Carlier R, Roby-Brami A, Bussel B, Cazalis F, Pierot L, et al. Longitudinal study of motor recovery after stroke: Recruitment and focusing of brain activation. Stroke 2002;33:1610-7.  Back to cited text no. 21
22.Fadiga L, Fogassi L, Gallese V, Rizzolatti G. Visuomotor neurons: Ambiguity of the discharge or 'motor' perception? Int J Psychophysiol 2000;35:165-77.  Back to cited text no. 22
23.Michielsen ME, Smits M, Ribbers GM, Stam HJ, Van Der Geest JN, Bussmann JB, et al. The neuronal correlates of mirror therapy: An fMRI study on mirror induced visual illusions in patients with stroke. J Neurol Neurosurg Psychiatry 2011;82:393-8.  Back to cited text no. 23
24.Lotze M, Montoya P, Erb M, Hülsmann E, Flor H, Klose U, et al. Activation of cortical and cerebellar motor areas during executed and imagined hand movements: An fMRI study. J Cogn Neurosci 1999;11:491-501.  Back to cited text no. 24
25.Dong Y, Winstein CJ, Albistegui-DuBois R, Dobkin BH. Evolution of fMRI activation in the perilesional primary motor cortex and cerebellum with rehabilitation training-related motor gains after stroke: A pilot study. Neurorehabil Neural Repair 2007;21:412-28.  Back to cited text no. 25
26.Pineiro R, Pendlebury S, Johansen-Berg H, Matthews PM. Altered hemodynamic responses in patients after subcortical stroke measured by functional MRI. Stroke 2002;33:103-9.  Back to cited text no. 26
27.Johansen-Berg H, Dawes H, Guy C, Smith SM, Wade DT, Matthews PM. Correlation between motor improvements and altered fMRI activity after rehabilitative therapy. Brain 2002;125:2731-42.  Back to cited text no. 27
28.Dong Y, Dobkin BH, Cen SY, Wu AD, Winstein CJ. Motor cortex activation during treatment may predict therapeutic gains in paretic hand function after stroke. Stroke 2006;37:1552-5.  Back to cited text no. 28
29.Lotze M, Cohen LG. Volition and imagery in neurorehabilitation. Cogn Behav Neurol 2006;19:135-40.  Back to cited text no. 29
30.Fogassi L, Ferrari PF, Gesierich B, Rozzi S, Chersi F, Rizzolatti G. Parietal lobe: From action organization to intention understanding. Science 2005;308:662-7.  Back to cited text no. 30
31.Stinear CM, Barber PA, Smale PR, Coxon JP, Fleming MK, Byblow WD. Functional potential in chronic stroke patients depends on corticospinal tract integrity. Brain 2007;130:170-80.  Back to cited text no. 31
32.Johansson BB. Brain plasticity and stroke rehabilitation. The Willis lecture. Stroke 2000;31:223-30.  Back to cited text no. 32
33.Nudo RJ. Postinfarct cortical plasticity and behavioral recovery. Stroke 2007;38:840-5.  Back to cited text no. 33
34.Hess G, Donoghue JP. Long-term potentiation of horizontal connections provides a mechanism to reorganize cortical motor maps. J Neurophysiol 1994;71:2543-7.  Back to cited text no. 34
35.Shelton FN, Reding MJ. Effect of lesion location on upper limb motor recovery after stroke. Stroke 2001;32:107-12.  Back to cited text no. 35
36.Kwakkel G, Van Peppen R, Wagenaar RC, Wood Dauphinee S, Richards C, Ashburn A, et al. Effects of augmented exercise therapy time after stroke: A meta-analysis. Stroke 2004;35:2529-39.  Back to cited text no. 36
37.Kwakkel G, Wagenaar RC, Koelman TW, Lankhorst GJ, Koetsier JC. Effects of intensity of rehabilitation after stroke. A research synthesis. Stroke 1997;28:1550-6.  Back to cited text no. 37
38.Kopp B, Kunkel A, Mühlnickel W, Villringer K, Taub E, Flor H. Plasticity in the motor system related to therapy-induced improvement of movement after stroke. Neuroreport 1999;10:807-10.  Back to cited text no. 38
