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Systematicreviewoftheeffectivenessofmirrortherapyinupperextremityfunction

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Systematic review of the effectiveness of mirror therapy in upper extremityfunctionDaniëlle Ezendam ab; Raoul M. Bongers a; Michiel J. A. Jannink bc

a Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen,Groningen, The Netherlands b Roessingh Research and Development, Enschede, The Netherlands c

Department of Biomechanical Engineering, University of Twente, Enschede, The Netherlands

First Published on: 20 May 2009

To cite this Article Ezendam, Daniëlle, Bongers, Raoul M. and Jannink, Michiel J. A.(2009)'Systematic review of the effectiveness ofmirror therapy in upper extremity function',Disability & Rehabilitation,99999:1,

To link to this Article: DOI: 10.1080/09638280902887768

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REVIEW

Systematic review of the effectiveness of mirror therapy in upperextremity function

DANIELLE EZENDAM1,2, RAOUL M. BONGERS1 & MICHIEL J. A. JANNINK2,3

1Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The

Netherlands, 2Roessingh Research and Development, Enschede, The Netherlands, and 3Department of Biomechanical

Engineering, University of Twente, Enschede, The Netherlands

Accepted March 2009

AbstractPurpose. This review gives an overview of the current state of research regarding the effectiveness of mirror therapy in upperextremity function.Method. A systematic literature search was performed to identify studies concerning mirror therapy in upper extremity. Theincluded journal articles were reviewed according to a structured diagram and the methodological quality was assessed.Results. Fifteen studies were identified and reviewed. Five different patient categories were studied: two studies focussed onmirror therapy after an amputation of the upper limb, five studies focussed on mirror therapy after stroke, five studiesfocussed on mirror therapy with complex regional pain syndrome type 1 (CRPS1) patients, one study on mirror therapy withcomplex regional pain syndrome type 2 (CRPS2) and two studies focussed on mirror therapy after hand surgery other thanamputation.Conclusions. Most of the evidence for mirror therapy is from studies with weak methodological quality. The present reviewshowed a trend that mirror therapy is effective in upper limb treatment of stroke patients and patients with CRPS, whereasthe effectiveness in other patient groups has yet to be determined.

Keywords: Mirror therapy, stroke, pain, amputation, upper extremity

Introduction

Presenting visual feedback about motor performance

to improve the effect of training is widespread in

rehabilitation practice. A relative new way of using

visual feedback to help patients is exploited in mirror

therapy. Ramachandran [1] first used mirror therapy

in patients who suffered from a phantom limb after

amputation. Patients who participated in these

experiments mainly experienced phantom arms that

were ‘paralysed’ or ‘frozen’ in an awkward and

sometimes painful position, i.e. the phantom arms

could not be moved voluntary by the patients. To

relieve these patients from awkward or painful

feelings they were given the idea that their ampu-

tated limb was still ‘alive’. To achieve this, a mirror,

which showed the reflection of the intact arm, was

placed in the sagittal plane. The mirror image of the

intact arm gives the patient the illusion the ampu-

tated arm is resurrected: Moving the intact limb and

looking at its reflection in the mirror produces visual

feedback of the whereabouts of an arm at the

location of the amputated arm. In this setup, some

amputees with a phantom arm reported that they felt

as though their phantom arm was moving. This

movement relieved some of the patients from the

awkward position and pain of their phantom arm. In

short, the visual feedback via the mirror gives the

illusion that the phantom arm is moving in response

to the brain’s command, suggesting that the

amputated arm is ‘alive’ again and can be moved

around [2].

On the basis of effect of visual feedback through a

mirror in patients with phantom pain, mirror therapy

was employed with more patient groups. The appeal

of mirror therapy lies therein that it provides some

Correspondence: Michiel J. A. Jannink, Roessingh Research and Development, PO Box 310, 7500 AH Enschede, The Netherlands. Tel: þ3153-48-75-738.

E-mail: m.jannink@rrd.nl

Disability and Rehabilitation, 2009; 1–15, iFirst article

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2009 Informa UK Ltd.

DOI: 10.1080/09638280902887768

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

kind of access to a body part that is otherwise not

accessible. For example, in the case of phantom pain

the mirror gave access to the phantom and with this

access the phantom could be put in a less awkward

position [3]. The fact that a phantom limb could be

acted upon through mirror therapy inspired several

researchers to look for more patient-groups with

which mirror-therapy might work. Pathological

conditions in which the patient could not get an

entrance to an affected body part, as is the case with

amputation, stroke, and pain syndromes, for in-

stance, were situations for which it might be expected

that mirror therapy could also work.

With the application of mirror therapy to these

different types of pathological conditions, each with

their own type of injury from which it emerges and

underlying type of disorder, the question arose

regarding the effectiveness of mirror therapy with

all these different types of patients. The current

article evaluated with which types of patients mirror

therapy was effective. This serves at least two

purposes: Information about the effectiveness of

mirror therapy is relevant for the clinical practice

because it can be determined for which patients this

therapy might work. Second, establishing the type of

patient groups with which mirror therapy is effective

should allow for a better understanding of the

underlying working mechanisms of mirror therapy.

Understanding the working mechanisms of mirror

therapy is useful in determining the (new) types of

patients for who mirror therapy might be helpful. To

examine the extend to which mirror therapy was

effective we performed a systematic analysis of the

literature into the effectiveness of mirror therapy in

upper extremity rehabilitation.

Method

Literature search

The following keywords were used to search the

electronical database PubMed (1970–2008): mirror

neuron, mirror therapy, nervous system diseases, upper

extremity, pain. An additional search was performed

using the following Keywords: cerebrovascular

accident, stroke. The search was limited to humans.

The search strategy that was used is presented in the

Appendix. In addition to searching the database also

the reference lists of relevant publications were

checked.

Study selection

The studies that were identified using the keywords

were independently assessed by two reviewers (D. E.,

M. J.). The following inclusion criteria were used to

include studies for the review:

. The study had to concern mirror therapy;

. The focus of the study had to be on the upper

extremity;

. The study had to be a full-length publication in

a peer-reviewed journal.

The reviewers decided, in a consensus meeting,

whether the studies should be included in the final

review. To enable the most complete view of the

current literature the search was not limited by

publication type or by patient group.

Methodological judgment

To assess the methodological quality of the

different papers a classification of study designs

as described by Jovell & Navarro-Rubio [4] was

used (Table I).

Data analysis

The included journal articles were reviewed accord-

ing to a structured diagram. The content of the

papers were scanned for: the diagnosis, subjects (n,

age, sex), side of lesion, time since injury, design

classification, baseline measurements, intervention,

outcome measurements and conclusions by the two

reviewers (D. E., M. J.). The data of these categories

were put into tables. Differences in opinion were

resolved by discussion.

Table I. Classification of study design as described by Jovell &

Navarro-Rubio [4]. This classification was used to assess the

methodological quality of the included papers.

Level

Strength of

evidence Type of study design

I Good Meta-analysis of randomised

controlled trials

II Large-sample randomised controlled

trials

III Good

to fair

Small-sample randomised controlled

trials

IV Nonrandomised controlled

prospective trials

V Nonrandomised controlled

retrospective trials

VI Fair Cohort studies

VII Case–control studies

VIII Poor Noncontrolled clinical series;

descriptive studies

IX Anecdotes or case reports

2 D. Ezendam et al.

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

Results

Study selection

The literature search identified 717 studies. Of these

717, 15 studies fulfilled the inclusion criteria and

were included for data extraction [3,5–18]. The main

reason to exclude studies was that these studies

didn’t involve the effects of mirror therapy, but

studied the mirror neuron system. One of the

included studies involves mirror therapy with

patients after an amputation of the upper extremity

[3]. One study involves mirror therapy with patients

who suffered from deafferentation pain following

amputation, partial spinal cord injury, brachial

plexus lesion or traumatic peripheral nerve lesion

[5]. Five studies involve the effects of mirror therapy

in stroke patients [6–10]. Six involve the effects of

the therapy in patients with complex regional pain

syndrome (CRPS) [11–16]; one of these six is about

CRPS type 1 patients and patients with phantom

limb pain following amputation or brachial plexus

avulsion [14], one concerns CRPS type 2 patients

[16] and the other four concern only CRPS type 1

patients. The last two studies involve mirror therapy

after hand surgery other than amputation [17,18].

The subject characteristics of the fifteen included

studies are summarised in Table II.

Amputation

The study characteristics (design classification, the

intervention, baseline/outcome measurements and

conclusions) of the studies focusing on upper limb

amputees are listed in Table III. The time since the

amputation in the study performed by Ramachan-

dran & Rogers-Ramachandran [3] differed from 19

days to 9 years. The treatment procedure for the 10

subjects differed among individuals. The patients

who suffered from a clenching spasm of the phantom

limb mainly used the mirror to unclench the arm and

to be relieved from pain. In four out of five patients

of the experimental group the clenching spasm could

be relieved by means of mirror therapy. Besides

relieving the clenching spasms Ramachandran &

Rogers-Ramachandran [3] also found some addi-

tional effects as a consequence of mirror therapy

including sensation referral. The intact hand was

touched, scraped or dipped into water while the

patients looked into the mirror. It appeared that

certain modalities of sensation (related to touching,

scraping, dipping and vibration) could be referred to

the phantom hand but that others could not

(temperature and pain). The control group existed

of four healthy subjects who did not have the same

experience as the experimental group. Different

outcome measurements were taken, such as kinaes-

thetic sensations, presence of ‘clenching spasm’ and

sensations in the phantom. Note that these outcome

measurements mainly focussed on sensory function

instead of motor function. The results presented in

this study are only descriptive and were not

statistically analysed. The study by Sumitani et al.

