Original Article| Volume 23, ISSUE 6, P1319-1326, July 2014

Asymmetric Training Using Virtual Reality Reflection Equipment and the Enhancement of Upper Limb Function in Stroke Patients: A Randomized Controlled Trial


      Asymmetric movements with both hands contributed to the improvement of spatially coupled motion. Thus, the aim of this study was to investigate the effects of an asymmetric training program using virtual reality reflection equipment on upper limb function in stroke patients.


      Twenty-four stroke patients were randomly allocated to an experimental group (n = 12) or a control group (n = 12). Both groups participated in conventional physical therapy for 2×30 min/d, 5 d/wk, for 4 weeks. The experimental group also participated in an asymmetric training program using virtual reality reflection equipment, and the control group participated in a symmetric training program. Both asymmetric and symmetric programs were conducted for 30 min/d, 5 d/wk, for 4 weeks. To compare upper limb function before and after intervention, the Fugl–Meyer Assessment (FMA), the Box and Block Test (BBT), grip strength, range of motion (ROM), and spasticity were assessed.


      Both groups showed significant increases in upper limb function, excepting spasticity, after intervention (P < .05, 1-way repeated-measures analysis of variance [ANOVA]). A significant group–time interaction was demonstrated only for shoulder/elbow/wrist items of FMA, BBT, grip strength, and ROM of wrist flexion, extension, and ulnar deviation (P < .05, 2-way repeated-measures ANOVA).


