Effects of Home-Based Versus Clinic-Based Rehabilitation Combining Mirror Therapy and Task-Specific Training for Patients With Stroke: A Randomized Crossover Trial

  • Yu-wei Hsieh
    Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan

    Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan

    Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan
    Search for articles by this author
  • Ku-chou Chang
    Division of Cerebrovascular Diseases, Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

    Department of Neurology, College of Medicine, Chang Gung University, Taoyuan, Taiwan
    Search for articles by this author
  • Jen-wen Hung
    Department of Rehabilitation, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

    School of Physical Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan
    Search for articles by this author
  • Ching-yi Wu
    Corresponding author Ching-yi Wu, ScD, OTR, Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, Taiwan, Republic of China.
    Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan

    Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan

    Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan
    Search for articles by this author
  • Mu-hui Fu
    Division of Cerebrovascular Diseases, Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
    Search for articles by this author
  • Chih-chi Chen
    Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan

    School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
    Search for articles by this author
Published:April 24, 2018DOI:



      We investigated the treatment effects of a home-based rehabilitation program compared with clinic-based rehabilitation in patients with stroke.


      A single-blinded, 2-sequence, 2-period, crossover-designed study.


      Rehabilitation clinics and participant’s home environment.


      Individuals with disabilities poststroke.


      During each intervention period, each participant received 12 training sessions, with a 4-week washout phase between the 2 periods. Participants were randomly allocated to home-based rehabilitation first or clinic-based rehabilitation first. Intervention protocols included mirror therapy and task-specific training.

      Main Outcome Measures

      Outcome measures were selected based on the International Classification of Functioning, Disability and Health. Outcomes of impairment level were the Fugl-Meyer Assessment, Box and Block Test, and Revised Nottingham Sensory Assessment. Outcomes of activity and participation levels included the Motor Activity Log, 10-meter walk test, sit-to-stand test, Canadian Occupational Performance Measure, and EuroQoL-5D Questionnaire.


      Pretest analyses showed no significant evidence of carryover effect. Home-based rehabilitation resulted in significantly greater improvements on the Motor Activity Log amount of use subscale (P=.01) and the sit-to-stand test (P=.03) than clinic-based rehabilitation. The clinic-based rehabilitation group had better benefits on the health index measured by the EuroQoL-5D Questionnaire (P=.02) than the home-based rehabilitation group. Differences between the 2 groups on the other outcomes were not statistically significant.


      The home-based and clinic-based rehabilitation groups had comparable benefits in the outcomes of impairment level but showed differential effects in the outcomes of activity and participation levels.


      List of abbreviations:

      AOU (amount of use), COPM (Canadian Occupational Performance Measure), EQ-5D (EuroQoL-5D Questionnaire), MAL (Motor Activity Log), UE (upper extremity)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Feigin V.L.
        • Lawes C.M.
        • Bennett D.A.
        • Barker-Collo S.L.
        • Parag V.
        Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review.
        Lancet Neurol. 2009; 8: 355-369
        • Anderson C.
        • Rubenach S.
        • Mhurchu C.N.
        • Clark M.
        • Spencer C.
        • Winsor A.
        Home or hospital for stroke rehabilitation? results of a randomized controlled trial: I: health outcomes at 6 months.
        Stroke. 2000; 31: 1024-1031
        • Duncan P.
        • Studenski S.
        • Richards L.
        • et al.
        Randomized clinical trial of therapeutic exercise in subacute stroke.
        Stroke. 2003; 34: 2173-2180
        • Green J.
        • Forster A.
        • Bogle S.
        • Young J.
        Physiotherapy for patients with mobility problems more than 1 year after stroke: a randomised controlled trial.
        Lancet. 2002; 359: 199-203
        • Pang M.Y.
        • Harris J.E.
        • Eng J.J.
        A community-based upper-extremity group exercise program improves motor function and performance of functional activities in chronic stroke: a randomized controlled trial.
        Arch Phys Med Rehabil. 2006; 87: 1-9
        • Tousignant M.
        • Corriveau H.
        • Kairy D.
        • et al.
        Tai Chi-based exercise program provided via telerehabilitation compared to home visits in a post-stroke population who have returned home without intensive rehabilitation: study protocol for a randomized, non-inferiority clinical trial.
        Trials. 2014; 15: 42
        • Turton A.J.
        • Cunningham P.
        • Heron E.
        • et al.
        Home-based reach-to-grasp training for people after stroke: study protocol for a feasibility randomized controlled trial.
        Trials. 2013; 14: 109
        • Siemonsma P.
        • Dopp C.
        • Alpay L.
        • Tak E.
        • Meeteren N.
        • Chorus A.
        Determinants influencing the implementation of home-based stroke rehabilitation: a systematic review.
        Disabil Rehabil. 2014; 36: 2019-2030
        • Piron L.
        • Turolla A.
        • Tonin P.
        • Piccione F.
        • Lain L.
        • Dam M.
        Satisfaction with care in post-stroke patients undergoing a telerehabilitation programme at home.
        J Telemed Telecare. 2008; 14: 257-260
        • Nilsen D.M.
        • DiRusso T.
        Using mirror therapy in the home environment: a case report.
        Am J Occup Ther. 2014; 68: e84-e89
        • Linder S.M.
        • Rosenfeldt A.B.
        • Reiss A.
        • et al.
        The home stroke rehabilitation and monitoring system trial: a randomized controlled trial.
        Int J Stroke. 2013; 8: 46-53
        • Barzel A.
        • Ketels G.
        • Stark A.
        • et al.
        Home-based constraint-induced movement therapy for patients with upper limb dysfunction after stroke (HOMECIMT): a cluster-randomised, controlled trial.
        Lancet Neurol. 2015; 14: 893-902
        • Standen P.J.
        • Threapleton K.
        • Richardson A.
        • et al.
        A low cost virtual reality system for home based rehabilitation of the arm following stroke: a randomised controlled feasibility trial.
        Clin Rehabil. 2017; 31: 340-350
        • Turton A.J.
        • Cunningham P.
        • van Wijck F.
        • et al.
        Home-based reach-to-grasp training for people after stroke is feasible: a pilot randomised controlled trial.
        Clin Rehabil. 2017; 31: 891-903
        • Coupar F.
        • Pollock A.
        • Legg L.A.
        • Sackley C.
        • van Vliet P.
        Home-based therapy programmes for upper limb functional recovery following stroke.
        Cochrane Database Syst Rev. 2012; CD006755
        • Altschuler E.L.
        • Wisdom S.B.
        • Stone L.
        • et al.
        Rehabilitation of hemiparesis after stroke with a mirror.
        Lancet. 1999; 353: 2035-2036
        • Michielsen M.E.
        • Selles R.W.
        • Van Der Geest J.N.
        • et al.
        Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial.
        Neurorehabil Neural Repair. 2011; 25: 223-233
        • Thieme H.
        • Mehrholz J.
        • Pohl M.
        • Behrens J.
        • Dohle C.
