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Article

Proprioceptive Neuromuscular Facilitation and Mirror Therapy Methods Are Comparable Methods of Rehabilitation after a First-Ever Ischemic Stroke: A Randomized Study

by
Wojciech Borowicz
1,2,*,
Kuba Ptaszkowski
3,
Eugenia Murawska-Ciałowicz
4 and
Joanna Rosińczuk
2
1
Department of Pediatric Infectious Diseases, Wroclaw Medical University, 50-368 Wroclaw, Poland
2
Department of Nursing and Obstetrics, Wroclaw Medical University, 51-618 Wroclaw, Poland
3
Department of Physiotherapy, Wroclaw Medical University, 50-368 Wroclaw, Poland
4
Department of Physiology and Biochemistry, Wroclaw University of Health and Sport Sciences, 51-612 Wroclaw, Poland
*
Author to whom correspondence should be addressed.
Sustainability 2022, 14(22), 15246; https://0-doi-org.brum.beds.ac.uk/10.3390/su142215246
Submission received: 7 October 2022 / Revised: 9 November 2022 / Accepted: 16 November 2022 / Published: 17 November 2022
(This article belongs to the Special Issue Development Sustainable with Diet and Physical Activity on Health and Performance)
Browse Figure
Versions Notes

Abstract

:
Stroke is a serious cause of premature death among adults and the reason for much long-term disability. Understanding the mechanisms of disability and the potential for recovery of stroke patients should be one of the highest priorities of the health care system. Neurorehabilitation of post-stroke patients focuses on functional recovery by activating mechanisms of natural reorganization. Proprioceptive neuromuscular facilitation (PNF) and mirror therapy (MT) are neurorehabilitation methods activating brain plasticity, and their clinical utility for stroke survivors is still under studied. This study compared two neurorehabilitation methods using PNF or MT on functional recovery in patients after a first-ever ischemic stroke. This prospective and interventional randomized clinical study involved a group of 50 patients (34 males and 16 females) with first-ever ischemic stroke, aged 48–82 years being in the recovery-compensation stage and admitted to the unit for early post-stroke rehabilitation. Patients were randomly enrolled into two groups in terms of rehabilitation method used: PNF (n = 26) or MT (n = 24). Barthel Index (BI) was used for assessing functional status at baseline (M0), and 3 (M1) and 6 weeks (M2) after intervention), and modified Rankin Scale (mRS) was used for assessing a disability level at baseline (M0), and 6 weeks (M2) after the intervention. Statistically significant differences were noted in the two study groups in BI (main effect: <0.05). There was an improvement in the MT group between M1 and M2 by 3.6 points, M1 and M3 by 6.9 points, and M2 and M3 by 6.9 points. For the PNF group, there were differences between M1 and M2 by 4.1 points, M1 and M3 by 7.2 points, and M2 and M3 by 3.1 points. Moreover, statistically significant differences were noted in both groups in mRS (main effect: p < 0.05). There was a decrease of 2.2 points in the MT group between M1 and M2 measurements. For the PNF group, there were differences between M1 and M2 by 2.3 points. There were no statistically significant differences between the MT and PNF groups in both BI and mRS scores (p < 0.05). In conclusion, both PNF and MT neurorehabilitation methods could be useful for improving functional status and reducing disability level in patients after first-ever stroke during the regenerative-compensatory stage.

