Introduction to the use of mirrors in rehabilitation

M. Penny Bartzen OTR/L
Graded Motor Imagery Program
Gently Rewires the Brain: CRPS
Chronic Regional Pain Syndrome (CRPS)
Laterality Reconstruction
Restore the brain’s concept of right and left
Graded identification of right/left photos of hands until 80 %
2. Visual and motor imagery
Visualizing without movement or threat
Visualize progressive movements
Mirror Therapy
Watch uninvolved hand
Gradually increase movement
Replicate with other hand
(S. Stralka, 2011)
 Mirror Neurons
 History of the approach
 Diagnoses
 Research review
 Application to your population
 Further information
Have you tried this?
TED Talk
Mirror Neurons
Mirror neurons are a particular class of visuomotor neurons, originally
discovered in area F5 of the monkey premotor cortex, that discharge both
when the monkey does a particular action and when it observes another
individual (monkey or human) doing a similar action.
Rizzolatti G, Craighero L, “The mirror-neuron system,” in Annual Review of
Neuroscience, issue 27 (2004) p. 1
Mirror Neurons
 Activated by
observing and
executing movement
 Imitation and learning
 Motor imagery and
visual imagery
 Autism Spectrum
A. Non-object related
B. Object related
Red - mouth movements
Green - hand movement
Blue- Foot movements
(G. Blinkofski et al., Eur J Neurosci, 13:400-4, 2001)
Cortical Homunculus Images
Mirror Neurons & Autism
Dysfunction responsible for impairments?
Deficits in imitation
Theory of mind
Social communication
Neural strategies differ
Neural systems interfaces with limbic system
Seemingly not engaged in children with ASD
(Dapretto, Davies, Pfeifer, Scott, Sigman, Bookheimer & Iacoboni, 2005)
Mirror Neuron Dysfunction and
Autism Spectrum Disorders
 Treatment Experiments: Imitation
 Children being imitated by an adult
demonstrated much more “social behavior”
and reciprocal play vs. children who were only
playing with an adult
(Nyberg, J., n.d.)
Mirror Visual Feedback (MVF)
 Visual feedback dominates somatosensory
feedback for cortical proprioceptive
 Mirror therapy increases cortical and spinal
motor excitability (the mirror neuron system)
 Sensory experiences can be evoked on the
basis of visual information alone.
 Visual input enhances tactile sensitivity.
(Moseley, Gallace & Spence, 2008)
Remapping, cortical plasticity
and mirror therapy
• Learned paralysis may be unlearned using
the mirror
• Residue of mirror neurons that survived
lesion are dormant may be stimulated with
• Visual feedback may revive the dormant
ipsilateral connection between the motor
cortex and the spinal cord.
(Ramachandran & Altschuler, 2009)
Mirror Visual Feedback (MVF):
Mirror Box Therapy (MVT)
 Strokes
 Autism
 Amputations
 Complex Regional Pain Syndrome
(CRPS)/Reflex Sympathetic Dystrophy (RSD)
 Neurological Disorders
 Arthritis
Evidence: Cochrane Review
 “Cochrane Reviews are systematic reviews of
primary research in human health care and health
policy, and are internationally recognised as the
highest standard in evidence-based health care.
They investigate the effects of interventions for
prevention, treatment and rehabilitation. They also
assess the accuracy of a diagnostic test for a given
condition in a specific patient group and setting.
They are published online in The Cochrane Library. “
( The Cochrane Collaboration, 2012)
Thieme H, Mehrholz J, Pohl M,
Behrens J, Dohle C. (2012). Mirror
therapy for improving motor
function after stroke. Cochrane
Database of Systematic Reviews.
