This document provides a literature review on the role of mirror therapy in neurological conditions. It summarizes 14 studies that examine the effectiveness of mirror therapy for various conditions such as stroke, phantom limb pain, complex regional pain syndrome, cerebral palsy, and Parkinson's disease. The studies generally found that mirror therapy improved motor function, decreased pain, and enhanced cortical excitability when used individually or as an adjunct to other therapies. The review concludes that mirror therapy is a promising treatment approach for re-educating the brain and stimulating mirror neurons to improve motor control and recovery from neurological impairments.

1. ROLE OF MIRROR THERAPY IN
NEUROLOGICAL CONDITIONS
PRESENTED BY:
RUCHIKA GUPTA
MPT
SUBMITTED TO:
DR. HIMANSHU MATHUR (PT)

2. INTRODUCTION
• The purpose of mirror therapy is to increase the brain’s activity and to
increase the brain’s ability to reorganize in the affected area of the brain by
giving more feedback to the brain.(1)
• Mirror therapy is defined as an intervention that uses a mirror to create a
reflection of the non-paretic upper or lower limb, thus giving the person
visual feedback of normal movement of the paretic limb.(2)
• Ramachandran and Rogers-Ramachandran first devised the technique in an
attempt to help those with phantom limb pain resolve what they termed
a ‘learned paralysis’ of the painful phantom limb. (3)
• A Mirror box is a device which allows the clinician to easily create this
illusion.
• It' is a box with one mirror in the center where on each side of it, the hands
are placed in a manner that the affected limb is kept covered always and the
unaffected limb is kept on the other side whose reflection can be seen on the
mirror.

3. • This approach exploits the brain’s preference to prioritise visual feedback
over somatosensory/proprioceptive feedback concerning limb position.
• MT has been shown to increase cortical and spinal motor excitability,
possibly through the effect on the 'mirror neuron system which accounts for
about 20% of all the neurons present in a human brain.
• These mirror neurons are responsible for laterality reconstruction i.e.,
ability to differentiate between the left and the right side.
• When using the Mirror box, these mirror neurons gets activated and helps in
the recovery of affected parts.
• This system is thought to use the observation of movement to stimulate the
motor processes which would be involved in that movement.
• Similarities have been drawn with motor imagery where by the individual
will mentally imagine movements rather than observing the reflection of a
movement in a mirror . (3)
• It is thought that the brains natural inclination to prioritise visual feedback
over all others would make MT a more powerful tool .
• The major difference in the neuronal reorganisation while using a mirror box
is that the ipsilateral hemisphere's neurons gives connection to the same side
affected limbs rather than the conventional therapies which targets the
neuronal reorganization of the contra-lateral hemisphere.

4. PURPOSE OF STUDY
• The purpose of this study is to collect and analyse data that
give evidences of effectiveness of mirror therapy in various
neurological conditions .
• To collect recent advances for use of mirror therapy in various
conditions.
• To analyse the spectrum of mirror therapy treatable
neurological condition.

5. CLINICAL SIGNIFICANCE OF STUDY
• This study shortlists widely accepted, approved and varified
studies and recent advances helping physical therapists to
know about spectrum of use of mirror therapy in various
neurological conditions that might omit the cumbersome
process by therapists to search for some of the most significant
and recent studies on world wide web.

6. REVIEW OF LITERATURE
Study Subjects Study
Design
Aims Methodology Conclusion
Thieme H
et.al.
(2018)
1982
subjects post
stroke
population
mean age 59
yr(30 to
73yr )
Meta
analysis
Effectiveness of
mirror therapy
compared with
no treatment,
placebo, sham or
other treatments
for improving
motor function
and impairment
after stroke.
Mirror therapy (3 to 7
times a week,
between 15 and 60
minutes for each
session for 2 to 8
weeks (on average 5
times a week, 30
minutes a session for
4 weeks).
The results
indicate evidence
for the
effectiveness
of
mirror therapy in
post stroke
patients
Diers et al
(2010)
14 upper
extremity
amputees - 7
with
phantom
limb pain
and 7 (non-
PLP) and
9(HC).
RCT Applying MT as
part of a
sequence of
modalities
appeared to
produce positive
results against
applying it in
isolation
Executed movement
activated the
contralateral
sensorimotor area in
all three groups but
ipsilateral cortex was
only activated in the
non-PLP and HC
group.
Patients with
CRPS and PLP
showed decrease in
pain, and improved
function both
immediately post
treatment and at a
6 month follow-up
when using graded
motor imagery
(GMI).

