When is Mirror Therapy used?

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Mirror therapy

Mirror therapy is a ground-breaking, non-invasive treatment for the administration of chronic pain. The primary device of this therapy is a mirror from which the patient gets visual feedback so as to train the brain to organize a new assumption about the body. This new assumption is just the mental illustration that permits an individual to be aware of where each part of the body is at all times, even in total darkness. This fixed illustration also allows a person to move in difficult ways without having to intentionally concentrate on each step to execute. An interesting study about Phantom limbs was presented before some years at the national meeting of the American Neurological Association. Phantom limb is a painful sensation that affects approximately 40 to 80 percent of all amputees, in which a surgically removed limb is still part of the body. The study showed that phantom limb pain was reduced in patients randomized to receive therapy using a mirror to help them visualize moving a normal limb instead of the amputation. It appears that the visual component of the mirror led to the decrease in phantom limb pain. Mirror therapy uses a mirror to assist with visual imagery of the amputated limb. It is a method which has been used for the rehabilitation of stroke victims and patients with regional pain syndromes.


What is mirror box and who invented it?

Mirror box was invented by Vilayanur S. Ramachandran, a neuroscientist, who is best known for his work in the fields of behavioral neurology and psychophysics. A mirror box is a box with two mirrors in the center (one facing each way), to help ease phantom limb pain, in which patients feel they still have a limb after having it amputated or surgically removed.


What is a mirror box theory for phantom limbs?

Ramachandran predicted the "learned paralysis" theory of painful phantom limbs. The theory stated that every time the patient tried to move the paralyzed limb, they got sensory feedback through vision and the sense of the relative position of neighboring parts of the body that the limb did not move. This feedback embossed itself into the brain circuitry in such a way that even when the limb was no longer present, the brain had learned that the limb (and following phantom) was paralyzed. Often a phantom limb is painful, since it is felt to be stuck in a painful or abnormal position, and the patients feel they are not able to move it. Ramachandran discovered the mirror box, in order to retrain the brain, and in so doing to eliminate the learned paralysis.


How does the mirror therapy work?

After the patient positions the good limb into one side, and the stump into the other, he/she looks into the mirror on the side with good limb and makes "mirror symmetric" movements similar to a symphony conductor or as people do when they clap their hands. Since the subject is seeing the reflected image of the good hand moving, it appears as if the phantom limb is also moving. By means of this artificial visual feedback, it becomes possible for the patient to "move" the phantom limb, and to unclench it from extremely painful positions. As this visual feedback draws out the kinesthetic sensations, it is referred to as a type of visual-kinesthetic synesthesia, a neurologically-based condition in which stimulation of one sensory or cognitive pathway leads to automatic, involuntary experiences in a second sensory or cognitive pathway. However, this is true only in the broadest sense of the term. Frequent training in some subjects has led to enduring improvement, and in one exceptional case, even to the complete abolition of the phantom limb between the hand and the shoulder (so that the phantom hand was dangling from the shoulder).


What do the research in mirror therapy depicts?

A research conducted in 2007 by a Navy Commander Jack Tsao, an associate professor of neurology at the Uniformed Services University of the Health Sciences in Bethesda, MD, was described as one of the better efforts to elucidate the true value of mirror therapy for phantom limb pain. Jack Tsao, M.D., is a physician who has studied the use of mirrors to treat phantom limb pain in Iraq war veterans. The researcher’s randomly assigned 22 lower-limb amputees with phantom limb pain to one of three groups:

  • Mirror movements: patients watched the reflected image of their intact foot in a mirror while they moved both feet simultaneously. (Obviously, amputees can't move their missing foot, but they can move their phantom foot.)
  • Covered mirror movements: patients performed the same movements but the mirror was covered so they did not see a moving limb.
  • Imagined movements: subjects mentally pictured moving the phantom foot, with eyes closed.

All patients performed 15 minutes per day of their assigned therapy and recorded the number, duration and intensity of pain episodes. After four weeks, there were two primary findings. 

  •  First, pain decreased significantly in all six patients doing the mirror movements, with the median decrease, as reported on a 100 point scale being from 30/100 to about 5/100.
  •  Second, three out of six patients in the covered mirror movements group, and four out of six patients in the imagined movements group, got worse and not better.
  •  At the end of the trial, the researchers offered the mirror therapy to all of the participants. After using the mirror, 90% of the patients reported decreased pain.
  •  Dr. Tsao has found that by using this technique, he is able to decrease opioid use, decrease painful phantom pain sensations, and help the wounded veterans return to work.


What are the other benefits of mirror therapy?

The use of the mirror box has been extended to rehabilitation of hemiparesis, or paralysis one side of the body, due to stroke and to rehabilitation of spatial neglect, a neuropsychological condition in which, after damage to one hemisphere of the brain, a deficit in attention to and awareness of one side of space is observed. These extensions have met with moderate success, but further research is essential to evaluate their clinical effectiveness.


What is the bottom line?

Although doctors are still unsure what exactly causes the effect, this treatment may prove to be an inexpensive and effective way to “force” the brain to stop telling the body that the limb is in pain. The results are promising for the hundreds of amputees from the conflicts in Afghanistan and Iraq, as well as populations around the world that have suffered limb loss due to war, landmines and disease. There isn’t a lot of research on this treatment method, but the research that has been done seems very promising. And, since mirror therapy is really a modified form of mental practice, one might consider the much larger body of research in support of mental practice as being an indirect support of mirror therapy.


How to perform the mirror therapy?

  •  Take a standard mirror (closet-size for leg amputation; shorter for arm amputation).
  •  For Arm amputation position, sit at a table and for Leg amputation position, sit on the ?oor, sofa or bed.
  •  Place the mirror across the midline of the body, so that the amputation site is hidden behind the mirror.
  •  The mirror should re?ect the image of the intact arm or leg. Thus, one can view his/her healthy limb and the image of another healthy limb. In this way, the brain instructs the information that no amputation has occurred.
  •  A better way to stabilize the mirror is found so that the patient is not concerned about balancing the mirror while he/she is performing the treatment.
  •  Perform gentle movements while looking in the mirror for 20-25 minutes daily.
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