508468

research-article2013
NNRXXX10.1177/1545968313508468Neurorehabilitation and Neural RepairLin et al

Clinical Reasearch Article

Neurorehabilitation and

Combining Afferent Stimulation and Mirror

Neural Repair
2014, Vol. 28(2) 153­–162
© The Author(s) 2013
Therapy for Rehabilitating Motor Function, Reprints and permissions:
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Motor Control, Ambulation, and Daily DOI: 10.1177/1545968313508468

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Functions After Stroke

Keh-chung Lin, ScD1,2, Pai-chuan Huang, ScD3, Yu-ting Chen, MS3,

Ching-yi Wu, ScD3, and Wen-ling Huang, MS4

Abstract
Background. Mirror therapy (MT) and mesh glove (MG) afferent stimulation may be effective in reducing motor impairment
after stroke. A hybrid intervention of MT combined with MG (MT + MG) may broaden aspects of treatment benefits.
Objective. To demonstrate the comparative effects of MG + MT, MT, and a control treatment (CT) on the outcomes
of motor impairments, manual dexterity, ambulation function, motor control, and daily function. Methods. Forty-three
chronic stroke patients with mild to moderate upper extremity impairment were randomly assigned to receive MT + MG,
MT, or CT for 1.5 hours/day, 5 days/week for 4 weeks. Outcome measures were the Fugl-Meyer Assessment (FMA) and
muscle tone measured by Myoton-3 for motor impairment and the Box and Block Test (BBT) and 10-Meter Walk Test (10
MWT) for motor function. Secondary outcomes included kinematic parameters for motor control and the Motor Activity
Log and ABILHAND Questionnaire for daily function. Results. FMA total scores were significantly higher and synergistic
shoulder abduction during reach was less in the MT + MG and MT groups compared with the CT group. Performance on
the BBT and the 10 MWT (velocity and stride length in self-paced task and velocity in as-quickly-as-possible task) were
improved after MT + MG compared with MT. Conclusions. MT + MG improved manual dexterity and ambulation. MT +
MG and MT reduced motor impairment and synergistic shoulder abduction more than CT. Future studies may integrate
functional task practice into treatments to enhance functional outcomes in patients with various levels of motor severity.
The long-term effects of MG + MT remain to be evaluated.

Keywords
stroke rehabilitation, mirror therapy, electrical stimulation, kinematics, activities of daily living

Introduction spasticity, ambulation function, and daily function have

Stroke has become the most frequent cause of adult-onset
disability and costs a tremendous amount of related care
expense.1 About 65% of people after stroke experience dif-
ficulty in incorporating the affected hand into activities.1
Several novel and theory-based rehabilitation interventions
have been developed to improve motor recovery of the
upper extremity (UE).2 Among novel interventions, mirror
therapy (MT) was beneficial and comparatively low cost.2
Substantial evidence showed that MT reduced UE motor
impairment, as measured by the Fugl-Meyer Assessment
(FMA). Reduced impairments might result from recruiting
the premotor cortex or balancing neural activation within
the primary motor cortex toward the affected hemisphere.2-4
The benefits in certain aspects of outcomes are inconclu-
sive, however; for instance, Cacchio et al5 found MT
improved hand function, but others2 reported no significant
effect. Results of research on the effects of MT on
been inconsistent.5-10
Another compelling approach is afferent sensory stimu-
lation applied to the UE, which was beneficial for motor
recovery, as demonstrated by the FMA.11 One type of affer-
ent stimulation is provided by the mesh glove (MG; Prizm-
Medical Inc, Oakwood, GA). The MG uses a 2-channel
electrical stimulator to provide synchronous or reciprocal
sensory stimulation with variant amplitudes and can
1
National Taiwan University, Taipei, Taiwan
2
National Taiwan University Hospital, Taipei, Taiwan
3
Chang Gung University, Taoyuan, Taiwan
4
Chang Gung Medical Foundation, Taoyuan, Taiwan
Corresponding Author:
Ching-yi Wu, Department of Occupational Therapy and Graduate
Institute of Behavioral Sciences, College of Medicine, Chang Gung
University, 259 Wenhua 1st Rd, Taoyuan 333, Taiwan.
Email: cywu@mail.cgu.edu.tw

