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Introduction to the use of mirrors in rehabilitation. M. Penny Bartzen OTR/L. Graded Motor Imagery Program Gently Rewires the Brain: CRPS. Chronic Regional Pain Syndrome (CRPS) Laterality Reconstruction Restore the brain’s concept of right and left

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graded motor imagery program gently rewires the brain crps
Graded Motor Imagery Program Gently Rewires the Brain: CRPS

Chronic Regional Pain Syndrome (CRPS)

  • Laterality Reconstruction
    • Restore the brain’s concept of right and left
    • Graded identification of right/left photos of hands until 80 % accurate
  • Visual and motor imagery
    • Visualizing without movement or threat
    • Visualize progressive movements
  • Mirror Therapy
    • Watch uninvolved hand
    • Gradually increase movement
    • Replicate with other hand

(S. Stralka, 2011)

  • Mirror Neurons
  • History of the approach
  • Diagnoses
  • Research review
  • Application to your population
  • Further information
mirror neurons
Mirror Neurons

Mirror neurons are a particular class of visuomotor neurons, originally discovered in area F5 of the monkey premotor cortex, that discharge both when the monkey does a particular action and when it observes another individual (monkey or human) doing a similar action.Rizzolatti G, Craighero L, “The mirror-neuron system,” in Annual Review of Neuroscience, issue 27 (2004) p. 1

mirror neurons1
Mirror Neurons
  • Activated by observing and executing movement
  • Imitation and learning
  • Motor imagery and visual imagery
  • Autism Spectrum Disorders
  • Non-object related

B. Object related

Red - mouth movements

Green - hand movement

Blue- Foot movements

(G. Blinkofski et al., Eur J Neurosci, 13:400-4, 2001)

cortical homunculus images
Cortical Homunculus Images



mirror neurons autism
Mirror Neurons & Autism

Dysfunction responsible for impairments?

Deficits in imitation

Theory of mind

Social communication


Neural strategies differ

Neural systems interfaces with limbic system

Seemingly not engaged in children with ASD

(Dapretto, Davies, Pfeifer, Scott, Sigman, Bookheimer& Iacoboni, 2005)

mirror neuron dysfunction and autism spectrum disorders
Mirror Neuron Dysfunction and Autism Spectrum Disorders
  • Treatment Experiments: Imitation Therapy
    • Children being imitated by an adult demonstrated much more “social behavior” and reciprocal play vs. children who were only playing with an adult

(Nyberg, J., n.d.)

mirror visual feedback mvf
Mirror Visual Feedback (MVF)
  • Visual feedback dominates somatosensory feedback for cortical proprioceptive representation.
  • Mirror therapy increases cortical and spinal motor excitability (the mirror neuron system)
  • Sensory experiences can be evoked on the basis of visual information alone.
  • Visual input enhances tactile sensitivity.

(Moseley, Gallace & Spence, 2008)

remapping cortical plasticity and mirror therapy
Remapping, cortical plasticity and mirror therapy
  • Learned paralysis may be unlearned using the mirror
  • Residue of mirror neurons that survived lesion are dormant may be stimulated with mirror
  • Visual feedback may revive the dormant ipsilateral connection between the motor cortex and the spinal cord.

(Ramachandran & Altschuler, 2009)

mirror visual feedback mvf mirror box therapy mvt
Mirror Visual Feedback (MVF): Mirror Box Therapy (MVT)
  • Strokes
  • Autism
  • Amputations
  • Complex Regional Pain Syndrome (CRPS)/Reflex Sympathetic Dystrophy (RSD)
  • Neurological Disorders
  • Arthritis
evidence cochrane review
Evidence: Cochrane Review
  • “Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are internationally recognised as the highest standard in evidence-based health care. They investigate the effects of interventions for prevention, treatment and rehabilitation. They also assess the accuracy of a diagnostic test for a given condition in a specific patient group and setting. They are published online in The Cochrane Library. “

( The Cochrane Collaboration, 2012)


