Mirror therapy: A potential intervention for pain management

Wittkopf, Priscilla G.; Johnson, Mark I.

doi:10.1590/1806-9282.63.11.1000

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REVIEW ARTICLE • Rev. Assoc. Med. Bras. 63 (11) • Nov 2017 • https://doi.org/10.1590/1806-9282.63.11.1000 copy

Mirror therapy: A potential intervention for pain management

Authorship SCIMAGO INSTITUTIONS RANKINGS

Summary

The consequences of chronic pain and associated disabilities to the patient and to the health care system are well known. Medication is often the first treatment of choice for chronic pain, although side effects and high costs restrict long-term use. Inexpensive, safe and easy to self-administer non-pharmacological therapies, such as mirror therapy, are recommended as adjuncts to pain treatment. The purpose of this review is to describe the principles of use of mirror therapy so it can be incorporated into a health care delivery. The physiological rationale of mirror therapy for the management of pain and the evidence of clinical efficacy based on recent systematic reviews are also discussed. Mirror therapy, whereby a mirror is placed in a position so that the patient can view a reflection of a body part, has been used to treat phantom limb pain, complex regional pain syndrome, neuropathy and low back pain. Research evidence suggests that a course of treatment (four weeks) of mirror therapy may reduce chronic pain. Contraindications and side effects are few. The mechanism of action of mirror therapy remains uncertain, with reintegration of motor and sensory systems, restored body image and control over fear-avoidance likely to influence outcome. The evidence for clinical efficacy of mirror therapy is encouraging, but not yet definitive. Nevertheless, mirror therapy is inexpensive, safe and easy for the patient to self-administer.

Keywords:
chronic pain; self care; pain/physiopathology/psychology

Study and design	Condition	Total duration	Intervention	Author's conclusion
Cacchio et al.¹⁷17 Cacchio A, Blasis E, Necozione S, Orio F, Santilli V. Mirror therapy for chronic complex regional pain syndrome type 1 and stroke. N Engl J Med. 2009; 361(6):634-6.RCT	Complex regional pain syndrome	4 weeks 7 days a week 30 minutes	Patients performed all of the cardinal (proximal to distal) movements of the affected arm
Cacchio et al.¹⁶16 Cacchio A, De Blasis E, De Blasis V, Santilli V, Spacca G. Mirror therapy in complex regional pain syndrome type 1 of the upper limb in stroke patients. Neurorehabil Neural Repair. 2009; 23(8):792-9.RCT		First 2 weeks 5 days a week 30 minutes Last 2 weeks 5 days a week 1 hour	Flexion and extension of the shoulder, elbow and wrist, and pronosupination of the forearm	Evidence of effect and effect maintained after 6 months
Chan et al.¹⁸18 Chan BL, Witt R, Charrow AP, Magee A, Howard R, Pasquina PF, et al. Mirror therapy for phantom limb pain. N Engl J Med. 2007; 357(21):2206-7.RCT	Phantom limb pain	4 weeks 7 days a week 15 minutes	Not specified	Evidence of effect
Brodie et al.²⁸28 Brodie EE, Whyte A, Niven CA. Analgesia through the looking-glass? A randomized controlled trial investigating the effect of viewing a 'virtual' limb upon phantom limb pain, sensation and movement. Eur J Pain. 2007; 11(4):428-36.RCT	Phantom limb pain	1 session	Patients attempted to perform the following movements: straighten and bend the legs at the same time, and alternately. Point feet upwards, and downwards. Turn soles in towards and away from each other. Move feet in a circle. Lift feet off the ground in a walking movement. Point toes upwards and downwards keeping ankle and foot still. Clench, unclench, spread out and relax toes. Point up big toe and point down the other toes, then reverse
Michielsen et al.²³23 Michielsen ME, Selles RW, van der Geest JN, Eckhardt M, Yavuzer G, Stam HJ, et al. Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial. Neurorehabil Neural Repair. 2011; 25(3):223-33.RCT		6 weeks 5 days a week 1 hour	Participants performed bimanual exercises, with the difficulty of the exercises depending on the patients' individual levels of functioning	Evidence of no effect
Dohle et al.¹⁹19 Dohle C, Püllen J, Nakaten A, Küst J, Rietz C, Karbe H. Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial. Neurorehabil Neural Repair. 2009; 23(3):209-17.RCT	Severe hemiparesis	6 weeks 5 days a week30 minutes	Arm, hand and finger postures in response to verbal instructions, protocol scaled according to the patients' level of performance
Moseley²¹21 Moseley GL. Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology. 2006; 67(12):2129-34.RCT	Complex regional pain syndrome type 1	2 weeks 7 days a week 10 minutes for each waking hour	Patients were instructed to conduct smooth and pain-free movements in accordance to pictures randomly presented	Evidence of effect in combination with GMI
Moseley²⁰20 Moseley GL. Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain. 2004; 108(1-2):192-8.RCT	Complex regional pain syndrome type 1	2 weeks 7 days a week 10 minutes for each waking hour	Patients were instructed to conduct smooth and pain-free movements in accordance to pictures randomly presented	Evidence of effect in combination with GMI
Flinn et al.²⁹29 Flinn SR, Hotle AC. A case series report on amputees with pro digit hand prostheses receiving mirror therapy. J Hand Ther. 2011; 24(4):390-1.Non-randomized controlled trial	Phantom limb pain	Not specified	Not specified	Evidence of no effect
McCabe et al.³⁰30 McCabe CS, Haigh RC, Ring EF, Halligan PW, Wall PD, Blake DR. A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology (Oxford). 2003; 42(1):97-101.RCT	Complex regional pain syndrome	1 session 5 minutes	Flexion-extension cycles of both limbs with the range of movement and speed dictated by the patients' pain	Evidence of effect
Michenthaler³⁰30 McCabe CS, Haigh RC, Ring EF, Halligan PW, Wall PD, Blake DR. A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology (Oxford). 2003; 42(1):97-101.RCT	Complex regional pain syndrome	6 weeks 2 days a week 30 minutes	Motor activities in 5 positions (not specified)	Not reported
Stein²⁶26 Stein R. Influence of non-pharmacological interventions (repetitive transcranial magnetic stimulation or mirror therapy) on pain intensity and pain associated central nervous plasticity in patients with phantom limb pain. Bochum: Ruhr-Universität Bochum; 2012. RCT	Phantom limb pain	5 days 45 minutes	Motor and sensory tasks (not specified)	Not reported
Acerra et al.²⁷27 Acerra NE. Is early post-stroke upper limb mirror therapy associated with improved sensation and motor recovery? A randomised-controlled trial. Sensorimotor dysfunction in CRPS1 and stroke: characteristics, prediction and intervention. Australia: University of Queensland; 2007. RCT	Stroke	2 weeks 7days a week 20 to 30 minutes	Functional motor tasks (i.e. with objects); motor coordination tasks; sensory discrimination tasks; grip strength; active range of motion	Not reported

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[1] *Correspondence: School of Clinical and Applied Sciences, Leeds Beckett University, City Campus, Leeds – United Kingdom. Postal code: LS1 3HE. p.wittkopf@leedsbeckett.ac.uk