INTRODUCTION TO THE USE OF MIRRORS IN REHABILITATION M. Penny Bartzen OTR/L
Graded Motor Imagery Program Gently Rewires the Brain: CRPSChronic Regional Pain Syndrome (CRPS)
1. Laterality Reconstruction• Restore the brain’s concept of right and left• Graded identification of right/left photos of hands
until 80 % accurate 2. Visual and motor imagery
• Visualizing without movement or threat• Visualize progressive movements
3. Mirror Therapy• Watch uninvolved hand• Gradually increase movement• Replicate with other hand (S.
Stralka, 2011)
Objectives
Mirror Neurons History of the approach Diagnoses Research review Application to your population Further information
Have you tried this?
Ramachandran TED Talk
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 Neurons
Activated by observing and executing movement
Imitation and learning
Motor imagery and visual imagery
Autism Spectrum Disorders
Watching
A. 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
(http://trivialperusal.files.wordpress.com/2011/04/sensory_homunculus.jpg?w=497)
(http://www.zbynekmlcoch.cz/informace/images/stories/medicina/neurologie/somatosenzoricky_a_motoricky_homunculus.jpg)
Mirror Neurons & Autism
Dysfunction responsible for impairments? Deficits in imitationTheory of mindSocial communication Empathy
Neural strategies differNeural 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
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) 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• 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)
http://www.orble.com/images/ns312.jpg
Mirror Visual Feedback (MVF): Mirror Box Therapy
(MVT) Strokes Autism Amputations Complex Regional Pain Syndrome
(CRPS)/Reflex Sympathetic Dystrophy (RSD)
Neurological Disorders Arthritis
Mirrors
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
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
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
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
Include as adjunct to standard therapy
Utilize with CRPS type-1 after stroke for pain reduction
Continued research (p. 15)
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)
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
Laterality Visual Imagery Mirror Therapy Localization Kinesthesia Graphesthesia Stereognosis Sensorimotor accuracy (Stralka ,2011)
Sound Familiar?
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
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
Protocol 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).
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
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
ProtocolsYavuzer 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
Altschuler et al. 1999
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
Protocols
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 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?
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?
Exercise
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).
Doug and the Mirror Box
"The best thing about mirror therapy is,
… it's cheap, safe, easy and it's fun.“
Dr. Eric Lewin Altschuler
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
Giacomo Rizotalli on the discovery of mirror neurons_ http://www.youtube.com/watch?v=rPVNAESOWSo&feature=relmfu
Mirror box therapy with David Butler_ http://www.youtube.com/watch?v=hMBA15Hu35M
The social brain (ep 4)- Charlie Rose: The social brain_ http://www.youtube.com/watch?v=nPH8TctMRXY&feature=related
Acting and mirror neurons_ http://www.youtube.com/watch?v=loB-Lg0X1qo
Mirror Box Visual Therapy_ http://www.youtube.com/watch?v=xh8Pc6v7KAg
How to use a mirror box for hand therapy_ http://www.youtube.com/watch?v=GNanQtMBwys
Phantom limb mirror box video_ http://www.youtube.com/watch?v=gc3CmS8_vUI
Doug and mirror box therapy in action 3 sep _ http://www.youtube.com/watch?v=MIucuMWOdKE
Mirror neurons in autism_ http://www.youtube.com/watch?v=_8WV1zAh9zU
References
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 http://ot.creighton.edu/community/EvidenceReviews/OTD541_09/JEnsen
%282009%29_CAT_Mirro_Therapy_UE_Motor_Recovery_CVA.pdf
.
References
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 http://www.cied.uark.edu/Mirror_Neurons.pptx
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.
References
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 http://www.ted.com/talks/vs_ramachandran_the_neurons_that_shaped_civilization.html
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 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008449.pub2/full
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
Top Related