      This study confirms that the asymmetric training program using virtual reality reflection equipment is an effective intervention method for improving upper limb function in stroke patients. We consider that an additional study based on a program using virtual reflection, which is more functional than performing simple tasks, and consisting of tasks relevant to the activities of daily living be conducted.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Prange G.B.
        • Jannink M.J.
        • Groothuis-Oudshoorn C.G.
        • et al.
        Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after stroke.
        J Rehabil Res Dev. 2006; 43: 171-184
        • Kim P.
        • Warren S.
        • Madill H.
        • et al.
        Quality of life of stroke survivors.
        Qual Life Res. 1999; 8: 293-301
        • Trombly C.A.
        • Radomski M.V.
        • Trexel C.
        • et al.
        Occupational therapy and achievement of self-identified goals by adults with acquired brain injury: phase II.
        Am J Occup Ther. 2002; 56: 489-498
        • Yavuzer G.
        • Selles R.
        • Sezer N.
        • et al.
        Mirror therapy improves hand function in subacute stroke: a randomized controlled trial.
        Arch Phys Med Rehabil. 2008; 89: 393-398
        • Langhorne P.
        • Coupar F.
        • Pollock A.
        Motor recovery after stroke: a systematic review.
        Lancet Neurol. 2009; 8: 741-754
        • Krebs H.I.
        • Mernoff S.
        • Fasoli S.E.
        • et al.
        A comparison of functional and impairment-based robotic training in severe to moderate chronic stroke: a pilot study.
        NeuroRehabilitation. 2008; 23: 81-87
        • Platz T.
        • Eickhof C.
        • van Kaick S.
        • et al.
        Impairment-oriented training or Bobath therapy for severe arm paresis after stroke: a single-blind, multicentre randomized controlled trial.
        Clin Rehabil. 2005; 19: 714-724
        • Ring H.
        • Rosenthal N.
        Controlled study of neuroprosthetic functional electrical stimulation in sub-acute post-stroke rehabilitation.
        J Rehabil Med. 2005; 37: 32-36
        • Masiero S.
        • Celia A.
        • Rosati G.
        • et al.
        Robotic-assisted rehabilitation of the upper limb after acute stroke.
        Arch Phys Med Rehabil. 2007; 88: 142-149
        • Summers J.J.
        • Kagerer F.A.
        • Garry M.I.
        • et al.
        Bilateral and unilateral movement training on upper limb function in chronic stroke patients: a TMS study.
        J Neurol Sci. 2007; 252: 76-82
        • Page S.J.
        • Levine P.
        • Leonard A.
        • et al.
        Modified constraint-induced therapy in chronic stroke: results of a single-blinded randomized controlled trial.
        Phys Ther. 2008; 88: 333-340
        • Kim D.G.
        • Cho Y.W.
        • Hong J.H.
        • et al.
        Effect of constraint-induced movement therapy with modified opposition restriction orthosis in chronic hemiparetic patients with stroke.
        NeuroRehabilitation. 2008; 23: 239-244
        • Lin K.C.
        • Wu C.Y.
        • Wei T.H.
        • et al.
        Effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional performance after chronic stroke: a randomized controlled study.
        Clin Rehabil. 2007; 21: 1075-1086
        • Hu X.L.
        • Tong K.Y.
        • Song R.
        • et al.
        A comparison between electromyography-driven robot and passive motion device on wrist rehabilitation for chronic stroke.
        Neurorehabil Neural Repair. 2009; 23: 837-846
        • Blanton S.
        • Wolf S.L.
        An application of upper-extremity constraint-induced movement therapy in a patient with subacute stroke.
        Phys Ther. 1999; 79: 847-853
        • Liepert J.
        • Hamzei F.
        • Weiller C.
        Motor cortex disinhibition of the unaffected hemisphere after acute stroke.
        Muscle Nerve. 2000; 23: 1761-1763
        • Jack D.
        • Boian R.
        • Merians A.S.
        • et al.
        Virtual reality-enhanced stroke rehabilitation.
        IEEE Trans Neural Syst Rehabil Eng. 2001; 9: 308-318
        • Rizzo A.A.
        • Bowerly T.
        • Buckwalter J.G.
        • et al.
        A virtual reality scenario for all seasons: the virtual classroom.
        CNS Spectr. 2006; 11: 35-44
        • Ramachandran V.S.
        • Rogers-Ramachandran D.
        Synaesthesia in phantom limbs induced with mirrors.
        Proc Biol Sci. 1996; 263: 377-386
        • Altschuler E.L.
        • Wisdom S.B.
        • Stone L.
        • et al.
        Rehabilitation of hemiparesis after stroke with a mirror.
        Lancet. 1999; 353: 2035-2036
        • Sathian K.
        • Greenspan A.I.
        • Wolf S.L.
        Doing it with mirrors: a case study of a novel approach to neurorehabilitation.
        Neurorehabil Neural Repair. 2000; 14: 73-76
        • Stevens J.A.
        • Stoykov M.E.
        Using motor imagery in the rehabilitation of hemiparesis.
        Arch Phys Med Rehabil. 2003; 84: 1090-1092
        • Dohle C.
        • Pullen J.
        • Nakaten A.
        • et al.
        Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial.
        Neurorehabil Neural Repair. 2009; 23: 209-217
        • Lee M.M.
