Rehabilitation of hemiparesis after stroke with a mirror.

global burden of stroke is staggering (millions of strokes a year). Hemiparesis is one of the most common and disabling sequelae of stroke. In patients with immobile phantom limbs after amputation, vivid kinaesthetic sensations of movement can be evoked when the patient watches movement of the non-amputated hand or arm in a vertical parasagittal mirror. 1 Encouraged by a good initial result, 2 we have now done a larger trial of mirror therapy on patients with hemiparesis following stroke. All patients were at least 6 months post-stroke proven by computed tomography or magnetic resonance imaging (mean 4·8 years post-stroke, SD 8·2 years, range 6 months to 26·25 years), to preclude effects from spontaneous recovery. The patients gave written informed consent. The patients were randomly assigned to spend the first 4 weeks using a mirror or transparent plastic, and then crossed over to the other treatment for the next 4 weeks. We used mirrors sized 18ϫ24 inches (45 cmϫ60 cm) made of plastic with a mirror coating, and transparent plastic sheets of the same size. Patients were put on a practice schedule of 15 min, twice a day, 6 days a week, moving both hands or arms symmetrically (moving the affected arm as best they could) while watching the good arm in the mirror, or the paretic arm through the clear plastic (figure). A " bootstrapping " approach was employed in designing regimens for patients, typically moving proximal to distal, working from movements patients could perform to those they could not. The patients were videotaped at 0, 2, 4, 6, and 8 weeks making all of the cardinal movements of the upper limb. Subjective comments were obtained from the patients, and the patients' progress was assessed from the videotape by two senior neurologists from our team who were unaware of which treatment the patients used first, or the patients' subjective comments, assessing the change from baseline in patients' movement ability in terms of range of motion, speed, and accuracy using a –3 to +3 scale with 0 representing no change. Subjectively, all the patients liked using a mirror more than the clear plastic and felt that the mirror was more helpful than the plastic. One patient said that while " all my other methods of therapy exercise my muscles, the mirror is the only one which exercises my brain and nerves ". Another said he liked using the mirror and thought …