Mirror therapy is a form of motor imagery in which a mirror is used to convey visual stimuli to the brain through observation of one's unaffected body part as it carries out a set of movements. The underlying principle is that movement of the affected limb can be stimulated via visual cues originating from the opposite side of the body. Hence, it is thought that this form of therapy can prove useful in patients who have lost movement of an arm or leg including those who have had a stroke.

Mirror therapy for lower extremity rehabilitation

One "high" quality RCT (Sütbeyaz et al. 2007) investigated the effect of mirror therapy on motor recovery and functioning of the lower limb in 40 patients in the sub-acute phase post-stroke. Significant differences in improvement were observed at 6 months post treatment in favor of the mirror group (mirror therapy + standard therapy) compared to the control group (placebo mirror therapy + standard therapy) for lower-extremity motor recovery (measured by Brunnstrom stages, p = .002) and motor function (measured by Functional Independence Measure, p = .001). No significant between-group differences in improvement were found for spasticity (measured by the Modified Ashworth Scale, p = .102) or walking abilities (measured by the Functional Ambulation Categories, p = .620).

Conclusion: There is moderate evidence (level 1b) from one "high" quality RCT that in the sub-acute period post-stroke, mirror therapy combined with standard therapy is more effective than standard therapy alone for improving motor recovery and functioning in the lower extremities.

Mirror therapy for hand rehabilitation

One "high" quality RCT (Yavuzer et al. 2008) investigated the effect of mirror therapy on motor recovery, spasticity and hand related functioning in 40 patients in the sub-acute phase post-stroke. Significant differences in improvement were observed following 4 weeks of treatment and at 6 months post treatment in favour of the mirror group (mirror therapy + standard therapy) compared to the control group (placebo mirror therapy + standard therapy) for hand and upper extremity motor recovery (measured by Brunnstrom stage - hand, p = .001 - 4 weeks, p=0.048 - 6 months follow up; upper extremity p= 0.001 - 4 weeks, p=0.006 - 6 months follow up) and hand related function (measured by self-care items of the Functional Independence Measure , p = .001 at both 4 weeks and 6 month follow up). No significant between-group differences in improvement were found for spasticity (measured by the Modified Ashworth Scale, p = .925 - 4 weeks, p=.876).

Conclusion: There is moderate evidence (level 1b) from one "high" quality RCT that in the sub-acute period post-stroke, mirror therapy combined with standard therapy is more effective than standard therapy alone for improving hand motor recovery and functioning.

Mirror therapy for upper extremity rehabilitation

One pre-post design study with clinical and behavioral analyses of single cases (Stevens and Stoykov, 2003) examined the effectiveness of motor imagery training in the rehabilitation of upper limb hemiparesis in the chronic phase. Performance of the paretic limb improved after the imagery intervention as indicated by increases in assessment scores and functionality (grip strength, 4 wrist functionality measurements) and decreases in movement times. The improvements over baseline performance remained stable over a 3-month period. Another case report (Sathian et al. 2000) investigated the effectiveness of mirror therapy in a patient who had difficulty using his right upper extremity, 6 months post-stroke. Standardized assessment of upper limb function suggested the patient showed improvement in functional use of his right arm in terms of manual movement and strength.

Conclusion: There is level 3 evidence from 2 pre-post studies that mirror therapy may be effective for upper limb rehabilitation. The positive results of these preliminary studies suggest the need for further research, using randomized controlled studies.

• Sathian K., Greenspan A.I. & Wolf S.L. (2000). Doing It with Mirrors: A Case Study of a Novel Approach to Neurorehabilitation. Neurorehabil Neural Repair, 14(1), 73-76.PEDro Score: Not ratable
  Country: USA

  A 57 year old male, 6 months post-stroke who reported difficulty moving his right side, and right-sided paraethesias, received a program consisting of weekly physical therapy visits at home (intensity of intervention is unknown). The initial intervention was to use a "motor copy" strategy that involved using a mirror to attempt bimanual upper extremity movements. As a progression to this intervention, the patient closed his eyes and focused on somatosensory cues from the intact limb and residual cues from the affected one. As the patient's motor function began to improve, daily activities using the affected limb (forced use) were implemented. Outcome measures were grip strength, shoulder flexibility and time to complete common daily tasks (e.g.. pick up a pen, fold a towel into quarters etc). Following this progressive regimen, the patient improved in all these areas and was better able to use his affected hand in daily activities, such as dressing and inserting a key in a lock with greater precision and ease of movement.

