Mirror Therapy and the Pediatric Hemiparetic Cerebral Palsy Population

Posted on April 13th, 2013 by Denise | No Comments

Mirror Therapy and the

Pediatric Hemiparetic Cerebral Palsy Population

By

Denise Koonce OTR

Mirror therapy was initially introduced in 2005 but has been gaining attention as more therapeutic uses are being investigated and viewed to provide benefit.   Mirror therapy, rather simply, involves the use of a mirror to trick the brain, per se.  Mirror therapy is set up so the patient observes their non affected extremity moving in the mirror while attempting to mimic the movement with their affected side which is hidden behind the mirror.  Your brain takes the new mirrored image and replaces it’s previously set view of the affected side with the new mirrored view.  Mirror therapy is also referred to in the literature as mirror visual feedback (MVF) and mirror box therapy.  Mirror therapy was initially introduced and developed by Dr. V.S.  Ramachandran, a cognitive neuroscientist and the Director of the Center for Brain and Cognition, University of California, San Diego for the treatment of phantom pain in patients status post amputation.  Dr. Ramachandran’s clinical research showed that by using a mirror image of the intact extremity, whereby replacing the visual image of the amputated side, the brain used the new visual imaging to adapt it’s paraparesis response, decreasing the phantom pain.  The evidence reflected that the neuroplasticity of the adult brain is more latent than previously expected and that the brain may work more through a complex set of interacting networks instead of just through a hierarchical manner.   It has also shown positive results for patients with complex regional pain syndrome, arthritis, and neuropathic pain.  Mirror therapy was then applied to the adult stroke population with effective and promising results.  This led the medical community to the next most probable population, the pediatric hemiparetic population.  Studies were performed in the United Kingdom to determine the efficacy and effectiveness of mirror therapy in the pediatric hemiparetic cerebral palsy population and the results were published in 2010.  All of the studies showed effective results in children with a hemiparetic upper extremity.   In 2011, an article was published discussing a pilot study performed in the Paediatric Neurology and Neurorehabilitation Unit at the Centre Hospitalier Universitaire Vaudois in Lausanne, Switzerland using mirror therapy in children with hemiplegia.   This study tried to continue to answer questions posed from the previous studies performed in 2010 and also showed positive results in the use of mirror therapy in the pediatric hemiplegic population.  More studies are being conducted to determine the why, but the research community appears to have decided that mirror therapy is an appropriate therapeutic intervention for the pediatric hemiparetic cerebral palsy population. 

The item or tool necessary to engage in mirror therapy is very simple in that it basically requires a mirror.  There are products on the market that provide a box shaped entity, soft or hard sides, with a mirror on one side.  There are other products which include only the mirror and do not have a covering for the affected extremity, but due to the mirrors height, occlude from sight the affected extremity.  The difference between the various products is more around the materials surrounding or occluding the extremities and whether or not there is an enclosed entity for the affected side.  There is diversity in the products offered because it is a great tool for the patient to use in the clinic but also in their home as part of a home program.  Mirror therapy is not exclusive to the upper extremity and can be used for the lower extremity as well.  Granted, it is easier to use mirror therapy at home with an affected upper extremity than a lower extremity, because of the mirror size needed to occlude a larger extremity while performing the mirrored activities.  It is important that the patient not view their affected side while performing the tasks or activities, as some studies showed this created an adverse affect.   Studies have shown that improvements are reached faster when the frequency of mirror therapy is performed at least daily or up to 2-3 times a day.  The activities that need to be performed by the patient while using the mirror should be directed by their physical or occupational therapist.  The activities are dependent on what the patient’s diagnosis is and what movements or activities are necessary to make progress.  These can include simple active range of motions, grip and pinch activities, squeezing putty, etc.  Some companies provide picture cards of positions or movements that the patient can perform while engaged in mirror therapy.   

Mirror therapy still needs further research to fully understand how the brain is processing the information it receives and why it provides the positive results seen clinically in patients.  Fortunately, the research that has been performed concludes mirror therapy to be an effective and evidence-based treatment technique.  If you have used mirror therapy in your practice please share with us your experience and results, especially with the pediatric hemiparetic cerebral palsy population.   

                                           

References:

Feltham MG, Ledebt A, Bennett SJ, Deconinck FJ, Verheul MH, Savelsbergh GJ (2010a) The “mirror box” illusion:  effect of visual information on bimanual coordination in children with spastic hemiparetic cerebral palsy.  Mot Control 14(1):68 – 82

Feltham MD, Ledebt A, Deconinck FJ, Savelsbergh GJ (2010b) Assessment of neuromuscular activation of the upper limbs in children with spastic hemiparetic cerebral palsy during a dynamical task.  J Electromyogr Kinesiol 20(3):448-456

Feltham MG, Ledebt A, Deconinck FJ, Savelsbergh GJ (2010c) Mirror visual feedback induces lower     neuromuscular activity in children with spastic hemiparetic cerebral palsy.  Res Dev Disabil 31(6):1525-1535

Gygax MG, Schneider P, Newman CJ (2011) Mirror therapy in children with hemiplegia:  a pilot study. Dev Med and Child Neurol 53(5):473-476.

Ramachandran VS (2205) Plasticity and functional recovery in neurology. Clin Med 5(4):368-373

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