Christian Dohle

Mirror Therapy Promotes Recovery From Severe Hemiparesis: A Randomized Controlled Trial

Background. Rehabilitation of the severely affected paretic arm after stroke represents a major challenge, especially in the presence of sensory impairment. Objective. To evaluate the effect of a therapy that includes use of a mirror to simulate the affected upper extremity with the unaffected upper extremity early after stroke. Methods. Thirty-six patients with severe hemiparesis because of a first-ever ischemic stroke in the territory of the middle cerebral artery were enrolled, no more than 8 weeks after the stroke. They completed a protocol of 6 weeks of additional therapy (30 minutes a day, 5 days a week), with random assignment to either mirror therapy (MT) or an equivalent control therapy (CT). The main outcome measures were the Fugl-Meyer subscores for the upper extremity, evaluated by independent raters through videotape. Patients also underwent functional and neuropsychological testing. Results. In the subgroup of 25 patients with distal plegia at the beginning of the therapy, MT patients regained more distal function than CT patients. Furthermore, across all patients, MT improved recovery of surface sensibility. Neither of these effects depended on the side of the lesioned hemisphere. MT stimulated recovery from hemineglect. Conclusions. MT early after stroke is a promising method to improve sensory and attentional deficits and to support motor recovery in a distal plegic limb.

Mirror Therapy for Improving Motor Function After Stroke

Mirror therapy is used to improve motor function after stroke. During mirror therapy, a mirror is placed in the patient’s midsagittal plane, thus reflecting movements of the nonparetic side as if it were the affected side. This systematic review summarizes the effectiveness of mirror therapy for improving motor function, activities of daily living, pain, and visuospatial neglect in patients after stroke. We searched the Cochrane Stroke Group’s Trials Register (June 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to June 2011), EMBASE (1980 to June 2011), CINAHL (1982 to June 2011), AMED (1985 to June 2011), PsycINFO (1806 to June 2011), and PEDro (June 2011). We also handsearched relevant conference proceedings, trials, and research registers; checked reference lists; and contacted trialists, researchers, and experts in our field …

Different coupling for the reach and grasp components in bimanual prehension movements.

In this study on functional coupling in bimanual grasping movements, nine normal subjects had to reach and grasp two different objects simultaneously. Both objects could be either small or large, resulting in four different conditions of bimanual grasping. The main dependent variables were the coupling coefficients calculated either between the hand displacements or between the grip apertures of both hands, serving as variables for the coupling of the reach and the grasp component respectively. The correlation was significantly higher for the reach component than for the grasp component, with only the latter one changing significantly with variation of object size. These findings suggest different temporo-spatial coupling modes for the reach and the grasp components of bimanual grasping movements.

Cerebral activation evoked by the mirror illusion of the hand in stroke patients compared to normal subjects

BACKGROUND Mirror therapy (MT) was found to improve motor function after stroke, but its neural mechanisms remain unclear, especially in single stroke patients. OBJECTIVES The following imaging study was designed to compare brain activation patterns evoked by the mirror illusion in single stroke patients with normal subjects. METHODS Fifteen normal volunteers and five stroke patients with severe arm paresis were recruited. Cerebral activations during movement mirroring by means of a video chain were recorded with functional magnetic resonance imaging (fMRI). Single-subject analysis was performed using SPM 8. RESULTS For normal subjects, ten and thirteen subjects displayed lateralized cerebral activations evoked by the mirror illusion while moving their right and left hand respectively. The magnitude of this effect in the precuneus contralateral to the seen hand was not dependent on movement speed or subjective experience. Negative correlation of activation strength with age was found for the right hand only. The activation pattern in stroke patients is comparable to that of normal subjects and present in four out of five patients. CONCLUSIONS In summary, the mirror illusion can elicit cerebral activation contralateral to the perceived hand in the majority of single normal subjects, but not in all of them. This is similar even in stroke patients with severe hemiparesis.

Different effects of the mirror illusion on motor and somatosensory processing

PURPOSE Mirror therapy can improve motor and sensory functions, but effects of the mirror illusion on primary motor and somatosensory cortex could not be established consistently. METHODS Fifteen right handed healthy volunteers performed or observed a finger-thumb opposition task. Cerebral activations during normal movement (NOR), mirrored movement (MIR) and movement observation (OBS) by means of a video chain were recorded with functional magnetic resonance imaging (fMRI). Activation sizes in movement > static conditions were identified using SPM8 (p < 0.001, unc.) and attributed to predefined areas employing the Anatomy toolbox 1.8. Laterality indices for the responsive areas were calculated on the basis of the number of activated voxels. RESULTS Relevant bilateral BOLD responses were found in primary motor (M1) and somatosensory (S1 - BA 2, 3b and 3a) cortex, premotor and parietal areas and V5. When comparing MIR to NOR, no significant change of contralateral activation in M1 was found, but clearly at S1 with differences between hands. CONCLUSION The mirror illusion does not elicit immediate changes in motor areas, yet there is a direct effect on somatosensory areas, especially for left hand movements. These results suggest different effects of mirror therapy on processing and rehabilitation of motor and sensory function.

