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Presented by Hector Huerta, OTD, OTR/L

Description

Mirror or mirror box

Positioned in midsagittal plane

Slight lateral shift toward affected UE

Description

Individual observes reflection of

unaffected UE

Encouraged to concentrate on “seeing”

the moving affected UE obscured by

mirror

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Description

Creates visual illusion

“Tricked” into believing activities of the

uninvolved UE are attributed to involved

UE

Background

Originally conceived to alleviate

phantom limb pain

Began to be used for CRPS

Eventually with hemiplegia/hemiparesis

Theoretical Mechanism

Exploits preference for visual feedback

over somatosensory/proprioceptive

feedback

Stimulation of cortical and spinal motor

neurons

Cortical Reorganization

Neuroplasticity

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Intervention

Simple isolated joint movements

Functional movements with objects

Occupation-based activities

AROM of affected UE

Occurs often

Not always

Does not appear to affect efficacy

Literature Review

Search terms

Mirror therapy

Brain injury

TBI

Traumatic brain injury

Acquired brain injury

Health Sciences Databases

CINAHL, Health Source, AgeLine,

SPORTdiscus, etc.

Results

No articles specific to mirror therapy and

“brain injury”

Paucity of specific data

Substantial number of articles related to

mirror therapy and stroke-related

hemiplegia/hemiparesis

Several articles examining cortical

excitability using mirror therapy in

individuals with intact CNS

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Interpretation of Results

No articles specific to “Brain Injury”

Paucity of evidence to guide clinical

practice

Caution when generalizing

Hemiplegia/hemiparesis subsequent to

CVA vs. acquired brain injury

Literature Review

Three level 1 articles

Outcome measures

○ Related to UE function

○ Addressing participation and engagement in

meaningful activity

2 studies reported positive findings

1 study demonstrated UE function

maintained at 6-month follow up

Literature Review

Strong evidence from 2 high quality RCT

Effective vs placebo

Subacute phase of recovery

Sustained results at 6-month follow up

Limitations

Functional Independence Measure

○ Validity concerns (inpatient scale)

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RCT: Mirror Therapy & Unilateral

Neglect

48 participants recruited within 48 hours

of stroke onset

Parietal and thalamic lobe lesions

UE limb weakness and unilateral neglect

Intervention group

Mirror therapy 1-2 hrs/day for 4 weeks

Control group

Similar activities with nonreflecting mirror

Reference: Pandian, J.D., Arora, R, Kaur, P., Sharma,

D., Vishwambaran, D., & Arima, H. (2014)

Reference: Pandian, J.D., Arora, R, Kaur, P., Sharma,

D., Vishwambaran, D., & Arima, H. (2014)

RCT: Mirror Therapy & Unilateral

Neglect

Used combination of purposeful and

occupation-based activities

Outcome measures

Star cancellation test

Line bisection test

Picture identification task

Functional Independence Measure (FIM)

Improvements noted at 6-month interval

with intervention group Reference: Pandian, J.D., Arora, R, Kaur, P., Sharma,

D., Vishwambaran, D., & Arima, H. (2014)

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Mirror Therapy & Functional Tasks

RCT examining the efficacy of mirror

therapy containing functional tasks

60 individuals with hemiplegia post-CVA

Experimental group received mirror

therapy during functional bimanual tasks

20 mins/day; 5 days/week for 4 weeks

Control group performed same tasks

without mirror therapy

Reference: Lim, K. et al. (2016)

Mirror Therapy & Functional Tasks

Reference: Lim, K. et al. (2016)

Mirror Therapy & Functional Tasks

Reference: Lim, K. et al. (2016)

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Mirror Therapy & Functional Tasks

Reference: Lim, K. et al. (2016)

Measurement Tools

Fugl-Meyer Motor Function Assessment

Modified Barthel Index

Findings

Intervention group demonstrated greater

improvement than control

Statistically significant increase in ADL

performance

Mirror Therapy & Functional Tasks

Reference: Lim, K. et al. (2016)

Improvements are attributed to:

Mirror therapy

Repetitive task-oriented training

Limitations

Only short-term effects were studied

○ No follow-up assessment

Delayed Mirror Visual Feedback

Mirror therapy generates mirror visual

feedback

Literature supports cortical activation

Limitation of conventional mirror therapy

No asymmetric mode

Only symmetrical bimanual tasks

Pilot study on feasibility of delayed

mirror visual feedback on mirror therapy

Reference: Lee, H., Li, P., & Fan, S. (2015).

