558598

research-article2014
NNRXXX10.1177/1545968314558598Neurorehabilitation and Neural RepairHarmsen et al

Original Research Articles

Neurorehabilitation and

A Mirror Therapy–Based Action

Neural Repair
1­–8
© The Author(s) 2014
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Motor Learning After Stroke DOI: 10.1177/1545968314558598

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Wouter J. Harmsen, MSc1,2, Johannes B. J. Bussmann, PhD1, Ruud W.

Selles, PhD1,3, Henri L. P. Hurkmans, PhD1, and Gerard M. Ribbers, MD, PhD1,2

Abstract
Background. Mirror therapy is a priming technique to improve motor function of the affected arm after stroke. Objective.
To investigate whether a mirror therapy–based action observation (AO) protocol contributes to motor learning of the
affected arm after stroke. Methods. A total of 37 participants in the chronic stage after stroke were randomly allocated to
the AO or control observation (CO) group. Participants were instructed to perform an upper-arm reaching task as fast
and as fluently as possible. All participants trained the upper-arm reaching task with their affected arm alternated with
either AO or CO. Participants in the AO group observed mirrored video tapes of reaching movements performed by
their unaffected arm, whereas participants in the CO group observed static photographs of landscapes. The experimental
condition effect was investigated by evaluating the primary outcome measure: movement time (in seconds) of the reaching
movement, measured by accelerometry. Results. Movement time decreased significantly in both groups: 18.3% in the AO
and 9.1% in the CO group. Decrease in movement time was significantly more in the AO compared with the CO group
(mean difference = 0.14 s; 95% confidence interval = 0.02, 0.26; P = .026). Conclusion. The present study showed that a
mirror therapy–based AO protocol contributes to motor learning after stroke.

Keywords
stroke, mirror therapy, action observation, motor learning, upper limbs, rehabilitation

Introduction
More than 50% of stroke survivors suffer from impaired
motor function in the upper extremity.1 Because of the huge
impact, motor rehabilitation is the focus of clinical work in
daily clinical practice as well as of neurorehabilitation
research. The affected limb typically is weak, slow, and
lacks coordination and dexterity with a loss of the ability to
generate fractionated movements, and spasticity may be
present.
Treatment paradigms for the affected limb may be
classified into augmenting techniques, task-specific exer-
cises, and priming techniques.2 Priming techniques aim at
increasing the excitability of the involved neural networks
and promoting plastic reorganization. Mirror therapy is an
example of a priming technique for improving motor
function after stroke.3,4 In mirror therapy, a mirror is placed
in the midsagittal plane, which reflects movements of the
unaffected limb. The mirror reflection creates the illusion
that the affected side moves with a normal movement
pattern, creating a form of “virtual feedback.”
A number of trials on mirror therapy in stroke have
been reported,5-7 and various mirror therapy protocols are
composed and evaluated. Although many studies reported
on a positive effect of mirror therapy on motor recovery
after stroke,8-10 the exact working mechanisms are not
fully understood. Selles et al11 examined the effects of
unimanual and bimanual mirror therapy protocols on
motor learning after stroke. The largest intervention
effects were found in the condition in which patients only
trained the affected arm without a mirror and in the
condition in which patients moved the unaffected arm in
front of the mirror while observing the mirror reflection.
1
E rasmus MC, Department of Rehabilitation Medicine, Rotterdam, the
Netherlands
2
Rijndam Rehabilitation Centre, Rotterdam, the Netherlands
3
Erasmus MC, Department of Plastic and Reconstructive Surgery,
Rotterdam, the Netherlands
Corresponding Author:
Wouter J. Harmsen, MSc, Department of Rehabilitation Medicine,
Erasmus MC–University Medical Center, Room: Ee 1622, Dr
Molewaterplein 50, 3015 GE Rotterdam, Netherlands.
Email: w.harmsen@erasmusmc.nl

