Mirror Therapy for Stroke Rehabilitation: A Viable Treatment Option

If you are an occupational therapist who works in stroke rehabilitation (no matter the setting), you know that you must constantly update your skills and educate yourself on the latest treatment techniques. There is so much research out there to advance the treatment of stroke patients!

One treatment that is gaining attention in the field of stroke rehabilitation is mirror therapy. This simple, low tech treatment may be worth your attention as a supplement to the traditional stroke rehabilitation techniques you already use.

This article will explain what mirror therapy for stroke intervention is, what evidence supports its use, and how to begin using this treatment.

First, What is Mirror Therapy?

Mirror therapy (also called mirror box therapy) is a form of neuromuscular treatment used to help people who have suffered a stroke to reduce pain and regain function in the affected upper extremity. The technique is also used to reduce phantom limb pain for amputees and to reduce chronic pain for people with complex regional pain syndrome and other painful conditions.

Mirror therapy uses visual feedback to take advantage of the brain’s neuroplasticity.

The theory behind mirror therapy hypothesizes that the visual feedback from the mirror stimulates the mirror neuron system to reroute motor signals away from the damaged motor neurons and on to the motor cortex. This rerouting “tricks” the brain into characterizing the affected arm as “okay.”

The affected arm might be painful, significantly weaker, or might have very limited movement, but the interaction of visual feedback and mirror neurons makes the brain forget this and treat the affected arm the same as the unaffected arm. As mirror therapy sessions progress, the rerouted pathways are retained and the characterization of the affected arm by the brain becomes more permanent.

To perform mirror therapy, a mirror is placed along the mid-sagittal or para-sagittal plane with the reflective surface on the person’s unaffected side. Exercises and activities are then performed using the unaffected arm. The mirror is placed so that the patient can see the unaffected arm moving in the mirror as he or she performs exercises. The patient visualizes that the reflection in the mirror is the affected arm, with guidance from the therapist.

What Evidence Supports Mirror Therapy for Stroke Rehab?

Up until recently, there has been minimal research pertaining to the use of mirror therapy for stroke rehabilitation. There were several initial studies conducted in 2011 and 2012, however, the samples were small and not all research methods were available.

Thieme, et. al. (2012) conducted a literature review regarding the effectiveness of mirror therapy for improving motor function, activities of daily living, pain, and visuospatial neglect in patients following CVA. The results found that mirror therapy had a moderate effect on improving motor function and activities of daily living, a significant effect on pain reduction, and minimal effect on visuospatial neglect.

Rothgangel, et. al. (2011) reviewed the literature regarding the clinical aspects of mirror therapy for stroke, phantom limb pain, and complex regional pain syndrome. This review found a moderate quality of evidence for improvement in arm function following stroke when mirror therapy was used as an additional treatment.

Recent research has found more favorable results in support of mirror therapy for stroke.

In a study that compared mirror therapy as an addition to conventional therapeutic techniques for rehabilitation of the hand following stroke, Mohanty, et. al. (2017) found that patients who received mirror therapy in addition to conventional therapy made significantly more improvement than patients who received conventional therapy alone.

Bondoc, et.al. (2018) studied the effects of mirror therapy in combination with task-oriented training and found that when mirror therapy is used as an adjunct technique to task-oriented training, it provides clinically meaningful improvements in motor function.

Significant improvements in tactile sensation were found in a study conducted on the effectiveness of mirror therapy following stroke with severe upper limb impairment (Colomer, et. al. 2016).

Which Patients Will Benefit from Mirror Therapy?

Treatment protocols and techniques for mirror therapy are hard to come by, but as seen by the evidence presented above, mirror therapy appears to be the most effective when used in combination with traditional stroke rehabilitation techniques.

To participate, a patient should have enough postural control to sit independently in a wheelchair or regular chair. The patient should have enough functional vision to be able to see the reflection of the unaffected limb in the mirror. If a patient has visual field neglect, he or she should be able to compensate by turning the head to see the mirror.

The patient should also have enough cognitive ability to be able to follow the therapist’s instructions and to visually attend to the limb in the mirror for about 10 minutes at a time. The patient’s unaffected limb should have enough pain-free, functional range of motion to allow full participation in therapeutic exercise and activity.

As you can see by these factors, not every patient will benefit from mirror therapy and the patient’s existing abilities should be carefully considered before attempting it.

