The use of mirror visual feedback with patients with conversion disorder, motor type.

The application of the mirror design has been shown in patients with phantom
pain, complex regional pain syndrome and people who had loss of motor function
after a stroke. In this study we want the applicability of the mirror structure
in patients with motor conversion studies. The effect of the mirror feedback in
motor conversion can be explained from different theoretical backgrounds
(cognitive dissonance, dissociation and mirror neurons). Also, the reflection
of the functioning hand or arm the system of mirror neurons can activate. In
addition, the structure generated by the mirror illusion can help the
dissociation of patients can break through.

Primary objective: The main research issue here is whether the intervention
with the mirrorfeedback in patients with motor conversion of the arm or hand
leads to improvement handgrip strength.

Secondary objectives: The secondary research question is whether the mirror
design leads to improved sensitivity and increased the functionality of the
hand or arm. Another exploratory question focuses on whether there is evidence
from research that mirror the structure dissociation in patients with motor
conversion can be reduced.

A replicated randomized single-case AB design, with six patients treated. Such
designs are particularly appropriate when little is known about a treatment
method (such as mirror visual feedback) both with regard to the treatment
effect as the required training intensity. Because the outcomes of the patients
are repeatedly determined and a baseline measurement is performed, the patients
function as their own control (Bulte & Onghena, 2008, Guyatt et al, 1988; Brain
& Barlow, 1984). The baseline phase has the same goal as the untreated control
group in randomized controlled trials. If the behavior changes after the
baseline phase, it can be assumed that the intervention is responsible for this
change. Although this design does not allow the validity of the findings to the
public directly to determine the possibility of generalising considerably
strengthened when a similar effect is observed in several patients. Repetition
of the AB design in several patients strengthens the findings. The design of
such a study gives reliable results (for an overview see: Yin, 2003, Barlow &
Brain, 1984).

As with clinical trials, randomization in single-case experiments offers a
solution to control for (confusing) variables, with respect to time,
respondents and setting. Unlike randomized controlled trials (RCTs), the
randomisation in single-case designs not include random assignment to a
treatment condition. In single-case randomization experiments refers to the
purely accidental determining the time of the phase change. Random assignment
used in a single-case experiment, obtained on time-based statistical control
known and unknown variables. This makes possible a statistical test based on
randomization, as in the study design is applied (Ter Kuile et al, 2009,
Onghena & Bulte, 2008). To avoid that random distribution would lead to too
little (or no) measurement dates in one of the two phases of a limited
randomized phase change is recommended, with a minimum number of measurement
dates for each phase is fixed in advance (Bulte & Onghena, 2008) .

The total duration of the study covers seven weeks, with included clinical
patients. On the weekends, patients go home (total of 35 working days remain)
The baseline phase (A) consists of no treatment and the experimental phase (B)
consists of two weeks daily intervention and a possible follow-up period. The
start of the experimental phase B (start intervention) for each participant on
a purely fortuitous manner determined with the restriction that the baseline
phase A at least 1 week (five days) duration and each patient 2 weeks (10 days)
consecutive can practice with the mirror design. This means that intervention
can begin at any time between the second and sixth week (20 random).

The main outcome measure the strength and the sensitivity is measured daily
during the 7 weeks. Because the patients go home on weekends over a period of 7
weeks in total 35 times measured. In this way a comparison can be made in
outcome measures between the ranges of the baseline phase and the experimental
phase (Ter Kuile et al, 2009; Onghena & Bulte, 2008).

Randomization done with replacement. Because the baseline / control phase
lasts at least 5 days and everyone a block of ten days with the mirror design
exercise, so there remain twenty days (p =. 05) on the random assignment. The
study design is a schematic representation of the design. The table is not
included in the template.

Baseline (5 days)
Randomization (20 measuring days), P = 0.05

During this period (day 1 to day 20) is started with random intervention, in a
block of ten consecutive (measurement) days.
During the last 10 test days (day 21) could not be randomized.

In one patient, it might be that the fate that after the baseline measurements
of five straight starts with the intervention. There then follows a period of
ten days, when the protocol is practiced in the mirror design. Then the
practice stopped, but is measured daily. The period of twenty days following,
is the follow-up period. Patient 2, for example, randomly assigned to eight
days after the baseline measurement of five, starting with the intervention.
This patient has a total of 12 baseline measurements (fixed + five days seven
days assigned by lot) when no intervention takes place. Then started ten days
in which the established practice with the mirror setup, after which a period
of thirteen days follow-up follows.

The intervention includes the addition of practice with the mirror up to the
retirement program. For patients with an affected arm or hand mirror
arrangement consists of a vertically positioned mirror that stands between two
tables. The healthy and the affected arm to either side of the mirror on the
table. The mirror is directed to the poor functioning. The affected arm is
shielded, so that these patients are not visible. When the patient looks in the
mirror, he sees two arms: the arm functioning and it reflected. Asked the
healthy arm to move in the mirror at a reflection of the moving arm. The
reflection of the healthy arm creates the illusion that the affected arm move
symmetrically along with the healthy arm.
For practicing with the mirror up in the experimental phase, a training
protocol was developed. Patients are practicing five times a day for ten
consecutive days with. Each training session lasts twenty minutes. Where, in
the experimental phase starts with the mirror structure is determined by
randomization, as previously described. There is a time twenty minutes
practicing with a fixed practisingprotocol.

Patients participating in the study are treated following the regular
treatmentprogram for patients. The first phase of clinical treatment consists
of deactivation. This phase is important in the treatment of motor conversion
disorder, because often these patients show long lasting patterns of
overburdening. This program requires that patients participate in non-treatment
activities in the clinical group, such as meals and coffee. During the
low-stimulus program, no treatment modules offered. The rationale behind this
program is often the chronic overloading of patients to quit. Many patients do
not register bodily or ignore these signals. This is often an important
maintaining factor in the disorder. Discontinuation of activities is an initial
attempt to reconnect with the physical signals. Patients are asked to record
the physical signals. This is monitored by a physiotherapist. This is the main
goal in this phase of treatment. The duration of the low-stimulus program is
four weeks, depending on the load of the patient. In later stages of the
regular treatment graded activity is added, using physical signals to
discriminate the limits of activation. During the low-stimulus program patients
can participate in the creative actvities, with the aim of leisurement.

As part of this research, the procedures described below was added to the
standard treatment offer.

• During the low-stimulus program, somewhere between week 2 and week 6 for ten
days twenty minutes five times a day practicing with the mirror structure
according to the exercise routine. Both the training protocol as the mirror
arrangement already described in Section 6.1.
• grip strength and sensibility are determined on a daily base (35
measurements)
• Weekly, the dissociative symptoms are measured by a psychological assistant
and functional dimensions measured.

The risk to patients is negligible. The mirror structure has little negative
side effects. Only in a study of Moseley Meaningless sensory experiences are
described, which disappear when the intervention was ceased.