Mirror therapy (MT)

Mirror therapy (MT) is a noninvasive treatment primarily designed to provide relief for amputees who suffer from phantom limb pain. This unique form of therapy involves the use of a mirror or mirror box to create visual stimuli that help the brain rewire itself. In effect, MT tricks the brain into thinking the affected limb is moving the same way as the unaffected limb. It does this by triggering motor pathways in the nervous system to fire just as they would if the patient were actually moving their limb. Many patients who undergo MT eventually find that the treatment allows them to move their missing limb into a more comfortable position that reduces or eliminates their phantom pain. MT can also be used to rehabilitate patients who have lost the use of a limb due to a stroke or have been diagnosed with conditions such as arthritis, carpal tunnel syndrome, and complex regional pain syndrome.

Background

The concept of MT was developed by Indian-born neurologist Vilayanur S. Ramachandran. Among other things, Ramachandran focused his attention on the challenge of phantom limb pain. Phantom limb pain is a phenomenon that often occurs in patients who have had a limb amputated. Whether their missing limb was surgically removed or lost as a result of traumatic injury, many amputees experience intense pain that seems to be coming from a part of their body that no longer exists. As phantom limb pain became a recognized condition, physicians tried to determine its cause. Some believed that it occurred simply because of damaged nerve endings. Others thought that it was a purely psychological response to amputation.

Neither of the common explanations of phantom limb pain was satisfactory to Ramachandran. He approached the problem differently. Whereas others typically viewed the brain as part of the body, Ramachandran viewed the body as part of the brain. This led him to develop a hypothesis on the cause of phantom limb pain built on the idea that the body and the brain are interdependent. Like other neurologists, Ramachandran understood that the brain holds a sort of sensory map of the body. He also understood that problems result when the body sends sensory data that does not match the map to the brain. Based on that information, Ramachandran reasoned that the signals a limb sends out before it is amputated may continue because the brain still expects signals from the missing limb after it is removed. He further believed that these trapped signals were one possible cause of phantom limb pain.

Armed with his hypothesis, Ramachandran then sought a new way to treat phantom limb pain. Preferring a simple approach, he devised a therapy method that used a mirror to simulate the existence of the missing limb and fool the brain into thinking that the limb was actually moving. When Ramachandran put this new therapy method to the test, his first patient experienced both pain relief and a reduction in the perceived size of the phantom limb itself. With those results, MT showed encouraging early results.

Overview

The technique involved in MT is relatively simple. The patient uses a mirror or mirror box to visually simulate the movement of an amputated limb by moving that limb's existing counterpart. To do this, the patient puts the remaining stump behind the mirror or inside the mirror box so that it is hidden from view. The patient then moves and performs exercises with the existing counterpart limb in front of the mirror box or mirror so that it appears as though the amputated limb is there and moving normally. By regularly repeating this easy process, most patients are able to improve their condition and reduce phantom limb pain over time. Studies of mirror therapy show mixed results, and researchers note that differences in study design and small sample sizes can affect how well the treatment appears to work.

The internal processes that make MT an effective treatment are a bit more complex. While MT is often casually described as a way of tricking the brain into thinking the amputated limb is still there, the scientific reality is more nuanced. MT actually relies on something called neuroplasticity. Neuroplasticity is the brain's ability to change and adapt as conditions require. In stroke victims, for example, neuroplasticity allows the brain to rewire itself so that functions normally controlled by a damaged part of the brain can be taken over by another part of the brain. MT helps to initiate this rewiring process to alter the brain's perception of the amputated limb.

The brain's neuroplasticity during MT may involve special cells called mirror neurons. Neurons are cells that transmit nerve impulses. When motor neurons fire in the nervous system, they tell muscles in the body to move. Mirror neurons are located in brain regions involved in movement and action observation. Unlike motor neurons, however, mirror neurons fire when a person sees movement. For example, a person's mirror neurons fire when they see another person move. When an amputee does MT and watches themselves moving their unaffected limb in a mirror, the mirror neurons start firing. This means that the brain essentially perceives the mirror image of the unaffected limb as the real affected limb. When performed repeatedly over time, MT essentially makes it possible for an amputee to learn how to move their affected limb into a more comfortable, pain-free position.

As MT came into wider use, physicians found that it had potential applications beyond serving as a treatment for phantom limb pain. MT can be particularly beneficial for stroke victims who experience paralysis of a limb or even one whole side of their body. The same is true for patients who undergo surgery to repair paralysis-causing nerve damage. In both cases, patients can gain partial or even full use of the affected limb through MT. MT can also provide similar benefits for patients dealing with conditions such as arthritis, carpal tunnel syndrome, or complex regional pain syndrome. In these instances, MT can alleviate pain by reorganizing the brain's motor and sensory cortical networks. As research into the mechanics of MT continues, even more potential benefits may be found in the years to come.

Bibliography

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