M. Penny Bartzen OTR/L. Graded Motor Imagery Program Gently Rewires the Brain: CRPS Chronic Regional Pain Syndrome (CRPS) 1. Laterality Reconstruction.

INTRODUCTION TO THE USE OF MIRRORS IN REHABILITATION M. Penny Bartzen OTR/L

Graded Motor Imagery Program Gently Rewires the Brain: CRPSChronic Regional Pain Syndrome (CRPS)

1. Laterality Reconstruction• Restore the brain’s concept of right and left• Graded identification of right/left photos of hands

until 80 % accurate 2. Visual and motor imagery

• Visualizing without movement or threat• Visualize progressive movements

3. Mirror Therapy• Watch uninvolved hand• Gradually increase movement• Replicate with other hand (S.

Stralka, 2011)

Objectives

Mirror Neurons History of the approach Diagnoses Research review Application to your population Further information

Have you tried this?

Ramachandran TED Talk

Mirror Neurons

Mirror neurons are a particular class of visuomotor neurons, originally discovered in area F5 of the monkey premotor cortex, that discharge both when the monkey does a particular action and when it observes another individual (monkey or human) doing a similar action. Rizzolatti G, Craighero L, “The mirror-neuron system,” in Annual Review of Neuroscience, issue 27 (2004) p. 1

Mirror Neurons

Activated by observing and executing movement

Imitation and learning

Motor imagery and visual imagery

Autism Spectrum Disorders

Watching

A. Non-object related

B. Object related

Red - mouth movements

Green - hand movement

Blue- Foot movements

(G. Blinkofski et al., Eur J Neurosci, 13:400-4, 2001)

Cortical Homunculus Images

(http://trivialperusal.files.wordpress.com/2011/04/sensory_homunculus.jpg?w=497)

(http://www.zbynekmlcoch.cz/informace/images/stories/medicina/neurologie/somatosenzoricky_a_motoricky_homunculus.jpg)

Mirror Neurons & Autism

Dysfunction responsible for impairments? Deficits in imitationTheory of mindSocial communication Empathy

Neural strategies differNeural systems interfaces with limbic system Seemingly not engaged in children with ASD (Dapretto, Davies, Pfeifer, Scott, Sigman, Bookheimer & Iacoboni, 2005)

Mirror Neuron Dysfunction and Autism Spectrum Disorders

Treatment Experiments: Imitation Therapy Children being imitated by an adult

demonstrated much more “social behavior” and reciprocal play vs. children who were only playing with an adult

(Nyberg, J., n.d.)

Mirror Visual Feedback (MVF) Visual feedback dominates somatosensory

feedback for cortical proprioceptive representation.

Mirror therapy increases cortical and spinal motor excitability (the mirror neuron system)

Sensory experiences can be evoked on the basis of visual information alone.

Visual input enhances tactile sensitivity. (Moseley, Gallace &

Spence, 2008)

Remapping, cortical plasticity and mirror

therapy• Learned paralysis may be unlearned using the mirror

• Residue of mirror neurons that survived lesion are dormant may be stimulated with mirror

• Visual feedback may revive the dormant ipsilateral connection between the motor cortex and the spinal cord.

(Ramachandran & Altschuler, 2009)

http://www.orble.com/images/ns312.jpg

Mirror Visual Feedback (MVF): Mirror Box Therapy

(MVT) Strokes Autism Amputations Complex Regional Pain Syndrome

(CRPS)/Reflex Sympathetic Dystrophy (RSD)

Neurological Disorders Arthritis

Mirrors

Evidence: Cochrane Review

“Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are internationally recognised as the highest standard in evidence-based health care. They investigate the effects of interventions for prevention, treatment and rehabilitation. They also assess the accuracy of a diagnostic test for a given condition in a specific patient group and setting. They are published online in The Cochrane Library. “

( The Cochrane Collaboration, 2012)

Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. (2012). Mirror therapy for improving motor function after stroke. Cochrane Database of Systematic Reviews.

