This document provides an overview of mirror therapy as a treatment approach to support upper extremity recovery after stroke. It discusses the theoretical foundations of mirror therapy, describing how visual feedback of movement can facilitate cortical reorganization. Several studies are summarized that demonstrate the effectiveness of mirror therapy for improving motor function, activities of daily living, and pain when used as an adjunct to traditional stroke rehabilitation. The document concludes with a demonstration of how mirror therapy is performed in a clinical setting.

1. Melina Marte, OTS
University of
Illinois at Chicago
March 2015
MIRROR THERAPY TO
SUPPORT UE RECOVERY
POST STROKE: A
CONTEMPORARY MOTOR
CONTROL APPROACH

2.  5th leading cause of death
 #1 leading cause of disability
 Individuals >65, at 6 mo. post ischemic stroke
 50% have hemiparesis
 30% are unable to walk without assistance
 26% are dependent in basic ADLs
 “Initial severity of upper limb weakness is the best predictor
of ultimate recovery of upper limb motor function.”
 Most stroke patients experience
 spontaneous recovery within the first 3 mo.
 motor recovery with learning within 6 mo.
STROKE STATISTICS
American Heart Association (2014); Lee, et al. (2012)

3. Sensorimotor/Neurofacilitation Approaches Contemporary Motor Approaches
CNS is hierarchical-upper neurological
systems control lower, lacks emphasis
environment/context, relies on
biomechanical/neuromuscular factors
CNS is heterarchical-greatly influenced by
dynamic systems theory (person’s abilities
and limitations, the task itself, and the
environmental conditions)
Focus - Improving motor control by using
sensory input techniques to influence motor
output
Focus - Motor control is learned when a
person seeks optimal solutions for
occupational performance
Recovery and motor learning is expected to
follow a normal developmental sequence
Does not emphasize a fixed developmental
sequence of motor learning and recovery
Assumes that mastery of normal movement
patterns will generalize to functional task
performance
The role of the functional task being
performed and the context are emphasized
for mastery of movement patterns
Eg., Bobath’s NDT, PNF, Rood Approach,
Brunnstrom movement therapy
Eg., Task-Oriented Approach, Task-Specific
Training
THEORETICAL FOUNDATIONS FOR
STROKE REHABILITATION

4.  Neurofacilitation is NOT more effective than
contemporary approaches and should be used as a
preparatory method.
 The use of REAL OBJECTS from environment versus
simulated objects produces better functional
movement.
 ENVIRONMENT plays a large role in motor skill
acquisition and transfer of skills to other tasks.
 OCCUPATION-BASED approaches are more effective
than rote exercises in remediating motor control
impairments.
EVIDENCE-BASED CONCLUSIONS TO
SUPPORT CONTEMPORARY APPROACH
Gillen (2011)

5.  Motor learning takes place when persons have
MULTIPLE OPPORTUNITIES to practice across
environmental contexts.
 Participating in the WHOLE task, versus part, elicits
a more efficient, forceful, and coordinated motor
response.
 50% feedback, FADED feedback, SUMMARY feedback
is more effective for long-term learning (KOP for
initial learning, KOR for generalization/transfer of
learning).
 RANDOM INTERVAL PRACTIVE is better than blocked
practice for long-term learning.
EVIDENCE-BASED CONCLUSIONS TO
SUPPORT CONTEMPORARY APPROACH
Gillen (2011)

6. “…this approach is occupation-based
and client-centered and focuses on
enabling the client to achieve motor
recovery through occupational
performance using real objects,
environments, and meaningful
occupations.”
OCCUPATIONAL THERAPY TASK-
ORIENTED APPROACH (TOA)
Gillen (2011)

7. OCCUPATIONAL THERAPY TASK-
ORIENTED APPROACH (TOA)
 Assumptions:
 1. Personal and environmental
systems are heterarchically
organized.
 2. Functional tasks help
organize behavior.
 3. Occupational performance
emerges from interaction of
person and environment
 4. Experimentation with various
strategies leads to optimal
solutions to motor problems
 5. Recovery is variable.
 6. Behavioral changes reflect
attempts to compensate and
achieve task.
Gillen (2011)