1. Introduction

Stroke is a major cardiovascular diseases worldwide; it is the second leading cause of death and the third leading cause of death and disability combined [1]. Stroke is also one of the major public health problems. Data from the World Health Organization (WHO) determine that globally 15 million people each year experience a stroke, of which about one-third suffer from disability [2]. In Poland, there are 60–70 thousand new stroke cases each year [3]. According to European demographic forecasts, the number of new cases will increase. The incidence of stroke is estimated to rise by 37% and 38% for men and women, respectively, between 2005 and 2025 [4].
Approximately 75% of all strokes affect the population over the age of 65, and its prevalence will rise systematically due to demographic changes [5]. This phenomenon is expected to lead to increased demand for rehabilitation protocols aimed at improving the functional status and quality of life of patients. Therefore, understanding the mechanisms of disability and the potential for recovery of stroke patients should be one of the highest priorities of the health care system. Currently, in Poland and around the world, more and more novel physiotherapy methods based on natural principles of central nervous system (CNS) reorganization are being applied in dealing with stroke patients. Physiotherapy is employed when there is a disturbance in the automatic, free, or reflex organization of movement, which manifests as paresis, impaired motor coordination, and muscle tone control, i.e., typical signs of a cerebrovascular event [6].
The main goal of modern rehabilitation of post-stroke patients is to strive to recover lost functions by activating mechanisms of natural functional reorganization. Appropriate interactions, among others in the rehabilitation program, induce CNS remodeling [7,8,9]. Physiotherapy in the management of post-stroke patients is conditional on the type and severity of motor and cognitive deficits as well as disease stage [10]. The individual therapeutic goals run from restoring the patients as fully as possible to their functions and social roles to achieving a relatively high quality of life [11,12].
Some well-evidenced neuroprotective strategies may be complementary to neurorehabilitation management, especially in post-stroke patients. One such method inducing neuroprotective action can be oxygen therapy in the form of normobaric oxygen (NBO) and hyperbaric oxygen (HBO), which improve reperfusion rate and makes favorable changes in brain metabolism [13]. Moreover, reperfusion therapies such as remote ischemic conditioning (RIC) can be clinically useful in the prevention of the progression of ischemic necrosis after stroke and limit ischemia-reperfusion injury of the brain [14]. It should be noted that interventions reducing the harmful effect of oxidative stress by decreasing reactive oxygen species (ROS) can be found. An antioxidant strategy using vitamins (C and E), resveratrol, or allopurinol may have a beneficial effect on preventing brain tissue damage and enhancing outcomes after stroke [15].
Activities concerning the recovery of motor function over the past decades have become the focus of research by scientists dedicated to developing the topic of brain plasticity, which ensures that the subject adapts to the environment by learning and self-repairing after damage [16,17]. A typical example of neural plasticity is the healing process after an ischemic stroke, which initiates CNS reorganization and the assumption of some functions by undamaged parts of the brain structures. The reorganization also involves expanding cortical areas that provide the neuronal substrate for recovery or adaptation of motor activities after damage [18]. The results of research on brain plasticity have enabled the development of neurorehabilitation, which is reflected in various physiotherapeutic methods, including proprioceptive neuromuscular facilitation (PNF) and mirror therapy (MT) [19,20,21,22,23].
This study aimed to compare the effects two neurorehabilitation methods using PNF or MT on functional recovery in patients after a first-ever ischemic stroke during the regenerative-compensatory period.

2. Materials and Methods

2.1. Participants and Design

This prospective and interventional randomized clinical study was carried out in the Department of Neurological Rehabilitation from January 2021 to December 2021. Patients were qualified for the project by a team consisting of a medical rehabilitation physician, neurologist, neurologopedist, clinical psychologist, and physiotherapist. Eligibility criteria for all participants included status after a first-ever ischemic stroke confirmed by MRI or CT scan, with upper limb hemiparesis, consent to participate in the study, and consent from the supervising physician. The exclusion criteria were: (1) complete lack of movement of the upper limb, (2) highly functional upper limb, (3) time since stroke longer than 30 days, (4) complete lack of cooperation from the patient (global aphasia, lack of patient consent), (5) complete stiffness of the shoulder joint, (6) history of myocardial infarction, (7) chronic respiratory disease (asthma, COPD), and (8) previously established permanent musculoskeletal impairment.
A group of 62 patients after their first-ever ischemic stroke was assessed for eligibility. All patients were admitted directly from the neurology department to the neurorehabilitation department and screened for inclusion. During this stage, 12 patients were excluded: discontinuation of rehabilitation due to the onset of COVID-19 (n = 4) and the occurrence of complications in the form of a second stroke (n = 4), as well as the inability to participate in follow-up assessments (n = 4). The study finally included a group of 50 patients (34 males and 16 females) with first-ever ischemic stroke, aged 48–82 years, in the recovery-compensation stage, admitted to the unit for early post-stroke rehabilitation.
Hemiparetic patients were randomly assigned to two groups in terms of rehabilitation method: PNF (n = 26) or MT (n = 24). Patients signed their informed consent to participate in the study. In addition, they were informed and instructed about their options for discontinuing participation in the experiment in case of health problems or other reasons.