• Stevens J.A., Stoykov P.M.E. (2003). Using motor imagery in the rehabilitation of hemiparesis. Arch Phys Med Rehabil, 84(7), 1090-2.PEDro Score: Not ratable
  Country: USA

  Two individuals with post-stroke upper limb hemiparesis, 14 months post-stroke (patient #1) and 6 years, 2 months post-stroke (patient #2) received a motor imagery training program: imagining movements of the wrist (extension, pronation, supination) and receiving mental stimulations of reaching as well as manipulating objects using a mirror box apparatus (the patient sits perpendicular to a mirror and watches their non-paretic arm move through space, while using the mirror to imagine that it is their paretic arm that is moving). This one hour training program was done 3 times per week for 4 consecutive weeks. The outcome measures include two standardized clinical assessments ( Fugl-Meyer Upper Extremity Motor Function Test, arm and hand dimension of the Physical Impairment Inventory of the Chedoke-McMaster Stroke Assessment), grip strength, wrist movement and 3 standardized measures of wrist functionality (Jebsen Test of Hand Function: light object, Jebson: heavy object, Jebson: card turning). Both patients showed an improvement (no p value indicated) in the performance of their paretic limb after the intervention, with patient #1 showing greater improvement. These improvements for both patients remained stable at 3 months follow-up.

• Sütbeyaz S., Yavuzer G., Sezer N., Koseoglu B. F. (2007). Mirror Therapy Enhances Lower-Extremity Motor Recovery and Motor Functioning After Stroke: A Randomized Controlled Trial. Arch Phys Med Rehabil, 88, 555-559.PEDro Score: 7
  Country: USA

  40 patients, mean age 63.5, within 12 months post stroke were recruited and randomized to one of two treatment groups. The mirror group (n=20) underwent non-paretic ankle dorsiflexion movement (while viewing a mirror image of the non-paretic limb in a mirror placed on the mid-sagittal plane and imagining it to be the paretic limb that was moving) in conjunction with standard rehabilitation. The control group (n=20) underwent standard rehabilitation in conjunction with a placebo version of the mirror treatment described above, where the mirror treatment was the same except that the unreflective side of the mirror was used. The treatments were carried out through a period of 4 weeks with a follow-up at 6 months (both real and placebo mirror treatments were 30 minutes per day, and standard therapy was 5 days per week, 2-5 hours per day). Assessments at baseline, 1 month (post-treatment) and 6 months (follow-up) were obtained on lower-extremity motor recovery as measured by the Brunnstrom stages, on motor function as measured by the Functional Independence Measure, on spasticity as measured by the Modified Ashworth Scale, and on walking ability as measured by the Ambulation Categories. At 1 month, patients showed significant improvements in all categories and continued to improve to follow-up. Statistical analysis for between-group differences was only provided for improvement from baseline to follow-up (6 months). At follow-up the mirror therapy group showed significantly more improvement compared to the control group according to the Brunstrom lower limb stages (p=.002) and the Functional Independence Measure score (p=.001). No significant between-group differences in improvement were found for spasticity (measured by the Modified Ashworth Scale, p = .102) or walking abilities (measured by the Functional Ambulation Categories, p = .620).

• Yavuzer G., Selles R., Sezer N., Sütbeyaz S., Bussmann J.B., Köseoglu F., Atay M.B., Stam H.J.(2008). Mirror Therapy Improves Hand Function in Subacute Stroke: A Randomized Controlled Trial. Arch Phys Med Rehabil, 89, 393-398.PEDro Score: 8
  Country: Turkey

  40 patients, mean age 63.2, within 12 months post stroke were recruited and randomized to one of two treatment groups. The mirror group (n=20) participated in non-paretic side wrist and finger flexion and extension movements (while viewing a mirror image of the non-paretic limb in a mirror placed vertically between hands) in conjunction with standard rehabilitation. The control group (n=20) underwent standard rehabilitation in conjunction with a placebo version of the mirror treatment described above, where the mirror treatment was the same except that the unreflective side of the mirror was used. The treatments were carried out through a period of 4 weeks with a follow-up at 6 months (both real and placebo mirror treatments were 30 minutes per day, and standard therapy was 5 days per week, 2-5 hours per day). Assessments at baseline, 1 month (post-treatment) and 6 months (follow-up) were obtained on hand and upper-extremity motor recovery as measured by the Brunnstrom stages, on hand related function as measured by the self-care items of the Functional Independence Measure, and on spasticity as measured by the Modified Ashworth Scale. Immediately following treatment, patients who received mirror therapy in addition to conventional therapy showed significant improvement in scores of the Brunnstrom stages for the hand and upper extremity as well as in the FIM self-care score ( all p<.01). The above measures also showed statistical significance in favour of the mirror group for between-group differences measured from post treatment to 6 months follow-up (all p <.05). No significant between-group differences in improvement were found at either measured time for spasticity (p=0.925 - 4 weeks, p= 0.875 - 6 months follow up)

• Info taken directly from http://www.medicine.mcgill.ca/strokengine/module_mirror_summary-en.html