Mirror therapy has become one of the more recent innovations in nonpharmacological pain management for neuropathic pains including phantom limb pain and complex regional pain syndrome.
This guide is based on clinical practice, rather than pure experimental design. It’s based on practical observation during clinical sessions. As a result, it combines findings from research with the practical aspects that therapists might face in a real clinical setting.
Mirror therapy doesn’t necessarily need to be carried out in a purpose-built mirror box, although there are some advantages in terms of weight and portability if a collapsible mirror box is used (like those available at NOI Australia).
Firstly, it’s important to discuss the rationale and aims for this type of therapy with the person experiencing pain. Unlike the majority of coping strategies I mention in this blog, mirror box therapy aims to reduce pain by fooling the brain into adjusting sensory feedback via vision. As a result of this therapy, it is hoped that the neural representation of the affected part of the body will return to normal, thus reducing the experience of pain. Some people find their pain is substantially reduced from the outset of therapy, while others have less positive responses, and it may even be important for the therapy to stop because of adverse reactions.
When focusing on pain reduction, it’s important to remember that many people find it difficult to think about using pain management strategies at the same time. So it may be that this therapy is used at the beginning of your time working with an individual – then turn to pain management once the person has achieved what he or she can from mirror therapy.
OK, on to the practical parts.
Firstly, position the mirror so that the person’s unaffected limb can easily be seen.
It’s helpful to make sure the affected limb is not visible at all and is resting comfortably.
Then place the unaffected limb in a neutral position and ask the person to look at it in the mirror. What they should see is their unaffected limb reflected in the mirror so that it looks like it is the opposite (affected) limb. Make sure they don’t move either limb at this stage. While they are looking at the reflected limb at rest, ask them to notice what is happening in their affected limb. Some people may notice a weird sensation, some may find their pain changes – it may increase or decrease, or they may experience some other change to the sensation such as tingling or ‘zapping’. Allow them to fully experience any sensations without moving either limb for as long as they feel comfortable, but for a maximum of 5 – 10 minutes.
If they feel no change, or pain reduction, they may begin moving the unaffected limb slowly into different positions while leaving the affected limb in a resting position. Once again, ask them to notice what is happening in their affected limb. Allow them to experience any sensations without moving the affected limb but moving the unaffected limb as long as they feel comfortable for a maximum of 5 – 10 minutes. Most people find that if they experience any change to their pain (reduction or alteration) they become quite fatigued. If they become fatigued, their pain can increase once the mirror is removed.
The next gradation is to move both the affected and the unaffected limbs into the same positions while watching the mirror. As before, allow them to experience any sensations while moving both limbs into the same positions as long as they feel comfortable for a maximum of 5 – 10 minutes.
The final gradation is to move the unaffected limb into different positions from the affected limb, while watching the affected limb in the mirror. Tolerance to this in many people without pain problems is limited – so be careful and don’t exceed more than 5 – 10 minutes even when no changes to sensation are experienced.
Exposure to movement in the mirror needs to be closely monitored and calibrated to ensure excessive increases to pain after exposure is not experienced. While some increase in pain is expected – especially when the affected limb is involved in active movement – it’s important not to experience increased pain for more than 24 hours. The optimal frequency of exposure has not yet been determined – ‘as often as can be tolerated’ is not really a helpful guide! Many people find that two or three mirror sessions of about 5 – 10 minutes each day is sufficient for them to see progress without adverse effects. If adverse effects such as swelling or significantly increased pain occurs for more than 24 hours, the time spent in mirror therapy should be reduced, or the level of exposure can be stepped back. Some exacerbation of the condition is to be expected however.
I am in some dilemma about mirror therapy – the risks of using pain reduction as a goal, and pain exacerbations as a guide are well-known, and it takes a great deal of care to ensure that the person does not learn to avoid fluctuations of pain and develop fear/anxiety and avoidance of pain or harm. Because of this, I recommend that active coping strategies to reduce physiological arousal are introduced at the same time as mirror therapy. I also recommend that the person is given specific information about the need to tolerate fluctuations of pain during the therapy. Alongside mirror therapy, visualised movements (in hypnosis or not), and actual movements should also be carried out – but any actual movements are usually at a lower level than those being carried out in mirror therapy.
