Mirror therapy

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An occupational therapy assistant using mirror therapy to address phantom pain US Navy 110613-N-YM336-079 Lynn Boulanger, an occupational therapy assistant and certified hand therapist, uses mirror therapy to help address phan.jpg
An occupational therapy assistant using mirror therapy to address phantom pain

Mirror therapy (MT) or mirror visual feedback (MVF) is a therapy for pain or disability that affects one side of the patient more than the other side. It was invented by Vilayanur S. Ramachandran to treat post-amputation patients who had phantom limb pain (PLP). Ramachandran created a visual (and psychological) illusion of two intact limbs by putting the patient's affected limb into a "mirror box," with a mirror down the center (facing toward a patient's intact limb).

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The patient then looks into the mirror on the side with the good limb and makes "mirror symmetric" movements, as a symphony conductor might, or as a person does when they clap their hands. The goal is for the patient to imagine regaining control over a missing limb. Because the subject is seeing the reflected image of the good limb moving, it appears as if the phantom limb is also moving. Through the use of this artificial visual feedback, it becomes possible for the patient to "move" the phantom limb and to unclench it from potentially painful positions.

Mirror therapy has expanded beyond its origin in treating phantom limb pain to the treatment of other kinds of one-sided pain or disability, for instance, hemiparesis in post-stroke patients and limb pain in patients with complex regional pain syndrome.

Post-amputation phantom limb pain

Ramachandran (right) with his original mirror box Dr. Vilayanur S. Ramachandran and psychology student Matthew Marradi holding the original Mirror Box.jpg
Ramachandran (right) with his original mirror box
A diagram of a mirror box. A patient inserts a whole hand into one hole and the "phantom" hand into the other. When viewed from an angle, an image of two complete hands is created in the brain. Ramachandran-mirrorbox.svg
A diagram of a mirror box. A patient inserts a whole hand into one hole and the "phantom" hand into the other. When viewed from an angle, an image of two complete hands is created in the brain.

Based on the observation that phantom limb patients were much more likely to report paralyzed and painful phantoms if the actual limb had been paralyzed prior to amputation (for example, due to a brachial plexus avulsion), Ramachandran and Rogers-Ramachandran proposed the "learned paralysis" hypothesis of painful phantom limbs. [1] Their hypothesis was that every time the patient attempted to move the paralyzed limb, they received sensory feedback (through vision and proprioception) that the limb did not move. This feedback stamped itself into the brain circuitry through a process of Hebbian learning so that, even when the limb was no longer present, the brain had learned that the limb (and subsequent phantom) was paralyzed. [2]

Ramachandran created the mirror box to relieve pain by helping an amputee imagine motor control over a missing limb. Mirror therapy is now also widely used for treatment of motor disorders such as hemiplegia or cerebral palsy. As Deconick et al. state in a 2014 review, the mechanism of improved motor control and pain relief may differ from the mechanism of pain relief. Deconick et al., who reviewed only the effects of MVF on sensorimotor control, found that MVF can exert a strong influence on the motor network, mainly through increased cognitive penetration in action control. [3]

Although there has been much research on MVF, authors of many review articles complain about the poor methodology often used, for example, small sample sizes or lack of control groups. For this reason, one 2016 review (based on a review of 8 studies) concluded that the level of evidence was insufficient to recommend MT as a first intention treatment for phantom limb pain. [4]

A 2018 review, (based on 15 studies conducted between 2012 and 2017, out of a pool of 115 publications) also criticized the quality of many reports on mirror therapy (MT), but concluded that "MT seems to be effective in relieving PLP, reducing the intensity and duration of daily pain episodes. It is a valid, simple, and inexpensive treatment for PLP." [5]

A 2018 literature review of phantom limb pain stated that, in randomized controlled trials, mirror therapy reduced pain. [6]

Post-stroke hemiparesis

Treatment with mirror therapy soon expanded beyond its origin in treating phantom limb pain to treatment of other kinds of one-sided pain and loss of motor control, for example in stroke patients with hemiparesis. In 1999 Ramachandran and Eric Altschuler expanded the mirror technique from amputees to improving the muscle control of stroke patients with weakened limbs. [7]