8.  Constraint Induced Movement Therapy (CIMT)
 Modified Constraint Induced Therapy (mCIMT)
 Forced Use
 Virtual Reality
 Mental Practice/Mental Imagery
 Biofeedback Triggered Stimulation
 Functional Electrical Stimulation
 Task-Specific Training
 Repetitive Task Training
 Bilateral Arm Training
 Mirror Therapy
CONTEMPORARY-BASED TREATMENTS
http://physical-therapy.advanceweb.com/Features/Articles/Mirror-Therapy.aspx

9. WHAT IS MIRROR THERAPY?
MIRROR THERAPY OVERVIEW
WHO IT IS FOR?
 Mirror Therapy can be used with individuals who have
experienced a stroke, phantom limb syndrome/pain,
peripheral nerve injury, and coordination disorder.
WHAT IS IT?
 Patients are instructed to place their affected limb inside a
“mirror box” that is placed perpendicular to the center of
the body.
 The patient performs identical, exaggerated movements or
sensory experiences with both limbs.
 While attempting to move or feel, the patient is encouraged
to look at the mirror image of their non-affected limb.
 As recovery emerges, movements progress from simple
exercises to more functional activities.

10. WHAT IS MIRROR THERAPY?
MIRROR THERAPY OVERVIEW
WHERE IS IT DONE?
 Mirror therapy can be done with a therapist in an
outpatient setting, inpatient setting, or private home.
WHEN IS IT DONE?
 Mirror therapy can be done after a recent or long-term
stroke, with individuals who have no or limited
movement in affected limb.
 It must be used with people who demonstrate full
ability to follow 1-3 step instructions.
WHY IS IT DONE?
 Mirror Therapy is used to promote recovery of
movement in the affected limb, post stroke.
 For individuals post amputation, it is used to reduce
sensitivity/pain in the residual limb.

11. WHAT IS MIRROR THERAPY?
MIRROR THERAPY OVERVIEW
HOW IT WORKS?
(THEORETICAL
FOUNDATION)
 While performing movements, patients are receiving
visual feedback of enhanced movement.
 The brain percieves an illusion of movement capacity in
the affected limb.
 This feedback provides visual-motor congruence.
 Transcranial Magnetic Stimulation, PET scan, and
fMRI studies have shown more motor cortex activation
in the hemisphere contralateral to affected limb with
passive observation, imitation, and MT.
 Research postulates that MT may be able to faciliatate
cortical reorganization for motor recovery.

12. MIRROR THERAPY OVERVIEW
SO WHAT?
(CLINICAL BOTTOM
LINE)
 Studies have shown moderate positive findings in UE
function with use of MT for acute stroke.
 More research is required to establish standardized
protocols, intensity, and duration for MT.
 Clinical judgment should determine use of therapist
facilitated limb movement, bilateral movement, or
unilateral movement due to limitations in research.
 Patient-therapist collaboration is important in
determining an individualized plan.
 MT has not been found more beneficial than other
contemporary treatments, but may compliment
traditional therapy and provide self-directed practice.
WHAT IS MIRROR THERAPY?

13.  Nilson, & DiRusso (2014) – CASE REPORT
 N=1, 27 mo. post stroke
 Self-directed MT protocol in the home environment encouraged 30
min/day, 5 days/week
 Design: Single subject, pre/post test
 Outcome measures: Fugl-Meyer, Jebson-Taylor Test of Hand Function,
Manual Ability Measure (UE function)
 Participant logged MT protocol intensity
 Findings: decreased pain, improved sensation, improvements in hand
function
CLINICAL BOTTOM LINE
1. MT can be feasible for self-directed therapy in the home
environment for appropriate candidates.
EVIDENCE TO SUPPORT MIRROR
THERAPY

