Review Article
M IRROR THERAPY: A REVIEW OF EVIDENCES
Aishath Najiha
1, Jagatheesan Alagesan *
2, Vandana J. Rathod
3, Poongundran
Paranthaman
4.
1 Internee, Saveet ha College of physiot herapy, Chennai, Tamil Nadu, India. * 2 Professor, Saveet ha College of physiot herapy, Chennai, Tamil Nadu, India. 3 Lect urer, SPB Physiot herapy College, Ugat Bhesan Road, Surat , India. 4 Principal, Sigma Inst it ute of Physiot herapy, Vadodara, India.
The aim of t his r eview w as t o ident ify and sum m arize t he exist ing evidences on m irr or box t herapy for t he m anagem ent of var ious m usculoskelet al condit ions. A syst em ic lit erat ure search w as perf orm ed t o ident ify st udies concerning m ir ror t herapy. The included journal art icles w ere review ed and assessed for it s significance. Fifty one st udies w ere ident ified and review ed. Five different pat ient cat egories w ere st udied: 24 st udies focussed on m irror t herapy aft er st r oke, t hir t een st udies f ocussed on m ir ror t herapy aft er an am put at ion, t hree st udies focussed on m irror t herapy w it h com plex r egional pain syndrom e pat ient s, t w o st udies on m irror t herapy for cer ebral palsy and one st udy focussed on m irror t herapy aft er a fract ure. The art icles r eview ed show ed a t r end t hat m ir ror t herapy is eff ect ive in st roke, phant om lim b pain, com plex regional pain syndrom e, cerebr al palsy and fract ure rehabilit at ion.
KEY W ORDS: M irror Therapy, St roke, Cerebral Palsy, Fract ure Rehabilitat ion.
ABSTRACT
INTRODUCTION
Address for correspondence: Dr. Jagat heesan Alagesan, PT, PhD, Professor, Saveet ha College of physiot herapy, Chennai, Tamil Nadu. India - 602105. M obile: +91 72999 05242
E-M ail: jagaphd@yahoo.in
Int J Physiother Res 2015, Vol 3(3):1086-90. ISSN 2321-1822 DOI: ht t p:/ / dx.doi.org/10.16965/ ijpr.2015.148
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International Journal of Physiotherapy and Research
ISSN 2321- 1822
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DOI: 10.16965/ ijpr.2015.148
Received: 21-05-2015 Peer Review : 21-05-2015 Revised: None
Accept ed: 01-06-2015 Published (O): 11-06-2015 Published (P): 11-06-2015
M irror t herapy w as invent ed by Vilayanur S. Ramachandran t o help alleviat e t he Phant om limb pain, in w hich pat ient s feel t hey st ill have a pain in the limb even aft er having it amputated. Ramachandran and Rogers-Ramachandran [1] first devised the t echnique in an at t empt t o help t hose w ith phant om limb pain resolve w hat t hey t er m ed a ‘ lear ned paralysis’ of t he painf ul ph an t o m li m b . Th e vi su al f eedb ack, f r o m view ing t he reflect ion of t he int act limb in place of t he phant om limb, made it possible for t he pat ient t o perceive movement in t he phant om
limb. Their hypothesis was that every time the
pat ient at t empt ed t o move t he paralyzed limb, t hey received sensory feedback (t hrough vision and Propriocept ion) t hat t he limb did not move. This feedback st am ped it self int o t he brain circuit ry t hrough a process of Hebbian learning, so t hat , even w hen t he lim b w as no longer present, the brain had learned t hat t he limb (and subsequent phant om) w as paralyzed.
limb [2]. A M irror box is a device w hich allow s t he clinician t o easily create t his illusion. It ’ is a box w it h one mirror in t he cent re w here on each side of it , t he hands are placed in a manner t hat t he affected limb is kept covered always and t he unaffected limb is kept on t he ot her side w hose reflect ion can be seen on t he mirror. M T is a non-pharmacological and alt ernat ive t reat ment st rat egy t hat has been proposed as a means of m anaging phant om lim b pain. It is a neuro-rehabilit at ion technique designed to remodulat e cor t ical m echanism s. W it h t his t echnique, p at i ent s per f or m m o v em en t s u sin g t h e unaff ect ed lim b w hilst w at ching it s m ir r or r ef lect ion super im posed over t he (unseen) affect ed limb. This creat es a visual illusion and provides posit ive feedback t o t he mot or cort ex that movement of the affected limb has occurred. The approach is t hought t o offer pot ent ial relief t hrough t he visual dominance upon mot or and sensory processes [3].