A review article published in 2016 concluded that "Mirror therapy (MT) is a valuable method for enhancing motor recovery in poststroke hemiparesis." [8]

According to a 2017 review of fifteen studies that compared mirror therapy to conventional rehabilitation for the recovery of upper-limb function in stroke survivors, mirror therapy was more successful than CR in promoting recovery. [9]

A 2018 review based on 1685 patients recovering from hemiplegic stroke found mirror therapy provided significant pain relief, while improving motor functions and activities of daily living (ADL). [10]

Thirteen out of seventeen randomized controlled trials found that MT was beneficial for post-stroke patients' legs and feet, according to a 2019 review paper. [11]

Despite considerable research, as of 2016 the underlying neural mechanisms of mirror therapy (MT) for stroke were still unclear. [8] [12] As Deconick et al. state in a 2014 review, the mechanism of improved motor control may differ from the mechanism of pain relief. [3]

Complex regional pain syndrome

Mirror therapy is also a recommended therapy for complex regional pain syndrome (CRPS). [13] [14]

Virtual reality

Since the 2000s, the visual illusion of regaining control of a damaged limb, which mirror therapy provides, has also been available through virtual reality or robotics. [15]

See also

Related Research Articles

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<span class="mw-page-title-main">Complex regional pain syndrome</span> Array of painful conditions in humans

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<span class="mw-page-title-main">Apraxia</span> Medical condition

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<span class="mw-page-title-main">Phantom limb</span> Sensation that an amputated or missing limb is attached

A phantom limb is the sensation that an amputated or missing limb is still attached. Approximately 80–100% of individuals with an amputation experience sensations in their amputated limb. However, only a small percentage will experience painful phantom limb sensation. These sensations are relatively common in amputees and usually resolve within two to three years without treatment. Research continues to explore the underlying mechanisms of phantom limb pain (PLP) and effective treatment options.

<span class="mw-page-title-main">V. S. Ramachandran</span> Indian-American neuroscientist

Vilayanur Subramanian Ramachandran is an Indian-American neuroscientist. He is known for his wide-ranging experiments and theories in behavioral neurology, including the invention of the mirror box. Ramachandran is a distinguished professor in UCSD's Department of Psychology, where he is the director of the Center for Brain and Cognition.

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Phantom pain is a painful perception that an individual experiences relating to a limb or an organ that is not physically part of the body, either because it was removed or was never there in the first place.

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Virtual reality therapy (VRT), also known as virtual reality immersion therapy (VRIT), simulation for therapy (SFT), virtual reality exposure therapy (VRET), and computerized CBT (CCBT), is the use of virtual reality technology for psychological or occupational therapy and in affecting virtual rehabilitation. Patients receiving virtual reality therapy navigate through digitally created environments and complete specially designed tasks often tailored to treat a specific ailment; and is designed to isolate the user from their surrounding sensory inputs and give the illusion of immersion inside a computer-generated, interactive virtual environment. This technology has a demonstrated clinical benefit as an adjunctive analgesic during burn wound dressing and other painful medical procedures. Technology can range from a simple PC and keyboard setup, to a modern virtual reality headset. It is widely used as an alternative form of exposure therapy, in which patients interact with harmless virtual representations of traumatic stimuli in order to reduce fear responses. It has proven to be especially effective at treating PTSD, and shows considerable promise in treating a variety of neurological and physical conditions. Virtual reality therapy has also been used to help stroke patients regain muscle control, to treat other disorders such as body dysmorphia, and to improve social skills in those diagnosed with autism.

Constraint-induced movement therapy is a form of rehabilitation therapy that improves upper extremity function in stroke and other central nervous system damage patients by increasing the use of their affected upper limb. Due to its high duration of treatment, the therapy has been found to frequently be infeasible when attempts have been made to apply it to clinical situations, and both patients and treating clinicians have reported poor compliance and concerns with patient safety. In the United States, the high duration of the therapy has also made the therapy not able to get reimbursed in most clinical environments.

