Content uploaded by Susy M Braun
Author content
All content in this area was uploaded by Susy M Braun
Content may be subject to copyright.
SPIEGELTHERAPIE
Praxisleitfaden Neurologie
L
E
I
T
F
A
D
E
N
Johanna Genius
Saskia Roß
Sarah Uhr
Susy Braun
Andreas Rothgangel
Pflaum Verlag
www.physiotherapeuten.de
C
MIRROR THERAPY
Practical Protocol for Stroke Rehabilitation
Andreas Rothgangel
Susy Braun
P
R
O
T
O
C
O
L
2
EDITORIAL
Preface
The main reason to develop a practice-based protocol was because mirror therapy is still inconsistently used in clinical situations and
many physical and occupational therapists expressed a strong need for some form of guidance to structure therapy and support imple-
mentation of mirror therapy in routine care. As in most protocols, evidence based practice was the starting point: Evidence from literatu-
re, clinical experience from therapists and patient preferences* were taken into account to determine the content and select the examples.
As in almost all specific rehabilitation interventions, effect sizes for mirror therapy are still relatively small and new evidence might
overturn existing evidence. Mirror therapy should therefore be considered as one of several therapy interventions within a rehabilitation
programme where other interventions can be offered as well, or sometimes may even be preferred.
The present protocol should be seen as a framework, not a predefined recipe for all patients. Within the protocol the basic principles
and many examples of how to apply mirror therapy are given. The framework however leaves enough room for the therapist to adjust the
protocol and tailor it to the abilities and preferences of his / her patient. This way the clinical experience and the preferences of therapists
are incorporated in the protocol as well, making it easier to use the protocol in everyday practice. A critical mind is of course still requi-
red.
The first version of this protocol for mirror therapy was developed by Andreas Rothgangel and Susy Braun together with students of
Zuyd University of Applied Sciences (Heerlen, The Netherlands) as part of their physiotherapy bachelor thesis in 2011. The protocol was
published in the German Journal of Physical Therapy in 2012. Since then the protocol has been updated, expanded, restructured and trans-
lated into English. New evidence and experiences have been incorporated into this second version. Also, the content has been restructu-
red with two overview figures being added. The protocol is now presented in the order a professional would need to start providing mir-
ror therapy in everyday practice.
We hope that this protocol facilitates the tailored treatment of patients after stroke with mirror therapy in everyday care.
Andreas Rothgangel & Susy Braun July 2013
* A group of twelve german occupational and physical therapists and three stroke patients was interviewed.
Acknowledgment
We would like to thank the students who were involved in the first drafts of this protocol. All therapists and patients involved in the deve-
lopmental stage of the protocol should be acknowledged: Thank you for sharing your experiences and thoughts with us. Many thanks to
Frank Aschoff and Dr. Annie McCluskey for making this project happen.
Suggested citation: Rothgangel AS, Braun SM. 2013. Mirror therapy: Practical protocol for stroke rehabilitation.
Munich: Pflaum Verlag. doi: 10.12855/ar.sb.mirrortherapy.e2013 [Epub]
Available online at: www.physiotherapeuten.de/epub
This work was supported by the State of North Rhine-Westphalia (NRW, Germany) and the European Union through the NRW Ziel2 Pro-
gram as a part of the European Fund for Regional Development.
Content
Introduction Page 3
Chapter I: General requirements Page 4
Chapter II: First therapy session Page 7
Chapter III: Training of motor function Page 10
Chapter IV: Neglect Page 13
Chapter V: Spasticity, Sensation and Pain Page 13
Chapter VI: Facilitating unsupervised training Page 15
© Copyright 2013
by Richard Pflaum Verlag GmbH & Co. KG: München
Translation of the original ‚Praxisleitfaden Neurologie’
© Copyright 2012 by Richard Pflaum Verlag GmbH & Co.
KG: München
Publishing and editing_Frank Aschoff
Photos_Johanna Genius, Saskia Roß, Sarah Uhr
Composition_Manfred Huber
Final English editing_Dr. Annie McCluskey, The Univer-
sity of Sydney, Australia
3
INTRODUCTION
Stroke is a major cause of limitations in the everyday acti-
vities of patients, often leading to dependency on long-
term care (1). In particular, recovery of upper limb func-
tion is challenging (2, 3). Currently there is limited evi-
dence that specific treatment methods are more effective
than others. However, we do know that treatments should
include high-intensity, repetitive tasks-specific and goal-
oriented practice with feedback on performance (4). Seve-
ral treatment strategies have emerged during the last few
years that try to incorporate these elements, such as cons-
traint induced movement therapy, mental practice and
mirror therapy (4). First applied in patients with phantom
limb pain following amputation (5), mirror therapy was
soon used to treat hemiparesis in stroke patients (6).
The principle of mirror therapy is simple: When looking
into the mirror, the patient observes the reflection of the
unaffected limb positioned as the affected limb. When
performing motor or sensory exercises with the non-affec-
ted limb, the reflection in the mirror is often perceived as
the affected, paretic limb. This strong visual cue from the
mirror can therapeutically be used to improve motor per-
formance and the perception of the affected limb (7, 8).