There will come a time when either the person’s pain has completely gone, or they plateau, or even have no positive response, and it therapy should stop. This is something to review on a regular basis – mirror therapy can be time consuming, intrude on normal activity, and impede other aspects of rehabilitation, so it’s not something that should be continued ad infinitum. If there is little or no change after a month or so of mirror therapy, and at any time when mirror therapy exacerbates pain for more than 24 hours even when the unaffected limb is only at rest, mirror therapy should probably be stopped.
Please remember the above description is not based on strong empirical studies! Use your own clinical judgement and keep reviewing the literature!
References: – only a few from the many!
Acerra, N. E., & Moseley, G. L. (2005). Dysynchiria: watching the mirror image of the unaffected limb elicits pain on the affected side.[see comment]. Neurology, 65(5), 751-753.
Eisenberg, E., Chistyakov, A. V., Yudashkin, M., Kaplan, B., Hafner, H., & Feinsod, M. (2005). Evidence for cortical hyperexcitability of the affected limb representation area in CRPS: A psychophysical and transcranial magnetic stimulation study. Pain, 113(1-2), 99-105.
Eisenberg, E., Chistyakov, A. V., Yudashkin, M., Kaplan, B., Hafner, H., & Feinsod, M. (2005). Evidence for cortical hyperexcitability of the affected limb representation area in CRPS: a psychophysical and transcranial magnetic stimulation study.[see comment]. Pain, 113(1-2), 99-105.
Moseley, G. L. (2004). Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain, 108(1-2), 192-198.
Wilder, R. T. (2006). Management of pediatric patients with complex regional pain syndrome. Clinical Journal of Pain, 22(5), 443-448.
Filed under: Chronic pain, Clinical reasoning, Cognitive behavioral therapy, therapy | Tagged: Chronic pain, coping, CRPS, mirror, occupational therapy, phantom limb, physiotherapy, therapy
[...] Practical Mirror Therapy for Pain Relief [...]
I’m very glad to see you have posted about this remarkable therapy. I use it very successfully and have observed some things that may help you.
Research by Dr Lorimer Moseley suggests value in doing guided visualization, limb laterality recognition (noi has a program “Recognize” that supports this, and mirror visual feedback.
I move only my better side and only for a matter of seconds not minutes. I repeat several times during a day. Doing a little and often lessens the chance of causing pain which is counterproductive. I try and make the experience different by adding things like different temperature (fan on fan off), chewing something, music or other sounds, different smells (maybe aromatherapy oils) etc. Matthias Weinberger wrote in an email “The brain needs to be reminded over and over again – but by doing short “training sessions” habituation doesn’t set in and the movement is always new and interesting.” Here is a link to his wonderful site.
http://www.neurotopian.blogspot.com/
I now know if mirror therapy dosn’t seem to help then I am not doing it correctly so if it doesn’t work don’t abandon it but examine what you are doing. In my case usually I find I am not focusing on exactly the right spot or area. When I change it is very effective.
Finally let me tell you mirror therapy is so effective that I stopped the acute pain of a tooth abscess which returned when I stopped mirror therapy. I kept this up for a few months. This was unwise. If pain returns when you stop mirror therapy it is wise to look for a cause.
Mirror therapy works. I have gone from intractable whole body CRPS/RSD to manageable flare ups in 12 months.
However the most important thing is physical therapy. It really is a case of use it or lose it.
jeisea
http://www.crps-rsd-a-better-life.blogspot.com
Thanks for your visit and comments Jeisea. It’s always great to hear of someone who finds a helpful therapy.
My only caution about the laterality suggestion is that so far I haven’t found a lot of peer-reviewed evidence to support it in clinical use, although theoretically it has some promise. So far there is no published normative on the ‘Recognise’ programme, so we can’t tell whether someone with a certain score shows impairment of recognition, and neither is there any predictive data to suggest that better scores over time predict reduction in CRPS symptoms. So while it might be helpful for some people, we don’t have sufficient data to know whether it works for many, nor the characteristics of those it does help. But I watch and wait with interest – anything that is demonstrated to help will be useful to add to our repertoire.
