Journal of Applied Holistic Nursing Science, e-ISSN 3090-1316 Vol.
No.
June 2025 https://doi.
org/10.
70920/jahns.
Original Research/Systematic Review The Application of Mirror Therapy in Ischemic Stroke Patients with Hemiparesis to Improve Upper Extremity Muscle Strengt Shafira Youanita Gunawan1.
Anggri Noorana Zahra1 Faculty of Nursing.
Universitas Indonesia.
Indonesia
ABSTRACT
Background: Ischemic stroke is one of the leading causes of disability worldwide, with hemiparesis being the most common clinical manifestation after stroke.
Hemiparesis may reduce muscle strength and increase the risk of complications such as joint contractures Methods: This study aimed to evaluate the effectiveness of mirror therapy in improving upper extremity muscle strength in a 45-year-old male patient with ischemic stroke and left-sided A case study design was used, with the intervention carried out over five consecutive days.
The therapy consisted of adaptation exercises, basic movements, variations, and combination exercises, each repeated eight times.
ARTICLE HISTORY
Received : 12-6-2025 Accepted : 16-6-2025.
KEYWORDS
mirror therapy.
muscle strength.
CONTACT
Shafira Youanita Gunawan youanita@gmail.
Faculty of Nursing.
Universitas Indonesia.
Indonesia Results: The evaluation showed an improvement in upper extremity muscle strength from a score of 5555 | 4432 to 5555 | Additionally, there were no observed decreases in physical tolerance or therapy-related injuries.
Conclusion: These findings suggest that mirror therapy is an effective, safe, and feasible rehabilitation intervention that can be implemented by nursing professionals in clinical settings for stroke patients with hemiparesis.
Cite this as: Shafira Youanita Gunawan.
Anggri Noorana Zahra .
The Application of Mirror Therapy in Ischemic Stroke Patients with Hemiparesis to Improve Upper Extremity Muscle Strengt.
Journal of Applied Holistic Nursing Science,1.
https://doi.
org/10.
70920/jahns.
INTRODUCTION
Cerebrovascular accident (CVA), or stroke, is a general term for functional disturbances of the central nervous system (CNS) caused by an interruption of blood supply to the brain (Hinkle & Cheever, 2.
According to Hinkle and Cheever .
, stroke can be divided into two main categories: ischemic stroke .
ccurring in approximately 87% of case.
and hemorrhagic stroke .
ccurring in approximately 13% of case.
These two types differ in terms of etiology, pathophysiology, management, and nursing care provided.
In 2020, there were approximately 89.
1 million cases of stroke worldwide, including 2 million ischemic strokes, 18.
9 million intracerebral hemorrhages, and 8.
1 million subarachnoid hemorrhages.
Stroke-related deaths globally reached 7.
1 million (American Heart Association, 2.
In Indonesia, the prevalence of stroke was reported to be 2,120,362 cases in 2018 based on data from the Ministry of Health (Kemenkes RI, 2.
Besides being one of the leading causes of mortality, stroke is also a major cause of disability worldwide (Carvalho-Pinto & Faria, 2.
Stroke-related disabilities include impairments in motor and https://jurnal.
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June 2025 sensory function, cranial nerve dysfunction, altered levels of consciousness, and changes in mental status (El Tallawy et al.
, 2015.
Hinkle & Cheever, 2018.
Winstein et al.
, 2.
The most commonly observed condition in stroke patients is hemiparesis (El Tallawy et al.
Carvalho-Pinto & Faria, 2016.
Meena et al.
, 2.
Hinkle and Cheever .
define hemiparesis as a condition where one side of the body experiences weakness due to injury in the brainAos motor area.
Stroke rehabilitation efforts focus on physical, psychological, and social aspects (Stewart et al.
, 2.
The success of stroke rehabilitation is influenced by several factors, including stroke severity, type and location of the stroke, and the patientAos general condition before and after the event.
One of the rehabilitation strategies to prevent joint contractures in stroke patients with hemiparesis is mirror therapy (Hardiyanti, 2013.
