the validity of our positive findings. We look forward to further studies to confirm our findings, and to discover new predictors of dementia. © 2015 American Academy of Neurology 1.
2.
3.
4.
5.
6.
Anang JB, Gagnon JF, Bertrand JA, et al. Predictors of dementia in Parkinson disease: a prospective cohort study. Neurology 2014;83:1253–1260. Peduzzi P, Concato J, Kemper E, et al. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996;49:1373–1379. Bagley SC, White H, Golomb BA. Logistic regression in the medical literature: standards for use and reporting, with particular attention to one medical domain. J Clin Epidemiol 2001;54:979–985. Vittinghoff E, McCulloch CE. Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 2007;165:710–718. Scanlon BK, Katzen HL, Levin BE, et al. A formula for the conversion of UPDRS-III scores to Hoehn and Yahr stage. Parkinsonism Relat Disord 2008;14:379–380. Courvoisier DS, Combescure C, Agoritsas T, GayetAgeron A, Perneger TV. Performance of logistic regression modeling: beyond the number of events per variable, the role of data structure. J Clin Epidemiol 2011;64:993–1000.
MIRROR THERAPY IN UNILATERAL NEGLECT AFTER STROKE (MUST TRIAL): A RANDOMIZED CONTROLLED TRIAL
Melissa J. Ng, Prateush Singh, Cambridge, UK: Pandian et al.1 reported that mirror therapy improves unilateral neglect in stroke patients. Mirror therapy has also been shown effective in the treatment of complex regional pain syndrome and phantom limb pain.2 The mechanisms driving these positive effects are unclear. Chan et al.3 proposed that the mechanisms are similar to those suggested by Pandian et al., namely the activation of mirror neurons in the contralateral hemisphere or modification of cortical activity via visual feedback of the imagined action. Other theories of why mirror therapy is effective in conditions with no apparent peripheral cause for pain (such as complex regional pain syndrome and phantom limb pain) suggest that visual illusion of normal, pain-free movement results in cortical reorganization of the homunculus, which reduces pain, or that it corrects the mismatch among motor control, proprioception, and vision.2
It would be interesting to reconcile the cortical mechanisms driving effectiveness of mirror therapy in pain syndromes and neglect in stroke. If this is achieved, mirror therapy could be more widely applied to other cortical conditions aiming to decrease pain or to improve motor function. Author Response: Jeyaraj D. Pandian, Rajni Arora, Paramdeep Kaur, Ludhiana, India: The authors read with interest the comments by Ng and Singh about the effectiveness of mirror therapy in treating unilateral neglect and also about the underlying mechanisms in regards to our article.1 Mirror therapy was first used in the treatment of phantom limb pain.4 The principle of mirror therapy is based on the mirror neuron system. In animal experiments, the mirror neuron system discharges when an animal performs a goal-directed hand action and also when it observes someone else performing a similar action.5 The activation of mirror neuron system leads to recruitment of functionally interconnected cortical structures coupling action execution and observation.6 In the present report, patients were asked to look into a mirror and practice nonparetic side wrist and finger flexion and extension movements, watching the image of their unaffected hand. When the nonparetic limb is engaged during motor training, crossed facilitatory drive from the intact hemisphere will give rise to increased excitability in the homologous motor pathways of the paretic limb, facilitating recovery of function. Similar mechanisms have been postulated in the alleviation of complex regional pain syndrome. © 2015 American Academy of Neurology 1.
2.
3. 4. 5. 6.
Pandian JD, Arora R, Kaur P, et al. Mirror therapy in unilateral neglect after stroke (MUST trial): a randomized controlled trial. Neurology 2014;83:1012–1017. Al Sayegh S, Filen T, Johansson M, et al. Mirror therapy for complex regional pain syndrome (CRPS): a literature review and an illustrative case report. Scand J Pain 2013;4:200–207. Chan BL, Witt R, Charrow AP, et al. Mirror therapy for phantom limb pain. N Engl J Med 2007;357:2206–2207. Ramachandran VS, Rogers-Ramachandran D, Cobb S. Touching the phantom limb. Nature 1995;377:489–490. Buccino G, Binkofski F, Riggio L. The mirror neuron system and action recognition. Brain Lang 2004;89:370–376. Carson RG. Neural pathways mediating bilateral interactions between the upper limbs. Brain Res Brain Res Rev 2005;49:641–662.
Author disclosures are available upon request ([email protected]). 1286
Neurology 84
March 24, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Mirror therapy in unilateral neglect after stroke (MUST trial): A randomized controlled trial Melissa J. Ng, Jeyaraj D. Pandian, Prateush Singh, et al. Neurology 2015;84;1286 DOI 10.1212/01.wnl.0000462978.57606.5a This information is current as of March 23, 2015 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/84/12/1286.full.html
References
This article cites 6 articles, 1 of which you can access for free at: http://www.neurology.org/content/84/12/1286.full.html##ref-list-1
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2015 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
2.
