How To Use Mirror Image Therapy for Complex Regional Pain Syndrome (CRPS)
Have you tried mirror image therapy for your Complex Regional Pain Syndrome (CRPS) or your chronic neuropathic pain condition? Mirror therapy has various titles including mirror imagery, mirror therapy, mirror visual feedback, imagery therapy, mirror image therapy… But essentially it is a non invasive, completely drug free alternative therapy to help you and your CRPS, phantom limb pain or chronic neuropathic pain. This blog will deal with 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. Apparently 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. 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)Mirror Therapy or Mirror Visual Feedback is usually started by physiotherapy but it is possible for you to continue using mirror therapy at home. 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 the article – Complete Guide to Graded Motor Imagery (GMI) for Complex Regional Pain Syndrome (CRPS).
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How Does Mirror Therapy for CRPS Work?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 sufferers in McCabe, C.S. et al. (2003) research they found that after stopping the mirror therapy the pain returned to the CRPS sufferers:
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“…when the intervention is stopped there is an abrupt return of pain.”So 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 recent 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.
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How To Carry Out Mirror Therapy ExercisesThe 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/RSD limb inside the box with the mirror on 1 side and your other ‘good’ limb in front of the mirror. 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 of 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
- Try and do some exercises little and often, for example every day
- 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!
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Mirror Therapy for CRPS ExercisesSome possible exercises you could try with the Mirror Therapy:
- looking into the mirror and concentrate on the image that you see whether it is your hand, arm, foot or leg
- move each finger separately
- tapping each finger separately and then 2 fingers, 3 fingers, then all fingers
- moving your ankle up and down
- moving your ankle in circles
- flattening out your hand
- taking a small weight on your flattened hand
As you can see from this article about how to use mirror therapy for CRPS there are a mixture of reviews and thoughts from the available research. Mirror therapy is now believed to have been overtaken by Virtual Reality. Please feel free to share this blog article on mirror box therapy treatment and Graded Motor Imagery programme or make comments below. What are your thoughts about mirror therapy for CRPS and chronic pain? Do you think it works as an effective treatment? Let us know your thoughts on this. P.S. Have you seen our blog Series of Alternative Therapies for CRPS yet or our blog series on Psychological Therapies for CRPS? Don’t forget to take a look!
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- Breivik, H. et al. (2013) ‘Mirror-therapy: An important tool in the management of Complex Regional Pain Syndrome (CRPS),’ Scandinavian Journal of Pain. 2013, October. Vol 4(4), pp 198-199. Full Text Available from: < http://www.scandinavianjournalpain.com/article/S1877-8860(13)00091-8/pdf>
- Cacchio, A. et al. Comment on research (2009) ‘Mirror Therapy for Complex Regional Pain Syndrome Type I and Stroke‘ The New England Journal of Medicine. 2009. Vol.361 pp. 634-636. 6 August 2009. Available from: < http://www.nejm.org/doi/full/10.1056/NEJMc0902799 > doi: 10.1056/NEJMc0902799 >
- Daly A & Bialocerkowski A. “Does evidence support physiotherapy management of adult complex regional pain syndrome type one? A systematic review,” Euro J Pain, in press.
- Diers, M. et al. (2015) ‘Illusion-related brain activations: A new virtual reality mirror box system for use during functional magnetic resonance imaging,’ Brain Research. 2015, January. Vol 12. 1594, pp173-82. Available from: < https://www.researchgate.net/profile/Sandra_Kamping/publication/268505237_Illusion-related_brain_activations_A_new_virtual_reality_mirror_box_system_for_use_during_functional_magnetic_resonance_imaging/links/547dbad60cf285ad5b08aa6c.pdf > doi: 10.1016/j.brainres.2014.11.001. Epub 2014 Nov 12
- Ezendam, D. et al. (2009), ‘Systematic review of the effectiveness of mirror therapy in upper extremity function,’ Disability and Rehabilitation. 2009. Vol 31 Issue 25 pp 2135-2149 Available from: <http://www.tandfonline.com/doi/full/10.3109/09638280902887768>
- Graded Motor Imagery website ‘What is Graded Motor Imagery?’ GMI website. Available from: <http://www.gradedmotorimagery.com/index.html>
- Hotta, J. (2015) ‘Painful view on motor actions,’ Body In Mind website. 2015, July 2. Available from: <http://www.bodyinmind.org/pain-motor-actions-crps/>
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- Johnson, S. et al. (2012) ‘Using graded motor imagery for complex regional pain syndrome in clinical practice: Failure to improve pain,’ European Journal of Pain. 04/2012. Vol 16(4), pp 550-561. FULL TEXT Available from: <http://www.researchgate.net/publication/221835349_Using_graded_motor_imagery_for_complex_regional_pain_syndrome_in_clinical_practice_Failure_to_improve_pain>
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- McCabe C.S. et al. (2003) ‘A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1),’ Rheumatology (Oxford). 2003; Vol 42 (1). pp 97-101. Available from: <http://rheumatology.oxfordjournals.org/content/42/1/97.long> doi: 10.1093/rheumatology/keg041
- Mirror Box Therapy (2015) ‘About Visualization Therapy,’ 2015. Available from: <http://www.mirrorboxtherapy.com/>
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- Ramachandran, V.S., Rogers-Ramachandran D. (1996) ‘Synaesthesia in phantom limbs induced with mirrors,’ Proc Biol Sci. 1996, April. Vol 263. pp 377-386. Available from: <http://www.ncbi.nlm.nih.gov/pubmed/8637922>
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