Incorporating Mirror Box Therapy into Hand Therapy Practice



Incorporating Mirror Box Therapy into Hand Therapy Practice

by Tara Packham, MSc, OT Reg. (Ont)

Hamilton Health Sciences/McMaster University

Hamilton, Ontario, Canada

Mirror box therapy (also known as mirror visual feedback) is an application of motor imagery where the image of an unaffected limb is viewed in a mirror strategically positioned to create the sensory illusion that the person is viewing their affected limb. The idea was pioneered by Ramachandran for persons experiencing phantom limb pain after amputation1, and it has since been used with stroke, complex regional pain syndrome (CRPS) and other hand and nerve injuries2-6. It would appear to be a hot topic at recent conferences. The strength of the evidence

ranges from descriptive case studies to small, randomized controlled trials, and it has been described in systematic reviews7-9 as indicating a trend towards support for utilization with post-stroke and CRPS, with

limited evidence for other hand conditions. So why, when and how might a hand therapist incorporate this technique into their practice?

Indications for use

Post- Stroke

Review of the literature suggests mirror therapy (MT) has been studied for persons at a variety of temporal and functional stages of motor recovery3,10. It may be contraindicated for those with premorbid or associated cognitive or visual impairments, including neglect and apraxia.3

CRPS

Most of the studies using MT with this population have applied it as part of one component of a graded motor imagery program11-13 and use laterality and motor imagery activities as the initial steps. However, others have reported small case series of MT14,15 with positive results using MT alone. It is worth noting that those who benefited from MT were described as having early CRPS14 and CRPS II.15 In my clinical experience using this

modality, I have also found the use of additional motor imagery components is not necessarily required when MT is used early in the syndrome (less than three months since the development of symptoms). However, I always use the client’s initial response to gauge the need for a more comprehensive program.

Other Hand Injuries/Surgeries

While there is little formal research evidence for application of MT to other populations, there remain several

theoretical arguments for its use. This technique has been shown to be useful for phantom limb pain, and three of the papers describing the use of MT with hand injuries also include populations where there is an element of deafferentation.4-6 Simply put, when the patient has lost the sensory feedback from their hand because of nerve injury (amputation being the most extreme form of this), MT may provide a useful surrogate. The second

(and related) argument is for those cases where sensory feedback exists but does not match the cortical expectations of the motor prediction patterns underpinning normal movement.16,17 The so-called sensorimotor incongruence may be the result of nerve injury, pain, stiffness, edema or immobilization, and MT may help

to correct the mismatch and facilitate movement.

Instructions for use

Review of the literature demonstrates an overall lack of consistency and detail in program implementation. Therapists new to the concept are directed to Priganc and Stralka’s detailed description of graded motor imagery17 and McCabe’s excellent summary of applications in clinical practice16 for more detail. General guidelines include daily practice, working in a comfortable seated position and removing all jewelry from the hand that will be seen in the mirror. Most authors suggest the patient perform a series of arm, hand and finger postures in front of mirror with unaffected hand and attempt to “mirror” with affected hand. Exercises are tailored to patient abilities and graded as appropriate. In my clinical experience, the biggest key to success is careful patient education, taking the time to explain what you are trying to do and why you think it might help them. I will usually have the person start for short periods of 3-5 minutes and increase time to 10-15 minutes as

tolerated.

I use these instructions with my clients:

1. Place affected arm inside box with mirror facing unaffected arm. Make sure the box is comfortably positioned

in front of you where you can see the reflection of your unaffected arm clearly in the mirror.

2. Start by concentrating on the reflected image in the mirror. Try to imagine that what you are seeing is actually

your other hand. This may take a minute or two, but sometimes happens quite quickly.

3. Keeping your affected hand relaxed, start by gently doing the exercises your therapist has selected with you only with the unaffected hand. Try to focus on the image in the mirror while you do the movements.

4. Now repeat the same exercises, but this time, try to do them with both hands at the same time. Again, focus on the image in the mirror while you do the movements. Do not do anything with your affected hand that

produces pain. Stop if you become tired or experience any feelings of nausea or dizziness. If the person does not experience the sensory illusion at step two, then we do not progress any further. I may try again at a different time of day or in a completely quiet or private area of the clinic to see if there was some distraction factor.

Do not underestimate the power of this technique to create a response in the central nervous system–there are

several studies that document the impact of creating an artificial sensorimotor incongruence even in healthy

volunteers.18,19 Sometimes clients will have a strong sensory or emotional reaction even at this point–nausea, dizziness, tears, even transient pain in the unaffected limb. If a negative response is elicited at any point,

we move back to the previous step, which may mean laterality and motor imagery rather than using the mirror box.

On a practical note, I use a purpose-made box of melamine for easy cleaning, open at both ends, 12” high by 14” wide and 16” long–this allows for lots of room to move within the box. I also have an extra unit for short-term loan to patients to get them started, and then will encourage them to make one for home use with a sturdy

cardboard box and a 12” square sticky-back mirror tile from the hardware store.