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154 Neurorehabilitation and Neural Repair 28(2)
Potentially eligible participants (n = 168)
Enrollment
Excluded (n = 83)
Not meeting inclusion
criteria (n = 42)
Randomized (n = 43)
Allocation
MG+MT MT CT
(n = 14) (n = 14) (n = 15)
Analysis
Analyzed Analyzed Analyzed
(n = 14) (n = 14) (n = 14)
Figure 1.  Flow diagram shows enrollment of patients and
completion of study according to the CONSORT statement.
Abbreviations: CT, control therapy; MG, mesh glove; MT, mirror
therapy.
provide stimulation of the entire hand. The MG can be used
to reduce muscle hypertonia and facilitate residual move-
ment, which may ameliorate motor impairment and increase
volitional activity of the hand and arm in stroke patients.12,13
A study by Zehr et al14 also suggests that stimulation of the
superficial radial nerve at the wrist may increase dorsiflex-
ion bilaterally in the stance-swing transition of ambulation.
Providing MG stimulation might also result in plastic
changes in the primary motor cortex15 and induce a long-
lasting effect on motor cortical excitability.16-18
Combining 2 treatment protocols has been advocated as
a way to improve treatment efficacy.19-21 MG stimulation
could be used to supplement other treatment,22 such as MT,
to normalize muscle tone and enhance hand or ambulation
function. Besides, the possible mechanism of brain plastic-
ity underlying MG is similar to the mechanism behind MT,
in that the primary motor cortex might be activated. Adding
MG to MT might further augment cortical reorganiza-
tion.19,20 MG stimulation added to MT improved manual
dexterity and ability to transfer skill during daily activi-
ties.23 However, this pilot study did not recruit a control
group and therefore could not estimate a possible gained
value, if any, in providing this new approach. The present
study included a larger sample of stroke patients, a control
group that received task-oriented therapy, and further
explored the possible benefits of MT coupled with MG.
This study used the Myoton-3 myometer to objectively
assess the treatment effects on muscle tone in the UE instead
of a subjective measure such as the Modified Ashworth
Scale (MAS).24 This study also included kinematic analyses
to obtain objective information on spatial and temporal
characteristics (eg, movement time, displacement, and joint
recruitment) of UE movements. Kinematic analysis helps
us understand whether a true change in the end point control
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and joint motion/synergy patterns has occurred21,25,26 and
infer possible reorganization of the brain after treatment.27,28
No previous research, to our knowledge, has addressed
change in the motor control mechanism after MT.
The present study combined MG stimulation with MT
(MT + MG) and compared the efficacy of MT + MG, MT,
and a control therapy (CT) on motor impairment, as mea-
sured by the FMA and Myoton-3, and on motor function, as
measured by the Box and Block Test (BBT) and 10-Meter
Walk Test (10-MWT). Also investigated were strategies of
motor control indicated by kinematic parameters and func-
tion in daily life situations measured by the Motor Activity
Log (MAL) and ABILHAND questionnaire. Possible
adverse effects, including pain and fatigue, were monitored.
Methods
Participants
The study recruited 43 patients (11 women) with stroke
from 4 medical centers who had met the following criteria:
(a) onset of an ischemic or hemorrhagic stroke of at least 6
months duration; (b) the ability to reach Brunnstrom stage
III or above in the proximal and distal part of the arm; (c) no
severe spasticity in any joints of the affected arm (Modified
Ashworth Scale ≤ 2)29; (d) no serious cognitive deficits
(Mini-Mental State Examination score > 24)30; (e) no seri-
ous vision or visual perception deficits (score of 0 on the
best gaze and visual subtest of the National Institutes of
Health Stroke Scale)31; (f) no history of other neurologic,
neuromuscular, or orthopedic disease; and (g) no participa-
tion in other studies concurrent with this study. Participants
signed informed consent forms approved by the institu-
tional review boards of the participating facilities.
Design
The study was a single-blind, randomized, pretest and
posttest control group design (Figure 1). Participants were
stratified into 4 strata according to the side of lesion and
the level of motor impairment (the cutoff point was 40 in
total scores of the FMA UE subtest32). A set of numbered
envelopes containing cards indicating the allocated group
was prepared for each stratum. When a new eligible par-
ticipant was registered, an envelope was randomly
extracted, and the relevant therapist was informed of the
group allocation.
Four certified occupational therapists were trained in the
administration of these 3 protocols by 2 primary investiga-
tors to conduct consistent intervention. Outcome measure-
ments were administered at baseline and immediately after
the intervention by 2 trained occupational therapists. The
evaluators were unaware of group allocation, and the par-
ticipants were blinded to the study hypotheses.
