Brief Guide On How To Use Mirror Therapy for CRPS

Have you tried mirror image therapy as a management option for your Complex Regional Pain Syndrome (CRPS)? Mirror therapy has various titles including mirror imagery, mirror therapy, mirror visual feedback, imagery therapy, mirror image therapy...

Mirror therapy is a non invasive, completely drug free alternative therapy to help you and your CRPS, phantom limb pain or chronic neuropathic pain. This article will deal with what mirror therapy is and how to use Mirror Therapy for Complex Regional Pain Syndrome (CRPS).

Mirror therapy was first introduced by Ramachandran & Rogers-Ramachandran for the treatment of phantom limb pain. The idea behind mirror therapy is to try and ‘trick’ or retrain your brain into thinking you are moving your limb or digit; foot, leg, arm, hand, fingers, toes without pain and freely.

Essentially the brain can be effectively taught to move normally and not to think that it is in pain, this all takes a bit of practice.

Mirror therapy is a pain management technique usually started during physiotherapy but can then be continued at home with the right equipment. It is considered easy to perform and can be a useful adjunct to aid physical rehabilitation and decrease pain in Complex Regional Pain Syndrome patients. (Sayegh, S.A. et al (2013)

In Mirror Therapy, the patient sits in front of a mirror that is faced parallel to their midline blocking the view of the (affected) limb, positioned behind the mirror. When looking into the mirror, the patient sees the reflection of the unaffected limb positioned as the affected limb. This is to create a visual illusion whereby movement of or touch to the intact limb may be perceived as affecting the painful limb. (Rothgangel, A.S. et al 2011)

As with other CRPS treatments, it may work for some CRPS patients but not for others, because every CRPS patient reacts different to every available CRPS treatment. Both Mirror Therapy and Graded Motor Imagery (GMI) programmes are two specific modalities of physical therapy which are especially promising options for managing CRPS (Cochrane Review 2016).

Learn more about Graded Motor Imagery (GMI) for CRPS via our other article – Complete Guide to Graded Motor Imagery (GMI) for Complex Regional Pain Syndrome (CRPS).

Mirror therapy was originally used to treat phantom limb pain (Ramachandran V.S. et al. 1996). In the research study undertaken by McCabe, C.S. et al (2003) they say that:

"The mirror reflection permits the subject to rehearse and practice movements of the affected limb without having to directly activate those parts of maladaptive central processes that typically produce pain.”

According to Mosely, G.L. (2004) in their research they said:

“Complex regional pain syndrome type 1 (CRPS1) involves cortical abnormalities similar to those observed in phantom pain and after stroke. In those groups, treatment is aimed at activation of cortical networks that subserve the affected limb, for example mirror therapy.”

But Mosely, G.L. (2004) also says about Mirror Therapy:

"However, mirror therapy is not effective for chronic CRPS 1, possibly because movement of the limb evokes intolerable pain.”  

In another research study Mosely, G.L. et al. (2008) they stated that:

“Motor imagery increased pain and swelling in patients with chronic painful disease of the arm. The effect increased in line with the duration of symptoms and seems to be modulated by autonomic arousal and beliefs about pain and movement."

However contrary to the research by Mosely, G.L. et al (2008) in a different study a year later Ezendam, D. et al. (2009), they showed:

"… a trend that mirror therapy is effective in upper limb treatment of stroke patients and patients with CRPS…”

The results from mirror therapy are different depending on which research study you read, and even though mirror therapy may have worked for some CRPS patients, in McCabe, C.S. et al. (2003) research they found that after stopping the mirror therapy the pain returned immediately to the CRPS patients:

As you can see there are inconsistencies even in the research world about mirror therapy for CRPS. Cacchio, A. et al (2009) in their comments regarding research on mirror box therapy stated:

"... the use of mirror therapy and therapy involving imagery of movement in patients with chronic complex regional pain syndrome type 1 (lasting 6 months or more) remains controversial.”

In a study by Breivik, H. et al (2013) they said:

"As for phantom pain, attacking the “neglect-like” symptoms of CRPS with mirror-therapy may normalize the functional disorganization in the CNS, contributing to restoring functions and abolishing the pathological pain."

Many Complex Regional Pain Syndrome patients have issues with body perception. Body Perception Disturbance in CRPS is often overlooked in CRPS patients. However patients can often describe their CRPS affected area in a negative way such as repulsion, hate, anger or disgust.

For many patients they may describe their limb as if it wasn’t their own or if it wasn’t there. They may call their limb 'it' or ‘the’ instead of ‘my’. Recent research has also identified a strong desire for amputation of the affected limb, perceived changes in limb size and structure and dissociation from the limb. (Lewis, J. 2015 Practical Pain Management).

