Abstract of Thesis entitled

“An Evidence-based Guideline of Using Mirror Therapy to Promote

Motor Function Recovery of Upper Limb in Stroke Patient”

Submitted by

Lau Yuen Pan

for the Degree of Master of Nursing

at the University of Hong Kong

in August 2014

Overview

Stroke is common around the world. It causes many disabilities every year.

Among the stroke survivors, half of them have the problem of hemiparesis. It still

persists and disturbs their lives more than half year. In Hong Kong, the hospital

setting is busy and standard stroke rehabilitation is not enough for recovery of stroke.

These lead to delay of rehabilitation process. Therefore, introduction of mirror therapy

is the alternatives to improve their motor function and quality of life with low cost

and manpower. Mirror therapy triggers the activation of the brain to help the recovery

of the motor function. Therefore, the aims of this research are to explore the

effectiveness of mirror therapy to help the stroke survivors to cope with the disability

of upper limb function and to develop an evidence-based guideline of using mirror

therapy for health care profession in Hong Kong setting.

Method

A literature review was conducted to evaluate the possibility of using mirror

therapy to improve stroke survivors’ upper limb motor function. The selected topic of

this study was that “in patients suffering from stroke with hemiparesis, how effective

is the mirror therapy in promoting motor function recovery of their paretic upper

limbs?” and the target group of this review was stroke patients. Database “ProQuest”

and “PubMed” were used for searching for the studies related to stroke and mirror

therapy and eight studies were found finally. Critical Appraisal tool from Scottish

Intercollegiate Guidelines Network was used to assess the quality of the studies.

Results

After summarized the studies, statistically significant results were noted towards

mirror therapy’s arm. Evidence showed that mirror therapy was a possible treatment

to improve patient’s upper limb function recovery with long term effect. The detail of

the studies provided useful information to develop the evidence-based guideline of

mirror therapy. A 4 weeks mirror therapy with 4 and 24 weeks follow-up was given to

stroke survivors to enhance their recovery. Assessment tools, the Action Research

Arm Test and the Functional Independence Measure, were used at baseline, after

intervention and during follow-up to assess their improvements.

Implementation potential was assessed to improve the transferability and

feasibility in Hong Kong public hospital setting. Implementation plan was proposed to

improve the communication between stakeholders. Evaluation plan was used to assess

the outcomes of survivors’ upper limb function and level of independence.

Satisfaction level of staff and patients were also included.

Conclusion

From the results of the relevant studies, mirror therapy is found to promote the

motor function recovery of upper limb in stroke survivors. It is worthwhile to conduct

this program to help the stroke survivors to improve quality of life.

An Evidence-based Guideline of Using Mirror Therapy to

Promote Motor Function Recovery of Upper Limb in Stroke

Patient

by

Lau Yuen Pan

B.Sc. (Nurs); H.K.U., R.N.

A thesis submitted in partial fulfilment of the requirements for

the Degree of Master of Nursing

at The University of Hong Kong

August 2014

i

Declaration

I declare that this thesis represents my own work, except where due

acknowledgement is made, and that it has not been previously included in a thesis,

dissertation or report submitted to this University or to any other institution for a

degree, diploma or other qualifications.

…………………………………………………………….

Lau Yuen Pan

ii

Acknowledgements

I would like to express my great appreciation to my supervisor, Dr. Athena Hong,

for her valuable suggestions during the construction of my thesis in the past 2 years.

Without her opinions and guidance, this thesis would not have been possible. I also

take this opportunity to thank Dr. Daniel Fong and Dr. Patsy Chau for their valuable

information during tutorial which helped me in completing my thesis.

I am obliged to staff members of School of Nursing in the University of Hong

Kong for their help during my study in the Master of Nursing course. Secondly, I am

grateful to my colleague of my workplace whose willingness to share their knowledge

made me understands more on my thesis.

Lastly, I would also like to thank my friends and classmates for their sharing of

sadness and happiness during master work.

iii

TABLE OF CONTENTS

Page

Declaration………………………………………………………… i

Acknowledgement…………………………………………………. ii

Table of Contents………………………………………………….. iii

Chapter 1: Introduction…………………………………………. 1

1.1 Background……………………………………………………….. 1

1.2 Affirming Needs…………………………………………………...

1.2.1 Current Practice in Hong Kong……………………………..

1.2.2 Problem of Clinical Situation…………………………….....

1.2.3 Introduction of Mirror Therapy……………………………..

1.2.4 Affirming Needs of Mirror Therapy………………………...

2

2

3

4

5

1.3 Research Question, Objectives, Significance……………………

1.3.1 Research Question…………………………………………..

1.3.2 Objectives…………………………………………………...

1.3.3 Significance…………………………………………………

6

6

6

7

Chapter 2: Critical Appraisal…………………………………... 9

2.1 Search Strategies…………………………………………………..

2.1.1 Search Methodology………………………………………...

2.1.2 Keywords……………………………………………………

2.1.3 Selection Criteria……………………………………………

2.1.3.1 Inclusion Criteria…………………………………...

2.1.3.2 Exclusion Criteria…………………………………..

9

9

9

10

10

10

2.2 Appraisal Strategies………………………………………….…... 10

iv

Page

2.3 Appraisal Results………………………………………………....

2.3.1 Searching Results……………………………………………

2.3.2 Overview of the Research Design…………………………..

2.3.3 Subject Allocation…………………………………………...

2.3.4 Sample Size………………………………………………….

2.3.5 Application to Local Setting………………………………...

2.3.6 Summary of Quality Appraisal……………………………...

11

11

11

12

12

13

13

2.4 Summary and Synthesis of Results………………………………

2.4.1 Study Design………………………………………………...

2.4.2 Characteristics of the Subjects………………………………

2.4.3 Intervention and Control……………………………………

2.4.3.1 Consideration of Mirror……………………………

2.4.3.2 Execution of Movement during Therapy…………...

2.4.3.3 Therapy Intensity…………………………………...

2.4.3.4 Control Group………………………………………

2.4.4 Data Collection……………………………………………...

2.4.5 Outcome Measurement……………………………………...

2.4.6 Results of the Studies………………………………………..

14

15

15

17

17

18

18

19

19

20

21

2.4 Implication………………………………………………………… 22

Chapter 3: Translation and Implementation…………….. 24

3.1 Implementation Potential……………………………………………….. 24

3.1.1 Proposed Setting and Audience……………………………..

3.1.2 Transferability of the Findings………………………………

3.1.2.1 Target Setting and Population………………………

24

25

25

v

Page

3.1.2.2 Philosophy of Care………………………………….

3.1.2.3 Number of Patients Involved……………………….

3.1.2.4 Duration for Implementation and Evaluation………

3.1.3 Feasibility……………………………………………………

3.1.3.1 Freedom of Implementation………………………...

3.1.3.2 Interference with Routine…………………………..

3.1.3.3 Administration and Colleague Support…………….

3.1.3.4 Skills and Training………………………………….

3.1.3.5 Equipment and Facility……………………….…….

3.1.3.6 Measuring Tools for Evaluation…………….………

3.1.4 Cost and Benefit Ratio of Intervention……………….……..

3.1.4.1 Potential Risk and Benefit of Patients……………...

3.1.4.2 Potential Benefit of Staff and Hospital……….…….

3.1.4.3 Potential Material Costs…………….………………

3.1.4.4 Potential Non-material Costs……………………….

26

26

27

27

27

28

28

29

30

30

30

30

31

32

32

Chapter 4: Developing an Evidence-based Practice

Guideline…………………………………………………….

34

4.1 Title of the Evidence-based Guideline…………………………… 34

4.2 Background……………..………………………………………… 34

4.3 Purpose and Objectives of Guideline……………………………. 35

4.4 Target Group………………………………………………………

4.4.2 Target Population……………………………………………

4.4.1 Target Audience……………………………………………..

35

35

35

4.5 Level of Evidence and Grades of Recommendations…………... 36

vi

Page

4.6 Recommendations………………………………………………… 36

Chapter 5: Implementation Plan………………………….. 39

5.1 Stakeholders Identification…………………………………………...

5.1.1 Administrators……………………………………………….

5.1.2 Trainers……………………………………………………...

5.1.3 Users of the Evidenced-based Guideline……………………

39

39

40

40

5.2 Communication Plan…………………………………………………..

5.2.1 Setting up a Team……………………………………………

5.2.2 Communicating with Administrators………………………..

5.2.3 Briefing Session……………………………………………..

5.2.4 Training Session……………………………………………..

5.2.5 Initiating, Guiding and Sustaining the Intervention…………

40

40

41

42

42

42

5.3 Pilot Test…………………………………………………………………

5.3.1 Aims and Objectives of Pilot Test…………………………...

5.3.2 Recruitment and Duration…………………………………...

5.3.3 Evaluation of Pilot Test……………………………………...

5.3.3.1 Feasibility of Implementing Mirror Therapy……….

5.3.3.2 The difficulty of Subject Recruitment……………...

5.3.3.3 The Evidence-based Guideline in Local Setting……

5.3.3.4 The Acceptance of Staffs…………………………...

43

43

43

44

44

45

45

45

Chapter 6: Evaluation Plan….……………………………. 46

6.1 Identifying Outcomes………………………………………………….

6.1.1 Patient Outcomes……………………………………………

6.1.1.1 Primary Measurement………………………………

46

46

46

vii

Page

6.1.1.2 Secondary Measurement……………………………

6.1.1.3 Level of Satisfaction (Patient)……………………...

6.1.2 Healthcare Provider Outcomes……………………………...

6.1.2.1 Level of Satisfaction (Staff)………………………..

6.1.3 System Outcomes…………………………………………...

6.1.3.1 Length of Hospitalization…………………………..

46

47

47

47

48

48

6.2 Nature of Subjects…………………………………………………….. 48

6.3 Number of Subjects…………………………………………………… 48

6.4 Data Collection………………………………………………………… 49

6.5 Data Analysis…………………………………………………………… 50

6.6 Basis Criteria of Effective Guideline………………………………..

6.6.1 Upper Limb Motor Function of Patients…………………….

6.6.2 Level of Independence of Patients…………………………..

6.6.3 Level of Satisfaction of Patients…………………………….

6.6.4 Level of Satisfaction of Staffs……………………………….

6.6.5 Length of Hospitalization…………………………………...

51

51

51

52

52

52

Chapter 7: Conclusion…………………………………………… 53

viii

Page

Appendices

Appendix (A) Flow Chart of the Search Strategy……………………

Appendix (B) Quality Assessments of the Articles………………..…

Appendix (C) Table of Evidence……………………………………….

Appendix (D) Table of comparison……………………………………

Appendix (E): Potential Material Cost……………………………….

Appendix (F): Recommendation of Evidence-based Practice

Guideline (Detailed)…………………………………………………….

Appendix (G): Level of Evidence and Grades of Recommendation

Appendix (H): Time Frame of the Mirror Therapy Program………

Appendix (I): Post Pilot Study Questionnaire for Staff…………….

Appendix (J): Satisfaction Survey (Patient)………………………….

Appendix (K): Satisfaction Survey (Staff)…………………………….

54

55

61

72

74

75

81

82

83

84

85

References …………………………………………………………………… 86

1

Chapter 1: Introduction

1.1 Background

Stroke onset is unpredictable and sudden. It is the loss of brain function due to

insufficient blood supply to the brain. Patients usually suffer from disabilities on limb

function, language and speech (Bare & Smeltzer, 2004). Their physical activities are

highly affected after this shocking event.

In Hong Kong, stroke is the major cause of death and disability. It was the fourth

leading cause of dead (The department of health, 2012). According to the Hospital

Authority Statistical Report (2011), nearly 25 000 people suffered from stroke in 2010.

There are a huge number of patients in Hong Kong’s health care system.

Long term disability is a frequent consequence of people suffering from stroke.

Hemiparesis on upper limb, weakness on one side of limb, is one of the common

symptoms. Nearly 85% of stroke patients suffered from this problem (Duncan, 2002).

Among those sufferers, only half of them had the chance to recover some of the motor

function after 6 months (Kollen, 2003). As mentioned before that around 25 000

people suffered from stroke, nearly 12 000 stroke survivors had this problem and it

affected them more than 6 months. Declined hand function affected patients’ quality

of life and their abilities to cope with daily living tasks. Not only the physical ability,

but also their psychosocial aspect was affected as their self-esteem was related to their

2

functional abilities (Chang & Mackenzie, 1998). As a result, rehabilitation plays an

important part to stroke survivors in recovery from the influence of this disease.

Mirror therapy is a possible treatment for training of upper limb’s motor function

in stroke survivors (Atay et al., 2008; Baricich et al., 2013; Blasis et al., 2009; Chen et

al., 2013; Cho, et al., 2012; Dohle et al., 2009). Originally, it was used to manage

phantom pain in orthopedics (Ramachandran, as cited in Bayn et al., 2012). Then it

was firstly introduced in stroke rehabilitation field for upper limb motor function

training with positive results (Altschuler et al., 1999). Unlike other training exercise,

mirror therapy was focused on the virtual image of the affected limb which was

observed by the patients (Byan et al., 2012). The virtual image stimulated our brain to

trigger the recovery of the affected side.

1.2 Affirming Needs

1.2.1 Current Practice in Hong Kong

Nowadays, when stroke patients survive the acute phase, they are usually sent to

the stroke rehabilitation unit for further management. Rather than coping life

threatening situation, the goal of sub-acute phase in stroke patients is to improve their

motor function, activities of daily living and facilitate their road back to the society by

providing frequent and intense training (Collier, Dewey & Sherry, 2007).

Multidisciplinary teams are involved to the whole rehabilitation process (Johansson,

3

2011).

In Hong Kong public hospital’s stroke rehabilitation unit, patients’ condition is

assessed during admission. Then a comprehensive training is started as soon as it may

after elimination of unfavorable condition such as high blood pressure, dizziness.

Physiotherapist, occupational therapist, speech therapist and nurses incorporate into

the rehabilitation program to help the patients.