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Delayed Mirror Visual Feedback

Methods

Three conditions

○ No MVF

○ MVF

○ 2-second delayed MVF

Reference: Lee, H., Li, P., & Fan, S. (2015).

Delayed Mirror Visual Feedback

Time-delayed MVF could be used to

augment traditional mirror therapy

Enhanced coordination training for wrist

and hand

Aim of pilot study was assess feasibility

Activation of cortical areas

Compare instant and delayed MVF with

condition of no MVF

Reference: Lee, H., Li, P., & Fan, S. (2015).

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Delayed Mirror Visual Feedback

Participants were 28 “healthy” adults

Repeatedly pressed a square button

with right index and middle fingers

Instructed not to move other body parts

Maintained visual fixation on central

mirror area

Opaque divider blocked view of right

hand

Reference: Lee, H., Li, P., & Fan, S. (2015).

Delayed Mirror Visual Feedback

3 conditions

No mirror image (blank screen)

Simultaneous mirror image

2-second delayed mirror image

Left hand was placed on identical button

Instructed not to move left hand

50 repetitions/condition

Reference: Lee, H., Li, P., & Fan, S. (2015).

Reference: Lee, H., Li, P., & Fan, S. (2015).

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Delayed Mirror Visual Feedback

Improved viewing angle

Less tension in cervical posture

Superimposed MVF above actual hand

May make more realistic illusion

Reference: Lee, H., Li, P., & Fan, S. (2015).

Delayed Mirror Visual Feedback

Measurements taken with surface EMG

Findings

Cortical activation was larger with MVF

Cortical activation was reinitiated and prolonged with delayed MVF

Researchers successfully evolved traditional mirror therapy to a form of digital mirror therapy

Alternating and reciprocal bimanual training?

Reference: Lee, H., Li, P., & Fan, S. (2015).

Advantages of Mirror Therapy

Literature appears to support

Early stage

Paucity of articles

Studies examine participation in functional

activity

No advanced training required

Within scope of OT practice

Minimal drain on resources

Clients can carryover into home program

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Advantages of Mirror Therapy

Can be combined with other approaches

Task-oriented training

Massed practice training

Repetitive task practice

Constraint-induced movement therapy

○ Modified versions

Strong support for approaches

Further study regarding combinations of

approaches

Limitations

General paucity of research data

Growing number of recent studies with CVA

Lack of data specific to acquired brain injury

Some data is impairment focused

Not emphasis on participation

Cannot generalize to participation

Difficult to isolate effect from

confounding variables

Summary

Appears to be effective in some high

level RCTs

Minimal cost

Non-invasive

One component of a therapist’s

“toolbox”

Good potential for carryover into home

program for clients

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Try it.

References:

Lee, M.M., Cho, H.Y., & Song, C.H. (2012). The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients. American Journal of Physical Medicine and Rehabilitation, 91, 689-696.

Nilsen, D.M., Gillen, G., Geller, D., Hreha, K., Osei, E., & Saleem, G.T. (2015). Effectiveness of interventions to improve occupational performance of people with motor impairments after stroke: An evidence-based review. American Journal of Occupational Therapy, 69, 6901180030.

Thieme, H., Bayn, M., Wurg, M., Zange, C., Pohl, M. & Behrens, J. (2013). Mirror therapy for patients with severe arm paresis after stroke – A randomized controlled trial. Clinical Rehabilitation, 27, 314-324.

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References:

Lim, K., Lee, H., Yoo, J., Yun, H., & Hwang, H. (2016). Efficacy of mirror therapy containing functional tasks in poststroke patients. Annals of rehabiliative medicine. 40(4): 629-636.

Thieme, H., Mehrholz, J., Pohl, M., Behrens, J., & Dohle, C. (2012). Mirror therapy for improving motor function after stroke. Cochrane Database of Systematic Reviews, 2012, CD008449.

Lee, H., Li, P., & Fan, S. (2015). Delayed mirror visual feedback presented using a novel mirror therapy system enhances cortical activation in healthy adults. Journal of Neuroengineering and Rehabilitation. 12(56).