Samuelkamaleshkumar et al.
, 2014.
Shih et al.
Mirror therapy is performed by placing a mirror along the patientAos midsagittal plane.
Figure 1.
Mirror Therapy (Corbetta et al.
, 2.
After the mirror is placed between the weakened extremities, the patient is instructed to perform range of motion (ROM) exercises (Shih et al.
, 2.
The ROM exercises implemented during mirror therapy consist of adaptation exercises, basic movement exercises, variation exercises, and combination exercises.
These exercises follow the Bonner protocol as outlined in Table 1.
Exercise Phase Adaptation exercise Counting Finger AbductionAdduction Basic Movement Exercises Elbow flexion Elbow extension Shoulder internal/ external rotation Variation Exercises PronationAe Supination Grip Prehension Finger counting Finger opposition Combination Exercises Table 1.
Bonner Protocol Movement description Performed when the patient is not yet accustomed to the mirror reflection.
Both hands are placed on the table.
extend each finger one by one or lift several fingers simultaneously.
Both hands are placed on the table.
perform abduction starting from the thumb followed by the index finger, and so on.
For adduction, start from the little finger followed by the ring finger, and so on.
Performed when the patient can focus on the mirror image and has completed the adaptation phase.
Position 1: Both forearms are placed on the table.
Position 2: Forearms are raised 45A with elbows resting on the table.
Position 3: Both forearms form a 90A angle with the Straighten the arms from the flexion position.
Posisi 1: Geser lengan bawah mendekati badan.
posisi 2: Kembali ke tengah.
posisi 3:
Menjauhi badan.
Dilakukan setelah pasien mampu melakukan gerak dasar terus-menerus.
Posisi 1: telapak ke bawah.
Posisi 2: telapak setengah terbuka.
Posisi 3: telapak ke Place both hands on the table and perform the following: grip both hands.
grip with thumb inside .
humb-in-pal.
hook grip .
alf-flexed finger.
finger extension .
traight and close togethe.
finger abduction .
traight and spread ou.
Count by lifting fingers one at a time in sequence.
Touch the thumb to each finger alternately.
A combination of two movements performed simultaneously.
Example: elbow flexion while gripping.
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June 2025 Mirror therapy can be applied to post-stroke patients with hemiparesis who are in generally stable condition (Shih et al.
, 2017.
Thieme et al.
, 2.
Gandhi et al.
stated that mirror therapy may be used in patients with a range of motion (ROM) from active to passive.
However, contraindications for mirror therapy include patients with cognitive impairments, visual disturbances, severe cardiopulmonary disorders, or other medical conditions that may interfere with functional activities or the ability to perform exercises (Hardiyanti et al.
, 2013.
Shih et al.
, 2.
According to a study by Thieme et al.
, mirror therapy has been proven effective as a rehabilitative intervention for post-stroke patients in the acute, subacute, and chronic phases.
Based on previous research, mirror therapy is a feasible procedure that can be implemented for stroke patients with hemiparesis.
The researchers believe that mirror therapy can be performed by nurses as part of nursing care for patients in the acute phase of stroke, such as the case of Mr.
Therefore, further evaluation is necessary to determine whether the procedure can effectively improve muscle strength, particularly in the upper extremities.
MATERIALS AND METHOD
This study employed a case study design using an evidence-based intervention approach.
The subject was Mr.
R, a patient diagnosed with ischemic stroke accompanied by left-sided The intervention applied was mirror therapy, which consisted of four phases:
adaptation exercises, basic movement exercises, variation exercises, and combination exercises.
Each exercise in every phase was performed in eight repetitions.
Mirror therapy was carried out in front of a flat mirror measuring 30 x 20 cm, placed along the patientAos midsagittal plane.
Each session lasted approximately 30 minutes and was conducted once daily for five consecutive days.
Nursing evaluations were conducted over the five-day intervention period and focused on two main aspects: .
changes in upper extremity muscle strength, and .
assessment of the patientAos physical tolerance before and after each mirror therapy session.