How Should Therapeutic Activities be Conducted Using Mirror Therapy?

Before beginning mirror therapy, the patient should be instructed in the purpose of the technique and the expected outcome. Each mirror therapy session should last between 10 and 30 minutes, depending on the patient’s ability to attend to the mirror.

Mirror therapy can be incorporated into treatment daily, if possible. The more often mirror therapy sessions occur, the more benefit is obtained.

Therapists should follow these guidelines when conducting a mirror therapy session:

• Mirror size and placement: The mirror should sit on the table top and should be large enough to reflect the entire unaffected arm. Rothgangel and Braun (2013) recommend a 20 x 25-inch mirror on a stand. The mirror should be placed at the patient’s midline. If the patient has trouble seeing the mirror or has visual field neglect, the mirror can be placed closer to the patient’s affected limb and angled slightly to facilitate ease of viewing.
• Affected limb placement: The affected limb should be placed on the table so it rests comfortably behind the mirror. If the limb has severe spasticity, treatment to reduce muscle tone and joint limitations may be necessary prior to mirror therapy.
• Unaffected limb placement: The unaffected limb should be placed in a position like the affected limb, with the reflection of the unaffected limb clearly visible in the mirror. Make sure that jewelry is removed to reduce distractions from the patient’s focus on the limb. Also cover any obvious marks such as tattoos or scars.
• Visualization: The therapist should spend some time during the initial session helping the patient to focus on the limb in the mirror and guiding the patient to visualize that limb as the affected limb.
• Therapeutic exercise and activity: Once the patient is comfortable visualizing the reflection as the affected limb, simple active range of motion exercises can be introduced. These can be graded according to the patient’s ability. As therapy progresses, more complex exercises and functional activities using objects can also be completed.

Rothgangel and Braun have written a detailed protocol on the use of mirror therapy with stroke patients:

Mirror Therapy: Practical Protocol for Stroke Rehabilitation

Does Mirror Therapy Have Any Side Effects?

Since the patients receiving mirror therapy are stroke patients, some of them may react emotionally to the thought of seeing their affected arm intact.

Some patients may also experience dizziness or nausea when viewing the image of the unaffected arm in the mirror. If this occurs, patients should look away from the mirror and focus on the unaffected arm, then gradually look at the mirror for short periods only until the sensations dissipate.

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Based on the current research, mirror therapy for stroke may be an effective treatment technique that you can use in combination with other treatments to benefit your patients affected by stroke. It might just be that breakthrough that you need to reduce pain in your patient’s affected limb or to build upon that grade 2 muscle activity.

Looking for more information about mirror therapy? Please refer to the references included below for more information about mirror therapy for stroke rehabilitation.

References

Bondoc, S., Booth, J., Budde, G., Caruso, K., DeSousa, M., Earl, B., … Humphreys, J. (2018). Mirror Therapy and Task-Oriented Training for People With a Paretic Upper Extremity. American Journal of Occupational Therapy, 72(2), 7202205080p1. doi:10.5014/ajot.2018.025064, accessed May 6, 2018.

Colomer, Carolina & Noé, Enrique & Llorens, Roberto. (2016). Mirror therapy in chronic stroke survivors with severely impaired upper limb function: A randomized controlled trial. European journal of physical and rehabilitation medicine. 52(3), accessed at https://www.researchgate.net May 6, 2018.

Mohanty, P. (2017). Effectiveness of Mirror Therapy in Rehabilitation of Hand Function in Sub-Acute Stroke. Palliative Medicine & Care: Open Access, 4(2), 1-8. doi:10.15226/2374-8362/4/2/00135, accessed May 6, 2018.

Rothgangel, A. S., Braun, S. M., Beurskens, A. J., Seitz, R. J., & Wade, D. T. (2011). The clinical aspects of mirror therapy in rehabilitation. International Journal of Rehabilitation Research, 34(1), 1-13. doi:10.1097/mrr.0b013e3283441e98, accessed May 3, 2018.

Rothgangel, Andreas & Braun, Susy. (2013). Mirror Therapy: Practical Protocol for Stroke Rehabilitation. 10.12855/ar.sb.mirrortherapy.e2013, accessed May 6, 2018.

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(3). doi/10.1002/14651858.CD008449, accessed May 3, 2018.

This post was originally published on August 3, 2018 and updated on June 30, 2021.