[5] involved deafferentation pain in patients after an

amputation, partial spinal cord injury, brachial

plexus lesion or traumatic peripheral nerve lesion.

This study used both upper and lower limb patients.

The time since the deafferentation pain differed from

2 weeks until 22 years. This study did not use a

control group and mirror therapy was applied in

addition to conventional interventions. The total

treatment period was different for each patient. The

mean duration was 20.4 weeks. Mirror therapy was

found to have a significant effect for reducing

deep pain.

Stroke

The study characteristics of the five studies that

involved mirror therapy with stroke patients are listed

in Table IV. Almost all studies used chronic stroke

patients (i.e. stroke occurred more than 6 months

before participation of the study) except for the study

by Yavuzer et al. [10] which also used subacute

stroke patients (i.e. stroke occurred more than 3

months prior to participation of the study). The time

since stroke was highly variable and ranged from

0.25 to 26.25 years for individual patients. Two of

the studies used mirror therapy as a part of a larger

therapy program [7,8].

In these five studies, 27 different outcome

measurements were taken. Six different standard

functional scales were used to assess the severity of

the motor deficit. There were three subjective

measurements undertaken: (a) Subjective comments

were obtained in the study of Altschuler et al. [6], (b)

Rothgangel et al. [9] undertook a process-evaluation

based on the reactions of the patients and the

observations of the physical therapists and, (c) they

also used the patient-specific method (‘Patient

Specifieke Klachten Schaal’ [severity of the main

complaint]) to get insight in the subjective percep-

tion of performing arm and hand activities. The

other outcome measures were used to assess

different single aspects of motor function (e.g. grip

strength, range of motion, movement times).

All studies showed a positive result of mirror

therapy. Altschuler et al. [6] concluded that mirror

therapy may be beneficial for at least some patients

with hemiparesis following stroke. The positive result

was based on a combination score given by two

neurologists and subjective comments. The score

Effectiveness of mirror therapy 3

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

Tab

leII

.S

ub

ject

char

acte

rist

ics

of

the

12

incl

ud

edst

ud

ies.

Au

tho

rsD

iagn

osi

s

Su

bje

cts

(n,

age

inye

ars

(mea

n+

s.d

.(r

ange)

),se

x)

Sid

eo

fle

sio

n

Tim

esi

nce

inju

ryin

year

s

(mea

n+

s.d

.(r

ange)

)

Am

puta

tion

Ram

ach

and

ran

&R

oger

s-

Ram

ach

and

ran

[3]

Up

per

lim

bam

pu

tees

Exp

erim

enta

lgro

up

:n¼

10

,

age¼

40

.60+

16

.85

(23–7

3),

sex¼

7m

,2

f,1

un

kn

ow

n

Exp

erim

enta

lgro

up

:5

left

,5

righ

tE

xp

erim

enta

lgro

up

:2

.43+

3.4

0

(0.0

5–9

.00

)

Co

ntr

ol

gro

up

:n¼

4,

age¼

un

kn

ow

n,

sex¼

un

kn

ow

n

Co

ntr

ol

gro

up

:h

ealt

hy

sub

ject

sC

on

tro

lgro

up

:–

Su

mit

ani

etal

.[5

]L

imb

amp

ute

es,

par

tial

spin

alco

rd

inju

ry,

bra

chia

lp

lexu

sle

sio

n,

trau

mat

icp

erip

her

aln

erve

lesi

on

n¼

22

,ag

e¼

48

.36+

16

.28

(17–

75),

sex¼

16

m,

6f

12

left

,10

righ

t4

.81+

7.4

8(0

.04

–2

2.2

7)

Str

oke

Alt

sch

ule

ret

al.

[6]

Ch

ron

icst

roke

pat

ien

tsn¼

9,

age¼

58

.22+

6.4

2(5

3–7

3),

sex¼

5m

,4

f

1le

ft,

8ri

gh

t4

.84+

8.1

8(0

.50

–2

6.2

5)

Sat

hia

net

al.

[7]

Str

oke

pat

ien

tw

ith

pro

fou

nd

sen

sory

defi

cits

con

tral

ater

alto

a

sub

cort

ical

infa

rct

n¼

1,

age¼

57

,se

x¼

m1

left

+0

.50

Ste

ven

s&

Sto

yko

v[8

]C

hro

nic

hem

ipar

esis

afte

rem

bo

lic

mid

dle

cere

bra

lar

tery

stro

ke

n¼

2,

age¼

76

&6

3,

sex¼

1m

,1

f1

left

,1

righ

t1

.16

,6

.16

Ro

thgan

gel

etal

.[9

]S

tro

ke

pat

ien

tsD

ayc

are

trea

tmen

tgr

oups:

Exp

erim

enta

lgro

up

:n¼

3,

age¼

73

(62–8

7)

(med

ian

),

sex¼

un

kn

ow

n

Dayc

are

trea

tmen

tgr

oups:

Exp

erim

enta

lgro

up

:0

left

,3

righ

t

Dayc

are

trea

tmen

tgr

oups:

Exp

erim

enta

l

gro

up

:1

.00

(0.7

5–1

.25

)(m

edia

n)

Co

ntr

ol

gro

up

:n¼

3,

age¼

80

(72–8

1)

(med

ian

),

sex¼

un

kn

ow

n

Co

ntr

ol

gro

up

:1

left

,2

righ

tC

on

tro

lgro

up

:1.0

0(0

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–1

.50

)

(med

ian

)

Clin

ical

reh

abilit

atio

ngro

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sC

lin

ical

reh

abilit

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up

sC

lin

ical

reh

abilit

atio

ngro

up

s

Exp

erim

enta

lgro

up

:n¼

5,

age¼

79

(49–8

7)

(med

ian

),

sex¼

un

kn

ow

n

Exp

erim

enta

lgro

up

:1

left

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righ

tE

xp

erim

enta

lgro

up

:0

.58

(0.2

5–1

.17

)

(med

ian

)

Co

ntr

ol

gro

up

:C

on

tro

lgro

up

:C

on

tro

lgro

up

:

n¼

5,

age¼

76

(73

–8

6)

(med

ian

),

sex¼

un

kn

ow

n

3le

ft,

2ri

gh

t0

.58

(0.4

2-2

.00

)(m

edia

n)

Into

tal

ther

ew

ere

6m

ales

and

10

fem

ales

ho

wd

ivid

edam

on

gth

e

gro

up

sis

un

kn

ow

n

(con

tinued

)

4 D. Ezendam et al.

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

Tab

leII

.(C

onti

nued

).

Au

tho

rsD

iagn

osi

s

Su

bje

cts

(n,

age

inye

ars

(mea

n+

s.d

.(r

ange)

),se

x)

Sid

eo

fle

sio

n

Tim

esi

nce

inju

ryin

year

s

(mea

n+

s.d

.(r

ange)

)

Yav

uze

ret

al.

[10

]S

tro

ke

Exp

erim

enta

lgro

up

:n¼

17

,

age¼

63

.2+

9.2

(49–8

0)

sex¼

9m

,8

f

Exp

erim

enta

lgro

up

:7

left

,1

0

righ

t

Exp

erim

enta

lgro

up

:0

.45+

0.2

4

(0.2

5–1

.00

)

Co

ntr

ol

gro

up

:n¼

19

,

age¼

63

.3+

9.5

(43

–7

9),

sex¼

10

m,

9f

Co

ntr

ol

gro

up

:8

left

,11

righ

tC

on

tro

lgro

up

:0.4

6+

0.2

1(0

.25

–1

.00

)

CR

PS

1

McC

abe

etal

.[1

1]

CR

PS

1n¼

8,

age¼

33

.00+

5.9

3(2

4–4

0),

sex¼

3m

,5

f

6le

ft,

2ri

gh

t1

.10+

1.1

1(0

.06

–3

.00

)

Mo

sele

y[1

2]

CR

PS

1E

xp

erim

enta

lgro

up

:n¼

7,

age¼

35

.00+

14

.74

(20–6

2),

sex¼

2m

,5

f

Exp

erim

enta

lgro

up

:4

left

,3

righ

tE

xp

erim

enta

lgro

up

:0

.97+

0.3

5

(0.6

3–1

.67

)

Co

ntr

ol

gro

up

:n¼

6,

age¼

38

.17+

13

.79

(18–5

6),

sex¼

2m

,4

f

Co

ntr

ol

gro

up

:4

left

,2

righ

tC

on

tro

lgro

up

:1.2

5+

0.3

6(0

.82

-1.6

9)

Kar

mar

kar

&L

ieb

erm

an[1

3]

CR

PS

1n¼

1,

age¼

63

,se

x¼

fri

gh

tu

nkn

ow

n

Mo

sele

y[1

4]

CR

PS

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nse

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ence

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uta

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ry

Exp

erim

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up

:n¼

25

,

age¼

41

.04+

14

.10

(18–6

2),

sex¼

10

m,

15

f

Exp

erim

enta

lgro

up

:1

6le

ft,

9

righ

t

Exp

erim

enta

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up

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.15+

0.8

2

(0.0

8–2

.50

Co

ntr

ol

gro

up

:n¼

25

,

age¼

41

.08+

13

.68

(20–6

1),

sex¼

8m

,1

7f

Co

ntr

ol

gro

up

:1

2le

ft;