Lin et al 155
Figure 2.  The intervention setup of mesh-glove stimulation
combined with mirror therapy.
Interventions
All participants received a 1.5-hour training session per day,
5 days/week for 4 weeks. The treatments were provided
during the daily occupational therapy sessions. All other
routine interdisciplinary stroke rehabilitation was continued
as usual.
MT Protocol. The MT protocol included 10 minutes of
warm-up, 1 hour of mirror box training, and 20 minutes of
functional task practice. The warm-up activities included
stretching and passive range of motion exercises. During
the mirror box training, a mirror box that reflected the
image of the unaffected arm was placed in the participant’s
midsagittal plane. Participants were required to symmetri-
cally move both hands as simultaneously as possible while
watching the reflection of the unaffected arm in the mirror
as if it were the affected one. To ensure that the participants
focused on the reflection, the unaffected arm was placed in
the mirror box, and vision of the affected arm was occluded
by a vertical board placed beside the mirror box. The activi-
ties consisted of transitive (eg, gross motor tasks, such as
reaching out to put a cup on a shelf, or fine motor tasks,
such as picking up marbles) and intransitive movements
(eg, gross motor movements, such as pronation and supina-
tion, or fine motor movements, such as finger opposition).
After the mirror box training, functional task practice was
provided according to task-oriented treatment principles.
MG Stimulation Combined With MT.  The protocols of the MT
+ MG group were similar to the MT group (ie, 10 minutes
of warm-up, 1 hour of mirror box training, and 20 minutes
of functional task practice). The MT + MG group also wore
the MG during mirror box training (Figure 2). For safety
reasons, the conscious sensory threshold, with a feeling of
tingling on palmar and dorsal sides, was set on the
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unaffected hand. Then, the MG was applied on the affected
hand.
The MG protocol depended on the muscle tone of the
participants. Participants with a MAS score of 2 points in
any joint of the affected hand received 2-step electrical
stimulation. The first step was 80% of the conscious sen-
sory threshold that was a subthreshold, and the second step
was at the conscious sensory threshold. Each step lasted
about 30 minutes. Participants with a MAS score lower
than 2 points received 3-step electrical stimulation. The
first 2 steps were the same as that mentioned above, and
step 3 was stimulation above the threshold, defined by
120% of the conscious sensory threshold. Each step took
20 minutes.16 The subthreshold stimulation could decrease
spasticity, and stimulation at the threshold or higher could
improve awareness of the hand and enhance volitional
activity.16,18,33
CT Group.  The CT group received 1.5 hours of therapeutic
activities equivalent in duration and intensity to the MT +
MG and MT groups, based on task-oriented treatment prin-
ciples. Tasks used for practice were selected in accord with
the abilities of the participants. In addition to functional
task practice, this group also received warm-up similar to
the other 2 groups.
Outcome Measures
This study included clinical measures for motor impair-
ment, motor function, daily function, and adverse effects,
and kinematic data for motor control. All measures have
been reported to be adequately reliable and valid.24,34-38
Primary Outcomes
Motor impairment.  The UE subscale of FMA total score
was used to evaluate several dimensions of motor impair-
ments. The FMA measures the movements and reflexes of
the UEs and coordination/speed on a 3-point ordinal scale
(0 = cannot perform; 1 = can perform partially; 2 = can per-
form fully).34
We used myotonometric measurements obtained with
the Myoton-3 device (Muomeetria AS, Tallinn, Estonia) to
assess the tone of skeletal muscles. The Myotone-3, which
is placed perpendicular to the skin surface above the muscle
to be tested, produces a short impulse on the muscle. An
acceleration transducer records the damped oscillations of
the muscle response. The muscle tone values of the biceps,
flexor carpi radialis, and flexor carpi ulnaris were recorded.24
Motor function.  The BBT was used to assess manual dex-
terity. A box is separated into 2 equal sides. Subjects used
the affected hand to move as many blocks as possible, one
at a time, from one side to the other in 60 seconds. The num-
ber of blocks is calculated at the end of the test.35
156 Neurorehabilitation and Neural Repair 28(2)
The 10-MWT was used to assess the mobility function,
measuring the time and the numbers of strides required to
walk 10 meters under 2 conditions: (a) each participant’s
self-pace (self-pace) and (b) the quickest speed that each
participant could walk (as quickly as possible [AQAP]).36
The velocity and stride length of the participant were
calculated.
Secondary Outcomes
Daily function. The MAL is a semistructured interview
that assesses subjective report of 30 common daily tasks
evaluating the frequency of affected UE use. It consists of