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 studies with 547 participants
  • Randomized controlled trials & randomized cross-over trials with any control
  • Measures of motor function, ADL, pain and visuospatial neglect
characteristics of studies
Characteristics of studies
  • 12 studies randomized control trials and 2 used a cross-over design with random allocation
  • 9 to 121 participants
  • Mean age 51 to 797
  • 55% left hemiparesis
  • Male 57% female 43%
  • 5 days to 5 years post stroke (4 acute and 8 chronic)
  • 83 % ischemic and 17% hemorrhagic
  • Settings included inpatient, in and out-patient, day hospital and home setting.
cochrane protocols
  • Mirror or a mirror box in the midsagittal plane between the upper or lower extremity
  • Reflect movement of the non-involved extremity
  • 2 studies incorporated another intervention, electrical stimulation or visual imagery
  • 10 to 60 min sessions, 1 to 7 x wk for up to 6 weeks.
  • 5- Bilateral movements, moving the affected arm as well as they could
  • 6- moved only the unaffected side
  • 1 therapist passively moved the affected arm to match unaffected motion
cochrane outcome measures
Cochrane: Outcome measures
  • Motor: Fugl-Meyer, Action Research Arm Test, Wolf Function Test, Motor Assessment Scale, Brunnstrom stages
  • ADL: FIM, Barthel Index,
  • Pain: Measure at rest and sduring motion that include the numerical rating scales, the Visual Analogue Scale (VAS), the pain section of Fugl-Meyer
  • Visuospatial: Behavioral Inattention Test (BIT), Test of Attentional Performance (TAP)
  • Measured pre and post as well as 1 to 6 months post.

(p. 9)

cochrane outcomes
Cochrane: Outcomes
  • Significant effect on motor function after stroke (p. 11)
  • Significant effect on ADL function (p. 12)
  • Significant positive effect on pain (p.12)
  • 1 study showed evidence for improving visuospatial neglect (p.12)
cochrane recommendations
Cochrane: Recommendations
  • Include as adjunct to standard therapy
  • Utilize with CRPS type-1 after stroke for pain reduction
  • Continued research (p. 15)
neuroplasticity and cva
Neuroplasticity and CVA
  • Neuro-reeducation may be more effective
    • Starting 5 days post onset rather than 30
    • Changes continue to occur months after onset
    • Try to avoid allowing the brain to reorganize for compensation
    • Give feedback and explain the purpose
    • Hebb’s Rule.
graded motor imagery program gmip
Graded Motor Imagery Program (GMIP)
  • Neuro Orthopedic Institute (NOI)
  • Chronic Regional Pain Syndrome (CRPS)
  • Utilizes mirrors and other approaches to reduce pain, normalize sensation and improve function.
  • Utilized in hand therapy and pain clinics.
gmip sensory re education and integration
GMIP: Sensory Re-education and Integration
  • Laterality
  • Visual Imagery
  • Mirror Therapy
  • Localization
  • Kinesthesia
  • Graphesthesia
  • Stereognosis
  • Sensorimotor accuracy (Stralka ,2011)

Sound Familiar?

gmip with stroke
GMIP with Stroke
  • Laterality - Restore brain’s concept of right and left.
    • 6 to 10 cards R/L hand to start
    • Acute BID 15 min
    • 80% accuracy
    • R/L in magazines, photos
    • Incorporate sensory information
    • Functional tasks
  • Mental Practice/Imagery
    • Imagine hand motions of cards
    • Imagine adopting position on cards
    • Repeat process 3x day

(Stralke, 2011)

gmip for stroke recovery
GMIP for Stroke Recovery
  • Mirror Box
    • Imagine the affected UE is moving while looking in mirror
    • Therapist /family move the limb to imitate non-involved hand
    • Move the involved hand asap
  • AROM
    • Supination/pronation
    • Wrist extension/flexion
    • Finger motions – hook, gross grasp
    • Opposition
    • Picking up /releasing ball.

