INTRODUCTION:

Overview

Mirror therapy was first described by Vilayanur. S. Ramachandran, who initially trained as a doctor and subsequently obtained a Ph.D. from Trinity College at the University of Cambridge^1,4. A mirror is used to convey visual stimuli to the brain through observation of one's unaffected body part as it carries out a set of movements.

Indications

• Phantom limb pain

• Complex regional pain syndrome (CRPS),

• Stroke rehabilitation

• Hand and foot rehabilitation following an injury or surgery

• Neuropathic pain

Purposes of Mirror Therapy

• Improve motor recovery in upper and lower extremities

• Increase the functional use of upper and lower extremities

• Work in conjunction with conventional therapy

Goals of mirror therapy

• Increase ROM

• Increase function

• Increase perception (neglect, inattention, awareness)

• Increase cortical reorganization of the brain

• Increase processing speed

• Increase strength

• Improve a lack or change in sensation

• Decrease apraxia

• Decrease pain

• Increase coordination

Patient Criteria

• Medically stable

• Diagnosis that has affected an extremity in strength, ROM, sensation and/or visual perception

• Must have intact/unaffected extremity

• Tolerates upright position

• Follows simple commands/directions

• Can attend to task for at least 15 minutes

Contraindications

• Precautions or restrictions limiting ROM to the affected extremity ie: DVT, sternal precautions, arthritis, contractures, tone

• Any visual impairments that will severely impact ability to see image in the mirror ie: macular degeneration, cataracts, etc.

How It’s used?

In mirror therapy (MT), the patient sits in front of a mirror that is oriented parallel to his midline blocking the view of the (affected) limb, positioned behind the mirror. Then using both limbs to do the gentle symmetrical exercises. When looking into the mirror, the patient sees the reflection of the unaffected limb positioned as the affected limb. This arrangement is suited to create a visual illusion whereby movement of or touch to the intact limb may be perceived as affecting the paretic or painful limb.

The underlying Principle is that movement of the affected limb can be stimulated via visual cues originating from the opposite side of the body. Mirror therapy enhances recovery by enlisting direct visual stimulation showing the affected limb working properly, rather than relying on mental imagery alone.

Practice symmetrical exercises that your Physiotherapist has suggested for you

It is very important to practice symmetrical movements only when the using the Mirror. Asymmetrical movements for e.g keeping the hand still and moving the hand outside the box or vice versa , may make the condition worse. Some patients may find using the Mirror difficult at first and more painful.

Principle of mirror therapy

The principle of mirror therapy is simple: When looking into the mirror, the patient observes the reflection of the unaffected limb positioned as the affected limb. When performing motor or sensory exercises with the non-affected limb, the reflection in the mirror is often perceived as the affected, paretic limb. This strong visual cue from the mirror can therapeutically be used to improve motor performance and the perception of the affected limb¹.

Pain relief in mirror therapy may be due to the activation of mirror neurons in the hemisphere of the brain that is contra-lateral to the amputated limb. These neurons fire when a person either performs an action or observes another person performing an action⁴. Alternatively, visual input of what appears to be movement of the amputated limb might reduce the activity of the systems that perceive protopathic pain. In a pilot study , fMRI demonstrates that brain areas, that are involved in sensory-motor learning (mirror neurons), are activated by the visual illusion from mirror therapy. Mirror neurons were found in areas of the ventral and inferior pre-motor cortex associated with observation and imitation of movements and in somatosensory cortices associated with observation of touch³.

Equipment includes

• Mirror box or full length mirror

• Table (for upper extremities)

• Mat or chair (for lower extremities)

• Quiet environment with limited visual and auditory distractions

• Side tables (depending on activity)

Guide lines

All identifiers are removed from unaffected extremity such as:

• Rings

• Name bands

• Bracelets/watches

• The affected upper extremity is placed inside the box or behind the full length mirror

• Patient sits with mirror at midline of face/body. Patient look at the mirror reflection of the normal upper/lower limb so that the reflections optically superimposed on the felt location of the affected limb, thus creating the visual illusion.

• Patient is positioned in appropriate position for desired ROM (supine with head elevated or seated in wheelchair/chair)if lower extremity is affected.

• The affected lower extremity is placed behind the full length or rolling mirror

• Selected exercises are completed with unaffected upper extremity while patient watches motion in mirror

• Patient should try to move both extremities together and coordinate throughout

• Depending on the pain and disability state, decide on an appropriate activity to perform with the good hand. This could range from just looking at the finger movements, or taking weight through the hand².

• Feel comfortable with your selected movements ‘conquer the movements’ before progressing to a more challenging movement. Once you feel comfortable with the movement, try and perform it in a different context².

• Grade the movements from easy to more difficult and then enrich the movement with different contexts for best results.

• If the hand in the box hurts or sweats, you may have taken the brain exercises too far even though the hand has not been harmed. Just take a break and try something a little less challenging next time².

CONCLUSION:

The rate and amount of recovery much depends upon the extent of the damage, and the intensity and duration of the therapy the pt receives. Recovery also to be influenced by personality, life experiences and coping styles. Motivation to recover is a key factor in obtaining optimal level of rehabilitation.

REFERENCE:

1. Deepti Goel, Sharad Goel, Mirror Therapy in Stroke Rehabilitation. Physiotherapy and Occupational Therapy Journal.1(1);2008:57-61

2. Arul Nisha. S, Mirror box therapy. Nightingale Nursing Times. 9(5);2013:33-34

3. V.S. Ramachandran, Plasticity and functional recovery in neurology. Clinical Medicine.5( 4); 2005:368-373

4. V. S. Ramachandran, Eric L. Altschuler, The use of visual feedback, in particular mirror visual feedback, in restoring brain function-review article. Brain. 132; 2009: 1693–1710.

5. http://www.mirrorboxtherapy.com/

Received on 12.11.2013 Modified on 28.12.2013

Int. J. Adv. Nur. Management 2(2): April- June, 2014; Page 97-99