Effects of visual feedback with a mirror on balance ability in patients with stroke
Identifieur interne : 000122 ( Pmc/Checkpoint ); précédent : 000121; suivant : 000123Effects of visual feedback with a mirror on balance ability in patients with stroke
Auteurs : Tae-Sung In ; Yu-Ri Cha ; Jin-Hwa Jung ; Kyoung-Sim JungSource :
- Journal of Physical Therapy Science [ 0915-5287 ] ; 2016.
Abstract
[Purpose] This study aimed to examine the effects of a visual feedback obtained from a mirror on balance ability during quiet standing in patients with stroke. [Subjects] Fifteen patients with stroke (9 males, 6 females) enrolled in the study. [Methods] Experimental trials (duration, 20s) included three visual conditions (eyes closed, eyes open, and mirror feedback) and two support surface conditions (stable, and unstable). Center of pressure (COP) displacements in the mediolateral and anteroposterior directions were recorded using a force platform. [Results] No effect of condition was observed along all directions on the stable surface. An effect of condition was observed on the unstable surface, with a smaller mediolateral COP distance in the mirror feedback as compared to the other two conditions. Similar results were observed for the COP speed. [Conclusion] Visual feedback from a mirror is beneficial for improving balance ability during quiet standing on an unstable surface in patients with stroke.
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DOI: 10.1589/jpts.28.181
PubMed: 26957753
PubMed Central: 4755999
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Effects of visual feedback with a mirror on balance ability in patients with
stroke</title><author><name sortKey="In, Tae Sung" sort="In, Tae Sung" uniqKey="In T" first="Tae-Sung" last="In">Tae-Sung In</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Cha, Yu Ri" sort="Cha, Yu Ri" uniqKey="Cha Y" first="Yu-Ri" last="Cha">Yu-Ri Cha</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Jung, Jin Hwa" sort="Jung, Jin Hwa" uniqKey="Jung J" first="Jin-Hwa" last="Jung">Jin-Hwa Jung</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Jung, Kyoung Sim" sort="Jung, Kyoung Sim" uniqKey="Jung K" first="Kyoung-Sim" last="Jung">Kyoung-Sim Jung</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">26957753</idno><idno type="pmc">4755999</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755999</idno><idno type="RBID">PMC:4755999</idno><idno type="doi">10.1589/jpts.28.181</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000515</idno><idno type="wicri:Area/Pmc/Curation">000515</idno><idno type="wicri:Area/Pmc/Checkpoint">000122</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Effects of visual feedback with a mirror on balance ability in patients with
stroke</title><author><name sortKey="In, Tae Sung" sort="In, Tae Sung" uniqKey="In T" first="Tae-Sung" last="In">Tae-Sung In</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Cha, Yu Ri" sort="Cha, Yu Ri" uniqKey="Cha Y" first="Yu-Ri" last="Cha">Yu-Ri Cha</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Jung, Jin Hwa" sort="Jung, Jin Hwa" uniqKey="Jung J" first="Jin-Hwa" last="Jung">Jin-Hwa Jung</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Jung, Kyoung Sim" sort="Jung, Kyoung Sim" uniqKey="Jung K" first="Kyoung-Sim" last="Jung">Kyoung-Sim Jung</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Physical Therapy Science</title><idno type="ISSN">0915-5287</idno><idno type="eISSN">2187-5626</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>[Purpose] This study aimed to examine the effects of a visual feedback obtained from a
mirror on balance ability during quiet standing in patients with stroke. [Subjects]
Fifteen patients with stroke (9 males, 6 females) enrolled in the study. [Methods]
Experimental trials (duration, 20s) included three visual conditions (eyes closed, eyes
open, and mirror feedback) and two support surface conditions (stable, and unstable).
