In mirror therapy, a mirror is placed in the client’s sagittal plane so the client cannot see the affected upper limb. The client watches in the mirror the movements made with the healthy limb and simultaneously tries to move the affected limb on the other side of the mirror. To explain why the reflection of the healthy limb in the mirror helps with the motor recovery of the affected limb, the current hypothesis is that the mirror neurons in the brain are activated during the imitation movements and interact simultaneously with the motor neurons.
Regarding the affective dimension, one of the main elements to consider is the client’s motivation to commit to the treatment process since it requires an almost daily investment of time. Mirror therapy is not recommended for clients who have a recent history of alcohol or drug abuse, severe depression or claustrophobia because these elements could interfere with the treatment.
Regarding the cognitive dimension, the key element is that the client must be able to follow instructions. Clients with cognitive disorders, aphasia, dementia, a mental health problem or attention deficit could have the therapy as long as these problems do not interfere with their understanding of the instructions and thus with the treatment for 30 minutes each day.
It is even more important to consider cognitive difficulties for clients who wish to have the therapy at home since they must be able to participate in self-directed treatment. This means they must not only be able to administer the therapy themselves, they must also be able to manage the treatment schedule, manage the material and how it is set up, keep their attention on the mirror without being reminded, self-correct, etc.
Clients with hemispatial neglect can have mirror therapy. Some studies exclude them from their research protocol but this is because their research objectives focus more specifically on the motor or functional recovery of the affected upper limb. Hemispatial neglect is excluded from their sample so that it cannot interfere with the expected results. Furthermore, clients who present severe hemispatial neglect and cannot turn their head on the contralateral side of the lesion upon request cannot have the therapy since they would not be able to keep their attention on the mirror.
Regarding the physical dimension, studies include both men and women, right- or left-handed, regardless of whether the affected side is the dominant side or not. The stroke may be ischemic or hemorrhagic with a cortical or subcortical lesion. Clients may present mild to severe hemiparesis as well as sensory deficits (paresthesia). They must be medically stable and able to maintain a sitting position throughout the treatment. Clients with vision impairments, apraxia and neurological disorders are usually excluded from studies for research purposes. Therefore, it is not known if mirror therapy is effective in the presence of these problems.
Mirror therapy is often given by occupational therapists and physiotherapists but any health professional can administer it.
It can also be given by a family caregiver or be self-administered following a brief explanation of how to do it and after receiving tools to do the therapy at home (user guide, written explanations, photos or videos of the movements to be done). It is important to do a regular follow-up (once a week) with clients doing the therapy at home, with or without the help of a family caregiver. The aim is to verify that the client is following instructions, understands the exercises and applies them correctly, is not making any compensating movements or taking the wrong position. The aim is also to vary the degree of difficulty, answer the client’s questions, etc. The follow-up can be done on the phone, at personal meetings, in a journal, etc. If the mirror therapy is done at home, it is important to consider the motivation of carers and the client to commit to the treatment.
If the hemiparesis is too severe and the client cannot reproduce with the affected side, simultaneously and as accurately as possible, the movements made with the healthy side, a therapist may be needed to guide or control the movements on the affected side passively. Hence it would be more difficult for such clients to do the therapy at home.
The person who administers the mirror therapy can stand in front of the client on the other side of the table. This person supervises the movements made on each side of the mirror and ensures that the client is really looking at the reflection of his/her healthy limb in the mirror.
How many weeks should mirror therapy last?
Between 3 and 6 weeks but most studies have a 4-week protocol.
How many times per week?
A minimum of 5 days per week.
How long does a mirror therapy session last?
A minimum of 30 minutes per day. This can be split into two shorter periods during the day.
What voluntary movements are done in front of the mirror?
- Flexion and extension of the shoulder
- Flexion and extension of the elbow
- Flexion and extension of the wrist
- Flexion and extension of the fingers
- Abduction and adduction of the shoulder
- Abduction and adduction of the fingers
- Internal and external rotation of the shoulder
- Pronation and supination of the forearm
- Ulnar and radial deviation of the wrist
- Circumduction of the wrist
What actions can be done in front of the mirror?
Some examples of actions:
- Squeeze and release the fist
- Open and close the hand
- Tap the fingers on the table
- Oppose (touch) each finger to the thumb one by one
- With the hand closed, try to lift each finger, including the thumb, one at a time
What tasks can be done in front of the mirror?
Some examples of tasks:
- Handle objects using different types of grips, for example, make small balls of theraplast or modeling clay with the fingers, turn a cylindrical object in the hand (complex rotation), pick up beads or paper clips, put clothes pegs on the lip of a mug, insert pegs in a board, etc.
- Grasp and release objects with different textures (balls, sponges, etc.)