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<span class="mw-page-title-main">Cortical remapping</span>

Cortical remapping, also referred to as cortical reorganization, is the process by which an existing cortical map is affected by a stimulus resulting in the creating of a 'new' cortical map. Every part of the body is connected to a corresponding area in the brain which creates a cortical map. When something happens to disrupt the cortical maps such as an amputation or a change in neuronal characteristics, the map is no longer relevant. The part of the brain that is in charge of the amputated limb or neuronal change will be dominated by adjacent cortical regions that are still receiving input, thus creating a remapped area. Remapping can occur in the sensory or motor system. The mechanism for each system may be quite different. Cortical remapping in the somatosensory system happens when there has been a decrease in sensory input to the brain due to deafferentation or amputation, as well as a sensory input increase to an area of the brain. Motor system remapping receives more limited feedback that can be difficult to interpret.

<span class="mw-page-title-main">Tactile hallucination</span>

Tactile hallucination is the false perception of tactile sensory input that creates a hallucinatory sensation of physical contact with an imaginary object. It is caused by the faulty integration of the tactile sensory neural signals generated in the spinal cord and the thalamus and sent to the primary somatosensory cortex (SI) and secondary somatosensory cortex (SII). Tactile hallucinations are recurrent symptoms of neurological diseases such as schizophrenia, Parkinson's disease, Ekbom's syndrome and delirium tremens. Patients who experience phantom limb pains also experience a type of tactile hallucination. Tactile hallucinations are also caused by drugs such as cocaine and alcohol.

<span class="mw-page-title-main">Limb telescoping</span>

Limb telescoping is the progressive shortening of a phantom limb as the cortical regions are reorganized following an amputation. During this reorganization, proximal portions of the residual limb are perceived as more distal parts of the phantom limb. Such effect is responsible for increased phantom pain due to the discrepancy between the patient’s body perception and their actual body. This effect may last from weeks up to years after post-amputation.