1.2.2 Problem of Clinical Situation

However, due to the shortage of manpower, the ratio of therapist to patient is

extremely low. The bed occupancy rate is usually over 100%. Training can only be

provided to patients for approximately an hour per day. Camicia et al. (2012)

suggested that three hours per day were the thresholds for optimal outcomes for stroke

rehabilitation. One hour is far less than the required standard. Furthermore, in order to

facilitate the discharge of patients, walking on their own is the most promising result.

Therefore, the focusing point of training is mainly on lower limb of the patient. Upper

limb’s training is usually neglected or far lesser. The rehabilitation of upper limb may

not be sufficient to provide good outcome to the patients.

On the other hand, for rehabilitation of motor function of the affected arm, there

are many methods for upper limb training, for example, robot-assisted arm training

(Archambault, Fung & Norouzi-Gheidari, 2012). However, they require large amount

4

of manpower for intensive treatment for the patients. Forced usage of affected limb

also induced distress, physical pain and eventually affected the recovery process

(Bauder, Liepert & Miltner, as cited Cho, Lee & Song, 2012).

1.2.3 Introduction of Mirror Therapy

In consequences, stroke survivors face a difficult time without adequate support

and training. Mirror therapy can be an alternative to help hemiparetic stroke patients

in training motor function. Patients sit close to a table with a mirror placed

perpendicular to the midline of the patients. Then the unaffected upper limb was

placed on the reflected side of the mirror and patients observed the movement of it

(Baricich, 2013). Figure (1) showed the arrangement during applying mirror therapy.

How does mirror therapy work? Funase et al. (2012) said that when patient

observed the movement of the virtual image of affected limb in the mirror, it activated

Affected Unaffected

Mirror on reflected side

Figure (1) – Preparation of Mirror therapy

5

the mirror-neuron system which would be activated when the brain tried to observe

and carry out an action (Cattaneo & Rizzolatti, 2009). Then the primary motor cortex

of the affected limb would be activated due to the observation of action by the mirror

neuron (Craighero & Fadiga, 2004). From the MRI study of Matthys et al. (2009),

mirror therapy induced activation of the brain area involved the motor system of the

non-moving hand. Therefore, it is believed that mirror therapy promotes the

rehabilitation of the paretic limb in stroke patients.

1.2.4 Affirming Needs of Mirror Therapy

Mirror therapy can improve the upper limb function of stroke survivors (Atay et

al., 2008; Baricich et al., 2013; Blasis et al., 2009; Chen et al., 2013; Cho, et al., 2012;

Dohle et al., 2009). It is also simple with only a handy mirror as the equipment. The

cost of using the therapy is comparatively low.

Moreover, mirror therapy is a patient-directed therapy (Atay et al., 2008).

Although nurse to patient ratio is low, nurses may provide sufficient training to

patients as application of mirror therapy is relatively simple. After teaching patients

about the concept and method, patients may continue their training on their own with

low supervision. Sufficient training can be provided to achieve the goal of

rehabilitation.

In addition, since nurses have most of the time accompanying patients, providing

6

training exercise from nurses can be more effective as good rapport can be built easier.

It facilitates the training participation of patients which is one of the important issues

in rehabilitation process (Johansson, 2011).

1.3 Research Question, Objectives, Significance

In this dissertation, the practice guideline of mirror therapy were formulated,

assessed and evaluated. The result and evaluation of the evidence-based integrative

review for mirror therapy were identified in the coming part. Then, the

implementation potential and the development of the evidence-based guideline were

provided. At last, the implementation plan and evaluation of the clinical guideline

were discussed.

1.3.1 Research Question

The following research question was used to guide the integrative review of

mirror therapy:

In patients suffering from stroke with hemiparesis, how effective is the mirror therapy

in promoting motor function recovery of their paretic upper limbs?

1.3.2 Objectives

The objectives of the integrative review were:

To perform a quality critical appraisal of the selected studies related to mirror

therapy;

7

To evaluate the effectiveness and feasibility of mirror therapy in promoting

motor function of upper limb on hemiparetic stroke survivors;

To develop an evidence-based clinical protocol in guiding health care providers

for using mirror therapy to help stroke survivors.

1.3.3 Significance

Mirror therapy is beneficial to patients, health care providers and the hospital.

For patients’ aspect, it may help stroke survivors to improve the motor function of

upper limb. Their activities of daily living can be improved and, as the result, quality

of their lives.

For the health care providers’ aspect, patients under mirror therapy require less

manpower for supervision. After simple education to patients, they can perform

mirror therapy by themselves. Nurses may maximize their usage of time and provide

sufficient training for patients even in the situation of shortage in manpower. Nurses

can also have more involvement in the rehabilitation process despite bed side care.

For hospital aspect, mirror therapy requires only simple equipment and less

manpower. Less cost is needed to provide the treatment. Besides, better rehabilitation

progress may shorten patients’ length of stay in the hospital and reduce the

re-admission rate. These may further lower the cost of providing the services.

In conclusion, an effective evidence-based mirror therapy can improve patients’

8

upper limb motor function, enhance the rehabilitation care by the health care

providers and reduce the cost of stroke care due to shorten of patients’ hospitalization.

9

Chapter 2: Critical Appraisal

After discussing the affirming needs of mirror therapy and the significance of

carrying out mirror therapy to hemiparetic stroke patients, the searching strategies,

appraisal strategies and summary will be discussed in this chapter. Then the results of

the integrative review will be summarized and synthesized.

2.1 Search Strategies

2.1.1 Search Methodology

From 1st July, 2013 to 9

th July, 2013, systematic literature searching was done. It

was based on the research question about mirror therapy which was used to improve

the recovery of motor function on upper limb in hemiparetic stroke survivors.

Therefore, the searching process was focused on the population “stroke” patient and

the intervention “mirror therapy”. Two electronic bibliographic databases, “ProQuest”

and “PubMed”, were used. After screening of topic and abstract, relevant studies were

identified and the reference lists of the findings were also screened for any additional

one. Then the duplicated studies were removed.

2.1.2 Keywords

The following keywords were used for searching. They included “stroke or CVA

or cerebrovascular accident or cerebrovascular disease”, “rehabilitation” and “mirror

therapy or mirror therapy hand”. By combining these groups of keywords, studies

10

with the linkage of stroke and mirror therapy could be found.

2.1.3 Selection Criteria

During screening of topic and abstract, the following criteria were used to

narrow down the selection of studies. The searching strategies’ details and results

could be found in Appendix (A).

2.1.3.1 Inclusion Criteria

Intervention mirror therapy was the main focus of consideration during searching.

The included studies only examined stroke patients with paretic upper limb. Adult

population aged over 18 was the selected target group. Clinical trials, for example

randomized controlled trials (RCTs), were the priority type of studies. Only full text

available studies were included so that the detail of the studies could be accessed. The

outcome measures must include the measurement of upper limb’s function before and

after the intervention.

2.1.3.2 Exclusion Criteria

Studies which focused on the lower limb of stroke patients were excluded. Also,

studies were excluded if there was no measurement on motor function.

2.2 Appraisal Strategies

The quality assessment for all selected studies was done with the use of the

Scottish Intercollegiate Guidelines Network (SIGN) methodology checklist (Scottish

11

Intercollegiate Guidelines Network, 2013). As only clinical trials were included,

checklist SIGN for controlled trials was used. There were fourteen questions in the

checklist to evaluate the internal validity of the studies (SIGN, 2013). The results of

the quality assessment could be found in Appendix (B).

2.3 Appraisal Results

2.3.1 Searching Results

244 studies were identified and screened from the selected databases. Eight

studies which fulfilled the guidance of the inclusion and exclusion criteria were

selected (Altschuler et al., 1999; Atay et al., 2008; Baricich et al., 2013; Bayn et al.,

2012; Blasis et al., 2009; Chen et al., 2013; Cho et al., 2012; Dohle et al., 2009). The

rejected studies were mainly due to duplication, not focus on upper limb’s function or

availability of full text. No additional study was captured from their reference lists.

2.3.2 Overview of the Research Design

All of the selected studies were RCTs between the year of 1999 and 2013. This

type of studies was in high level of evidence and was suitable for drawing conclusion

about the effect of an intervention (Beck & Polit, 2008). They clearly addressed their

purpose of conducting the studies. One of the studies used planned crossover to yield

sample size (Altschuler et al., 1999). However, the effect of the intervention given

first could carry over to the second intervention and affect the results (Beck & Polit,

12

2008). No wash-out period was mentioned in the studies and this may lead to

potential bias.

2.3.3 Subject Allocation

6 of the studies included the randomization methods (Atay et al., 2008; Baricich

et al., 2013; Bayn et al., 2012; Chen et al., 2013; Cho et al., 2012; Dohle et al., 2009).

Concealment method was only mentioned in 3 of the studies (Atay et al., 2008; Chen

et al., 2013; Dohle et al., 2009). Selection bias could occur in the other studies which

may lead to biased sample and lower the quality of the randomization. Fortunately, all

of these studies did the comparison of the baseline measurement. Only one of the

studies’ patients had different characteristics at the start of the study which the time

since stroke of the subjects varied from 6 months to 26 years (Altschuler et al., 1999).

6 of the studies had single blinding to assessor while it could only be done for the

subject allocation because the treatment of mirror therapy could not be hided from the

subjects and the treatment providers (Altschuler et al., 1999; Atay et al., 2008;

Baricich et al., 2013; Blasis et al., 2009; Chen et al., 2013; Dohle et al., 2009).

Performance bias of the subjects could be present as blinding of subject was not

available.

2.3.4 Sample Size

Sample size calculation was mentioned in 6 studies to reach the required sample

13

size to minimize the risk for type II error (Atay et al., 2008; Baricich et al., 2013;

Bayn et al., 2012; Blasis et al., 2009; Chen et al., 2013; Dohle et al., 2009). However,

only two studies mentioned about Intention-to-treat (Bayn et al., 2012; Blasis et al.,

2009). The other studies did not include the dropout subjects and this could lead to

bias with positive treatment effect (Beck & Polit, 2008). Luckily, the dropout rate was

below 20% in most of the studies except the one with 21% in its control group (Chen,

2013). Some of the reasons for the dropout were that subjects refused follow-up,

moved to other district, were clinically deteriorated or died. Also, the problem of

unplanned crossover was not easy to appear as subjects could not do the intervention

without the mirror and all the intervention group were carried out individually except

the one mentioned as grouped mirror therapy (Bayn et al., 2012).

2.3.5 Application to Local Setting

In Hong Kong, stroke patients are usually transferred to stroke rehabilitation

ward after acute management. In seven studies, mirror therapy were used in

institutional base which was similar to local rehabilitation setting (Atay et al., 2008;

Baricich et al., 2013; Bayn et al., 2012; Blasis et al., 2009; Chen et al., 2013; Cho et

al., 2012; Dohle et al., 2009). The remaining one did not mention on it (Altschuler et

al., 1999). One study was conducted in Taiwan which was in Chinese race (Chen et al.,

2013). On instruments, only simple material is needed for mirror therapy. Patients

14

usually discharge from the local setting at most three months due to the shortage of

bed in Hong Kong. Only three studies started the therapy within this time frame

(Baricich et al., 2013; Bayn et al., 2012; Dohle et al., 2009).

2.3.6 Summary of Quality Appraisal

By the use of SIGN form, seven of the studies were graded as “acceptable (+)”

(Atay et al., 2008; Baricich et al., 2013; Bayn et al., 2012; Blasis et al., 2009; Chen et

al., 2013; Cho, et al., 2012; Dohle et al., 2009). The reason was that they could fulfill

60% to 80% of the criteria in the SIGN form. The failing criteria were mainly due to

the studies which had not mention about concealment method and could only do the

assessor blinded studies. Potential bias could alert their quality so they were graded as

acceptable.

The remaining one was only achieved 40% of the criteria. It was graded as

“unacceptable (0)” as there was not enough information provided in the studies like

randomization method, concealment. Furthermore, the measurement tool was

subjective self-rating scale which was not reliable (Altschuler et al., 1999).

2.4 Summary and Synthesis of Results

In this part, the results of the integrative review would be discussed. Based on

the studies with higher quality ranked acceptable, subjects had better improvement in

motor function of upper limb in mirror therapy group. Subjects received conventional

15

stroke rehabilitation program as usual. Then mirror therapy was added into their

program for motor function training (Atay et al., 2008; Baricich et al., 2013; Blasis et

al., 2009; Chen et al., 2013; Dohle et al., 2009). Details were summarized in the table

of evidence in Appendix (C).

2.4.1 Study Design

The study type of all the selected studies was RCTs. Two of them were multi-site

studies (Chen et al., 2013; Blasis et al., 2009). One of them was RCTs with planned

crossover studies (Altschuler et al., 1999). RCTs are the suitable type of study in

proving the effectiveness of an intervention.

2.4.2 Characteristics of the subjects

The comparisons of subject characteristics were summarized in Appendix (D).

The number of subjects in the studies ranged from 9 to 48. The baseline

characteristics of the patients in most of the studies were similar. All included studies

recruited subjects with the first time having stroke (Atay et al., 2008; Baricich et al.,

2013; Bayn et al., 2012; Blasis et al., 2009; Chen et al., 2013; Cho et al., 2012; Dohle

et al., 2009). The mean ages of the studies were between 54.2 and 67.2 years old. As a

result, adult patients were the priority type of recruitment. On the other hand, the sex

of the subjects varied from 45.8% male to 72.2% male. Although the sex was slightly

towards male, it was not significant and it showed that mirror therapy would be

16

suitable for both sex.

Mirror therapy could be applied to patients from sub-acute to chronic state. 6

studies focused on sub-acute patients (Atay et al., 2008; Baricich et al., 2013; Bayn et

al., 2012; Cho et al., 2012; Dohle et al., 2009) and one study focused on chronic

stroke patients (Chen et al., 2013). Baricich et al. (2013) recruited subjects in

sub-acute state with average 0.77 months after stroke whereas Chen et al. (2013)

recruited subjects with average 20.6 months after stroke. All of them showed

statistically significant results on upper limbs’ motor function of stroke patients.

However, the improvement of upper limb function in the chronic stage was less than

those in sub-acute stages. It was believed that mirror therapy had to start as earlier as

possible in order to achieve a better progress.

