1. Use of mirror box therapy and the graded Wolf Motor Function Test in upper limb rehabilitation: a practical workshop
Dr Alison Porter-Armstrong Mrs Patricia McIlwaine 2
Dr May Stinson Mrs Lourene Abbi 2
Ms Beverley Turtle Ms Fiona Morrow 2
Mrs Nicola Gallagher 1,2
1 Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health, School of Health Sciences, Ulster University (NI)
2 Occupational Therapy Service, Whiteabbey Hospital Northern Health and Social Care Trust

2. How it all began……..
2014 Research Priority Grant, United Kingdom Occupational Therapy Research Foundation “A pilot randomized controlled trial of mirror box therapy in upper limb rehabilitation with sub-acute stroke patients”
assess the feasibility of delivering MBT as a component of occupational therapy treatment with this population
Evaluate the use and sensitivity of the outcome measures selected

3. Workshop Aims
Learn about Mirror Box Therapy (MBT) and the graded Wolf Motor Function Test (gWMFT) outcome measure
Use the mirror box and practice the 8-stage upper limb protocol adopted within the research study
Conduct and assessment with the graded Wolf Motor Function Test
Discuss the clinical use of MBT and measurement issues using the gWMFT

4. Workshop Content Monday 12th June, 3:50pm – 5:25pm
3:50 – 4pm: Introduction to the team, the study objectives and orientation to MBT & gWMFT
4 – 4:30pm: MBT demonstration by clinical lead and audience practice session in pairs
5 minutes to clear away MBT & set-up gWMFT
4:35 – 5:15pm: gWMFT demonstration by clinical lead and audience practice session in groups
5:15- 5:25pm: Q&A session/discussion with the team & close of session.

5. Mirror Box Therapy Overview
Originally used in the treatment of phantom limb pain following amputation (Ramachandran & Rogers-Ramachandran, 1996)
Used in first stroke application by Altschuler et al (1999), subsequently many others (Yavuzer et al 2008; Dohle et al 2009; Invernizzi et al 2013; Wu et al 2013; Lin et al 2014; Cristina et al 2015; Colomer at al, 2016; Gurbuz et al 2016)
Based upon mirror visual feedback: a mirror is placed in the patients’s midsagittal plane, reflecting movements of the non-affected side as if it were the affected side. Can be used upper or lower limb
No clear consensus exists on the mechanism of how mirror therapy works; neural recovery in the brain can be stimulated using mirrored movements of the non-affected limb (Stevens & Stoykov, 2003), it is thought that visual feedback helps recruit dormant motor pathways that replace the damaged pathways and encourage the return of movement (Panadian et al, 2014)

6. Evidence Systematic Reviews
Thieme et al 2012 Review Mirror therapy for improving motor function after stroke, Cochrane Database of Systematic Reviews, / CD pub2
Objective: to summarise effectiveness of mirror therapy for improving motor function, activities of daily living, pain and visuospatial neglect
Reviewed the evidence of RCTs up to June 2011
Included 14 studies with a total of 567 participants
Found evidence to indicate effectiveness of mirror therapy for improving upper extremity motor function, ADL & Pain; did not find evidence to support visuospatial neglect
Zeng et al Mirror therapy for motor function of the upper extremity in patients with stroke: a meta-analysis, Journal of Rehabilitation Medicine, 50: 8-15
Objective: to evaluate the mean treatment effect of mirror therapy on motor function of the upper extremity in patients with stroke
Reviewed the evidence of RCTs from January 2007 – June 2017
Included 11 studies with a total of 347 participants
Found a moderate effect of mirror therapy on motor function of the upper extremity

7. Graded Wolf Motor Function Test Overview
Assessment of motor ability of upper limb using functional tasks
Two components: functional ability scale (FAS) and movement time
Two levels: A and B (the graded version has two levels of each task which can be chosen depending on the participants’ general functioning level).
The gWMFT is a 13-item standardised measure which determines the motor ability of participants by recording functional movement time ( seconds per item) and quality of movement (0-7 Likert scale per item with 0= no movement, to 7 = normal movement).
The graded version was developed from the original WMFT which has shown to have good reliability (Bonifer et al, 2005; Morris et al, 2001).
This outcome measure has also been used by other investigators in previous studies with a stroke cohort (Uswatte et al. 2005; Colomer et al 2016).
Scoring is by video-recording following assessent

