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REfLECTS is the Randomised Controlled Trial of Mirror Box Therapy in Upper Limb Rehabilitation with Sub Acute Stroke Patients. This study is funded by the Cross-border Healthcare Intervention Trials in Ireland Network (CHITIN).

Impact of Stroke

Stroke is the second leading cause of death (Feigin et al 2014) and a major cause of complex disability (Mendis 2013). Around half of stroke survivors will be left with significant, long-term effects including residual deficits of the upper limb (Higgins et al 2005), which result in reduced independence in daily activities and participation (Lang et al 2013).

Everyday tasks such as washing, dressing, feeding, walking and household activities can be more difficult. To help regain movement, the brain needs to relearn how to move the arm of the affected side.

Occupational therapists play a vital role in rehabilitation of the upper limb, enabling stroke patients to increase their independence and self-manage their condition (Allied Health Professions Federation 2005, ISWP 2008, ISWP 2012).

Multi-Centre Research Trial

This multi-centre REfLECTS study is based throughout Ireland.
Led by Dr Alison Porter-Armstrong from the Institute of Nursing and Health Research at Ulster University, the study has been developed and implemented by a team of cross-border occupational therapists who are highly skilled senior therapists in the field of stroke rehabilitation.

Mirror Box Therapy (MBT)

Mirror box therapy is a relatively new intervention in the rehabilitation of upper limb function after stroke.

Mirror box therapy is a novel, simple and cost-effective intervention (Yavuzer et al 2008). It was originally devised to reduce pain experienced in an amputated limb, known as phantom limb pain (Ramachandran and Rogers-Ramachandran 1996), but was later identified as a potential intervention for upper limb impairment following stroke (Deconinck et al 2015) and is gaining recognition within occupational therapy for its potential in the rehabilitation of upper limb function (Altschuler et al 1999, Yavuzer et al 2008).

Mirror therapy involves neural recovery in the brain which can be stimulated using mirrored movements of the non-affected upper limb (Stevens and Stoykov 2003). No consensus has been reached regarding its exact mechanism of action, but it is believed that observing movements in the mirror stimulates nerve cells involved in learning and controlling movement in the affected limb (Deconinck et al 2015).

Another theory is that visual feedback from the mirror therapy helps to recruit dormant motor pathways that replace the damaged pathways and encourage the return of movement. Thus, mirror box therapy is thought to improve upper limb function through both movement and mental stimulation (Stevens and Stoykov 2003, Uswatte et al 2005).

Current Research

A Cochrane review by Thieme et al (2018) on the use of mirror therapy in stroke rehabilitation demonstrated that it may improve movement, completion of daily activities and pain, when used with standard treatment.

Existing research studies in mirror box therapy, however, are limited due to variation in the time since onset of stroke across participants (ranging from 3-12 months) (Altschuler et al 1999, Yavuzer et al 2008).

Few studies have included patients in the sub-acute period post stroke (0-3 months), yet this is the population considered most likely to benefit from this therapy at the early recovery stage.

The REfLECTS research study is investigating the use of mirror therapy in this specific post stroke population (0-3 months) and follows on from a pilot study completed in October 2018, that tested the intervention with n=40 participants within the NHSCT.

This pilot study provided the foundation to expand this research to the whole of Ireland, where we hope to provide definitive evidence of effectiveness of the mirror box intervention, and therefore contribute to the body of evidence.

The Pilot Study

A Pilot Randomised Controlled Trial (RCT) of Mirror Box Therapy in Upper Limb Rehabilitation with Sub-acute Stroke Patients (January 2015 to October 2018) was led by Dr Alison Porter-Armstrong in Ulster University and was funded through a Research Priority Grant awarded by the United Kingdom Occupational Therapy Research Foundation. Occupational therapists from the NHSCT (Patricia McIlwaine, Lourene Abbi and Fiona Morrow) and the University (Dr May Stinson) were co-applicants.

The aims of the pilot study were:

  1. To evaluate the feasibility of patient recruitment within an in-patient sub-acute setting
  2. To assess the feasibility of delivering MBT as a component of OT treatment in the sub-acute in-patient population
  3. To evaluate the sensitivity of the outcome measures for use in a fully powered trial and conduct a power calculation
  4. To conduct a preliminary analysis of the data to identify potential treatment gains within and between the 2 groups

The findings were:

  1. More sensitive screening for cognitive deficits and post-stroke fatigue was required;
  2. Mirror Box Therapy delivery was feasible however, maintaining blinding of the researcher required further consideration;
  3. Outcome measures were sensitive for use (Turtle et al 2020); 180 participants would be required to support a fully powered trial;
  4. Total satisfaction scores were greater in the intervention group than in the control group. However, there was no significant effect of treatment group or time-by-treatment group on participant scores for the Functional Independence Measure or Graded Wolf Motor Function Test.

Aims of the REfLECTS Study

Our objective is to recruit 180 patients to participate in the study.

In this fully powered study, we aim to investigate the outcome of using MBT in rehabilitation of upper limb function in stroke patients. The study places emphasis on:

  1. Determining the upper limb movement, functional, quality of life and occupational gains acquired through mirror box therapy between baseline, hospital discharge and 12 weeks post discharge;
  2. Exploring the effect of time, treatments and patient differences on upper limb movement, functional, quality of life and occupational gains across all measurement points.

Anticipated Outcome

This study aims to provide robust evidence as to whether Mirror Box Therapy offers greater potential in functional gains in the sub-acute recovery period of stroke than standard rehabilitation of the upper limb alone.

We expect this trial to take 3 years to complete. Our first participant was recruited in June 2019 and the trial will end in April 2022.