When talking about subjects’ level of severity, the higher the severity was, the

better the improvement was noted. According to Dohle et al. (2009), the study

recruited patients with severe hemiparesis. The improvement had around 6 times

when compared with baseline. Also, it was hard to have other treatment for severe

hemiparesis in real setting. Therefore, mirror therapy was suitable for paretic patients

especially with severe condition.

Two of the studies were conducted in Asian culture (Chen et al., 2013; Cho et al.,

2012) while the other six were in western culture (Altschuler et al., 1999; Atay et al.,

17

2008; Baricich et al., 2013; Bayn et al., 2012; Blasis et al., 2009; 2012; Dohle et al.,

2009). In both culture situations, results were statistically significant towards mirror

therapy group. Therefore, the intervention did not affected by culture issue and it was

generalizable to local setting.

Besides, following instruction was essential for the intervention. Therefore, most

of the studies mentioned the inclusion criteria about the cognitive function of the

subjects who could follow commands. Some of the studies involved the use of

Mini-Mental State Examination (MMSE) for excluding patients with poor cognitive

function (Atay et al., 2008; Baricich et al., 2013; Chen et al., 2013; Cho et al., 2012).

2.4.3 Intervention and Control

Six studies included the standard stroke rehabilitation program for the patients

(Atay et al., 2008; Baricich et al., 2013; Bayn et al., 2012; Blasis et al., 2009; Chen et

al., 2013; Dohle et al., 2009). It included the use of neurorehabilitation techniques like

electrical stimulation, occupational therapy, physiotherapy and speech therapy.

2.4.3.1 Consideration of Mirror

Simple equipment was needed for mirror therapy. From the reviewed studies, the

size of the mirror varied from the length 30cm to 120cm. The most important

consideration was whether the reflection of the non-paretic upper limb could be seen

by the patients themselves. Another issue was that it had to be easy to carry and could

18

be placed on the table with little support. A simple bed side table with lock could be

used to support the mirror which was placed perpendicular to the midline of the

patients.

2.4.3.2 Execution of Movement during Therapy

The non-paretic upper limb placed on the reflecting side. The movement of the

upper limb included flexion and extension of shoulder, elbow and wrist, supination

and pronation of forearm (Atay et al., 2008; Baricich et al., 2013; Blasis et al., 2009;

Chen et al., 2013; Cho, et al., 2012; Dohle et al., 2009). Other motion like squeezing

sponges, flipping card could also be used (Chen et al., 2013). Apart from the

non-paretic limb, bilateral movement, that was the movement of paretic upper limb as

best as possible together with non-paretic upper limb, was involved in two of the

studies (Chen et al., 2013; Dohle et al., 2009).

2.4.3.3 Therapy Intensity

All the selected studies used mirror therapy in the intervention group with total

treatment duration ranged from 10 (Atay et al., 2008; Bayn et al., 2012) to 20 hours

(Chen et al., 2013). The optimal duration of mirror therapy had to be at least 15 hours

in 4 weeks for the whole treatment. Those studies whose training duration of mirror

therapy equal to or more than 10 hours in 4 weeks had statistically significant results

on motor function improvement (Baricich et al., 2013; Blasis et al., 2009; Chen et al.,

19

2013; Cho et al., 2012; Dohle et al., 2009). One of the studies resulted insignificantly

in motor function improvement was possibly due to lack intensity with only 10 hours

in 5 weeks (Byan et al., 2012). Details could be referred to the table of comparison (II)

in Appendix (D).

2.4.3.4 Control Group

There were three types of control group. Sham therapy was the replace of mirror

with other materials or covered up which led to the surface without reflecting the

movement of the upper limb (Altschuler et al., 1999; Atay et al., 2008; Baricich et al.,

2013; Bayn et al., 2012; Blasis et al., 2009). The second type was that the mirror was

removed (Dohle et al., 2009) and the last type was not included any sham therapy but

the standard rehabilitation were extended with extra time which was the same as the

mirror group (Chen et al., 2013; Cho et al., 2012).

2.4.4 Data Collection

Most of the studies had pre- and post- treatment evaluation (Altschuler et al.,

1999; Atay et al., 2008; Baricich et al., 2013; Bayn et al., 2012; Chen et al., 2013; Cho

et al, 2012; Dohle et al., 2009). Four of the studies were conducted follow-up to

subjects ranged from 1 week to 24 weeks (Atay et al., 2008; Baricich et al., 2013;

Blasis et al., 2009; Chen et al., 2013). The significant result of mirror therapy group

still persisted in the follow-up measurement and this showed that the intervention had

20

long term effect.

2.4.5 Outcome Measurement

Among the selected studies, most of them used the mean differences of changes

between intervention and control group for comparison. They included the description

of effect size and p-value in their results (Atay et al., 2008; Baricich et al., 2013; Bayn

et al., 2012; Blasis et al., 2009; Chen et al., 2013; Cho, et al., 2012; Dohle et al., 2009).

Six studies mentioned about confidence interval or alpha level (Atay et al., 2008;

Baricich et al., 2013; Bayn et al., 2012; Blasis et al., 2009; Chen et al., 2013; Dohle et

al., 2009). Therefore, the results were precise and conclusion could be drawn from

their data. However, Altschuler et al. (1999) reported no information about p-value or

confidence interval. One of the reasons was that this study was the pilot study of using

mirror therapy on stroke patients. No data could be referred from the previous study.

As mentioned above that measurement of motor function for upper limb was the

inclusion criteria, all of the selected studies included these kind of measurements, for

example Fugl-Meyer Assessment, Action Research Arm Test (Atay et al., 2008;

Baricich et al., 2013; Bayn et al., 2012; Blasis et al., 2009; Chen et al., 2013; Cho, et

al., 2012; Dohle et al., 2009). Although they were introduced by different people, they

were the same type of assessment tools for motor function (Lyle, 1981; Fugl-Meyer et

al., 1975).

21

Activities of daily living measurement and the level of independence were

second most common outcome measurements (Atay et al., 2008; Baricich et al., 2013;

Bayn et al., 2012; Chen et al., 2013; Dohle et al., 2009). Since one of the important

points in rehabilitation was to help patient back to the society, their level of taking

care of themselves was an important issue. Therefore, most studies included this kind

of assessment.

Other measurements like spasticity, sensation, reaction time, neglect and pain

were used in the selected studies (Atay et al., 2008; Bayn et al., 2012; Blasis et al.,

2009; Chen et al., 2013; Dohle et al., 2009).

2.4.6 Results of the Studies

As the goal of this review was to find out the effectiveness of mirror therapy on

stroke patients, subjects among 6 of the studies had significant effect on improvement

of their motor function for upper limb when compared with the control group (Atay et

al., 2008; Baricich et al., 2013; Blasis et al., 2009; Chen et al., 2013; Cho, et al., 2012

& Dohle et al., 2009). Altschuler et al. (1999) also reported improvement of upper

limb function but using self-design rating scale without testing of validity and

reliability. Bayn et al. (2012) reported no significant difference on motor function

between intervention and control group due to the treatment intensity. Overall, mirror

therapy was beneficial to upper limb function of stroke survivors.

22

2.5 Implication

Mirror therapy in stroke rehabilitation was firstly introduced by Altschuler and

his colleague in 1999. The development is just having about fifteen years with slow

progress. As the mechanism involves our most complicated part “brain”, the studies

become far more difficult. Many areas remain only hypothesis and the recruitment of

subject’s characteristics are not specific enough. Further studies to the mechanism of

activation in brain area are needed with the use of imaging in stroke patients. Also,

vigorous studies are performed to find out a more precise target group of patients

which are the most beneficial from the therapy. Nevertheless, it is surprised that this

cheap, simple treatment can improve motor function of paretic upper limb. It is

possible to try in the clinical setting by nurses in order to know more about its effect

on stroke patients.

There was limitation for the studies in this integrative review. Since mirror

therapy required the participants to focus on the reflecting surface to get the virtual

image of the paretic limb. However, all of the studies did not measure on their

compliance during intervention. Further studies are needed to assess whether the

patient was focused to the task during intervention.

In conclusion, integrative review was done and seven papers were found with

acceptable quality. Evidence had showed that mirror therapy could improve the

23

recovery of stroke survivors’ upper limb motor function with long lasting effect. At

the same time, their activities of daily living were improved and, therefore, quality of

their lives. It could be used in adult patient without any restriction to sex. Optimum

intensity was needed to achieve the effect of improvement. Moreover, the training

needed to start as earlier as possible. Apart from movement of the limb alone, object

could be used during the procedure. The intervention could be applicable to local

setting and help stroke survivors during their rehabilitation process.

24

Chapter 3: Translation and Implementation

From the previous charter, the integrative review was proved that mirror therapy

was beneficial to the recovery of upper limb function in stroke patients. In order to

formulate the evidence-based practice guideline, the implementation potential of

mirror therapy will be examined according to the following aspects: proposed

audience and setting, transferability, feasibility and cost and benefit ratio.

3.1 Implementation Potential

3.1.1 Proposed Setting and Audience

The proposed local setting is the stroke rehabilitation wards in Hong Kong public

hospital and the target audience is the patients who are having stroke staying in the

wards. The rehabilitation wards include one male and one female ward which have 40

beds in each of the ward. About 50% of patients are diagnosed with stroke and they

need to undergo rehabilitation as another half are patients with other diagnosis. The

geriatric day hospital is the out-patient clinic for the follow-up session of the stroke

patients.

Before transferring to rehabilitation wards, stroke patients receive treatment in

acute medical setting. Then they transfer to rehabilitation wards when the condition is

stabilized. In rehabilitation phase in the proposed setting, patients are under

multidisciplinary care with doctor, nurse, physiotherapist, occupational therapist,

25

speech therapist, dietitian and social worker. A weekly conference is held to integrate

the information of patient’s progress between different disciplines. The average length

of stay in the rehabilitation unit is around 4 to 6 weeks which depends on the

condition and progress of the patients. Then follow-up is arranged for review in the

community. Some of them continue their treatment in geriatric day hospital or

out-patient clinic of physiotherapy and occupation therapy.

3.1.2 Transferability of the Findings

It is important to generalize and transfer the findings from the reviewed studies

to the proposed setting. The following session will be discussed about the

transferability of the findings.

3.1.2.1 Target Setting and Population

The proposed setting of rehabilitation wards is similar to the setting of the

reviewed studies with the purpose of providing institutional rehabilitation to stroke

patients before going back to the society. Both the proposed setting and the reviewed

studies include multidisciplinary care to the patients. They can provide similar

services and environment to stroke patients for rehabilitation. For example,

multidisciplinary team can be referred for rehabilitation needs. Furthermore, patient

characteristics are similar in terms of mean age and gender. They are mostly elderly

patients and include both sexes in the proposed setting.

26

On the other hand, the main difference of the target population is that they come

from different countries and culture. Two of the reviewed studies included Asian

population (Chen, 2013; Cho et al., 2012) which was similar to Hong Kong’s culture.

The others were from western countries (Atay et al., 2008; Baricich et al., 2013; Bayn

et al., 2012; Dohle et al., 2009). Although they may have cultural difference, the aim

of rehabilitation is the same. Also, as both cultures’ target population have positive

results towards mirror therapy, it is believed that culture difference may not affect the

application of the intervention and the intervention of the reviewed studies may fit the

target population.

3.1.2.2 Philosophy of Care

The philosophy of care for the reviewed studies is similar to the purposed

rehabilitation wards which its mission is to give holistic care to patients having stroke.

It aims at providing intensive rehabilitation and mobilizing patients as early as

possible so as to improve their quality of life by recovery of motor function. They can

be prepared to reintegrate to the community with independence. Besides, it

emphasizes multidisciplinary care which is the same as the proposed setting.

Therefore, the proposed setting matches the philosophy of care of the intervention.

3.1.2.3 Number of Patients Involved

Each of the wards contains 40 beds with approximately 50% of patients who are

27

diagnosed with stroke. The admission rate of stroke patients are around 30 patients

each month for both wards. When compared with the mean sample size in the

reviewed studies which is around 36 patients, it is less than the reviewed setting but

still there are sufficient numbers of patients who can be benefit from the proposed

intervention.

3.1.2.4 Duration for Implementation and Evaluation

As discussed in Chapter 2, in order to have statistically significant results, the

optimal duration of mirror therapy was about 4 weeks. It matches the average length

of stay 4 to 6 weeks in the proposed setting. After that, a 4 weeks follow-up session is

normally arranged for patient discharged from the proposed setting. Then further

follow-up session will be arranged at least for a year. Adequate follow-up provides

chances for evaluation of patients’ condition and motor function. It is the same as the

integrated review that follow-up is needed to assess mirror therapy’s long term effect.

3.1.3 Feasibility

This part is going to discuss the feasibility of carrying out a new intervention. It

is important to get consent from the colleague and to solve those practical problems.

3.1.3.1 Freedom of Implementation

Nurses have the freedom to carry out the intervention as they are the

nurse-in-charge for the patients accompanying patients most of the time. They can

28

provide treatment to patients for their best interest. They can also terminate the

intervention if it is inappropriate based on their professional judgment. Senior nurses

can provide supervision and advice to their staffs during implementing the

intervention. Weekly conference allows multidisciplinary discussion to evaluate the

progress of patients so as to determine the continuation of the proposed intervention.

3.1.3.2 Interference with Routine

Mirror therapy has minimal interference with the routine care. As mentioned in

the previous chapter, mirror therapy has an advantage of requiring less manpower for

supervision. The setup is also simple. Although, from the summarized results in

Chapter 2, it was recommended to have 15 hours in 4 weeks, which was 45 minutes in

each working day, was needed to have a therapeutic effect. Patients have around 2

hours free time in the afternoon every day which would be a suitable time to conduct

the intervention. As a result, the intervention may not have much interference with the

current staff functions.