9. Discussion Points Mirror Box Therapy
Advantages
Disadvantages
Portable, lightweight, easy to use
Design
Cost less than £30
Clinical judgement
Take home to continue rehabilitation
Rings/ID bands and upper limb tattoos
Patient – self-directed therapy and caregiver support
Mirror Box Group
Motivational

10. Discussion Points: gWMFT
Advantages
Disadvantages
Standardised
Limited use with patient with little upper limb function
Scored/rescored including use of video
?Stop assessment if patient having difficulty (120 seconds)
Can demonstrate improvement – use of video
Time consuming set-up
Goes through full range of upper limb functions
Time consuming to gather up assessment components for use
Shoulder to fine motor skills
Difficult to conduct in patients home due to practicalities of set-up
Requires plenty of test practice prior to administration
Use of video – data protection etc

11. Interested in learning more?
Reliability and responsiveness of outcome measures in a stroke clinical trial. Turtle, B, Porter-Armstrong A & Stinson MD. Session 40: Stroke – Tuesday 11:30-12:15
RCOT Research and Development Review – supporting your team to engage in and with research. Watson, J, Ward G, McIlwaine P, Jones, N. Session 103a: RCOT Insights – Wednesday 2:50-3:35pm
- ‘Mirror Therapy for Stroke Rehabilitation: A viable treatment option” Stromsdorfer, Sarah May Includes link to:
Rothgangel AS & Braun SM (2013) “Mirror Therapy: Practical Protocol for Stroke Rehabilitation”. Munich: Pflaum Verlag. Doi: /ar.sb.mirrortherapy.e2013[Epub]

12. Social Media and useful link

13. Contact Details Dr Alison Porter-Armstrong: a.porter@ulster.ac.uk
Dr May Stinson:
Mrs Patricia McIlwaine:
Mrs Lourene Abbi:
Ms Fiona Morrow:
Mrs Nicola Gallagher:
Ms Beverly Turtle:
PLEASE DON’T FORGET TO RETURN THE WORKSHOP RESOURCES BEFORE YOU LEAVE. THANK YOU.

14. References
Altschuler, E.L., Wisdom, S.B., Stone, L., Foster, C., Galasko, D., Llewellyn, D.M.E. and Ramachandran, V.S. (1999) Rehabilitation of hemiparesis after stroke with a mirror. The Lancet, 353,
Dohle, C., Pullen, J., Nakaten, A., Kust, J., Rietz, C. and Karbe, H. (2009) Mirror therapy promotes recovery from severe hemiparesis: a randomised controlled trial. Neurorehabilitation and Neural Repair, 23(3),
Morris DM, Uswatte G, Crago JE, Cook EW, Taub E. (2001). The reliability of the Wolf Motor Function Test for assessing upper extremity function after stroke. Arch Phys Med Rehabil, 82,
Pandian, J.D., Arora, R., Kaur, P., Vishwambaran, D.K. and Arima, H. (2014) Mirror therapy in unilateral neglect after stroke (must trial). American Academy of Neurology, 83,
Ramachandran VS, Rogers-Ramachandran D (1996) Synaesthesia in phantom limbs induced with mirrors. Proc Biological Sci, 263,
Stevens JA, Stoykov MEP (2003) Using Motor Imagery in the Rehabilitation of Hemiparesis. Arch Phys Med Rehabil, 84,
Thieme, H., Bayn, M., Wurg, M., Zange, C., Pohl, M. and Behrens, J. (2012) Mirror therapy for patients with severe arm paresis after stroke a randomised controlled trial. Clinical Rehabilitation, 27(4),
Theime, H., Mehrholz, J., Pohl, M., Behrens, J. and Dohle, C. (2012) Mirror therapy for improving motor function after stroke. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD doi: / CD pub2.
Uswatte, G., Taub, E., D., Vignolo, M, McCulloch, K (2005). Reliability and validity of the upper-extremity Motor Activity Log-14 for measuring real-world arm use. Stroke, 36, 11,
Yavuzer G, Selles R, Sezer N, Sutbeyaz S, Bussmann JB, Koseoglu F, Atay MB, Stam HJ (2008). Mirror Therapy Improves Hand Function in Subacute Stroke: A Randomized Controlled Trial. Archives Physical Medicine and Rehabilitation , 89, 393-8
Zeng, W., Guo, Y., Wu, G., Liu, X. and Fang, Q. (2018) Mirror therapy for motor function of the upper extremity in patients with stroke: a meta-analysis. Journal of Rehabilitation Medicine, 50, 8-15.

15. Thank you for your participation!