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2 Neurorehabilitation and Neural Repair 
Several authors ascribed the effects of mirror therapy to
neuronal activations of frontoparietal circuitries in the
brain, involving mirror neurons.12,13 Mirror neurons dis-
charge during both action execution and action observation
(AO) of corresponding movements.14 Previous functional
magnetic resonance imaging studies showed that similar
parts of the neuronal network are involved in AO as in
mirror therapy.14,15
AO improves motor learning in healthy individuals16-18
and may be a promising tool in regaining motor function
after stroke.19-21 A recent pilot study showed that
self-directed video therapy improves motor recovery after
stroke.22 New motor skills become part of the patient’s
motor repertoire, and observation activates the mirror
neuron system.23 The beneficial effects of mirror therapy
may, at least partly, be explained by working mechanisms
similar to that in AO. This study addresses the question of
whether a mirror therapy–based AO protocol improves
motor learning in the chronic stage after stroke by studying
a simple upper-arm motor task.
Methods
Study Sample
Participants in the chronic stage after stroke were recruited
from the outpatient clinic of Rijndam Rehabilitation Centre
in Rotterdam, the Netherlands.. The inclusion criteria were
(1) a Brunnström score for upper-extremity function between
III and VI, (2) a home dwelling status, and (3) at least 6
months poststroke. Patients with neglect (indicated by the
star cancellation test and/or reported by the occupational
therapist or psychologist), comorbidities that influence
voluntary upper-extremity function, or who suffered from
multiple strokes were excluded. All participants gave
written informed consent, and the study was approved by
the Medical Ethics committee.
Power Analysis
The sample size was calculated on the data from the study
of Cirstea and Levin,24 on which our experimental
paradigm was based. We calculated that 12 participants in
each group would be sufficient to have an 80% chance of
detecting a statistically significant difference of 0.25 s
between groups. To increase power, we aimed for a total of
20 participants in each group.
Clinical Assessment
Before starting the experiment, motor ability of the upper
extremity was evaluated using the Fugl-Meyer assessment
(FMA).25 The upper-extremity part of the FMA examines
voluntary upper-limb movements, tendon reflexes, range of
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motion, muscle tone, and the ability to execute proximal
and distal movements inside and outside movement
synergies. The FMA scores range from 0 to 66, with higher
scores indicating better motor function.26
Randomization
Participants were randomly allocated to the AO or control
observation (CO) group. To minimize possible confounding
effects of motor ability and age, we stratified participants
into groups based on age (younger than 55 years of age or
55 years and older) and motor function (FM score <50 or a
FM score of ≥50). In this way, we created 4 strata. Stratified
randomization was achieved by performing a separate
randomization procedure within each stratum. The random-
ization was based on a computer-generated random code
using blocks of 20 patients and using sealed envelopes.
Motor Task
Participants performed a simple upper-arm reaching task.
The task consisted of making a reaching movement
from a starting position located next to the chair, toward a
target located in front of them (Figure 1). A light
indicated the start of each trial. After hitting the target,
participants had to move their arm back toward the starting
position and wait until the light turned on again for the next
reaching movement. Participants were instructed to make
the upper-arm reaching movement as fluently and fast as
possible toward the target end point.
Experimental Procedure
Participants start the experiment with a set of 10 upper-
arm reaching movements with the affected arm, which
served as baseline measurement (T0). Hereafter, partici-
pants performed a set of 10 trials with their unaffected arm,
which was recorded with a digital camera and used for AO.
After baseline measurements, participants start the training
within the allocated condition. The training contained sets
of affected-arm reaching movements, alternated with
periods of observation (AO or CO). As in mirror therapy,
the video screen was positioned in the midsagittal plane.
After training, participants performed another set of
10 affected-arm reaching movements, which served as
follow-up measurement (T1). Figure 2 shows the schematic
representation of the experimental procedure.
Experimental Conditions: AO and CO
In this study, AO is offered in such a way that the
observation of the upper-arm reaching movements is almost
similar to what patients would see in the mirror during
mirror therapy. AO was displayed from a first-person
Harmsen et al 3

Figure 1.  Side view of the experimental setup: Participants were instructed to move their arm from a position located next to
the chair (A) toward a target located in front of them (B). The distance of the target was adjusted to the body dimensions of each
participant and the participant’s ability to extend the arm, such that at the end of the reaching movement, the fingers would just hit
the target.

