MIRROR THERAPY: AN EFFECTIVE INTERVENTION FOR TREATING NEUROLOGICAL DEFICITS FOLLOWING STROKE AND TRAUMATIC BRAIN INJURY (TBI)
Debra Battistella, MS, OTR/L
Mirror Therapy, also known as Mirror Visual Feedback, is an evidence-based treatment approach that can be used with people who experience brain injuries such as cerebrovascular accident (CVA)/stroke or TBI. To understand what mirror therapy is and how it works, this article reviews common deficits that occur following stroke and brain injury along with various aspects of the brain and how each relates to function before explaining how mirror therapy works and why it should be a first choice intervention for Occupational Therapy Practitioners and the survivor.
Just so we know why this conversation is important, let’s get an idea of how prevalent CVA and TBI are. According to the CDC (2021), more than 795,000 people in the U.S. experience a stroke each year. It is the 3rd leading cause of death and is the leading cause of disability in the United States. World wide, 15 million people have strokes every year (Strokestatistics.org). It is also important to note that traumatic brain injuries are responsible for about 2.87 million emergency room visits, hospitalizations and deaths (CDC, 2019).
BRAIN INJURY DEFICITS
Brain injuries cause physiological changes within the brain that affect the body. Changes in any bodily area can result in deficits that negatively impact a person’s life. Here is a list of common changes that occur following stroke and brain injury. Often times, a person experiences more than one.
- Muscle tone changes – High/Low/Flaccid/Fluctuating
- Impaired sensation – Light touch/Deep pressure, Hot/Cold, Proprioception, Kinesthesia
- Decreased Active/Passive Range of Motion
- Decreased strength
- Decreased speed and/or accuracy of movement
- Decreased dexterity
- Blurred vision
- Double vision
- Visual field cuts (hemianopsia/hemianopia is one of the most common)
- Hemi-inattention/Neglect (Decreased/Absent awareness of one side of the body and environment)
- Decreased ability to perform executive functions (higher-level cognitive processes)
- Decreased insight
- Decreased Judgment
You can imagine how difficult it can be to navigate through life when a body changes in these ways. Life changes not only for the person with the injury, but also for those whom they love. We can view it as a family affair.
THE BRAIN AND FUNCTION
While the human brain might be considered small in comparison to the entire body, it is often thought of as the control center for everything we do. This mighty organ is very busy! Since we are talking about brain injuries, it is worthwhile to discover some of the ways the brain works. Here I review some key brain areas so you can understand how or why your body works the way it does.
The Frontal Lobe is home to areas involved with executive functions (those higher level cognitive skills necessary for living an independent life) and movement. Important areas associated with movement include the primary motor cortex (responsible for movement on the opposite/contralateral side of the body), the premotor cortex (responsible for movement observation) and the supplementary motor area (responsible for bimanual coordination).
The Posterior Parietal Cortex plays a role in planning movement.
The Cerebellum is positioned beneath the temporal and occipital lobes and plays keys roles in balance, coordination, executive functions and personality.
All of these areas plus more all work in harmony to produce meaningful thought processes and controlled movement.
Functional Magnetic Resonance Imaging (fMRI) makes it possible to see brain activity, demonstrating to researchers that there is activity in the brain before movement occurs when a person engages in object directed movement – picking up a bottle of water, for example. This brain activity occurs when a person is planning to pick up the bottle or visualizing picking up the bottle. This is important to understand because humans use the arms and hands in most tasks throughout the day. Arms and hands are used when engaging in Basic Activities of Daily Living (B-ADL) such as ambulating/transferring, bathing, toileting hygiene and dressing, as well as Instrumental Activities of Daily Living I-ADL) to include meal prep and driving/community mobility. The brain is very active before movement. Because of research such as this that shows brain activity during thought and planning, envisioned movement is considered a viable rehabilitation strategy.
Visual Illusion & Brain Re-organization
Mirror therapy creates a visual illusion when a person moves a NON-AFFECTED limb in front of a mirror. Watching the reflection in the mirror tricks the brain into believing the AFFECTED limb is moving normally. Many changes occur inside the brain when engaging in activities in front of the mirror. Overall, the brain is re-organized as multiple dormant areas are activated and over-active areas are suppressed. This happens both ipsilaterally and contralaterally, ultimately facilitating improved communication between both hemispheres.
Mirror neurons are located in the pre-motor cortex, inferior parietal lobule and spinal cord. Those within the pre-motor cortex and inferior parietal lobule are stimulated with observation, imagination or performance of a motor act. They are responsible for goal directed, organization of movement. Mirror neurons assist with re-organizing a damaged brain and enhance motor control.
When a person passively observes the image moving in the mirror, the mirror neuron system in the cerebral cortex and spinal cord are activated. The passive observation of the normal limb moving in the mirror activates the primary motor cortex of the AFFECTED limb, which can trigger movement.
Using a mirror in this way can cause many positive changes to occur in the brain. When the brain changes, the body can also change. There are possibilities for improving range of motion, strength, movement speed/control and dexterity. Additionally, as the brain re-organizes itself, cognition and attention can also get better. Lastly, because the survivor must look in the mirror (towards the affected side) when engaging in a mirror therapy program, the affected side is acknowledged. This may also help improve hemi-inattention/neglect.
Mirror therapy is an appropriate intervention for occupational therapy practitioners to use with clients who have experienced a stroke or traumatic brain injury. With proper training and education, mirror therapy is safe for survivors to use during therapy down time or as a home program. People with cognitive deficits and/or hemi-inattention/neglect may require supervision to safely engage in a mirror therapy program. Caregivers can be taught how to use it and may find meaning in helping a loved one with this intervention.
Occupational therapy practitioners understand how habits and routines impact a person’s life and may use this knowledge to integrate mirror therapy into a successful home program. Stroke and TBI recovery can be a long and arduous journey. Using science-backed interventions that demonstrate efficacy, such as mirror therapy, can be built into a routine that promotes improvement leading to greater levels of independence and quality of life for both the survivor and loved ones.
OT Practitioner, Podcaster, Professor
Debra Battistella, MS, OTR/L is a 20-year OT practitioner. She’s an educator, podcaster (THE NOGGINS AND NEURONS Podcast) and owner of Creative Concepts in Occupational Therapy PLLC (www.creativeconceptsot.com). She is passionate about helping OT Practitioners provide evidence-based interventions in simple and unique ways. She loves occupational therapy and truly believes that by stepping (slightly and ever so gently) outside of common, traditional practices we can improve our client’s healing journey while simultaneously up-leveling our practices and the profession.
Interested in MORE Mirror Therapy?
Check out the FULL Mirror Therapy Program
COMPLETE MIRROR THERAPY PRESENTATION:
“OT & Mirror Therapy: An Effective Intervention for Impaired Arm Function Following Stroke” is an in-depth presentation for anyone who works with survivors or is interested in working with them. Upon completion of this course, participants will:
- Link brain anatomy to function
- Summarize scientific evidence supporting the use of mirror therapy to improve impaired arm function in stroke survivors
- Identify at least one (1) benefit of using mirror therapy as it relates to:
- OT practice
- Client outcomes
- Profession of OT
- Create a mirror therapy protocol for clinical use
THE OT’S GUIDE TO MIRROR THERAPY
For practitioners and educators interested in up-leveling their practice, THE OT’S GUIDE TO MIRROR THERAPY is a ready-made program that incorporates trainings and video demonstrations of activities and exercises for each upper extremity joint.