39.Liepert J, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C. Treatment-induced cortical reorganization after stroke in humans. Stroke 2000;31:1210-6.  Back to cited text no. 39
40.Michielsen ME, Selles RW, Van Der Geest JN, Eckhardt M, Yavuzer G, Stam HJ, et al. Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: A phase II randomized controlled trial. Neurorehabil Neural Repair 2011;25:223-33.  Back to cited text no. 40


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]

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11 Effects of Action Observation Training and Mirror Therapy on the Electroencephalograms of Stroke Patients
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The Journal of Korean Physical Therapy. 2021; 33(2): 106
[Pubmed] | [DOI]
12 La Terapia Espejo en la Recuperación del Dańo Cerebral
Miguel Delicado Miralles
NeuroRehabNews. 2021; (Octubre)
[Pubmed] | [DOI]
13 Neural Processes Underlying Mirror-Induced Visual Illusion: An Activation Likelihood Estimation Meta-Analysis
Umar Muhammad Bello, Georg S. Kranz, Stanley John Winser, Chetwyn C. H. Chan
Frontiers in Human Neuroscience. 2020; 14
[Pubmed] | [DOI]
14 Role of kinaesthetic motor imagery in mirror-induced visual illusion as intervention in post-stroke rehabilitation
Umar M. Bello, Stanley J. Winser, Chetwyn C.H. Chan
Reviews in the Neurosciences. 2020; 31(6): 659
[Pubmed] | [DOI]
15 Effect of mirror therapy on hand functions in Egyptian chronic stroke patients
Hussein Shaker, Ebtesam Mohammed Fahmy, Ayman Anwar Nassif Honin, Shaimaa Shaheen Mohamed
The Egyptian Journal of Neurology, Psychiatry and Neurosurgery. 2020; 56(1)
[Pubmed] | [DOI]
16 Visual feedback therapy for restoration of upper limb function of stroke patients
Mei-Hong Zhu, Ming Zeng, Mei-Fang Shi, Xu-Dong Gu, Fang Shen, Ye-Ping Zheng, Ya-Ping Jia
International Journal of Nursing Sciences. 2020; 7(2): 170
[Pubmed] | [DOI]
17 Protective and Risk Factors for Phantom Limb Pain and Residual Limb Pain Severity
Marionna Münger, Camila B. Pinto, Kevin Pacheco-Barrios, Dante Duarte, Muhamed Enes Gunduz, Marcel Simis, Linamara R. Battistella, Felipe Fregni
Pain Practice. 2020; 20(6): 578
[Pubmed] | [DOI]
18 Effect of mirror use on lower extremity muscle strength of patients with chronic stroke
Myoung-Kwon Kim,Yu-Won Choe,Young-Jun Shin,Cheng Peng,Eun-Hong Choi
Journal of Physical Therapy Science. 2018; 30(2): 213
[Pubmed] | [DOI]
19 Recovery of Proprioception in the Upper Extremity by Robotic Mirror Therapy: a Clinical Pilot Study for Proof of Concept
Hyung Seok Nam,Sukgyu Koh,Jaewon Beom,Yoon Jae Kim,Jang Woo Park,Eun-sil Koh,Sun Gun Chung,Sungwan Kim
Journal of Korean Medical Science. 2017; 32(10): 1568
[Pubmed] | [DOI]
20 Effects of Mirror Therapy Using a Tablet PC on Central Facial Paresis in Stroke Patients
Jung-A Kang,Min Ho Chun,Su Jin Choi,Min Cheol Chang,You Gyoung Yi
Annals of Rehabilitation Medicine. 2017; 41(3): 347
[Pubmed] | [DOI]
21 Effects of observation of hand movements reflected in a mirror on cortical activation in patients with stroke
Moon-Young Chang,Hwan-Hee Kim,Kyeong-Mi Kim,Jae-Seop Oh,Chel Jang,Tae-Hyung Yoon
Journal of Physical Therapy Science. 2017; 29(1): 38
[Pubmed] | [DOI]
22 Network interactions underlying mirror feedback in stroke: A dynamic causal modeling study
Soha Saleh,Mathew Yarossi,Thushini Manuweera,Sergei Adamovich,Eugene Tunik
NeuroImage: Clinical. 2017; 13: 46
[Pubmed] | [DOI]
23 The neuronal correlates of mirror therapy: A functional magnetic resonance imaging study on mirror-induced visual illusions of ankle movements
Feng Guo,Qun Xu,Hassan M. Abo Salem,Yihao Yao,Jicheng Lou,Xiaolin Huang
Brain Research. 2016; 1639: 186
[Pubmed] | [DOI]