There is certainly support for visualisation in, for example, sports (golf swing! tennis serve!), dance, musical instrument playing etc. You have to really work on visualisation, and really see or feel yourself doing the movements – although some people find this very hard, especially if they’re not particularly visual or kinaesthetic.
With the duration of exposure to mirror therapy, each person will find the optimal length of time to use the mirror. My preference when working with people is to begin at a lower level of exposure, but for longer – partly this is to offset any initial increased physiological arousal (we wait for the arousal level to drop which reduces the learned avoidance of activity that is part of the CRPS problem. Take a look at Johan Vlaeyen and colleagues CRPS exposure treatment – de Jong, J. R., Vlaeyen, J. W. S., Onghena, P., Cuypers, C., den Hollander, M., & Ruijgrok, J. (2005). Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo. Pain, 116(3), 264-275.).
Frequency is really important also, but we need to balance the interference that this type of therapy has on everyday activity against the benefits. If a mirror is portable, and it’s possible to repeat the exposure many times through the day – great! Go for it! But if you can’t, then longer but lower level exposure is still useful.
Habituation is exactly what we want in this type of therapy – we are trying to normalise the pathways that have been disrupted, so by repeating the exposure we are reinforcing the normal neurological links. I think maybe it’s good to continue adding in novelty and fun because this helps to generalise the new learning, reduce negative arousal and if something is boring it’s going to be more difficult to keep doing it!
Hi again,
As a sufferer of CRPS/RSD not a therapist I can only tell you what happens with me. I developed CRPS after a wrist fracture in 1998. wasn’t diagnosed till late 200 and ended up with whole body problems including disautonomia with loss of consciousness. I tried mirror therapy myself at home working out what made sense to me after reading about it on the internet August 2006. I had no knowledge of limb laterality. Mirror therapy worked for me but there was no instant result. I just persisted. I’ve found by doing a little and often it does not break into my day.
I was given recognize by my physiotherapist as I have a significant left/right problem. I found the results were significantly worse when I had greater pain so there was never a possibility of establishing a base line and working towards improvement. I also feel for me the issue appears to be one of time. It isn’t that I can’t decide left or right but that the more pain/less sleep I have the longer it takes me and the program has a time limit. Cards would have been more suitable for me.
On the issue of habituation, I do the same exercise repeatedly. What is different is the sensory inputs doing this repeated task. The idea being that the brain gets a fresh set of inputs whilst having the same visual input so the visual stimulus is habitual while the inputs are fresh retraining that this movement is ok in a variety of situations. Moseley & Butler’s “Explain Pain” talks about doing the same movement but in different ways. I have photos on my blog of doing a raised arm movement standing, then lying over a bench or lying on the floor. This isn’t mirror therapy but a way of reinforcing the “it’s ok” message.
As Neurotopian says when mirror therapy stops pain it’s gone. I have completely stopped chronic pain from many “itises” I’ve been diagnosed with eg planta fasciitis, morton’s neuroma, achillies tendonitis and more. The pain is gone and unless I do something to irritate the foot, leg etc, the pain stays away. For a long time I would swing from one more severe pain to severe pain in another spot. Over time I gradually calmed the system by calmly dealing with each pain and moving on to the next. Last December I had 2 days with a break form major pain. After that weeks passed and another break. Over the year the time between major flare ups has extended with the longest being 3 weeks. I now have confidence that I’m winning the battle but it’s been hard work. What I have is a belief in this new science and determination to regain what I have lost.
I would like to post about your new website and give the link.
I am also happy to answer any questions you may have.
Jeisea
http://www.crps-rsd-a-better-life.blogspot.com
You make some really good points there Jeisea – especially about varying the inputs (including emotions). From a psychological point of view what you’re doing is generalising the learning from one situation to another – because brains are quite good at being specific about where learning occurs, particularly when it’s about something like pain. In evolutionary terms this makes really good sense – we don’t really want to learn to be scared of everything that looks like a hairy spider, just hairy spiders! But once we’ve learned an association especially one that is about fear or disgust, it is very difficult to unlearn it, which is why if you don’t quickly use the new skills in different contexts, it can return with a vengeance. This is particularly true with phobia’s of any type – and to a certain extent, fear of pain (or dislike of pain) is a sort of phobia. More about that in another future post of mine!