Center of pressure (COP) displacements in the mediolateral and anteroposterior directions
were recorded using a force platform. [Results] No effect of condition was observed along
all directions on the stable surface. An effect of condition was observed on the unstable
surface, with a smaller mediolateral COP distance in the mirror feedback as compared to
the other two conditions. Similar results were observed for the COP speed. [Conclusion]
Visual feedback from a mirror is beneficial for improving balance ability during quiet
standing on an unstable surface in patients with stroke.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Horak, Fb" uniqKey="Horak F">FB Horak</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Corriveau, H" uniqKey="Corriveau H">H Corriveau</name></author><author><name sortKey="Hebert, R" uniqKey="Hebert R">R Hébert</name></author><author><name sortKey="Raiche, M" uniqKey="Raiche M">M Raîche</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Dickstein, R" uniqKey="Dickstein R">R Dickstein</name></author><author><name sortKey="Abulaffio, N" uniqKey="Abulaffio N">N Abulaffio</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Laufer, Y" uniqKey="Laufer Y">Y Laufer</name></author><author><name sortKey="Sivan, D" uniqKey="Sivan D">D Sivan</name></author><author><name sortKey="Schwarzmann, R" uniqKey="Schwarzmann R">R 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Phys Ther Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Phys Ther Sci</journal-id><journal-id journal-id-type="publisher-id">JPTS</journal-id><journal-title-group><journal-title>Journal of Physical Therapy Science</journal-title></journal-title-group><issn pub-type="ppub">0915-5287</issn><issn pub-type="epub">2187-5626</issn><publisher><publisher-name>The Society of Physical Therapy Science</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">26957753</article-id><article-id pub-id-type="pmc">4755999</article-id><article-id pub-id-type="publisher-id">jpts-2015-800</article-id><article-id pub-id-type="doi">10.1589/jpts.28.181</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>Effects of visual feedback with a mirror on balance ability in patients with
stroke</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>In</surname><given-names>Tae-Sung</given-names></name><degrees>PhD, PT</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Cha</surname><given-names>Yu-Ri</given-names></name><degrees>PhD, PT</degrees><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Jung</surname><given-names>Jin-Hwa</given-names></name><degrees>PhD, PT</degrees><xref ref-type="aff" rid="aff3"><sup>3</sup></xref><xref rid="cor1" ref-type="corresp"><sup>*</sup></xref><xref ref-type="author-notes" rid="con"><sup>a</sup></xref></contrib><contrib contrib-type="author"><name><surname>Jung</surname><given-names>Kyoung-Sim</given-names></name><degrees>PhD, PT</degrees><xref ref-type="aff" rid="aff4"><sup>4</sup></xref><xref ref-type="author-notes" rid="con"><sup>a</sup></xref></contrib><aff id="aff1"><label>1)</label> Department of Physical Therapy, Shin-Hwa Rehabilitation Hospital, Republic of Korea</aff><aff id="aff2"><label>2)</label> Department of Physical Therapy, Sunlin College, Republic of Korea</aff><aff id="aff3"><label>3)</label> Department of Occupational Therapy, Semyung University, Republic of Korea</aff><aff id="aff4"><label>4)</label> Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea</aff></contrib-group><author-notes><corresp id="cor1"><label>*</label>Corresponding author. Jin-Hwa Jung, Department of Occupational Therapy, Semyung University: 65
Semyung-ro, Jecheon-si, Chungbuk 390-711, Republic of Korea. (E-mail: <email xlink:href="otsalt@nate.com">otsalt@nate.com</email>)</corresp><fn id="con"><label>a</label><p>Two authors have contributed equally to this work as
corresponding author.</p></fn></author-notes><pub-date pub-type="epub"><day>30</day><month>1</month><year>2016</year></pub-date><pub-date pub-type="ppub"><month>1</month><year>2016</year></pub-date><volume>28</volume><issue>1</issue><fpage>181</fpage><lpage>185</lpage><history><date date-type="received"><day>17</day><month>9</month><year>2015</year></date><date date-type="accepted"><day>14</day><month>10</month><year>2015</year></date></history><permissions><copyright-statement>2016©by the Society of Physical Therapy Science. Published by IPEC
Inc.</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/"><license-p>This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. </license-p></license></permissions><abstract><p>[Purpose] This study aimed to examine the effects of a visual feedback obtained from a
mirror on balance ability during quiet standing in patients with stroke. [Subjects]
Fifteen patients with stroke (9 males, 6 females) enrolled in the study. [Methods]
Experimental trials (duration, 20s) included three visual conditions (eyes closed, eyes
open, and mirror feedback) and two support surface conditions (stable, and unstable).