24 Effect of mirror therapy on upper extremity motor function in stroke patients: a randomized controlled trial
Nigar Gurbuz,Sevgi Ikbali Afsar,Sehri Ayas,Sacide Nur Saracgil Cosar
Journal of Physical Therapy Science. 2016; 28(9): 2501
[Pubmed] | [DOI]
25 Systematic review of the effects of mirror therapy in children with cerebral palsy
Eom-ji Park,Soon-hyung Baek,Soohee Park
Journal of Physical Therapy Science. 2016; 28(11): 3227
[Pubmed] | [DOI]
26 Paracrine Mechanisms of Intravenous Bone Marrow-Derived Mononuclear Stem Cells in Chronic Ischemic Stroke
Ashu Bhasin, M.V. Padma Srivastava, Sujata Mohanty, Sivasubramaniam Vivekanandhan, Sakshi Sharma, Senthil Kumaran, Rohit Bhatia
Cerebrovascular Diseases Extra. 2016; 6(3): 107
[Pubmed] | [DOI]
27 Exploring Biological Motion Processing in Parkinson’s Disease Using Temporal Dilation
Ruihua Cao,Xing Ye,Xingui Chen,Long Zhang,Xianwen Chen,Yanghua Tian,Panpan Hu,Kai Wang,Marina A. Pavlova
PLOS ONE. 2015; 10(9): e0138502
[Pubmed] | [DOI]
28 Reflections on Mirror Therapy
Frederik J. A. Deconinck,Ana R. P. Smorenburg,Alex Benham,Annick Ledebt,Max G. Feltham,Geert J. P. Savelsbergh
Neurorehabilitation and Neural Repair. 2015; 29(4): 349
[Pubmed] | [DOI]
29 A Mirror Therapy–Based Action Observation Protocol to Improve Motor Learning After Stroke
Wouter J. Harmsen,Johannes B. J. Bussmann,Ruud W. Selles,Henri L. P. Hurkmans,Gerard M. Ribbers
Neurorehabilitation and Neural Repair. 2015; 29(6): 509
[Pubmed] | [DOI]
30 Does Action Observation Training With Immediate Physical Practice Improve Hemiparetic Upper-Limb Function in Chronic Stroke?
Kita Sugg,Sean Müller,Carolee Winstein,David Hathorn,Alasdair Dempsey
Neurorehabilitation and Neural Repair. 2015; 29(9): 807
[Pubmed] | [DOI]
31 Efectos de la terapia de espejo en el ictus. Revisión sistemática
M. Reboredo Silva,M. Soto-González
Fisioterapia. 2015;
[Pubmed] | [DOI]
32 Action observation network in childhood: a comparative fMRI study with adults
Laura Biagi,Giovanni Cioni,Leonardo Fogassi,Andrea Guzzetta,Giuseppina Sgandurra,Michela Tosetti
Developmental Science. 2015; : n/a
[Pubmed] | [DOI]
33 Task-Based Mirror Therapy Augmenting Motor Recovery in Poststroke Hemiparesis: A Randomized Controlled Trial
Kamal Narayan Arya,Shanta Pandian,Dharmendra Kumar,Vinod Puri
Journal of Stroke and Cerebrovascular Diseases. 2015; 24(8): 1738
[Pubmed] | [DOI]
34 Modulation of interhemispheric activation balance in motor-related areas of stroke patients with motor recovery: Systematic review and meta-analysis of fMRI studies
Qing Tang,Guangming Li,Tao Liu,Anguo Wang,Shenggang Feng,Xiang Liao,Yu Jin,Zhiwei Guo,Bin He,Morgan A. McClure,Guoqiang Xing,Qiwen Mu
Neuroscience & Biobehavioral Reviews. 2015; 57: 392
[Pubmed] | [DOI]
35 Inadvertent recovery in communication deficits following the upper limb mirror therapy in stroke: A case report
Kamal Narayan Arya,Shanta Pandian
Journal of Bodywork and Movement Therapies. 2014;
[Pubmed] | [DOI]
36 Changes in functional brain organization and behavioral correlations after rehabilitative therapy using a brain-computer interface
Brittany M. Young,Zack Nigogosyan,LĂ©o M. Walton,Jie Song,Veena A. Nair,Scott W. Grogan,Mitchell E. Tyler,Dorothy F. Edwards,Kristin Caldera,Justin A. Sattin,Justin C. Williams,Vivek Prabhakaran
Frontiers in Neuroengineering. 2014; 7
[Pubmed] | [DOI]
37 Mirror Therapy Combined With Biofeedback Functional Electrical Stimulation for Motor Recovery of Upper Extremities After Stroke: A Pilot Randomized Controlled Trial
Jung Hee Kim,Byoung-Hee Lee
Occupational Therapy International. 2014; : n/a
[Pubmed] | [DOI]


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