The left/right problem may well be part of the reason people get CRPS in the first place (maybe laterality never developed?) but until we have some normative data,that is, we know what the majority of people get on a particular test, we can’t tell whether a score is more or less like the majority of people – we can only tell what you got and what progress you’ve made. So it’s not a diagnostic process yet. My daughter for example does very poorly at the ‘recognise’ programme, as do I – but neither of us have CRPS. Maybe, given the right set of circumstances, we would develop CRPS, but we don’t really know what predicts people who are at greater risk of developing it.
I question whether you have to ’suffer’ CRPS – experiencing is essential, but suffering is about the emotional distress we have alongside the sensation. I think I can choose whether I suffer or whether I simply experience a sensation including pain. Again I’ll post on this shortly. I’d prefer, as a person who experiences fibromyalgia, to be know as ‘having’ fibro, rather than ’suffering’.
Anyway, I’m glad to see you have had some periods of time without pain, it’s great – my role in pain management is to help people live in the periods when they don’t have pain-free time, because although there are many therapies that do reduce pain, there are many people who don’t experience pain relief and want to live despite the pain.
It would be a pleasure to have you post about my website, I’m enjoying cybermeeting people this way!
Bronnie
You are right about the laterality program. I know a medical professional with crps who scores perfectly and two others with no pain who score poorly.
There are some known predisposing factors. Here’s a link to what I posted about this. Let me know if this link doesn’t work for you.
http://www.blogger.com/posts.g?blogID=33458048&searchType=ALL&txtKeywords=&label=predisposing+factors+for+crps
Blogger: crps/rsd a better life – Manage Posts
Here is another link which might interest you about fibromyalgia. I do not have this problem.
http://www.medicalnewstoday.com/articles/87058.php
Fibromyalgia Pain Caused By Neuron Mismatch, Suggests Study
HTCwP gives a brief bio which, because the owner is a pain specialist, gives her “street cred” so to speak. Being a person who knows pain helps people relate.
I have a couple of websites to feature and then I’ll introduce yours. I’ll also pass your information to health news site owners I know. You may be aware from my site I encourage others not to look for what can be done for us, but rather what we do for ourselves as it is what we do for ourselves that empowers us.
Please email me if I can help you ever.
jisea
http://www.crps-rsd-a-better-life.blogspot.com
I see this is for sale on an Australian site. I would like to purchase this but it looks like it maybe used for the hand only. Do you have on that will work for an above knee amputee/ If you say this one will work-then how? I would greatly appreciate your help. I have endured 68 operations and have excrutiating phantom limb pain for 11 years. I am willing to try just about anything.
thanks
Hi snowgoer – no you can definitely use mirror therapy on lower limbs, and you don’t even need to purchase a purpose-built one! Just grab any old mirror and place it between your legs so you can see your remaining leg reflected in the mirror – and go from there. If this works for you, I would encourage you to contact a local physiotherapist who has a good understanding of phantom pain and can help you with a programme and/or put you in touch with other people who may be able to help.
All the very best for you with living with this very challenging pain problem.
Isn’t the issue of limb laterality recognition all about the habituation and learned response, rather than comparison to set of norms? For example over a period of several weeks ‘practice’ you would anticipate a participant to improve by both increasing accuracy and reducing speed.
The rate at which they learn (their personal improvement) helps provide an indicator as to how well they are able to manipulate these images (a diagnostic process), but also one forum in which they can rehearse and practise these skills.
This all falls down of course when you struggle with left and right (younger children) and potentially less computer confident adults (holding the ‘right’ key down and flicking through 20 images in 3 seconds!).
You are so right! The problem with laterality recognition is that programmes like ‘Recognise’ assume that people with CRPS are (1) less accurate in identifying laterality, and (2) slower to become more accurate, and (3) that improvement in laterality reflects somehow in functional improvement.
What isn’t clear is (1) whether people with CRPS are less accurate in identifying laterality, (2) whether they are slower to become accurate than others or (3) that improvement in limb recognition is correlated with functional improvement.
I would expect that anyone who rehearses a skill (such as left and right recognition) will improve with repeated exposure – that’s the basis of all learning. What I’m not so sure of is whether better recognition means anything in functional terms.