M i r r or t h er ap y h as b een used in pat ien t s suffering from st roke, cerebral palsy, complex regional pain syndrome, phant om limb pain and f r act ur e r eh abi l i t at i on . Th r ee p ar t i cul ar condit ions t hat have been st udied t he most are st roke, CRPS and phant om limb pain. During mirror t herapy, a mirror is placed in t he patient ’s mid sagit t al plane, t hus reflect ing movement s of t he nonparet ic side as if it w ere t he affect ed side. This arrangem ent is suit ed t o creat e a visual illusion w hereby movement of or t ouch t o t he int act limb may be perceived as affect ing t he paret ic or painful lim b. The under lying m echanism s o f t he ef f ect s in t h ese t hr ee pat ient groups have mainly been relat ed t o t he act ivat ion of ‘mirror neurones’, w hich may also be act ivat ed w hen observing ot hers perform movement s and also during ment al pract ice of m ot or t asks. M irr or neur ons w er e found in areas of t he vent r al and inf erior prem ot or co r t ex associ at ed w i t h o b ser v at i o n an d imit at ion of movement s and in somat osensory cort ices associat ed w it h observat ion of t ouch. Th ese co r t ical ar eas ar e su pp o sed t o b e act ivated by M T. Unt il now, direct evidence for the mirror-related recruitment of mirror neurons is lacking. Ot her pot ent ial mechanisms such as enhanced self-aw areness and spat ial at t ent ion by act ivat ion of t he superior t emporal gyrus,
precuneus and t he post erior cingulat e cort ex have been proposed. The superior t emporal gy-rus is also t hought t o play an import ant role in recovery from neglect , and is act ivat ed by ob-servat ion of biological mot ion.
M ETHODOLOGY & SEARCH CRITERIA
Ind ep en d ent sear ch w as car r i ed o u t b y researchers using a w ell defined search st rat egy in follow ing dat abases; M edline, EBSCO, DOAJ, Science Direct and Google Scholar published from 1996 t o 2013 using t he key terms mirror box, mirror box therapy, mirror therapy and mirror visual feedback. All randomized cont rolled t rials (RCTs), cohort , case cont rolled st udies, single-case st udies and single-case ser ies w er e used in evaluat ing t he clinical aspect s of mirror t herapy. All age groups and bot h sexes w ere included for select ion of review s. Only physiot herapy int ervent ion has been included, no medical or surgical int ervent ion or comparison w it h any ot her alt ernat ive t herapies. Visual analogue scale, range of m ot ion, numerical pain rat ing scal e, gr ip st r en gt h , w r i st f un ct io n ali t y m easur em ent s, t i m ed per f o r m an ce t est s, funct ional independence m easure, m odified Ash w o r t h scal e, f un ct io n al am bu l at i o n cat egories, funct ional independent measure, wolf mot or function t est, motor activit y log, Fugl-M eyer t est , behavioral inat t ent ion t est , t est of at t ent ion performance, manual muscle t est ing, manual functional t est , act ion research arm t est , box and block t est and 10-met er w alk t est w ere taken as an outcome measures
improvement . St udies included w ere present ed here w it h t w o t it les, clinical t rials and review s.
M irror therapy in stroke: Lin KC et al evaluated aff erent st im ulat ion and m ir ror t her apy for rehabilit at ing mot or funct ion, mot or cont rol, ambulat ion, and daily funct ions aft er st roke. Fort y-t hree chronic st roke pat ient s w it h mild t o moderat e upper ext remit y received M T + M G, M T, or CT for 1.5 hours/ day, 5 days/ w eek for 4 w eeks. Result s show s M T + M G and M G w it h r educed m ot or im pairm ent and syner gist ic shoulder abduct ion more t han CT [4].
M irror therapy in phantom limb pain: Jack W. Tsao et al. evaluated mirror t herapy in phant om limb pain. Tw ent y-t w o pat ient s w ere assigned t o one of t hree groups: one t hat view ed a reflective image of themselves in a mirror (mirror group); on that view ed a covered mirror; and one t hat w as t rained in ment al visualizat ion. The study found that mirror therapy reduced phantom li m b p ain in pat ient s w ho had und er go ne amput at ion of t he low er limbs. Such pain w as not reduced by eit her covered mirror or ment al visualizat ion t reat ment s. These result s suggest t hat mirror t herapy may be helpful in alleviat ing phant om pain in low er limbs [5].