subscales assessing the amount of use (AOU) and quality of
movement (QOM). The MAL uses a 6-point ordinal scale,
with higher scores indicating better performance.37
The ABILHAND questionnaire is a self-report assess-
ment of UE function that consists of 23 bilateral activities in
daily life. Patients were asked to estimate their difficulty in
performing each activity using a 3-point ordinal scale. The
higher the scores, the more difficulty the patients feel.38 The
Rasch model was used to estimate a linear ability for each
patient and linear difficulty for each item.38
Motor control. The experimental task required par-
ticipants to press a desk bell with their affected hand as
quickly as possible. Participants sat on a height-adjustable,
straight-backed chair with the seat height set to 100% of
the lower leg length. The tested arm was pronated, and
the hand rested on the edge of the table in a neutral posi-
tion with 90° flexion at the elbow joint. The desk bell was
placed in the midline of the table. The bell distance, mea-
suring from the medial border of the axilla to the bell, was
standardized to 125% of the participant’s functional arm
length (defined as from the medial border of the axilla to
the distal wrist crease39). If the maximum distance the par-
ticipant could reach was less than 125% of the functional
arm length, the bell distance was adjusted to the maximum
reachable distance. The instruction to the participants was,
“When you hear the start signal ring, please use the index
finger of the affected hand to reach and press the bell as
fast as possible.” After a practice trial, 3 trials were per-
formed.
A 7-camera motion capture system (VICON MX, Oxford
Metrics Inc, Oxford, UK) at a sampling frequency of 120
Hz was used with a personal computer to record kinematic
data. Three channels of analog signals were collected simul-
taneously: one for instruction of movement start and the
others for target bells. Markers were placed on the acro-
mion, middle of humerus, lateral epicondyle, styloid pro-
cess of ulna and radius, and index nail of the affected side.
Movement onset was defined as a rise of tangential wrist
velocity above 5% of its peak value. Movement offset was
defined as a fall of tangential wrist velocity below 5% of its
peak value. Movement was digitally low-pass filtered at 5
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Hz using a second-order Butterworth filter with forward
and backward pass.
Kinematic data were processed with an analysis program
coded by LabVIEW language (National Instruments, Inc,
Austin, TX). Kinematic variables included normalized
movement time and normalized movement units to repre-
sent end point control, and joint recruitment, including nor-
malized shoulder flexion, normalized elbow extension, and
maximum shoulder abduction, to describe movement pat-
terns. Movement time, which refers to the execution time of
the reaching movement and is the interval between move-
ment onset and offset, was a variable to represent temporal
efficiency.40,41 Movement unit was defined as 1 acceleration
and 1 deceleration, which refers to motor smoothness.40,41
Joint recruitment was defined as the difference of shoulder
flexion or elbow extension from movement onset and
movement offset, and maximum shoulder abduction during
each reaching motion. Maximum shoulder abduction and
elbow flexion are 2 critical components of the flexor syn-
ergy pattern often exhibited by patients with stroke.42,43
Reduced maximum shoulder abduction with enhanced
elbow extension indicates a diminished synergy pattern.42
Because bell distance varied, depending on the individual’s
arm length, and therefore influenced reaching distance
(defined as the distance between the initial index marker
position at resting and the target desk bell), all variables,
except for maximum shoulder abduction, were normalized
to reaching distance.
Possible adverse effects. Self-reported assessments on
pain and fatigue severity were administered immediately
after the first and last treatment sessions to evaluate adverse
effects. The evaluator presented the question, “What did
you feel in terms of pain/fatigue severity during the treat-
ment today?” The participant responded on an 11-point
ordinal scale (0 = no pain/fatigue; 10 = the most severe
pain/fatigue).
Data Analysis
Data were analyzed with SPSS 19.0 software (SPSS Inc,
Chicago, IL). We calculated that a sample size of 42 was
needed for an 80% likelihood in detecting a group differ-
ence with a type I error of .05, based on the previous pilot
study showing that MT combined with afferent stimulation
resulted in improvements with effect sizes of approximately
.50.23 Baseline differences among groups were analyzed by
analysis of variance for continuous data and by χ2 for cate-
gorical data. To control the variance among groups in the
pretest scores, analysis of covariance was used to compare
the treatment effects among groups on different end points
at posttest. The pretest performance was the covariate,
group was the independent variable, and posttest perfor-
mance was the dependent variable. No multiple testing
Lin et al 157

