Mirror Therapy in Unilateral Neglect After Stroke (MUST trial)

Abstract

Objective: We explored the effectiveness of mirror therapy (MT) in the treatment of unilateral neglect in stroke patients. Methods: This is an open, blinded endpoint, randomized controlled trial carried out from January 2011 to August 2013. We included stroke patients with thalamic and parietal lobe lesions with unilateral neglect 48 hours after stroke. Patients were randomized to the MT group or the control group (sham MT), and both the groups received limb activation. Patients received treatment for 1-2 hours a day 5 days a week for 4 weeks. The primary outcome was unilateral neglect assessed by a blinded assessor using the star cancellation test, the line bisection test, and a picture identification task at 1, 3, and 6 months. This study was registered at http://clinicaltrials.gov (NCT 01735877). Results: Forty-eight patients were randomized to MT (n 5 27) or the control group (n 5 21). Improvement in scores on the star cancellation test over 6 months was greater in the MT group (mean difference 23, 95% confidence interval [CI] 19-28; p , 0.0001). Similarly, improvement in the MT group was observed in the scores on the picture identification task (mean difference 3.2, 95% CI 2.4-4.0; p , 0.0001) and line bisection test (mean difference 8.6, 95% CI 2.7-14.6; p 5 0.006). Conclusions: In patients with stroke, MT is a simple treatment that improves unilateral neglect. Classification of evidence: This study provides Class I evidence that for patients with neglect from thalamic and parietal lobe strokes, MT improves neglect. Neurology ® 2014;83:1012-1017 GLOSSARY CI 5 confidence interval; CMC 5 Christian Medical College; FIM 5 functional independence measure; LBT 5 line bisection test; mRS 5 modified Rankin scale; MT 5 mirror therapy; PIT 5 picture identification task; RCT 5 randomized controlled trial; SCT 5 star cancellation test; SMD 5 standardized mean difference. About 30%-50% of stroke patients are left with considerable residual deficits. 1 Hemispatial neglect can be a major source of functional limitation after stroke. 2-4 Hemineglect occurs mostly in right hemispheric strokes but can also be seen in left hemisphere strokes. In an observational study, neglect was found in 70% of right and 49% of left hemispheric strokes. 5 Neglect occurs most frequently and dramatically in left hemispace in association with lesions of the right hemisphere. 6 Lesions involving the inferior parietal lobe and superior temporal cortex have been associated with neglect. 4 Various techniques, such as scanning, visual cueing approaches, limb activation strategies, visual imagery, prisms, and sustained attention training, are being used to treat unilateral neglect. 7 Mirror therapy (MT) enables patients to control their movements by themselves and is known to be effective in improving upper limb motor recovery and motor function after stroke. 8 In studies involving a small number of patients, MT has been found to improve hand function and unilateral neglect. 9 Researchers have used MT in the chronic phase of stroke and have also tested different modalities in the same patient to treat neglect. 10 Hence, we carried out From the Stroke Unit, Department of Neurology (J.D.P., R.A., P.K., D.S.) and College of Physiotherapy (D.