Center of pressure (COP) displacements in the mediolateral and anteroposterior directions
were recorded using a force platform. [Results] No effect of condition was observed along
all directions on the stable surface. An effect of condition was observed on the unstable
surface, with a smaller mediolateral COP distance in the mirror feedback as compared to
the other two conditions. Similar results were observed for the COP speed. [Conclusion]
Visual feedback from a mirror is beneficial for improving balance ability during quiet
standing on an unstable surface in patients with stroke.</p></abstract><kwd-group><title>Key words</title><kwd>Balance</kwd><kwd>Feedback</kwd><kwd>Stroke</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="s1"><title>INTRODUCTION</title><p>Postural control refers to the sensorimotor control that maintains center of pressure (COP)
within the base of support when postural sway occurs due to active or external forces<xref rid="r1" ref-type="bibr">1</xref><sup>)</sup>. Patients with stroke show a pattern of
increased postural sway during quiet standing due to motor, sensory, and cognitive
impairments<xref rid="r2" ref-type="bibr">2</xref>, <xref rid="r3" ref-type="bibr">3</xref><sup>)</sup>, which increases the risk of falls, as well as limits their ability
to independently perform daily life activities<xref rid="r4" ref-type="bibr">4</xref>,<xref rid="r5" ref-type="bibr">5</xref>,<xref rid="r6" ref-type="bibr">6</xref><sup>)</sup>.</p><p>Many studies have reported that providing additional sensory information to patients with
balance impairment results in improved postural control<xref rid="r7" ref-type="bibr">7</xref>,<xref rid="r8" ref-type="bibr">8</xref>,<xref rid="r9" ref-type="bibr">9</xref><sup>)</sup>. One of the methods is using a computer screen to provide visual
feedback on the displacement of COP. However, this method has its limitations for home-use
because of its high cost<xref rid="r10" ref-type="bibr">10</xref><sup>)</sup>.</p><p>Visual feedback training using a mirror is a method that can lead to improvements in
postural control by providing feedback on induced movements through a reflection of the body
image in the mirror<xref rid="r11" ref-type="bibr">11</xref><sup>)</sup>. Hlavackova et
al.<xref rid="r12" ref-type="bibr">12</xref><sup>)</sup> reported that when visual
feedback was obtained by transfemoral amputees from a mirror placed in front of them, a
significant decrease was observed in the subsequent measurement of sway distance. Moreover,
a study of the elderly that measured the effects of visual feedback from a mirror reported
significant improvement in the mediolateral postural sway<xref rid="r10" ref-type="bibr">10</xref><sup>)</sup>.</p><p>Many studies have reported that mirror therapy is effective for motor learning in patients
with stroke<xref rid="r13" ref-type="bibr">13</xref>,<xref rid="r14" ref-type="bibr">14</xref>,<xref rid="r15" ref-type="bibr">15</xref>,<xref rid="r16" ref-type="bibr">16</xref><sup>)</sup>. Few studies have been conducted on the effects of visual feedback
from a mirror on the balance ability of patients with stroke. In addition, most of the
studies only measured the effect on stable surfaces. Hence, there is a need for studies on
the effects of visual feedback on unstable surfaces. This study aimed to measure the effects
of visual feedback from a mirror on the balancing ability of patients with stroke on various
supporting surfaces.</p></sec><sec sec-type="methods" id="s2"><title>SUBJECTS AND METHODS</title><p>Fifteen patients with hemiparetic stroke were recruited for this study from Myongii
chonnhey hospital. The inclusion criteria for subjects were as follows: patients who were
diagnosed with first onset of unilateral hemisphere stroke, could stand independently for 1
minute on a stable surface, had no visual deficit, had no vestibular deficit, and were able
to understand and follow simple verbal instructions. <xref rid="tbl_001" ref-type="table">Table 1</xref><table-wrap id="tbl_001" orientation="portrait" position="float"><label>Table 1.</label><caption><title>Subject characteristics (<italic>N</italic>=15)</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1"></th><th align="center" rowspan="1" colspan="1">Mean±SD</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Gender (male/female)</td><td align="center" rowspan="1" colspan="1">9/6</td></tr><tr><td align="left" rowspan="1" colspan="1">Age (years)</td><td align="left" rowspan="1" colspan="1">54.9 ± 10.9</td></tr><tr><td align="left" rowspan="1" colspan="1">Height (cm)</td><td align="left" rowspan="1" colspan="1">165.7 ± 8.3</td></tr><tr><td align="left" rowspan="1" colspan="1">Weight (kg)</td><td align="left" rowspan="1" colspan="1">63.7 ± 8.0</td></tr><tr><td align="left" rowspan="1" colspan="1">Post-stroke duration (mo)</td><td align="left" rowspan="1" colspan="1">12.9 ± 4.7</td></tr><tr><td align="left" rowspan="1" colspan="1">Paretic side (right/left)</td><td align="center" rowspan="1" colspan="1">8/7</td></tr><tr><td align="left" rowspan="1" colspan="1">Lesion type (hemorrhage/ischemia)</td><td align="center" rowspan="1" colspan="1">7/8</td></tr><tr><td align="left" rowspan="1" colspan="1">MMSE</td><td align="left" rowspan="1" colspan="1">26.15 ± 1.83</td></tr></tbody></table><table-wrap-foot><p>MMSE: mini mental state examination</p></table-wrap-foot></table-wrap> shows a list of general characteristics of the subjects. After being informed