Table 1.  Characteristics of Study Participants (N = 43).

Variable MT + MG (n = 14) MT (n = 14) CT (n = 15) Statistica P Value

Gender, n 0.02 .90
 Male 11 10 11  
 Female 3 4 4  
Age (years), X (SD) 55.79 (14.59) 56.01 (12.53) 53.34 (10.12) 0.21 .82
Side of brain lesion, n 0.62 .74
 Right 8 6 8  
 Left 6 8 7  
Months after stroke onset, X (SD) 22.71 (13.62) 18.50 (11.61) 17.80 (10.56) 0.70 .50
Years of education, X (SD) 10.54 (5.01) 11.07 (4.75) 11.17 (3.71) 0.08 .93
Brunnstroms stage, X (SD)
 Proximal 4.25 (0.64) 4.25 (0.64) 4.17 (0.62) 0.33 .85
 Distal 4.11 (0.86) 4.00 (0.83) 4.10 (0.83) 0.12 .94
MMSE, X (SD) 27.62 (2.47) 27.91 (1.76) 28.21 (2.15) 0.26 .77

Abbreviations: MT + MG, mirror therapy combined with mesh glove; MT, mirror therapy; CT, control treatment; MMSE, Mini-Mental State Examination.
a
Statistic associated with χ2 test or the Fisher exact test for categorical variables, 1-way analysis of variance for continuous variables, and nonparametric
test for ordinal variables.

corrections were made to restrain the type II error consider-
ing the early stage of intervention development.
Post hoc analysis using highly significant differences
was used to evaluate the difference of each group. The η2
was calculated for each outcome variable to index the mag-
nitude of group differences. The η2 value represents the
variability in the dependent variable (posttest performance)
that can be explained by the independent variable (group).
A large effect is represented by an η2 of at least 0.14, a mod-
erate effect by an η2 of 0.06, and a small effect by an η2 of
0.01. The level of statistical significance (α) was set at .05
for all comparisons.44
Results
The study recruited 43 participants (mean age = 55.0
years). The MT + MG and the MT group consisted of 14
participants each, and the CT group consisted of 15 partici-
pants. After the treatment programs, the Myoton and kine-
matic data were missing for 2 participants. There were no
significant differences in demographic characteristics
among groups (Table 1). Group differences were not sig-
nificant for pain (F2,39 = 1.65, P = .06) and fatigue (F2,39 =
3.05, P = .21).
Primary Outcomes. Table 2 reports the descriptive and
inferential results, except the kinematic performance.
Total FMA scores were significantly different, with a
large effect among the 3 groups (F2,40 = 3.35, P = .045, η2
= .147). Post hoc analyses revealed that the MT + MG and
the MT groups were significantly higher than the CT
group for the FMA total score (P = .0032 and .0031,
respectively). Group differences in the muscle tone were
not significant.
Significant and large effects on motor function were
measured by the BBT (F2,40 = 4.39, P = .019, η2 = .184)
and the 10-MWT (velocity of self-pace: F2,40 = 5.02, P =
.011, η2 = .205; stride of self-pace: F2,40 = 7.13, P = .002,
η2 = .268; velocity of AQAP: F2,40 = 4.06, P = .025, η2 =
.176). No significant difference was found in stride length
of the AQAP subscores in the10-MWT. Post hoc analyses
revealed that the MT + MG and the CT group improved
more than the MT group in the BBT (P = .007 and P =
.036, respectively). The MG + MT group showed larger
improvements than the MT group on the velocity of self-
paced ambulation (P = .004), the stride of self-paced
ambulation (P = .016), and the velocity of AQAP (P =
.014). The CT group showed larger improvements than the
MT group on the velocity of self-paced ambulation (P =
.031), the stride of self-paced ambulation (P = .016), and
the velocity of AQAP (P = .023).
Secondary Outcomes. For daily function, no significant
group effects were found on the ABILHAND or on the AOU
and QOM of the MAL. Table 3 reports the descriptive and
inferential results for the kinematic performance. The results
revealed significant and large effects on normalized shoul-
der flexion (F2,38 = 3.43, P = .043, η2 = .157) and reduction
of maximum shoulder abduction during reach (F2,38 = 4.55,
P = .017, η2 = .198) among the 3 groups. Post hoc analyses
revealed that the MG + MT (P = .008) and the MT groups (P
= .023) showed significantly greater reduction of maximum
shoulder abduction than the CT group. The CT group showed
larger improvements than the MT group on normalized
shoulder flexion (P = .0013). Small and nonsignificant
effects were found on normalized movement time, normal-
ized movement unit, and the normalized elbow extension.