3.1.3.3 Administration and Colleague Support

Administration approval and support is an important issue in hospital setting

when trying to carry out a new intervention. In the proposed setting, the

administration is positive towards evidence-based-practice’s intervention which

mirror therapy can be one of them. The organization has good attitude on new

29

intervention as regular “Kaizen” program is launched which allows colleague to share

and approve their new interventions. The administration supports the intervention by

allowing prior study in destined ward setting before carrying out to the other suitable

area.

However, as the shortage of manpower still persists in Hong Kong public

hospital, the new intervention may increase the workload of colleague in the proposed

ward setting. It is one of the potential barriers to the proposed intervention. Sufficient

explanation is needed to reinforce the needs and benefit of the intervention.

3.1.3.4 Skills and Training

Although nursing staffs and allied health colleagues have experience in carrying

out stroke rehabilitation, the proposed intervention is rather new to the field. The

skills include setting of the intervention, education to patients and the evaluation of

patient’s performance.

Therefore, before implementation of the intervention, briefing and training

session will be arranged for all frontline staffs to facilitate smoothness of the

intervention and to equip knowledge and skills for mirror therapy. Weekly evaluation

will be conducted to update the information and receive feedback from the frontline

staffs during implementation of the intervention.

For the training session, staffs need to spend extra time from working hours.

30

Compensation for extra working time can be given back to staff when available based

on the hospital policy. This can help to maintain the morale of the colleague in coping

new routine and extra workload.

3.1.3.5 Equipment and Facility

Since mirror therapy only needs a handy mirror, the cost is relatively low.

Bed-side tables and geriatric chairs are available with sufficient among in the

proposed setting. Patients can conduct the intervention along bedside during sit out

position and there is no need to transfer to other place.

Printer, paper and computer are needed in preparing training material and

assessment form. They are readily available in each proposed ward setting.

3.1.3.6 Measuring Tools for Evaluation

From the reviewed studies, the upper limb motor function is the evaluation

method for the patients under mirror therapy. Validated measuring tools, the Action

Research Arm Test and the Functional Independence Test, are available and the

occupational therapist in the proposed ward is professional in performing it. The skills

in performing the tool can be taught during skill training session with the help of

occupational therapist.

3.1.4 Cost and Benefit Ratio of Intervention

3.1.4.1 Potential Risk and Benefit of Patients

31

From the integrative review, there was no evidence showing any risk to the

patient during implementation of the mirror therapy. No adverse effect was noted

during the procedure (Altschuler et al., 1999; Atay et al., 2008; Baricich et al., 2013;

Bayn et al., 2012; Blasis et al., 2009; Chen et al., 2013; Cho et al., 2012; Dohle et al.,

2009).

When the proposed intervention is implemented, patients’ motor function is the

most significant benefit from it. According to the integrative review, their activities of

daily living increase and their quality of life improve (Atay et al., 2008; Baricich et al.,

2013; Blasis et al., 2009; Chen et al., 2013; Cho et al., 2012; Dohle et al., 2009). They

can have a shorter length of stay in the hospital. Better motor function also allows

them to reintegrate to the community easier than not having the intervention.

3.1.4.2 Potential Benefit of Staff and Hospital

From the view of administration, shorter length of hospitalization indicates better

use of public hospital facilities. The cost of caring each patient in the hospital can be

decreased and more money can be saved. Moreover, better reintegration of patient to

the community can lower the potential chance of re-admission. This can further lower

the burden of needs of the hospital facilities. In a long run, the quality of care

provided by the health care profession can be increased because they can have more

time to care the patients.

32

3.1.4.3 Potential Material Costs

The material costs are mostly come from the manpower, the mirror and the

training material. The table in Appendix (E) showed that the estimated sum of cost are

$55 220.

The amount for caring 40 patients in 4 weeks looks like a huge amount of money.

However, when comparing the Table of Material Cost on not implementing the Mirror

Therapy in Appendix (E), it is around 30% less cost when using the proposed

intervention. Thus, implementation of mirror therapy can probably lower the material

cost by shortening the length of hospitalization.

3.1.4.4 Potential Non-material Costs

In a short run, staffs morale may be affected due to increase workload on

carrying out the intervention. If the length of hospitalization and the re-admission rate

reduce, the workload will be deducted and the working environment will be improved.

The morale will be increased in long term.

On patients’ aspect, they can have a higher satisfaction when the intervention

helps them in recovery of motor function. They can have a better quality of life after

discharge.

In conclusion, after discussing the implementation potential of the intervention, it

should be carried out with slightly changes needed so that the intervention can be

33

carried out in the local setting.

34

Chapter 4: Developing an Evidence-based Practice

Guideline

As discussed the implementation potential in the last chapter, an evidence-based

practice guideline will be developed. Based on the reviewed studies, purpose,

objectives, target audience and recommendations will be generated and listed in this

chapter.

4.1 Title of the Evidence-based Guideline

An Evidence-based Guideline of Using Mirror Therapy to Promote Motor Function

Recovery of Upper Limb in Stroke Patient

4.2 Background

Stroke is the major cause of disability in Hong Kong. Nearly 25 000 people

suffered from stroke in 2010 (the Hospital Authority Statistical Report, 2011). Half of

them had the problem of hemiparesis (Beiser et al., as cited in American Heart

Association, 2011). It is important to help the stroke survivors to cope with this

disease before facing the community.

This guideline was based on the integrative review of eight studies which

discussed the effectiveness of mirror therapy on hemiparesis of upper limb in stroke

patients (Altschuler et al., 1999; Atay et al., 2008; Baricich et al., 2013; Bayn et al.,

2012; Blasis et al., 2009; Chen et al., 2013; Cho et al., 2012; Dohle et al., 2009).

35

4.3 Purpose and Objectives of Guideline

The main purpose of this guideline is to help nurses in using mirror therapy on

hemiparetic stroke patients. It aims at promoting the recovery of upper limb motor

function of stroke survivors.

The objectives of the Guideline are:

To summarize the clinical evidence for mirror therapy on hemiparetic stroke

patients;

To formulate clinical practice instructions for the use of mirror therapy based on

the best evidence;

To improve the recovery of motor function on paretic upper limb;

To maximize the usage of time for the health care profession and, at the same time,

provide sufficient training to the patients;

To shorten the length of stay of patients and reduce the re-admission rate.

4.4 Target Group

4.4.1 Target Audience

This guideline is for nurses who attend to stroke patient with the right to assess

and carry out intervention to help them from the disease.

4.4.2 Target Population

The guideline applies to stroke patients in stroke rehabilitation wards aged 18

36

years or above who has the problem of hemiparesis on upper limb with understanding

of simple instruction.

4.5 Level of Evidence and Grades of Recommendations

The recommendations were made based on the level of evidence and grades of

recommendations produced by SIGN (Scottish Intercollegiate Guidelines Network,

2011). The table of the level of evidence and grades of recommendations could be

found in Appendix (G).

4.6 Recommendations

Here were the recommendations of the guideline. The details were presented in

Appendix (F).

Recommendation 1: Mirror therapy is proved to be effective on improving recovery of

upper limb motor function in stroke patients.

(Grades of Recommendation: A)

Recommendation 2: Mirror therapy should be used in stroke patient aged above 18

years old with first time having stroke. Also, it can be applied to both sexes.

(Grades of Recommendation: A)

Recommendation 3: Mirror therapy should be applied to stroke patients from

sub-acute to chronic state.

(Grades of Recommendation: A)

37

Recommendation 4: Patients should be able to understand and follow verbal

instructions.

(Grades of Recommendation: A)

Recommendation 5: Sitting position with a mirror sized enough for patient to see his

entire upper limb is needed for the use of mirror therapy on training of upper limb in

stroke patients. The non-paretic upper limb is placed on the reflecting side. Patients

observe the motion of the non-paretic side in the mirror as if the motion of the paretic

side.

(Grades of Recommendation: A)

Recommendation 6: The movement of the upper limb includes flexion and extension

of shoulder, elbow, wrist and finger, pronation and supination of forearm, moving arm

from side to side. Objects can be involved in the motion like squeezing sponges,

placing object in holes, flipping card.

(Grades of Recommendation: A)

Recommendation 7: Bilateral movement, which is the movement of paretic upper limb

together with non-paretic upper limb, should be involved.

(Grades of Recommendation: A)

Recommendation 8: Conventional stroke rehabilitation program, for example

occupational therapy and physiotherapy, should be included apart from mirror

38

therapy.

(Grades of Recommendation: A)

Recommendation 9: Patients should be in priority when the severity of patient’s

paretic upper limb was higher.

(Grades of Recommendation: A)

Recommendation 10: Mirror therapy should be applied equal to or more than 10 hours

in 4 weeks.

(Grades of Recommendation: A)

Recommendation 11: Assessment and evaluation should be done prior and after the

application of mirror therapy:

Measuring tool the Action Research Arm Test is recommended to use to evaluate

the progress of the upper limb motor function.

Measuring tool the Functional Independence Test should be used to assess the

independence of patients.

(Grades of Recommendation: A)

Recommendation 12: Follow-up session should be arranged to evaluate patient’s

progress of the paretic upper limb function. It is recommended to follow the progress

at least for half year.

(Grades of Recommendation: A)

39

Chapter 5: Implementation Plan

After formulating the evidence-based guideline, in this chapter the

communication plan and the pilot test will be discussed to ensure the smoothness and

success of the intervention. To set up a good communication plan, identification of the

stakeholders will be the first step. Communication plan will be developed between

each party of stakeholders so that the program can be maintained in the proposed

setting. Then, the implementation process will be evaluated by pilot test. At last, the

mirror therapy can be delivered smoothly and the frontline staff can provide good

services to the patient with better cooperation.

5.1 Stakeholders Identification

Stakeholder is the one who may involve in the innovation of the mirror therapy.

Identification of stakeholder is important as cooperation and support is essential on

carrying out the intervention. The Chief of Service, the Department Operations

Manager, the Ward Managers, ward and day hospital nurses, allied healthcare workers

and the healthcare assistance are the main stakeholders of the intervention.

5.1.1 Administrators

Administrators are responsible for the usage of limited resource in the

department. The Chief of Service, the Department Operations Manager, the Ward

Managers of the stroke rehabilitation wards and geriatric day hospital are the

40

administrators of this intervention. They make decision to approve any program in the

department of rehabilitation. Seeking for their approval and support is needed before

implementation.

5.1.2 Trainers

The core team members of the implementation team are responsible for the

leading of mirror therapy program based on the guideline. The team is the trainer of

the mirror therapy program. The occupational therapist also provides support to the

team for educating the intervention providers based on the guideline.

5.1.3 Users of the Evidenced-based Guideline

The implementation team, ward nurses and the healthcare assistance are the users

of the guideline. They maintain the operation of the intervention. Apart from the ward

frontline staffs, the colleagues in the day hospital are the users of the guideline who

carry out the intervention during patient’s follow-up.

5.2 Communication Plan

5.2.1 Setting up a Team

Good communication is very important. At the beginning, setting up of the

implementation team is needed to initialize the intervention. The proposer will be the

coordinator of the team. Three advanced practiced nurses, three registered nurses and

one occupational therapist will be involved as the core team members.

41

The advanced practice nurses are experienced so that they can give advice inside

the implementation team. Further research can be made if needed in order to get the

best evidence. Moreover, the registered nurses can act as a link between proposer and

the frontline staffs of wards and day hospital in order to ensure the coordination of the

intervention. The occupational therapist is responsible for providing information on

mirror therapy and the assessment skills.

5.2.2 Communicating with Administrators

Getting approval is an important issue of the implementation team since the

administrators control the usage of limited resources like equipment, manpower or

expenditure. It is a must to get approval from them. Individual meeting will be

conducted to set up communication with the Ward Managers, the Department

Operations Manager and at last the Chief of Service of the rehabilitation department.

Firstly, the team will approach ward managers to get their support. Then, in order to

promote this idea to the Department Operations Manager and Chief of Service for

granting permission, presentation will be held with the use of demonstration and

visual aids. The content will include the background, objective, significance of the

program, reviewed evidence, implementation potential and the developed guideline

with literature support. Feedback will be obtained from the administrative view during

the meeting.

42

5.2.3 Briefing Session

After getting approval, briefing session will be conducted to the stakeholders.

Healthcare providers in the target setting may join the session to know more about the

intervention and share their opinions. It, therefore, can help the implementation team

to explore different point of views. At the same time, doubt can be solved to convince

those oppose the intervention. After the session, questions and opinions will be

investigated and changes can be made to improve the intervention so as to meet the

target setting.

5.2.4 Training Session

As mirror therapy needs to be learnt before application, a training session will be

held for the nurses involved. Procedure of the application and assessment skills will

be taught by the implementation team based on the evidence-based guideline.

Materials, the mirror, will be available for demonstration and practice. Printed notes

and guideline will be provided for refreshing memory. Feedback and difficulty of

using mirror therapy can be obtained during practice. Further clarification can be

instantly made during training.

5.2.5 Initiating, Guiding and Sustaining the Intervention

The implementation team will have the duty of designing the time schedule of

the intervention and its evaluation. They will also monitor the program regularly to

43

maintain the progress of the intervention. Difficulties will be reviewed during the

regularly meeting in order to update the guideline and remove any obstacles. The

process and the result will be reported to the administrators to get continuation of the

program. Appendix (H) shows the time frame of the mirror therapy program.

5.3 Pilot Test

Pilot test aims at testing the feasibility of the intervention and, as a result,

improving it (Beck & Polit, 2008). During the study, the intervention will be carried

out in a small scale with similar workflow. The intervention will be tested to see if it

contains any problem in each procedure. Evaluation of information taken provides an

opportunity to reveal and modify the limitation of the proposed intervention.

5.3.1 Aims and Objectives of Pilot Test

The main objectives of the pilot test are:

To assess the feasibility of implementing the intervention.

To determine any difficulty of subject recruitment;

To examine the evidence-based guideline in local setting;

To examine the acceptance of staffs;

5.3.2 Recruitment and Duration

The target setting will be the stroke rehabilitation units including one male and

one female ward. The follow-up session will be held in the clinic of geriatric day

44

hospital. The target recruitment will be 5 patients in each ward (10 in totals). Each

subject will receive mirror therapy in weekdays (5 patients x 5 days x 4 weeks = 100

sessions). Each nurse will have sufficient chance to practice the intervention with

accounting for the possibility of subject withdrawal. As mentioned in Chapter 3 that

the admission rate is around 30 patients every month, 2 weeks will be needed to

recruit sufficient among of subjects.