Recently a Cochrane Review (8) was published that indi-
cated evidence for the effectiveness of mirror therapy in
improving upper limb motor function in stroke patients.
The effects of mirror therapy have mainly been related to
the activation of mirror neurons, which may also be acti-
vated when observing others perform movements and
during mental practice of motor tasks (9, 10). In addition,
activation of brain areas that are associated with enhanced
self-awareness, spatial attention and recovery from
neglect such as the superior temporal gyrus have been
shown to be activated by mirror therapy (11–13).
Despite emerging evidence regarding the effectiveness
of mirror therapy in stroke patients, one systematic
review (7) has shown that many variations in treatment
protocols for mirror therapy still exist, such as the type of
movement performed. For example, patients have been
instructed to move the unaffected limb only (14–16) or
both limbs in a synchronized manner, as much as possible
(17–20). Additionally, therapists have supported the
movements of the affected limb in one study (21). The cur-
rently available evidence does not allow any firm conclu-
sions on which of these treatment characteristics are more
effective. The fact that variations in treatment protocols
exist led to the development of this practical protocol that
could help implementation of mirror therapy in routine
care. Besides published evidence, substantial parts of this
protocol reflect the opinion and experience of a group of
therapists. This protocol was specifically designed to faci-
litate quick and easy orientation, allowing therapists to
get a general idea about the basic approach when using
mirror therapy following stroke.
The protocol is structured as follows: First, guidance is
provided about selecting and treating eligible patients.
Next, the content of the first treatment session is described
in detail, followed by examples of exercises that can be
used in subsequent therapy sessions. Finally, ways of faci-
litating unsupervised training and relevant literature are
provided.
Introduction
Notes: The emphasis of this practical protocol is on arm and hand training as evidence is stronger for upper limb
mirror therapy. However, the principles described in this protocol also apply to the lower limb. The examples are
given to show the scope of application possibilities.
4
Characteristics that are important when choosing eligible
patients are first described, followed by treatment aims
and how the circumstances and materials can be chosen in
relation to the goals of treatment. Finally, we describe dif-
ferent intervention characteristics that should be conside-
red before starting treatment.
Patient characteristics
The following patient characteristics are important to con-
sider when choosing patients for this kind of treatment.
These characteristics were derived from clinical experien-
ce of therapists and the selection criteria used in publis-
hed studies (7, 8).
Motor abilities
The available evidence does not provide clear advice or
guidance about who to select for mirror therapy based on
the level of motor ability or severity. In one study (18) it
was suggested that mirror therapy is more effective for
stroke patients with severe paresis or even a flaccid upper
limb. Other studies (7, 8) and clinical experience suggest
that patients with better motor ability also benefit from
the treatment.
Cognitive abilities
Eligible patients should have sufficient cognitive and ver-
bal abilities (e.g. attention, working memory and concen-
tration) to focus at least for ten minutes on the mirror
reflection and follow instructions given by the therapist.
Patients with severe neuropsychological deficits such as
severe neglect or apraxia are less suitable for mirror the-
rapy. Given the fact that many patients in the acute phase
have limitations in cognitive abilities, one might argue
that mirror therapy is less applicable in this stage after
stroke. However, the optimal starting point of mirror the-
rapy after stroke is unclear; the same applies to the phase
of recovery in which mirror therapy is the most effective.
We do know that after the occurrence of stroke most reco-
very takes place within the first six to twelve months (3).
Most of the studies on mirror therapy were conducted in
patients within this time frame after stroke (7, 8). Howe-
CHAPTER I: GENERAL REQUIREMENTS
ver, some cases are reported in which improvement of
motor functions was also achieved after severeal years
post-stroke (17).
Vision
In case of visual impairments (e.g. hemianopsia), thera-
pists should determine if a patient can see a clear image of
the entire limb in the mirror. Patients with visuospatial
neglect should be able to turn their head towards the mir-
ror image when asked to do so and keep their attention
focused on the mirror image at least for five to ten minu-
tes.
Trunk control
Patients should have sufficient trunk control to be able to
sit unsupervised in a wheelchair or a normal chair for the
duration of the treatment.
Cardiopulmonary function
Patients with cardiopulmonary abnormalities, who are
not able to sit for the duration of the therapy, are not eli-
gible for this kind of treatment.
Non-affected limb
The non-affected limb should ideally have a normal and
pain free range of motion. Severe constraints of the non-
affected limb (e.g. range of motion, pain) could hamper
execution of mirror therapy exercises.
Treatment aims
The existing evidence (7, 8, 22) supports the positive
effects of mirror therapy in stroke patients on the follo-
wing domains:
• Improving motor function and ADLs
• Reducing pain
• Reducing neglect
• Reducing sensory impairment
Effects on spasticity have not yet been established in clini-
cal studies, but clinical experience from participating the-
rapists suggests that mirror therapy may help with the
short-term reduction of spasticity in patients with stroke.