M irro r t herap y in cere bral palsy: M ax G. Felt ham et al. evaluat ed t he effect of visual information on bimanual coordination in children w it h spast ic hem iparet ic cerebral palsy. The st u d y i n cor p o r at ed t w o ad di t i on al v i sual feedback conditions by placing a glass or opaque scr een bet w een t he ar m s. During bilat eral symmetric circular arm movements mirror visual f eed b ack in d u ced lo w er n eur o m uscu lar int ensit ies in t he shoulder muscles of t he less impaired arm of children w it h SHCP compared t o t he ot her visual condit ions. In addit ion, t he m irror lead t o shor t er relat ive durat ions of eccent ric and concent ric act ivit y in t he elbow muscles of t he more impaired arm, w hereas no eff ect s of visual f eedback w er e f ound in a mat ched cont rol group. These result s suggest t hat replacing veridical visual informat ion of t he more impaired arm w it h a mirror reflect ion of the less impaired arm improves the motor control of children w it h SHCP during int er limb coupling [6].
M irror therapy in CRPS: G.L M oseleyet al has
done a randomized cont rolled t rial on effect ive-ness for long-st anding complex regional pain syndrome. Thirteen chronic CRPS1 pat ient s were randomly allocated to a mot or imagery program (M IP) or t o ongoing m anagem ent . The M IP consist ed of t w o w eeks each of a hand lat eralit y recognition t ask, imagined hand movements and mirror t herapy. After 12 weeks, t he control group was crossed-over t o M IP. The result s uphold t he hypot hesis t hat a M IP init ially not involving limb movement is effect ive for CRPS and support t he involvem ent of cort ical abnorm alit ies in t he development of t his disorder [7].
M irror therapy in fracture: Alt schuler E. et al exam ined mirror t herapy in a pat ient w it h a fract ured w rist and no act ive w rist ext ension. Pat ient w as t rained by moving bot h hands while w at ching t he reflect ion of t he present or good hand in a parasaggit al mirror. M irror t herapy found ext remely useful aft er a fract ured w rist [8].
This lit erat ure review has given an account of t he reasons for t he w idespread use of m irror t herapy. Some of t he potent ial limitat ions of this r eview w ere t he lack of m et a-analysis and qualit y scoring of t he included st udies.
Kelly Lamont et al., 2009 summarize t he current evidence support ing use of M irror Box Therapy and its successor, Immersive Virt ual Realit y. They show ed, in recent years t he Phant om Limb Pain (PLP) and t o som e degree Com plex Regional Pain Syndr om e (CRPS) m ay pr ove t o be an except ion [9].
M irror t herapy has show n positive effect s in t he t reat ment of st roke rehabilitat ion and complex regional pain syndrome. It also show s posit ive effect s on hand and foot rehabilit at ion following an injury or surgery [9,11].
Rot hgangel AS et al., review ed clinical aspect s
of mirror therapy in rehabilitation They found
litt le is know n about w hich pat ient s are likely t o benef it m ost fr om M T, and how M T should preferably be applied. Fut ure st udies w it h clear descript ions of int ervent ion prot ocols should focus on st andardized out come measures and syst emat ically regist er adverse effect s [12]. M ore r esearch is needed t o det er m ine t he opt imal dose of t herapy, opt imal t ime t o start t his int ervent ion, and t he right t arget group. Accordingly, no firm conclusions can now be draw n on t he effect iveness of M T unt il m ore evidence is present [13].
DISCUSSION
This review w as a clinically and scient ifically app l i cab l e f o r u se b o t h b y cl in i cian s an d researchers involved w it h pat ient s of unilat eral lim b involvem ent like st roke, cerebral palsy, phant om limb and CRPS. Some of t he pot ent ial limit at ions of t his review w ere t he lack of met a-analysis and qualit y scor ing of t he included st udies. This review included st udies of all designs leading t o het erogeneit y not only in int ervent ions, out come assessment and follow -up, but also in analysis and effect size. Only st udies in English w ere review ed and t his might have missed some ot her import ant st udies. The increased variabilit y regarding different p hy si ot h er ap y m o d al i t ies, co m par i so n interventions, follow -up, and outcome measures also made it very difficult t o com pare result s across st udies and draw relevant conclusions. Furt her good qualit y cont rolled clinical t rials on com p ar i so n b et w een t h e p h ysi o t h er ap y m od al it i es an d l i f est yl e m o d i f i cat i o n ar e necessary t o derive valid conclusions.
CONCLUSION
The art icles r eview ed show ed a t r end t hat mirror t herapy is effect ive in st roke, phant om lim b pain, com plex regional pain syndrom e, cerebral palsy and fract ure rehabilit at ion. This st udy w ould facilit at e clinicians and
research-ers t o undresearch-erst and t he use of M T, it s feasibilit y and applicability in the management of patients’ w it h neuro musculoskeletal condit ions affect ing unilat eral limb.
Conflicts of interest: None
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