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1
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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2
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).