3.
4.
5.
6.
Anang JB, Gagnon JF, Bertrand JA, et al. Predictors of dementia in Parkinson disease: a prospective cohort study. Neurology 2014;83:1253–1260. Peduzzi P, Concato J, Kemper E, et al. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996;49:1373–1379. Bagley SC, White H, Golomb BA. Logistic regression in the medical literature: standards for use and reporting, with particular attention to one medical domain. J Clin Epidemiol 2001;54:979–985. Vittinghoff E, McCulloch CE. Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 2007;165:710–718. Scanlon BK, Katzen HL, Levin BE, et al. A formula for the conversion of UPDRS-III scores to Hoehn and Yahr stage. Parkinsonism Relat Disord 2008;14:379–380. Courvoisier DS, Combescure C, Agoritsas T, GayetAgeron A, Perneger TV. Performance of logistic regression modeling: beyond the number of events per variable, the role of data structure. J Clin Epidemiol 2011;64:993–1000.
MIRROR THERAPY IN UNILATERAL NEGLECT AFTER STROKE (MUST TRIAL): A RANDOMIZED CONTROLLED TRIAL
Melissa J. Ng, Prateush Singh, Cambridge, UK: Pandian et al.1 reported that mirror therapy improves unilateral neglect in stroke patients. Mirror therapy has also been shown effective in the treatment of complex regional pain syndrome and phantom limb pain.2 The mechanisms driving these positive effects are unclear. Chan et al.3 proposed that the mechanisms are similar to those suggested by Pandian et al., namely the activation of mirror neurons in the contralateral hemisphere or modification of cortical activity via visual feedback of the imagined action. Other theories of why mirror therapy is effective in conditions with no apparent peripheral cause for pain (such as complex regional pain syndrome and phantom limb pain) suggest that visual illusion of normal, pain-free movement results in cortical reorganization of the homunculus, which reduces pain, or that it corrects the mismatch among motor control, proprioception, and vision.2
It would be interesting to reconcile the cortical mechanisms driving effectiveness of mirror therapy in pain syndromes and neglect in stroke. If this is achieved, mirror therapy could be more widely applied to other cortical conditions aiming to decrease pain or to improve motor function. Author Response: Jeyaraj D. Pandian, Rajni Arora, Paramdeep Kaur, Ludhiana, India: The authors read with interest the comments by Ng and Singh about the effectiveness of mirror therapy in treating unilateral neglect and also about the underlying mechanisms in regards to our article.1 Mirror therapy was first used in the treatment of phantom limb pain.4 The principle of mirror therapy is based on the mirror neuron system. In animal experiments, the mirror neuron system discharges when an animal performs a goal-directed hand action and also when it observes someone else performing a similar action.5 The activation of mirror neuron system leads to recruitment of functionally interconnected cortical structures coupling action execution and observation.6 In the present report, patients were asked to look into a mirror and practice nonparetic side wrist and finger flexion and extension movements, watching the image of their unaffected hand. When the nonparetic limb is engaged during motor training, crossed facilitatory drive from the intact hemisphere will give rise to increased excitability in the homologous motor pathways of the paretic limb, facilitating recovery of function. Similar mechanisms have been postulated in the alleviation of complex regional pain syndrome. © 2015 American Academy of Neurology 1.
2.
3. 4. 5. 6.
Pandian JD, Arora R, Kaur P, et al. Mirror therapy in unilateral neglect after stroke (MUST trial): a randomized controlled trial. Neurology 2014;83:1012–1017. Al Sayegh S, Filen T, Johansson M, et al. Mirror therapy for complex regional pain syndrome (CRPS): a literature review and an illustrative case report. Scand J Pain 2013;4:200–207. Chan BL, Witt R, Charrow AP, et al. Mirror therapy for phantom limb pain. N Engl J Med 2007;357:2206–2207. Ramachandran VS, Rogers-Ramachandran D, Cobb S. Touching the phantom limb. Nature 1995;377:489–490. Buccino G, Binkofski F, Riggio L. The mirror neuron system and action recognition. Brain Lang 2004;89:370–376. Carson RG. Neural pathways mediating bilateral interactions between the upper limbs. Brain Res Brain Res Rev 2005;49:641–662.
Author disclosures are available upon request ([email protected]). 1286
Neurology 84
March 24, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Mirror therapy in unilateral neglect after stroke (MUST trial): A randomized controlled trial Melissa J. Ng, Jeyaraj D. Pandian, Prateush Singh, et al. Neurology 2015;84;1286 DOI 10.1212/01.wnl.0000462978.57606.5a This information is current as of March 23, 2015 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/84/12/1286.full.html
References
This article cites 6 articles, 1 of which you can access for free at: http://www.neurology.org/content/84/12/1286.full.html##ref-list-1
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2015 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