13

righ

tC

on

tro

lgro

up

:1.0

1+

0.6

6(0

.08

–2

.17

)

Tic

hel

aar

etal

.[1

5]

CR

PS

1n¼

3,

age¼

23

,4

2,

46

,se

x¼

1m

,

2f

2le

ft,

1ri

gh

t2

.50

,0

.67

,9

.00

CR

PS

2

Sel

les

etal

.[1

6]

CR

PS

2n¼

2,

S1¼

36

year

s,fe

mal

e

S2¼

33

year

s,fe

mal

e

S1¼

righ

th

and

atw

rist

leve

l,

S2¼

righ

th

and

S1¼

0.5

0,

S2¼

3.0

0

Hand

surg

ery

Ro

sen

&L

un

db

org

[17]

Pat

ien

tsaf

ter

han

dsu

rger

yn¼

3,

age¼

26

,5

8,

38

,se

x¼

2m

,

1f

0le

ft,

3ri

gh

t1

.00

,3

.00

,0

.08

Alt

sch

ule

r&

Hu

[18]

Fra

ctu

red

dis

tal

rad

ius

n¼

1,

age¼

39

,se

x¼

fL

eft

0.3

3

m,

mal

e,f,

fem

ale;

MC

A,

med

ial

cere

bra

lar

tery

;C

RP

S1

,co

mp

lex

regio

nal

pai

nsy

nd

rom

ety

pe

1;

CR

PS

2,

com

ple

xre

gio

nal

pai

nsy

nd

rom

ety

pe

2.

Ran

ge

of

the

age

and

tim

esi

nce

lesi

on

are

list

edw

hen

avai

lab

leth

rou

gh

the

pap

ers.

Effectiveness of mirror therapy 5

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

Tab

leII

I.S

tud

ych

arac

teri

stic

so

fth

em

irro

rth

erap

yp

erfo

rmed

wit

hp

atie

nts

afte

ran

amp

uta

tio

n.

Au

tho

rsB

asel

ine

mea

sure

men

tsIn

terv

enti

on

Ou

tco

me

mea

sure

men

tsC

on

clu

sio

n

Ram

ach

and

ran

&

Ro

ger

s-

Ram

ach

and

ran

[3];

met

ho

do

logic

al

sco

re*

:‘l

evel

VII

I’

Neu

rolo

gic

alev

alu

atio

nan

d

‘men

tal

stat

us’

exam

inat

ion

Mir

ror

ther

apy.

At

firs

tth

ep

atie

nt

had

to

pla

ceh

isu

nim

pai

red

arm

on

on

esi

de

of

the

mir

ror

inth

em

irro

rb

ox

and

the

ph

anto

mo

nth

eo

ther

sid

e.T

he

un

imp

aire

dar

mh

adto

be

mo

ved

gra

du

ally

un

til

its

mir

ror

imag

e

mat

ched

the

felt

po

siti

on

of

the

ph

anto

m.

Aft

erth

isth

ep

atie

nt

had

to

close

his

eyes

and

per

form

mir

ror

sym

met

ric

mo

vem

ents

.T

he

pat

ien

t

then

op

ened

his

eyes

and

looked

inth

e

mir

ror

wh

ile

per

form

ing

the

sam

eta

sk.

No

tal

lp

atie

nts

per

form

edth

esa

me

pro

toco

laf

ter

this

and

som

ep

atie

nts

too

kth

em

irro

rb

ox

ho

me

Kin

aest

het

icse

nsa

tio

ns

Th

ere

ferr

alo

fse

nsa

tio

ns

fro

mth

eu

nim

pai

red

arm

toth

ep

han

tom

can

emer

ge

inth

ead

ult

hu

man

bra

inin

less

than

3w

eeks.

Th

isim

plies

that

new

pat

hw

ays

are

pre

cise

lyo

rgan

ised

and

fun

ctio

nal

ly

effe

ctiv

e

Pre

sen

ceo

f‘c

len

chin

gsp

asm

s’T

he

mir

ror

bo

xm

ayp

rovi

de

au

sefu

ln

ewto

ol

for

exp

lori

ng

inte

r-se

nso

ryef

fect

sin

ph

anto

mlim

bs

Sen

sati

on

sin

the

ph

anto

mT

he

fin

din

go

fim

med

iate

rest

ora

tio

no

fvi

vid

illu

sory

mo

vem

ents

inth

ep

han

tom

usi

ng

a

mir

ror;

incl

ud

ing

the

‘op

enin

g’

of

ati

gh

tly

clen

ched

ph

anto

mfi

st,

dem

on

stra

tes

that

‘mo

du

les’

con

cern

edw

ith

visi

on

and

pro

pri

oce

pti

on

mu

stin

tera

ctto

am

uch

gre

ater

exte

nt

than

pre

vio

usl

yas

sum

ed

Th

efi

nd

ing

that

the

bo

dy

imag

eo

fo

ne

par

ticu

lar

pat

ien

tw

asp

erm

anen

tly

alte

red

dem

on

stra

tes

the

trem

end

ou

sab

ilit

yo

fn

eura

lco

nn

ecti

on

sin

the

adu

lth

um

anb

rain

and

itm

ayh

ave

som

e

ther

apeu

tic

imp

lica

tio

ns

for

stro

ke

reh

abilit

atio

n

Su

mit

ani

etal

.[5

];

met

ho

do

logic

al

sco

re*:

‘lev

elIV

’

Bef

ore

each

MV

Fp

roce

du

re:

Dai

lym

irro

rth

erap

ytr

eatm

ent.

10

min

.

exer

cise

of

un

affe

cted

lim

ban

d

sim

ult

aneo

usl

yp

erfo

rmsi

milar

exer

cise

or

imag

ined

mo

vem

ents

of

the

affe

cted

lim

b.

Th

ed

ura

tio

no

fth

ein

terv

enti

on

was

ind

ivid

ual

ised

(mea

n

20,4

+2

3,8

s.d

.w

eeks)

.

Aft

erea

chM

VF

pro

ced

ure

:M

VF

trea

tmen

tis

ap

rom

isin

gth

erap

euti

cap

pro

ach

toce

rtai

nty

pes

of

dea

ffer

enta

tio

np

ain

.P

ain

alle

viat

ing

effe

cto

fM

VF

pro

mis

ingly

corr

esp

on

ds

wit

hth

eem

ergen

ceo

fw

ille

dvi

suo

mo

tor

imag

ery

of

the

affe

cted

lim

b.

Itw

asm

ore

effe

ctiv

efo

r

red

uci

ng

dee

pp

ain

than

sup

erfi

cial

pai

n.

Dic

ho

tom

ou

sm

easu

rem

ent

of

ph

anto

mlim

baw

aren

ess

(pre

sen

ce/a

bse

nce

)

Dic

ho

tom

ou

sm

easu

rem

ent

of

ph

anto

mlim

baw

aren

ess

(pre

sen

ce/a

bse

nce

)

Mo

tor

imag

ery

of

affe

cted

lim

b

(wille

d/in

volu

nta

ry

mo

vem

ents

/im

mo

bilis

ed/

abse

nce

)

Mo

tor

imag

ery

of

affe

cted

lim

b

(wille

d/in

volu

nta

ry

mo

vem

ents

/im

mob

ilis

ed/

abse

nce

)

NR

Sm

easu

rem

ent

NR

Sm

easu

rem

ent

Su

bje

ctiv

ed

escr

ipti

on

so

f

qu

alit

ies

of

dea

ffer

enta

tio

n

pai

n

Su

bje

ctiv

ed

escr

ipti

on

sof

qu

alit

ies

of

dea

ffer

enta

tio

n

pai

n

*A

cco

rdin

gto

Jove

ll&

Nav

arro

-Ru

bio

[4]

(tab

leI)

.

MV

F,

mir

ror

visu

alfe

edb

ack;

NR

S,

nu

mer

ical

rati

ng

scal

eo

fp

ain

(0¼

no

pai

n,

10¼

seve

rep

ain

);sd

,st

and

ard

dev

iati

on

.

6 D. Ezendam et al.

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

Tab

leIV

.S

tud

ych

arac

teri

stic

so

fth

em

irro

rth

erap

yp

erfo

rmed

wit

hst

roke

pat

ien

ts.

Au

tho

rsB

asel

ine

mea

sure

men

tsIn

terv

enti

on

Ou

tco

me

mea

sure

men

tsC

on

clu

sio

n

Alt

sch

ule

ret

al.

[6];

met

ho

do

logic

alsc

ore

*:

‘lev

elII

I’

Ass

essm

ent

by

two

blin

ded

neu

rolo

gis

tso

fa

vid

eota

pe

sho

win

gal

lo

fth

eca

rdin

al

mo

vem

ents

mad

eb

yth

e

pat

ien

ts.

Mir

ror

ther

apy.

Ran

do

mas

sign

men

tto

the

mir

ror

or

tran

spar

ent

pla

stic

(co

ntr

ol)

con

dit

ion

.A

fter

4

wee

ks

pat

ien

tscr

oss

edo

ver

toth

eo

ther

trea

tmen

t

for

the

nex

t4

wee

ks.

To

tal

du

rati

on

of

the

inte

rven

tio

np

erio

dw

as8

wee

ks.