(Stralka, 2011)

Christian Dohle et al. (2009). Mirror therapy promotes recovery from severe hemiparesis: A randomized control trial.
  • Participants
    • 36 patients
    • 1st ischemic CVA in territory of middle cerebral artery
    • < 8 weeks post onset
  • Intervention
    • 6 wk, 30 min. per day, 5 x wk.
    • Random assignment control or mirror therapy (MT)
    • All other standard therapies
dohle et al 2009
Dohle et al, 2009


  • Patients watched the mirror image of the unaffected arm as if it were the affected one.
  • Executed arm, hand and finger postures in response to verbal instructions
  • Protocol scaled according to abilities
  • Asked to move their affected arms as well as possible
christian dohle et al 2009
Christian Dohle et al. (2009).
  • Outcome Measure
    • Fugl-Meyer, functional and neuropsych testing
  • Subgroup of 25 with initial distal plegia
    • Improved distal function in MT group
    • Increase in surface sensibility
    • Not dependent on side of lesion
mirror visual feedback with stroke
Mirror Visual Feedback with Stroke
  • 2008, Yvuzer et al.
    • 40 patients with UE hemiparesis
      • Mirror Therapy group statistical improvement in Burnnstrom stages of motor recovery and FIM self-care score over control group
  • 2008, Matsuo et al.
    • 15 sub-acute patients with hemiparesis
      • Mirror therapy group superior to the control treatment using the Fugel –Meyer assessment of the paretic arm.
  • Ramchandram (2009) notes:
    • Benefit variables may include the location of lesion and duration of paralysis.
    • Motor visual feedback (MVF) should be implemented routinely due to the simplicity of the approach
Altschuler et al. 1999Protocols

Yavuzer et al. 2008

40 inpatients, w/in 12 months of onset

30 min mirror therapy

Sitting with involved hand behind mirror

Wrist and finger flexion and extension movement

Watching non-involved

Asked to do the same with involved

  • 9 patients, 6 mo post
  • 15 min, 2x day, 6 day per wk
  • Watch non-involved hand in mirror
  • Move hands and arms symmetrically
  • Proximal to distal
  • Easy movements to difficult

Case Study

  • 63 y.o. gentleman with R hemisphere, posterior internal capsule stroke resulting in L side paresis, onset 1 yr and 3 months prior to study
  • 18 x 24” mirror attached to 2 wooden posts.
  • 1 hr visit, 3x wk for 3 wk
  • 20 min mental imagery
  • 35 mirror box training
    • Identify hand reflection as his own: Finger tapping, wrist flexion/extension
    • Simple tasks: Manipulation tasks with object of various size and weights including pouring liquid and drinking from a cup.
    • More perceptually challenging tasks: Placement of number objects in distinct order, use of stylus and asked to draw simple picture.
  • 4 pt increase in Fugl-Meyer and improved times for the Jebsen after 3 weeks of therapy. Baseline 47/66 to Day 21- 51/66

(Stevens & Stoykov, 2004)

mirror visual feedback with stroke1
Mirror Visual Feedback with Stroke

Ramachandran & Altschuler (2009) review of the use of visual feedback in restoring brain function with PLP, CRPS and CVA.

  • 1999, Altschuler et al.
    • 9 patients
      • 3 moderate recovery of function
      • 3 mild recovery
      • 3 no recovery
  • 2007, Sutbeyaz, et al
    • 40 patients with LE Hemiparesis
      • Mirror therapy group showed significant improvement in Brunnstrom stages and FIM motor scores compared with control group.

(Ramachandran & Altschuler, 2009)

standard of practice
Standard of Practice?
  • Non breakable mirrors of varied sizes in hospital and for out-patients
  • Home program
    • Photographs of movements
    • Functional tasks
    • Sensory information
  • Sequential protocol that is easily adapted to the individual
  • Explain to families and clients (staff?) for improved adherence
  • What do you think?
  • Small Group
    • Population
    • How are you using it already?
    • How could you incorporate it?
    • How do you explain it?
  • Share

“ The procedure is not miracle cures by any means, but even if only a small proportion of patients is helped, they would be a enormous value given the high incidence of phantom pain and stroke….Moreover, even if the procedure benefits a minority of patients, it is likely to pave the way for future more completely effective therapies once we understand the variables involved”

(Ramachandran & Altschuler, 2009, p 1694).