Furthermore, in Chapter 2 summarized that the optimal duration of mirror

therapy is about 4 weeks. Assessment will be done before and after intervention for

the two wards’ nurses to practice their skills. After that, follow-up session will be

carried out 2 weeks after discharge of subjects so that the workflow of doing

follow-up assessment can be tested. The nurses in day hospital will have the chance of

practicing assessment for the subjects. All in all, 4 months will be needed to carry out

the pilot test. Detail can be found in Appendix (H).

5.3.3 Evaluation of Pilot Test

Based on the objectives, the following methods are used to evaluate the results of

the pilot test.

5.3.3.1 Feasibility of Implementing Mirror Therapy

The link nurses in the team can receive feedbacks from frontline staffs in wards

and geriatric day hospital. Regular meeting between implementation team will be held

45

to discuss the progress of the pilot test. At the end, the difficulties collected will be

summarized and evaluated to update the guideline.

5.3.3.2 The difficulty of Subject Recruitment

Individual interview will be conducted to patients who withdraw from the study.

The interview will be focused on the reason behind the withdrawal and the problem of

the workflow.

5.3.3.3 The Evidence-based Guideline in Local Setting

The nurses have to record the time of each session provided to patients. This can

provide the information whether the intervention can be provided in busy local setting

based on the guideline. Reason of not completing the session can also be noted so that

the guideline can be modified to suit the local setting.

5.3.3.4 The Acceptance of Staffs

A simple questionnaire (Appendix (I)) will be used to the frontline staffs for

examining their acceptance of the intervention. It will be delivered to the staffs after

the last session of mirror therapy. It will mainly focus on their opinions about the

intervention with their usual practice and their suggestions on conducting the whole

program.

46

Chapter 6: Evaluation Plan

Evaluation plan is needed to assess the effectiveness of the mirror therapy to the

local clinical setting. The aim of the mirror therapy is to promote the recovery of

motor function of upper limb on hemiparetic stroke patients. Thus, the outcome of the

mirror therapy is the upper limb motor function and the level of activities of daily

living. The satisfaction level is assessed for patients and healthcare provider.

6.1 Identifying Outcomes

6.1.1 Patient Outcomes

6.1.1.1 Primary Measurement

The measuring tool, the Action Research Arm Test, will be the primary outcome

measurement of mirror therapy to assess the recovery of upper limb motor function of

the patients (Baricich et al., 2013; Bayn et al., 2012; Dohle et al., 2009). It was highly

specific to assess the changes in upper limb function and it was used for evaluation of

clinical treatment (Lyle, 1981). In the test, Score ranged from 0 to 57 is recorded. 4

sub-scales, including grasp, grip, pinch and gross movement, are involved to assess

the function of the upper limb.

6.1.1.2 Secondary Measurement

For the secondary outcome measurement, the Functional Independence Measure

will be used to assess the self-caring ability (Baldry et al., 1995). The motor part will

47

be chosen as the motor function will be the focus of the studies with total score ranged

from 13 to 91. Eating, Bathing, toileting, dressing, grooming, bowel and bladder

control, transfer and mobility are involved in the measurement. It was widely used

assessment tools in the local setting for assessing stroke patient (Cheng et al., 2010)

and was also used in the reviewed studies (Atay et al., 2008; Baricich et al., 2013;

Dohle et al., 2009).

6.1.1.3 Level of Satisfaction (Patient)

A descriptive patient satisfaction survey will be used to assess the satisfaction of

patient on mirror therapy. Statements will be ranked by the patients from “very

unsatisfied” to “extremely satisfied”. Then Score represents each level and the sum of

the score can be calculated. The higher the score, the better the satisfaction level will

be. Appendix (J) shows the sample of the patient satisfaction survey.

6.1.2 Healthcare Providers Outcomes

The Outcome of the healthcare providers will be to measure their level of

satisfaction on this program.

6.1.2.1 Level of Satisfaction (Staff)

A staff satisfaction survey will be delivered to the healthcare providers to assess

their satisfaction level on the program. Score of 1 to 5 will be recorded in each

question. The higher the score means that the satisfaction level is higher. The

48

questions in the survey will focus on the information provided, workload, cooperation

between colleague and their knowledge on mirror therapy. Detail can be found in

Appendix (K).

6.1.3 System Outcomes

The patient’s length of hospitalization will be the system outcome measure in the

evaluation plan.

6.1.3.1 Length of Hospitalization

It refers to the number of days that the patients stay in the hospital. It starts from

the day of admission to the discharge day. This number can reflect the effectiveness of

the mirror therapy by showing whether this program can shorten the patients’ length

of hospital stay.

6.2 Nature of Subjects

Subjects will be included in the study when they are diagnosed with first time

having stroke with hemiparesis, adult with aged over 18 and they can follow

commands. Moreover, they have to be the patients admitted to the stroke

rehabilitation department.

6.3 Number of Subjects

In order to calculate the change of motor function before and after the

intervention with the use of measuring tools Action Research Arm Test, paired t-test is

49

used with the power of 0.8 and alpha 5%. The effect size is 0.6. As a result, 24

subjects are needed to be recruited. However, the dropout rate from the reviewed

studies is between 0% and 21% (Baricich et al., 2013; Chen et al., 2013). Since

follow-up will be needed for the studies, the possibility of dropping out of studies has

to be considered. When calculating the worst situation that 21% of subjects will be

dropped out of the studies, at least 31 subjects will be required to ensure a sufficient

number of subjects for the studies. Below is the calculation:

Required sample size: 24+7= 31 subjects

Dropout subjects: 31 x 21% = 6.51, ~7 subjects

6.4 Data Collection

For the patient outcomes, as discussed in the evidence-based guideline that the

measurement should be done before and after the intervention. Subjects will receive

baseline assessment for upper limb motor function and independence measure before

application of mirror therapy. Demographics details of patients will also be collected

at the same time. After 4 weeks mirror therapy treatment, post assessment will be

given to subjects before discharged to the community.

From the reviewed studies, 4 and 24 weeks are recommended to assess the

recovery of motor function after mirror therapy (Atay et al., 2008; Baricich et al.,

2013; Chen et al., 2013) Therefore, the motor function and independence

50

measurements will be assessed in the geriatric day hospital at 4 and 24 weeks after

discharge.

For the level of satisfaction of patients and healthcare providers, the satisfaction

survey will be delivered to them before and after the implementation. On the other

hand, the length of hospitalization will be collected after each discharge of the

patients.

6.5 Data Analysis

To compare the progress of patients before and after mirror therapy on the upper

limb motor function and the level of independence, paired t-test will be used to

compare the difference at baseline, week 4 and week 24.

For the satisfaction level of patients and healthcare providers, paired t-test will

be used to compare the difference of mean score before and after implementation of

mirror therapy.

For the patients’ length of hospitalization, paired t-test will also be used to

compare between the average length of stay and the length of stay in the hospital

database.

This quantitative data will be analyzed using the Statistical Package for the

Social Science (SPSS) for Windows.

51

6.6 Basis Criteria of Effective Guideline

The evaluation objectives is to determine whether there is significant

improvement in patient’s upper limb motor function, level of independence for

patients, level of satisfaction for patients and staffs and the length of hospitalization of

patients.

6.6.1 Upper Limb Motor Function of Patients

With the use of measuring tools Action Research Arm Test, mirror therapy will

be an effective treatment if there is significant improvement of upper limb motor

function on paretic side in the follow-up sessions when compared with the baseline

assessment.

In the reviewed studies, the significant improvement ranges from 12% to 585%

with different severity of impairment (Detail can be referred to Appendix (D)).

Therefore, the target improvement is more than 12% on the recovery of upper limb

motor function on paretic side.

6.6.2 Level of Independence of Patients

The secondary outcome is the improvement of level of independence of patients

based on the Functional Independence Measure. There were significant improvements

between 35% and 79% in the reviewed studies (Atay et al., 2008; Baricich et al., 2013;

Dohle et al., 2009). As a result, it is said to be effective when the level of

52

independence increases with at least 35% when compared with the baseline

assessment.

6.6.3 Level of Satisfaction of Patients

For the satisfaction level of patients, it is said to be an effective outcome if the

mean score before intervention is higher than the score after intervention.

6.6.4 Level of Satisfaction of Staffs

The healthcare providers outcomes is the increase of level of satisfaction based

on the self-designed satisfaction questionnaire. It is said to be effective if the mean

score after the implementation is higher than baseline.

6.6.5 Length of Hospitalization

The hospital can lower the material cost by shortening the length of stay of the

patients. It is said to be effective if it helps the patients to stay shorter in the hospital.

53

Chapter 7: Conclusion

From the eight reviewed studies, the results provide information to develop the

evidence-based guideline of mirror therapy for patients suffered from stroke with

hemiparesis. It is proved that mirror therapy program benefited upper limb motor

function recovery in stroke patients in acute to chronic phase.

By assessing the implementation potential, the proposed intervention can be

modified to fit the proposed setting. It is possible to incorporate into the usual practice

so that the stroke patients can receive a better rehabilitation progress. Pilot test

provides a chance to run the program in order to review and modify the intervention

by removing the obstacles. After that, implementation plan is used to improve

communication between different parties during conduction of intervention.

Evaluation plan is required to review the effectiveness of the intervention.

Based on the evidence-based guideline, it is believed that the healthcare

providers can cooperate effectively to provide mirror therapy to the patients and this

program can help the patients to cope with the disease of stroke. It can become one

part of the stroke rehabilitation program. However, further research is needed on

program’s application time, content and target population’s characteristics.

54

Appendix (A): Flow Chart of the Search Strategy

Stroke/ Post stroke/ Stroke

rehabilitation/ CVA/ CVA

rehabilitation/ Post CVA/

Cerebrovascular accident/

cerebrovascular disease

Mirror therapy/ Mirror therapy

and stroke/ Mirror therapy

rehabilitation/ Mirror therapy

hand

PubMed ProQuest

7/7/2013 9/7/2013

204 40

Topic screened

and abstract

read

Number of

selected articles 8 4

Selected articles

without

duplication

Search date

Database

Search

item

Article reviewed

from reference

list

Final Selection

8

0

8

Search Result

1 2

365825 7423 484257 6321 1 or 2

1 and 2 289 300

55

Appendix (B): Quality Assessments of the Articles [SIGN form (2012)]

Article

Statement

Baricich et al.

(2013)

Chen et al.

(2013)

Bayn et al.

(2012)

Cho et al.

(2012)

Blasis et al.

(2009)

Dohle et al.

(2009)

Atay et al.

(2008)

Altschuler et al.

(1999)

Section 1: Interval Validity

1.1 The study

addresses an

appropriate and

clearly focused

question

Yes Yes Yes Yes Yes Yes Yes Yes

1.2 The assignment

of subjects to

treatment groups is

randomized

Yes

(Randomization

scheme

generated by

software)

Yes

(Randomly

extracted

envelopes)

Yes

(Computer-gen

erated random

number

sequence)

Yes

(Random

allocation

software)

Can’t say

(Not mention

the method)

Yes

(Envelopes

with

randomization

sequence)

Yes

(Computer-gen

erated random

number list

with blocks)

Can’t say

(Not mention

the method)

1.3 An adequate

concealment

method is used

Can’t say Yes

(Sealed

envelopes)

Can’t say Can’t say Can’t say Yes

(Sealed

envelopes)

Yes

(Blinded doctor

for

randomization)

Can’t say

1.4 Subjects and

investigators are

Yes, assessor

blinded

Yes, assessor

blinded

No Can’t say Yes, assessor

blinded

Yes. Assessor

blinded

Yes. Assessor

blinded

Yes, assessor

blinded

56

Article

Statement

Baricich et al.

(2013)

Chen et al.

(2013)

Bayn et al.

(2012)

Cho et al.

(2012)

Blasis et al.

(2009)

Dohle et al.

(2009)

Atay et al.

(2008)

Altschuler et al.

(1999)

kept ‘blind’ about

treatment allocation

1.5 The treatment

and control groups

are similar at the

start of the trial

Yes Yes Yes Yes Yes Yes Yes No

(1 subject’s

time since

stroke was

different from

the others)

1.6 The only

difference between

groups is the

treatment under

investigation

Yes Yes Yes Yes Yes Yes Yes Yes

1.7 All relevant

outcomes are

measured in a

standard, valid and

reliable way

Yes Yes Yes Yes Yes Yes Yes Yes

1.8 What

percentage of the

I: 13/13: 0%

C:12/13: 3.8%

I: 11/16: 15%

(5 lost

I(1): 15/18: 5%

(3 discharged)

I: 13/14: 3.6%

(1 low

I: 22/24: 4.2%

(1 moved to

I: 6/18: 16.7%

(1 transferred

I: 17/20: 7.5%

(3 lost

I: 9/9: 0%

C: 9/9: 0%

57

Article

Statement

Baricich et al.

(2013)

Chen et al.

(2013)

Bayn et al.

(2012)

Cho et al.

(2012)

Blasis et al.

(2009)

Dohle et al.

(2009)

Atay et al.

(2008)

Altschuler et al.

(1999)

individuals or

clusters recruited

into each treatment

arm of the study

dropped out before

the study was

completed?

*Intervention group

=I

Control group =C

**follow-up/begin:

dropout rate

(1 new stroke

episode)

follow-up)

C: 10/17: 21%

(7 lost

follow-up)

I(2): 16/21:

8.3%

(2 discharged, 2

withdrawal, 1

died)

C: 18/21 =5%

(2 discharged, 1

withdrawal)

participation

rate)

C: 13/14: 3.6%

(1 low

participation

rate)

other city, 1

used other

treatment)

C: 17/24:

14.6%

(3 used other

treatment, 4

withdrawal)

out, 4 due to

insurance, 1

withdrawal)

C: 12/18:

16.7%

(2 transfer out,

1 deterioration,

1 due to

insurance, 2

withdrawal)

follow-up)

C: 19/20: 2.5%

(1 lost

follow-up)

(Planned

cross-over with

9 subjects)

1.9 All the subjects

are analyzed in the

groups to which

they were randomly

allocated (often

referred to as

intention to treat

analysis)

No No Yes No Yes No No No

58

Article

Statement

Baricich et al.