Ase

ssio

nw

as

per

form

edfo

r1

5m

in,

twic

ea

day

,6

day

s/w

eek,

mo

vin

gb

oth

han

ds

or

arm

ssy

mm

etri

cally

(mo

vin

gth

eim

pai

red

arm

asb

est

asth

eyco

uld

)

wh

ile

wat

chin

gth

eu

nim

pai

red

arm

mo

vein

the

mir

ror

or

the

imp

aire

dar

mth

rou

gh

the

clea

r

pla

stic

Pat

ien

tsw

ere

vid

eota

ped

at2

,4

,6

and

8w

eeks

and

pro

gre

ssw

as

asse

ssed

by

two

blin

ded

neu

rolo

gis

tsas

sess

ing

the

pat

ien

ts’

mo

vem

ent

abilit

yin

term

so

f

RO

M,

spee

dan

dac

cura

cyu

sin

ga

73

toþ

3sc

ale

(0re

pre

sen

tin

gn

o

chan

ge)

Su

bje

ctiv

eco

mm

ents

wer

eal

so

ob

tain

edfr

om

the

pat

ien

ts

Bo

thn

euro

logis

tsfo

un

dth

at

sub

stan

tial

lym

ore

pat

ien

tsim

pro

ved

on

mir

ror

than

on

con

tro

l

Mir

ror

ther

apy

may

be

ben

efici

alfo

rat

leas

tso

me

pat

ien

tsw

ith

hem

ipar

esis

follo

win

gst

roke

Sat

hia

net

al.

[7];

met

ho

do

logic

alsc

ore

*:

‘lev

elIX

’

Pre

-tes

t:

Gri

pst

ren

gth

Rel

ease

tim

e

Max

.sh

ou

lder

flex

ion

Max

.sh

ou

lder

abd

uct

ion

Max

.sh

ou

lder

exte

rnal

rota

tio

n

Fu

nct

ion

alre

ach

Cu

pto

mo

uth

tim

e

Tim

eto

dra

pe

tow

elo

ver

sho

uld

ers

Tim

eto

pic

ku

pp

en

Tim

eto

fold

tow

elin

qu

arte

rs

Sp

asti

city

(Asw

ort

hgra

de)

Mir

ror

ther

apy

inco

mb

inat

ion

wit

h‘m

oto

rco

py’

stra

tegy

and

‘fo

rced

use

’.T

he

pat

ien

th

adto

per

form

syn

chro

no

us

bim

anu

alm

ove

men

tsin

a

mir

ror-

bo

xw

hile

loo

kin

gat

his

un

imp

aire

dle

ft

arm

and

its

refl

ecti

on

inth

em

irro

r.T

he

pat

ien

t

star

ted

wit

hw

eekly

ph

ysic

alth

erap

yvi

sits

that

wer

eu

sed

tod

irec

tan

dm

on

ito

ra

ho

me

pro

gra

m.

Init

ial

ther

apy

invo

lved

use

of

the

mir

ror

to

faci

lita

tea

‘mo

tor

cop

y’st

rate

gy.

Lat

erth

e

ther

apeu

tic

stra

tegy

pro

gre

ssed

to‘f

orc

edu

se’

of

the

imp

aire

dar

min

dai

lyac

tivi

ties

Po

st-t

est:

Gri

pst

ren

gth

Rel

ease

tim

e

Max

.sh

ou

lder

flex

ion

Max

.sh

ou

lder

abd

uct

ion

Max

.sh

ou

lder

exte

rnal

rota

tio

n

Fu

nct

ion

alre

ach

Cu

pto

mo

uth

tim

e

Tim

eto

dra

pe

tow

elo

ver

sho

uld

ers

Tim

eto

pic

ku

pp

en

Tim

eto

fold

tow

elin

qu

arte

rs

Sp

asti

city

(Asw

ort

hgra

de)

Th

eu

seo

fa

mir

ror

was

ben

efici

alin

the

reh

abilit

atio

no

fth

isp

atie

nt.

Th

e

mir

ror

was

acr

itic

alfa

cto

rin

faci

lita

tin

gu

seo

fm

ore

esta

blish

ed

stra

tegie

ssu

chas

mo

tor

cop

yan

d

forc

edu

se.

Th

een

dre

sult

was

incr

ease

dfu

nct

ion

alu

seo

fth

e

imp

aire

du

pp

erlim

b

Ste

ven

s&

Sto

yko

v[8

];

met

ho

do

logic

alsc

ore

*:

‘lev

elIX

’

Th

ree

sub

test

sfr

om

the

Jeb

sen

Tes

to

fH

and

Fu

nct

ion

FM

-UE

MF

T

Gri

pst

ren

gth

RO

Mw

rist

exte

nsi

on

RO

Mw

rist

flex

ion

RO

Mw

rist

pro

nat

ion

RO

Mw

rist

sup

inat

ion

Arm

and

han

dd

imen

sio

ns

of

the

Ph

ysic

alIm

pai

rmen

tIn

ven

tory

of

the

CM

SA

Mo

tor

imag

ery

trai

nin

gin

wh

ich

two

task

sw

ere

per

form

edd

uri

ng

4w

eeks,

3se

ssio

ns/

wee

k,

each

sess

ion

too

k+

1h

ou

r.T

ask

1(+

25

min

)–

com

pu

ter-

faci

lita

ted

imag

ery.

Fo

cuse

do

nw

rist

exte

nsi

on

and

wri

stp

ron

atio

n-t

o-s

up

inat

ion

of

the

imp

aire

dlim

b.

Co

mp

ute

rgen

erat

edm

ovi

es

pro

vid

edvi

sual

cues

,su

bje

cts

had

toim

agin

e

per

form

ing

the

mo

vem

ents

that

wer

ed

epic

ted

by

the

mo

vie.

Th

em

ove

men

tsw

ere

sho

wn

fro

m3

angle

san

dat

4d

iffe

ren

tsp

eed

s

Tas

k2

(+3

0m

in)

–m

irro

rb

ox-f

acilit

ated

mo

tor

imag

ery.

At

wee

k1

:fo

cus

on

lear

nin

gto

iden

tify

the

refl

ecte

dh

and

aso

wn

imp

aire

dlim

bm

ovi

ng

aro

un

dfr

eely

.A

tw

eek

2þ

3:

sim

ple

ob

ject

man

ipu

lati

on

task

s.A

tw

eek

4:

com

ple

xo

bje

ct

man

ipu

lati

on

task

s.

Per

form

edat

1w

k,

2.5

wk

and

4w

k

afte

rth

est

art

of

the

inte

rven

tio

n.

Fo

llo

w-u

pm

easu

rem

ent

at1

mo

nth

and

3m

on

ths

afte

r

trea

tmen

tte

rmin

atio

n:

Th

ree

sub

test

sfr

om

the

Jeb

sen

Tes

to

fH

and

Fu

nct

ion

FM

-UE

MF

T

Gri

pst

ren

gth

RO

Mw

rist

exte

nsi

on

RO

Mw

rist

flex

ion

RO

Mw

rist

pro

nat

ion

RO

Mw

rist

sup

inat

ion

Arm

and

han

dd

imen

sio

ns

of

the

Ph

ysic

al

Imp

airm

ent

Inve

nto

ryo

fth

e

CM

SA

Per

form

ance

of

the

imp

aire

dlim

b

imp

rove

daf

ter

the

imag

ery

inte

rven

tio

n,

ind

icat

edb

yin

crea

ses

in

asse

ssm

ent

sco

res

and

fun

ctio

nal

ity

and

dec

reas

esin

mo

vem

ent

tim

es.

Th

eim

pro

vem

ents

ove

rb

asel

ine

per

form

ance

rem

ain

edst

able

ove

ra

3-

mo

nth

per

iod

.T

hes

ere

sult

s

dem

on

stra

teth

ep

ote

nti

alfo

ru

sin

g

mo

tor

imag

ery

asa

cogn

itiv

est

rate

gy

for

fun

ctio

nal

reco

very

fro

m

hem

ipar

esis

.T

he

inte

rven

tio

nta

rget

s

the

cogn

itiv

ele

vel

of

acti

on

pro

cess

ing

wh

ile

its

effe

cts

may

be

real

ised

in

ove

rtb

ehav

iou

ral

per

form

ance

(con

tinued

)

Effectiveness of mirror therapy 7

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

Tab

leIV

.(C

onti

nued

).

Au

tho

rsB

asel

ine

mea

sure

men

tsIn

terv

enti

on

Ou

tco

me

mea

sure

men

tsC

on

clu

sio

n

Ro

thgan

gel

etal

.[9

];

met

ho

do

logic

alsc

ore

*:

‘lev

elII

I’

Pri

mar

ym

easu

rem

ents

:

AR

AT

PS

K

Sec

on

dar

ym

easu

rem

ent:

MA

S

2ex

per

imen

tal

gro

up

s(1

day

care

trea

tmen

tgro

up

and

1cl

inic

alre

hab

ilit

atio

ngro

up

)re

ceiv

ed

stan

dar

dis

edex

erci

seth

erap

yw

ith

mir

ror

ther

apy,

2co

ntr

ol

gro

up

s(1

day

care

trea

tmen

t

gro

up

and

1cl

inic

alre

hab

ilit

atio

ngro

up

)o

nly

rece

ived

stan

dar

dis

edex

erci

seth

erap

y.P

atie

nts

rece

ived

no

co-i

nte

rven

tio

nd

uri

ng

the

exp

erim

ent

and

wer

ein

stru

cted

no

tto

pra

ctic

eat

ho

me.

To

tal

inte

rven

tio

nd

ura

tio

nw

as5

wee

ks,

inw

hic

h

the

day

care

trea

tmen

tgro

up

rece

ived

ther

apy

2

tim

esp

erw

eek,

2x/d

ayfo

r3

0m

in.

