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, and mirror image therapy.

Mirror therapy is a drug-free, non-invasive treatment option for individuals suffering from CRPS, phantom limb pain, or chronic neuropathic pain.

In this article, we will discuss the concept of mirror therapy and its application for treating Complex Regional Pain Syndrome (CRPS). 

Ramachandran & Rogers-Ramachandran initially presented mirror therapy as an alternative solution for phantom limb pain.

Essentially, mirror therapy tricks the brain by creating the illusion of pain-free movement in limbs. A patient can use it for limbs and digits like feet, legs, arms, hands, fingers, and toes. With practice, mirror therapy teaches the brain to react normally and not feel pain.

This treatment is employed to manage the pain commonly experienced during physical therapy and can be continued at home using suitable equipment. It is easy to do and can help with physical rehabilitation and reduce pain in patients with Complex Regional Pain Syndrome. (Sayegh, S.A. et al. (2013)

Mirror Therapy involves the patient sitting in front of a mirror, with the mirror blocking their view of the affected limb, the affected limb is positioned behind the mirror.

When looking into the mirror, the patient sees the reflection of the unaffected limb positioned as the affected limb. It creates a visual illusion whereby the brain may perceive movement or touch to the intact limb as affecting the painful limb. (Rothgangel, A.S. et al 2011).

Like other treatments for CRPS, it might be effective for certain patients but not for others, as each individual with CRPS responds uniquely to each treatment option. Mirror Therapy and Graded Motor Imagery (GMI) are two particular methods of physical therapy that show great potential in treating CRPS (Cochrane Review, 2016).

You can learn more about GMI for CRPS in our other article - Complete Guide to GMI for Complex Regional Pain Syndrome.

The initial purpose of mirror therapy was to address the issue of phantom limb pain (Ramachandran V.S. et al. 1996).

According to the research conducted by McCabe, C.S. et al. (2003), it is stated 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 the research conducted by Mosely (2004), it is stated that: "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 activating cortical networks that subserve the affected limb, for example, mirror therapy."

It was further stated by Mosely (2004) that "mirror therapy is not effective for chronic CRPS 1, possibly because the movement of the limb evokes intolerable pain." In another research study, Mosely, G.L. et al. (2008) stated, "Motor imagery increased pain and swelling in patients with chronic painful disease of the arm. The effect increased in line with the symptoms' duration and seemed modulated by autonomic arousal and beliefs about pain and movement."

In contrast to Mosely's research, G.L. et al. (2008), Ezendam, D. et al. (2009) conducted a separate study a year later; they stated: "A trend that mirror therapy is effective in upper limb treatment of stroke patients and patients with CRP."

The outcomes of mirror therapy vary depending on the research study you decide to consult. While mirror therapy may have been effective for specific individuals with CRPS, McCabe, C.S. et al. (2003) discovered that the pain in CRPS patients resurfaced immediately upon discontinuing the therapy.

Some researchers disagree about whether mirror therapy is effective for CRPS. Cacchio et al. (2009) pointed out these differences when discussing the study on mirror box therapy: "The use of mirror therapy and therapy involving imagery of movement in patients with chronic complex regional pain syndrome type 1 (lasting six months or more) remains controversial."

A study by Breivik, H. et al. (2013) found that: "As for phantom pain, attacking the "neglect-like" symptoms of CRPS with mirror-therapy may normalise the functional disorganisation in the CNS, contributing to restoring functions and abolishing the pathological pain."

Many individuals suffering from Complex Regional Pain Syndrome experience difficulties perceiving their bodies.

The disturbance in body perception that occurs in CRPS patients is often disregarded. Nevertheless, patients often express negative emotions towards the area affected by CRPS, such as repulsion, hatred, anger, or disgust. 

Some patients may feel like the affected limb doesn't belong to them or is missing. They might refer to it as 'it' or 'the' instead of 'my'. New studies have discovered that individuals strongly desire to remove the affected limb. They also experience a perception that the limb has altered in size and shape. 