Figure 2.  Schematic representation of the experimental setup. Baseline measurement: 10 affected arm movements (T0) followed by
10 unaffected arm movements, which were videotaped with a digital camera. Training: affected arm movements were alternated with
either action observation (AO) or control observation (CO). Follow-up: 10 affected arm movements (T1). The numbers under each
block represent the amount of physical repetitions, whereas the time in minutes indicates the duration of observation.

perspective, so the observed movements correspond to
the orientation of the participant. To provide participant-
specific videos, reaching movements from the unaffected
arm were videotaped and mirrored. Thereby, we tried to
create maximal postural familiarity and the illusion that the
affected arm performed the reaching movements in a
normal movement pattern. Participants were instructed to
focus on the arm reaching movements, which were
displayed on the computer monitor (Figure 3). In addition,
participants were instructed to observe the AO with the
intention to reproduce the reaching task with the affected
arm because this is proven to be a beneficial strategy in
observational learning.26,27
Participants in the CO group observed a slideshow with
static photographs of landscapes as control stimuli. The
photographs contained no images of humans or animals and
were selected such that they would not trigger the mirror
neuron system; therefore, they were not likely to interfere
with the goal in this study.
Data Acquisition and Analysis
Accelerometer data measured at the arm and target end
point were recorded using a TEMEC Vitaport 3 digital
recording system. A switch was used to turn on a light,
which indicated the start of each reaching movement, and

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4 Neurorehabilitation and Neural Repair 

Figure 3.  Side view of the experimental setup during action observation (AO) and control observation (CO): Participants in the AO
group observed mirrored reaching arm movements of the videotaped unaffected arm, as can be seen on the left image. Participants in
the CO group observed a slideshow with static photographs of landscapes, as can be seen on the right image.

simultaneously left a marker signal in the recorded time
series. Two 2D acceleration sensors (biaxial piezo-resistive
accelerosensor, Temec Instruments, Netherlands) were
placed on the ventral side of the wrist, measuring accelera-
tions during the reaching movements in 3 dimensions.
Another 2D acceleration sensor (bi-axial piezoresistive
accelerosensor, Temec Instruments, Netherlands) was
attached at the target end point and measured acceleration
in 2 dimensions to indicate the end of each reaching
movement. Accelerations were recorded at a sample
frequency of 128 Hz.
Because movement time was found to be a predictive
measure in learning a simple upper-arm motor task after
stroke,11,24 it was selected as the primary outcome.
Movement time was defined as the time between the start
signal derived from the marker signal and hitting the target
end point, derived from the accelerometer signal on the
target end point. All data were analyzed using custom-made
Matlab algorithms (7.4.0 r2007 a).
Statistical Analysis
To evaluate the experimental condition effect on motor
performance, change in movement time between baseline
(T0) and follow-up (T1) was measured and compared
between groups. For each block of 10 movements, we
calculated the median movement time of 9 trials (2-10),
omitting the first reaching movement. Median values for
movement time were used for group analysis. The assump-
tion for normality was checked by visual inspections of
the histogram and normal curve and by performing a
Shapiro-Wilk test. Independent Student t tests, χ2, or
Mann-Whitney U tests were selected to test for differences
between groups.
We evaluated the effect of the following possible
confounders on the experimental conditions: age, gender,
time since stroke, stroke type (hemorrhagic or ischemic),
FM score, affected side (dominant or nondominant), group
(AO or CO), and movement time at baseline measurement
(T0). To do so, first, we individually added each possible
confounder to a multiple regression model, with experi-
mental condition as the other dependent variable using the
Enter-method, selecting each confounder that changed the β
of the experimental condition effect by more than 10%. As
a second step, we entered each selected confounder in a
forward regression model, in order of confounding effect
size. If the added confounder did not further change the β of
the experimental condition effect by more than 10%, it was
excluded from the final regression model.
All statistical analyses were 2-tailed and performed
using IBM SPSS Statistics 20, and a P < .05 was considered
statistically significant.
Results
A total of 134 participants were eligible for inclusion, of
whom 37 participated in the present study (Figure 4).
Table 1 shows group characteristics of participants
allocated to the AO (n = 18) and CO group (n = 19). As can
be seen, the poststroke time period was relatively long in
both groups; most participants suffered from ischemic
stroke and had a middle cerebral artery lesion. Based on the
FMA, there was no baseline difference in upper-extremity
function between both groups (P = .48).
Movement time decreased significantly in both groups:
18.3% in the AO group (P < .001) and 9.1% in the CO
group (P = .036), with a significant difference in movement
time decrease between groups (mean difference = 0.14 s;