Clin

ical

reh

abilit

atio

ngro

up

rece

ived

ther

apy

4ti

mes

per

wee

k,

2x/d

ayfo

r3

0m

in.

Sta

nd

ard

ised

exer

cise

ther

apy:

10

min

–to

nu

s

inh

ibit

ing

or

stim

ula

tin

gex

erci

ses;

10

min

–

fun

ctio

nal

exer

cise

sw

ith

dif

fere

nt

ob

ject

s;1

0m

in

–p

ract

icin

gfi

ne

mo

tor

skills

.

Bo

thar

ms

mo

ved

and

itw

asim

po

rtan

tth

atb

oth

arm

sm

ove

dsy

nch

ron

ou

s.A

ph

ysic

alth

erap

ist

faci

lita

ted

mo

vem

ents

of

imp

aire

du

pp

erlim

b

wh

enn

eces

sary

.T

he

exp

erim

enta

lgro

up

s

focu

sed

on

the

mir

ror

du

rin

gal

lm

ove

men

ts.

Sam

em

easu

rem

ents

asb

asel

ine

mea

sure

men

tsw

ere

taken

afte

r2

,5

wee

ks

afte

rth

est

art

of

the

trea

tmen

tp

erio

d,

afte

r5

wee

ks

at

the

end

of

the

trea

tmen

tp

erio

d

and

afo

llo

w-u

pm

easu

rem

ent

was

un

der

taken

at1

0w

eeks

afte

rth

e

star

to

fth

etr

eatm

ent

per

iod

.

Inad

dit

ion

ap

roce

ss-e

valu

atio

nw

as

un

der

taken

du

rin

gan

dat

the

end

of

the

trea

tmen

tp

erio

dto

asse

ss

the

pra

ctic

alap

plica

bilit

yan

d

feas

ibilit

y.T

he

reac

tio

ns

of

the

pat

ien

tsan

dth

eo

bse

rvat

ion

so

f

the

ph

ysic

alth

erap

ists

wer

e

collec

ted

.

Mir

ror

ther

apy

sho

ws

po

siti

vech

anges

in

han

dan

dar

mfu

nct

ion

of

chro

nic

CV

Ap

atie

nts

.D

uri

ng

the

10

wee

k

follo

w-u

pp

has

eth

ere

was

no

dec

lin

e

regar

din

gh

and

and

arm

fun

ctio

n.

Yav

uze

ret

al.

[10

];

met

ho

do

logic

alsc

ore

*:

‘lev

elII

I’

Bru

nn

stro

mst

age

(han

d)

Bru

nn

stro

mst

age

(UE

)

MA

S

FIM

Bo

thth

em

irro

rgro

up

and

con

tro

lgro

up

par

tici

pat

edin

aco

nve

nti

on

alst

roke

reh

abilit

atio

np

rogra

m,

5d

ays

aw

eek,2

-5h

ou

rsa

day

,fo

r4

wee

ks.

Fo

rth

esa

me

per

iod

,th

em

irro

r

gro

up

rece

ived

anad

dit

ion

al3

0m

inu

tes

of

mir

ror

ther

apy

and

the

con

tro

lgro

up

per

form

edth

e

sam

eex

erci

ses

usi

ng

the

no

n-r

eflec

tin

gsi

de

of

the

mir

ror.

Pat

ien

tsw

ere

seat

edcl

ose

toa

tab

leo

n

wh

ich

am

irro

rw

asp

lace

dve

rtic

ally

.T

he

invo

lved

han

dw

asp

lace

db

ehin

dth

em

irro

r.

Bilat

eral

mo

vem

ent

was

stim

ula

ted

.

Bru

nn

stro

mst

age

(han

d)

Bru

nn

stro

mst

age

(UE

)

MA

S

FIM

Inth

egro

up

of

stro

ke

pat

ien

ts,

han

d

fun

ctio

nim

pro

ved

mo

reaf

ter

mir

ror

ther

apy

inad

dit

ion

toa

con

ven

tio

nal

reh

ablita

tio

np

rogra

mco

mp

ared

wit

h

con

tro

ltr

eatm

ent

(aft

er4

wee

ks

and

6

mo

nth

follo

w-u

p).

Mir

ror

ther

apy

did

no

taf

fect

spas

tici

ty

*ac

cord

ing

toJo

vell

&N

avar

ro-R

ub

io[4

](T

able

I);

RO

M,

ran

ge

of

mo

tio

n;

AR

AT

,ac

tio

nre

sear

char

mte

st;

PS

K,

pat

ien

tsp

ecifi

eke

kla

chte

nsc

haa

l;M

AS

,m

od

ified

ash

wo

rth

scal

e;F

;F

M-U

EM

FT

,

Fu

gl-

Mey

eru

pp

erex

trem

ity

mo

tor

fun

ctio

nte

st;

CM

SA

,C

hed

oke-

McM

aste

rst

roke

asse

ssm

ent;

UE

,u

pp

erex

trem

ity;

FIM

,fu

nct

ion

alst

atu

sco

mp

on

ent

of

the

un

ifo

rmd

ata

syst

emfo

rm

edic

al

reh

abilit

atio

n.

8 D. Ezendam et al.

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

represented change based on range of motion, speed

and accuracy. Which component really was affected

by mirror therapy was unclear in this study. The

results of this score were not statistically analysed.

Sathian et al. [7] used mirror therapy to facilitate

other forms of therapy, namely a ‘motor copy’

strategy and ‘forced use’. The authors state that the

employment of the mirror was the critical factor in

facilitating the use of these strategies. The results

were not statistically analysed. Because this is a case

study and no control case was presented it remains

unclear whether the mirror really was the critical

factor. In the study performed by Stevens and

Stoykov [8] mirror therapy was used as a part of a

motor imagery program which consisted of two tasks.

Two patients participated and both improved after

the therapy program. The program had a positive

result for the functional recovery from hemiparesis

assessed by different functional outcome measure-

ments. The results of these different outcome

measurements were not statistically analysed.

Rothgangel et al. [9] undertook a pilot-study in two

different groups of stroke patients. One group

received daycare treatment and the other group

received clinical rehabilitation. In both groups mirror

therapy was found to be effective, with the clinical

rehabilitation group showing more progress than the

daycare treatment group. However, these differences

were not statistically tested. Yavuzer et al. [10]

performed mirror therapy using a mirror and

bilateral movements in addition to a conventional

stroke rehabilitation program. The experimental

group received mirror therapy and the control group

had to perform the same therapy but without using

the reflecting side of the mirror. Mirror therapy

seems to have a significant effect in terms of motor

recovery and hand-related functioning. There was no

significant effect found on spasticity.

Complex regional pain syndrome

Complex regional pain syndrome type 1. The study

characteristics of the five studies that involved

mirror therapy with complex regional pain

syndrome type 1 (CRPS1) patients are listed in

Table V. Three of these studies involved mirror

therapy with both upper and lower limb patients

[11,14,15]. The other two studies involved only

upper limb patients [12,14]. One study by Moseley

[14] involved mirror therapy with both CRPS1

patients and patients who suffer from phantom limb

pain as a consequence of amputation or brachial

plexus avulsion injury. Both studies of Moseley

[12,14] used mirror therapy as a part of a motor

imagery program. In the 2004 study, he used a very

restricted group of CRPS1 patients; the patients had

developed CRPS1 as a result of a non-complicated

wrist fracture. The patients were chronic

CRPS1 patients (�6 months after injury). The

motor imagery program had a significant effect for

these patients. In the 2006 study, Moseley showed

that the program had a significant effect for a more

general CRPS1 population and also for patients

who suffered from phantom limb pain. Because the

mirror therapy in these two studies is a part of a

larger therapy program it is difficult to determine

whether the mirror therapy was the factor that

caused the positive outcome. It could be that other

parts of the program or the total program caused

the positive effects found by Moseley. The study of

McCabe et al. [11] examined mirror therapy with

the use of a mirror. In this study mirror therapy

was effective in patients with early CRPS1

(�8 weeks) and with intermediate CRPS1 (�1

year). In patients with chronic CPRS1 (�2 years),

the treatment was not effective. The mirror therapy

had an immediate analgesic effect in early CRPS1

and led to a reduction in stiffness in intermediate

CRPS1. These effects were not statistically ana-

lysed. In this study, both patients with upper as

lower limb CRPS1 were included. The positive

effects were present in both lower as upper

extremity patients. The patients where the mirror

therapy was ineffective all concerned lower limb

patients. The patient in the study by Karmarkar and

Lieberman [13] experienced immediate and dra-

matic improvement in range of motion and pain of

the affected upper limb while using mirror therapy.

This effect was not statistically tested. Tichelaar

et al. [15] used cognitive behavioural therapy

combined with mirror therapy in three patients.

Two of these patients suffered from CRPS1 of the

lower limb and mirror therapy had a beneficial

effect in these cases and one patient suffered from

CRPS1 of the upper limb and mirror therapy wasn’t

effective at all. The results of this study were not

statistically analysed.

In these five studies, 17 different outcome

measurements were used. Three of these measure-

ments were scales to assess the amount of pain in the

affected limb. Seven of the measurements were

clinical assessments to define the severity of CRPS1

or to define the signs and symptoms of the stump or

phantom limbs for amputees. Three of the measure-

ments were related to the performance of the

different tasks in the studies of Moseley [12,14],

i.e. response time, movement time and frequency of

training. Two measurements concerned the tem-

perature and circumference of the affected limb in

CRPS1. One outcome measure was a subjective

assessment about mirror box therapy and about the

affected limb. The last measurement was a scale to

define the functional level of the patients.