7. Jaume-i-Capo
et al.
( 2014)
32 children of
cerebral palsy
CP group
Mirror feedback
and no mirror
feedback
Normal
children mirror
feedback and no
mirror feedback
Comparative
study
Improving
vision-based
motor
rehabilitation
interactive
system for users
with disabilities
using mirror
feedback
Video games
based visual
feedback and
mirror therapy
is used and
results are
accessed on
basis of time of
therapy and
their prognosis
Significant
improvement in
the
experimental
group in time
between
starting time
and finishing
the mirror
program.
Candida S.
McCabe et al
(2008)
Meta- analysis Mirror visual
feedback for the
treatment of
complex
regional pain
syndrome (type
1)
Inclusion of
studies thst
shows
effectiveness of
mirror therapy
in CRPS
describes mirror
visual feedback
development
with amputees,
its original
application in
CRPS, and
further
researches
demonstrating
its potential
benefit within
graded motor
imagery
programs

8. Ho Jeong Lee
(2007)
35 stroke
patients
RCT The effects of
action
observation
training and
mirror therapy
on gait and
balance in
stroke patients
action
observation
therapy with
activity group
(n=12), mirror
therapy with
activity group
(n=11), action
observation
therapy group
(n=12)
AOTA
improves static
balance and gait
function, and
MOT improves
gait function.
Young-Lan
Son
(2018)
20 post stroke
patients
RCT The effects of
mirror neuron
system-based
self-observation
training on
lower limb
muscle activity
and dynamic
balance in
patients with
chronic stroke
experimental
group with
mirror
feedback
(n=10) and a
control group
withoutt
mirror
feedback(n=1
0)
Significant
improvement
in mirror
feedback
experimental
group as
compared to
control group

9. Grunt S
(2017)
20 subjects Comparative
study
To investigate
the effect of the
mirror illusion
(MI) on the
excitability of
the primary
motor cortex
(M1) in
children and
adolescents.
Twelve patients
with
hemiparesis
(10-20 years)
and 8 typically
developing
subjects (8-17
years)
participated
MI increases
the excitability
of M1 in
hemiparetic
patients with
contralateral
corticospinal
organization
and in typically
developing
subjects.
Gaia Bonassi
(2016)
33 subjects Pilot study Mirror Visual
Feedback to
Improve
Bradykinesia in
Parkinson's
Disease
21 (parkinson
disease patient)
and 12 normal
subjects.
Motor training
was performed
with the use of
a mirror box.
And control
group was
given non
mirror visual
feedback
therapy
novel evidence
that MVF
training might
induce
improvement in
finger
movements'
bradykinesia of
the more
affected
(untrained)
hand in PD
patients

10. Beurskens and
Heymans
(2004)
25 patients with
unilateral PFP
for at least nine
months and 25
patients with
PFP on a
waiting list for
three months
RCT Positive Effects
of Mime
Therapy on
Sequelae of
Facial
Paralysis:
Stiffness, Lip
Mobility, and
Social and
Physical
Aspects of
Facial
Disability
Mime therapy
with a
homework
manual
(exercises to
stimulate facial
emotional
expression and
functional
movements) for
3 months; 45-
minute weekly
sessions
Mime therapy
seems to be an
important
treatment
option for
patients with
sequelae of
longstanding
peripheral facial
paralysis
Hsiu-Yun Hsu
(2019)
12 patients with
median nerve
injury
RCT To investigate
the effects of
touch-
observation and
task-based
mirror therapy
on the
sensorimotor
outcomes of
patients with
nerve repair
randomized
into touch-
observation and
task-based
mirror therapy
or control
groups, and
both groups
received
training for 12
wk.
Touch-
observation and
task-based
mirror therapy
is an effective
treatment in
patients with
peripheral nerve
injury.

