In contrast to varied therapy approaches, mirror therapy (MT) can be used even in completely plegic stroke survivors, as it uses visual stimuli for producing a desired response in the affected limb. MT has been studied to have effects not just on motor impairments but also on sensations, visuospatial neglect, and pain after stroke. This paper attempts to systematically review and present the current perspectives on mirror therapy and its application in stroke rehabilitation, and dosage, feasibility and acceptability in stroke rehabilitation. An electronic database search across Google, PubMed, Web of Science, etc., generated 3871 results. After screening them based on the inclusion and exclusion criteria, we included 28 studies in this review. The data collected were divided on the basis of application in stroke rehabilitation, modes of intervention delivery, and types of control and outcome assessment. We found that most studies intervened for upper limb motor impairments post stroke. Studies were equally distributed between intervention in chronic and acute phases post stroke with therapy durations lasting between 1 and 8 weeks. MT showed definitive motor and sensory improvements although the extent of improvements in sensory impairments and hemineglect is limited. MT proves to be an effective and feasible approach to rehabilitate post-stroke survivors in the acute, sub-acute, and chronic phases of stroke, although its long-term effects and impact on activities of daily living need to be analysed extensively.

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Background and Aims: The use of visual stimuli to facilitate a desired response in the affected limb in mirror therapy (MT) makes it an effective treatment modality even in instances of a complete plegic upper extremity poststroke. This article analyzes the effects of MT on impairments, activity limitation, and participation restriction in the acute and chronic phases poststroke. Methods: In total, 16 out of 3871 studies were included in the meta-analysis, using PRISMA guidelines. Data were categorized based on application in stroke rehabilitation (acute/chronic, motor/sensory/neglect/activity of daily living, upper limb/lower limb), modes and dosage of intervention delivery, types of control, and outcome assessment. RevMan 5.0 software was used for analysis. Results: Studies were equally distributed between chronic and acute phases. Therapy durations lasted between 1 and 8 weeks. Most studies intervened for upper limb motor impairments showing improvement in Brunnstrom motor recovery stages of arm ( P value: .04, 95% CI, 0.05-1.54, I2 = 59%) and hand ( P value: <.001, 95% CI, 0.80-2.01, I2 = 0%) during acute phase (0-4 weeks). “Activity/function” measured by functional independence measure showed improvement only in self-care subsection ( P value: <.001, 95% CI, 2.05-5.16, I2 = 0%). No long-term effects were analyzed in any of the included studies. Conclusion: A significant finding of this study is the role of MT in improving arm and hand impairments in acute phase poststroke. Rehabilitation protocols can be improved based on this finding. As MT is effective, affordable, and feasible, we have made suggestions toward its incorporation in physiotherapy protocols for low- and middle-income countries.

Objective The study aims to determine the effects of implementing stroke unit (SU) care in a remote hospital in North-East India. Materials and Methods This before-and-after implementation study was performed at the Baptist Christian Mission Hospital, Tezpur, Assam between January 2015 and December 2017. Before the implementation of stroke unit care (pre-SU), we collected information on usual stroke care and 1-month outcome of 125 consecutive stroke admissions. Staff was then trained in the delivery of SU care for 1 month, and the same information was collected in a second (post-SU) cohort of 125 patients. Statistical Analysis Chi-square and Mann–Whitney U test were used to compare group differences. The loss to follow-up was imputed by using multiple imputations using the Markov Chain Monto Carlo method. The sensitivity analysis was also performed by using propensity score matching of the groups for baseline stroke severity (National Institute of Health Stroke Scale) using the nearest neighbor approach to control for confounding, and missing values were imputed by using multiple imputations. The adjusted odds ratio was calculated in univariate and multivariate regression analysis after adjusting for baseline variables. All the analysis was done by using SPSS, version 21.0., IBM Corp and R version 4.0.0., Armonk, New York, United States. Results The pre-SU and post-SU groups were age and gender matched. The post-SU group showed higher rates of swallow assessment (36.8 vs. 0%, p < 0.001), mobility assessment, and re-education (100 vs. 91.5%, p = 0.037). The post-SU group also showed reduced complications (28 vs. 45%, p = 0.006) and a shorter length of hospital stay (4 ± 2.16 vs. 5 ± 2.68 days, p = 0.026). The functional outcome (modified ranking scale) at 1-month showed no difference between the groups, good outcome in post-SU (39.6%) versus pre-SU (35.7%), p = 0.552. Conclusion The implementation of this physician-based SU care model in a remote hospital in India shows improvements in quality measures, complications, and possibly patient outcomes.