Effectiveness of mirror therapy 9

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

Complex regional pain syndrome type 2. The study

characteristics of the study that involved mirror

therapy with Complex regional pain syndrome type

2 (CRPS2) patients are listed in Table V. This case

study concerned two patients with CRPS2 [16]. In

CRPS2, a local origin for the pain in generally

assumed in contrast with CRPS1 where a clear

peripheral etiology for pain is lacking. In these two

patients, mirror therapy had a positive effect. For the

first patient pain was relieved during and immedi-

ately after mirror therapy, but the overall level of pain

did not decrease. For the second patient, mirror

therapy caused a systematic overall decrease in pain.

The authors state that mirror therapy in CRPS2 is

worthy of further exploration.

Hand surgery

The study characteristics of the studies with the

patients after hand surgery other than amputation are

listed in Table VI. In the study by Rosen and

Lundborg [17] mirror therapy was applied in

combination with traditional hand training and was

a successful part of the treatment program in the

three included subjects. On these three patients,

different outcome measurements were taken. Most

measurements concerned motor function. The re-

sults of these measurements were not statistically

analysed. Following Rosen and Lundborg,

Altschuler and Hu [18] also applied mirror therapy

to a patient after hand surgery other than amputa-

tion. This patient had a fractured wrist. Conven-

tional treatment had no effect and mirror therapy was

started. The patient performed mirror therapy in

combination with electrical stimulation to the left

wrist extensors for 2–3 times per week and besides

that also practiced at home 5–6 times per week. At

the end of the treatment active wrist extension was

308. The results of this study were not statistically

analysed.

Discussion

In the present review, 15 studies were qualitatively

analysed to investigate the effects of mirror therapy

on the impaired motor function and pain reduction

of the upper limb. As much as five different patient

categories were studied: amputation of the upper

limb, stroke, CRPS1 and CRPS2 and hand surgery

other than amputation.

Mirror therapy is still in its early stages, therefore

only a small number of studies could be included in

this review. The methodological quality of the

included studies is variable. The highest methodo-

logical score according to Jovell and Navarro-Rubio

[4] (Table I) of the studies in this review is level II,

which corresponds to a good strength of evidence.

Only five of the 15 included studies were randomised

controlled trials (RCTs) of which four were small-

sample RCTs. The remainder of the studies had a

poor strength of evidence and concerned descriptive

studies or case reports. The studies on amputation

and hand surgery other than amputation all had a

weak methodological quality, hence, these studies

were not used to draw conclusions regarding the

effectiveness of mirror therapy. Our conclusions on

the effectiveness of mirror therapy, as explained in

the following, were drawn using only three studies in

stroke patients [6,9,10] and two studies with CRPS1

patients [12,14].

Note that although all of these five studies are

RCT’s and those studies have a high methodological

score relative to the other studies, there are still

aspects of these studies that possibly bias the results.

For instance, the number of participants in the

studies is small. An other factor that may have biased

the results was that the time spent at training with the

mirror box was not similar in all studies; in some of

the studies the patients could take the mirror box

home and practice whenever they wanted to, which

made that the intensity of the therapy could not be

controlled. Finally, in some of the studies mirror

therapy was performed in combination with other

therapy forms, which made it difficult to determine

which part of the therapy contributed to the reported

effects.

The potential of mirror therapy in CRPS1 patients

was recognised based on the fact that characteristics

of CRPS pain (burning, cramping, mislocalisation)

are also observed with phantom pain [cf. 11; cf. 14].

Since mirror therapy seemed effective with phantom

pain [3], it was thought that this therapy might also

work with CRPS1. The two studies of Mosely

[12,14] showed that mirror therapy was effective

for chronic CRPS1 patients. Importantly, in the

studies of Moseley mirror therapy was combined

with a motor imagery program, hence, it could be

that it was this combination of motor imagery and

mirror therapy that caused the positive effect.

Therefore, it is difficult to determine the role of

mirror therapy in CRPS1 rehabilitation.

With regard to the working mechanisms of mirror

therapy in CRPS1 patients, Moseley suggested that a

possible explanation for the positive effect of mirror

therapy are sequential activation of cortical pre-

motor and motor networks, or sustained and

focussed attention on the affected limb, or both.

The attention a patient pays to the affected limb in

mirror therapy might reverse the disuse of the limb.

The forced attention of the limb in the mirror

therapy might activate neuromotor networks, which

might relieve the pain [14]. Despite that the

10 D. Ezendam et al.

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

Tab

leV

.S

tud

ych

arac

teri

stic

so

fth

em

irro

rth

erap

yp

erfo

rmed

wit

hp

atie

nts

wit

hco

mp

lex

regio

nal

pai

nsy

nd

rom

e.

Au

tho

rsB

asel

ine

mea

sure

men

tsIn

terv

enti

on

Ou

tco

me

mea

sure

men

tsC

on

clu

sio

n

CR

PS

1

McC

abe

etal

.[1

1];

met

ho

do

logic

al

sco

re*:

‘lev

el

VII

I’

Pai

nV

AS

IRT

Bo

thm

easu

red

on

pre

sen

tati

on

acco

rdin

gto

anas

sess

men

t

pro

toco

lth

atco

nsi

sted

of

2co

ntr

ol

ph

ases

(usi

ng

no

dev

ice

and

view

ing

an

on

-refl

ecti

vesu

rfac

e)

and

anin

terv

enti

on

ph

ase

(vie

win

g

am

irro

r)

Mir

ror

ther

apy.

Su

bje

cts

wer

ed

irec

ted

tou

seth

e

mir

ror

asfr

equ

entl

yas

they

wis

hed

for

ap

erio

do

f

6w

eeks.

Th

em

axim

um

tim

efo

rea

chp

erio

do

f

mir

ror

ther

apy

was

10

min

.P

atie

nts

had

to

per

form

flex

ion

-exte

nsi

on

cycl

eso

fth

ere

leva

nt

bo

dy

par

tsw

ith

thei

ru

nim

pai

red

lim

ban

d,

if

po

ssib

le,

wit

hth

eir

imp

aire

dlim

bin

asy

mm

etri

c

way

.T

he

RO

Man

dsp

eed

of

thes

eex

erci

ses

was

dic

tate

db

yth

esu

bje

ct’s

pai

n

Pai

nV

AS

IRT

Mea

sure

dat

the

end

of

the

6w

eek

trea

tmen

tp

erio

d.A

dai

lyd

iary

was

use

dto

reco

rdfr

equ

ency

of

mir

ror

use

and

pai

nse

veri

tyb

etw

een

asse

ssm

ents

Inea

rly

CR

PS

1vi

sual

inp

ut

fro

ma

mo

vin

g,

un

imp

aire

dlim

bre

-

esta

blish

esth

ep

ain

-fre

e

rela

tio

nsh

ipb

etw

een

sen

sory

feed

bac

kan

dm

oto

rex

ecu

tio

n.

Tro

ph

icch

anges

and

ale

ssp

last

ic

neu

ral

pat

hw

ayp

recl

ud

eth

isin

chro

nic

dis

ease

Mo

sele

y[1

2];

met

ho

do

logic

al

sco

re*:

‘lev

elII

I’

NP

S

Fin

ger

circ

um

fere

nce

Mea

sure

dat

the

star

to

fth

e

trea

tmen

t-o

rco

ntr

ol

per

iod

Exp

erim

enta

lgro

up

:m

oto

rim

ager

yp

rogra

m

con

sist

ing

of

3st

ages

,ea

cho

f2

wee

ks

du

rati

on

Sta

ge

1–

reco

gn

itio

no

fh

and

late

rality

.5

6

pic

ture

so

fa

righ

to

rle

fth

and

wer

esh

ow

nan

d

pat

ien

tsh

adto

resp

on

das

qu

ick

and

accu

rate

po

ssib

leb

yp

ress

ing

ab

utt

on

atth

em

om

ent

they

reco

gn

ised

the

han

dto

be

righ

to

rle

ft.

Pat

ien

ts

wer

ead

vise

dto

per

form

the

task

3ti

mes

(10

min

)

each

wak

ing

ho

ur.

Sta

ge

2–

imag

ined

han

dm

ove

men

ts.

28

pic

ture

so

f

the

imp

aire

dh

and

wer

era

nd

om

lysh

ow

n.

Pat

ien

tsh

adto

imag

ine

that

thei

ro

wn

han

dw

as

mo

vin

gto

ado

pt

the

po

stu

resh

ow

nin

the

pic

ture

,

thre

eti

mes

.T

he

emp

has

isw

aso

nac

cura

cy.

Pat

ien

tsw

ere

advi

sed

top

erfo

rmth

eta

skth

ree

tim

esev

ery

wak

ing

ho

ur

(+1

5m

in.)

Sta

ge

3–

mir

ror

ther

apy.

Wit

hth

eu

seo

fa

mir

ror

bo

xp

atie

nts

had

toad

op

tth

ep

ost

ure

sho

wn

in2

0

pic

ture

so

fth

eu

nim

pai

red

arm

wit

hb

oth

arm

s

slo

wly

and

smo

oth

ly.