about the study, all subjects agreed to participate and signed a consent form. The study was
approved by the Institutional Review Board of Sahmyook University.</p><p>The subjects were asked to stand, barefoot and with their heels separated by a distance of
8.4 inch on a force plate. They were asked to remain in their position as quietly as
possible. They were instructed to hang both the arms at the sides of the body. Experimental
trials included three visual (eyes closed, eyes open, and mirror feedback) and two support
surface (stable and unstable) conditions. In the eyes open condition, the subjects were
asked to fix their gaze on the wall 1 m in front of them, at the eye level. In the mirror
feedback condition, the subjects were able to visualize their frontal reflected image in a
mirror placed on the wall 1 m in front of them<xref rid="r12" ref-type="bibr">12</xref><sup>)</sup>. For the trials on an unstable surface, the subjects stood on a
balance pad (Airex<sup>®</sup>, Aalen, Germany)<xref rid="r17" ref-type="bibr">17</xref><sup>)</sup>. The foot positions were marked on the forceplate and maintained
constant between the trials. Three trials were conducted for each condition for a duration
of 30 seconds. The order of blocks was randomized for all subjects. The effect of muscle
fatigue was minimized by providing a 1-minute rest between measurements. All subjects wore a
harness and a therapist stood behind each of them for safety.</p><p>The subject’s balance ability was measured using a force platform (Wii Balance Board [WBB],
Nintendo, Kyoto, Japan). The size of the WBB with four load cells was 45 cm × 26.5 cm. This
instrument is reported to have a high test-retest reliability (intraclass correlation
coefficient [ICC] = 0.66–0.94) and construct validity (ICC=0.77–0.89)<xref rid="r18" ref-type="bibr">18</xref><sup>)</sup>. Data was exchanged between the WBB and a laptop using the
built-in Bluetooth and Balancia software (Balancia v2.0, Mintosystems, Seoul, Republic of
Korea).</p><p>The sampling rate was set at 50 Hz, and 12 Hz low pass filtering was performed. Balancia
software is reported to have a high interrater reliability (ICC=0.89–0.79) and intrarater
reliability (ICC=0.92−0.70)<xref rid="r19" ref-type="bibr">19</xref><sup>)</sup>.</p><p>In order to compare balance ability in different conditions, data were analyzed using
one-way repeated measures analysis of variance (ANOVA). The least significant difference
post hoc test was used to examine the differences within each trials. Data were analyzed
using the SPSS v12.0 statistical program. All the significance levels used were α=0.05.</p></sec><sec sec-type="results" id="s3"><title>RESULTS</title><p>For all directions, COP distance and speed increased when the subjects stood on the stable
surface with their eyes closed. During stance on the stable surface, no significant
differences were observed in COP distance and speed between the eyes open and mirror
feedback conditions (<xref rid="tbl_002" ref-type="table">Table 2</xref><table-wrap id="tbl_002" orientation="portrait" position="float"><label>Table 2.</label><caption><title>Center of pressure (COP) in patients with stroke during stance under three
conditions on a stable surface</title></caption><table frame="hsides" rules="groups"><thead><tr><th valign="top" align="left" rowspan="1" colspan="1"></th><th valign="top" align="left" rowspan="1" colspan="1"></th><th valign="top" align="center" rowspan="1" colspan="1">Eyes closed</th><th valign="top" align="center" rowspan="1" colspan="1">Eyes open</th><th valign="top" align="center" rowspan="1" colspan="1">Mirror feedback</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="3" colspan="1">COP distance (cm)</td><td align="left" valign="top" rowspan="1" colspan="1">Anteroposterior</td><td align="center" valign="top" rowspan="1" colspan="1">58.3±24.0<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">36.8±13.0<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">36.9±11.3<sup>*</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Mediolateral</td><td