Chapter I: General requirements
5
CHAPTER I: GENERAL REQUIREMENTS
Informing the patient
Before the first session, patients should be sufficiently
instructed about the background and aims of mirror the-
rapy as well as possible side effects of the treatment. Fur-
thermore, patients should be able to engage in this kind of
treatment and that they will be asked to imagine that the
mirror image is their affected limb. There are indications
that the intensity or vividness of the “mirror illusion” may
predict the outcomes of the treatment (23). For this reason,
jewellery and other visual marks should be removed to
make it easier for the patient to perceive the reflection as
their affected limb when looking into the mirror. Patients
should have realistic expectations with respect to the
improvements that are achievable by using mirror thera-
py. They should be made aware of the importance of con-
tinuous, frequent training and self-management.
Possible negative side effects
The mirror image of two intact limbs can evoke emotional
reactions (24). Other reactions like dizziness, nausea or
sweating can be triggered in individual patients when
observing the mirror reflection. In such cases, patients are
instructed to no longer look into the mirror but to focus on
the unaffected limb or another point in the room. The mir-
ror can be pulled away a little from the patients’ body, so
that only a part of the affected limb (e.g. the hand) is cove-
red by the mirror. Patients should then be instructed to
observe the mirror image only over a short period of time
and then turn their gaze away towards the unaffected
limb. This procedure should be repeated several times,
until the side effects resolve.
Environment and required materials
Surroundings
As stated before, patients need to have sufficient attention
and concentration when using mirror therapy, which
implies that at least during the first sessions the environ-
ment should be free of other stimuli that attract the
patients’ attention. For the same reason at least the first
sessions should be delivered individually instead of in a
group, especially in easily distracted patients.
Jewellery and other marks
The mirror image has to match with the perception of the
affected limb in order to facilitate an intense mirror illu-
sion. This means that jewellery should be removed from
both limbs before starting the treatment as far as it hinders
the patient when looking into the mirror. The same
applies to other visual marks on the non-affected limb
such as birth marks, scars or tattoos that should be cove-
red if they prevent a vivid image (e.g. with a plaster, glove
or make-up).
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 (fig. 1). A size of 25
x 20 inches for the upper limb and at least 35 x 25 inches
for the lower limb should be large enough for everyday
usage.
There are mirrors available made of different materials
(glass, foil, acrylic glass). When choosing a mirror one
should pay attention to the following aspects:
• It should provide a coherent mirror image without any
noteworthy distortion.
• There should be no risk of injury, e.g. through the edges
of the mirror.
Fig. 1_Example of a mirror used for mirror therapy
6
CHAPTER I: GENERAL REQUIREMENTS
Exercise materials
Besides objects that are needed for functional motor trai-
ning (e.g. cups, towels) materials with more sensory input
can be used, especially in patients with impairments in
body perception (fig. 2), like:
• Plastic bowl or tubs filled with sand or peas
• Hedgehog ball
• Temperature stimuli (warm, cold)
• Different brushes
• Washing up gloves
• Sand paper
Treatment characteristics
Frequency of therapy & duration of sessions
The available literature (7, 8) recommends performing
mirror therapy at least once daily with a minimum dura-
tion of ten minutes. The maximum duration of each ses-
sion is dependent on the cognitive abilities of the indivi-
dual patient and / or negative side effects, but in most
cases will be around 30 minutes (7, 8). It is also possible to
split one session into two shorter sessions of 10 to 15
minutes with a short break in between, if the patient’s
abilities do not allow longer sessions. A daily treatment
session using mirror therapy will be beyond the possibili-
ties in many clinical settings. In such cases, patients will
require instruction about unsupervised training using the
mirror as early as possible, to enhance treatment intensity.
The unguided training can be monitored using logs
(fig. 12, p. 16 and appendix).
Fig. 3_Positioning of the non-affected arm in front of the mir-
ror
Fig. 2_Exercise materials used for mirror therapy
Fig. 4_Diagonal positioning of the mirror in a patient with
neglect of the left side of the body
7
CHAPTER I: GENERAL REQUIREMENTS / CHAPTER II: FIRST SESSION
Position of affected limb
The affected limb should be positioned on a height adju-
stable table so that its position can be adjusted to the
length of the patient’s trunk and arm. The affected limb is
situated in a safe and preferably comfortable position
behind the mirror. In case of severe muscle spasticity, pre-
liminary manual mobilization may be necessary and help-
ful before positioning the limb.
Position of non-affected limb
The patient should try to facilitate a vivid “mirror illu-
sion” (mirror image perceived as the affected limb) by
matching the position and image of the non-affected limb
to the affected side. For example, the non-affected limb
should be positioned in a similar position as the affected
limb, as this facilitates the intensity of the mirror illusion.
Position of the mirror
Generally, the mirror is positioned in front of the patient’s
midline, so that the affected limb is fully covered by the
mirror and the reflection of the unaffected limb is comple-
tely visible (fig. 3). In the case of visuospatial neglect or
severe muscle spasticity in the affected limb, the position
of the mirror can be adjusted in such a way that it points
more diagonally towards the unaffected limb (fig. 4). The
important point when adjusting the position of the mirror
is to assure that the mirror image still matches with the
perception of the affected limb.
Chapter II: First therapy session
After patients have been informed about the background
and aims of treatment, basic assessment on the different
domains of the International Classification of Functions (25)
takes place, followed by positioning of the affected limb and
the mirror on the table. The unaffected limb should take up
a position similar to that of the affected limb.