Th

eem

ph

asis

was

on

wat

chin

gth

ere

flec

tio

no

fth

eir

un

imp

aire

dh

and

inth

em

irro

r.P

atie

nts

wer

ead

vise

dto

per

form

the

task

10

tim

esea

chw

akin

gh

ou

ran

dto

sto

pif

they

had

anin

crea

sein

pai

n

Co

ntr

ol

gro

up

:th

ese

pat

ien

tsh

adto

mai

nta

inth

eir

on

go

ing

man

agem

ent,

wh

ich

con

sist

edm

ost

lyo

f

2-3

sess

ion

so

fp

hys

ical

ther

apy

per

wee

k

NP

S

Fin

ger

circ

um

fere

nce

Th

ese

two

mea

sure

men

tsw

ere

per

form

edat

2,4

and

6w

eeks

afte

r

the

star

to

fth

etr

eatm

ent-

or

con

tro

lp

erio

dan

da

follo

w-u

p

mea

sure

men

tw

asp

erfo

rmed

at1

2

wee

ks

Of

the

exp

erim

enta

lgro

up

the

follo

win

gad

dit

ion

alm

easu

res

wer

eta

ken

aso

utc

om

e:

Res

po

nse

tim

eto

reco

gn

ise

the

imp

aire

dh

and

(sta

ge

1)

Tim

eat

wh

ich

each

tria

lw

as

per

form

ed(s

tage

2)

Dia

ryo

ftr

ain

ing

(sta

ge

3)

Th

isst

ud

ysu

pp

ort

sa

mo

tor

imag

ery

app

roac

hto

chro

nic

CR

PS

1.

Th

e

resu

lts

up

ho

ldth

eh

ypo

thes

isth

at

am

oto

rim

ager

yp

rogra

min

itia

lly

no

tin

volv

ing

lim

bm

ove

men

tsis

effe

ctiv

efo

rC

RP

S1

and

sup

po

rt

the

invo

lvem

ent

of

cort

ical

abn

orm

alit

ies

inth

ed

evel

op

men

t

of

this

dis

ord

er.

(con

tinued

)

Effectiveness of mirror therapy 11

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

Tab

leV

.(C

onti

nued

).

Au

tho

rsB

asel

ine

mea

sure

men

tsIn

terv

enti

on

Ou

tco

me

mea

sure

men

tsC

on

clu

sio

n

Kar

mar

kar

&

Lie

ber

man

[13

];

met

ho

do

logic

al

sco

re*:

‘lev

elIX

’

RO

MM

irro

rb

ox

ther

apy

RO

M Pai

nsc

ore

s(u

nsp

ecifi

ed)

Mir

ror

bo

xth

erap

yh

adan

imm

edia

tean

dd

ram

atic

imp

rove

men

tin

the

RO

Mo

fth

e

affe

cted

han

dan

da

red

uct

ion

in

pai

nsc

ore

so

fm

ore

than

50

%.

Aft

er1

tria

lm

irro

rb

ox

ther

apy

pro

ved

tob

eve

ryu

sefu

lin

the

pat

ien

tw

ith

CR

PS

1

Mo

sele

y[1

4];

met

ho

do

logic

al

sco

re*

:‘l

evel

II’

Un

der

taken

atp

rera

nd

om

isat

ion

.

Qu

esti

on

nai

res:

Fu

nct

ion

NR

S

MP

Q

Pai

nV

AS

Clin

ical

asse

ssm

ent:

Dia

gn

ost

iccr

iter

iafo

rC

RP

S1

Sym

pto

ms

and

sign

so

fh

yper

alges

ia

and

allo

dyn

iao

fth

est

um

pfo

r

amp

ute

es

Sym

pto

ms

of

swel

lin

gan

d

tem

per

atu

rech

anges

inth

e

ph

anto

mlim

b

Sym

pto

ms

of

mo

tor

dis

ord

ers

of

the

ph

anto

mlim

b

Exp

erim

enta

lgro

up

:m

oto

rim

ager

yp

rogra

m

con

sist

ing

of

3st

ages

,ea

cho

f2

wee

ks

du

rati

on

.

Sta

ge

1–

lim

bla

tera

lity

reco

gn

itio

n.

Pat

ien

tssa

w

pic

ture

san

dh

adto

resp

on

db

yp

ress

ing

ale

fto

r

righ

tp

ress

ure

-sen

siti

veb

utt

on

acco

rdin

gto

wh

eth

erth

ep

ictu

resh

ow

eda

left

or

righ

tlim

b.

Sta

ge

2–

imag

ined

mo

vem

ents

.P

ictu

res

of

bo

th

lim

bs

wer

era

nd

om

lyp

rese

nte

dan

dp

atie

nts

had

toim

agin

etw

ice

ado

pti

ng

the

po

stu

resh

ow

nw

ith

asm

oo

than

dp

ain

free

mo

vem

ent.

Sta

ge

3–

mir

ror

mo

vem

ents

.W

ith

the

use

of

a

mir

ror

bo

xp

atie

nts

wer

ead

vise

dto

twic

ead

op

t

the

po

stu

resh

ow

nw

ith

bo

thh

and

s,u

sin

gsm

oo

th

and

pai

nfr

eem

ove

men

ts.

Wit

hin

all

thre

est

ages

the

trai

nin

glo

adw

as

incr

ease

db

ysh

ow

ing

po

stu

res

of

lim

bs

that

wer

e

mo

rep

ain

ful

toad

op

t.A

nd

pat

ien

tsh

adto

trai

n

ath

om

eev

ery

wak

ing

ho

ur

Co

ntr

ol

gro

up

:m

edic

al/

ph

ysio

ther

apy

man

agem

ent.

Th

ese

pat

ien

tsre

ceiv

eda

6w

eek

ph

ysio

ther

apy

pro

gra

man

dm

ain

tain

edu

sual

med

ical

care

.T

he

ph

ysio

ther

apy

pro

gra

md

idn

ot

con

tain

trea

tmen

tssi

milar

toth

ose

use

din

the

exp

erim

enta

lgro

up

.It

con

sist

edo

fat

leas

t1

trea

tmen

t/w

eek

and

ah

om

ep

rogra

mth

at

invo

lved

atr

ain

ing

load

com

par

able

toth

atin

the

mo

tor

imag

ery

pro

gra

m(i

.e.

ho

url

ytr

ain

ing)

Un

der

taken

at6

wee

ks

afte

r

com

ple

tio

no

fth

etr

eatm

ent

per

iod

.

Qu

esti

on

nai

res:

Fu

nct

ion

NR

S

MP

Q

Pai

nV

AS

Clin

ical

asse

ssm

ent:

Dia

gn

ost

iccr

iter

iafo

rC

RP

S1

Sym

pto

ms

and

sign

so

fh

yper

alges

ia

and

allo

dyn

iao

fth

est

um

pfo

r

amp

ute

es

Sym

pto

ms

of

swel

lin

gan

d

tem

per

atu

rech

anges

inth

e

ph

anto

mlim

b

Sym

pto

ms

of

mo

tor

dis

ord

ers

of

the

ph

anto

mlim

b

Of

the

exp

erim

enta

lgro

up

the

follo

win

gad

dit

ion

alm

easu

res

wer

eta

ken

aso

utc

om

e:

Res

po

nse

tim

eto

reco

gn

ise

the

imp

aire

dh

and

(sta

ge

1)

Tim

eat

wh

ich

each

tria

lw

as

per

form

ed(s

tage

2)

Dia

ryo

ftr

ain

ing

(sta

ge

3)

At

6m

on

ths

follo

w-u

pfu

nct

ion

NR

S

and

pai

nV

AS

wer

eal

so

un

der

taken

Gra

ded

mo

tor

imag

ery

red

uce

dp

ain

and

dis

abilit

yin

aw

ider

CR

PS

1

po

pu

lati

on

and

inth

ose

wit

h

ph

anto

mlim

bp

ain

afte

r

amp

uta

tio

no

rb

rach

ial

ple

xu

s

avu

lsio

nin

jury

.T

he

follo

win

g

resu

lts

sup

po

rtth

isp

osi

tio

n:

1)

pai

nd

ecre

ased

and

fun

ctio

n

incr

ease

dfo

rth

em

oto

rim

ager

y

gro

up

,th

isef

fect

was

sign

ifica

nt;

2)

NN

Ts

for

resp

on

seto

trea

tmen

tat

6m

on

ths

of

abo

ut

3

(con

tinued

)

12 D. Ezendam et al.

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

Tab

leV

.(C

onti

nued

).

Au

tho

rsB

asel

ine

mea

sure

men

tsIn

terv

enti

on

Ou

tco

me

mea

sure

men

tsC

on

clu

sio

n

Tic

hel

aar

etal

.

[15

];

met

ho

do

logic

al

sco

re*:

‘lev

elIX

’

RO

M(d

ors

al/p

alm

arfl

exio

no

r

do

rsal

/p

lan

tar

flex

ion

)

mu

scle

stre

ngth

allo

dyn

ia(u

pp

erb

ord

ero

fth

ear

ea

was

mea

sure

d)

hyp

eral

ges

ia(u

pp

erb

ord

ero

fth

e

area

was

mea

sure

d)

po

siti

on

of

han

do

rfo

ot

inw

hic

h

pat

ien

tw

asm

ost

com

fort

able

at

rest

sub

ject

ive

asse

ssm

ent

abo

ut

mir

ror

bo

xth

erap

yan

dab

ou

tth

e

affe

cted

lim

b

Qu

anti

tati

veas

pec

tso

fp

ain

VA

S,

mea

sure

d:

At

rest

Aft

erte

stin

gR

OM

Aft

erte

stin

gR

OM

Aft

erte

stin

gm

usc

lest

ren

gth

Aft

erte

stin

gm

usc

lest

ren

gth

Aft

erte

stin

gal

lod

ynia

Aft

erte

stin

gh

yper

alges

ia

CB

T(c

ogn

itiv

eb

ehav

iou

ralth

erap

y)co

mb

ined

wit

h

mir

ror

bo

xth

erap

yai

min

gat

regai

nin

glim

b

fun

ctio

nan

dp

ain

red

uct

ion

.

