Effects of mirror therapy preceding augmented reality in stroke rehabilitation: a randomized controlled trial

Abstract

Background: Mirror therapy (MT) and augmented reality (AR) are gaining popularity in stroke rehabilitation. MT uses mirror visual feedback to promote bilateral brain coupling and increase primary motor cortex excitability. AR offers an interactive context of practice for promoting motor and cognitive recovery. MT and AR may complement each other for hybrid interventions in stroke rehabilitation. This study investigated the benefits of MT-primed AR (MT + AR) versus AR group, relative to conventional therapy (CT) for individuals with stroke.

Method: The study randomly assigned 45 stroke survivors to the MT + AR group, the AR, or the CT group, and 44 of them completed the experiment and were included in the analysis. Each treatment session was 90 min, 3 times a week, for 6 weeks. All assessments were administered before, immediately after treatment, and at 3 months. Primary outcome measures were the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and the Berg Balance Scale (BBS). Secondary outcome measures were the revised Nottingham Sensory Assessment (rNSA), Chedoke Arm and Hand Activity Inventory (CAHAI), Motor Activity Log (MAL), and Stroke Impact Scale Version 3.0 (SIS). Adverse events were monitored before and after each session.

Results: After 6 weeks of treatment, the three groups demonstrated significant improvements in the FMA-UE, BBS, CAHAI, MAL, and SIS. In the between-group comparisons, MT + AR and AR groups demonstrated significant advantages in the BBS, proprioception scale of rNSA and SIS, compared with the CT group. Only the MT + AR group, not the AR group, showed significantly better improvements in the FMA-UE and tactile scale of rNSA than the CT group. The MT + AR and AR alone showed differential benefits in the FMA-UE, tactile scale of rNSA, and SIS; the MT + AR rendered significantly better benefits. There were no significant differences among the three groups in the stereognosis scale of rNSA and MAL. No adverse effects were observed.

Conclusion: MT + AR and AR both effectively enhanced sensorimotor functions, balance and postural control, task performance, and life quality in patients with stroke with moderate-to-severe motor impairments. The results showed that MT + AR and AR were more beneficial for improving stroke survivors’ balance, functional mobility, proprioception recovery, and quality of life than the CT group. Furthermore, the MT + AR revealed better outcomes in the upper limb motor function and tactile sensory recovery. Between the MT + AR and AR comparisons, the MT + AR was more beneficial for improving upper limb motor function, tactile sensory recovery, and quality of life.

Trial registration NCT05993091.

Keywords: Augmented reality; Combinatory regimen; Gamification; Mirror therapy; Stroke.

Fig. 1

Study flowchart

Fig. 2

Mirror therapy (left) and augmented reality (right) practice

Fig. 3

Unilateral mirror therapy with movement-based practice

Fig. 4

Bilateral mirror therapy with movement-based practice

Fig. 5

Unilateral mirror therapy with task-oriented practice

Fig. 6

Bilateral mirror therapy with task-oriented practice

Fig. 7

The illustration of the raw scores of the FMA-UE

Fig. 8

The illustration of the raw scores of the BBS