Background India is a large country with geographically diverse populations and varying risk factors. Identification of regional differences can improve healthcare policy decisions. Aim To study regional differences in stroke between North and South India. Methods We analyzed data from the Indo-US Collaborative Stroke Project, a National Institute of Health-funded multicentre prospective study conducted in five academic centers in India with a US-based coordinating center. Risk factors, severity, mechanisms, management, complications, and outcomes among ischemic stroke patients were compared between North and South Indian centers. Results Of the 2066 patients enrolled from North ( n = 1060) and South India ( n = 1006), North Indian patients were significantly older with fewer men and had lower rates of diabetes (32.8% vs. 38.7%, p < 0.01), dyslipidemia (3.5% vs. 25.7%, p < 0.01), tobacco use (27% vs. 38%, p < 0.001), and alcohol use (30.1% vs. 38.6%, p < 0.01). North Indian patients had higher median National Institute of Health stroke scale scores (10 vs. 9, p < 0.01), more frequent large-artery atherosclerosis mechanism (34% vs. 25.6%, p < 0.001), intravenous thrombolysis (14.0% vs. 6.1%, p < 0.001), and lower rates of pneumonia (10.5% vs. 15.1%, p = 0.02). The three-month outcome (modified Rankin Scale score 0–2, 45.8% vs. 50.3%, p = 0.08) did not differ; however, North Indian patients had higher 90-day mortality (23.5% vs. 13.5%, p < 0.0001). Conclusions The substantial regional differences in stroke risk factors and mechanisms may be partly explained by factors such as differing dietary habits and lifestyle, which can be addressed at a national level. Differences in acute and inpatient stroke care suggest a need for better adoption of national stroke management guidelines.

Introduction Despite a high burden of stroke, access to rapid brain imaging is limited in many middle- and low-income countries. Previous studies have described the astroglial protein GFAP (glial fibrillary acidic protein) as a biomarker of intracerebral hemorrhage. The aim of this study was to test the diagnostic accuracy of GFAP for ruling out intracranial hemorrhage in a prospective cohort of Indian stroke patients. Patients and methods This study was conducted in an Indian tertiary hospital (Christian Medical College, Ludhiana). Patients with symptoms suggestive of acute stroke admitted within 12 h of symptom onset were enrolled. Blood samples were collected at hospital admission. Single Molecule Array technology was used for determining serum GFAP concentrations. Results A total number of 155 patients were included (70 intracranial hemorrhage, 75 ischemic stroke, 10 stroke mimics). GFAP serum concentrations were elevated in intracranial hemorrhage patients compared to ischemic stroke patients [median (interquartile range) 2.36 µg/L (0.61–7.16) vs. 0.18 µg/L (0.11–0.38), p < 0.001]. Stroke mimics patients had a median GFAP serum level of 0.14 µg/L (0.09–0.26). GFAP values below the cut-off of 0.33 µg/L (area under the curve 0.871) ruled out intracranial hemorrhage with a negative predictive value of 89.7%, (at a sensitivity for detecting intracranial hemorrhage of 90.0%). Discussion The high negative predictive value of a GFAP test system allows ruling out patients with intracranial hemorrhage. Conclusion In settings where immediate brain imaging is not available, this would enable to implement secondary prevention (e.g., aspirin) in suspected ischemic stroke patients as soon as possible.

Background and Purpose: Very few large scale multicentric stroke clinical trials have been done in India. The Indian Council of Medical Research funded INSTRuCT (Indian Stroke Clinical Trial Network) as a task force project with the objectives to establish a state-of-the-art stroke clinical trial network and to conduct pharmacological and nonpharmacological stroke clinical trials relevant to the nation and globally. The purpose of the article is to enumerate the structure of multicentric stroke network, with emphasis on its scope, challenges and expectations in India. Methods: Multiple expert group meetings were conducted by Indian Council of Medical Research to understand the scope of network to perform stroke clinical trials in the country. Established stroke centers with annual volume of 200 patients with stroke with prior experience of conducting clinical trials were included. Central coordinating center, standard operating procedures, data and safety monitoring board were formed. Discussion: In first phase, 2 trials were initiated namely, SPRINT (Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India) and Ayurveda treatment in the rehabilitation of patients with ischemic stroke in India (RESTORE [Rehabilitation of Ischemic stroke Patients in India: A Randomized controlled trial]). In second phase, 4 trials have been approved. SPRINT trial was the first to be initiated. SPRINT trial randomized first patient on April 28, 2018; recruited 3048 patients with an average of 128.5 per month so far. The first follow-up was completed on May 27, 2019. RESTORE trial randomized first patient on May 22, 2019; recruited 49 patients with an average of 3.7 per month so far. The first follow-up was completed on August 30, 2019. Conclusions: In next 5 years, INSTRuCT will be able to complete high-quality large scale stroke trials which are relevant globally. REGISTRATION: URL: http://www.ctri.nic.in/ ; Unique Identifier: CTRI/2017/05/008507.