11. Farzaneh
Saberi
(2018)
20 patients
with
median/ulnar
nerve damage
RCT This study aims
to determine
the effect of
mirror visual
feedback as a
complementary
method on the
outcomes of
sensory
relearning in
patients
following
median/ulnar
nerve repair.
Both groups
received
traditional
rehabilitation in
three 40-
minute sessions
a week. In
addition, the
treatment
group received
mirror visual
feedback 15
minutes a day, 5
days a week, for
8 weeks.
Mirror visual
feedback in
conjunction
with traditional
sensory
retraining
programmes
led to greater
improvements.
Frederik J. A.
Deconinck
(2014)
347 articles
included
Systemic
review
Reflections on
Mirror Therapy:
A Systematic
Review of the
Effect of Mirror
Visual
Feedback on the
Brain
Effectivenness
of mirror
therapy on brian
cells and future
scopes

12. Ippei Nojima
(2012)
Subjects. Sixty-
three
neurologically
healthy subjects
Systemic
review
The clinical use
of mirror visual
feedback
(MVF) was
initially
introduced to
alleviate
phantom pain,
and has since
been applied to
the
improvement of
hemiparesis
following
stroke
The effects of
MVF on
corticospinal
excitability and
motor behavior,
and especially
on hand
dexterity,
suggest that it
might be useful
in stroke
rehabilitation.
V. S.
Ramachandra
n, Eric L.
Altschuler
(2009)
Systemic
review
The use of
visual
feedback, in
particular
mirror visual
feedback, in
restoring
brain
function
This article
reviews the
potential use
of visual
feedback,
focusing on
mirror visual
feedback
There is a
very wide
scope and use
of mirror
therapy in
clinical
practice.

13. METHODOLOGY
• The articles included in this study are taken from Wiley online library ,
Google scholar, Pubmed.gov, NCBI,MEDLINE,Cochrane Library, Taylor
and Francis online, physiopedia, Frontier, Research gate and Science
Direct, Directory of open access journals.
• Inclusion criteria
– Systemic reviews
– Randomised control trials
– Meta analysis
– Comparative studies
– Studies included in journals
– Studies which are approved by ethical commitee.
– Year ( 2004-2019)
– Full text articles only

14. • Exclusion criteria
– Biased studies.
– Case studies.
– Studies with no significant results in concerning conditions .
– Studies with many limitations.
– Studies with ethical issues.
– Studies needing further research.
– Studies with unclear results.

15. PRISMA STATEMENT
Records identified through
database searching
(n = 308)
ScreeningIncludedEligibilityIdentification
Additional records identified
through other sources
(n =20 )
Records after duplicates removed
(n = 182 )
Records screened
(n = 146 )
Records excluded
(n = 96 )
Full-text articles
assessed for eligibility
(n = 50 )
Full-text articles
excluded, with reasons
(n =36 )
Studies included in
qualitative synthesis
(n = 5 )
Studies included in
quantitative synthesis
(meta-analysis)
(n = 9 )

16. DISCUSSION
Fig (1) Mirror box therapy

17. • This study consist of review of 308 articles from which 14 articles are
shortlisted and refined.
• These articles not only provide an insight for clinical practice of
mirror therapy but also opens a new pathway for research areas to be
explored.
• The mirror cells in brain are responsible for behavioural and spatial
and bilateral symmetry cognition. When these cells are damaged as in
any insult to the brain or any problem with transmission of signals
these result into unilateral neglect and other associated changes.
• These brain cells have proven to be reeducated by the use of mirror
box therapy , motor imaging and mirror feedback mechanisms aalone
or along with other modalities of treatments as in MIMS.
• This articles shortlists some of the most accurate and accepted articles
of past 15 years in the feild of research related to scopes of mirror
therapy in various neurological conditions.

18. RELEVANCE
• According to this study there is a lot more scope of mirror
therapy than just stroke and extremity rehabilitation.
• It can be used in many neurological cinditions which include
damage of mirror cells inside brain.
• There are lot more diseases like ALS, Autism,SCI, Meningitis,
Encephalopathy ,etc. In which further role of mirror therapy
has to be evolved.

19. CONCLUSION
• The above review of various type of studies ,of use of mirror therapy in various
neurological disorders ,suggest positive roles in improving the control of
cerebral cortex over skeletal muscles and re-education of functional motor
control of cerebral cortex by stimulating mirror cells for visual and mirror
feedback mechanism.
• The papers reviewed in this article have major implications—both for
clinical practice and for our theoretical understanding of the brain.
• The treatment can be done by use of mirror therapy in various ways such as
Graded motor imagery (5),mental imagery,or MVF in adjunct with other
therapies.
• Moreover studies suggest that mirror therapy is far more effective in cognitive
impairments than non mirror video games based feedback protocols. (6)
• Apart from its clinical importance, mirror visual feedback paves the way
for a paradigm shift in the way we approach neurological disorders.

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