2.2. Ethical Considerations

This research project obtained a positive recommendation of the Independent Bioethics Committee of the Wroclaw Medical University in Poland (no. KB-813/2020). The trial was prospectively registered on the ISRCTN platform (no. ISRCTN16891871). The study was conducted under the principles of Declaration of Helsinki and Good Clinical Practice. All study participants gave their written informed consent before participating in the study.

2.3. Randomization Procedure

The study was designed as a randomized trial. Participants who were screened successfully for eligibility were randomly assigned to one of two groups (rehabilitated with MT and PNF methods) using a computerized random number generator (simple 1:1 randomization). Patients in both groups had sessions with a clinical psychologist and a neurologist and attended occupational therapy. Assignment to a particular group was independent of those implementing the therapy and analyzing the results. The same physician administered all tests and questionnaires.

2.4. Interventions

Patients enrolled in the study group were rehabilitated using either the PNF concept [24,25,26] or MT method [27,28,29]. The exercise schedule was set at five times each week. With each improvement session lasting 60 min. Heart rate (HR) and blood pressure (BP) were taken before each exercise session for patients in the study group who met the inclusion criteria. The rehabilitation training was always individualized for each patient, according to the current physical capabilities and needs. Its intensity was analyzed based on HR, which simultaneously provided up-to-date information that characterized the patient’s emotional state and fatigue level. Each patient was rehabilitated for 6 weeks, or 36 days (based on a Monday–Saturday schedule). In addition, the following 90-min sessions were continued for 5 days a week: occupational therapy (30 min a day), psychologist visit (30 min a day), and neurologist visit (30 min a day). Due to significant differences in functional status, an individualization of the rehabilitation program was applied in each randomly selected group.

2.5. Measurements

Validated scales were used to measure therapeutic progress. The Barthel Index (BI) was used for assessing a functional status, and the modified Rankin Scale (mRS) was used for evaluating a disability level.
The BI assesses independence in performing ten activities of daily living in patients undergoing physiotherapy after an ischemic stroke. It measures deficits in self-care, mobility, and sphincter control. BI score range of 0–20 pts.: ≤4 pts. (very severe disability); 5–9 pts. (severe disability); 10–14 pts. (moderate severity of disability); 15–19 pts. (mild disability); and 20 pts. (full independence) [30,31]. The BI was performed 3 times (before MT or PNF interventions, 3 and 6 weeks after completing the program).
The mRS is used to provide a simple description of the level of independent functioning. It mainly deals with locomotor function and the degree of dependence on third parties and is simple to use and useful in the initial general assessment of the patient [32,33]. It allows an assessment of the patient’s disability. mRS score range of 0–5: 0 (no symptoms); 1 (no significant disability); 2 (slight disability); 3 (moderate disability); 4 (moderately severe disability); and 5 (severe disability). The mRS was performed twice (before MT or PNF interventions and 6 weeks after completing the program).

