There was a new admission on the ward, a young practicing midwife. She presented with weakness in her left arm and had lost all movement in her fingers. The delicate task of handling a new born requires more manual dexterity and fine motor control than anyone can hope to achieve so we knew the task at hand (pun intended).
Working in the acute stroke unit is a blessing as we begin therapy within a matter of hours after their admission. Using daily Functional Integration (one to one hands on) lessons I could feel that she was beginning to integrate her whole body into the movement of her arm. It was day 3 and we had full range of motion in her upper limb and sensation in her hand was completely intact though still no movement- I thought to myself
‘the brain just needs to remember it has a left hand.’
– MIRROR THERAPY – my physiotherapist colleague on the ward is brilliant and her husband made a mirror therapy box for us to trial. The results were almost instantaneous and such a wonderful addition to therapy as patients are able to complete independently after the initial set up. Unfortunately I was unable to capture our very first session on film, it was fascinating to see her concentrating intently on her right hand and her left by the magic of neuroscience begins to open and close spontaneously!
Mirror therapy consists in creating the illusion of perfect bilateral synchronization. If you put your left hand behind a mirror and your right in front, you can trick the brain into believing that the reflection of your right hand in the mirror is your left. You are now exercising your left hand in the brain, especially when you start to move your right hand. It is believed that the reflection of the intact or unaffected limb normalises the perception of the affected limb, replacing or driving proprioception movement. Proprioception is the stimuli, sensation or feedback that is activated with the movement of the body. The concept was created by Vilayanur S. Ramachandran and initially used for treating phantom limb pain of amputees. By superimposing the intact arm on the phantom limb using a mirror reflection patients reported they could move and relax the often cramped phantom limb and experience pain relief. Since then the technique has been utilised for a number of conditions including, but not limited to, complex regional pain syndrome, carpel tunnel syndrome, painful arthritis, multiple sclerosis and of course hemiplegia following a stroke. The article that sparked my initial curiosity was published through the Archive of Physical Medicine and Rehabilitation, ‘Mirror Therapy Improves Hand Function in Subacute Stroke: A Randomized Control Trial.’ The article is available here and found that after four weeks of mirror therapy improvements were noted and again at follow up 6 months later.
So first have a watch….. and then once the concept is visualised we can get into specifics.
The literature suggests that the set up is very important and paramount to success:
- Patients are to remove all items of hand verification (i.e. rings, jewellery, cover any tattoos, roll up sleeves of shirt) the brain needs to believe it is looking at the opposite hand.
- Bi lateral integration is key. Both hands are to be moved simultaneously.
- The patient is to look at the image reflected in the mirror – both hands are out of direct sight.
Many of the studies have used flexion/extension (opening and closing) of the hand as the ‘reference movement’ and recommend this be the only movement experienced. Personally I think it is a terrible movement to use as patients already apply this as their ‘test’ and judge of ‘is my hand working? will it ever work again?’ then the neck and shoulders become involved through extraneous effort to ‘get it right’ or ‘make it work.’ I have found that starting with slow gentle and minimal movements sequences to be the best option. Hand function is elicited most easily in a side lying position (little finger resting on table) as there is minimal resistance from gravity and no wrist extension involved. Begin with small circular movements of each finger (there is no ‘story’ to this movement- taking movement out of a context.) Then moving onto the sensation involved by running the thumb over the tips of each finger separately and deliberately before progressing onto every day movement sequences.
The patients need to immerse themselves into this therapy of ‘tricking the brain’ as with many neuro-plasticity driven treatment options. In order to rewire the brain and its connection patients should spend time just looking at the reflected image of their hand as ‘non affected’ and believing it is so. They need to understand why this treatment is effective what we are trying to achieve with the simulation.
Overall I found that if the patient has movement in their affected limb then mirror therapy sessions are relatively shorter than for those that have no movement. The ones with movement begin to feel that their affected limb tire and the sensation and attention returns to their actual limb rather than the reflected image. Sessions should stop when this occurs as it defeats the purpose of the experience. However the marvellous benefit of such a treatment is that there is relatively no set up involved (or it could remain permanently set up in the home) and be used for brief sessions multiple times in a day.
I began each session on the ward with a Functional Integration lesson to heighten their body awareness and overall connection to sense of self. It directed their focus to how they were moving rather than what they were moving which is exactly the mindframe required by Mirror Therapy. As Feldenkrais Practitioners we are extremely versed in explaining the workings of the nervous system and the often gentle exploratory movement of our work is exactly the approach needed in Mirror Therapy.
This has revolutionised my approach to therapy and I hope that by sharing it will spark some interest from you and carry into benefit for your clients.
Yours in Health,
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- Feldenkrais & Mirror Therapy for Stroke Patients - 14 October, 2013