"The best thing about mirror therapy is,

… it's cheap, safe, easy and it's fun.“

Dr. Eric LewinAltschuler

for further information
For further information
  • READ the Cochrane report!
  • Search Mirror Neurons
  • Books
    • The Brain that Changes Itself (Doidge, 2007)
    • The Tell-Tale Brain (Ramachandran, 2011)
  • You Tube
    • Search for Mirror Box Therapy
    • Ramachandran
    • Mirror Neurons
  • TED Talks
    • Ramanchandran
    • Mirror Neurons
youtube mirror neurons boxes therapy
YouTube: Mirror neurons, boxes & therapy
  • GiacomoRizotalli on the discovery of mirror neurons_
  • Mirror box therapy with David Butler_
  • The social brain (ep 4)- Charlie Rose: The social brain_
  • Acting and mirror neurons_
  • Mirror Box Visual Therapy_
  • How to use a mirror box for hand therapy_
  • Phantom limb mirror box video_
  • Doug and mirror box therapy in action 3 sep _
  • Mirror neurons in autism_

Altschuler, E.,L. Wisdom, S.B, Ston, L., Foser, C., Galasko, D., Llewellyn, M. E. & Ramachandron, R.S. (1999). Rehabilitation of hemiparesis after stroke with a mirror. Lancet, 353, 2035-2036.

Dapretto, M., Davies, M., Pfeifer, J., Scott, A., Signman, M., Bookheimer, S., & Iaconboni, M. (2005). Understanding emotions in others: mirror neuron dysfunction in children with autism spectrum disorders. Nature Neuroscience, (9),28-30. doi: 10.1038/nn1611

Dohle, C., Pullen, J, Nakaten, A., Kust, J., Rietz, C., & Karbe, H. (2009) Mirror therapy promotes recovery from severe hemiparesis : A randomized controlled trial. Neurorehabilitation and Neural Repair, 23, 209-217.

Doidge, N. (2007). The brain that changes itself: Stories of personal triumph from the frontier of brain science. New York: Penguin Group, Inc.

Jenson, L, (2009) Critically Appraised Topic (CAT): What is the effectiveness of mirror therapy for improving upper extremity motor recovery and functional use in adults with hemiparesis following stroke? Retrieved from




Mosely, G.L & Wiech, K. (2009). The effect of tactile discrimination training is enhanced when patpients watch the relfected image of their unaffected limb during training. PAIN, 144, 314-319. doi:10.1016/j.pain.2009.04.030

Moseley, G. L., Gallace, A. & Spense, C. (2008). Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain, 138, 7-10. doi: 10.1016/j. pain.2008.06.026.

Nyberg, J. (n.d.). Mirror neurons. Retrieved from

Pomeroy, V. M., Clark, C. A., Miller, S., G., Baron, J., Markus, H. S. & Tallis, R. C. (2005). The potential for utilizing the “mirror neurone system” to enhance recovery of the severely affected upper limb early after stroke: A review and hypothesis. Neurorehabilitation and Neural Repair, 19, 4-13. doi: 10.1177/1545968304274351.

Ramachandram, V.S. & Alstchuler, E. L. ( 2009). The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain: A Journal of Neurology, 132, 1993-1710. doin: 10.1093/brain/awp135.


Stevens, J. A. & Stoykov, M. E. (2004). Simulation of bilateral movement training through mirror reflection: A case report demonstrating an occupational technique for hemiparesis. Topics in Stroke Rehabilitation, 11, 59-66.

Stralka, S. W. (2011, January 28-29). Graded Motor Imagery Program for upper extremity injuries: Using GMIP to retrain the brain). Presented for Sister Kenny at John Nasseff Conference Center, United Hospital, St. Paul, Minnesota.

TEDindia (2010, January). V.S. Ramachandran: The neurons that shaped civilizations. [Video File]. Retrieved from

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

Yavuzer, G., Selles, R., Sezer, N., Sutbeyaz, S., Bussmann, J., Koseoglu, F., Atay, M. & Stam, H., (2007). Mirror therapy improves hand function in subacute stroke: A randomized controlled trial. Achives of Physical Medicine and Rehabilitation, 89, 393-398. doi: 10.1016/j.apmr.2007.08.162.


There are two ways of spreading light: to be the candle or the mirror that reflects it. -Edith Wharton