2.6. Statistical Analysis

Statistica 13.1 software (TIBCO Inc., Palo Alto, CA, United States) was used to perform all statistical analyses. The Shapiro–Wilk test was used to determine the type of distribution of quantitative variables. Arithmetic means, medians, standard deviations, quartiles, and range of variation (extreme values) were calculated for measurable variables. Frequencies (percentages) were calculated for qualitative variables. Comparisons of qualitative variables between groups were made using the chi-square test (χ2). Intra-group comparisons between the results obtained in measures 1 (M1) and 2 (M2) were made using the Wilcoxon test, while in measures 1–4 (M1-4) were made using Friedman’s ANOVA analysis of variance and post-hoc test (Dunn’s test). An inter-group comparison was assessed using the U-Mann–Whitney test. All comparisons were assumed to be statistically significant at α = 0.05.

3. Results

Patients in both study groups were homogeneous in terms of the baseline characteristics of the population studies. Table 1 shows the characteristics of the study groups in terms of selected variables. Both groups were homogenous and no statistically significant differences (p > 0.05) were found between the study groups at baseline (Table 1).
Table 2 shows a comparison of changes in BI scores in the MT and PNF groups in three consecutive measurements (M1, M2, M3). Statistically significant differences were noted in the two study groups (main effect: p < 0.05). There was an improvement in BI scores in the MT group between M1 and M2 by 3.6 points, between M1 and M3 by 6.9 points, and between M2 and M3 by 6.9 points. For the PNF group, there were differences between M1 and M2 by 4.1 points, M1 and M3 by 7.2 points, and M2 and M3 by 3.1 points (Table 2).
Table 3 shows a comparison of changes in mRS scores in the groups undergoing MT and PNF methods in two consecutive measurements (M1, M2). Statistically significant differences were noted in both groups (main effect: p < 0.05). There was a decrease of 2.2 points in mRS scores in the MT group between M1 and M2 measurements. For the PNF group, there were differences between M1 and M2 by 2.3 points (Table 3).
In addition, a comparison of BI scores on three measurements (M1, M2, M3) between the MT and PNF groups were analyzed (Figure 1). Again, no statistically significant differences were observed (p > 0.05). Moreover, a comparison of mRS scores on two measurements (M1, M2) between the MT and PNF groups was analyzed (Figure 1). No statistically significant differences were observed (p > 0.05).