14 studies with 547 participants Randomized controlled trials &

randomized cross-over trials with any control

Measures of motor function, ADL, pain and visuospatial neglect

Characteristics of studies

12 studies randomized control trials and 2 used a cross-over design with random allocation

9 to 121 participants Mean age 51 to 797 55% left hemiparesis Male 57% female 43% 5 days to 5 years post stroke (4 acute and 8

chronic) 83 % ischemic and 17% hemorrhagic Settings included inpatient, in and out-patient,

day hospital and home setting.

Cochrane:Protocols Mirror or a mirror box in the midsagittal plane

between the upper or lower extremity Reflect movement of the non-involved extremity 2 studies incorporated another intervention,

electrical stimulation or visual imagery 10 to 60 min sessions, 1 to 7 x wk for up to 6

weeks. 5- Bilateral movements, moving the affected

arm as well as they could 6- moved only the unaffected side 1 therapist passively moved the affected arm to

match unaffected motion

Cochrane: Outcome measures

Motor: Fugl-Meyer, Action Research Arm Test, Wolf Function Test, Motor Assessment Scale, Brunnstrom stages

ADL: FIM, Barthel Index, Pain: Measure at rest and sduring motion that

include the numerical rating scales, the Visual Analogue Scale (VAS), the pain section of Fugl-Meyer

Visuospatial: Behavioral Inattention Test (BIT), Test of Attentional Performance (TAP)

Measured pre and post as well as 1 to 6 months post. (p. 9)

Cochrane: Outcomes

Significant effect on motor function after stroke (p. 11)

Significant effect on ADL function (p. 12)

Significant positive effect on pain (p.12)

1 study showed evidence for improving visuospatial neglect (p.12)

Cochrane: Recommendations

Include as adjunct to standard therapy

Utilize with CRPS type-1 after stroke for pain reduction

Continued research (p. 15)

Neuroplasticity and CVA

Neuro-reeducation may be more effective Starting 5 days post onset rather than 30 Changes continue to occur months after

onset Try to avoid allowing the brain to reorganize

for compensation Give feedback and explain the purpose Hebb’s Rule.

Graded Motor Imagery Program (GMIP)

Neuro Orthopedic Institute (NOI) Chronic Regional Pain Syndrome (CRPS) Utilizes mirrors and other approaches to

reduce pain, normalize sensation and improve function.

Utilized in hand therapy and pain clinics.

GMIP: Sensory Re-education and Integration

Laterality Visual Imagery Mirror Therapy Localization Kinesthesia Graphesthesia Stereognosis Sensorimotor accuracy (Stralka ,2011)

Sound Familiar?

GMIP with Stroke

Laterality - Restore brain’s concept of right and left. • 6 to 10 cards R/L hand to start• Acute BID 15 min • 80% accuracy• R/L in magazines, photos• Incorporate sensory information • Functional tasks

Mental Practice/Imagery• Imagine hand motions of cards• Imagine adopting position on cards• Repeat process 3x day

(Stralke, 2011)

GMIP for Stroke Recovery

Mirror Box • Imagine the affected UE is moving while looking in

mirror• Therapist /family move the limb to imitate non-involved

hand• Move the involved hand asap

AROM • Supination/pronation• Wrist extension/flexion• Finger motions – hook, gross grasp• Opposition• Picking up /releasing ball.

(Stralka,

2011)

Christian Dohle et al. (2009). Mirror therapy promotes recovery from severe hemiparesis: A randomized control trial.

Participants• 36 patients• 1st ischemic CVA in territory of middle

cerebral artery• < 8 weeks post onset

Intervention• 6 wk, 30 min. per day, 5 x wk.• Random assignment control or mirror

therapy (MT)• All other standard therapies

Dohle et al, 2009

Protocol Patients watched the mirror image of the

unaffected arm as if it were the affected one.

Executed arm, hand and finger postures in response to verbal instructions

Protocol scaled according to abilities Asked to move their affected arms as well

as possible

Christian Dohle et al. (2009).