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Harmsen et al 5

Figure 4.  Flowchart describing the study sample and distribution of participants.

Table 1.  Patient Characteristics.a

Characteristics AO (n = 18) CO (n = 19) P Value

Age (years) 57 (10.4) 60 (8.8) .280
Stroke type (ischemic:hemorrhagic) 13:5 12:7 .401
Time since stroke (months) 46 (37) 38 (25) .753
Sex (male:female) (9:9) (13:6) .254
Affected side (dominant:nondominant) 8:10 9:10 .858
Fugl-Meyer score (ranging from 0 to 66) 54.3 (12.7) 57.1 (10.5) .300
Location artery lesion .476
  Middle cerebral artery 13 16  
  Posterior cerebral artery 1 0  
 Brainstem 3 2  
  Not specified 1 1  
Baseline movement time (s) 1.32 (0.44) 1.11 (0.28) .091

Abbreviations: AO, action observation; CO, control observation

a
Values are presented as mean (SD).

95% confidence interval [CI] = 0.02 to 0.26; P = .026).
Although movement time at baseline differed on average
0.21 s between groups, this was not significant (P = .09).
The extended regression analyses indicated that baseline
movement time (β = 0.001; P = .063; 95% CI = −0.009 to
0.305) and type of stroke (β = 0.141; P = .030; 95%
CI = 0.014 to 0.269) were independent confounding
variables of the experimental condition effect (AO vs CO).
However, the regression model that included these
confounding variables still showed a significant effect of
the experimental grouping condition on movement time
(R = 0.58; β = 0.126; 95% CI = 0.009 to 0.244; P = .036).