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 158
Table 2.  Descriptive and Inferential Statistics for Clinical Outcome Measures.

Pretest ( X ± SD) Posttest ( X ± SD) ANCOVA

Variable MT + MG MT CT MT + MG MT CT F P η2
FMA (n = 14) (n = 14) (n = 15) (n = 14) (n = 14) (n = 15) F2,40  
 Proximal 31.86 (4.77) 30.50 (4.00) 31.13 (4.36) 34.43 (4.91) 33.57 (3.99) 32.73 (3.83) 2.004 .15 .09
 Distal 13.57 (6.90) 13.71 (7.37) 12.67 (7.66) 16.50 (6.67) 16.29 (5.62) 14.40 (7.53) 1.614 .21 .08
 Total 45.43 (9.23) 44.21 (10.69) 43.80 (10.68) 50.93 (9.41) 49.86 (8.97) 47.13 (10.12) 3.350 .045a .15
Myoton (n = 14) (n = 13) (n = 14) (n = 14) (n = 13) (n = 14) F2,38  
 Biceps 14.41 (1.86) 13.39 (2.23) 13.87 (3.45) 14.16 (1.67) 12.90 (1.98) 12.56 (1.64) 2.200 .13 .11
  Flexor carpi radialis 15.85 (2.19) 14.13 (2.38) 15.41 (2.61) 15.45 (3.20) 15.17 (1.59) 15.20 (2.46) 0.129 .88 .007
  Flexor carpi ulnaris 14.15 (2.47) 13.57 (2.56) 13.15 (7.13) 14.34 (2.49) 13.75 (2.16) 12.28 (6.15) 1.68 .20 .083
BBT affected hand 12.00 (11.11) 16.43 (14.41) 15.73 (14.38) 17.29 (12.38) 16.93 (16.46) 19.93 (15.23) 4.392 .02a .18
10 MWT (n = 14) (n = 14) (n = 15) (n = 14) (n = 14) (n = 15) F2,40  
  Self-paced velocity (m/s) 0.557 (0.234) 0.707 (0.317) 0.580 (0.268) 0.658 (0.284) 0.697 (0.314) 0.649 (0.251) 5.020 .01a .21
  Self-paced stride length (m) 0.377 (0.120) 0.444 (0.144) 0.415 (0.118) 0.430 (0.130) 0.431 (0.145) 0.443 (0.098) 7.129 .002a .27
  AQAP velocity (m/s) 0.772 (0.293) 0.916 (0.418) 0.796 (0.383) 0.878 (0.355) 0.914 (0.441) 0.873 (0.378) 4.061 .03a .18
  AQAP stride length (m) 0.453 (0.151) 0.496 (0.163) 0.522 (0.235) 0.523 (0.206) 0.491 (0.178) 0.522 (0.119) 0.787 .46 .04
MAL (n = 14) (n = 14) (n = 15) (n = 14) (n = 14) (n = 15) F2,40  

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 AOU 1.00 (1.05) 1.35 (1.07) 0.86 (0.97) 1.23 (0.89) 1.43 (1.09) 1.14 (1.25) 0.796 .46 .04
 QOM 1.09 (1.18) 1.31 (1.02) 0.97 (1.02) 1.22 (1.02) 1.61 (1.19) 1.18 (1.10) 0.617 .55 .03
ABILHAND total score 29.14 (8.74) 38.43 (12.91) 28.00 (14.27) 33.07 (11.27) 40.64 (13.25) 34.13 (14.18) 0.215 .81 .01