Physical tolerance parameters included monitoring of systolic and diastolic blood pressure, mean arterial pressure (MAP), pulse rate, respiratory rate, and oxygen saturation.
RESULTS
On the fourth day of hospitalization, initial assessment of Mr.
R revealed blood pressure of 131/81 mmHg, pulse rate of 83 beats per minute, capillary refill time (CRT) under 2 seconds, warm extremities, no edema, strong and regular peripheral pulses, and absence of paresthesia.
Notably, the patient experienced muscle weakness on the left side, particularly in the left arm, with an inability to grip using the left hand.
Muscle strength assessment showed scores of 5555 | 4432 .
pper extremitie.
and 5555 | 4444 .
ower extremitie.
Passive range of motion (ROM) examination indicated limitations in the thenar and hypothenar muscles of the left hand.
Facial asymmetry was observed, and the patient reported a throbbing headache on the right side.
The patient had a history of ischemic stroke in 2020 and admitted to noncompliance with antihypertensive medications.
Laboratory results showed elevated LDL cholesterol at 133 mg/dL.
MRI and MRA imaging revealed chronic lacunar infarcts in the periventricular white matter of the bilateral posterior horns, bilateral thalamus, suspected thrombus in the internal carotid artery, and severe stenosis of the left middle cerebral artery (M1 segmen.
Based on this assessment, the primary nursing diagnosis was impaired physical mobility related to decreased muscle strength.
Mirror therapy intervention was performed daily for five consecutive days, with monitoring of physical tolerance before and after each session.
This included measuring systolic and diastolic blood pressure.
MAP, pulse rate, respiratory rate, and oxygen Pre-intervention measurements from November 7Ae11, 2023, showed systolic blood pressure ranging from 122Ae132 mmHg, diastolic pressure from 72Ae85 mmHg.
MAP from 89Ae101 mmHg, and pulse rate from 73Ae88 bpm.
Post-intervention measurements showed systolic pressure of 124Ae https://jurnal.
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June 2025 134 mmHg, diastolic pressure of 76Ae87 mmHg.
MAP of 93Ae102 mmHg, and pulse rate of 76Ae87 Respiratory rate ranged from 18Ae21 breaths/min before the intervention and 18Ae22 breaths/min after.
Oxygen saturation ranged from 97100% before therapy and 98100% Figure 2a.
Trend of the PatientAos Circulatory Status Figure 2b.
Trend of the PatientAos Respiratory Status Muscle strength in the left upper limb was evaluated daily and showed progressive improvement over the five days.
Initial strength was 5555 | 4432 and improved to 5555 | 4443 by the fifth day, as presented in the table below:
Date
07/11/2023
08/11/2023
09/11/2023
10/11/2023
11/11/2023
Table 2.
Upper and Lower Extremity Muscle Strength Progression Right Arm Left Arm Right Leg Left Leg These findings suggest that mirror therapy contributed to the gradual improvement of muscle strength in the patientAos affected upper extremity without any adverse effects or decrease in physical https://jurnal.
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DISCUSSION
Ischemic stroke is caused by the blockage of cerebral blood vessels by a thrombus or embolus, leading to a reduction in cerebral blood flow, and subsequently, decreased oxygen and glucose supply.
This results in cellular ischemia and ultimately cerebral infarction (Black & Hawks.
Hammond & Zimmermann, 2.
According to Lewis et al.
and LeMone .
, stroke risk factors are classified into modifiable and non-modifiable factors.
Non-modifiable factors include age and gender, with individuals over 55 years being twice as likely to experience a stroke, and males being more frequently affected.
Modifiable factors are closely related to lifestyle and the quality of medical care received.
In this case, after being diagnosed with hypertension, the patient admitted to not regularly taking prescribed medication.
Poorly controlled hypertension increases the risk of recurrent stroke.
Therefore, blood pressure control is critical in stroke prevention.
Cholesterol, although essential in bodily functions, can also pose a threat to cerebral vasculature when present in excessive amounts.