 14 studies with 547 participants
 Randomized controlled trials & randomized
cross-over trials with any control
 Measures of motor function, ADL, pain and
visuospatial neglect
Characteristics of studies
 12 studies randomized control trials and 2 used a
cross-over design with random allocation
9 to 121 participants
Mean age 51 to 797
55% left hemiparesis
Male 57% female 43%
5 days to 5 years post stroke (4 acute and 8
83 % ischemic and 17% hemorrhagic
Settings included inpatient, in and out-patient,
day hospital and home setting.
 Mirror or a mirror box in the midsagittal plane
between the upper or lower extremity
 Reflect movement of the non-involved extremity
 2 studies incorporated another intervention, electrical
stimulation or visual imagery
 10 to 60 min sessions, 1 to 7 x wk for up to 6 weeks.
 5- Bilateral movements, moving the affected arm as
well as they could
 6- moved only the unaffected side
 1 therapist passively moved the affected arm to
match unaffected motion
Cochrane: Outcome measures
 Motor: Fugl-Meyer, Action Research Arm Test, Wolf
Function Test, Motor Assessment Scale, Brunnstrom
 ADL: FIM, Barthel Index,
 Pain: Measure at rest and sduring motion that
include the numerical rating scales, the Visual
Analogue Scale (VAS), the pain section of Fugl-Meyer
 Visuospatial: Behavioral Inattention Test (BIT), Test
of Attentional Performance (TAP)
 Measured pre and post as well as 1 to 6 months post.
(p. 9)
Cochrane: Outcomes
 Significant effect on motor function after
stroke (p. 11)
 Significant effect on ADL function (p. 12)
 Significant positive effect on pain (p.12)
 1 study showed evidence for improving
visuospatial neglect (p.12)
Cochrane: Recommendations
 Include as adjunct to standard therapy
 Utilize with CRPS type-1 after stroke for pain
 Continued research (p. 15)
Neuroplasticity and CVA
 Neuro-reeducation may be more effective
 Starting 5 days post onset rather than 30
 Changes continue to occur months after onset
 Try to avoid allowing the brain to reorganize for
 Give feedback and explain the purpose
 Hebb’s Rule.
Graded Motor Imagery Program
 Neuro Orthopedic Institute (NOI)
 Chronic Regional Pain Syndrome (CRPS)
 Utilizes mirrors and other approaches to reduce pain,
normalize sensation and improve function.
 Utilized in hand therapy and pain clinics.
GMIP: Sensory Re-education and
 Laterality
 Visual Imagery
 Mirror Therapy
 Localization
 Kinesthesia
 Graphesthesia
 Stereognosis
 Sensorimotor accuracy
(Stralka ,2011)
Sound Familiar?
GMIP with Stroke
 Laterality - Restore brain’s concept of right and left.
• 6 to 10 cards R/L hand to start
• Acute BID 15 min
• 80% accuracy
• R/L in magazines, photos
• Incorporate sensory information
• Functional tasks
 Mental Practice/Imagery
• Imagine hand motions of cards
• Imagine adopting position on cards
• Repeat process 3x day
(Stralke, 2011)
GMIP for Stroke Recovery
 Mirror Box
• Imagine the affected UE is moving while looking in mirror
• Therapist /family move the limb to imitate non-involved
• Move the involved hand asap
• Supination/pronation
• Wrist extension/flexion
• Finger motions – hook, gross grasp
• Opposition
• Picking up /releasing ball.
(Stralka, 2011)
Christian Dohle et al. (2009). Mirror therapy
promotes recovery from severe hemiparesis: A
randomized control trial.
 Participants
• 36 patients
• 1st ischemic CVA in territory of middle cerebral
• < 8 weeks post onset
 Intervention
• 6 wk, 30 min. per day, 5 x wk.
• Random assignment control or mirror therapy
• All other standard therapies
Dohle et al, 2009
 Patients watched the mirror image of the unaffected
arm as if it were the affected one.
 Executed arm, hand and finger postures in response
to verbal instructions
 Protocol scaled according to abilities
 Asked to move their affected arms as well as possible
Christian Dohle et al. (2009).