- Pick up and move various objects (balls, sticks, cubes, mug, glass, etc.) in different directions, for example, move an object following a sequence of movements forming a square or an ‘X’, put a ball in a glass and take it out, lift a glass, lift a rectangular object, place beads or pegs in a container with a small opening, insert pegs in holes in a piece of wood, transfer grains of rice from one pot to another, manipulate rings, etc.
- Turn over playing cards
- Color, connect the dots to make a drawing, copy shapes on a piece of paper
- Use different shaped stamps with an ink pad
- Handle utensils
- Wipe, clean and dust the table with cloths with different textures (scouring pad, soft sponge, silk cloth, etc.)
How must the movements be done?
The movements in front of the mirror must be done simultaneouly on the affected and the non-affected side. This encourages bilateral use of the upper limbs. If the mirror therapy involves use of an object by the healthy upper limb, the affected upper limb must try to reproduce the movement as accurately as possible but without the object.
At what speed must the movements be done?
- The client can choose the speed of the movements.
- Some studies combining the mirror with electrical stimuli suggest that the voluntary movements are done in 5 or 10 seconds. The time the movements take must match the duration of the electrical stimuli.
- The emphasis should be on active movements in front of the mirror. Clients must try their best to make the same movements with their affected upper limb. According to some studies, assistance can be offered to make the movements with the affected upper limb passively, especially if the hemiparesis is severe. To date, there is no consensus regarding whether physical assistance interferes with the mirror therapy treatment.
- The desired movement may be demonstrated.
- The client can be given an instruction booklet containing written instructions, photos or videos of the movements, actions and tasks to be done, especially if the mirror therapy is done at home. A toolbox containing the material needed to use the mirror may also be offered or loaned to the client.
- The client can use a journal, especially if the therapy is done at home, as a tool to help with follow-up and to inform the therapists of the progress of the therapy (mirror therapy schedule, client’s experiences, exercises done, etc.).
Studies exploring mirror therapy have used different assessments to measure participants’ progress, including:
- Fugl-Meyer Assessment to measure motor recovery of the upper limb
- Brunnstrom Scale to measure the type of movement done
- Demeurisse Motricity Index for the upper limb to assess motor function
- Action Research Arm Test (ARAT) to measure specific changes in upper limb activity
- Functional Independence Measure (FIM)
There are no contraindications to using mirror therapy at the same time as other therapies. In fact, some studies combine training on specific tasks, bilateral use of the upper limbs and electrical stimuli with the use of mirror therapy.
Study participants have not reported any side effects. However, one study reported that some participants got bored during the therapy.
- The mirror is placed in the client’s midsagittal plane. The client must watch the reflection of his/her healthy limb in the mirror in order to simulate that the image is actually of the affected upper limb.
- Different materials can be used to build the structure of the mirror (wood, corrugated cardboard, plastic, etc.).
- The size of the mirror can vary between 12 in x 12 in and 28 in x 48 in. Its size depends on the types of movements to be done in front of the mirror.
- To ensure that the client cannot see it behind the mirror, the affected upper limb can be inserted in an enclosed box or the affected hand can be covered by a screen.
- One study designed a folding mirror that is easy to carry. The angle of the mirror is supported by velcro strips.
All jewelry and watches must be removed so that the illusion of the reflection is as credible as possible.
When is the best time to have mirror therapy?
In what settings can mirror therapy be used?
Mirror therapy can be used in different settings, including in the hospital (acute care), in-patient rehabilitation, out-patient rehabilitation and at home. The treatment setting varies with the client’s level of functional and socio-residential autonomy.
Mirror therapy can be done at home, self-administered or supervised by a family caregiver. However, clinical reasoning must be used before determining if a client is eligible.
Can mirror therapy be given in a group?
Mirror therapy can be given individually or in a group. However, including clients with attention deficits or hemispatial neglect in a group is not recommended because there is less progress in a group with respect to reducing hemispatial neglect.
Altschuler, E. L., et al. (1999). “Rehabilitation of hemiparesis after stroke with a mirror.” The Lancet 353(9169): 2035-2036.
Arya, K. N. and S. Pandian (2013). “Effect of task-based mirror therapy on motor recovery of the upper extremity in chronic stroke patients: a pilot study.” Topics in Stroke Rehabilitation 20(3): 210-217.
Cacchio, A., et al. (2009). “Mirror therapy for chronic complex regional pain syndrome type 1 and stroke.” New England Journal of Medicine 361(6): 634-636.
Cacchio, A., et al. (2009). “Mirror therapy in complex regional pain syndrome type 1 of the upper limb in stroke patients.” Neurorehabilitation & Neural Repair 23(8): 792-799.
de Almeida Oliveira, R., et al. (2014). “Mental practice and mirror therapy associated with conventional physical therapy training on the hemiparetic upper limb in poststroke rehabilitation: a preliminary study.” Topics in Stroke Rehabilitation 21(6): 484-494.