4. Discussion

Synthesizing the interpretation of the present results and considering their significance in the light of the available literature indicates that physical exercise in post-stroke patients may have induced neuroplasticity mechanisms that led to improved CNS function in rehabilitated patients after their first ischemic stroke. These processes are likely to occur at multiple levels, beginning at the cellular level and progressing via neurotransmission to neuronal networks that build functional connections between co-operating brain areas [18].
The results presented are not conclusive about the effectiveness of a particular form of therapy in the overall rehabilitation process. However, the functional status of both patient groups improved significantly in the BI and RS. Therapy conducted with the PNF concept and MT allows using the phenomenon of CNS plasticity to activate the receptors of the movement system [34,35].
Analysis of functional tests of patients undergoing rehabilitation showed improvement in functional status in all patients regardless of the type of therapy used (MT or PNF). Similar results were obtained by Rynkiewicz et al. [36]; their study group consisted of 85 ischemic stroke patients aged from 28 to 92 years (mean age 65). They also used the BI and mRS to assess rehabilitated patients’ functional status changes. According to the authors, the results obtained from the mRS show a very highly statistically significant (p < 0.001) improvement in the patients’ functional abilities. In the first study, patients obtained an average of 4.07 points, and in the second study, an average of 3.24 points.
Moreover, Starosta et al. [37] evaluated the effectiveness of a specific psychomotor rehabilitation program after first-ever ischemic stroke patients underwent 25 days of rehabilitation. Functional status was assessed in 57 patients based on the ADL and mRS tools. Functional improvement based on the ADL scale was observed by 32% and on the mRS by 22% (with a mean score of 4.1 points at admission and 3.2 points at discharge). Our study recorded scores of 3.5 and 1.3 points in MT and 3.5 and 1.2 points in PNF therapy, respectively.
Our results are difficult to compare to the preceding research because the authors did not identify the sort of exercise therapy employed, how many days per week, or for how long. Nevertheless, the presented studies support the thesis that comprehensive rehabilitation conducted by an interdisciplinary team is necessary and significantly improves functional status, thus reducing the degree of disability. However, in summary—despite methodological differences—the conclusions are similar.
Przysada et al. [38] emphasize that the BI which was also used in our study to measure the state and effects of rehabilitation of patients after stroke, reliably shows increasing independence in fundamental ADLs under the influence of rehabilitation. In our study, patients who were qualified for MT on the day of admission averaged 9.7 points and 16.5 points after 6 weeks of rehabilitation; similarly to our research project, patients rehabilitated with the PNF method averaged 9.5 points on admission and 16.7 points after 6 weeks.
In the PNF concept, special attention is paid to the patient’s motivation and positive attitude towards therapy, achievable through an individualized approach to the patient’s needs. Wolny et al. [39] stressed the need to individualize improvement programs for each patient. There is substantial literature on the relationship between serotonin system deregulation [14] and post-stroke depression, where the negative impact of depression on stroke-related outcomes includes slower recovery, presence of recurrent vascular accidents, lower quality of life, and higher mortality [40].
All the time, the search is ongoing for methods that will respond to the expectations of patients and their relatives while at the same time working multifacetedly using all the possible reserves of the body.
Mosiejczuk et al. [41] showed that significantly better results were obtained in patients participating in the full rehabilitation program after stroke for 4 weeks than patients participating in therapeutic sessions for 2 weeks. Rehabilitation using the PNF method is an effective form of achieving functional improvement in patients after stroke. However, these results cannot be fully applied to our study since, although the age range of the patients was similar, the daily dose of rehabilitation was not specified. It was also shown that the rehabilitation led to significant functional improvement and that better results were obtained by patients after 6 weeks than after 3 weeks of rehabilitation, demonstrating the need for prolonged improvement.
On the other hand, Kaniewski et al. [42] proved that the PNF method improves the condition of patients in the acute phase of stroke and that the degree of disability assessed by the mRS significantly decreased. Furthermore, significant improvement was observed in the patients’ overall disability score after the PNF method compared to the pre-therapy results (3.65 vs. 1.8; p < 0.05). This was corroborated in our study, where patients scored by the mRS had an average of 3.5 points, and after 6 weeks, an average of 1.2 points.
