Tuesday, November 27, 2007

Mirror Box Therapy - Part I

As stated in this posting Mirror Box Treatment was first described by V.S. Ramachandran and colleagues in 1995.

As always in the Sciences he built on the work that was done before him - he just happened to connect the dots. ;-)
There are some indications that even back in the 1920's or 1930's there was a German scientist who thought along these lines - but never followed through. Imagine how different the treatment of chronic pain syndromes would've been during the past 70 years if they'd started back then!

So how does it work?
Say you have one affected limb - be it that the limb was amputated or you are suffering from CRPS.
You put a mirror in front of you - put the affected limb behind the mirror so that it is hidden from view - the other one goes on front - and you start moving both in the same fashion.


You of course know that the limb that you see in the mirror is just a reflection of the healthy one - but your brain can't.
Vision is a very useful but notoriously unreliable sense. Just look at any visual illusion to see how easy it is to fool the eyes/brain.
This is one of the best illusions ever: rotating spiral.

After staring at the spiral for about 20-30 seconds look at the back of your hand!
Even if you know that there cannot possibly be movement there you will still see something crawling under your skin - your brain gives you the illusion of movement.
There is no way you can override this illusion. Consciousness - like it or not - is just a bag of tricks.

The brain thinks that the limb in the mirror is perfectly alright (even when in reality you lost it through an amputation) - sensory-motor congruence is re-established and the brain stops sending warning messages to higher centers of the brain - what we call "pain".
Somatosensory maps are re-modeled (which happens very quickly) - and the pain is gone (forever).
This is one the key points of this type of treatment: it actually changes the very structure of your brain! (Flor, H.; M. Diers & C. Christmann et al. (2006), "Mirror illusions of phantom hand movements. Brain activity mapped by fMRI", NeuroImage 31: S159)

This type of treatment has been tested over and over again - most recently at the Walter Reed Medical Hospital - and success rates are well beyond 80% - some even report numbers as high as 95%.
All that with a treatment method that costs a maximum of 20 Dollars and only takes a few weeks.
There simply is no easier way to treat these conditions.
And the best thing: you can do it yourself!

There are a few commercial suppliers of so called mirror boxes - all favor a different approach: some are collapsible, one here in Germany favors an occupational therapy approach so you can do more difficult hand functions, ....
Fact is: it's the basic principle behind the treatment thats key - by providing (visual) feedback.

How about bilateral problems?
Well - back in March of 2003 I proposed (on the Yahoo Group Supertraining, Message 29357) that the same principle could be applied to paraplegics who often suffer from central pain. The part of the body below the spinal lesion is often felt as being very painful. I proposed to put a mirror on top of a TV set so that the brain sees the reflection of the upper body - and have a video tape show a couple of legs walking. That way the brain might be fooled into thinking that the legs are able to move and the pain should be gone.

I didn't have the resources back then to do this experiment myself - so I described it to Dr. Mel Siff whose wife is paraplegic. Unfortunately before I could describe to them how to set up the experiment Dr. Siff died and the whole enterprise came to a stop.

Enter Lorimer Moseley - the genius from Australia and one the most incredible thinkers and teachers you can imagine - and his study he published in "Pain" in 2007. He actually did what I was thinking about in 2003.
And it gives me great pleasure to say: of course it worked!

This is what I want you to recognize: don't ever ever ever - not in your job, in life or - as in my case physiotherapy (and photography) - let yourself become stuck in thinking in techniques and applications - start thinking in principles.
That way you are able to adjust what you know according to the circumstances.

The same here: it doesn't matter if you have chronic pain in a limb or in the lower back - feedback is the key. You can't see your lower back - visual feedback is out of the question - so use tactile feedback which works just as well as Herta Flor (another genius) has proven.
If you become stuck in specifics you can't treat LBP because you are thinking that is has to be visual; thinking in principles of "just give feedback" enables you to do so much more.

As for the how to - here are a few pointers:

1) concentrate - by paying attention to what you see and feel you tell the brain that something important is going on

2) 10-15 minutes at a time: you really can't concentrate any longer. Try several sessions a day.

