Mirror Therapy and Action Observation Therapy on Upper Limb Sensory Motor Recovery and Quality of Life in Subacute Stroke Patients

Background Stroke is a major cause of adult disability worldwide. One of the most disabling consequences is upper limb impairment, which reduces independence and daily functioning. Although traditional rehabilitation helps, recovery is often incomplete. Therefore, innovative, neuroplasticity-driven therapies like Mirror Therapy (MT) and Action Observation Therapy (AOT) are gaining interest.

MT relies on visual feedback from a mirror to create an illusion of movement in the affected limb, activating motor cortical areas. AOT involves observing purposeful movement followed by imitation, leveraging the brain's mirror neuron system to promote recovery.

While both therapies have shown individual effectiveness, few studies have directly compared them in subacute stroke-a critical recovery window. This study aims to address that gap, offering evidence to inform clinical practice.

Objectives

Primary Objective:

To compare the effects of MT and AOT on upper limb sensorimotor recovery in individuals with subacute stroke.

Secondary Objective:

To assess the impact of these therapies on stroke survivors' quality of life.

Hypotheses

Null Hypothesis (H₀):

There is no significant difference between MT and AOT in improving motor function or quality of life.

Alternative Hypothesis (H₁):

There is a significant difference between the two interventions in enhancing motor recovery and life quality.

Study Design Type: Randomized Controlled Trial (RCT)

Setting: Outpatient Neurological Rehabilitation Center

Duration: 6-week intervention

Sample Size: 40 participants (20 per group)

Randomization: Block randomization with concealed allocation

Blinding: Assessor-blinded

Assessment Points: Baseline, Week 3, Week 6

Eligibility Criteria

Inclusion criteria

Aged 40-70 years

First-ever ischemic or hemorrhagic stroke (diagnosed via imaging)

Stroke onset within 6 months (subacute phase)

Hemiparesis involving upper limb

MMSE score ≥ 24

Medically stable

Exclusion criteria

MAS score > 2 (severe spasticity)

Cardiac instability or other severe comorbidities

Visual impairments affecting mirror or screen-based tasks

History of upper limb orthopedic surgeries

Enrolled in other rehabilitation trials

Intervention Groups Group A: Mirror Therapy (MT) Participants will perform upper limb tasks while viewing the mirrored reflection of their unaffected limb for 30 minutes/session, 5 days/week for 6 weeks.

Group B: Action Observation Therapy (AOT) Participants will observe upper limb task videos (15 min) followed by 15 minutes of physical practice of the same tasks, 5 days/week for 6 weeks.

All participants will continue to receive standard rehabilitation care, including physiotherapy and occupational therapy.

Outcome Measures

Primary Outcome:

Fugl-Meyer Assessment - Upper Extremity (FMA-UE):

Evaluates upper limb motor control and coordination.

Secondary Outcomes:

Stroke Impact Scale (SIS):

Assesses quality of life across physical and emotional domains.

Modified Ashworth Scale (MAS):

Quantifies muscle spasticity.

Box and Block Test:

Measures gross manual dexterity.

Motor Activity Log (MAL):

Evaluates the functional use of the affected arm in daily tasks.

Assessments will be conducted at three time points: baseline, week 3, and week 6.

Inclusion criteria

• Age between 45 and 65 years (Tsai et al., 2012).
• Gender as either male or female (Tsai et al., 2012).
• Only subacute stroke patients will be included (Uyttenboogaart et al., 2005).
• A baseline Fugl-Meyer Assessment (FMA) score between 20 and 60 for upper limb motor function (Fugl-Meyer et al., 1975).
• The ability to follow study instructions, assessed using the Taiwan version of the Montreal Cognitive Assessment (MoCA) (Tsai et al., 2012), with scores below 26 indicating cognitive impairment, as patients scoring around 60 are considered to have near-normal cognitive function.
• The capability to participate in therapy and assessment sessions (Wang et al., 2011).
• Patient who have 1st onset of stroke ( 1st time stroke) (Hsieh et al., 2009).

Exclusion criteria

• Participants having hamonomus hemianopia (Tsai et al., 2012).
• Other neurological conditions for example, parkinsons, alzehmiers, ADHD, autism, etc (Tsai et al., 2012).
• Participants having recurrent stroke history (Wang et al., 2011).
• Global or receptive aphasia (Banks and Marotta, 2007).
• Severe neglect (Duncan et al., 2003).
• Major medical problems or comorbidities that influenced UE usage or cause severe pain (Hsieh et al., 2009).