Olak et al. [43] evaluated the dynamics of motor recovery in acute and subacute ischemic stroke patients undergoing the PNF method using Rivermead Motor Assessment (RMA), National Institutes of Health Stroke Scale (NIHSS), BI, and RS. They observed statistically significant improvement for the study group in functional assessment and independence. The summary scores according to the BI at the beginning of therapy were: 9.30 ± 6.80, and at the end of therapy, 16.86 ± 4.32 points. mRS score 3.78 ± 0.76 vs. 2.45 ± 0.86. It should be noted that our findings are difficult to relate explicitly to the findings by Olak et al. [43], since the patients were rehabilitated in the acute and subacute periods in this study (regenerative-compensatory period). In addition, the participants in our project underwent a full rehabilitation program lasting 42 days (6 weeks) rather than 56 days or longer. The daily dose of exercise therapy, occupational therapy, and classes with a psychologist and a neurologist were identical to those in the discussed publication by Olak et al. [43]. However, in summary—despite the methodological differences—the conclusions are similar. Moreover, in our study, even though the patients’ improvement time was only 42 days, functional status and independence improvements were achieved.
Our study shows that post-stroke patients rehabilitated in our project (PNF and MT methods) achieved significant improvement in functional status as assessed with BI. Similar results were obtained by Starosta et al. [37], who noted that the applied program of comprehensive neurorehabilitation led to functional improvement based on the ADL scale by 32% (36% in women, 30% in men) and on the mRS by 22% (22% in women, 21% in men).
The presented results of our study correspond with the study by Jankowska et al. [44], who evaluated the effectiveness of comprehensive in-hospital neurorehabilitation of ischemic stroke patients who achieved significantly greater improvements in functional status compared to patients who improved in an ambulatory setting. Everyday rehabilitation of patients using both the PNF and MT methods for 6 weeks after ischemic strokes affects the recovery of lost motor functions. An interdisciplinary team provides intensive, individualized neurological physiotherapy results in better functional therapy outcomes.
In addressing the results of MT (despite the considerable number of papers and systematic reviews on the use of this method to evaluate the effectiveness of this simple and low-cost method with a post-stroke patient-centered treatment that can improve upper limb function) to other research papers, it should be kept in mind that this is quite difficult, as in reviewing the literature, no similar studies as in our project evaluating the effectiveness of MT were found. Based on the literature review on MT implemented in patients after a first-ever ischemic stroke, it can be noted that most studies do not meet the fair methodological quality and present limited level of evidence. It makes difficult to incorporate the clinical efficacy of MT in daily neurorehabilitation practice. These papers did not use a well-established qualification protocol or proper randomization, and the studies were often conducted based only on subjective questionnaires and pain sensation scales (no measurement methods to objectify treatment progress).
In a review article, Thieme et al. [28] emphasized the potential of MT to aid in the motor recovery of post-stroke patients, which would in turn improve ADL quality, decrease their level of pain, and lessen the impact of visuospatial neglect. The authors analyzed 14 articles on the MT effectiveness among a group of 567 post-stroke participants. It was confirmed that the use of MT affected motor recovery in post-stroke patients and facilitated ADL performance. In contrast, the authors noted that visuospatial neglect in post-stroke patients was not significantly improved.
In the available literature on the subject discussed, only one Polish paper can be found. Radajewska et al. [22] evaluated the use of an MT in hand rehabilitation in 60 patients with upper limb hemiparesis after stroke. The study patients were divided into two groups of 30 patients each: one received comprehensive neurorehabilitation and second received additional MT (five days a week, two 15-min sessions a day for 21 days). The function of the upper limb paresis was assessed using two functional tests: Frenchay Arm Test (FAT) and the “Repty” Functional Index (RFI), performed at admission and after 21 days. It was shown that patients who underwent MT presented greater degree of hand function recovery. In our study, patients were rehabilitated during the recovery-compensation period. In addition, the participants in our study underwent a complete rehabilitation program lasting 42 days (6 weeks) rather than 21 days. The BI scores in the MT group in three consecutive measurements (M1, M2, M3) were statistically significant differences (main effect: p < 0.05). There was an improvement in BI scores in the MT group between measurements M1 and M2 by 3.6 points, M1 and M3 by 6.9 points, and M2 and M3 by 6.9 points. In the above-mentioned study, the measurements of M1 vs. M2 were made at admission and after 3 weeks of rehabilitation; however, our results indicate that the rehabilitation period should last 6 weeks.
As can be seen from the above discussion, a study in this field including both PNF and MT methods, randomization, consistent study material, a strict protocol for qualification, subjective and objective measurement tools, and early results were warranted. To further strengthen the scientific evidence, it is recommended that the collected data be independently confirmed by other institutions. Recently, there are still limited evidence of high scientific merit to unequivocally prejudge the effectiveness of PNF therapy over MT or vice versa in patients after a first ischemic stroke. At the moment, the results of the studies so far are promising, but this fact needs further verification.

