JOURNAL ARTICLE

PRESENTATION

• Every year, 15 million people worldwide suffer a stroke.

Nearly six million die and another five million are left

permanently disabled

• World heart federation 

• By 2015, India will report 1.6 million cases of stroke

annually, at least one-third of whom will be disabled.

• Stroke is the second leading cause of disability, after

dementia.

Stroke rehabilitation

• Mobility training 

• Range-of-motion therapy 

Mirror therapy

• Mirror therapy was

invented by

V. S.Ramachandran,

Neuro scientist.

• To help alleviate

the Phantom limb pain.

Mirror therapy in stroke

rehabilitation

Treatment effects

• Improving motor function

• Reducing pain

• Reducing neglect

• Reducing sensory impairment.

Principle of mirror therapy

• In mirror therapy, a mirror is

placed beside the unaffected

limb, blocking the view of the

affected limb. This creates the

illusion that both limbs are

functioning properly.

Mirror therapy

Principle of mirror therapy

• Mirror theory is based on evidence that action observation

activates the same motor areas of the brain as action

execution.

• Observed actions lead to the generation of intended actions,

engaging motor planning and execution.

• Further, evidence suggests that damaged areas of the brain’s

motor cortex may improve by viewing movements of intact,

functioning limbs.

Principle of mirror therapy

• Mirror neurons are a type of

brain cell that respond equally

when we perform an action and

when we witness someone else

perform the same action.

Mirror neurons

• They were first discovered in the early

1990s, when a team of Italian researchers

found individual neurons in the brains of

monkeys that fired both when the monkeys

grabbed an object and also when the

monkeys watched another primate grab the

same object.

Patient characteristics

• Motor abilities – more effective in patients with severe

paresis

• Cognitive abilities- patients should have sufficient

cognitive abilities and verbal abilities to focus at least for

10 minutes on the mirror reflection and follow instructions

given by the therapist.

• Vision- therapist should determine if patient can see a

clear image of the entire limb in the mirror.

Patient characteristics• Trunk control- Patient should be able to sit unsupervised

in a wheel chair or a normal chair for the duration of

treatment.

• Cardipulmonary function- Patient with cardiopulmonary

abnormalities are not eligible.

• Non affected limb- The non affected limb should ideally

have a normal and pain free range of motion.

Negative effects

• Dizziness

• Nausea

• Sweating

• Can be triggered when

observing mirror reflection

Mirror • The dimension of the mirror

should be big enough to cover

the entire affected limb and

should allow patients to see all

major movements in the mirror.

• A size of 25x20 inches for the

upperlimb.

• A size of 35x25 inches for the

lower limb.

Precautions while choosing mirror

• It should provide a coherent mirror image

without any noteworthy distortion.

• There should be no risk of injury

Mirror box

• A mirror box is a box with

two mirrors in the center

(one facing each way), 

• In a mirror box the patient

places the unaffected limb

into one side, and the

affected limb into the other.

Frequency of therapy and duration

• At least once daily with minimum duration of

10 minutes.

• The maximum duration of each session is

dependent on the cognitive abilities of the

individual patient and negative side effects.

Before mirror therapy

• Inform the patient about the aims and side effects.

• Jewellery and other visual mark should be removed to

make it easier for the patient to perceive the reflection as

their affected limb.

• Environment should be free from any stimuli that attract

patient attention.

Positioning

• The affected limb is situated in a safe and preferably comfortable

position behind the mirror.

• The non affected limb should be positioned in the similar position as

the affected limb.

• Mirror should be positioned in front of the patient’s midline so that the

affected limb is fully covered by the mirror and the reflection of

unaffected limb is completely visible.

When to stop mirror therapy

• A minimum duration of 5 to 6 weeks of

continuous mirror therapy treatment should be

performed in order to evaluate the effects of

treatment.

• A study conducted in Korea to

investigate the effects of mirror

therapy on the upper extremity

functions of stroke patients using the

manual function test

• The subjects of this study were 14

hemiplegia patients. .

• The Korean version of the manual function test

(MFT) was used in this study.

• The test was performed in the following order: arm

movement (4 items), grasp and pinch (2 items),

and manipulation (2 items).

• The scores in all areas of the MFT increased after

the intervention compared with before the

intervention

A systematic review Mirror therapy for improving motor function after stroke.

• It included 14 studies which included randomized

controlled trials and randomized crossover trials

comparing mirror therapy with any control intervention

for patients after stroke. 

• When compared with all other interventions, mirror

therapy was found to have a significant effect on motor

function

• Mirror therapy was found to improve activities of daily

living (P=0.02)

Effectiveness of mirror therapy on lower extremity motor recovery, balance and mobility in patients with

acute stroke: A randomized controlled pilot trial.

OBJECTIVE: To evaluate the effectiveness of mirror

therapy on lower extremity motor recovery, balance

and mobility in patients with acute stroke.

DESIGN: A randomized, blinded, pilot trial.

SETTING: Inpatient stroke rehabilitation unit.

SUBJECTS: First time onset of stroke with mean post-

stroke duration of 6.41 days, able to respond to verbal

instructions.

• INTERVENTION:

Mirror therapy group performed for 30 minutes . In addition,

both groups were administered with conventional stroke

rehabilitation regime. Altogether 90 minutes therapy session

per day, six days a week, for two weeks duration was

administered to both groups.

• OUTCOME MEASURES:

Lower extremity motor subscale of Fugl Meyer Assessment

(FMA), Brunnel Balance Assessment (BBA) and Functional

Ambulation Categories (FAC).

• RESULTS:

There was no statistical difference between

groups, except for FAC.

• CONCLUSION:

Administration of mirror therapy early after

stroke is not superior to conventional treatment in

improving lower limb motor recovery and

balance, except for improvement in mobility.

References

• Kim H, Shim B. Investigation of the effects of

mirror therapy on the upper extremity functions

of stroke patients using the manual function test.

J. Phys. Ther. Sci.27: 1681–1683, 2015

• Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle

C Mirror therapy for improving motor function

after stroke. Stroke. 2013 Jan;44(1):e1-2.

References

• Mohan U, Babu SK, Kumar KV, Suresh BV, Misri

ZK, Chakrapani M. Effectiveness of mirror therapy on

lower extremity motor recovery, balance and mobility

in patients with acute stroke: A randomized sham-

controlled pilot trial. Ann Indian Acad Neuro. 2013

Oct;16(4):634-9. doi: 10.4103/0972-2327.120496

• Andreas Stefan Rothgangel, Susy M Braun. Mirror

Therapy: Practical Protocol for Stroke Rehabilitation.

07/2013; DOI: 10.12855/ar.sb.mirrortherapy.e2013

Mirror therapy“Small spark to ignite thousands of hope among stroke survivors & amputees”