Mirror Therapy for Occupational Therapy Stroke Rehabilitation – Latest Evidence-based Practice

Occupational therapists working in stroke rehabilitation may use mirror therapy (MT) as an intervention for managing their symptoms and promoting function. This post will highlight the history of mirror therapy (MT), what it was and is used for, the evidence, and its pros and cons. This post will address each of these factors for the feasibility of MT for the management and rehabilitation of stroke symptoms in occupational therapy.

MT is also called mirror-box therapy. For example, Saebo manufactures [1]https://www.saebo.com/shop/saebo-mirror-box/ a foldable box with mirrors for the upper extremities rehabilitation used in the seated position.

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Ramachandran was the first to describe MT as an effective method for relieving amputee pain. A mirror was placed on the desk and the patient’s unaffected arm placed in front of the mirror. The affected one was placed behind the mirror and hidden from view. MT works by using visual feedback from the unaffected arm’s movements in the mirror. This was thought to make patients feel as though their affected arm was restored. [2]Ramachandran VS, Rogers-Ramachandran D, Cobb S. Touching the phantom limb. Nature 1995; 377: 489–490.

MT also belongs to a set of treatments called Graded Motor Imagery (GMI). GMI uses a top-down paradigm to treat pain. Traditional examples of GMI are for targeting complex regional pain syndrome in the upper extremities [3]Priganc, V. W., & Stralka, S. W. (2011). Graded motor imagery. Journal of Hand Therapy24(2), 164-169. and phantom limb pain (PLP).

A RCT published in 2020 evaluated the effectiveness of GMI for reducing PLP. This single-blinded RCT (n=21) of outpatient departments in South Africa found significant improvements in pain as measured by the Brief Pain Inventory at 6 weeks and 6 months compared to a control group. Limakatso, Madden, Manie, and Parker state that their GMI is better than routine physiotherapy for reducing PLP. [4]Limakatso K, Madden VJ, Manie S, Parker R. The effectiveness of graded motor imagery for reducing phantom limb pain in amputees: a randomised controlled trial. Physiotherapy. 2020 Dec;109:65-74. doi: … Reference List

Since Altschuler et al.’s study which documented the first use of MT as a possible method to promote motor function in CVA survivors[5]Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DM, et al. Rehabilitation of hemiparesis after stroke with a mirror. Lancet 1999; 353: 2035–2036., there have been further studies that report its positive effect on motor function in the upper extremities. [6]Gurbuz N, Afsar SI, Ayaş S, Cosar SNS. Effect of mirror therapy on upper extremity motor function in stroke patients: a randomized controlled trial. J Phys Ther Sci 2016; 28: 2501–2506. [7]Wu CY, Huang PC, Chen YT, Lin KC, Yang HW. Effects of mirror therapy on motor and sensory recovery in chronic stroke: a randomized controlled trial. Arch Phys Med Rehabil 2013; 94: 1023–1030. [8]Yavuzer G, Selles R, Sezer N, Sütbeyaz S, Bussmann JB, Köseoglu F, et al. Mirror therapy improves hand function in subacute stroke: a randomized controlled trial. Arch Phys Med Rehabil 2008; 89: … Reference List [9]Dohle C, Püllen J, Nakaten A, Küst J, Rietz C, Karbe H. Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial. Neurorehabil Neural repair 2009; 23: 209–217. [10]Invernizzi M, Negrini S, Carda S, Lanzotti L, Cisari C, Baricich A. The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial. Eur J … Reference List [11]Lin KC, Huang PC, Chen YT, Wu CY, Huang WL. Combining afferent stimulation and mirror therapy for rehabilitating motor function, motor control, ambulation, and daily functions after stroke. … Reference List [12]Samuelkamaleshkumar S, Reethajanetsureka S, Pauljebaraj P, Benshamir B, Padankatti S, David J. Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized … Reference List [13]Cristina LM, Matei D, Ignat B, Popescu CD. Mirror therapy enhances upper extremity motor recovery in stroke patients. Acta Neurol Belg 2015; 115: 597–603. [14]Colomer C, Noé E, Llorens R. Mirror therapy in chronic stroke survivors with severely impaired upper limb function: a randomized controlled trial. Eur J Phys Rehabil Med [Internet]. 2016.