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6 Neurorehabilitation and Neural Repair 
Discussion
To our knowledge, this is the first study ever to specifically
investigate a mirror therapy–based AO protocol. Most
studies on mirror therapy mainly focus on its effect on
motor learning10 and specific neuronal activations
involved.8,13,15,28 Training without a mirror or with a
nontransparent screen between both arms are commonly
used control conditions, generally showing that mirror
therapy is beneficial for increasing motor learning after
stroke.8,9,11 The present study specifically investigated the
effects of a mirror therapy–based AO protocol on motor
learning in patients in the chronic stage after stroke. A
significantly larger decrease in movement time was found
in the AO compared with the CO group. The results indicate
that a mirror therapy–based AO protocol contributes to
motor learning after stroke and, at least partly, clarifies the
beneficial effects of mirror therapy on motor learning.
The primary aim of this study was not to create a
clinically meaningful change in arm function that would
persist over longer time periods but merely to study the
short-term impact of AO on learning a simple upper-arm
motor task after stroke. This experimental approach is in
line with previous studies that suggest that simple motor
tasks can be selected to study the effects of different train-
ing paradigms on motor learning in an efficient way.11,15,28
Our findings indicate that AO increases motor learning
when a simple upper-arm motor task was trained. Previous
studies on AO in stroke evaluated the effects of several
weeks of AO therapy, using functional outcome tests such
as the Frenchay arm test, Wolf motor function test, or the
Box and Block test.22,29 In the study of Ertelt et al,22 patients
in the chronic stage after stroke significantly improved
motor function following a 4-week video therapy program
compared with a control group. Patients entering the AO
group observed sequences of daily arm and hand actions
with increasing complexity, from 3 different perspectives
on a television screen positioned in front of the patient.
Beneficial effects of AO on motor learning were also found
in the subacute phase after stroke by Franceschini et al,29
who studied AO therapy as an add-on treatment to the
standard rehabilitation of arm function. Patients observed 3
different motor sequences with increasing complexity from
a first-person perspective, based on actions of daily living,
which were performed by young nondisabled men and
women. These studies provide evidence for an additional
positive impact of AO on motor learning after stroke, which
matches the findings of the present study. However, the AO
setup and training paradigms selected in these studies do
not allow transferring the results to the mirror therapy–
based AO paradigm investigated in the present study.
In this experiment, a simple upper-arm motor task was
selected to study the effects of AO on motor learning, which
allowed us to examine change in motor performance over
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relatively short time periods. It should be noted that
repetitive practice of sequentially simple motor tasks may
lead to motor improvements by adaptation,30 and short-term
effects of AO on motor learning may not transfer to more
complex motor and more clinically meaningful tasks, which
are typically learned more slowly over multiple training ses-
sions, such as hand dexterity or hand function in daily life.31,32
Despite randomized stratification, there were some base-
line differences that might explain different intervention
effects between groups. For example, patients in the
CO group had, on average, a better Fugl-Meyer score
and a faster baseline reaching movement. Therefore, we
performed an extended regression analyses to control for
possible confounding variables. Although we indeed found
that baseline movement time and type of stroke were
independent confounding variables of the condition effect,
the condition effect was still significant after control for
baseline values, indicating a Group × Time interaction effect.
Some limitations of the present study should be
discussed. First, the mirror therapy–based AO slightly
differed from the mirror reflection during mirror therapy.
In contrast to the mirror reflection, the computer screen has
limited resolution and depth perception. In addition, to gain
a clear view, the computer screen was positioned close to
the participant, and therefore differs slightly from the
mirror position during mirror therapy. However, the
presented AO corresponds to the mirror reflection and
creates the illusion that the affected arm performed the
reaching movements. Second, the relative heterogeneous
sample should be mentioned, with participants suffering
from either hemorrhagic or ischemic stroke. Including only
participants with specific brain lesions was not feasible
and would have decreased the external validity. A third
limitation is that the number of participants in both groups
was relatively small. The power analysis was based on
findings of Cirstea and Levin,24 who showed a 0.25-s
improvement in movement time in the affected no mirror
condition, which was similar to the improvement in the
present study (0.24-s improvement). Therefore, there seems
to be sufficient power to find a clear significant difference
in the main outcome measure. A fourth possible limitation
of the present study is that we did not further analyze
movement trajectory, which may have provided additional
information regarding motor learning after stroke. However,
previous research on motor learning after stroke showed that
movement time was a predictive measure when analyzing
a simple goal-directed upper-arm reaching task.11,24
The present study showed that a mirror therapy–based
AO protocol contributes to motor learning in patients in the
chronic stage after stroke and, at least partly, clarifies the
beneficial effects of mirror therapy on motor learning.
However, many questions remain. For example, it is still
not clear whether early priming techniques, applied in the
subacute stage after stroke, may actually promote recovery
Harmsen et al 7
beyond the level of spontaneous recovery. Additionally, it
might be that the effects of mirror therapy or AO on motor
learning can be maximized by combining it with other
priming techniques, such as transcranial direct current
stimulation. Answering these types of questions will help in
changing the pragmatic, experience-based orientation of
neurorehabilitation to an experimental and theory-based
approach.
Conclusion
The present study showed that a mirror therapy–based
AO protocol contributes to motor learning in patients after
stroke.
Authors’ Note
Trial number: ISRCTN40128145.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
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