        • Cho H.Y.
        • Song C.H.
        The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients.
        Am J Phys Med Rehabil. 2012; 91: 689-696
        • Kim H.J.
        • Lee G.H.
        • Song C.H.
        Effect of functional electrical stimulation with mirror therapy on upper extremity motor function in poststroke patients.
        J Stroke Cerebrovasc Dis. 2013; 23: 655-661
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Welmer A.K.
        • Holmqvist L.W.
        • Sommerfeld D.K.
        Hemiplegic limb synergies in stroke patients.
        Am J Phys Med Rehabil. 2006; 85: 112-119
        • Saghaei M.
        Random allocation software for parallel group randomized trials.
        BMC Med Res Methodol. 2004; 4: 26
        • Graham J.V.
        • Eustace C.
        • Brock K.
        • et al.
        The Bobath concept in contemporary clinical practice.
        Top Stroke Rehabil. 2009; 16: 57-68
        • Grünert-Plüss N.
        • Hufschmid U.
        • Santschi L.
        • et al.
        Mirror therapy in hand rehabilitation: a review of the literature, the St Gallen protocol for mirror therapy and evaluation of a case series of 52 patients.
        Br J Hand Therapy. 2008; 13: 4-11
        • Fugl-Meyer A.R.
        • Jaasko L.
        • Leyman I.
        • et al.
        The post-stroke hemiplegic patient. 1. A method for evaluation of physical performance.
        Scand J Rehabil Med. 1975; 7: 13-31
        • Duncan P.W.
        • Propst M.
        • Nelson S.G.
        Reliability of the Fugl-Meyer Assessment of sensorimotor recovery following cerebrovascular accident.
        Phys Ther. 1983; 63: 1606-1610
        • Mathiowetz V.
        • Volland G.
        • Kashman N.
        • et al.
        Adult norms for the Box and Block Test of manual dexterity.
        Am J Occup Ther. 1985; 39: 386-391
        • Platz T.
        • Pinkowski C.
        • van Wijck F.
        • et al.
        Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study.
        Clin Rehabil. 2005; 19: 404-411
        • Napier J.R.
        The prehensile movements of the human hand.
        J Bone Joint Surg Br. 1956; 38-B: 902-913
        • Fess E.E.
        Guidelines for evaluating assessment instruments.
        J Hand Ther. 1995; 8: 144-148
        • Sloan R.L.
        • Sinclair E.
        • Thompson J.
        • et al.
        Inter-rater reliability of the modified Ashworth Scale for spasticity in hemiplegic patients.
        Int J Rehabil Res. 1992; 15: 158-161
        • Gregson J.M.
        • Leathley M.
        • Moore A.P.
        • et al.
        Reliability of the Tone Assessment Scale and the modified Ashworth scale as clinical tools for assessing poststroke spasticity.
        Arch Phys Med Rehabil. 1999; 80: 1013-1016
        • van de Pol R.J.
        • van Trijffel E.
        • Lucas C.
        Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review.
        J Physiother. 2010; 56: 7-17
        • Nirkko A.C.
        • Ozdoba C.
        • Redmond S.M.
        • et al.
        Different ipsilateral representations for distal and proximal movements in the sensorimotor cortex: activation and deactivation patterns.
        Neuroimage. 2001; 13: 825-835
        • Lazarus J.-A.C.
        • Whitall J.
        • Franks C.A.
        Isometric force regulation in children.
        J Exp Child Psychol. 1995; 60: 245-260
        • Kelso J.A.
        • Southard D.L.
        • Goodman D.
        On the coordination of two-handed movements.
        J Exp Psychol Hum Percept Perform. 1979; 5: 229-238
        • Kelso J.A.
        • Putnam C.A.
        • Goodman D.
        On the space-time structure of human interlimb co-ordination.
        Q J Exp Psychol A. 1983; 35: 347-375
        • Renner C.I.
        • Woldag H.
        • Atanasova R.
        • et al.
        Change of facilitation during voluntary bilateral hand activation after stroke.
        J Neurol Sci. 2005; 239: 25-30
        • Sutbeyaz S.
        • Yavuzer G.
        • Sezer N.
        • et al.
        Mirror therapy enhances lower-extremity motor recovery and motor functioning after stroke: a randomized controlled trial.
        Arch Phys Med Rehabil. 2007; 88: 555-559
        • Ertelt D.
        • Small S.
        • Solodkin A.
        • et al.
        Action observation has a positive impact on rehabilitation of motor deficits after stroke.
        Neuroimage. 2007; 36: T164-T173
        • Cowles T.
        • Clark A.
        • Mares K.
        • et al.
        Observation-to-imitate plus practice could add little to physical therapy benefits within 31 days of stroke: translational randomized controlled trial.
        Neurorehabil Neural Repair. 2013; 27: 173-182
        • Rizzolatti G.
        The mirror neuron system and its function in humans.
        Anat Embryol (Berl). 2005; 210: 419-421
        • Garrison K.A.
        • Aziz-Zadeh L.
        • Wong S.W.
        • et al.
        Modulating the motor system by action observation after stroke.
        Stroke. 2013; 44: 2247-2253
        • Kawashima R.
        • Yamada K.
        • Kinomura S.
        • et al.
        Regional cerebral blood flow changes of cortical motor areas and prefrontal areas in humans related to ipsilateral and contralateral hand movement.
        Brain Res. 1993; 623: 33-40