Visual illusion
Next, patients are instructed to observe the mirror reflec-
tion for one to two minutes, trying to visualize the mirror
image as the affected limb. Additionally, patients can be
instructed to imagine looking through a window instead
of a mirror, to enhance the vividness of the mirror illusion.
The therapist can use bilateral, synchronous stimulation
(e.g. tactile) to further facilitate the mirror illusion. The
first exercises can start when the patient indicates that
he / she perceives the mirror image as the affected limb.
Treatment approach in relation to the aim
After the first exercises on establishing a vivid mirror illu-
sion the subsequent treatment approach is chosen accor-
ding to the individual treatment aim. Generally, corre-
sponding to the aim of the treatment, clinical experience
has shown that the basic treatment approaches shown in
figure 5 are useful. Based on experience, the approach
used for improving motor function seems more tailored to
the individual client, depending on the vividness of the
mirror image and type of motor performance. Contrary to
the more tailored approach used for improvements in
motor function, the treatment approach used for impro-
ving neglect, muscle tone, sensation or pain is more stan-
dardized.
Depending on the capacity of an individual patient to
process information, the amount of stimuli must be adap-
ted (fig. 6). For example, in patients with hypersensitivity
or pain after stroke, the amount of stimuli applied to the
affected limb should be minimized. The latter implies that
motor and sensory stimuli are applied to the non-affected
limb only; the intensity of these stimuli should be adapted
to the individual’s pain threshold.
8
CHAPTER II: FIRST SESSION
Fig. 5_Treatment approach in relation to the aim
Potential
candidate
“mirror therapy
treatment”
Not eligible or
reconsider mirror
therapy treatment
after 4-6 weeks
Determine
treatment aims
inform patient
Ensure optimal
circumstances for
therapy and
select materials
Focus on:
Basic exercises
Functional
movements
Focus on:
Observation of
different posi-
tions
Bilateral sensory
stimuli
Focus on:
Unilateral motor
exercises with
non-affected
limb
Focus on:
Bilateral sensory
stimuli &
movements
Focus on:
Unilateral motor
& sensory
exercises with
non-affected limb
Tailored treatment
More dependent on:
• vividness of image
• motor performance
Standardized treatment: More pre-defined protocols
Motor
function Neglect Tone Sensibility Pain
Aims,
environment,
materials
Participation
related
Yes
Cognition
Vision
Trunk control
Cardiopulmunary
stability
Condition non-
affected limb
No
9
CHAPTER II: FIRST SESSION
First therapy session
“mirror therapy
treatment”
More tailored More standardized
Involvement of
body sides:
Exercises with one
or both limbs
Movement
performance:
Passive, guided or
active
Sensory input:
Use of (which)
materials, use of
manual facilitation
Determine: treatment duration & frequency
Treatment
Content /
Approach
Aim Neglect, Tone, Sensibility, Pain
Motor function
Fig. 6_Amount of stimuli used depending on abilities and preferences of the individual patient
Amount of stimuli
10
CHAPTER III: TRAINING OF MOTOR FUNCTION
Step 3: Identifying the basic approach
Clinical experience suggests that the way movements are
executed by the patient (tab. 1) should be based on the
intensity or vividness of the mirror illusion. Therefore, the
vividness of the mirror illusion should be evaluated after
the first exercise has been executed (step 2). Each option
for movement execution is repeated up to 15 times. After
all options have been performed, the patient decides
together with the therapist which exercise best facilitates a
vivid mirror illusion. This option for movement execution
Figure 7 gives an overview of
the different steps taken
when mirror therapy is used
to improve motor function.
Step 1: Choosing an appropriate
motor exercise
Over the first two to three
weeks, therapists generally
start with simple exercises
like flexion and extension
movements of the fingers,
wrist and elbow (fig 8). This
is also the case in patients
with a flaccid limb. In princi-
ple all degrees of freedom of
the joints may be addressed.
Most common is to start with
the range of motion that can
also be achieved in the affec-
ted side, slowly increasing
the range and the complexity
of the movements (“sha-
ping”). Remember to apply the basic principles of motor
learning: a high number of repetitions combined with
variation of the movement performance.
Step 2: Execution of motor exercise
After the first exercise has been agreed upon, it can be
visually or verbally demonstrated in the unaffected side
with assistance of the therapist. Then the patient executes
the movement according to the different options shown in
table 1.
Chapter III: Training of motor function
Step IV:
Functional tasks
with objects
Step I:
Choose basic motor
exercise according
to available
functions of affected
limb
Step II & V:
Execution of motor
exercise or task
(active, passive,
guided)
-> Tab. 1
Step III & VI:
Choose type of
exercise performance
according to vividness
of mirror illusion
(= basic approach)
Fig. 7_Overview and step-by step approach when training motor function
Tab. 1_Options for movement execution (7)
Motor exercises without an object Motor exercises with an object
Unilateral movements of the non-affected arm only Unilateral movements of the non-affected arm with an object
Bilateral movements (“as good as possible”) Bilateral movements with an object only in the non-affected side
Guiding of the affected arm by the therapist Bilateral movements without objects on both sides (imagining the
objects)
Guiding of both arms by the therapist (fig. 9) Bilateral movements with guidance of the affected arm by the
therapist (with or without an object at the affected side)
11
CHAPTER III: TRAINING OF MOTOR FUNCTION
will sequentially be used for the next motor exercises. The
complexity of these motor exercises depends on the seve-
rity of the paresis. All movements should be executed
very slowly, as this facilitates the intensity of the mirror
illusion.