The underlying mechanisms of why MT worked for this population were not well understood. Some hypotheses include the activation of the M1 motor cortex, mirror neurons, right temporal gyrus, and the right occiptal gyrus for why MT may work for this population. [15]Garry MI, Loftus A, Summers JJ. Mirror, mirror on the wall: viewing a mirror reflection of unilateral hand movements facilitates ipsilateral M1 excitability. Exp Brain Res 2005; 163: 118–122. [16]Cattaneo L, Rizzolatti G. The mirror neuron system. Arch Neurol 2009; 66: 557–560. [17]Matthys K, Smits M, Van der Geest JN, Van der Lugt A, Seurinck R, Stam HJ, et al. Mirror-induced visual illusion of hand movements: a functional magnetic resonance imaging study. Arch Phys Med … Reference List [18]Michielsen ME, Smits M, Ribbers GM, Stam HJ, van der Geest JN, Bussmann JB, et al. The neuronal correlates of mirror therapy: an fMRI study on mirror induced visual illusions in patients with stroke. … Reference List What researchers can assume due to improvements in function and pain is that this biofeedback approach helps improve function due to neuroplasticity.

Despite an increase in systematic reviews on the effectiveness of MT, they contained limitations such as small sample sizes or issues with empirical evidence, especially about the long-term motor function with MT. [19]Mei Toha SF, Fong KNK. Systematic review on the effectiveness of mirror therapy in training upper limb hemiparesis after stroke. Hong Kong J Occup Ther 2012; 22: 84–95. [20]Rothgangel AS, Braun SM, Beurskens AJ, Seitz RJ, Wade DT. The clinical aspects of mirror therapy in rehabilitation: a systematic review of the literature. International journal of rehabilitation … Reference List More evidence is suggesting that MT to be associated with immediate improvement in motor functional outcome, such as with the Fugl-Meyer Assessment (FMA). [21]Zeng, W., Guo, Y., Wu, G., Liu, X., & Fang, Q. (2018). Mirror therapy for motor function of the upper extremity in patients with stroke: A meta-analysis. Journal of Rehabilitation … Reference List

Further RCT meta-analyses showed MT to significantly improve motor function according to the Functional Independence Measure (FIM), Modified Ashworth Scale (MAS), and ADL participation as measured by the Modified Barthel Index (MBI) and Motor Activity Log (MAL). Similar to other conditions, MT was found to be effective in pain management for CVA as measured by the Pain Visual Analog Scale (VAS). These authors concluded that all the interventions of MT alone or combined with other rehabilitation therapies were significantly more effective than controls with or without sham therapy and electrical stimulation to promote motor function and motor recovery in stroke patients. [22]Y. Yang, Q. Zhao, Y. Zhang, Q. Wu, X. Jiang, G. Cheng, Effect of mirror therapy on recovery of stroke survivors: A systematic review and network meta-analysis, Neuroscience (2018), doi: https:// … Reference List

Potential Uses of Mirror Therapy for CVA

  • Pain Management
  • Function (neuro-return)

Benefits of MT

  • Cheap: a large mirror is used
  • Simple: demonstration by an OT with multiple sample videos online for review
  • Convenient (rehabilitation is applicable in multiple settings)

Cons and Considerations of MT

  • Does not work with smaller mirrors. [23]McCabe C. Mirror visual feedback therapy. A practical approach. J Hand Ther. 2011; 24(2):170-8.
  • The mirror must be of good quality, clean, and the image not distorted.
  • Mirror must be placed at midline.
  • Jewelry, tattoos may be distracting.
  • Poor compliance with regime such as at home.
  • Possible side effects: motor extinction, increased pain, exacerbation of movement disorders, confusion and dizziness. [24]Casale, R., Damiani, C., & Rosati, V. (2009). Mirror therapy in the rehabilitation of lower-limb amputation: are there any contraindications?. American journal of physical medicine & … Reference List