Study Limitations

There are several limitations of this study to be explained. First of all, the absence on negative control group consisted of patients undergoing only standard neurorehabilitation management (with no PNF and MT) is an important limitation. The absence of blinding does not exclude that the results are affected by observer bias. In future studies, there is a need for the use other objective measurement methods and continue the project with a larger number of participants and for a more extended period (follow-up). An important aspect is to establish standardized treatment parameters other research studies can verify. Moreover, it would also be beneficial to expand the assessment of disability to include other questionnaires and scales, such as FIM or RFI.

5. Conclusions

Both PNF and MT neurorehabilitation methods could be useful for improving functional status and reducing disability level in patients after first-ever stroke during the regenerative-compensatory stage.

Author Contributions

Conceptualization, W.B., E.M.-C. and J.R.; methodology, W.B., K.P., E.M.-C. and J.R.; software, W.B. and K.P.; validation, W.B., E.M.-C. and K.P.; formal analysis, W.B. and K.P.; investigation, W.B. and E.M.-C.; resources, W.B., K.P. and J.R.; data curation, W.B. and E.M.-C.; writing—original draft preparation, W.B., K.P., E.M.-C. and J.R.; writing—review and editing, W.B., K.P., E.M.-C. and J.R.; visualization, W.B. and K.P.; supervision, E.M.-C. and J.R.; project administration, W.B. and E.M.-C.; funding acquisition, E.M.-C. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the internal grant of University School of Physical Education in Wrocław, Poland (project no. 503 62/05): Effectiveness of various therapeutic forms and their influence on nervous, muscular and vascular plasticity in patients after ischemic stroke.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Bioethics Committee of the Wroclaw Medical University in Poland (approval no. KB-813/2020).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Acknowledgments

We would like to thank all the patients participated in this study.

Conflicts of Interest

The authors declare no conflict of interest.