Abbreviations: ANCOVA, analysis of covariance; MT + MG, mirror therapy combined with mesh glove; MT, mirror therapy; CT, control treatment; FMA, Fugl-Meyer Assessment; BBT, Box and
Block Test; 10 MWT, 10-Meter Walk Test; AQAP, as quickly as possible; MAL, Motor Activity Log; AOU, amount of use; QOM, quality of movement.
a
P < .05.
Lin et al 159
Discussion
The present study demonstrated that patients in the MT +
MG and MT groups performed better compared with those
in the CT group in the reduction of motor impairment.
Combining MT with MG stimulation showed additional
effects on manual dexterity of the affected hand, self-paced
ambulation, and velocity of quickly paced ambulation com-
pared with MT alone. Relative to CT, MT + MG and MT
reduced maximum shoulder abduction during forward
reach, which is regarded as reducing a critical component of
the flexor synergy pattern. However, CT increased shoulder
flexion more than the other groups. For daily function, we
found no group differences immediately after the 4-week
interventions. There was no adverse effect as measured by
self-reported pain and fatigue.
Compared with the CT group, the MT + MG and MT
groups showed improved motor impairment as indicated by
the FMA total scores, in line with previous research on
MT.2,6,10 As an explanation for the treatment effects, the
visual input during MT could substitute for absent or
reduced proprioceptive input from the affected body side45
and, consequently, helped recruit the premotor cortex or
balance the neural activation within the primary motor cor-
tex toward the affected hemisphere to facilitate motor
improvements.3,4,46
We found MT combined with MG stimulation provided
additional benefits on manual dexterity compared with MT
alone, consistent with the findings of a pilot study on MT
combined with somatosensory stimulation23 and studies
related to electrical stimulation.47,48 The extra benefit on
manual dexterity is very encouraging, considering its
importance for activities of daily living49 and that previous
studies of MT showed unclear results on manual dexter-
ity.2,6 MG stimulation might induce rapid plastic change in
sensorimotor regions of the cortex16,17,50 related to the hand
to which the stimulation was applied and modulate the
intracortical γ-aminobutyric acid pathways that reduce
intracortical inhibition in the motor cortex of the ipsile-
sional hemisphere.48 Combining MT with MG could pro-
vide cross-modal inputs (ie, sensation from electric
stimulation and visual image input from the mirror) during
training that may modulate activation of the somatosensory
cortex and facilitate dexterity recovery.21,51
Another important finding is that combining MT with
MG demonstrated significant improvements on ambulation
function measured by the 10-MWT compared with MT
alone. This finding is consistent with a pilot study23 and
some studies of electrical stimulation on the UE.12,52
Stimulation of cutaneous nerves of the hand could elicit an
interlimb reflex response in muscles across the body that is
believed to be related to motor coordination between arms
and legs during walking.14,53 In addition, arm integration
during reciprocal activities, which were part of the training,
Downloaded from nnr.sagepub.com by guest on May 14, 2015
could alter leg movement via propriospinal neural path-
ways.54 Improvement in UE motor control may contribute
to arm swing and help generate forward propulsion at the
foot.55
Our kinematic results revealed that MT + MG or MT
might reduce shoulder synergy movements, as indicated by
less maximum shoulder abduction42 during elbow exten-
sion, compared with the CT group. According to the
assumption of motor learning, the neural structures control-
ling movement are required to adapt to constraints imposed
by, at least, physical demands.56 MT restrained arm move-
ment in a size-limited box, which might not allow for a
great range of shoulder abduction during task performance.
Consequently, the synergy pattern of shoulder abduction
might be inhibited. This result can also be cross-validated
by our findings of improved total FMA scores, because the
FMA involves the ability to perform out-of-synergy move-
ments,34 the scores of the FMA indicated a reduction in
shoulder synergy movement.57 In contrast, the CT patients
gained a greater amount of shoulder flexion than the MT +
MG and MT patients. The CT involved a variety of thera-
peutic activities requiring shoulder forward flexion and
elevation. Accordingly, the CT patients exhibited better
improvement in shoulder flexion than patients receiving the
other 2 treatments. Task-specific training has been shown to
be effective in recovery of movement poststroke.58
No group differences were noted in the muscle tone of
the biceps, flexor carpi radialis, and flexor carpi ulnaris.
One possibility is that our participants had mild to moderate
spasticity (MAS ≤ 2) at pretest. Most participants in the MT
+ MG group received the 3-step MG stimulation protocol to
increase awareness of the affected hand and enhance voli-
tional activity rather than the protocol to reduce spastic-
ity,15,17,32 resulting in nonsignificant effects on spasticity.
We found no group differences in daily function, which
is in accord with previous research.23 However, a scrutiny
of the descriptive data showed all groups improved in some
activities of daily living outcomes, and additional statistical
analysis showed significant differences between pre- and
posttreatment for each group (P = .014-.047), indicating
that all treatments were beneficial to daily function. Future
research might include follow-up assessments to study pos-
sible changes in activities of daily living or incorporate
more functional task practice into MT + MG or MT to
improve function in daily-life situations.
As a limitation, our study included only people with mild
to moderate motor impairments. Some studies have reported
that patients with severe motor deficits achieved more
improvements after interventions.59 The evidence for opti-
mal intensity of afferent stimulation (eg, electric current
intensity) for stroke rehabilitation is limited.59 Because we
found no adverse effects using stimulation at the threshold
level, it might be possible to increase the intensity of the
electrical stimulation.59
 160
Table 3.  Descriptive and Inferential Statistics for Analysis of Kinematics Performance.