Typical Protocol

  1. Treatment begins with the adaptive phase in which the patient simply observes the reflection of the limb without movement.
  2. Patients having difficulty experiencing the reflection as an additional limb will require OT to cue the patient to imagine ‘looking through a glass instead of a mirror’.
  3. The patient then moves the affected limb (hidden) in sync with the unaffected limb.
  4. If the movement of the affected limb is currently not possible, e.g., due to hemiparesis, the patient can observe the movements of the unaffected limb until the patient feels ready to progress to movements. [25]McCabe C. Mirror visual feedback therapy. A practical approach. J Hand Ther. 2011; 24(2):170-8.
  5. The patient repeatedly practices this technique over time, e.g., daily at home. Patients will benefit more from shorter duration with higher frequency. For example, 5 minute sessions, 5-6x/day, every day. Longer sessions with low frequency, e.g., 30 min sessions once a day or once a week are not encouraged.[26]Grünert-Plüss N, Hufschmid U, Santschi L, Grünert J. Mirror therapy in hand rehabilitation: a review of the literature, the St Gallen protocol for mirror therapy and evaluation of a case series of … Reference List
  6. A diary where the patient documents time using the mirror, types of movements, symptoms and outcomes can be a useful aid to sustain adherence to the treatment regimen.[27]Grünert-Plüss N, Hufschmid U, Santschi L, Grünert J. Mirror therapy in hand rehabilitation: a review of the literature, the St Gallen protocol for mirror therapy and evaluation of a case series of … Reference List

Conclusion

Backed by recent significant evidence of MT for CVA in motor function recovery, CVA, and pain management, occupational therapy practitioners can incorporate this method of intervention into their practice. Most rehabilitation gyms have large mirrors or they can be acquired for low cost to use with stroke survivors. As the side-effects are few and not likely to be debilitating, MT can be incorporated relatively safely with most CVA patients. And as MT sessions are encouraged to be short, occupational therapy practitioners may use the extra time to combine this intervention with other evidence-based approaches in stroke recovery such as promoting ADLs, sensory return, social participation, and cognition with dual-tasking. As practice in a real environment, such as participation in grooming at the sink is likely to promote the best outcome, occupational therapy practitioners can also observe improvements in function with the affect limb in these scenarios.

An example of a treatment session may include MT in the beginning, ADL training, followed by facilitation of cognitive strategies such as filling in the daily diary or memory book for ADLs and MT performance, symptoms, and times completed. Overall, promotes the stroke survivor’s occupation of health management with clear set goals, self-monitoring, and empowers them to do their own exercises and daily activities. Collaborative MT practice with an OT such as in ARU can also promote transfer to other environments such as follow-up by a home health OT.