        Mirror therapy for improving motor function after stroke.
        Cochrane Database Syst Rev. 2012; 3CD008449
        • Sathian K.
        • Greenspan A.I.
        • Wolf S.L.
        Doing it with mirrors: a case study of a novel approach to neurorehabilitation.
        Neurorehabil Neural Repair. 2000; 14: 73-76
        • Stoykov M.E.
        • Madhavan S.
        Motor priming in neurorehabilitation.
        J Neurol Phys Ther. 2015; 39: 33-42
        • Intercollegiate Stroke Working Party
        National clinical guideline for stroke.
        4th ed. Royal College of Physicians, London2012
        • Lang C.E.
        • Birkenmeier R.L.
        Upper-extremity task-specific training after stroke or disability: a manual for occupational therapy and physical therapy.
        AOTA Press, Bethesda, MD2014
        • Shepherd R.B.
        Exercise and training to optimize functional motor performance in stroke: driving neural reorganization?.
        Neural Plast. 2001; 8: 121-129
        • Kleim J.A.
        • Jones T.A.
        Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage.
        J Speech Lang Hear Res. 2008; 51: S225-S239
        • Fleming M.K.
        • Sorinola I.O.
        • Roberts-Lewis S.F.
        • Wolfe C.D.
        • Wellwood I.
        • Newham D.J.
        The effect of combined somatosensory stimulation and task-specific training on upper limb function in chronic stroke: a double-blind randomized controlled trial.
        Neurorehabil Neural Repair. 2015; 29: 143-152
        • Banks J.L.
        • Marotta C.A.
        Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: a literature review and synthesis.
        Stroke. 2007; 38: 1091-1096
        • Sanford J.
        • Moreland J.
        • Swanson L.R.
        • Stratford P.W.
        • Gowland C.
        Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke.
        Phys Ther. 1993; 73: 447-454
        • Lum P.S.
        • Burgar C.G.
        • Shor P.C.
        • Majmundar M.
        • Van der Loos M.
        Robot-assisted movement training compared with conventional therapy techniques for the rehabilitation of upper-limb motor function after stroke.
        Arch Phys Med Rehabil. 2002; 83: 952-959
        • Law M.
        • Baptiste S.
        • McColl M.
        • Opzoomer A.
        • Polatajko H.
        • Pollock N.
        The Canadian occupational performance measure: an outcome measure for occupational therapy.
        Can J Occup Ther. 1990; 57: 82-87
        • Doucet B.M.
        • Gutman S.A.
        Quantifying function: the rest of the measurement story.
        Am J Occup Ther. 2013; 67: 7-9
        • Fugl-Meyer A.R.
        • Jaasko L.
        • Leyman I.
        • Olsson S.
        • Steglind S.
        The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance.
        Scand J Rehabil Med. 1975; 7: 13-31
        • Hsieh Y.W.
        • Wu C.Y.
        • Lin K.C.
        • Chang Y.F.
        • Chen C.L.
        • Liu J.S.
        Responsiveness and validity of three outcome measures of motor function after stroke rehabilitation.
        Stroke. 2009; 40: 1386-1391
        • Platz T.
        • Pinkowski C.
        • van Wijck F.
        • Kim I.H.
        • di Bella P.
        • Johnson G.
        Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicenter study.
        Clin Rehabil. 2005; 19: 404-411
        • Lin K.C.
        • Chuang L.L.
        • Wu C.Y.
        • Hsieh Y.W.
        • Chang W.Y.
        Responsiveness and validity of three dexterous function measures in stroke rehabilitation.
        J Rehabil Res Dev. 2010; 47: 563-571
        • Mathiowetz V.
        • Volland G.
        • Kashman N.
        • Weber K.
        Adult norms for the Box and Block Test of manual dexterity.
        Am J Occup Ther. 1985; 39: 386-391
        • Gaubert C.S.
        • Mockett S.P.
        Inter-rater reliability of the Nottingham method of stereognosis assessment.
        Clin Rehabil. 2000; 14: 153-159
        • Lincoln N.B.
        • Jackson J.M.
        • Adams S.A.
        Reliability and revision of the Nottingham Sensory Assessment for stroke patients.
        Physiotherapy. 1998; 84: 358-365
        • van der Lee J.H.
        • Beckerman H.
        • Knol D.L.
        • de Vet H.C.
        • Bouter L.M.
        Clinimetric properties of the motor activity log for the assessment of arm use in hemiparetic patients.
        Stroke. 2004; 35: 1410-1414
        • Lin K.C.
        • Wu C.Y.
        • Liu J.S.