Step 4: Using functional tasks
After this first phase consisting of basic exercises, additio-
nal functional tasks with different objects (e.g. cups, woo-
den blocks or balls) can be integrated into the treatment
program.
Step 5: Execution of functional tasks
Again the therapist should first identify the best way to
execute the individually chosen functional task (with
object, Tab. 1). The different options for movement execu-
tion are performed according to the method described
above (step 3).
Step 6: Identifying the basic approach
The basic approach used for training functional tasks also
depends on the vividness and intensity of the mirror illu-
sion. After all options have been performed, again, the
patient decides together with the therapist which one faci-
litates a vivid mirror illusion most.
First, simple functional movements can be performed,
like the sliding of an object over a surface (fig. 10). More
complex movements, like grasping, carrying and placing
of a cup in another position, can first be divided into
easier movement parts. These parts or movement compo-
nents are practiced repeatedly in isolation before grouped
together again into an entire skill or activity (26).
Structure of exercises in the case of moderate to
mild paresis
If the patient has moderate to mild paresis, the therapist
may also choose to start mirror therapy with the simple
Fig. 8_Simple exercises
Fig. 9_Facilitating bilateral movements by the therapist
12
CHAPTER III: TRAINING OF MOTOR FUNCTION
basic exercises. Unlike the more severe paresis the com-
plexity of exercises can be increased more quickly in these
patients. As these patients will also benefit from other
active functional interventions like forced-use (27), we
leave it up to the judgment of the therapist to which extent
he/she wants to use mirror therapy in this specific target
population. One option would be to use the mirror in the
context of constraint induced movement therapy as a pre-
paration tool: Functional exercises are rehearsed in front
of the mirror using the non-affected arm only. The patient
watches the performance in the mirror closely. Then, the
exercise is repeated with the affected arm only, this time
not using the mirror (principle of movement observation).
Fig. 10_Functional training with objects
13
CHAPTER IV: NEGLECT / CHAPTER V: SPASTICITY, SENSATION AND PLAIN
treatment protocol by Dohle et al. (18) can be used, which
means that different positions are coded with numbers.
During mirror therapy treatment only numbers will be
used by the therapist after which the correct position is
assumed and observed. In addition bilateral sensory sti-
muli can be used as soon as a new position is taken.
Alternatively, positions can be demonstrated by the the-
rapist and then imitated by the patient. After this initial
phase of imitating positions the therapist can start with
adding movement training to the basic exercises (see
chapter III).
When treating patients with neglect one should consider
its extent. The neglect should not be so severe that
patients cannot face the mirror if asked to do so. The mir-
ror can be placed in a slightly diagonal position to facili-
tate looking into it because this way the patient does not
need to turn his / her head that far (fig. 4, p. 6).
Structure and content of therapy
The limbs are positioned in front of the mirror. First,
directed by the instructions of the therapist, the patient
will set his / her arm or leg in different positions. The
Chapter IV: Neglect
pattern of spasticity. In addition, several positions of
loosened postures of the non-affected side can be obser-
ved in the mirror.
Facilitating sensation
In addition to motor exercises (see chapter III) bilateral,
synchronous sensory stimuli are now increasingly being
used. Patients should observe in the mirror the materials
which may be applied like brushes (fig. 2).
Additionally, patients can feel and describe different
materials such as sandpaper. The mirror may contribute
to increases in sensation of stimuli on the affected side.
Pain syndromes after stroke
Potential syndromes and situations in which mirror thera-
py can be applied to reduce pain include the thalamic
stroke syndrome or complex regional pain syndrome (14,
15). The latter should not primarily be caused by periphe-
ral pathologies, like subluxation of the shoulder.
The affected limb should be positioned as comfortably
as possible before treatment. To avoid aggravating the
pain, motor and sensory exercises are carefully performed
with the non-affected limb only (fig. 11). The sensory sti-
Reducing spasticity
Mirror therapy appears anecdotally to have a positive but
short-term influence on spasticity. However, these effects
often last only for a short period because spasticity often
increases as the patients become more active. In order to
regulate spasticity the affected arm is positioned on a
table. In case of extremely high tone it might be necessary
to first reduce the stiffness manually to enable an arm
position on the table. After that the mirror is positioned,
and the non-affected arm is placed in a similar position
to the affected arm. This is the starting point for the
therapy session and the instructions of the therapist
(tab. 2). Movements are performed with the non-affected
side only, using movements directed opposite to the
Chapter V: Spasticity, Sensation and Pain
Tab. 2_Exercise instructions aimed at spasticity
reduction
Patient Therapist
Performs movements with
unaffected side only.
Observes relaxed postures
in the mirror.
The therapist gives visual
and / or verbal instructions
about the movement perfor-
mance without guidance of
the affected side.
muli are first provided to pain free areas before applying
these stimuli to the more painful regions on the non-affec-
ted side (tab. 3).