See also

References

References
1 https://www.saebo.com/shop/saebo-mirror-box/
2 Ramachandran VS, Rogers-Ramachandran D, Cobb S. Touching the phantom limb. Nature 1995; 377: 489–490.
3 Priganc, V. W., & Stralka, S. W. (2011). Graded motor imagery. Journal of Hand Therapy24(2), 164-169.
4 Limakatso K, Madden VJ, Manie S, Parker R. The effectiveness of graded motor imagery for reducing phantom limb pain in amputees: a randomised controlled trial. Physiotherapy. 2020 Dec;109:65-74. doi: 10.1016/j.physio.2019.06.009. Epub 2019 Jun 28. PMID: 31992445.
5 Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DM, et al. Rehabilitation of hemiparesis after stroke with a mirror. Lancet 1999; 353: 2035–2036.
6 Gurbuz N, Afsar SI, Ayaş S, Cosar SNS. Effect of mirror therapy on upper extremity motor function in stroke patients: a randomized controlled trial. J Phys Ther Sci 2016; 28: 2501–2506.
7 Wu CY, Huang PC, Chen YT, Lin KC, Yang HW. Effects of mirror therapy on motor and sensory recovery in chronic stroke: a randomized controlled trial. Arch Phys Med Rehabil 2013; 94: 1023–1030.
8 Yavuzer G, Selles R, Sezer N, Sütbeyaz S, Bussmann JB, Köseoglu F, et al. Mirror therapy improves hand function in subacute stroke: a randomized controlled trial. Arch Phys Med Rehabil 2008; 89: 393–398.
9 Dohle C, Püllen J, Nakaten A, Küst J, Rietz C, Karbe H. Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial. Neurorehabil Neural repair 2009; 23: 209–217.
10 Invernizzi M, Negrini S, Carda S, Lanzotti L, Cisari C, Baricich A. The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial. Eur J Phys Rehabil Med 2013; 49: 311–317.
11 Lin KC, Huang PC, Chen YT, Wu CY, Huang WL. 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.
12 Samuelkamaleshkumar S, Reethajanetsureka S, Pauljebaraj P, Benshamir B, Padankatti S, David J. Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial. Arch Phys Med Rehabil 2014; 95: 2000–2005.
13 Cristina LM, Matei D, Ignat B, Popescu CD. Mirror therapy enhances upper extremity motor recovery in stroke patients. Acta Neurol Belg 2015; 115: 597–603.
14 Colomer C, Noé E, Llorens R. Mirror therapy in chronic stroke survivors with severely impaired upper limb function: a randomized controlled trial. Eur J Phys Rehabil Med [Internet]. 2016.
15 Garry MI, Loftus A, Summers JJ. Mirror, mirror on the wall: viewing a mirror reflection of unilateral hand movements facilitates ipsilateral M1 excitability. Exp Brain Res 2005; 163: 118–122.
16 Cattaneo L, Rizzolatti G. The mirror neuron system. Arch Neurol 2009; 66: 557–560.
17 Matthys K, Smits M, Van der Geest JN, Van der Lugt A, Seurinck R, Stam HJ, et al. Mirror-induced visual illusion of hand movements: a functional magnetic resonance imaging study. Arch Phys Med Rehabil 2009; 90: 675–681.
18 Michielsen ME, Smits M, Ribbers GM, Stam HJ, van der Geest JN, Bussmann JB, et al. The neuronal correlates of mirror therapy: an fMRI study on mirror induced visual illusions in patients with stroke. J Neurol Neurosurg Psychiatry 2011; 82: 393–398.
19 Mei Toha SF, Fong KNK. Systematic review on the effectiveness of mirror therapy in training upper limb hemiparesis after stroke. Hong Kong J Occup Ther 2012; 22: 84–95.
20 Rothgangel AS, Braun SM, Beurskens AJ, Seitz RJ, Wade DT. The clinical aspects of mirror therapy in rehabilitation: a systematic review of the literature. International journal of rehabilitation research Internationale Zeitschrift fur Rehabilitationsforschung Revue internationale de recherches de readaptation 2011; 34: 1–13.
21 Zeng, W., Guo, Y., Wu, G., Liu, X., & Fang, Q. (2018). Mirror therapy for motor function of the upper extremity in patients with stroke: A meta-analysis. Journal of Rehabilitation Medicine50(1), 8-15.
22 Y. Yang, Q. Zhao, Y. Zhang, Q. Wu, X. Jiang, G. Cheng, Effect of mirror therapy on recovery of stroke survivors: A systematic review and network meta-analysis, Neuroscience (2018), doi: https:// doi.org/10.1016/j.neuroscience.2018.06.044
23, 25 McCabe C. Mirror visual feedback therapy. A practical approach. J Hand Ther. 2011; 24(2):170-8.
24 Casale, R., Damiani, C., & Rosati, V. (2009). Mirror therapy in the rehabilitation of lower-limb amputation: are there any contraindications?. American journal of physical medicine & rehabilitation88(10), 837-842.
26, 27 Grünert-Plüss N, Hufschmid U, Santschi L, Grünert J. Mirror therapy in hand rehabilitation: a review of the literature, the St Gallen protocol for mirror therapy and evaluation of a case series of 52 patients. Hand Therapy. 2008; 13(1):4-11.