(2013)

Chen et al.

(2013)

Bayn et al.

(2012)

Cho et al.

(2012)

Blasis et al.

(2009)

Dohle et al.

(2009)

Atay et al.

(2008)

Altschuler et al.

(1999)

1.10 Where the

study is carried out

at more than one

site, results are

comparable for all

sites

Not applicable Can’t say

(No site

specific data

available)

Not applicable Not applicable Can’t say

(No site

specific data

available)

Not applicable Not applicable Not applicable

Section 2: Overall Assessment of the Study

2.1 How well was

the study done to

minimize bias?

- High quality (++)

- Acceptable (+)

- Low quality (0)

+ + + + + + + 0

2.2 Taking into

account clinical

considerations, your

evaluations of the

methodology used,

and the statistical

power of the study,

-Performance

bias was

present as

blinding of

subject was not

available

-Selection bias

-Performance

bias was

present as

blinding of

subject was not

available

-Overall effect

-Performance

bias was

present as

blinding of

subject was not

available

-Detection bias

-Performance

bias was

present as

blinding of

subject was not

available

-Detection bias

-Performance

bias was

present as

blinding of

subject was not

available

-Selection bias

-Performance

bias was

present as

blinding of

subject was not

available

-Overall effect

-Performance

bias was

present as

blinding of

subject was not

available

-Overall effect

-Performance

bias was

present as

blinding of

subject was not

available

-Selection bias

59

Article

Statement

Baricich et al.

(2013)

Chen et al.

(2013)

Bayn et al.

(2012)

Cho et al.

(2012)

Blasis et al.

(2009)

Dohle et al.

(2009)

Atay et al.

(2008)

Altschuler et al.

(1999)

are you certain that

the overall effect is

due to the study

intervention?

may be present

as unclear about

concealment

-Overall effect

was due to the

intervention

although mild

potential bias

was present

was due to the

intervention

although mild

potential bias

was present

was present as

no blinding was

noted

-Selection bias

may be present

as unclear about

concealment

-Overall effect

was due to the

intervention

although mild

potential bias

was present

may be present

as blinding of

assessor was

unclear

-Selection bias

may be present

as unclear about

concealment

-Overall effect

was due to the

intervention

although mild

potential bias

was present

may be present

as unclear about

concealment

-Overall effect

was due to the

intervention

although mild

potential bias

was present

was due to the

intervention

although mild

potential bias

was present

was due to the

intervention

although mild

potential bias

was present

was present as

unclear about

randomization

and

concealment

- Carry over

effect due to

crossover

method, no

wash out period

was mentioned

- Sample size

was small

-Overall effect

was highly

affected by the

potential bias

2.3 Are the results

of this study

directly applicable

Yes Yes Yes Yes Yes Yes Yes No

60

Article

Statement

Baricich et al.

(2013)

Chen et al.

(2013)

Bayn et al.

(2012)

Cho et al.

(2012)

Blasis et al.

(2009)

Dohle et al.

(2009)

Atay et al.

(2008)

Altschuler et al.

(1999)

to the patient group

targeted by this

guideline?

2.4 Notes:

Summaries the

authors’

conclusions. Add

any comments on

your own

assessment of the

study, and the

extent to which it

answers your

question and

mention any areas

of uncertainty

raised above.

The mirror

group had more

improvement in

upper limb

motor recovery

than control

group.

The mirror

group had more

improvement in

upper limb

motor recovery

than control

group but there

was no

difference on

ADL

performance.

There was no

significant

difference

between mirror

or control group

The mirror

group had more

improvement in

upper limb

motor recovery

than control

group

The mirror

group had more

improvement in

reducing pain

and enhancing

upper limb

motor function

than control

group

The mirror

group had more

improvement in

distal function

than control

group.

The mirror

group had more

improvement in

motor recovery

and

hand-related

functioning

than control

group. There

was no effect

on spasticity

The mirror

group had more

improvement in

motor recovery

of upper limb

than control

group but

majority of

potential bias

was present

which may

affect the result

Abbreviation: ADL =Activities of Daily Living

61

Appendix (C): Table of Evidence

Remarks:

*Sham therapy: Placebo treatment

**Bilateral movement: Apart from moving the non-paretic upper limb, moving of paretic upper limb as best as possible is also encouraged

***Effect size: The values of the results were the difference of mean score between the follow-up and baseline assessment. E.g. mean difference

(group) [p value]

Bibliographic

Citation

Study

type

Level of

Evidence

Patient

Characteristics

Interventions Comparison Length of

follow-up

Outcome measure Results and effect size***

Baricich et

al.

(2013)

RCTs 1+ - n =26

- Mean age

=66.6

- Male sex

=50%

- Mean time

since stroke

=0.77months

- First stroke

- ARAT at

baseline

=18.45/57

MT (n=13):

Detail

- Flexion /extension of

shoulder , elbow, wrist

- Pronation /supination

of forearm

Duration

- 30 min /day, 5 times

/week (first 2 weeks), 1

hour /day, 5 times /week

(last 2 weeks)

- Total time =15 hours

CT (n=13):

Detail

- Reflecting

part of the

mirror was

covered with

paper

Duration

- Same as MT

- Baseline

- 4 weeks

follow-up

Primary

1. ARAT

Secondary

2. MI

3. FIM

After 4 weeks,

-MT had greater improvement in

upper limb function than CT

1. 31.74 (MT) vs 12.67 (CT)

[p<0.05]

2. 36.73 (MT) vs 14.75 (CT)

[p<0.05]

-MT had greater improvement in

independence than CT

3. 41.18 (MT) vs 21.75 (CT)

[p<0.05]

62

(32.4%)

Remarks:

Assessor was blinded. Subject could not be blinded due to the intervention.

Abbreviation: CT = Control therapy, MT = Mirror therapy, ARAT = Action Research Arm Test, MI = Motricity Index of upper limb, FIM = Functional Independence

Measure

63

Bibliographi

c Citation

Study

type

Level of

Evidence

Patient

Characteristics

Interventions Comparison Length of

follow-up

Outcome

measure

Results and effect size***

Chen et al.

(2013)

RCTs 1+ - n =33

- Mean age

=54.2

- Male sex

=70%

- Mean time

since stroke

=20.6months

- Mean MMSE

=28.5

- FMA at

baseline =45.2

(68.5%)

MT (n=16):

Detail

- Squeezing sponges

/placing pegs in holes

/flipping card /touch

a switch or keyboard

- Flexion /extension

of wrist, finger

- Pronation

/supination of

forearm

- Bilateral

movement**

Duration

- 60 min /day, 5 days

/week, for 4 weeks

- Total time =20

hours

CT (n=17):

Detail

- Task-oriented

functional

practice for

motor control

training

- No sham

therapy*

Duration

- same as MT

- Baseline

- Post

treatment

- 24 weeks

follow-up

Primary

1. FMA

2. Kinematic

analysis

Secondary

3. rNSA

4. MAL

(Amount of

use)

5. MAL

(Quality of

movement)

6. ABILHAN

D

Post-treatment,

-MT had greater improvement in

upper limb function than CT

1. 5.31 (MT) vs 3.47(CT)

[p<0.05]

-MT had shorter reaction time

than CT

2. -0.06 (MT) vs 0.01 (CT)

[p<0.05]

-MT improved insignificantly in

sensation than CT

3. 12.63 (MT) vs 1.5 (CT)

[p=0.1]

On 24 weeks follow-up,

-No significant improvement of

ADL in MT was noted

4. 0.61 (MT) vs 0.44 (CT)

[p=0.45]

5. 0.77 (MT) vs 0.56 (CT)

[p=0.45]

64

6. 7.86 (MT) vs 9.06 (CT)

[p=0.43]

Remarks:

Assessor was blinded. Subject could not be blinded due to the intervention.

Multi-site studies: No site specific data was available.

Abbreviation: CT = conventional therapy, MT = mirror therapy, FMA =Fugl-Meyer Assessment, rNSA =Revised Nottingham Sensory Assessment, MAL = Motor Activity

Log, ADL =Activities of Daily Living

65

Bibliographic

Citation

Study

type

Level of

Evidence

Patient

Characteristics

Interventions Comparison Length of

follow-up

Outcome

measure

Results and effect size***

Bayn et al.

(2012)

RCTs 1+ - n =60

- Mean age

=67.2

- Male sex

=58%

- Mean time

since stroke

=1.5months

- First stroke

- ARAT at

baseline

=0.69/57

(1.2%)

- FMA at

baseline =4.1

(6.2%)

iMT (n=18):

Detail

- First week:

isolated

movements of

fingers, wrist,

lower arm, elbow

and shoulder joints

- Second & third

week: putting a ball

or bigger squares in

different directions

/moving sticks

/wipe-like

movements with a

cloth.

- Bilateral

movement**

Duration

- 30 min /day, 20

CT (n=21):

Detail

- same as

gMT but

wooden

board was

used

Duration

- Same as

gMT

gMT

(n=21):

Detail

- same as

iMT but

group of 2-6

patients was

used

Duration

- Baseline

- Post

treatment

Primary

1. ARAT

2. FMA

(Motor)

Secondary

3. BI

4. SIS

5. FMA

(arm

somatos

ensory)

6. FMA

(Range

of

motion)

7. FMA

(Pain)

8. MAS

(Finger)

Post-treatment,

-MT showed no effect on motor function of

upper limb, ADL & QoL

1. 3.4 (iMT), 1.1 (gMT) vs 2.8 (CT)

[p>0.05]

2. 3.2 (iMT), 5.1 (gMT) vs 5.2 (CT),

[p>0.05]

-No significant improvement of ADL, QoL in

MT was noted

3. 11.9 (iMT), 12.5 (gMT) vs 15.0 (CT),

[p>0.05]

4. 9.5 (iMT), 8.2 (gMT) vs 7.3 (CT),

[p>0.05]

-No significant improvement of upper limb

sensory, ROM and pain in MT was noted

5. 0.7 (iMT), 0.9 (gMT) vs 0.3 (CT),

[p>0.05]

6. -0.9 (iMT), -1.6 (gMT) vs -2.2 (CT),

[p>0.05]

7. -1.3 (iMT), -1.8 (gMT) vs -2.3 (CT),

66

sessions in 5 weeks

-Total time =10

hours

- Same as

iMT

9. MAS

(Wrist)

10. SCT

[p>0.05]

-No significant improvement of resistance in

movement for finger and wrist in MT was

noted

8. 1 (iMT), 0 (gMT) vs 0 (CT), [p<0.05]

9. 0 (iMT), 0 (gMT) vs 0 (CT), [p>0.05]

-MT had improvement on visuospatial neglect

10. 20 (iMT), 4.4 (gMT) vs -2.3 (CT),

[p<0.01]

Remarks:

Insignificant results may due to the duration (10 hours only) and intensity (5 weeks) of treatment.

There is no blinding.

Abbreviation: CT = Conventional therapy, iMT = Individual Mirror therapy, gMT =Group Mirror Therapy, FMA =Fugl-Meyer Assessment, ARAT =Action Research Arm

Test, BI =Barthel Index, SIS =Stroke Impact Scale, MAS =Modified Ashworth Scale, SCT =Star Cancellation Test, ADL =Activities of Daily Living, QoL =Quality of Life

67

Bibliographic

Citation

Study

type

Level of

Evidence

Patient

Characteristics

Interventions Comparison Length of

follow-up

Outcome measure Results and effect size***

Cho et al.

(2012)

RCTs 1+ - n =26

- Mean age

=57.1

- Male Sex

=57.7%

- Mean time

since stroke

=3.55months

- Mean MMSE

=25.4

- FMA at

baseline =19.1

(28.9%)

MT (n=14):

Detail

- Flexion

/extension of

elbow, wrist, hand

- Moving arm

from side to side

- Tapping the table

Duration

- 25 min x2 /day, 5

times /week, for 4

weeks

- Total time =16.7

hours

CT (n=14):

- No sham

therapy*

- Baseline

- Post

treatment

Primary

1. FMA (Shoulder

/elbow

/forearm)

2. FMA (Wrist)

3. FMA (Hand)

4. FMA

(Coordination)

5. BS (Upper

limb)

6. BS (Hand)

Secondary

7. MFT (Upper

limb)

8. MFT (Hand)

Post-treatment,

-MT had greater improvement in

upper limb motor function than CT

1. 9.5 (MT) vs 4.6 (CT) [p=0.001]

2. 2.8 (MT) vs 1.1 (CT) [p=0.013]

3. 4.2 (MT) vs 1.5 (CT) [p=0.017]

4. 0.7 (MT) vs 0.4 (CT) [p=0.278]

5. 1.8 (MT) vs 0.7 (CT) [p=0.02]

6. 1.9 (MT) vs 0.5 (CT) [p=0.002]

7. 5.0 (MT) vs 2.2 (CT) [p=0.004]

8. 3.1 (MT) vs 0.5 (CT) [p=0.001]

Remarks:

Blinding & concealment did not be mentioned in the article.

Abbreviation: CT = conventional therapy, MT = mirror therapy, FMA = Fugl-Meyer Assessment, BS = Brunnstrom Stages, MFT = Manual Function Test

68

Bibliographic

Citation

Study

type

Level of

Evidence

Patient

Characteristics

Interventions Comparison Length of

follow-up

Outcome measure Results and effect size***

Blasis et al.

