EFFECTIVENESS OF THE COMBINATION OF MIRROR THERAPY AND ELECTRICAL STIMULATION ON LOWER LIMB MOTOR FUNCTION AND GAIT IN SUBACUTE AND CHRONIC STROKE PATIENTS: A SYSTEMATIC REVIEW
Abstract
Title: Effectiveness of the combination of mirror therapy and electrical stimulation on lower limb motor function and gait in subacute and chronic stroke patients: A systematic review.
Background: Stroke is a major, common and serious neurological problem. Patients who have suffered stroke usually have functional impairments such as sensory and motor impairments in the upper and lower limbs and other impairments which involve language, speech, swallowing, balance, gait and cognition. Thus, physical rehabilitation is fundamental to regain motor function and to enhance independence following stroke. Various therapeutic approaches are beneficial in improving these outcomes. Mirror therapy is a promising therapy, as it is characterized by its simplicity, low cost and patient-directed intervention. As suggested by many researchers, the combination of MT with other rehabilitation modalities is more effective than using a single therapy. The aim of this review is to analyse whether combining MT with ES is effective in enhancing LL motor function and gait in subacute and chronic stroke survivors.
Methodology: A systematic review was conducted. AMED (Ovid), CINAHL, PubMed, Medline (Ovid), PEDro, Emcare (Ovid) and Embase (Ovid) were searched on November 6th, 2020. Five randomised controlled trials (RCTs) met the inclusion criteria, and the methodological quality of these studies was assessed by two independent reviewers using the JBI critical appraisal tool (JBI 2020). Then, a narrative synthesis was performed due to lack of homogeneity between the included studies.
Results: Four studies demonstrated statistically significant improvements in gait ability (p<0.05) in MT combined with functional electrical stimulation (FES), afferent electrical stimulation (AES) or neuromuscular electrical stimulation (NMES) compared to MT alone, sham MT, conventional therapy or sham MT with sham AES in subacute and chronic stroke patients (Ji et al. 2014; Salhab et al. 2016; Xu et al. 2017; Lee and Lee 2019). For motor function, only Salhab et al. (2016) and Xu et al. (2017) found that combining MT with NMES or FES demonstrated significant improvement in LL motor function (p<0.05) in subacute stroke patients. Additionally, another two studies (Lee et al. 2016; Lee and Lee 2019) showed that MT combined with NMES or AES resulted in a statistically significant increase (p=0.046) in ankle dorsiflexor muscle strength in chronic stroke patients.
Conclusion: It seems that combining MT with NMES, AES or FES is more effective than MT alone, sham MT, conventional therapy or sham MT with sham AES in enhancing LL motor function and walking ability in subacute and chronic stroke patients. MT combined with different forms of ES does not show any adverse effects, so it can be applied at home, but further research is needed to confirm its suitability as a home-based intervention. However, these findings are based on heterogeneous RCTs which had several methodological limitations: thus, further high-quality research is needed.