Additionally, they feel a sense of disconnection from the limb. (Lewis, J. 2015 Practical Pain Management). A study conducted in 2019 by Kotiuk V. et al. examined the impact of Mirror Therapy on body schema disruptions observed in patients with complex regional pain syndrome type I (CRPS I). The study revealed that these disruptions had not been identified.

In this research, it was discovered that Mirror therapy could enhance the understanding of the body's structure as part of a comprehensive approach to treating CRPS I that arises from distal fractures lasting over three years.

A study conducted in 2007 examined the combination of mirror therapy and Cognitive Behavioural Therapy (CBT) and discovered that the duration of CRPS impacted the treatment's effectiveness.

Additionally, the study revealed that patients who perceived their affected CRPS limb as separate from their own body experienced less improvement from mirror box therapy. Describing a patient's limb not being part of their own body or not belonging to them may reflect irreversible changes to the primary somatosensory cortex.

The usual method consists of positioning a limb behind a mirror in the middle of an observer. When the patient looks in the mirror, they then see their hidden limb as the one reflected on the mirror's surface. (Mosely, G.L. et al. 2008 Pain) .

Locate a sizeable mirror, like a bathroom or dressing mirror, or buy a mirror box online. However, a regular mirror is equally effective, especially if you experience CRPS pain in your lower extremities.

To prepare:

• Find a quiet place and get comfortable.
• Remove any jewellery or other items from your limb to keep it bare and undisturbed.
• If you have a mirror box, place your affected CRPS limb inside the box with the mirror on one side and your other 'good' limb facing in front of the mirror to see an image of your good limb.

If you are using a simple mirror, then place the mirror between your two limbs, i.e. between your legs. If your CRPS is in your arms or hands, 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 normal state rather than seeing your CRPS-affected limb.

Start performing gentle movements or exercises prescribed by your physiotherapist or doctor, explicitly targeting your unaffected limb and keeping your gaze fixed on the reflection in the mirror.

Keep focusing and thinking that you are moving and exercising your CRPS-affected limb. The idea is to 'trick' your mind into thinking you are moving the affected limb.

Furthermore, try to engage in brief and frequent physical activities, such as 4 or 5 daily sessions lasting only 5-10 minutes each. However, cease the exercises if you feel fatigued or experience increased discomfort.

With guidance from your physiotherapist, doctor, or OT, here are some movements to try during Mirror Therapy.

Place the mirror between your arms or legs, look into it, 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

• Try simple gestures using your fingers, hand, arm, foot, or leg. For instance, move each "healthy" finger while focusing on the reflection in the mirror.
• Try tapping each finger separately and then tap two fingers, three fingers, and 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.

Several physical therapists recommend attempting the exercises approximately four to five times daily, each lasting at most five to ten minutes. If pain prevents you from continuing, stop earlier.

You must speak to your health professional before attempting any exercises. The information above is merely a guide. We are not trained health professionals.

Our information about mirror therapy for CRPS demonstrates that ongoing studies encompass various assessments and viewpoints. Mirror therapy is regarded as a cost-efficient, readily implementable approach to rehabilitation that is non-invasive and carries minimal hazards.

Nevertheless, additional extensive research is required to compare the long-term results in individuals with hemiplegia who also have CRPS type 1. (Vural, Secil Pervane, et al. 2016).

According to a study conducted by Maihöfner, Christian, et al. in 2004, it was discovered that mirror box therapy seems to have a reduced impact on retraining the brain in cases of long-term CRPS with significant changes in the primary somatosensory cortex.

If you still need to attempt mirror box therapy as a component of your CRPS treatment strategy, it would be beneficial to consult your physiotherapist to explore its suitability.

Disclaimer

This article is for information use only.

Please note mirror therapy is not meant to replace your current treatment regime; this will be explained to you in a hospital or clinic setting.

You must seek medical advice before attempting mirror therapy. If in doubt, don't hesitate to contact your doctor or pain specialist. Burning Nights CRPS Support is a charity and is not medically trained.

Burning Nights CRPS Support is not liable for any damage, injury or illness caused by the information within this blog and website. Please see our disclaimer for more information.