Outcome Measure• Fugl-Meyer, functional and neuropsych

testing Subgroup of 25 with initial distal plegia

• Improved distal function in MT group• Increase in surface sensibility• Not dependent on side of lesion

Mirror Visual Feedback with Stroke

2008, Yvuzer et al. • 40 patients with UE hemiparesis

Mirror Therapy group statistical improvement in Burnnstrom stages of motor recovery and FIM self-care score over control group

2008, Matsuo et al.• 15 sub-acute patients with hemiparesis

Mirror therapy group superior to the control treatment using the Fugel –Meyer assessment of the paretic arm.

Ramchandram (2009) notes:• Benefit variables may include the location of lesion and

duration of paralysis. • Motor visual feedback (MVF) should be

implemented routinely due to the simplicity of the approach

ProtocolsYavuzer et al. 2008

40 inpatients, w/in 12 months of onset

30 min mirror therapy Sitting with involved

hand behind mirror Wrist and finger

flexion and extension movement

Watching non-involved

Asked to do the same with involved

Altschuler et al. 1999

9 patients, 6 mo post 15 min, 2x day, 6 day

per wk Watch non-involved

hand in mirror Move hands and arms

symmetrically Proximal to distal Easy movements to

difficult

Protocols

Case Study 63 y.o. gentleman with R hemisphere, posterior internal

capsule stroke resulting in L side paresis, onset 1 yr and 3 months prior to study

18 x 24” mirror attached to 2 wooden posts. 1 hr visit, 3x wk for 3 wk 20 min mental imagery 35 mirror box training

• Identify hand reflection as his own: Finger tapping, wrist flexion/extension

• Simple tasks: Manipulation tasks with object of various size and weights including pouring liquid and drinking from a cup.

• More perceptually challenging tasks: Placement of number objects in distinct order, use of stylus and asked to draw simple picture.

4 pt increase in Fugl-Meyer and improved times for the Jebsen after 3 weeks of therapy. Baseline 47/66 to Day 21- 51/66

(Stevens & Stoykov, 2004)

Mirror Visual Feedback with Stroke

Ramachandran & Altschuler (2009) review of the use of visual feedback in restoring brain function with PLP, CRPS and CVA.

1999, Altschuler et al.

9 patients 3 moderate recovery of function 3 mild recovery 3 no recovery

2007, Sutbeyaz, et al• 40 patients with LE Hemiparesis

Mirror therapy group showed significant improvement in Brunnstrom stages and FIM motor scores compared with control group.

(Ramachandran & Altschuler, 2009)

Standard of Practice?

Non breakable mirrors of varied sizes in hospital and for out-patients

Home program Photographs of movements Functional tasks Sensory information

Sequential protocol that is easily adapted to the individual

Explain to families and clients (staff?) for improved adherence

- What do you think?

Exercise

Small Group Population How are you using it already? How could you incorporate it? How do you explain it?

Share

“ The procedure is not miracle cures by any means, but even if only a small proportion of patients is helped, they would be a enormous value given the high incidence of phantom pain and stroke….Moreover, even if the procedure benefits a minority of patients, it is likely to pave the way for future more completely effective therapies once we understand the variables involved”

(Ramachandran & Altschuler, 2009, p 1694).

Doug and the Mirror Box

"The best thing about mirror therapy is,

… it's cheap, safe, easy and it's fun.“

Dr. Eric Lewin Altschuler

For further information READ the Cochrane report! Search Mirror Neurons Books

The Brain that Changes Itself (Doidge, 2007) The Tell-Tale Brain (Ramachandran, 2011)

You Tube Search for Mirror Box Therapy Ramachandran Mirror Neurons

TED Talks• Ramanchandran• Mirror Neurons

YouTube: Mirror neurons, boxes & therapy

Giacomo Rizotalli on the discovery of mirror neurons_ http://www.youtube.com/watch?v=rPVNAESOWSo&feature=relmfu

Mirror box therapy with David Butler_ http://www.youtube.com/watch?v=hMBA15Hu35M

The social brain (ep 4)- Charlie Rose: The social brain_ http://www.youtube.com/watch?v=nPH8TctMRXY&feature=related

Acting and mirror neurons_ http://www.youtube.com/watch?v=loB-Lg0X1qo

Mirror Box Visual Therapy_ http://www.youtube.com/watch?v=xh8Pc6v7KAg

How to use a mirror box for hand therapy_ http://www.youtube.com/watch?v=GNanQtMBwys