align="center" valign="top" rowspan="1" colspan="1">43.6±12.8<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">36.2±8.9<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">36.1±9.3<sup>*</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Total </td><td align="center" valign="top" rowspan="1" colspan="1">80.8±27.6<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">57.7±16.7<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">58.9±16.2<sup>*</sup></td></tr><tr><td align="left" valign="top" rowspan="3" colspan="1">COP speed (cm/s)</td><td align="left" valign="top" rowspan="1" colspan="1">Anteroposterior</td><td align="center" valign="top" rowspan="1" colspan="1">2.9±1.2<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">1.8±0.7<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">1.8±0.6<sup>*</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Mediolateral</td><td align="center" valign="top" rowspan="1" colspan="1">2.2±0.6<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">1.8±0.5<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">1.9±0.5<sup>*</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Total</td><td align="center" valign="top" rowspan="1" colspan="1">4.0±1.4<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">2.9±0.8<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">2.9±0.8<sup>†#</sup></td></tr></tbody></table><table-wrap-foot><p>Values are expressed as mean±SD. *significant difference compared with the eyes
closed condition. <sup>†</sup>significant difference compared with the eyes open
condition. <sup>#</sup>significant difference compared with the mirror feedback
condition</p></table-wrap-foot></table-wrap>).</p><p>During stance on the unstable surface, an effect of condition was observed along the
mediolateral direction with a smaller mediolateral COP distance in the mirror feedback than
in the eyes open and eyes closed conditions, whereas no effect of condition was observed
along the anteroposterior direction. COP speed was significantly reduced by mirror feedback
when the subjects stood on the unstable surface (<xref rid="tbl_003" ref-type="table">Table
3</xref><table-wrap id="tbl_003" orientation="portrait" position="float"><label>Table 3.</label><caption><title>Center of pressure (COP) in patients with stroke during stance under three
conditions on an unstable surface</title></caption><table frame="hsides" rules="groups"><thead><tr><th valign="top" align="left" rowspan="1" colspan="1"></th><th valign="top" align="left" rowspan="1" colspan="1"></th><th valign="top" align="center" rowspan="1" colspan="1">Eyes closed</th><th valign="top" align="center" rowspan="1" colspan="1">Eyes open</th><th valign="top" align="center" rowspan="1" colspan="1">Mirror feedback</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="3" colspan="1">COP distance (cm)</td><td align="left" valign="top" rowspan="1" colspan="1">Anteroposterior</td><td align="center" valign="top" rowspan="1" colspan="1">84.9±24.6<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">47.9±14.6<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">43.9±10.3<sup>*</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Mediolateral</td><td align="center" valign="top" rowspan="1" colspan="1">74.1±23.3<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">48.5±13.7<sup>*#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">42.1±8.3<sup>*†</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Total </td><td align="center" valign="top" rowspan="1" colspan="1">125.2±37.1<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">75.8±20.8<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">67.5±13.5<sup>*</sup></td></tr><tr><td align="left" valign="top" rowspan="3" colspan="1">COP speed (cm/s)</td><td align="left" valign="top" rowspan="1" colspan="1">Anteroposterior</td><td align="center" valign="top" rowspan="1" colspan="1">4.9±2.53<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">2.4±0.73<sup>*</sup></td><td align="center" valign="top" rowspan="1" colspan="1">1.8±0.6<sup>*</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Mediolateral</td><td align="center" valign="top" rowspan="1" colspan="1">3.7±1.2<sup>†#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">2.4±0.7<sup>*#</sup></td><td align="center" valign="top" rowspan="1" colspan="1">2.1±0.4<sup>*†</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Total</td><td align="center" valign="top" rowspan="1" colspan="1">6.8±2.9</td><td align="center" valign="top" rowspan="1" colspan="1">3.8±1.0</td><td align="center" valign="top" rowspan="1" colspan="1">3.4±0.7</td></tr></tbody></table><table-wrap-foot><p>Values are expressed as mean±SD. *significant difference compared with the eyes