As a result, I’m not sure whether it’s useful to get someone to do this kind of practice with the aim to help them to improve their function – or whether it’s better to get them to do normal functional activities.
Thanks for your comment!
Is the aim of laterality work to directly improve function? That seems like a big ask. I wonder if it offers a way to initiate the required cognitive remodelling.
I’m sure physical exposure, particularly graded weight bearing work for both upper and lower limb conditions, will always be the cornerstone of successful rehab., and in more moderate cases is probably sufficient (hence successful resolution in cases managed in mainstream practice), but it is clearly too aggravating in isolation for some cases.
Perhaps Moseley’s work helps to identify some more ‘basic’ skill acquisition and foundations to allow the graded activity to be less aggravating and increase the chances of success.
Just a thought.
I’m not sure that it’s meant to directly improve function, but there should be some correlation between it and functional gains even if it’s a moderater – but I haven’t seen studies to demonstrate this. Do you know of any experimental evidence to demonstrate a relationship between recognition of laterality and cognitive remodelling (which could be an intermediate step)? I’m curious!
As far as graded exposure goes, I’m thinking less of physical exposure ie based on reduction of pain and more of guiding exposure based on cognitive constructs – eliciting what the person is fearful of, and developing an exposure hierarchy based on this. Perhaps it’s a terminology thing, I think of graded desensitisation as a term for the graded weightbearing and use of textures on the limb, whereas I think of graded exposure for where the activities are based on cognitive constructs.
Great discussion – keep it coming!
Just jumping in again here. My ability to recognize left/right is directly proportional to the amount of pain I’m in. Practice does not improve performance. So for me more pain means lower score. In fact I tried when I had a migraine and got my lowest score. So it is not just CRPS pain that affects this ability to recognize left right.
In my opinion it is not a case of can or cannot recognize left/right, it’s more a case of when in pain much more time is needed to process.
On the graded exposure side I believe the more we move, the more we normalize movement with the exception of over doing things. Expanding time and movement range and type build on the “ok” message.
jeisea
I have widespread fibromyalgia pain all over my body. Since I don’t have a “side” without pain, how might mirror therapy work for someone like me?
Tamra
Hi Tamra
As far as I know, there have been no studies looking at mirror therapy in fibromyalgia. I also have FM, and because it’s diffuse pain, because it’s about generalised central nervous system sensitivity, there are very few pain reduction approaches that have much effect. So far I think the only pharmacological option is either a tricyclic antidepressant, or maybe a membrane stabiliser like sodium valproate. If paracetamol is no help, and these other two types don’t work, then taking a pill is probably not the route to go to manage your pain.
Mirror therapy is specifically engaging your visual system to ‘trick’ your brain into recognising that the limb is intact and that the information it is receiving via nerves from the arm is incorrect. In fibromyalgia there is no specific side of the body or limb to ‘fool’ your brain with, so it’s not effective.
So far the best management of fibromyalgia appears to be cognitive behavioural therapy and a cognitive behavioural approach which usually includes relaxation, breathing and other physiological arousal techniques, cognitive therapy around thoughts and beliefs, goal setting, planning, and activity scheduling.
I hope this helps, and I’m sorry there is not much good news in terms of mirror therapy for you!
Bronnie
Hope you don’t mind another comment here.
I wonder if acupuncture, in particular Yamamoto New Scalp Acupuncture (possibly Chinese Scalp Acupuncture) could help fibromyalgia pain. The scalp acupuncture utilizes the cortical representation of the body in the brain just as mirror therapy or virtual reality therapy.
As all inputs affect the brain I also speculate that moving consciously correctly, in different ways and in different situations should also retrain the brain in a positive way. I don’t know much about fibro but wonderf if posture or movemnet is changed due to pain and discomfort. If so giving correct and positive feedback may help.
If interested in YNSA I have links to research to the left of my crps/rsd a better life blog. Google will find it.
Hi Jeisea
No problem at all! I don’t write about it because I haven’t seen any research around acupuncture, and what is there is either not directly about CRPS. Most studies on acupuncture have methodological problems because it’s difficult to ‘double-blind’ the providers in order to provide an effective control condition. The studies I have read haven’t provided strong evidence, and as a result I’m reluctant to suggest it on here. When there is good evidence I’ll be happy to report on it.