(2009)

RCTs 1+ - n =48

- Mean age =58.3

- Male sex

=45.8%

- Mean time since

stroke =5months

- First stroke

- WMFT at

baseline =3.55/5

(71.0%)

MT (n=24):

Detail

- Flexion /extension of

shoulder, elbow, wrist

- Pronation /supination

of forearm

Duration

- 30 min /day, 5

sessions /week, for 1st

& 2nd week

- 60 min /day, 5

sessions /week, for 3rd

& 4th week

- Total time =15 hours

CT (n=24):

- Same as MT

but covered

mirror

Duration

- same as MT

- Baseline

- 1 week

follow-up

- 24 weeks

follow-up

Primary

1. Pain score

at rest

2. Pain score

on

movement

3. Pain tactile

allodynia

Secondary

4. WMFT

(functional

ability)

5. WMFT

(performanc

e time)

6. MAL

After 24 weeks,

-MT had greater pain control on upper limb

than CT

1. -2.9 (MT) vs 0.6 (CT) [p<0.001]

2. -3.9 (MT) vs 0.3 (CT) [p<0.001]

3. -3.3 (MT) vs 0.3 (CT) [p<0.001]

-MT had greater improvement in upper

limb motor function than CT

4. -1.6 (MT) vs 0.6 (CT) [p<0.001]

5. -2.0 (MT) vs 1.6 (CT) [p<0.001]

6. 2.3 (MT) vs 0.3 (CT) [p<0.001]

Remarks:

Assessor was blinded. Subject could not be blinded due to the intervention.

Abbreviation: CT = conventional therapy, MT = mirror therapy, WMFT = Wolf Motor Function Test

69

Bibliographic

Citation

Study

type

Level of

Evidence

Patient

Characteristics

Interventions Comparison Length of

follow-up

Outcome

measure

Results and effect size***

Dohle et al.

(2009)

RCTs 1+ - n =48

- Mean age

=56.5

- Male sex

=72.2%

- Mean time

since stroke

=0.9months

- First stroke

- ARAT at

baseline =0.7/57

(1.23%)

MT (n=18):

Detail

- Execution of arm,

hand, finger postures

- Bilateral movement**

Duration

- 30 min /day, 5 days

/week, for 6 weeks

- Total time =15 hours

CT (n=18):

Detail

- No mirror

- Movement

of both hand

Duration

- Same as MT

- Baseline

- Post

treatment

Primary

1. FMA

(hand

section)

2. ARAT

Secondary

3. FIM

4. Neglect

score

Post treatment,

-MT had greater improvement in

upper limb motor function than CT

1. 4.4 (MT) vs 1.4 (CT) [p<0.05]

2. 4.1 (MT) vs 3.1 (CT) [p<0.05]

-MT had greater improvement in

ADL than CT

3. 18.3 (MT) vs 16.9 (CT)

[p>0.05]

-MT had greater improvement on

neglect than CT

4. 0.9 (MT) vs 0.2 (CT) [p=0.005]

Remarks:

Assessor was blinded. Subject could not be blinded due to the intervention.

Randomization (Envelopes with randomization sequence) and concealment (Sealed envelopes) method were mentioned

Abbreviation: CT = Control therapy, MT = mirror therapy, FM = Fugl-Meyer assessment of upper extremity test, ARAT = Action Research Arm Test, FIM = Functional

Independence Measure, ADL =Activities of Daily Living

70

Bibliographic

Citation

Study

type

Level of

Evidence

Patient

Characteristics

Interventions Comparison Length of

follow-up

Outcome

measure

Results and effect size***

Atay et al.

(2008)

RCTs 1+ - n =36

- Mean age

=63.2

- Male sex

=52.8%

- Mean time

since stroke :5.5

months

- First stroke

- BS (Upper

limb) at

baseline =2.73

(45.5%)

MT (n=20):

Detail

- Flexion /extension of

wrist, finger

Duration

- 30 minutes /day, 5

days /week, for 4 weeks

- Total time =10 hours

CT (n=20):

Detail

- Same as MT

but covered

mirror

Duration

- Same as MT

- Baseline

- Post

treatment

- 24

weeks

follow-up

1. BS (Hand)

2. BS (Upper

limb)

3. MAS

4. FIM

self-care

items

At 24 weeks follow-up,

-MT had greater improvement in

upper limb motor function than CT

1. 1.4 (MT) vs 0.5 (CT)

[p=0.001]

2. 1.5 (MT) vs 0.3 (CT)

[p=0.001]

- No significant improvement of

spasticity in MT was noted

3. -0.3 (MT) vs -0.3 (CT)

[p=0.904]

-MT had greater improvement on

ADL than CT

4. 8.3 (MT) vs 1.8 (CT)

(p=0.001)

Remarks:

Assessor was blinded. Subject could not be blinded due to the intervention.

Randomization (Computer-generated random number list with blocks) and concealment (Blinded doctor for randomization) method were mentioned

Abbreviation: CT = conventional therapy, MT = mirror therapy, BS = Brunnstrom Stages, FIM = the Functional Independence Measure, MAS = Modified Ashworth Scale

71

Bibliographic

Citation

Study

type

Level of

Evidence

Patient

Characteristics

Interventions Comparison Length of

follow-up

Outcome measure Results and effect size***

Altschuler et

al.

(1999)

RCTs,

planned

crossov

er

1- - n=9

- Mean age

=58.2

- Male sex

=55.6%

- Mean time

from stroke :57.6

months

- Level of

severity =7

severe, 1

moderate, 1 mild

MT (n=9):

Detail

- 4 weeks MT, then 4

weeks CT

- Bilateral movement**

- Proximal and distal

movement

Duration

- 15 min x2 /day, 6

days /weeks, for 4

weeks

- Total time =12 hours

CT (n=9):

Detail

- 4 weeks CT,

then 4 weeks

MT

- Same as MT

but transparent

plastic sheet

was used

Duration

- Same as MT

- Baseline

- Post

treatment

- 4 weeks

follow-up

1. Self-rated

scale

-MT had greater improvement in

upper limb motor function than

CT

1. 0.36 (MT), 0.08 (CT)

[No P value]

Remarks:

Self-rated scale =Change from baseline in terms of range of motion, speed and accuracy (-3 to +3), 0 represent no change

1 subject’s time since stroke was largely different from the others and thus increased the mean time from stroke.

Assessor was blinded. Subject could not be blinded due to the intervention.

Randomization and concealment method were not mentioned.

Abbreviation: CT = conventional therapy, MT = mirror therapy

72

Appendix (D): Table of comparison (I)

Aspect

Articles

Quality of

studies

Significant

Result

Subject characteristics

Mean age Male sex Time after stroke (Month) First time stroke Level of severity* Difference Level** Improvement***

Baricich et al.

(2013) + Y 66.6 50% 0.77 Y 32.4% 55.7% 172%

Chen et al.

(2013) + Y 54.2 70% 20.6 Y 68.5% 8.1% 11.8%

Bayn et al.

(2012) + N 67.2 58% 1.5 Y 6.2% 6% 96.8%

Cho et al.

(2012) + Y 57.1 57.7% 3.55 Y 28.9% 26.1% 90.3%

Blasis et al.

(2009) + Y 58.3 45.8% 5 Y 71% 32% 45.1%

Dohle et al.

(2009) + Y 56.5 72.2% 0.9 Y 1.23% 7.2% 585%

Atay et al.

(2008) + Y 63.2 52.8% 5.5 Y 45.5% 25% 54.9%

Abbreviation: Y = Yes, N = No

* Level of severity = Mean Motor function score in Mirror group at baseline / Total score x 100%

** Difference level = Mean difference between pre- & post- score / Total score x 100%

***Improvement = Mean difference between pre- & post- score / Mean Motor function score in Mirror group at baseline x 100%

73

Appendix (D): Table of comparison (II)

Aspect

Articles

Quality of

studies

Significant

Result

Data

collection

(Week)

Treatment Intensity Practice of upper limb

Duration of

Therapy (Hour)

Treatment

period (Week)

Flexion and extension

of upper limb’s joint Use of objects

Bilateral

movement

Baricich et al.

(2013) + Y 4 15 4 Y

Chen et al.

(2013) + Y 24 20 4 Y Y Y

Bayn et al.

(2012) + N Post 10 5 Y Y

Cho et al.

(2012) + Y Post 16.7 4 Y

Blasis et al.

(2009) + Y 2 15 4 Y

Dohle et al.

(2009) + Y Post 15 6 Y Y

Atay et al.

(2008) + Y 24 10 4 Y

Abbreviation: Y = Yes, N = No, Post = Post-treatment

74

Appendix (E): Potential Material Cost

Table of Material Cost of Implementing Mirror Therapy

Procedure Item Amount Each

Cost

Total

Amount

Material of mirror

therapy

Mirror (60cm

x 30cm)

20 pieces $100 $2000

Training session Paper 100 sheets $0.2 $20

Printer ink 1 piece $100 $100

APN 3 Nurses for 2 hours $300 $1800

Nurse 35 nurses for 2 hours $170 $11 900

OT 1 OT for 2 hours $170 $340

Briefing Session Paper 50 sheets $0.2 $10

Printer ink 1 piece $100 $100

APN 3 Nurses for 1 hours $300 $900

Nurse 35 nurses for 1 hour $170 $5950

Allied health

(PT, OT)

20 colleague for 1 hour $170 $3400

Physician 5 physicians for 1 hour $300 $1500

Implementation of

mirror therapy

Nurse 6 nurses with 1 hour for

5 days a week, 4 weeks

$170 $20 400

Evaluation during

follow-up

Nurse 40 patients in each 4

weeks, 1 hour for each

follow-up patients

$170 $6800

Total $55 220

(Abbreviation: APN = Advanced Practice Nurse, PT = Physiotherapist, OT = Occupational

therapist)

Material Cost of not Implementing Mirror Therapy

Procedure Item Amount Each

Cost

Total

Amount

Estimated 7 days

longer in

hospitalization

Patient 40 patients $2000 $80 000

Total $80 000

75

Appendix (F): Recommendation of Evidence-based

Practice Guideline (Detailed)

Recommendations

A. Reason of Providing Mirror Therapy to Stroke Patient

Recommendation 1:

Mirror therapy is proved to be effective on improving recovery of upper limb

motor function in stroke patients.

Evidence:

Participants in mirror therapy group had statistically significant results on

improving their motor function of upper limb when compared with the control group

(Atay et al., 2008 (Level 1+); Baricich et al., 2013 (Level 1+); Blasis et al., 2009

(Level 1+); Chen et al., 2013 (Level 1+); Cho et al., 2012 (Level 1+); Dohle et al.,

2009 (Level 1+)).

(Grades of Recommendation: A)

B. Target population

Recommendation 1:

Mirror therapy should be used in stroke patient aged above 18 years old with

first time having stroke. Also, it can be applied to both sexes.

Evidence:

Studies had recruitment criteria of first time stroke, adult age with mean age

ranged from 54.2 to 67.2 years old. They also recruited both gender in their studies.

The results were significant in these requirements’ patients (Atay et al., 2008 (Level

1+); Baricich et al., 2013 (Level 1+); Blasis et al., 2009 (Level 1+); Chen et al., 2013

(Level 1+); Cho et al., 2012 (Level 1+); Dohle et al., 2009 (Level 1+)).

76

(Grades of Recommendation: A)

Recommendation 2:

Mirror therapy should be applied to stroke patients from sub-acute to chronic

state.

Evidence:

From the reviewed studies, the mean time from stroke ranged from 0.77 to 20.6

months. Both sub-acute and chronic phase had statistically significant result towards

mirror therapy group (Atay et al., 2008 (Level 1+); Baricich et al., 2013 (Level 1+);

Blasis et al., 2009 (Level 1+); Chen et al., 2013 (Level 1+); Cho et al., 2012 (Level

1+); Dohle et al., 2009 (Level 1+)).

(Grades of Recommendation: A)

Recommendation 3:

Patients should be able to understand and follow verbal instructions.

Evidence:

In order to carry out the intervention, patients had to be cooperated and

understood simple commands so that they could move their non-paretic upper limb

while looking at the reflected image (Atay et al., 2008 (Level 1+); Baricich et al.,

2013 (Level 1+); Chen et al., 2013 (Level 1+); Cho et al., 2012 (Level 1+)).

(Grades of Recommendation: A)

C. Application of mirror therapy on stroke patients

Recommendation 1:

Sitting position with a mirror sized enough for patient to see his entire upper

limb is needed for the use of mirror therapy on training of upper limb in stroke

patients. The non-paretic upper limb is placed on the reflecting side. Patients

observe the motion of the non-paretic side in the mirror as if the motion of the

77

paretic side.

Evidence:

Patients had to be in sitting position with a mirror positioned perpendicular to the

midline of the patients. Then they moved their unaffected upper limb in front of the

reflective surface. Patients were told to focus on the image of the mirror (Altschuler et

al., 1999 (Level 1-); Atay et al., 2008 (Level 1+); Baricich et al., 2013 (Level 1+);

Blasis et al., 2009 (Level 1+); Chen et al., 2013 (Level 1+); Cho et al., 2012 (Level

1+); Dohle et al., 2009 (Level 1+)).

(Grades of Recommendation: A)

Recommendation 2:

The movement of the upper limb should include flexion and extension of

shoulder, elbow, wrist and finger, pronation and supination of forearm, moving

arm from side to side. Objects can be involved in the motion like squeezing

sponges, placing object in holes, flipping card.

Evidence:

The movement included flexion and extension of shoulder, elbow, wrist and

pronation and supination of forearm (Atay et al., 2008 (Level 1+); Baricich et al.,

2013 (Level 1+); Blasis et al., 2009 (Level 1+); Chen et al., 2013 (Level 1+); Cho et

al., 2012 (Level 1+); Dohle et al., 2009 (Level 1+)). Flexion and extension of finger

was included in the motion (Atay et al., 2008 (Level 1+). The upper limb were also

move from side to side (Cho et al., 2012 (Level 1+). Objects were used to perform

fine motor tasks like squeezing sponges, placing pegs in holes or flipping cards (Chen

et al., 2013 Level 1+)).

(Grades of Recommendation: A)

Recommendation 3:

Bilateral movement, which is the movement of paretic upper limb together with

78

non-paretic upper limb, should be involved.

Evidence:

Patients were instructed to view the image in the mirror and perform bilateral

symmetrical movements (Chen et al., 2013 (Level 1+); Dohle et al., 2009 (Level 1+)).