closed condition. <sup>†</sup>significant difference compared with the eyes open
condition. <sup>#</sup>significant difference compared with the mirror feedback
condition</p></table-wrap-foot></table-wrap>).</p></sec><sec sec-type="discussion" id="s4"><title>DISCUSSION</title><p>In this study we examined the effects of visual feedback from a mirror for patients with
stroke in a standing position on various supporting surfaces. The sway distance and speed
were the highest when the subjects were standing on a stable surface with their eyes closed,
whereas no significant difference was observed in all directions when the mirror feedback
was obtained with their eyes open. In a study of amputees that examined the effect of visual
feedback from a mirror, a significant decrease was reported in the postural sway. This was
attributed to the improved balance ability through the visual information reflected in the
mirror that acted as a sensory substitution for diminished proprioception from the injured
limb<xref rid="r12" ref-type="bibr">12</xref><sup>)</sup>. Furthermore, visual feedback
from a mirror helps in learning accurate motions through adjustment of errors observed
during task performance<xref rid="r20" ref-type="bibr">20</xref><sup>)</sup>. A study that
used visual feedback in conducting balance training in patients with stroke also reported
that such training improved weight distribution and balance ability<xref rid="r21" ref-type="bibr">21</xref><sup>)</sup>.</p><p>However, in this study, no significant improvement effect was observed from visual feedback
for subjects who could maintain a standing position on their own for at least 1 minute on
the stable surface with relatively small postural sway. Horak et al.<xref rid="r22" ref-type="bibr">22</xref><sup>)</sup> indicated that dependency on the vestibular organs and
vision increased for postural control as the surface became more unstable. A study on the
effects of providing additional somatic sensory information for balance in the elderly also
reported that greater improvements were observed on a more unstable surface with increased
postural sway<xref rid="r23" ref-type="bibr">23</xref><sup>)</sup>.</p><p>Accordingly, the effect of visual feedback from a mirror on the postural sway on unstable
surfaces was observed in this study. Significant improvement was observed in the
mediolateral sway distance and speed. It has been reported that mediolateral sway is
significantly correlated with falls and can be a predictive factor for falls<xref rid="r24" ref-type="bibr">24</xref>, <xref rid="r25" ref-type="bibr">25</xref><sup>)</sup>. Therefore, improving postural control in this direction is important
for reducing the incidence of falls<xref rid="r26" ref-type="bibr">26</xref><sup>)</sup>.</p><p>Mediolateral sway can be recognized as the error associated with the movement that deviates
from the body’s centerline, while anteroposterior sway can be visually recognized through
changes in the sizes of images reflected in the mirror. Valiant et al. <xref rid="r10" ref-type="bibr">10</xref><sup>)</sup> reported that when visual feedback from a mirror was
obtained by the elderly, significant improvement was observed only in the mediolateral
direction, and the authors attributed this to the threshold difference in the visual
recognition of mediolateral and anteroposterior sway. Decreased mediolateral sway distance
and speed was observed when visual feedback was obtained from a mirror, compared to the
condition in which the eyes were either closed or open, but the findings were not
statistically significant. Moreover, since the anteroposterior sway was not large enough to
show changes in the size of the image, a significant difference based on the visual feedback
was not exhibited.</p><p>The visual feedback from a mirror for patients with stroke led to a significant decrease in
the postural sway on surfaces that are more unstable, where the sway distance and speed had
increased. However, generalization of the result is difficult due to the small number of
subjects. In addition, because the subjects were recruited regardless of fall experience, a
correlation of visual feedback with falls could not be determined. Therefore, future studies
should examine the effects of visual feedback from a mirror in dynamic states such as sit to
stand, and visual feedback training using a mirror on balance and falls in patients with
fall experience.</p></sec></body><back><ref-list><title>REFERENCES</title><ref id="r1"><label>1</label><mixed-citation publication-type="journal"><person-group><name><surname>Horak</surname><given-names>FB</given-names></name></person-group>: <article-title>Postural orientation and equilibrium: what do we need to
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