Wee

k1

–al

lan

alges

ics

wer

egra

du

ally

red

uce

do

r

sto

pp

ed(d

eto

xifi

cati

on

)

Wee

k2

–m

irro

rb

ox

ther

apy

was

intr

od

uce

das

add

-

on

toth

ed

esen

siti

sati

on

ther

apy,

3ti

mes

per

day

for

2cy

cles

of

5m

in.

Wee

k3

–m

irro

rb

ox

ther

apy

5ti

mes

per

day

for

2

cycl

eso

f5

min

.

Sam

em

easu

rem

ents

asth

eb

asel

ine

mea

sure

men

t.P

erfo

rmed

on

cea

wee

kd

uri

ng

ther

apy

and

atfo

llo

w-

up

afte

rth

ecl

inic

alp

has

e

Pat

ien

t1

–fo

llo

w-u

paf

ter

14

wee

ks

Pat

ien

t2

–fo

llo

w-u

paf

ter

8w

eeks

Pat

ien

t3

–fo

llo

w-u

paf

ter

5w

eeks

Cas

e1

imp

rove

di.

e.h

eex

per

ien

ced

less

pai

nw

ith

ou

tu

sin

gan

y

med

icat

ion

and

cou

ldw

alk

alitt

le

dis

tan

cew

ith

ou

tu

sin

gel

bo

w-

cru

tch

es.

Cas

e2

imp

rove

dle

ss.

Sh

e

exp

erie

nce

dle

ssp

ain

bu

tm

ob

ilit

y

did

no

tim

pro

ve.

Cas

e3

imp

rove

dn

ot

atal

l.

CR

PS

2

Sel

les

etal

.[1

6];

met

ho

do

logic

al

sco

re*

:‘l

evel

IX’

Pai

nV

AS

Mir

ror

ther

apy.

Am

irro

rw

asp

lace

dve

rtic

ally

on

the

tab

lein

fro

nt

of

the

pat

ien

t.P

ain

ful

han

d

hid

den

beh

ind

the

mir

ror,

no

n-p

ain

ful

han

d

po

siti

on

edso

that

the

refl

ecti

on

of

the

han

dw

as

sup

erim

po

sed

on

the

pai

nfu

lo

ne.

Pat

ien

tsh

adto

pra

ctic

e3

-5ti

mes

each

day

for

15

min

ute

s.F

irst

5-1

0m

in.

un

ilat

eral

mo

vem

ents

.A

fter

that

5-

10

min

.b

ilat

eral

mo

vem

ents

.

S1

trai

ned

for

3w

eeks

S2

trai

ned

for

5m

on

ths

Pai

nV

AS

Th

ep

rese

nte

dca

ses

dem

on

stra

te

that

the

use

of

mir

ror

ther

apy

in

pat

ien

tsw

ith

CR

PS

2is

wo

rth

yo

f

furt

her

exp

lora

tio

nas

ap

ote

nti

al

trea

tmen

tm

od

alit

yin

pat

ien

ts

wit

hC

RP

S2

.

*A

cco

rdin

gto

Jove

ll&

Nav

arro

-Ru

bio

[4]

(Tab

leI)

;V

AS

,vi

sual

anal

ogu

esc

ale

(0,n

op

ain

;1

0,p

ain

asb

adas

itco

uld

be)

;IR

T,in

frar

edth

erm

ogra

ph

y;R

OM

,ra

nge

of

mo

tio

n;N

PS

,n

euro

pat

hic

pai

n

scal

e;fu

nct

ion

NR

S,

pat

ien

t-sp

ecifi

cta

sk-r

elat

edn

um

eric

alra

tin

gsc

ale;

MP

Q,

McG

ill

pai

nq

ues

tio

nn

aire

;N

NT

,n

um

ber

nee

ded

totr

eat;

CR

PS

1,

com

ple

xre

gio

nal

pai

nsy

nd

rom

ety

pe

1;

CR

PS

2,

com

ple

xre

gio

nal

pai

nsy

nd

rom

ety

pe

2.

Effectiveness of mirror therapy 13

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

underlying working mechanism is not clear yet, the

effects of mirror therapy with CRPS1 patients are

relevant for rehabilitation because these patients

seem to be locked in a vicious circle of pain and

disuse. Mirror therapy seems to be a possibility to

break through this vicious circle, which opens up

opportunities for rehabilitation for patients with

CRPS1. However, more systematic research is

needed before definite conclusions regarding mirror

therapy in CRPS1 patients can be drawn [19].

Three studies reported a positive effect of mirror

therapy on motor function after stroke. Within stroke

patients, the sensomotoric coupling is often dis-

turbed, which might compromise task-intrinsic feed-

back. Therefore, to recover motor function stroke

patients may be more dependent on augmented

feedback [20]. This augmented feedback might be

delivered in the form of visual feedback through

mirror therapy [6–9]. A possible working mechanism

of mirror therapy in stroke patients is based on the

fact that in mirror therapy movement of the

unimpaired upper limb is used to improve the motor

control of the impaired limb. This bilateral move-

ment suggest a bilateral transfer as an origin of the

effects of mirror therapy.

Moreover, there is evidence that both the motor

activity and the perceptual activity in mirror therapy

modulate the excitability of M1, pointing at a

mechanism that might explain effectiveness of mirror

therapy [21–24]. During mirror therapy, there are

two sources of changes in ipsilateral M1 excitability

[cf. 21], that is, through action performance activat-

ing M1 ipsilateral and through observation of that

action activating M1 contralateral. The simultaneous

changes in excitability of M1 in mirror therapy might

result in neural reorganisations appropriate for

functional recovery. This is hypothesised as a

possible mechanism by which mirror therapy can

work with stroke patients. Garry et al. [21] found a

trend in their data supporting this idea; the results

showed that looking at the moving hand facilitates

excitability of ipsilateral M1 compared to looking at

the inactive hand or a dummy position. However, the

difference between looking at the active hand and

looking at the mirror reflection did just not reach a

conventional significance level.

In summary, the interaction within M1 between

the mechanisms mediating the excitability as a

consequence of movement and the mechanisms

mediating the excitability as a consequence of

observation might serve as a hypothesis to explain

for the improved functional recovery with the use of

mirror therapy in stroke patients. Would this

hypothesis hold in future studies, it indicates that

the benefits of mirror therapy are not just a result of

motor training but of the mutual interactions

between perceptual and motor activity at the cortical

level. Of course, this hypothesis deserves further

studying but it might be an interesting starting point

to increase our understanding of the workings of

mirror therapy in stroke patients.

To conclude, mirror therapy seems to be effective

mainly for patients with CRPS1 and stroke patients –

but note that it is currently impossible to establish

the individual benefit of mirror therapy in CRPS1

patients [19]. However, the proposed working

Table VI. Study characteristics of the mirror therapy performed with patients after hand surgery other than amputation.

Authors

Baseline

measurements Intervention

Outcome

measurements Conclusion

Rosen & Lundborg

[17]; methodological

score* : ‘level IX’

On all three patients

the baseline

measurements

were different, e.g.

grip strength,

active ROM,

SWM

All patients used mirror

therapy combined with

traditional hand training

On all three patients the

outcome

measurements were

different, e.g. grip

strength, active ROM,

SWM, and STI test

Mirror therapy works in

these three case and

these examples

demonstrate new

applications of the

mirror therapy

Altschuler & Hu [18];

methodological

score* : ‘level IX’

Active ROM Mirror therapy combined

with electrical stimulation

to the left wrist extensors.

Bilateral movements were

requested. Duration:

15 min. 2–3 times per

week. Patient also

practiced at home

without electrical

stimulation for 15 min.

5–6 times per week

Active ROM Active wrist extension

was impossible until

mirror therapy

started. The authors

think that the

recovery of

functionally useful

and maintained active

wrist extension can be

attributed to mirror

therapy

*According to Jovell & Navarro-Rubio [4] (Table I); ROM, range of motion; SWM, Semmes-Weinstein monofilaments to test the

perception of touch/pressure; STI test, shape texture identification test.

14 D. Ezendam et al.

Downloaded By: [JHU John Hopkins University] At: 17:04 15 October 2009

mechanisms of mirror therapy differed in those two

patients groups. All in all, the current systematic

literature review has shown that the use of mirror

therapy in rehabilitation seems promising, especially

for CRPS1 patients, when combined with motor

imagery, and for stroke patients, while the effective-

ness in other patient groups has yet to be deter-

mined.

Declaration of interest: The authors report no

conflicts of interest. The authors alone are respon-

sible for the content and writing of the article.

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Appendix – PubMed search strategy

1. Mirror ‘neuron’ [MeSH]

2. Mirror therapy

3. ‘Nervous system diseases’ [MeSH]

4. ‘Upper extremity’ [MeSH]

5. ‘Cerebrovascular accident’ [MeSH]

6. Stroke

7. Pain

8. Nos. 1 and 3

9. Nos.1 and 4

10. Nos. 2 and 3

11. Nos. 2 and 4

12. Nos. 2 and 5 or 6

13. Nos. 2 and 7

MeSH, medical subject headings.

The search was limited to humans and there were

no limits set for publication type.

Effectiveness of mirror therapy 15

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