Progressing Therapy

If the person tolerates the mirror box, work on gradually increasing the length of use to 10-15 minute periods, as well as the number of times used daily. The amount of stimulation or challenge to the sensory system can also gradually be increased by varying the location where MT is performed, lighting, noise or other distractions. The person can also move from exercise to activity, adding tools or other objects to the experience. Other forms of sensory stimulation can also be added to MT, and this may increase the effectiveness of the program.20 Consider

adding sensory stimulation by touching different textures like smooth/rough, warm/ cold, hard/soft and/or furry.

Incorporating into overall treatment plan

The foundational framework of hand therapy is traditionally biomechanical; most treatment protocols arise from this perspective. However, when our clients are not following the expected course of recovery, hand therapists are skilled at incorporating components of other approaches (like cognitive-behavioral or exercise physiology). MT is yet another addition to the therapists’ toolkit. Consider using it when there is fear of movement, reports of dysthesias, deafferentation or difficulty in consistently recruiting the desired muscles or movement patterns.

Start with short periods of use in the clinic to monitor response before adding a home program. Continue to use as long as the symptoms persist, progressing the program as tolerated.

Be sure to incorporate measurement tools to objectively monitor progress and outcomes to further inform your practice and advance the evidence for this modality.

References and resources:

1. Ramachandran VS, Roger-Ramachandran D.

Synaesthesia in phantom limbs induced with

mirrors. Proc Biol Sci. 1996; 263: 377-86.

2. Altschuler E, Hu J. Mirror therapy in a

patient with a fractured wrist and no active

wrist extension. Scand J Plast Reconstr Surg

Hand Surg. 2008, 42:110-11.

3. Yavuzer G, Selles R, Sezer N, Sütbeyaz S,

Bussmann JB, Köseog˘lu F, Atay

MB, Stam HJ. Mirror therapy improves hand

function in subacute stroke: A randomized

controlled trial. Arch Phys Med Rehabil.

2008; 89:393-8.

4. Bjorkman A, Waites A, Rosen B, Lundborg

G, and Larsson E. Cortical sensory and

motor response in a patient whose hand has

been replanted: One year follow-up with

functional magnetic resonance imaging.

Scand J Plast Reconstr Surg Hand Surg. 2007,

41: 70-6.

5. Rosen B, Lundborg G. Training with a mirror

in rehabilitation of the hand Scand J Plast

Reconstr Surg Hand Surg. 2005, 39: 104-8.

6. Sumitani M, Miyauchi S, McCabe CS,

Shibata M, Maeda L, Saitoh Y, Tashiro

T, Mashimo T. Mirror visual feedback

alleviates deafferentation pain, depending on

qualitative aspects of the pain: a preliminary

report. Rheumatology. 2008; 47:1038–43.

7. Ezendam D, Bongers RM, Jannink MJA.

Systematic review of the effectiveness of

mirror therapy in upper extremity function.

Disabil Rehabil, 2009; 31(26): 2135–49.

8. Rothgangel AS, Braun SM, Beurskens AJ,

Seitz RJ, Wade DT. The clinical aspects of

mirror therapy in rehabilitation: a systematic

review of the literature. Int J Rehabil Res.

2011, 34:1–13.

9. Thieme H, Mehrholz J, Pohl M, et al. Mirror

therapy for improving motor function after

stroke. Cochrane Database Syst Rev. 2012

Mar 14;3:CD008449. (Review) PMID:

22419334

10. Dohle C, Pullen J, Nakaten A, Kust J,

Rietz C, Karbe H. Mirror therapy promotes

recovery from severe hemiparesis: a

randomized controlled trial. Neurorehabil

Neural Repair. 2009, 23:209–17.

11. Moseley GL. Graded motor imagery is

effective for long-standing complex regional

pain syndrome: a randomised controlled

trial. Pain. 2004, 108:192–98.

12. Moseley GL. Is successful rehabilitation

of complex regional pain syndrome due to

sustained attention to the affected limb? A

randomized clinical trial. Pain. 2005, 114:54

61.

13. Moseley GL (2006). Graded motor imagery

for pathologic pain: a randomized controlled

trial. Neurology. 2006, 67:2129–34.

14. McCabe CS, Haigh RC, Ring EFJ, Halligan

PW, Wall PD, Blake DR. A controlled pilot

study of the utility of mirror visual feedback

in the treatment of complex regional pain

syndrome (type 1). Rheumatology, 2003,

42:97–101.

15. Selles RW, Schreuders TAR, Stam HJ.

(2008) Mirror therapy in patients with

causalgia (CRPSII) following peripheral

nerve injury: 2 cases. J Rehabil Med 2008; 40:

312–14.

16. McCabe, CS. Mirror Visual Feedback: a

practical approach. J Hand Ther. 2011,

24:170-9.

17. Priganc VW, Stralka SW. Graded Motor

Imagery. J Hand Ther. 2011, 24:164-9.

18. Fukumura K, Sugawara K. (2007). Influence

of mirror therapy on human motor cortex.

Intern J Neuroscience, 2007; 117:1039–48.

19. McCabe CS, Haigh RC, Halligan PW, Blake

DR. Simulating sensory-motor incongruence

in healthy volunteers: implications for

a cortical model of rheumatology pain.

Rheumatology. 2005; 44:509–16.

20. Moseley, GL, Wiech, K. The effect of tactile

discrimination training is enhanced when

patients watch the reflected image of their

unaffected limb during training. Pain. 2009,

144:314–319.

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