General therapy suggestions
Please take the following suggestions into account when
applying a mirror therapy intervention:
• Start with basic exercises and continue with more com-
plex functional tasks in a later stage.
• Tailor the exercises to the patient’s individual perfor-
mance level.
14
CHAPTER V: SPASTICITY, SENSATION AND PLAIN
Fig. 11_Application of
sensory stimuli to the
non-affected side
• Try to aim for as high a number of repetitions as possi-
ble (at least 15 reps per exercise), at the same time inclu-
ding variations of separate exercises with regard to
range of motion, direction and starting position.
• Vary the exercises.
• Pay close attention to a slow movement performance
(“slow motion”).
• The length of a single session depends on the abilities of
the patient. If necessary, incorporate sufficient breaks.
• Check the gaze direction of the patient regularly in the
mirror and give feedback about the exercise perfor-
mance.
Ending therapy sessions
At the end of a therapy session patients should be prepa-
red for viewing their affected limb again when the mirror
is removed. If it helps the patient, some of the earlier per-
formed exercises can be repeated without the mirror.
Often patients can observe some improvement immedia-
tely after the therapy session already. The entire treatment
should be evaluated with appropriate measurement
instruments.
Tab. 3_Exercise instructions for patients with pain
syndromes after stroke
Patient Therapist
Performs unilateral move-
ment exercises with the
pain free non-affected
limb; in addition sensory
stimuli are applied to the
non-affected limb.
Gives verbal instructions on
the movement exercises
and desensitizes the non-
affected limb with a varie-
ty of sensory stimuli.
15
CHAPTER VI: FACILITATING UNSUPERVISED TRAINING
As soon as possible, patients should be instructed to perform unguided training. Once patients have understood the
exercises and are able to perform mirror therapy without the guidance of a therapist, self-directed treatment should be
initiated. In order to facilitate unguided mirror therapy it is useful to give written instructions (information sheet) and
to ask patients to keep a log on their progress. An example of a mirror therapy log is given below (fig. 12).
Chapter VI: Facilitating unsupervised training
Mirror therapy – important recommendations for patients (information sheet)
nConsult your therapists or doctor when you are using mirror therapy and ask for feedback when you are un-
sure if you are performing the exercises correctly.
nThe illusion in the mirror should be as realistic as possible. Therefore – if possible – take off all jewellery which
is visible in the mirror (rings, watch).
nImportant: Adjust the intensity of the exercises with regard to speed and range of motion depending on un-
pleasant sensations (e.g. pain) you might be experiencing. You may also want to vary exercises or change to
another kind of exercise. You should always practice below your pain threshold. Neither during practice nor
afterwards should you experience more pain than usual.
nMirror therapy is more likely to be successful if you practice regularly. You should therefore try to perform
your mirror therapy exercises at least once a day for at least 10 minutes.
nWhen starting with mirror therapy you should perform your exercises in a quiet surrounding to avoid distrac-
tion as much as possible.
nThe affected body side / limb should be hidden by the mirror while you are practising.
nIt is essential that you concentrate on your arm or leg in the mirror during the entire time you are practising.
Try to imagine that the reflection of your non-affected limb in the mirror actually is your affected limb. In most
cases the exercises will be more beneficial the more vivid or realistic your imagination is.
nTry to avoid looking at your non-affected limb during practice.
nPerform the movements slowly and with focus. The longer the symptoms have been existing, the slower you
should proceed.
nUse a log to record your exercise progress: How often and for how long have you performed which exercises?
What effect does the mirror therapy have on your complaints? Are there any unintended side effects?
When to stop mirror therapy?
A minimum duration of five to six weeks of continuous mirror therapy
treatment should be performed in order to evaluate possible effects of the
treatment. The total duration of the treatment depends on how long impro-
vements in functions are perceived by the individual patient and / or the
therapist or to which extend the patient thinks that the treatment is benefi-
cial. The treatment should be stopped in case of persistent negative side
effects or if unguided training only is sufficient.
For your consideration: Mirror therapy
can be used together with other cog-
nitive treatments such as mental
practice or limb laterality recogni-
tion (26, 28, 29). Mental practice
could be facilitated by using the mir-
ror image or audio tapes.