In a 2019 study by Kotiuk, V. et al, they researched the effect of Mirror Therapy on body schema disturbances registered in complex regional pain syndrome type I (CRPS I) patients which they found hadn’t actually been determined. In this study they found that Mirror therapy can improve the perception of the body schema as an element of integrated treatment of CRPS I developed after fractures of the distal radiusless than 3 years duration.

In a 2007 study where mirror therapy was combined with Cognitive Begavioural Therapy (CBT), it found that the longer the person had CRPS did have an affect on the treatment. Also the study found that the more a patient describes their affected CRPS limb as not part of their own body the less benefit from mirror box therapy was expected. The descriptions of a patient's limb not being part of their own body or not belonging to them may reflect (ir)reversible changes to the primary somatosensory cortex.

The typical approach involves placing one limb behind a mirror that is situated along an observer’s mid-line. The observer who looks at the mirror’s surface will perceive the reflected limb to be the limb that is hidden behind the mirror (Mosely, G.L. et al 2008 Pain) 

Find yourself either a fairly big mirror such as a bathroom or dressing mirror, or you can purchase a mirror box from the internet. However an ordinary mirror works just as well in fact better if you have your CRPS pain condition in your lower limbs.

• Find yourself a relaxed place where you won’t have any distractions
• Get yourself in a comfortable sitting position
• Remove any jewellery, so your limb is completely bare and free of any distractions
• If you have a mirror box then place your affected CRPS limb inside the box with the mirror on 1 side and your other ‘good’ limb facing in front of the mirror so you can see an image of your good limb. If you are using a simple mirror then place the mirror between your 2 limbs i.e. between your legs. If your CRPS is in your arms or hands then put the mirror on a table between your arms/hands
• Take a look in the mirror and you should see the reflection of your ‘good’ limb which will look like your opposite limb but in a good normal state rather than seeing your CRPS affected limb
• Begin some gentle movements or exercises that yoir physiotherapist or doctor has given you, to do with your unaffected ‘normal’ limb continue to look and focus your attention on the image in the mirror. It looks like you are moving your CRPS affected limb doesn’t it?
• Keep focusing and thinking that you are actually moving and exercising your CRPS affected limb. The idea is to ‘trick’ your mind into thinking that you are moving the bad limb
• Repeat the exercise you may have been given by your physiotherapist. If you don’t have any exercises, there are some suggestions below (please note we are not medical professionals but people with lived experience)
• Try and do some exercises little and often, for example 4 or 5 times every day for just 5-10 minutes each time, but if you start to tire or get more pain then stop
• Don’t continue if you are in severe agony because of the movements or your limb starts to sweat then you could have pushed it a little too far, so please be careful!

In conjunction with the advice of your physiotherapist, Doctor or OT, here are some possible movements you could try with the Mirror Therapy.

• Place the mirror in between your arms or legs, look into the mirror and concentrate on the image of your 'good' arm/leg that you see in the mirror whether it is your hand, arm, foot or leg

Upper Limb Exercises

• Attempt some basic moves with with your fingers, hand, arm, foot or leg for example move each 'good' finger separately all the time concentrating on the image in the mirror
• Or try tapping each finger separately and then tap 2 fingers, 3 fingers, then all fingers
• Flatten out your hand then make a fist then flatten it out again

Lower Limb Exercises

• Try to move your ankle up and down, or move your ankle in circles
• Point your toes downwards and back up
• Use a foam roller underneath your foot and roll it slowly forwards and backwards

You can find some more exercises you can do at home on the Neurorehab Directory website.

Many physiotherapists say to try to complete the exercises around 4-5 times per day for no longer than 5-10 minutes each time or sooner if you're unable to continue due to pain. But you must speak to your health professional before attempting any exercises. The information above is merely a guide. We are not trained health professionals.

As you can see from our article 'a brief guide on hhow to use mirror therapy for CRPS' there are a mixture of reviews and thoughts from the available research.

Mirror therapy is seen as a non-invasive, inexpensive, and simple applicable rehabilitation option with no significant complications. However, further large-scale studies to compare long-term outcomes in patients with hemiplegia accompanied by CRPS type 1 are still needed. (Vural, Secil Pervane, et al. 2016). Please note that Maihöfner, Christian, et al. (2004) found that the more definitive changes in the primary somatosensory cortex as in long standing CRPS, mirror box therapy appears to be less affective to retrain the brain.

However if you haven't tried mirror box therapy as part of your CRPS management plan, then do speak to your physiotherapist (physical therapist) to have a discussion about whether it is suitable for you or not.

Disclaimer

This article is for information use only. Please note mirror therapy is not meant to replace your regular current treatment regime, it is usually explained to you in a hospital or clinic setting. You must seek medical advice before attempting mirror therapy. If in doubt please contact your doctor or pain specialist. Burning Nights CRPS Support is a charity and as such are not medically trained. Burning Nights CRPS Support are not liable for any damage, injury or illness caused by the information within this blog and website. Please see our disclaimer for more information.