mirror box therapy for stroke rehab

[oc1dean]

has anyone used this therapy? I saw an article in the Lancet -Rehabilitation of hemiparesis after stroke with a mirror
Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DME, Ramachandran V
The Lancet - Vol. 353, Issue 9169, 12 June 1999, Pages 2035-2036
I was wondering what the therapy protocols for this are, My Occupational therapist has not heard of this. I'm looking at this to see if I can get my hand to open up.
Here is the actual article
All patients were at least 6 months post-stroke proven by computed tomography or magnetic resonance imaging (mean 4·8 years post-stroke, SD 8·2 years, range 6 months to 26·25 years), to preclude effects from spontaneous recovery. The patients gave written informed consent. The patients were randomly assigned to spend the first 4 weeks using a mirror or transparent plastic, and then crossed over to the other treatment for the next 4 weeks. We used mirrors sized 18×24 inches (45 cm×60 cm) made of plastic with a mirror coating, and transparent plastic sheets of the same size. Patients were put on a practice schedule of 15 min, twice a day, 6 days a week, moving both hands or arms symmetrically (moving the affected arm as best they could) while watching the good arm in the mirror, or the paretic arm through the clear plastic (figure). A “bootstrapping” approach was employed in designing regimens for patients, typically moving proximal to distal, working from movements patients could perform to those they could not. The patients were videotaped at 0, 2, 4, 6, and 8 weeks making all of the cardinal movements of the upper limb. Subjective comments were obtained from the patients, and the patients' progress was assessed from the videotape by two senior neurologists from our team who were unaware of which treatment the patients used first, or the patients' subjective comments, assessing the change from baseline in patients' movement ability in terms of range of motion, speed, and accuracy using a −3 to +3 scale with 0 representing no change.


Click to enlarge imageFigure. Demonstration of the technique
Subjectively, all the patients liked using a mirror more than the clear plastic and felt that the mirror was more helpful than the plastic. One patient said that while “all my

other methods of therapy exercise my muscles, the mirror is the only one which exercises my brain and nerves”. Another said he liked using the mirror and thought it was helpful because while using the mirror “it looks like my bad arm is moving normally,” even though it was not. Another patient characterised working with the mirror as “a blessing.” Both graders found that substantially more patients improved on mirror than on control (7–1 and 4–1, table).


The mirror provides patients with “proper” visual input–the mirror reflection of the moving good arm looks like the affected arm moving correctly–and perhaps “substitutes” for the often decreased or absent proprioceptive input. Use of the mirror may also help recruit the premotor cortex to help with motor rehabilitation3. The premotor cortex has a number of features suggesting it might possibly be a link from the visual image in the mirror to motor rehabilitation following stroke: non-trivial contributions to the descending corticospinal tracts; more bilateral control of movement than the motor cortex itself; and intimate connection between premotor areas and visual input4. On a number of neurological and psychological levels, mirror therapy may help to reverse elements of learned disuse5 of the affected limb.

We are encouraged that mirror therapy may be beneficial for at least some patients with hemiparesis following stroke, giving impetus to do larger trials of mirror therapy.
Thanks,
Dean

[kateannemith]

Hi, I am a newly qualified physio, but working as an assistant, at Blackpool Victoria on the stroke ward, we often use mirrors during treatment sessions as we feel it gives the patients good visual feedback and allows them to see where their body is in relation to space and allows them to understand what we are trying to achieve - "sit up in the midline, bring your body back to midline when slumping to one side" as often they have neglect so are unable to feel that they are slumping, pushing, leaning to the left or right. The article looks good though and have printed it off to take to work, this can be my contribution to journal club - thanks!!

[physiobob]

Thanks Kate but this is not actually mirror box therapy. This type of therapy is often used with a mirror to the hemi side of a stroke patient so that when they move their good side the patient perceives via the mirror that their hemi side is fully intact. This type of work has shown to be really useful in the treatment of pain, particularly with amputees and phantom limb pain.