LITERATURE
1. Johnson SC, Mendis S, Mathers CD. 2009. Global variation in stroke
burden and mortality, estimates from monitoring, surveillance, and
modeling. Lancet Neurol 4: 345-54
2. Mercier L, Audet T, Hebert R, Rochette A, Dubois MF. 2001. Impact
of motor, cognitive, and perceptual disorders on ability to perform
activities of daily living after stroke. Stroke 11: 2602-8
3. Kwakkel G, Kollen BJ, van der Grond J, Prevo AJ. 2003. Probability
of regaining dexterity in the flaccid upper limb: impact of severity
of paresis and time since onset in acute stroke. Stroke 9: 2181-6
4. Langhorne P, Coupar F, Pollock A. 2009. Motor recovery after stro-
ke: a systematic review. Lancet Neurol 8: 741-54
5. Ramachandran VS. 1994. Phantom limbs, neglect syndromes,
repressed memories, and Freudian psychology. Int Rev Neurobiol
37: 291-333
6. Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn
DM, Ramachandran VS. 1999. Rehabilitation of hemiparesis after
stroke with a mirror. Lancet 353 (9169): 2035-6
7. Rothgangel AS, Braun SM, Beurskens AJ, Seitz RJ, Wade DT. 2011.
The clinical aspects of mirror therapy in rehabilitation: a systematic
review of the literature. Int J Rehabil Res 1: 1-13
8. Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. 2012. Mirror the-
rapy for improving motor function after stroke. Cochrane Database
Syst Rev. 14; 3: CD008449
9. Buccino G, Solodkin A, Small SL. 2006. Functions of the mirror neu-
ron system: implications for neurorehabilitation. Cogn Behav Neurol
19: 55-63
10. Filimon F, Nelson JD, Hagler DJ, Sereno MI. 2007. Human cortical
representations for reaching: mirror neurons for execution, obser-
vation, and imagery. Neuroimage 37: 1315-28
11. Matthys K, Smits M, Van der Geest JN, Van der Lugt A, Seurinck R,
Stam HJ, Selles RW. 2009. Mirror-induced visual illusion of hand
movements: a functional magnetic resonance imaging study. Arch
Phys Med Rehabil 90: 675-681.
12. Michielsen ME, Smits M, Ribbers GM, Stam HJ, Van der Geest JN,
Bussmann JB, Selles RW. 2011. The neuronal correlates of mirror
therapy: an fMRI study on mirror induced visual illusions in patients
with stroke. J Neurol Neurosurg Psychiatry 82, 4: 393-8
13. Dohle C, Stephan KM, Valvoda JT, Hosseiny O, Tellmann L, Kuhlen T,
Seitz RJ, Freund HJ. 2011. Representation of virtual arm movements
in precuneus. Exp Brain Res. 208, 4: 543-55
16
CHAPTER VI: FACILITATING UNSUPERVISED TRAINING
P
R
O
T
O
C
O
L
L
E
I
T
F
A
D
E
N
Pf la u m V er la g
www.physiotherapeuten.de
Name:
Mirror therapy log
Week ___
Exercises for this week:
1
2
3
4
5
6
P
R
O
T
O
C
O
L
Fig. 12_Mirror therapy log (26) ( ⇒appendix)
L
E
I
T
F
A
D
E
N
P
R
O
T
O
C
O
L
Evaluation of mirror therapy
When
did you
practise
(time of
day)?
How long
did you
practise
(minutes)?
Which
exercise did
you practise
(number)?
How vivid was the mirror
illusion?
0: poor 10: excellent
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Comments:
Monday, ___-___-______
How are you feeling today?
17
Authors of this practical protocol “mirror therapy for patients after stroke”
ANDREAS ROTHGANGEL.
Physiotherapist, MSc, PhD student; epidemiologist 2006 (MSc), physiotherapist since 2002 (Bac./NL);
since 2009 lecturer at Zuyd University of Applied Sciences in Heerlen, the Netherlands; since January
2011 PhD project “Telerehabilitation, mirror therapy and phantom limb pain”; member of the “Rese-
arch Centre Autonomy and Participation for patients with a chronic illness” at Zuyd University and
department of rehabilitation medicine at Maastricht University, the Netherlands; clinical experience:
neurological rehabilitation, clinical gait analysis. Contact: andreas.rothgangel@zuyd.nl
SUSY BRAUN.
Movement scientist and physiotherapist, PhD, MSc; since 1994 movement scientist (Diplom-Sportlehre-
rin, Deutsche Sporthochschule Köln, Cologne, Germany), since 1997 physiotherapist (Zuyd University of
Applied Sciences, Heerlen, Netherlands); since 1998 lecturer at Zuyd University; since 2004 researcher
at the Research Centre Autonomy and Participation for patients with a chronic illness; since 2010 rese-
arch fellow at Maastricht University, research programme “Innovations in Health Care for the Elderly”;
2010 PhD defence “Motor learning in neurorehabilitation”. Contact: susy.braun@zuyd.nl
14. Cacchio A, De Blasis E, De Blasis V, Santilli V, Spacca G. 2009a. Mir-
ror therapy in complex regional pain syndrome type 1 of the upper
limb in stroke patients. Neurorehabil Neural Repair 23: 792-9
15. Cacchio A, De Blasis E, Necozione S, Di Orio F, Santilli V. 2009b. Mir-
ror therapy for chronic complex regional pain syndrome type 1 and
stroke. N Engl J Med 361: 634-6
16. Sutbeyaz S, Yavuzer G, Sezer N, Koseoglu BF. 2007. Mirror therapy
enhances lower-extremity motor recovery and motor functioning
after stroke: a randomized controlled trial. Arch Phys Med Rehabil
88: 555-9
17. Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn
DM, Ramachandran VS. 1999. Rehabilitation of hemiparesis after
stroke with a mirror. Lancet 353: 2035-6
18. Dohle C, Pullen J, Nakaten A, Kust J, Rietz C, Karbe H. 2009. Mirror
therapy promotes recovery from severe hemiparesis: a randomized
controlled trial. Neurorehabil Neural Repair 23: 209-17
19. Yavuzer G, Selles R, Sezer N, Sutbeyaz S, Bussmann JB, Koseoglu F et
al. 2008. Mirror therapy improves hand function in subacute stroke:
a randomized controlled trial. Arch Phys Med Rehabil 89: 393-8
20. Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. 2013. Mir-
ror therapy for patients with severe arm paresis after stroke – a ran-
domized controlled trial. Clin Rehabil. 27, 4: 314-24
21. Rothgangel AS, Morton A, Van den Hout JWE, Beurskens AJHM.
2004. Phantoms in the brain: mirror therapy in chronic stroke
patients; a pilot study. Ned Tijdschr Fys 114: 36-40
22. Doyle S, Bennett S, Fasoli SE, McKenna KT. 2010. Interventions for
sensory impairment in the upper limb after stroke. Cochrane Data-
base Syst Rev. 2010 Jun 16; 6: CD006331
23. Foell J, Bekrater-Bodmann R, Diers M, Flor H. 2011. Cortical effects
and multisensory integration in mirror therapy for phantom limb
pain. Eur J Pain Suppl 5: 242
24. Casale R, Damiani C, Rosati V. 2009. Mirror therapy in the rehabili-
tation of lower-limb amputation: are there any contraindications?
Am J Phys Med Rehabil 88: 837-42
25. World Health Organization. 2001. International Classification of
Functioning, Dis ability and Health (ICF). Geneva: World
Health6Organization
26. Braun S, Kleynen M, Schols J, Schack T, Beurskens A, Wade D. 2008.
Using mental practice in stroke rehabilitation: a framework. Clin
Rehabil. 22, 7: 579-91
27. Peurala SH, Kantanen MP, Sjögren T, Paltamaa J, Karhula M, Heino-
nen A. 2012. Effectiveness of constraint-induced movement therapy
on activity and participation after stroke: a systematic review and
meta-analysis of randomized controlled trials. Clin Rehabil. 26, 3:
209-23
28. Bowering KJ, O'Connell NE, Tabor A, Catley MJ, Leake HB, Moseley
GL, Stanton TR. 2013. The effects of graded motor imagery and its
components on chronic pain: a systematic review and meta-analysis.
J Pain 14, 1: 3-13
29. Moseley GL. 2006. Graded motor imagery for pathologic pain: a ran-
domized controlled trial. Neurology 67, 12: 2129-34
P
R
O
T
O
C
O
L
L
E
I
T
F
A
D
E
N
Pflaum Verlag
www.physiotherapeuten.de
Name:
Mirror therapy log
Week ___
Exercises for this week:
1
2
3
4
5
6
P
R
O
T
O
C
O
L
L
E
I
T
F
A
D
E
N
P
R
O
T
O
C
O
L
Evaluation of mirror therapy
When
did you
practise
(time of
day)?
How long
did you
practise
(minutes)?
Which
exercise did
you practise
(number)?
How vivid was the mirror
illusion?
0: poor ➔10: excellent
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Comments:
Monday, ___-___-______
How are you feeling today?
L
E
I
T
F
A
D
E
N
P
R
O
T
O
C
O
L
Evaluation der Übungen
When
did you
practise
(time of
day)?
How long
did you
practise
(minutes)?
Which
exercise did
you practise
(number)?
How vivid was the mirror
illusion?
0: poor ➔10: excellent
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Comments:
Tuesday, ___-___-______
How are you feeling today?
L
E
I
T
F
A
D
E
N
P
R
O
T
O
C
O
L
Evaluation der Übungen
When
did you
practise
(time of
day)?
How long
did you
practise
(minutes)?
Which
exercise did
you practise
(number)?
How vivid was the mirror
illusion?
0: poor ➔10: excellent
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Comments:
Wednesday, ___-___-______
How are you feeling today?
L
E
I
T
F
A
D
E
N
P
R
O
T
O
C
O
L
Evaluation der Übungen
When
did you
practise
(time of
day)?
How long
did you
practise
(minutes)?
Which
exercise did
you practise
(number)?
How vivid was the mirror
illusion?
0: poor ➔10: excellent
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Comments:
Thursday, ___-___-______
How are you feeling today?
L
E
I
T
F
A
D
E
N
P
R
O
T
O
C
O
L
Evaluation der Übungen
When
did you
practise
(time of
day)?
How long
did you
practise
(minutes)?
Which
exercise did
you practise
(number)?
How vivid was the mirror
illusion?
0: poor ➔10: excellent
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Comments:
Friday, ___-___-______
How are you feeling today?
L
E
I
T
F
A
D
E
N
P
R
O
T
O
C
O
L
Evaluation der Übungen
When
did you
practise
(time of
day)?
How long
did you
practise
(minutes)?
Which
exercise did
you practise
(number)?
How vivid was the mirror
illusion?
0: poor ➔10: excellent
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Comments:
Saturday, ___-___-______
How are you feeling today?
L
E
I
T
F
A
D
E
N
P
R
O
T
O
C
O
L
Evaluation der Übungen
When
did you
practise
(time of
day)?
How long
did you
practise
(minutes)?
Which
exercise did
you practise
(number)?
How vivid was the mirror
illusion?
0: poor ➔10: excellent
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Comments:
Sunday, ___-___-______
How are you feeling today?