References

  1. Ramachandran, V.S., Blakeslee, S.: "Phantoms in the Brain: Probing the Mysteries of the Human Mind", 1998, William Morrow & Company, ISBN   0-688-15247-3
  2. Wilson, Cassandra (2010). The Effectiveness of Mirror Therapy in the Treatment of Post-amputation Phantom Limb Pain.
  3. 1 2 Deconinck, Frederik JA; Smorenburg, Ana RP (August 26, 2014). "Reflections on Mirror Therapy: A Systematic Review of the Effect of Mirror Visual Feedback on the Brain". Neurorehabilitation and Neural Repair. 29 (4): 349–361. doi: 10.1177/1545968314546134 . PMID   25160567. S2CID   20486498.
  4. Jessie, Barbin; Seetha, Vanessa (2016). "The effects of mirror therapy on pain and motor control of phantom limb in amputees: A systematic review". Annals of Physical and Rehabilitation Medicine. 59 (4): 270–275. doi: 10.1016/j.rehab.2016.04.001 . PMID   27256539. As to the effect of MT on PLM, the 8 studies concerned reported effectiveness of MT: 4 with a low level of evidence and 4 with a high level of evidence...We cannot recommend MT as a first intention treatment in PLP. The level of evidence is insufficient.
  5. Campo-Prieto, P; Rodríguez-Fuentes, G (November 14, 2018). "Effectiveness of mirror therapy in phantom limb pain: A literature review". Neurologia. 37 (8): 668–681. doi: 10.1016/j.nrl.2018.08.003 . PMID   30447854. It is a valid, simple, and inexpensive treatment for PLP. The methodological quality of most publications in this field is very limited, highlighting the need for additional, high-quality studies to develop clinical protocols that could maximise the benefits of MT for patients with PLP.
  6. Kaur, A; Guan, Y (2018). "Phantom limb pain: A literature review". Chin J Traumatol. 21 (6): 366–368. doi:10.1016/j.cjtee.2018.04.006. PMC   6354174 . PMID   30583983. One of the studies showed all 22 patients went through mirror therapy reported a decrease in pain after 4 weeks of treatment. In contrast, only 17% and 33% of the patients in the two controlled groups reported decrease in pain.
  7. Altschuler, Eric Lewin; Wisdom, Sidney B (12 June 1999). "Rehabilitation of hemiparesis after stroke with a mirror". The Lancet. 353 (9169): 2035–2036. doi:10.1016/S0140-6736(99)00920-4. PMID   10376620. S2CID   3202937 . Retrieved 24 July 2019. Use of the mirror may also help recruit the premotor cortex to help with motor rehabilitation...On a number of neurological and psychological levels, mirror therapy may help to reverse elements of learned disuse of the affected limb.
  8. 1 2 Kamal Narayan Arya, Underlying neural mechanisms of mirror therapy: Implications for motor rehabilitation in stroke, Neurology India,2016, Volume64, Issue 1, Pages 38-44
  9. Pérez-Cruzado, D; Merchán-Baeza, JA; González-Sánchez, M; Cuesta-Vargas, AI (2017). "Systematic review of mirror therapy compared with conventional rehabilitation in upper extremity function in stroke survivors". Australian Occupational Therapy Journal. 64 (2): 91–112. doi:10.1111/1440-1630.12342. PMID   28032336. S2CID   41988219. Fifteen studies were included in the systematic review. Recovery of the upper limb, upper limb function and gross manual dexterity were frequently measured in these studies...In the primary variables in promoting recovery, MT alone showed better results in acute and chronic stroke patients in upper limb functioning than either conventional rehabilitation (CR ) or CR plus MT.
  10. Yang, Yue; Zhao, Qingchun (October 15, 2018). "Effect of Mirror Therapy on Recovery of Stroke Survivors: A Systematic Review and Network Meta-analysis". Neuroscience. 15 (390): 318–336. doi:10.1016/j.neuroscience.2018.06.044. PMID   29981364. S2CID   51601753. Thirty-seven RCTs (42 analyses, 1685 subjects) were eligible for inclusion in the meta-analysis... Overall, MT could effectively improve motor function and ADL, as well as relieve pain for stroke survivors.
  11. Louie, DR; Lim, SB; Eng, JJ (2019). "The Efficacy of Lower Extremity Mirror Therapy for Improving Balance, Gait, and Motor Function Poststroke: A Systematic Review and Meta-Analysis". J Stroke Cerebrovasc Dis. 28 (1): 107–120. doi:10.1016/j.jstrokecerebrovasdis.2018.09.017. PMID   30314760. S2CID   52976760. Seventeen RCTs involving 633 participants were included. Thirteen studies reported a significant between-group difference favoring mirror therapy in at least one lower extremity outcome.
  12. Rossiter, Borrelli, Borchert, Bradbury, Ward:"Cortical mechanisms of mirror therapy after stroke", Neurorehabil Neural Repair. 2015 Jun;29(5):444-52
  13. Al Sayegb, Samaa; Filén, Tove (2013). "Mirror therapy for Complex Regional Pain Syndrome (CRPS)—A literature review and an illustrative case report". Scandinavian Journal of Pain. 4 (4): 200–207. doi:10.1016/j.sjpain.2013.06.002. PMID   29913636. S2CID   49297754. The main treatment strategy for CRPS is physical rehabilitation for return of function and mirror therapy is one of many possible strategies to aid in this goal...There appears to be a clear indication for the use of mirror therapy to be included in the multidisciplinary treatment of CRPS types 1 and 2 with a positive effect on both pain and motor function.
  14. Jacobs, Benjamin; Creamer, Katharine (July 30, 2015). "Not all smoke and mirrors: mirror therapy for Complex regional pain syndrome". BMJ. 351: h2730. doi:10.1136/bmj.h2730. PMID   26224572. S2CID   15705979. Mirror therapy (MT) and graded motor imagery programmes (GMIP) are two specific modalities of physical therapy which are especially promising options for managing CRPS.
  15. Darbois, Nelly; Guillaud, Albin; Pinsault, Nicolas (2018). "Do Robotics and Virtual Reality Add Real Progress to Mirror Therapy Rehabilitation? A Scoping Review". Rehabilitation Research and Practice. 2018: 6412318. doi: 10.1155/2018/6412318 . PMC   6120256 . PMID   30210873.