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
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 i
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. ii
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... 1.3 Research Question, Objectives, Significance 1.3.1 Research Question.. 1.3.2 Objectives... 1.3.3 Significance 2 2 3 4 5 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 iii
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... 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.. 11 11 11 12 12 13 13 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 iv
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 v
4.6 Recommendations 36 Chapter 5: Implementation Plan.. 39 Page 5.1 Stakeholders Identification... 5.1.1 Administrators. 5.1.2 Trainers... 5.1.3 Users of the Evidenced-based Guideline 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 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... 39 39 40 40 40 40 41 42 42 42 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 vi
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 vii
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. 54 55 61 72 74 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). 75 81 82 83 84 85 References 86 viii
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 1
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, 2
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 3
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. Mirror on reflected side Unaffected Affected Figure (1) Preparation of 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 4
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 5
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; 6
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 7
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. 8
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 1 st 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 9
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 10
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, 11
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 12
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 13
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 14
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 15
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., 16
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 17
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., 18
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 19
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). 20
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. 21
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 22
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. 23
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, 24
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. 25
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 26
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 27
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 28
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. 29
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 30
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. 31
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 32