Effect of a mirror-like illusion on activation in the precuneus assessed with functional near-infrared spectroscopy

Abstract. Mirror therapy is a therapy to treat patients with pain syndromes or hemiparesis after stroke. However, the underlying neurophysiologic mechanisms are not clearly understood. In order to determine the effect of a mirror-like illusion (MIR) on brain activity using functional near-infrared spectroscopy, 20 healthy right-handed subjects were examined. A MIR was induced by a digital horizontal inversion of the subjects’ filmed hand. Optodes were placed on the primary motor cortex (M1) and the occipito-parietal cortex (precuneus, PC). Regions of interest (ROI) were defined a priori based on previous results of similar studies and confirmed by the analysis of effect sizes. Analysis of variance of the ROI signal revealed a dissociated pattern: at the PC, the MIR caused a significant inversion of a hemispheric lateralization opposite to the perceived hand, independent of the moving hand. In contrast, activity in M1 showed lateralization opposite to the moving hand, but revealed no mirror effect. These findings extend our understanding on interhemispheric rivalry and indicate that a MIR is integrated into visuomotor coordination similar to normal view, irrespective of the hand that is actually performing the task.

A COMPARISON OF NEURAL MECHANISMS IN MIRROR THERAPy AND MOvEMENT OBSERvATION THERAPy

OBJECTIVE To compare lateralized cerebral activations elicited during self-initiated movement mirroring and observation of movements. SUBJECTS A total of 15 right-handed healthy subjects, age range 22-56 years. METHODS Functional imaging study comparing movement mirroring with movement observation, in both hands, in an otherwise identical setting. Imaging data were analysed using statistical parametric mapping software, with significance threshold set at p < 0.01 (false discovery rate) and a minimum cluster size of 20 voxels. RESULTS Movement mirroring induced additional activation in primary and higher-order visual areas strictly contralateral to the limb seen by the subject. There was no significant difference of brain activity when comparing movement observation of somebody elses right hand with left hand. CONCLUSION Lateralized cerebral activations are elicited by inversion of visual feedback (movement mirroring), but not by movement observation.

Evidence-Based Quality Indicators for Stroke Rehabilitation

Background and Purpose— Previous stroke performance measures consider aspects of postacute treatment, but there are only few specific quality indicators or standards for poststroke rehabilitation. The purpose of this study was to develop a set of indicators for measuring the quality of postacute stroke rehabilitation in inpatient and outpatient facilities using a standardized evidence-based approach. Methods— Quality indicators were developed between January 2009 and February 2010 by an interdisciplinary board of healthcare professionals from rehabilitation centers cooperating in the Berlin Stroke Alliance. The Berlin Stroke Alliance is a regional network of >40 providers of acute treatment, rehabilitation, and aftercare aiming to improve stroke services within Berlin and Brandenburg. The indicators were developed according to published international recommendations and predefined methodological requirements. The applied standards included a systematic literature review, a rating of published evidence, an external peer review, and the evaluation in a pilot study before implementation. Results— Of an initial list of 33 indicators, 20 indicators were rated as being appropriate. After completion of the pilot phase, we agreed on a set of 18 indicators. The indicators measure processes (9 indicators), outcomes (5 indicators), and structures (4 indicators) in the following domains of stroke rehabilitation: completion of diagnostics; secondary prevention; cognition and affect; speech and swallowing; management of complications; sensorimotor functions and mobility; discharge status; and aftercare. Conclusions— Documentation of evidence-based quality indicators for stroke rehabilitation in clinical routine is feasible and can serve as a first step toward implementing standardized cross-institutional quality assurance programs for stroke rehabilitation.

Whole Genome Sequence Analysis of CTX-M-15 Producing Klebsiella Isolates Allowed Dissecting a Polyclonal Outbreak Scenario

Extended-spectrum β-lactamase (ESBL) producing Klebsiella pneumoniae pose an important threat of infection with increased morbidity and mortality, especially for immunocompromised patients. Here, we use the rise of multidrug-resistant K. pneumoniae in a German neurorehabilitation center from April 2015 to April 2016 to dissect the benefit of whole genome sequencing (WGS) for outbreak analyses. In total, 53 isolates were obtained from 52 patients and examined using WGS. Two independent analysis strategies (reference-based and -free) revealed the same distinct clusters of two CTX-M-15 producing K. pneumoniae clones (ST15, n = 31; ST405, n = 7) and one CTX-M-15 producing Klebsiella quasipneumoniae strain (ST414, n = 8). Additionally, we determined sequence variations associated with antimicrobial resistance phenotypes in single isolates expressing carbapenem and colistin resistance, respectively. For rapid detection of the major K. pneumoniae outbreak clone (ST15), a selective triplex PCR was deduced from WGS data of the major outbreak strain and K. pneumoniae genome data deposited in central databases. Moreover, we introduce two novel open-source applications supporting reference genome selection (refRank; https://gitlab.com/s.fuchs/refRank) and alignment-based SNP-filtering (SNPfilter; https://gitlab.com/s.fuchs/snpfilter) in NGS analyses.

Visualization of virtual reality neurological motor rehabilitation of the upper limb — A systematic review

Most virtual rehabilitation environments rely on visual feedback. However, little is known on the optimum characteristics of these feedbacks. Here, we present first results of a systematic literature review to assess and compare visual feedback types in virtual reality (VR) based neurological motor rehabilitation of the upper limb. Overall we identified 104 relevant publications. Within these some applied multiple visual feedback types. We found six main visualization groups: Avatar Feedback (N=52), Augmented Reality Feedback (N=16), Abstract Feedback (N=40), Tracking Feedback (N=13), Performance Evaluation Feedback (N=2), and Combined Feedback (N=7). However, there is insufficient evidence for the choice of a specific visual feedback in relation to motor outcome. Thus, further research is necessary.