Neurodevelopmental Technique Versus Mirror Therapy in Sub-acute Stroke Patients

The Neurodevelopmental Technique (NDT), also known as the Bobath concept, is a hands-on treatment approach focusing on normalizing movement patterns and reducing muscle tone abnormalities through guided and facilitated movement. It emphasizes postural control, alignment, and symmetrical movement to enhance motor recovery. Bobath approach works on the different types of movement dysfunctions and is based on the active involvement of the patients so that they can develop motor control. Manual handling is holding the patient at specific proprioceptive points, for example, joint compression and distraction, so that patients can respond actively to perform functions. Manual handling can be of different types and is slowly removed to make the patient independent in motor activities. This type of therapy incorporates improved functional control and independence. Mirror Therapy (MT), on the other hand, involves using a mirror to create a visual illusion of movement in the affected limb by reflecting the movements of the unaffected limb. This approach stimulates the brain's motor cortex and supports cortical reorganization through visual feedback, which may facilitate motor recovery and improve function Screening: Participants, will be referred by the Neuro Physician or Medicine Specialist of University of Lahore Teaching Hospital will be assessed for the eligibility criteria. Patients fulfilled the eligibility criteria will be asked to sign the consent forms before entering them to the study.

Recruitment: All the participants who will meet the criteria and sign the consent form will be recruited into the study.

Randomization and Allocation: All the screened and willing participants will be randomly allocated to two groups (Group A: Experimental group Neurodevelopmental technique, Group B: Experimental Group mirror therapy exercise) by lottery method.

Blinding: This study will be a single blinded study in which assessor will be blinded.

Intervention Routine Physical Therapy The treatment will start by routine physiotherapy (RPT) comprised of stretching and ROM in both experimental groups. In ROM following exercises including; hip (flexion, extension, abduction and adduction), knee (flexion, extension), ankle (plantarflexion, dorsiflexion, inversion, eversion and circumduction) and toe (flexion \& extension). Stretching exercises included heel cord, gastrocnemius and hamstring stretch. Each ROM exercises were repeated 10 times with rest gap of 1 minute. Stretching exercises will repeated 5 times in one session and stretch will be held for 10 seconds. Time for RPT will be 20-25 minutes including rest intervals.

Group A: Experimental Group 1 (Neurodevelopmental technique with routine physical therapy) The participants randomly allocated in Group A will receive the neurodevelopmental therapy along with RPT. Exercises in NDT program will be performed in different positions: Supine position (Rotation of the trunk, Bridging, Flexion and extension of the knee and hip, Lowering the affected lower limb from the bed with hip extension and knee flexion, Pushing the wall with both limbs), Prone position (Mobilization of the ankle joint and functional stretching of gastro-soleus and quadriceps), Sitting position (Weight bearing on the affected side, reaching with trunk rotation, knee flexion-extension, Exercises of hip flexion and knee extension and Dorsi flexion of the ankle.), Standing position (standing with bearing weight on both legs, stepping to different directions, rising on toe, one leg standing). Each exercise will be 20 times per set in one session 2 minute rest between each set. The whole treatment session will start by 15 min warm up and end with 5 min cool down, and delivered 3 times a week for 12 weeks yielding a total of 36 sessions within 3 months and duration of each session will be of 65 minutes in Group A.

Group B: Experimental Group 2 (Mirror therapy with routine physical therapy) The participants randomly allocated in Group B will receive the mirror therapy. The experimental group will receive an additional 45 min of MT training. The patients will be instructed to remain in sitting position with a mirror (60 cm × 90 cm) will be positioned between the affected and healthy legs perpendicular to the subject's mid line. During the Mirror therapy, the reflecting side of the mirror will adjust to the non-affected leg and patients will be instructed to look at the reflection of the unaffected leg in the mirror as if it will the affected leg and perform bilateral symmetrical movements as much as possible. The practices will consist of heel raises (not holding on \& sustained both separately), side stepping (not holding on \& sustained both separately), single leg standing, leg movements i.e hip-knee-ankle flexion, knee extension with ankle dorsiflexion and ankle eversion. Each exercise will be 20 times per set in one session2 minute rest between each set. The whole treatment session will be delivered 3 times a week for 12 weeks yielding a total of 36 sessions within 3 months and duration of each session will be of 60-65 minutes in Group B. The whole treatment plan will be performed under strict observation for the familiarization of participants to ensure that each exercise will be performed by using correct technique.