Discussion
post-stroke, chronic stroke, stroke, self-efficacy post-stroke, left hemisphere damage, hand movements, hemispheric lesions, right hemisphere damage, MR
STROKE
In this study, we used a randomized controlled trial to examine whether mirror therapy would augment therapeutic effects of robot-assisted therapy on motor function, daily function, and self-efficacy in chronic stroke survivors. Based on the timeline of stroke recovery framework proposed by SRRR group, chronic stroke is defined as 6 months after stroke onset and 3 to 6 months post-stroke refers to as late sub-acute phaseIn motor function domain, results of FMA-UE and WMFT-FAS demonstrated the positive effects of robot-assisted therapy on upper limb motor recovery and functional performance, and the effect size of intervention was large based on benchmarks suggested by CohenIn contrast to improvements in FMA-UE and WMFT-FAS scores, participants did not improve their performance time for completing the tasks after the interventions in both groups based on the results of WMFT-Time scores. One explanation is that movement speed was not the primary focus of our intervention in this study. Our robot-assisted therapy consisted of 10-min active-assisted training and 30-min interactive training. The primary focus of active-assisted training was to assist patients in precisely recruiting the desired muscle group and enhance muscle activation during functional movements. Additionally, interactive training emphasized on coordination of arm and hand movements to improve endpoint accuracy during functional tasks. Participants were not asked to move in a fast pace during training and therefore the speed of task performance did not significantly improve. While temporal efficiency is identified as an aspect of movement qualityOur results in motor function domain seemed to conflict with the findings from Rong et al.'s study, which showed mirror therapy could augment therapeutic effects of robot-assisted therapy in motor recovery measured by FMA-UEIn daily function domain, our findings showed that participants successfully transferred gains in upper limb motor function to daily functional ability after robot-assisted interventions, measured by NEADL. Regarding our robot-assisted intervention protocols, active-assisted training mainly focused on neuromuscular control of hand movement while interactive training required coordinated motions for arm and hand. Integration of distal and proximal upper limb training has been advocated as a key for enhancing functional gainsLimited research has been conducted to identify stroke survivors' self-efficacy after receiving robot-assisted therapy using standardized scales. We used two standardized scales to measure self-efficacy since they capture different aspects of self-efficacy in stroke population. Whereas SSEQ was developed to measure one's confidence in relation to functional performance following stroke, DLSES captures self-efficacy in a broader sense including psychosocial functioning and activities of daily living. Results of both measures suggest that applying mirror therapy prior to robot-assisted therapy could be advantageous for enhancing self-efficacy post-stroke. Applying mirror therapy prior to robot-assisted therapy led to significant improvements in stroke survivors' self-efficacy based on the results of SSEQ and DLSES scores. According to Bandura's self-efficacy theory, self-efficacy can be developed by four main sources of influence, including mastery experience , vicarious experience, verbal persuasion, and emotional arousalThis study has some limitations. First, there were more participants with left hemisphere damage in MR group and more participants with right hemisphere damage in SMR group. Although there were no statistically significant differences in participants' demographic and clinical characteristics between the MR and SMR groups, side of hemispheric lesions could affect stroke rehabilitation in upper limb training