Mirror Therapy for Post-Stroke Rehabilitation

1. Mirror Therapy for Post-Stroke Rehabilitation By: Kim Errico, OTR/L Kristen Daniels, OTR/L

2. Purpose of Mirror Therapy • Improve motor recovery in upper and lower extremities • Increase the functional use of upper and lower extremities • Work in conjunction with conventional therapy

3. Goals for Mirror Therapy • The following are goals for OT and PT treatment of the affected extremities • Increase ROM • Increase function • Increase perception (neglect, inattention, awareness) • Increase cortical reorganization of the brain • Increase processing speed • Increase strength • Improve a lack or change in sensation • Decrease apraxia • Decrease pain • Increase coordination

4. Patient Criteria • Medically stable • Diagnosis that has affected an extremity in strength, ROM, sensation and/or visual perception • Must have intact/unaffected extremity • Tolerates upright position • Follows simple commands/directions • Can attend to task for at least 15 minutes

5. Contraindications • Precautions or restrictions limiting ROM to the affected extremity • ie: DVT, sternal precautions, arthritis, contractures, tone • Any visual impairments that will severely impact ability to see image in the mirror • ie: macular degeneration, cataracts, etc.

6. Equipment • Mirror therapy requires very little for equipment and set-up • Equipment includes • Mirror box or full length mirror • Table (for upper extremities) • Mat or chair (for lower extremities) • Quiet environment with limited visual and auditory distractions • Side tables (depending on activity)

7. Use of Mirror Therapy for Upper Extremity Impairments • A baseline of range of motion, strength, coordination, and sensation • All identifiers are removed from unaffected extremity such as: • Rings • Name bands • Bracelets/watches • The affected upper extremity is placed inside the box or behind the full length mirror • Patient sits with mirror at midline of face/body • Selected exercises are completed with unaffected upper extremity while patient watches motion in mirror • Patient should try to move both extremities together and coordinate throughout

8. Use of Mirror Therapy for Lower Extremity Impairments • A baseline of range of motion, strength, coordination, and sensation • Patient is positioned in appropriate position for desired ROM (supine with head elevated or seated in wheelchair/chair) • The affected lower extremity is placed behind the full length or rolling mirror • Selected exercises are completed with unaffected upper extremity while patient watches motion in mirror • Patient should try to move both extremities together and coordinate throughout

9. Sample Protocols • Upper Extremity • Protocol 1 • 15 minutes, twice daily, 6 days a week for 4 weeks • Proximal to distal movements • Begin with movements patients can complete and move to more difficult • Protocol 2 • 30 minutes, once a day, 5 days a week for 4 weeks • Finger and wrist movements • Lower Extremity • 30 minutes a day, 5 days a week for 4 weeks • Ankle dorsifelxion movements

10. Assessments Used to Collect Data • The following assessments and tests have been chosen by numerous researchers to look at the efficacy of mirror therapy • Upper Extremity • Fugl Meyer Assessment • Action Research Arm Test • Motor Assessment Scale • Wolf Motor Function Test • Box and Block Text • Brunnstrom Stages • Lower Extremity • Fugl Meyer Assessment • Brunnstrom Stages

11. Research • Yavuzer, Selles, Sezer, Sutbeyaz, Bussmann, Köseoğlu, Atay, & Stam (2008) • Participants: 40 inpatients within 12 months post-stroke • Purpose: Evaluate effects of mirror therapy for motor recovery, spasticity, and upper extremity function • Intervention: 30 minutes a day, 5 days a week for 4 weeks in conjunction with conventional therapy • Results: Hand function improved at end of intervention as well as 6 month follow-up; spasticity was not changed

12. Research Continued • Sütbeyaz, Yavuzer, Sezer & Koseoglu (2007) • Participants: 40 inpatients within 12 months post-stroke • Purpose: Evaluate using mirror therapy and motor imagery on lower extremity functioning • Intervention: 30 minutes of mirror therapy a day, 5 days a week for 4 weeks in conjunction with conventional therapy • Results: Lower extremity recovery and functioning increases following mirror therapy combined with conventional therapy

13. Research Continued • Dohle, Pullen, Nakaten, Kust, Rietz, & Karbe (2009) • Participants: 36 patients no more than 8 weeks post stroke all with severe hemiparesis • Purpose: Evaluate affect of therapy including the use of a mirror to simulate the affected upper extremity with the unaffected upper extremity; this was a randomized controlled trial • Intervention: 30 minutes of mirror therapy a day, 5 days a week for 6 weeks with random assignment to either mirror therapy or an equivalent control therapy • Results: Mirror therapy is a promising method to improve sensory and attentional deficits and to support motor recovery

14. Research Continued • Case study • Stevens, & Stoykov (2004) • Outlined a method for using simulation of movement to provide a means for experiancing a range of smooth and controlled movements completed by a paretic limb. The simulation provides perceptual experience of bilateral motion beyond the current capabilities of the affected limb. Technique was done for a 3 week course of treatment. Results showed improved hand function as demonstrated by increases in Fugl-Meyer scores and faster movement speeds as demonstrated by decreased movement times for the Jebsen Test of Hand Function.

15. Conclusion • Mirror therapy is a relatively new treatment approach in the field of stroke rehabilitation which will require future research for efficacy. • It is difficult to discriminate gains in relation to just mirror therapy due to the fact that mirror therapy is rarely completed without conventional treatment.

16. Video Example

17. References • 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. • Laybourne, D. & Carrigan, P. “Doug and mirror box therapy in action” (2009). Online video clip. http://www.youtube.com/watch?v=MIucuMWOdKE. Accessed on May 1, 2011. • Stevens, J.A. & Stoykov, M.E.P. (2004). Simulation of bilateral movement training through mirror reflection: A case report demonstrating an occupational therapy technique for hemiparesis. Topics in Stroke Rehabilitation, 11, 59-66. • Sütbeyaz, S., Yavuzer, G., Sezer, N., & Koseoglu, F. (2007). Mirror therapy enhances lower-extremity motor recovery and motor functioning after stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 88, 555-559. • Yavuzer, G., Selles, R., Sezer, N., Sutbeyaz, S., Bussmann, J.B., Köseoğlu, F., Atay, M.B., & Stam, H.J. (2008). Mirror therapy improves hand function in subacute stroke: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 89, 393-398.