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 CRPS as well as Graded Motor Imagery programme or GMI for CRPS, which is an up to date rehabilitation programme.
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 / your mind 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 programmes are two specific modalities of physical therapy which are especially promising options for managing CRPS.
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 CRPS1, 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:
“…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.
How To Carry Out Mirror Therapy Exercises
Find yourself either a fairly big 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!
Mirror Therapy for CRPS Exercises
Some 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
GRADED MOTOR IMAGERY PROGRAMME or GMI
GMI was developed by Professor Lorimer Moseley and is an up to date rehabilitation programme that has been based on clinical trials and the latest science. We already are aware that the brain in CRPS sufferers perceive any touch no matter how soft or hard as painful. The idea behind both mirror therapy and GMI is to help ‘retrain the brain’ to not be painful and in recent studies it has been shown to be effective in reducing pain levels and also improving function.
According to Johnson, R. (2014) he states that:
“GMI as a treatment is focused on training the brain to re-connect to the body part affected by pain. When you have CRPS in one part of your body, your brain “disowns” the body part, recognizing it as threat, instead of your hand or foot. When your brain recognizes a threat to your survival, it produces pain to protect you. It is an alarm system that goes off so you can treat the injured area. However, in cases of CRPS, this alarm system is faulty.”
The GMI programme involves 3 stages that exercises the brain in different ways. Those stages are:
- Left/Right discrimination – Identify left or right images of their painful limb or body part
- Explicit motor imagery – Thinking about moving without actually moving
- Mirror therapy – As in earlier in the blog
(Graded Motor Imagery website)
How Does Graded Motor Imagery (GMI) for CRPS Work?
According to the Ranelli, S. (2013) GMI uses 2 main tools including:
- Flash cards – which are a random collection of pictures of hands and feet in different postures and position and doing different tasks. They are used to help re-train the ability to recognise where the body or body part is in space
- A computer program called ‘Recognise’
- This tool uses the same pictures as in the flash cards and also assesses your accuracy (how many of the positions and postures you recognise correctly as left or right side) and the time it took for you to record your response
- This means that you can take a step-by-step approach to improving your recognition ability and this is usually associated with a decrease in pain and an improvement in your function.
Here is an video example of the ‘Recognise’ programme by the NOI group used in GMI for CRPS
As you can see from this blog about how to use mirror therapy for CRPS and GMI for CRPS that 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?
How do you think GMI has worked for you either as a CRPS patient or medical professional? Let us know your thoughts on this.
- 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 >
- 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/>
- Johnson, R. (2014) ‘Graded Motor Imagery to Treat CRPS,’ MAPS website. 2014, October 16. Available from: <http://www.painphysicians.com/blog/graded-motor-imagery-to-treat-crps>
- 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>
- Lamont, K. et al. (2011) ‘Mirror box therpay: seeing is believing,’ Explore NY & NCBI NIH PubMed. 2011, Nov-Dec. Vol 7(6). pp 369-372. Available from: < doi: 10.1016/j.explore.2011.08.002
- 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/>
- Mosely, G.L. (2004) ‘Graded motor imagery is effective in longstanding complex regional pain syndrome: a randomised controlled trial,’ Pain. 2004, March. Vol 108 (1-2) pp 192-198. Available from: <http://www.ncbi.nlm.nih.gov/pubmed/15109523> PMID: 15109523> For FULL text visit Body In Mind website <http://www.bodyinmind.org/wp-content/uploads/Moseley-2004-PAIN-graded-motor-imagery-RCT11.pdf>
- Mosely, G.L. et al. (2008) ‘Thinking about movement hurts: The effect of motor imagery on pain and swelling in people with chronic arm pain,‘ Arthritis & Rheumatology. 2008, 15 May. Vol 59 Issue 5. pp 623-631. Available from: < http://onlinelibrary.wiley.com/doi/10.1002/art.23580/full> doi: 10.1002/art.23580
- Neuro Orthopaedic Institute (2014), ‘Graded Motor Imagery,’ 2014. Available from: <http://www.gradedmotorimagery.com/mirrortherapy.htm>
- 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>
- Ranelli, S. (2013) ‘Managing CRPS – Graded Motor Imagery programme,’ Pain Health website. 2013. Available from: <http://painhealth.csse.uwa.edu.au/pain-management-CRPS.html>
- Rothgangel, A.S. et al (2011) ‘The clinical aspects of mirror therapy in rehabilitation: a systematic review of the literature,’ International Journal of Rehabilitation Research. 2011. Vol 34, pp. 1–13. Available from: <https://www.researchgate.net/profile/Andreas_Rothgangel/publication/49840686_The_clinical_aspects_of_mirror_therapy_in_rehabilitation_A_systematic_review_of_the_literature/links/59f099d4aca272cdc7cde70f/The-clinical-aspects-of-mirror-therapy-in-rehabilitation-A-systematic-review-of-the-literature.pdf>
- Sato, K. et al. (2010), ‘Nonimmersive Virtual Reality Mirror Visual Feedback Therapy & It’s Application for the Treatment of CRPS: An open-label pilot study‘ Wiley Online Library, Vol.11. Issue 2, pp. 622-629. Available from:<http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2010.00819.x/abstract;jsessionid=E5E8251F4B4E2E1C624558822E3DB010.f01t04?deniedAccessCustomisedMessage=&userIsAuthenticated=false > [April 2010]
- Selle, R.W. et al (2008) ‘Mirror Therapy in Patients with causalgia (CRPS Type II) following peripheral nerve injury: two cases’ Journal of Rehabil Med. 2008, vol 40, pp 312–314. Available from: <http://med-engineers.com/wp-content/uploads/selles2008.pdf>
*Please note mirror therapy or GMI is not meant to replace your regular current treatment regime, it is usually explained to you in a hospital or clinic setting. If in doubt please contact your doctor or pain specialist.
Last Updated: 06/03/2018