Outcome Measure
• Fugl-Meyer, functional and neuropsych testing
 Subgroup of 25 with initial distal plegia
• Improved distal function in MT group
• Increase in surface sensibility
• Not dependent on side of lesion
Mirror Visual Feedback with Stroke
 2008, Yvuzer et al.
• 40 patients with UE hemiparesis
 Mirror Therapy group statistical improvement in Burnnstrom stages of
motor recovery and FIM self-care score over control group
 2008, Matsuo et al.
• 15 sub-acute patients with hemiparesis
 Mirror therapy group superior to the control treatment using the Fugel –Meyer
assessment of the paretic arm.
 Ramchandram (2009) notes:
• Benefit variables may include the location of lesion and duration of
• Motor visual feedback (MVF) should be implemented routinely due
to the simplicity of the approach
Yavuzer et al. 2008
 40 inpatients, w/in 12
months of onset
30 min mirror therapy
Sitting with involved hand
behind mirror
Wrist and finger flexion
and extension movement
Watching non-involved
Asked to do the same with
Altschuler et al. 1999
 9 patients, 6 mo post
 15 min, 2x day, 6 day per
Watch non-involved hand
in mirror
Move hands and arms
Proximal to distal
Easy movements to
Case Study
 63 y.o. gentleman with R hemisphere, posterior internal capsule stroke
resulting in L side paresis, onset 1 yr and 3 months prior to study
 18 x 24” mirror attached to 2 wooden posts.
 1 hr visit, 3x wk for 3 wk
 20 min mental imagery
 35 mirror box training
Identify hand reflection as his own: Finger tapping, wrist flexion/extension
Simple tasks: Manipulation tasks with object of various size and weights including
pouring liquid and drinking from a cup.
More perceptually challenging tasks: Placement of number objects in distinct order, use
of stylus and asked to draw simple picture.
 4 pt increase in Fugl-Meyer and improved times for the Jebsen after 3
weeks of therapy. Baseline 47/66 to Day 21- 51/66
(Stevens & Stoykov, 2004)
Mirror Visual Feedback with Stroke
Ramachandran & Altschuler (2009) review of the use of visual
feedback in restoring brain function with PLP, CRPS and CVA.
 1999, Altschuler et al.
 9 patients
 3 moderate recovery of function
 3 mild recovery
 3 no recovery
 2007, Sutbeyaz, et al
• 40 patients with LE Hemiparesis
 Mirror therapy group showed significant improvement in Brunnstrom stages
and FIM motor scores compared with control group.
(Ramachandran & Altschuler, 2009)
Standard of Practice?
 Non breakable mirrors of varied sizes in hospital and
for out-patients
Home program
 Photographs of movements
 Functional tasks
 Sensory information
Sequential protocol that is easily adapted to the
Explain to families and clients (staff?) for improved
What do you think?
 Small Group
 Population
 How are you using it already?
 How could you incorporate it?
 How do you explain it?
 Share
The procedure is not miracle cures by any
means, but even if only a small proportion of
patients is helped, they would be a enormous
value given the high incidence of phantom
pain and stroke….Moreover, even if the
procedure benefits a minority of patients, it is
likely to pave the way for future more
completely effective therapies once we
understand the variables involved”
(Ramachandran & Altschuler, 2009, p 1694).
Doug and the Mirror Box
"The best thing about mirror therapy is,
… it's cheap, safe, easy and it's fun.“
Dr. Eric Lewin Altschuler
For further information
 READ the Cochrane report!