Dohle, C., et al. (2009). “Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial.” Neurorehabilitation & Neural Repair 23(3): 209-217.
Ezendam, D., et al. (2009). “Systematic review of the effectiveness of mirror therapy in upper extremity function.” Disability & Rehabilitation 31(26): 2135-2149.
Faralli, A., et al. (2013). “Noninvasive strategies to promote functional recovery after stroke.” Neural Plasticity 2013: 854597.
Invernizzi, M., et al. (2013). “The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial.” European journal of physical & rehabilitation medicine. 49(3): 311-317.
Kim, H., et al. (2014). “Effect of functional electrical stimulation with mirror therapy on upper extremity motor function in poststroke patients.” Journal of Stroke & Cerebrovascular Diseases 23(4): 655-661.
Kojima, K., et al. (2014). “Feasibility study of a combined treatment of electromyography-triggered neuromuscular stimulation and mirror therapy in stroke patients: a randomized crossover trial.” Neurorehabilitation 34(2): 235-244.
Lee, M. M., et al. (2012). “The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients.” American Journal of Physical Medicine & Rehabilitation 91(8): 689-696, quiz 697-700.
Lin, K. C., et al. (2014). “Combining afferent stimulation and mirror therapy for rehabilitating motor function, motor control, ambulation, and daily functions after stroke.” Neurorehabilitation & Neural Repair 28(2): 153-162.
Lisa, L. P., et al. (2013). “The effectiveness of different treatment modalities for the rehabilitation of unilateral neglect in stroke patients: a systematic review.” Neurorehabilitation 33(4): 611-620.
Michielsen, M. E., et al. (2011). “Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial.” Neurorehabilitation & Neural Repair 25(3): 223-233.
Nilsen, D. M. and T. DiRusso (2014). “Using mirror therapy in the home environment: a case report.” American Journal of Occupational Therapy 68(3): e84-89.
Pandian, J. D., et al. (2014). “Mirror therapy in unilateral neglect after stroke (MUST trial): a randomized controlled trial.” Neurology 83(11): 1012-1017.
Pollock, A., et al. (2014). “Interventions for improving upper limb function after stroke.” Cochrane Database of Systematic Reviews 11: CD010820.
Radajewska, A., et al. (2013). “The effects of mirror therapy on arm and hand function in subacute stroke in patients.” International Journal of Rehabilitation Research 36(3): 268-274.
Rothgangel, A. S., et al. (2011). “The clinical aspects of mirror therapy in rehabilitation: a systematic review of the literature.” International Journal of Rehabilitation Research 34(1): 1-13.
Samuelkamaleshkumar, S., et al. (2014). “Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial.” Archives of Physical Medicine & Rehabilitation 95(11): 2000-2005.
Sathian, K., et al. (2000). “Doing it with mirrors: a case study of a novel approach to neurorehabilitation.” Neurorehabilitation & Neural Repair 14(1): 73-76.
Shinoura, N., et al. (2008). “Mirror therapy activates outside of cerebellum and ipsilateral M1.” Neurorehabilitation 23(3): 245-252.
Stevens, J. A. and M. E. P. Stoykov (2003). “Using motor imagery in the rehabilitation of hemiparesis.” Archives of physical medicine and rehabilitation 84(7): 1090-1092.
Thieme, H., et al. (2012). “Mirror therapy for improving motor function after stroke.” Cochrane Database of Systematic Reviews 3: CD008449.
Thieme, H., et al. (2013). “Mirror therapy for patients with severe arm paresis after stroke–a randomized controlled trial.” Clinical Rehabilitation 27(4): 314-324.
Wang, J., et al. (2013). “Cerebral activation evoked by the mirror illusion of the hand in stroke patients compared to normal subjects.” Neurorehabilitation 33(4): 593-603.
Wu, C. Y., et al. (2013). “Effects of mirror therapy on motor and sensory recovery in chronic stroke: a randomized controlled trial.” Archives of Physical Medicine & Rehabilitation 94(6): 1023-1030.
Yavuzer, G., et al. (2008). “Mirror therapy improves hand function in subacute stroke: a randomized controlled trial.” Archives of Physical Medicine & Rehabilitation 89(3): 393-398.
Yun, G. J., et al. (2011). “The synergic effects of mirror therapy and neuromuscular electrical stimulation for hand function in stroke patients.” Annals of Rehabilitation Medicine 35(3): 316-321.
Author of this section: Rachel Hains MSc OT
Editor: Annie Rochette PhD