14. EVIDENCE TO SUPPORT MIRROR
THERAPY
 Thieme, et al. (2013) - SYSTEMATIC REVIEW
 N=14 studies
 Primary outcome: motor function
 Mirror therapy vs. traditional therapy
 Findings
 MT significantly affected motor function and effects stable 6 mo. post
follow-up
 MT significantly improved ADL performance (*N= 4 studies)
 MT significant positive effect on pain
 Limited evidence in MT for improving visual-spatial neglect
CLINICAL BOTTOM LINE:
1. MT can be used as an additional intervention for stroke
rehabilitation, but no clear evidence supports its replacement of
other therapies.
2. MT may be beneficial for improving pain and motor function.

15.  Lee, et al. (2012)- RANDOMIZED CONTROL TRIAL
 N=26, individuals 6 mo. post stroke (attrition=2)
 13 (control group)= standard rehab only
 Standard rehab= LE ther. ex, UE training for ADLS, FES (UEs/LEs)
 13 (experimental group)= standard rehab + MT (25 min, 2x/day, 5
days/week)
 Design: pretest, 4 weeks intervention, post test
 Outcome measures: Fugl-Meyer Assessment, Brunnstrom stages, Manual
Function Test (UE motor function and recovery)
 Findings: experimental group showed significantly more improvements
than control group in all outcome measures
CLINICAL BOTTOM LINE
1. MT benefited UE motor recovery and function for patients with
acute stroke.
2. Additional research needed to determine MT protocols,
intensity, application time, and duration.
EVIDENCE TO SUPPORT MIRROR
THERAPY

16.  Ramachandran, & Altschule (2009) – LITERATUTE REVIEW
 “Learned paralysis”-swelling caused temporary interruption of
cortical pathways resulting in a conditioned response
 2 RCTs of MT vs control found significant improvements in LE
paralysis in participants 12 mo. post stroke (Brunnstrom, FIM scores)
 No sig. difference in Mod. Ashworth scores or functional ambulation
 RCT found MT superior to control in Fugl-Meyer Assessment of UE
CLINICAL BOTTOM LINE
1. Many patients show motor recovery using MT.
2. Variability in outcomes suggests some patients benefit more than
others.
3. Variables need to be understood to administer MT to appropriate
candidates, however, its feasibility should increase its use in practice.
4. “…restoring congruence between vision and motor output can lead to
an unlearning of learned paralysis in stroke patients.”
EVIDENCE TO SUPPORT MIRROR
THERAPY

17. MIRROR THERAPY DEMONSTRATION

18.  Gillen, G. (2010). Stroke rehabilitation: A function-based approach (3rd ed.).
St. Louis, Mo.: C.V. Mosby.
 Heart Disease and Stroke Statistics—2014 Update: A Report From the American
Heart Association. (2013). Circulation. 129, e28-e292. DOI:
10.1161/01.cir.0000441139.02102.80
 Lee, M.M., Cho, H., 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, 1-12
 Neuro Orthopaedic Institute. (2012). Noi Mirror Box Notes for users. Retrieved
from http://www.noigroup.com/documents/noi-mirror-box-instructions.pdf.
 Nilson, D.M., & DiRusso, T. (2014). Brief Report—Using mirror therapy in the
home environment: A case report. American Journal of Occupational Therapy,
68, e84–e89. http://dx.doi.org/10.5014/ajot.2014.010389
 Ramachandran, & Altschule.(2009). The use of visual feedback, in particular
mirror visual feedback, in restoring brain function. Brain A Journal of
Neurology, 132, 1693-1710. DOI: 10.1093/brain/awp135
 Thieme, H., Mehrholz, j., Pohl, M., Behrens, J., & Dohle, C. (2013). Mirror
Therapy for Improving Motor Function After Stroke. Stroke, 44, e1-e2. DOI:
10.1161/STROKEAHA.112.673087
 Pendleton, H., & Schultz-Krohn, W. (2012). Pedretti's occupational therapy:
Practice skills for physical dysfunction (7th ed.). St. Louis, Mo.: Mosby.
REFERENCES

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