Uzuner and Uzuner .
identified hyperlipidemia as one of the risk factors for recurrent stroke.
While considered a minor risk factor for recurrent ischemic stroke, hyperlipidemia should be addressed to prevent recurrence.
Excess LDL cholesterol may lead to the formation of plaques that can obstruct cerebral arteries (Ariani et al.
, 2023.
Koosgiarto & Salim, 2.
Collaborative administration of antiplatelet agents for Mr.
R aimed to prevent recurrent Clopidogrel, the antiplatelet prescribed, binds specifically and irreversibly to the P2RY12 purinergic receptors on platelets, inhibiting ADP-mediated platelet activation and aggregation (Sangkuhl et al.
, 2010.
Kamarova et al.
, 2.
The use of antihypertensive and statin medications was intended to control both blood pressure and LDL cholesterol levels.
Statins have been shown to improve functional outcomes in ischemic stroke patients (Alexxander & Pinzon, 2.
MRI and MRA results for Mr.
R revealed chronic lacunar infarcts in the periventricular area of the bilateral posterior horns and thalamus, suspected thrombus in the internal carotid artery, and severe stenosis of the left middle cerebral artery (M1 segmen.
According to Uzuner and Uzuner .
, large artery occlusion and lacunar infarction are significant risk factors for stroke recurrence.
Stenosis in the middle cerebral artery increases the likelihood of another stroke.
To address impaired physical mobility, mirror therapy was used in conjunction with monitoring of physical tolerance through vital sign checks before and after each session.
The intervention showed positive outcomes, with an increase in upper extremity muscle strength from 5555 | 4432 to 5555 | 4443 after five days of therapy.
Stevens and Stoykov .
demonstrated that muscle activation in the ipsilateral motor cortex can be stimulated by observing the mirrored movement of the unaffected hand.
When the right hand is used and perceived visually as the left, increased activation in the right hemisphere occurs, and vice versa.
The mirror image stimulates the contralateral hemisphere of the perceived limb, thus enhancing cortical muscle stimulation (Thieme et al.
, 2.
The findings from this case are consistent with the results reported by Maisyaroh et al.
, who found that mirror therapy effectively increased muscle strength in stroke patients with Setiyawan et al.
also confirmed that mirror therapy significantly improved upper limb muscle strength in patients with non-hemorrhagic stroke.
Additionally, monitoring of physical tolerance before and after therapy is crucial to assess fatigue levels and prevent complications such as injury (Doenges et al.
, 2.
In line with World Health Organization (WHO) recommendations for simple and safe rehabilitation methods for stroke patients with hemiparesis, mirror therapy is a cost-effective and safe intervention (Suaib & Kurniawan, 2022.
Thieme et al.
This was further supported by the stable vital signs observed in Mr.
R before and after therapy, indicating no reduction in physical tolerance or occurrence of injuries.
Brainin and Heiss .
also reported that mirror therapy, when administered over a six-month period, did not produce any adverse effects.
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CONCLUSION
Ischemic stroke is a condition in which a cerebral blood vessel becomes obstructed by a thrombus or embolus, resulting in reduced blood flow and, consequently, decreased oxygen and glucose supply.
This leads to cellular ischemia and ultimately cerebral infarction.
An obstruction in the frontal lobe, specifically in Brodmann area 4 along the pyramidal tract, can cause Prolonged hemiparesis may lead to complications such as joint contractures.
In this case study, the intervention applied by the researcher to improve muscle strength and prevent joint contractures was the implementation of mirror therapy.
Evaluation of the five-day mirror therapy intervention in a patient with ischemic stroke and hemiparesis demonstrated a successful increase in upper extremity muscle strength.
Moreover, the procedure was well tolerated, caused no adverse effects, and proved to be relatively simple to administer.
Conclusion: These findings suggest that mirror therapy is an effective, safe, and feasible rehabilitation intervention that can be implemented by nursing professionals in clinical settings for stroke patients with hemiparesis.
REFERENCES