        • Chen Y.T.
        • Hsu C.J.
        Constraint-induced therapy versus dose-matched control intervention to improve motor ability, basic/extended daily functions, and quality of life in stroke.
        Neurorehabil Neural Repair. 2009; 23: 160-165
        • Lin K.C.
        • Huang P.C.
        • Chen Y.T.
        • Wu C.Y.
        • Huang W.L.
        Combining afferent stimulation and mirror therapy for rehabilitating motor function, motor control, ambulation, and daily functions after stroke.
        Neurorehabil Neural Repair. 2014; 28: 153-162
        • Fuzaro A.C.
        • Guerreiro C.T.
        • Galetti F.C.
        • Juca R.B.
        • Araujo J.E.
        Modified constraint-induced movement therapy and modified forced-use therapy for stroke patients are both effective to promote balance and gait improvements.
        Rev Bras Fisioter. 2012; 16: 157-165
        • Tilson J.K.
        • Sullivan K.J.
        • Cen S.Y.
        • et al.
        Meaningful gait speed improvement during the first 60 days poststroke: minimal clinically important difference.
        Phys Ther. 2010; 90: 196-208
        • Tyson S.
        • Connell L.
        The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: a systematic review.
        Clin Rehabil. 2009; 23: 1018-1033
        • Cheng P.T.
        • Liaw M.Y.
        • Wong M.K.
        • Tang F.T.
        • Lee M.Y.
        • Lin P.S.
        The sit-to-stand movement in stroke patients and its correlation with falling.
        Arch Phys Med Rehabil. 1998; 79: 1043-1046
        • Silva P.F.
        • Quintino L.F.
        • Franco J.
        • Faria C.D.
        Measurement properties and feasibility of clinical tests to assess sit-to-stand/stand-to-sit tasks in subjects with neurological disease: a systematic review.
        Braz J Phys Ther. 2014; 18: 99-110
        • Cup E.H.
        • Scholte op Reimer W.J.
        • Thijssen M.C.
        • van Kuyk-Minis M.A.
        Reliability and validity of the Canadian Occupational Performance Measure in stroke patients.
        Clin Rehabil. 2003; 17: 402-409
        • Chen P.
        • Lin K.C.
        • Liing R.J.
        • Wu C.Y.
        • Chen C.L.
        • Chang K.C.
        Validity, responsiveness, and minimal clinically important difference of EQ-5D-5L in stroke patients undergoing rehabilitation.
        Qual Life Res. 2016; 25: 1585-1596
        • Herdman M.
        • Gudex C.
        • Lloyd A.
        • et al.
        Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L).
        Qual Life Res. 2011; 20: 1727-1736
        • Tsuchiya A.
        • Ikeda S.
        • Ikegami N.
        • et al.
        Estimating an EQ-5D population value set: the case of Japan.
        Health Econ. 2002; 11: 341-353
        • Williamson A.
        • Hoggart B.
        Pain: a review of three commonly used pain rating scales.
        J Clin Nurs. 2005; 14: 798-804
        • Benaim C.
        • Froger J.
        • Cazottes C.
        • et al.
        Use of the Faces Pain Scale by left and right hemispheric stroke patients.
        Pain. 2007; 128: 52-58
        • Wellek S.
        • Blettner M.
        On the proper use of the crossover design in clinical trials: part 18 of a series on evaluation of scientific publications.
        Dtsch Arztebl Int. 2012; 109: 276-281
        • Wright A.A.
        • Cook C.E.
        • Baxter G.D.
        • Dockerty J.D.
        • Abbott J.H.
        A comparison of 3 methodological approaches to defining major clinically important improvement of 4 performance measures in patients with hip osteoarthritis.
        J Orthop Sports Phys Ther. 2011; 41: 319-327
        • Cunningham P.
        • Turton A.J.
        • Van Wijck F.
        • Van Vliet P.
        Task-specific reach-to-grasp training after stroke: development and description of a home-based intervention.
        Clin Rehabil. 2016; 30: 731-740
        • Trombly C.A.
        • Wu C.Y.
        Effect of rehabilitation tasks on organization of movement after stroke.
        Am J Occup Ther. 1999; 53: 333-344
        • Dobkin B.H.
        A rehabilitation-internet-of-things in the home to augment motor skills and exercise training.
        Neurorehabil Neural Repair. 2017; 31: 217-227
        • Bohannon R.W.
        • Bubela D.J.
        • Magasi S.R.
        • Wang Y.C.
        • Gershon R.C.
        Sit-to-stand test: performance and determinants across the age-span.
        Isokinet Exerc Sci. 2010; 18: 235-240