 Search Mirror Neurons
 Books
 The Brain that Changes Itself (Doidge, 2007)
 The Tell-Tale Brain (Ramachandran, 2011)
 You Tube
 Search for Mirror Box Therapy
 Ramachandran
 Mirror Neurons
 TED Talks
• Ramanchandran
• Mirror Neurons
YouTube: Mirror neurons, boxes & therapy
 Giacomo Rizotalli on the discovery of mirror neurons_
 Mirror box therapy with David Butler_
 The social brain (ep 4)- Charlie Rose: The social brain_
 Acting and mirror neurons_
 Mirror Box Visual Therapy_
 How to use a mirror box for hand therapy_
 Phantom limb mirror box video_
 Doug and mirror box therapy in action 3 sep _
 Mirror neurons in autism_
Altschuler, E.,L. Wisdom, S.B, Ston, L., Foser, C., Galasko, D., Llewellyn, M. E. &
Ramachandron, R.S. (1999). Rehabilitation of hemiparesis after stroke with a mirror.
Lancet, 353, 2035-2036.
Dapretto, M., Davies, M., Pfeifer, J., Scott, A., Signman, M., Bookheimer, S., & Iaconboni, M.
(2005). Understanding emotions in others: mirror neuron dysfunction in children with
autism spectrum disorders. Nature Neuroscience, (9),28-30. doi: 10.1038/nn1611
Dohle, C., Pullen, J, Nakaten, A., Kust, J., Rietz, C., & Karbe, H. (2009) Mirror therapy
promotes recovery from severe hemiparesis : A randomized controlled trial.
Neurorehabilitation and Neural Repair, 23, 209-217.
Doidge, N. (2007). The brain that changes itself: Stories of personal triumph from the
frontier of brain science. New York: Penguin Group, Inc.
Jenson, L, (2009) Critically Appraised Topic (CAT): What is the effectiveness of mirror therapy
for improving upper extremity motor recovery and functional use in adults with
hemiparesis following stroke? Retrieved from
Mosely, G.L & Wiech, K. (2009). The effect of tactile discrimination training is enhanced
when patpients watch the relfected image of their unaffected limb during training.
PAIN, 144, 314-319. doi:10.1016/j.pain.2009.04.030
Moseley, G. L., Gallace, A. & Spense, C. (2008). Is mirror therapy all it is cracked up to be?
Current evidence and future directions. Pain, 138, 7-10. doi: 10.1016/j.
Nyberg, J. (n.d.). Mirror neurons. Retrieved from
Pomeroy, V. M., Clark, C. A., Miller, S., G., Baron, J., Markus, H. S. & Tallis, R. C. (2005). The
potential for utilizing the “mirror neurone system” to enhance recovery of the severely
affected upper limb early after stroke: A review and hypothesis. Neurorehabilitation
and Neural Repair, 19, 4-13. doi: 10.1177/1545968304274351.
Ramachandram, V.S. & Alstchuler, E. L. ( 2009). The use of visual feedback, in particular
mirror visual feedback, in restoring brain function. Brain: A Journal of Neurology, 132,
1993-1710. doin: 10.1093/brain/awp135.
Stevens, J. A. & Stoykov, M. E. (2004). Simulation of bilateral movement training through
mirror reflection: A case report demonstrating an occupational technique for
hemiparesis. Topics in Stroke Rehabilitation, 11, 59-66.
Stralka, S. W. (2011, January 28-29). Graded Motor Imagery Program for upper extremity
injuries: Using GMIP to retrain the brain). Presented for Sister Kenny at John Nasseff
Conference Center, United Hospital, St. Paul, Minnesota.
TEDindia (2010, January). V.S. Ramachandran: The neurons that shaped civilizations.
[Video File]. Retrieved from
Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. (2012) Mirror therapy for improving
motor function after stroke. Cochrane Database of Systematic Reviews. Retrieved
Yavuzer, G., Selles, R., Sezer, N., Sutbeyaz, S., Bussmann, J., Koseoglu, F., Atay,
M. & Stam, H., (2007). Mirror therapy improves hand function in subacute
stroke: A randomized controlled trial. Achives of Physical Medicine and
Rehabilitation, 89, 393-398. doi: 10.1016/j.apmr.2007.08.162.
There are two ways of spreading light: to be the candle or
the mirror that reflects it.
-Edith Wharton

similar documents