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Sustainability 14 15246 g001 550
Figure 1. Comparison between MT and PNF groups. regarding changes in BI scores on three measurements (M1, M2, and M3) and in mRS scores on two measurements (M1 and M2).
Figure 1. Comparison between MT and PNF groups. regarding changes in BI scores on three measurements (M1, M2, and M3) and in mRS scores on two measurements (M1 and M2).
Sustainability 14 15246 g001
Table
Table 1. Study group characteristics.
Table 1. Study group characteristics.
VariableMT (n = 24)PNF (n = 26)p-Value
x - MeMinMaxQ1Q3SD x - MeMinMaxQ1Q3SD
Age [years]65.568.148.182.059.772.39.466.965.553.282.060.275.38.70.590 a
Body height [cm]169.0171.0150.0180.0163.5175.58.0166.8168.0150.0186.0161.0172.09.30.371 a
Body mass [kg]74.173.546.0108.057.588.017.673.473.550.092.067.082.011.00.853 a
BMI [kg/m2]25.926.016.335.421.629.05.226.326.220.531.223.729.73.20.669 a
Stroke onset (days)23.622.519.029.022.025.02.5524.124.018.030.022.025.02.970.636 a
NIHSS score (pts.)17.017.016.019.016.018.01.0417.217.016.019.016.018.01.120.546 a
SexF–n = 8; 33.3%
M–n = 16; 66.7%		F–n = 8; 30.8%
M–n = 18; 69.2%		0.846 b
Tabaco smokeNo–n = 15; 62.5%
Yes–n = 9; 37.5%		No–n = 16; 61.5%
Yes–n = 10; 38.5%		0.944 b
Diabetes mellitusNo–n = 16; 66.7%
Yes–n = 8; 33.3%		No–n = 16; 61.5%
Yes–n = 10; 38.5%		0.706 b
HypertensionNo–n = 5; 20.8%
Yes–n = 19; 79.2%		No–n = 7; 26.9%
Yes–n = 19; 73.1%		0.614 b
Hypolipidemic drugs (Atorvasterol)40 mg–n = 22; 91.7%
60 mg–n = 2; 8.3%		40 mg–n = 24; 92.3%
60 mg–n = 2; 7.7%		0.933 a
Anticoagulant
drugs (Clexane)		40 mg/0.4 mL–n = 22; 91.7%
60 mg/0.6 mL–n = 2; 8.3%		40 mg/0.4 mL–n = 24; 92.3%
60 mg/0.6 mL–n = 2; 7.7%		0.933 a
Notes: a Mann-Whitney U test; b chi-square test. Abbreviations: MT, mirror therapy; PNF, proprioceptive neuromuscular facilitation; n, number of participants; F, female; M, male; x - , mean; Me, median; Min, minimal value; Max, maximal value; Q1, lower quartile; Q3, upper quartile; SD, standard deviation.
Table
Table 2. Comparison of changes in BI scores on three measurements (M1, M2, and M3) in the MT and PNF groups.
Table 2. Comparison of changes in BI scores on three measurements (M1, M2, and M3) in the MT and PNF groups.
VariableMMT (n = 24)PNF (n = 26)
x - MeMinMaxQ1Q3SD x - MeMinMaxQ1Q3SD
BIM19.79.07.013.08.511.01.69.59.07.013.09.010.01.6
M213.313.012.016.012.514.01.213.613.012.016.012.015.01.4
M316.617.015.018.016.017.01.016.716.514.019.016.017.01.3
p-value
(main effect) a		<0.001<0.001
p-value
(multiple comparisons) b		M1 vs. M2: p < 0.001
M1 vs. M3: p < 0.001
M2 vs. M3: p < 0.001		M1 vs. M2: p < 0.001
M1 vs. M3: p < 0.001
M2 vs. M3: p < 0.001
Notes: a Friedman’s ANOVA; b Dunn’s test. Abbreviations: BI, Barthel Index, MT, mirror therapy; PNF, proprioceptive neuromuscular facilitation; n, number of participants; x - , mean; Me, median; Min, minimal value; Max, maximal value; Q1, lower quartile; Q3, upper quartile; SD, standard deviation.
Table
Table 3. Comparison of changes in RS scores on two measurements (M1 and M2) in the MT and PNF groups.
Table 3. Comparison of changes in RS scores on two measurements (M1 and M2) in the MT and PNF groups.
VariableMMT (n = 24)PNF (n = 26)
x - MeMinMaxQ1Q3SD x - MeMinMaxQ1Q3SD
mRSM13.53.53.04.03.04.00.53.53.03.04.03.04.00.5
M21.31.01.02.01.02.00.51.21.01.02.01.01.00.4
p-value
(main effect) a		<0.001<0.001
Notes: a Wilcoxon test. Abbreviations: mRS, modified Rankin Scale, MT, mirror therapy; PNF, proprioceptive neuromuscular facilitation; n, number of participants; x - , mean; Me, median; Min, minimal value; Max, maximal value; Q1, lower quartile; Q3, upper quartile; SD, standard deviation.
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Borowicz, W.; Ptaszkowski, K.; Murawska-Ciałowicz, E.; Rosińczuk, J. Proprioceptive Neuromuscular Facilitation and Mirror Therapy Methods Are Comparable Methods of Rehabilitation after a First-Ever Ischemic Stroke: A Randomized Study. Sustainability 2022, 14, 15246. https://0-doi-org.brum.beds.ac.uk/10.3390/su142215246

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Borowicz W, Ptaszkowski K, Murawska-Ciałowicz E, Rosińczuk J. Proprioceptive Neuromuscular Facilitation and Mirror Therapy Methods Are Comparable Methods of Rehabilitation after a First-Ever Ischemic Stroke: A Randomized Study. Sustainability. 2022; 14(22):15246. https://0-doi-org.brum.beds.ac.uk/10.3390/su142215246

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Borowicz, Wojciech, Kuba Ptaszkowski, Eugenia Murawska-Ciałowicz, and Joanna Rosińczuk. 2022. "Proprioceptive Neuromuscular Facilitation and Mirror Therapy Methods Are Comparable Methods of Rehabilitation after a First-Ever Ischemic Stroke: A Randomized Study" Sustainability 14, no. 22: 15246. https://0-doi-org.brum.beds.ac.uk/10.3390/su142215246

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