1. Student Project by Daniela Cianci, OTS
Mirror Therapy
Student Project by Daniela Cianci, OTS

2. WHAT? V.S. Ramachandran, “Marco Polo of neuroscience” Neural mechanism
Reconciling motor output & sensory feedback (Acerra, Souvlis, & Moseley, 2007)
Mirror Neurons
Visual Feedback
Common Uses
Phantom limb pain
CRPS
CVA
3rd stage of GMI
Mirror therapy first described by V.S. Ramachandran who is considered to be the marco polo of neuroscience.
MT is using the visual feedback of normal movement patterns in the nonaffected limb to “trick the brain” into perceiving normal movement patterns in the affected limb.
The long-term effect of using MT is restructuring of the synapses in the brain so that the homunculus of the body is not distorted or disorganized
As I was researching mirror therapy I was very interested in the neural mechanism that allows for this type of therapy to be effective. What I found was that it is generally agreed upon in the current literature that mirror neurons are responsible for the effectiveness of mirror therapy. Mirror neurons are the neurons that become excited during action observation; in other words, if I watch one of you scratch your left hand, the mirror neurons in my somatosensory cortices are firing. However, I am not receiving the sensory or motor feedback in my own body that says “your left hand is being scratched” and therefore, I know that I am only observing that action and the signal is “vetoed” so to speak so that I know that I am not in fact creating the action myself. This is the mechanism by which mirror therapy works for phantom limb pain. The patient observes relief of some sort to the missing limb via the mirror reflection of the in tact limb, and the combination of the visual input and the lack of contradicting sensory input is enough to trick the brain into feeling the relief in the phantom limb.
In the case of neurorehabilitation for CVA, the visual stimuli provided by MT is stimulating to mirror neurons in the area of the somatosensory cortex that represents the affected limb, therefore retraining the brain to produce motoric output of the affected limb. In other words, by way of the visual sensory feedback created by the mirror image of the non-affected limb representing the affected limb, the sensorimotor pathways are reestablished in the area of the brain that represents the affected limb, thereby supporting cortical reorganization post-stroke to create normalized movement in the affected limb.
Since the brain is very plastic, over time if a patient is imagining moving their affected limb, however there is no visual or motor feedback that results from those signals, the brain may begin to reorganize the sensory and motor representations of the affected limb in the brain in a negative way that might inhibit future movement and sensation in that affected limb. Mirror therapy may inhibit that from happening by “reconcil[ing] motor output and sensory feedback” (Acerra, Souvlis, & Moseley, 2007). Essentially, mirror therapy is encouraging the brain to not give up on the affected limb.
As I’ve alluded to, mirror therapy has been used for phantom limb pain and CRPS, for hemiparesis as a result of CVAs, and as the 3rd stage in Graded Motor Imagery following laterality reconstruction and motor imagery.

3. WHO? Patient characteristics Motor Cognitive Visual Motorically
-literature is inconclusive regarding the motor function necessary for MT
-some suggest that some movement in the affected limb is preferred so that both limbs can be moved in conjunction even if the affected limb is not being observed.
-Some say that MT might ONLY be affected for patients who do not yet have movement in their affected limb. A study by Selles et al. (2014) found that mirror therapy using the unaffected limb for visual feedback was no more effective than training the affected limb with traditional therapy, and the authors suggested that therefore, MT might only be appropriate or helpful for patients who don’t yet have the ability to move their affected limb or quickly fatigue with use of the affected limb and therefore cannot directly train only the affected limb.
Cognitively
-Must be able to understand the protocol
-Must be able to sustain attention on the mirror
Visually
-need to be able to see and perceive the mirror image in full, so patients with visual field cuts or inattention may not be appropriate
-must be able to sustain fixation on the mirror

4. WHEN? Research varies for time frame post-injury
Acute vs. Chronic stages of neural recovery
The research was variable in terms of when mirror therapy was applied, whether it was in the acute or chronic stages post-injury
But one study pointed out that with chronic patients there might be more learned non-use and more time for disorganization of the homunculus mapping in the brain to occur and therefore, MT might be less effective in chronic stages than if it were used in acute stages.
However, given the plasticity of the brain and the concept behind mirror therapy, MT could still be effective in patients with chronic conditions.

5. WHERE? Inpatient Outpatient Home setting (HEP)
-most studies I read were based in the inpatient setting
-could be done in inpatient, outpatient, or home setting but this corresponds with time post-stroke
-should vary the environment as patient progresses. Recommended by David Butler in his video to perform MT in different lighting, with different levels and types of auditory stimuli such as people talking, music, etc., at different times of day to further help reconstruct the brain.

6. WHY? Current literature Generally shown to be effective in:
Improving motor recovery (Dohle et al., 2009; Sutbeyaz et al., 2007)
Improving sensation (Dohle et al., 2009)
Improving visuospatial neglect (Thieme et al., 2012)
Improved independence with ADLs (Invernizzi et al., 2012)
Combination with traditional PT/OT treatments (Rothgangel & Braun, 2013)
What I found in the current literature was kind of a mixed review on mirror therapy. Overall, when you take the average of the findings in the articles read, it’s agreed that mirror therapy is at least somewhat effective in improving motor recovery, sensation, visuospatial neglect, & independence with ADLs, however as I mentioned before some studies showed that MT was no more effective than training the affected limb with more traditional therapy approaches.
One article by V.S. Ramachandran suggested that the location of the lesion in the brain and the duration of paresis or paralysis may contribute to the highly variable effectiveness of MT
One of the most important take-aways I gathered was that MT should be used IN COMBINATION with other traditional OT/PT treatments to produce the best results for patients.