(Grades of Recommendation: A)

Recommendation 4:

Conventional stroke rehabilitation program, for example occupational therapy

and physiotherapy, should be included apart from mirror therapy.

Evidence:

Patients received interdisciplinary rehabilitation as usual. It included occupational

therapy, physiotherapy and speech therapy (Atay et al., 2008 (Level 1+); Baricich et

al., 2013 (Level 1+); Blasis et al., 2009 (Level 1+); Chen et al., 2013 (Level 1+);

Dohle et al., 2009 (Level 1+)).

(Grades of Recommendation: A)

Recommendation 5:

Patients should be in priority when the severity of patient’s paretic upper limb

was higher.

Evidence:

When comparing the improvement with the level of severity at the beginning between

the reviewed studies, more severe impairment’s patients had more improvement in

their upper limb functions after having mirror therapy. Less improvement was noted

in less severe patients (Atay et al., 2008 (Level 1+); Baricich et al., 2013 (Level 1+);

Blasis et al., 2009 (Level 1+); Chen et al., 2013 (Level 1+); Cho et al., 2012 (Level

1+)).

(Grades of Recommendation: A)

79

D. Treatment Intensity of Mirror Therapy

Recommendation 1:

Mirror therapy should be applied equal to or more than 10 hours in 4 weeks

Evidence:

Only studies equal to or more than 10 hours in 4 weeks had statistically significant

outcomes towards mirror therapy group (Atay et al., 2008 (Level 1+); Baricich et al.,

2013 (Level 1+); Blasis et al., 2009 (Level 1+); Chen et al., 2013 (Level 1+); Cho et

al., 2012 (Level 1+); Dohle et al., 2009 (Level 1+)).

(Grades of Recommendation: A)

E. Assessment and Evaluation

Recommendation 1:

Assessment and evaluation should be done prior and after the application of

mirror therapy:

Measuring tool the Action Research Arm Test is recommended to use to

evaluate the progress of the upper limb motor function.

Measuring tool The Functional Independence Measure should be used to

assess the independence of patients.

Evidence:

The Action Research Arm Test was used to assess motor function of upper limb. Score

ranged from 0 to 57 was recorded. Total of 19 items were included with 4 sub-scales

which were grasp, grip, pinch and gross movement. (Baricich et al., 2013 (Level 1+);

Dohle et al., 2009 (Level 1+)). The Functional Independence Measure was used to

evaluate patients’ self-care ability (Atay et al., 2008 (Level 1+); Baricich et al., 2013

(Level 1+)).

(Grades of Recommendation: A)

80

Recommendation 2:

Follow-up session should be arranged to evaluate patient’s progress of the

paretic upper limb function. It is recommended to follow the progress at least for

half year.

Evidence:

24 weeks follow-up session was arranged to patients to evaluate the long term

progress of patients’ upper limb function. Statistically significant results were noted

even for long term follow-up in mirror therapy group (Atay et al., 2008 (Level 1+);

Chen et al., 2013 (Level 1+)).

(Grades of Recommendation: A)

81

Appendix (G): Level of Evidence and Grades of

Recommendation (SIGN, 2011)

Level of Evidence

1++ - High quality meta-analyses, systematic reviews of RCTs, or RCTs with a

very low risk of bias

1+ - Well conducted meta-analyses, systematic reviews, or RCTs with a low risk

of bias

1- - Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ - High quality systematic reviews of case control or cohort studies

- High quality case control or cohort studies with a very low risk of

confounding or bias and a high probability that the relationship is causal

2+ - Well conducted case control or cohort studies with a low risk of

confounding or bias and a moderate probability that the relationship is causal

2- - Case control or cohort studies with a high risk of confounding or bias and a

significant risk that the relationship is not causal

3 - Non-analytic studies, e.g. case reports, case series

4 - Expert opinion

Grades of Recommendation

A - At least one meta-analysis, systematic review, or RCT rated as 1++, and

directly applicable to the target population; or

- A body of evidence consisting principally of studies rated as 1+, directly

applicable to the target population, and demonstrating overall consistency of

results

B - A body of evidence including studies rated as 2++, directly applicable to the

target population, and demonstrating overall consistency of results; or

- Extrapolated evidence from studies rated as 1++ or 1+

C - A body of evidence including studies rated as 2+, directly applicable to the

target population and demonstrating overall consistency of results; or

- Extrapolated evidence from studies rated as 2++

D - Evidence level 3 or 4; or

- Extrapolated evidence from studies rated as 2+

Note: The grade of recommendation relates to the strength of the evidence on which the

recommendation is based. It does not reflect the clinical importance of the recommendation.

82

Appendix (H): Time Frame of the Mirror Therapy Program

Stage Action Timeline (Months)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Communication Plan

Setting up of implementation

team

Communicating with

administrators

Material preparation

Briefing session

Training session

Pilot Test

Recruitment of Subject

Mirror therapy

Follow-up

Evaluation

Implementing mirror

therapy

Recruitment of Subject

Mirror therapy

Follow-up

Evaluation

83

Appendix (I): Post Pilot Study Questionnaire for Staff

Name: __________________(Optional) Date: ___________________________

Please fill in the questionnaire about the new intervention “Mirror Therapy”.

Circle the answer which is the most suitable.

Questions

Do not

agree Agree

Agree

most

1. Did you think that mirror therapy could help the

patient to cope with the disease?

0 1 2

2. Did you find mirror therapy difficult to conduct? 0 1 2

3. Was mirror therapy suitable to be added in the

routine?

0 1 2

4. Did the briefing and training session help you to

know more about mirror therapy?

0 1 2

5. What difficulty did you encounter during conducting mirror therapy?

_____________________________________________________________________

6. Did you have any suggestion on conducting mirror therapy?

_____________________________________________________________________

7. What additional information would you like to know in briefing or training session?

_____________________________________________________________________

8. Any other suggestion.

_____________________________________________________________________

Thank you very much!

Please return to the mirror therapy implementation team.

84

Appendix (J): Satisfaction Survey (Patient)

Name: __________________(Optional) Date: ___________________________

Please circle appropriately in the survey about the intervention “Mirror Therapy”.

Content

Very

Unsatisfied Unsatisfied Satisfied

Very

Satisfied

Extremely

Satisfied

1. Explanation of mirror

therapy 1 2 3 4 5

2. Staff attitude 1 2 3 4 5

3. Enough support when

needed 1 2 3 4 5

4. Enough training time 1 2 3 4 5

5. Material use (e.g.

mirror) 1 2 3 4 5

6. Environment 1 2 3 4 5

7. Feedback from

healthcare profession 1 2 3 4 5

8. Overall, how satisfied

with mirror therapy 1 2 3 4 5

Total score: ________

Thank you very much!

Please return to the mirror therapy implementation team.

85

Appendix (K): Satisfaction Survey (Staff)

Name: __________________(Optional) Date: ___________________________

Please circle appropriately in the survey about the intervention “Mirror Therapy”.

Content

Very

Unsatisfied Unsatisfied Satisfied

Very

Satisfied

Extremely

Satisfied

1. Aims and objectives 1 2 3 4 5

2. Briefing session 1 2 3 4 5

3. Training session 1 2 3 4 5

4. Guideline of mirror

therapy 1 2 3 4 5

5. Material use (e.g.

mirror) 1 2 3 4 5

6. Implementation time 1 2 3 4 5

7. Workload 1 2 3 4 5

8. Cooperation between

colleague 1 2 3 4 5

9. Knowledge of mirror

therapy 1 2 3 4 5

10. Overall, how satisfied

with mirror therapy 1 2 3 4 5

Total score: ________

Thank you very much!

Please return to the mirror therapy implementation team.

86

References:

Altschuler E.L., Foster C., Galasko D., Llewellyn D.M.E., Ramachandran V.S., Stone

L. & Wisdom S.B. (1999). Rehabilitation of hemiparesis after stroke with a

mirror. The Lancet, 353, 2035-2036.

American Heart Association (2011). Heart Disease and Stroke Statistics--2012

Update: A Report from the American Heart association. Dallas: American Heart

Association, the American Heart Association Statistics Committee and Stroke

Statistics Subcommittee. Retrieved August 20, from

http://circ.ahajournals.org/content/125/1/e2.

Archambault P.S., Fung J. & Norouzi-Gheidari N. (2012). Effects of robot-assisted

therapy on stroke rehabilitation in upper limbs: systematic review and

meta-analysis of the literature. Journal of rehabilitation research and

development, 49(4), 479-496.

Atay M.B., Bussmann J.B., Koseoglu F., Selles R., Sezer N., Stam H.J., Subeyaz S. &

Yavuzer G. (2008). Mirror therapy improves hand function in subacute stroke: a

randomized controlled trial. Archives of physical medicine and rehabilitation, 89,

393-398.

Baldry J., Johnson J., Kidd D., Petruckevitch A., Rossiter D., Stewart G. & Thompson

A.J. (1995). The functional independence measure: a comparative validity and

reliability study. Disability and Rehabilitation, 17, 10–14

Bare, B. & Smeltzer S. C. (2004). Brunner & suddarth’s textbook of medical-surgical

nursing (10th

ed.). Philadelphia, US: Lippincott Williams & Wilkins.

Baricich A., Carda S., Cisari C., Invernizzi M., Lanzotti L. & Negrini S. (2013). The

value of adding mirror therapy for upper limb motor recovery of subacute stroke

patients: a randomized controlled trial. European journal of physical and

87

rehabilitation medicine, 49, 311-317.

Bayn M., Behrens J., Pohl M., Thieme H., Wurg M. & Zange C. (2012). Mirror

therapy for patients with severe arm paresis after stroke - a randomized

controlled trial. Clinical rehabilitation, 27(4), 314-327

Beck C.T. & Polit D.F. (2008). Nursing research: generating and assessing evidence

for nursing practice (8th

ed.). Philadelphia, US: Lippincott Williams & Wilkins.

Blasis E.D., Blasis V.D., Cacchio A., Santilli V. & Spacca G. (2009). Mirror therapy in

complex regional pain syndrome type 1 of the upper limb in stroke patients.

Neurorehabilitation and neural repair, 23(8), 792-799.

Camicia M., Mannava M.K., Sandel M.E., Sidney S., Terdiman J. & Wang H. (2012).

Daily treatment time and functional gains of stroke patients during inpatient

rehabilitation. The American Academy of Physical Medicine and Rehabilitation,

5(2), 122-128.

Cattaneo L. & Rizzolatti G. (2009). The mirror neuron system. Archives of Neurology,

66(5), 557-560.

Chang A.M., Mackenzie A.E. (1998). State self-esteem following stroke. Stroke,

29(11), 2325-2328.

Chen Y.T., Huang P.C., Lin K.C., Yang H.W. & Wu C.Y. (2013). Effects of mirror

therapy on motor and sensory recovery in chronic stroke: a randomized

controlled trial. Archives of physical medicine and rehabilitation, 94, 1023-1030.

Cheng S.K., Lee T.M., Leung A.W., Leung K.K. & Mak A.K. (2010). Functional gain

in hemorrhagic stroke patients is predicted by functional level and cognitive

abilities measured at hospital admission. NeuroRehabilitation, 27(4), 351-358.

Cho H., Lee M.M. & Song C.H. (2012). The mirror therapy program enhances upper

limb motor recovery and motor function in acute stroke patients. American

journal of physical medicine & rehabilitation, 91, 689-700.

88

Collier J.M., Dewey H.M. & Sherry L.J (2007). Stroke rehabilitation 2007: what

should it be? International journal of stroke, 2(3), 191-200.

Craighero L. & Fadiga L. (2004). Electrophysiology of action representation. Journal

of clinical neurophysiology, 21(3), 157-169.

The Department of Health (2012). Number of deaths by leading causes of death. Hong

Kong: The government of the Hong Kong Special Administrative Region,

Department of Health, Centre for Health Protection. Retrieved August 7, 2013,

from http://www.chp.gov.hk/en/data/4/10/27/380.html

Dohle C., Karbe H., Kust J., Nakaten A., Pullen J. & Rietz C. (2009). Mirror therapy

promotes recovery from severe hemiparesis: a randomized controlled trial.

Neurorehabilitation and neural repair, 23(3), 209-217.

Duncan P.W., Lai S.M., Perera S. & Studenski S. (2002). Persisting consequences of

stroke measured by the stroke impact scale. Stroke, 33(7), 1840-1844.

Fugl-Meyer A.R., Jaasko L., Leyman I., Olsson S. & Steglind S. (1975). The

post-stroke hemiplegic patient. Scandinavian journal of rehabilitation medicine,

7(13), 13-31.

Funase K., Higashi T., Kasai T., Liang N. & Tabira T. (2007). Increased corticospinal

excitability during direct observation of self-movement and indirect observation

with a mirror box. Neuroscience letters, 419(2), 108-112.

Hospital Authority (2012). Hospital Authority statistical report (2010-2011). Hong

Kong: Author. Retrieved August 7, 2013, from

http://www.ha.org.hk/upload/publication_15/411.pdf.

Johansson B.B. (2011). Current trends in stroke rehabilitation. A review with focus on

brain plasticity. Acta neurologica scandinavica, 123(3), 147-159.

Kollen B.J., Kwakkel G., Prevo A.J.H. & Van der Grond J. (2003). Probability of

regaining dexterity in the flaccid upper limb. Stroke, 34, 2181-2186.

89

Lyle, R.C. (1981). A performance test for assessment of upper limb function in

physical rehabilitation treatment and research. International journal of

rehabilitation research, 4(4), 483-492.

Scottish Intercollegiate Guidelines Network (2011). Sign 50: A guideline developer’s

handbook. Edinburgh: Scottish Intercollegiate Guidelines Network, Healthcare

Improvement Scotland. Retrieved December 14, 2013, from

http://www.sign.ac.uk/pdf/sign50.pdf.

Scottish Intercollegiate Guidelines Network (2013). Critical appraisal: notes and

checklists. Edinburgh: Scottish Intercollegiate Guidelines Network, Healthcare

Improvement Scotland. Retrieved August 14, 2013, from

http://www.sign.ac.uk/methodology/checklists.html.