3) Vary the movements - pick up objects, do meaningful stuff

4) take your time - there's no advantage in rushing this

5) one session before bed-time. Sleeping helps with memory consolidation and learning new things (in this case it might "only" be re-learning old things) ;-)

6) and please change your thinking about what medicine is supposed to be and have a close look at what you expect from the medical services - by doing this we'll all be better off in the future.

7) don't let yourself be discouraged to give this type of treatment a try even when "medical professionals" tell you differently. The problems here are that a) most don't know about it and it is easier to say no to a new type of treatment than to take the time to learn about it and b) we medical professionals have shaped our own expectations of what constitutes treatment based on high-tech and other modalities and have often lost sight of what else is possible. We have to realize that it isn't we that heal a person - we are often only there to help a person heal himself - just managing the whole process. The medical field needs to acknowledge this more often I think.

8) at last: try it and share your experiences. Email and comments are always welcome because they provide me with important feedback (see!) ;-) so that I can update my thinking, learn and share it with others to help even more people.

9) be playful. Understand the principle (by reading this series) ;-) and find out how it works best for you.

Here's a short video - kind of a case study so that you can see the effect mirror therapy can have on improving range of motion:


Diane Jacobs said...

Great idea you hatched Neurotopian; thanks for drawing my attention to the article and the idea.

Matthias Weinberger said...

i just want people to see that once you are able to get your head around the concept you can apply it to anything - even pains of completely different origins (at least they seem different) ;-).

Ginger Campbell, MD said...

I like the practical nature of this post.

I discovered your blog from one of my listeners. If you would like to respond to her post, please feel free to join us at the Brain Science Podcast Discussion Forum.

Here is a link to the thread:

Anoopbal said...

Do you think taping and bracing, which reduces pain and sometimes prevent injuries, might be working by the tactile feedback ( and propioreceptive)it is receiving?


Matthias Weinberger said...

Absolutely. I vaguely remember one study that found just that.
The tactile input leads to the muscles being activated before something happens so that they provide stability right from the start.

jeisea said...

A little feedback Matthias. I do mirror therapy for a very short time eg maybe 10 movement over 30 seconds. This is to lessen the chance of causing discomfort. I also only move the "good" side. I do it several times a day and try to vary the inputs by adding things like different smells (maybe aromatherapy), no fan or fan at varied speeds (touch), while tasting different things, with different sounds eg music, adding in one or a number of the sensory inputs to keep the brain training fresh each time. I had whole body intractable CRPS and struggled to isolate a less pain side to begin. Now 12 months after beginning I treat flare ups.

As you say mirror therapy stops pain. It also stops other symptoms like hysensitivity, nerve firing, muscle spasm and sweating thta go with CRPS/RSD.

It also works for acute pain and I suspect all pain. The issue is to get it right ie direct your attention to the area from which the pain starts.

Just for interest, I believe they are also using virtual reality computer technology to treat PTSD with Iraq veterans in the US.

Unknown said...

Mirror therapy was first described by V.S. Ramachandran, but has since been proven in the treatment of complex regional pain syndrome (CRPS) / RSD, and stroke rehabilitation, as well as for hand and foot rehabilitation following an injury or surgery. www.mirrorboxtherapy.com is a good place to start; it has lots of information and a link to where you can purchase a mirror box.

Unknown said...

really a usefull article,which we are unaware of it..think to be useful...i'm not sure of that back pain stuff...can u get me some ideas

vasil said...

Does this work with stroke patients that have little movement of one arm?

Matthias Weinberger said...

@vasil: yes it works in stroke patients.
The best results can be achieved in the early stages-immediately after the stroke has happened. If you start within a day or two you will be able to stop the process of learned non-use and regain at least some function very quickly.
If the stroke happened months or years ago chances of recovery are slim.

CRPS News said...

If you're living with CRPS, give mirror therapy go. It may not work for everyone though. The technique has also shown positive results in early but not late CRPS.
sympathetic nervous system disorder

Unknown said...

I'm hemiplegia patient and I made a free iPhone/iPad application for mirror-box therapy.


Unknown said...

may be applied to my mother mirror therapy, hope to recover ready, thanks for the idea.