Phantom limb mirror box video_ http://www.youtube.com/watch?v=gc3CmS8_vUI

Doug and mirror box therapy in action 3 sep _ http://www.youtube.com/watch?v=MIucuMWOdKE

Mirror neurons in autism_ http://www.youtube.com/watch?v=_8WV1zAh9zU

References

Altschuler, E.,L. Wisdom, S.B, Ston, L., Foser, C., Galasko, D., Llewellyn, M. E. & Ramachandron, R.S. (1999). Rehabilitation of hemiparesis after stroke with a mirror. Lancet, 353, 2035-2036.

Dapretto, M., Davies, M., Pfeifer, J., Scott, A., Signman, M., Bookheimer, S., & Iaconboni, M. (2005). Understanding emotions in others: mirror neuron dysfunction in children with autism spectrum disorders. Nature Neuroscience, (9),28-30. doi: 10.1038/nn1611

Dohle, C., Pullen, J, Nakaten, A., Kust, J., Rietz, C., & Karbe, H. (2009) Mirror therapy promotes recovery from severe hemiparesis : A randomized controlled trial. Neurorehabilitation and Neural Repair, 23, 209-217.

Doidge, N. (2007). The brain that changes itself: Stories of personal triumph from the frontier of brain science. New York: Penguin Group, Inc.

Jenson, L, (2009) Critically Appraised Topic (CAT): What is the effectiveness of mirror therapy for improving upper extremity motor recovery and functional use in adults with hemiparesis following stroke? Retrieved from http://ot.creighton.edu/community/EvidenceReviews/OTD541_09/JEnsen

%282009%29_CAT_Mirro_Therapy_UE_Motor_Recovery_CVA.pdf

.

References

Mosely, G.L & Wiech, K. (2009). The effect of tactile discrimination training is enhanced when patpients watch the relfected image of their unaffected limb during training. PAIN, 144, 314-319. doi:10.1016/j.pain.2009.04.030

Moseley, G. L., Gallace, A. & Spense, C. (2008). Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain, 138, 7-10. doi: 10.1016/j. pain.2008.06.026.

Nyberg, J. (n.d.). Mirror neurons. Retrieved from http://www.cied.uark.edu/Mirror_Neurons.pptx

Pomeroy, V. M., Clark, C. A., Miller, S., G., Baron, J., Markus, H. S. & Tallis, R. C. (2005). The potential for utilizing the “mirror neurone system” to enhance recovery of the severely affected upper limb early after stroke: A review and hypothesis. Neurorehabilitation and Neural Repair, 19, 4-13. doi: 10.1177/1545968304274351.

Ramachandram, V.S. & Alstchuler, E. L. ( 2009). The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain: A Journal of Neurology, 132, 1993-1710. doin: 10.1093/brain/awp135.

References

Stevens, J. A. & Stoykov, M. E. (2004). Simulation of bilateral movement training through mirror reflection: A case report demonstrating an occupational technique for hemiparesis. Topics in Stroke Rehabilitation, 11, 59-66.

Stralka, S. W. (2011, January 28-29). Graded Motor Imagery Program for upper extremity injuries: Using GMIP to retrain the brain). Presented for Sister Kenny at John Nasseff Conference Center, United Hospital, St. Paul, Minnesota.

TEDindia (2010, January). V.S. Ramachandran: The neurons that shaped civilizations. [Video File]. Retrieved from http://www.ted.com/talks/vs_ramachandran_the_neurons_that_shaped_civilization.html

Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. (2012) Mirror therapy for improving motor function after stroke. Cochrane Database of Systematic Reviews. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008449.pub2/full

Yavuzer, G., Selles, R., Sezer, N., Sutbeyaz, S., Bussmann, J., Koseoglu, F., Atay, M. & Stam, H., (2007). Mirror therapy improves hand function in subacute stroke: A randomized controlled trial. Achives of Physical Medicine and Rehabilitation, 89, 393-398. doi: 10.1016/j.apmr.2007.08.162.

There are two ways of spreading light: to be the candle or the mirror that reflects it. -Edith Wharton