Pretest Posttest ANCOVA

Variable MT + MG (n = 14) MT (n = 13) CT (n = 14) MT + MG (n = 14) MT (n = 13) CT (n = 14) F2,38 P η2

Wrist Nmt (s/mm) 0.0050 (0.0056) 0.0032 (0.0015) 0.0039 (0.0023) 0.0033 (0.0013) 0.0033 (0.0017) 0.0030 (0.0014) 0.713 .50 .04
Wrist nMU (unit/mm) 0.0270 (0.0391) 0.0153 (0.0113) 0.0202 (0.0160) 0.0137 (0.0082) 0.0154 (0.0108) 0.0131 (0.0079) 1.006 .38 .05
nShoulder flex (°/mm) 0.1490 (0.0287) 0.1470 (0.0412) 0.1450 (0.0263) 0.1469 (0.0265) 0.1313 (0.0247) 0.1582 (0.0336) 3.432 .04a .16
nElbow ext (°/mm) 0.0624 (0.0505) 0.0691 (0.0391) 0.0802 (0.0195) 0.0720 (0.0375) 0.0708 (0.0351) 0.0821 (0.0211) 0.279 .76 .02
Max shoulder abd (°/mm) 0.1526 (0.0415) 0.1432 (0.0253) 0.1316 (0.0250) 0.1333 (0.0258) 0.1328 (0.0229) 0.1474 (0.0303) 4.554 .02a .20

Abbreviations: ANCOVA, analysis of covariance; MT + MG, mirror therapy combined with mesh glove; MT, mirror therapy; CT, control treatment; nMT, normalized movement time; nMU, normal-
ized motor unit; nShoulder flex, normalized angle recruitment of shoulder flexion; nElbow ext, normalized angle recruitment of elbow extension; Max shoulder abd, maximum angle recruitment of

Downloaded from nnr.sagepub.com by guest on May 14, 2015

shoulder abduction.
a
P < .05.
Lin et al 161
Conclusions
This study is unique in demonstrating the comparative
effects of MT + MG, MT alone, and task-oriented therapy
on a variety of motor and functional outcomes. MT + MG
and MT alone improved motor impairment and reduced the
critical component of synergy patterns (ie, shoulder abduc-
tion) more than CT. MT + MG yields broader aspects of
motor recovery. Our study showed the benefits of combin-
ing MT and MG stimulation for improving manual dexter-
ity and ambulation function. In addition, all treatments
here showed benefits in daily function. Future research
may address the dosing issue by studying the effects of
stimulation intensity and integrating functional task prac-
tice in the MT + MG protocol in an attempt to optimize the
effects on daily function.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
project was supported in part by the National Health Research
Institutes (NHRI-EX101-9920PI and NHRI-EX101-10010PI),
the National Science Council (NSC-100-2314-B-002-008-MY3
and NSC99-2314-B-182-014-MY3), and the Healthy Ageing
Research Center at Chang Gung University (EMRPD1B0371) in
Taiwan.
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