7. HOW? Protocol In literature: 30 min/day 5 days/week 4-6 weeks
In practice: Little and often (Neuro Orthopaedic Institute, n.d.)
Repeat, Grade, Enrich
In the literature it was largely 30 min/day, 5 days/week, for 4-6 weeks
Based on the highly variable results of the studies included in my lit review, I expanded my search to find more practice-based evidence, which suggested that perhaps the “little and often” approach would be more effective, that is doing MT maybe 5-10 minutes at a time, many different times during the day- this would allow for varying the setting, time of day, lighting, noise level, etc. of the MT intervention.
As I mentioned before mirror therapy is the 3rd stage in GMI. The GMI website suggests 3 important components to using MT. REPEAT movements until the patient is comfortable with them, GRADE movements from easier to harder and more complex, and ENRICH movements by performing movements in different contexts

8. SET-UP Seated at flat surface Mirror at midsagittal plane
Mirror perpendicular to work surface
Mirror in midsagittal plane
Want mirror perpendicular to the surface it’s on so that the image of the limb is not distorted in any way

9. TIPS Remove/cover jewelry, identifying marks, tattoos
Maintain gaze on mirror image
Graduated movements
1. Observe image of unaffected hand as affected hand in mirror
2. Pronate and supinate
3. Finger to thumb
4. Weight-bearing
5. Grasp and release
6. Manipulate objects
7. Begin moving affected hand in conjunction with unaffected hand
Vary contexts
Monitor patient for physiological signs of distress
-remove/hide anything that will make the visual image less compelling to the patient—want to create the most convincing image possible

10. PROS & CONS Conflicting evidence of effectiveness
Noninvasive treatment
Inexpensive
Specific patient population required
Easy set-up
Symmetric movements only
Neural basis
PROS
Foam board, velcro, mirror—do it yourself for about $15-$20
This portable mirror box is $65 on Amazon
CONS
Symmetric movements only—for example you wouldn’t be able to have the patient practice opening a jar of peanut butter because that requires different movements in each hand

11. QUESTIONS?

12. REFERENCES
Acerra, N.E., Souvlis, T., & Moseley, G.L. (2007). Stroke, complex regional pain syndrome and phantom limb pain: Can commonalities direct future management? Journal of Rehabilitation Medicine, 39(2), Arya, K.N. (2016). Underlying neural mechanisms of mirror therapy: Implications for motor rehabilitation in stroke. Neurology India, 64(1), 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(3), Imai, I., Takeda, K., Shiomi, T., Taniguchi, T., & Kato, H. (2008). Sensorimotor cortex activation during mirror therapy in healthy right-handed subjects: A study with near-infrared spectroscopy. Journal of Physical Therapy Science, 20, Invernizzi, M., Negrini, S., Carda, S., Lanzotti, L., Cisari, C., Baricich, A. (2012). The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: A randomized controlled trial. European Journal of Physical & Rehabilitation Medicine, 48, 1-7. Kojima, K., Ikuno, K., Morii, Y., Tokuhisa, K., Morimoto, S., & Shomoto, K. (2014). Feasibility study of a combined treatment of electromyography-triggered neuromuscular stimulation and mirror therapy in stroke patients: A randomized crossover trial. NeuroRehabilitation, 34, Lee, H., Li, P., & Fan, S. (2015). Delayed mirror visual feedback presented using a novel mirror therapy system enhances cortical activation in healthy adults. NeuroEngineering and Rehabilitation, 12(56), Michielsen, M.E., Selles, R.W., van der Geest, J.N., Eckhardt, M., Yavuzer, G., Stam, H.J., Smits, M., Ribbers, G.M., & Bussmann, J.B.J. (2011). Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: A phase II randomized controlled trial. Neurorehabilitation and Neural Repair, 25(3), Moseley, G.L., Gallace, A., & Spence, C. (2008). Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain, 138, Neuro Orthopaedic Institute. (n.d.). NOI mirror box: Notes for users. Retrieved from Ramachandran, V.S. & Altschuler, E.L. (2009). The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain, Rossiter, H.E., Borrelli, M.R., Borchert, R.J., Bradbury, D., & Ward, N.S. (2015). Cortical mechanisms of mirror therapy after stroke. Neurorehabilitation and Neural Repair, 29(5), Rothgangel, A., & Braun, S. (2013). Mirror therapy: Practical protocol for stroke rehabilitation. Munich: Pflaum Verlag. Selles, R.W., Michielsen, M.E., Bussmann, J.B., Stam, H.F., Hurkmans, H.L., Heijnen, I., de Groot, D., Ribbers, G.M. (2014). Effects of a mirror-induced visual illusion on a reaching task in stroke patients: Implications for mirror therapy training. Neurorehabilitation and Neural Repair, 28(7), Sutbeyaz, S., Yavuzer, G., Sezer, N., & Koseoglu, B.F. (2007). Mirror therapy enhances lower extremity motor recovery and motor functioning after stroke: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 88, Thieme, H., Bayn, M., Wurg, M., Zange, C., Pohl, M., & Behrens, J. (2012). Mirror therapy for patients with severe arm paresis after stroke—a randomized controlled trial. Clinical Rehabilitation, 27(4), Wu, C., Huang, P., Chen, Y., Lin, K., & Yang, H. (2013). Effects of mirror therapy on motor and sensory recovery in chronic stroke: A randomized controlled trial. Archives of Physical Medicaine and Rehabilitation, 1-8. Yavuzer, G., Selles, R., Sezer, B., Sutbeyaz, S., Bussmann, J.B., Koseoglu, F., Atay, M.B., & Stam, H.J. (2008). Mirror therapy improves hand function in subacute stroke: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 89, Yun, G.J., Chun, M.H., Park, J.Y., & Kin, B.R. (2011). The synergic effects of mirror therapy and neuromuscular electrical stimulation for hand function in stroke patients. Annals of Rehabilitation Medicine, 35,