Saturday, December 27, 2014

Mirror Therapy For The Shoulder

Mirror Therapy comes in many flavours. ;-)
You can use it for a variety of different symptoms, injuries and conditions.

Normally you would use a mirror that is perpendicular to your body.
But for external rotation that just doesn't work very well.
As soon as the arm starts to move too far outwards effectiveness decreases.

This also happens with the rubber hand illusion:
if the hands are more than 60cm apart it is very hard to evoke the illusion.
Somehow the brains processing changes and it doesn't integrate the rubber hand any longer.

So for a lot of problems concerning the shoulder mirror therapy is of limited use.
This video shows you how I use this type of therapy to increase range of motion - especially external rotation.

The patient in this clip had a motorcycle accident a year ago.
After rehabilitation and a follow-up neurological exam there still was no measurable EMG activity in his deltoid and biceps muscles.
He had surgery about 4 weeks ago where they removed scar tissue to free up the nerve to help it regenerate.

When asked to externally rotate the arm his initial reaction was "I don't know what to do", i.e. he had lost even the ability to mentally perform the movement.
This is one of the - let's call it side effects of immobilisation:
it's not that the joint, the muscle can't physically do the movement - but the brain has forgotten how to do it.
This is called learned non-use and is a big problem for example in stroke patients.

So the focus of the first treatment session was to show him what external rotation looks like.
That's why he has to be able to see both shoulders in the mirror.
He moves the unaffected one and can see how it looks.
As an additional visual aid I drew lines on his scapula so that he can better see them moving towards his spine.

In order for him to be able to focus on external rotation the weight of the arm is carried by the sling.
This setup is difficult to use at home - who has all that stuff laying around? - but it works great in the clinic.

Mirror Therapy for Low Back Pain

Mirror Therapy is a very promising treatment approach for a range of chronic pain problems.
CRPS, Phantom Limb Pain, Brachial Plexus Injuries, Frozen Shoulder and a lot of other conditions can be treated with this simple technique.

It can also be used in neurological rehabilitation - for example in treating foot drop.

Several different groups of researchers have now also started researching it's effects in chronic back pain patients. One of those groups is us. ;-)

We used mirror therapy combined with a sensory discrimination training and movement training protocol: "A brief intervention utilising visual feedback reduces pain and enhances tactile acuity in CLBP patients."J Back Musculoskelet Rehabil. 2014 Nov 11.

Our initial thought was, that we needed to show the patients their unaffected side as you do when you use mirror therapy for the extremities.
That's why we used a webcam and a laptop - that way we could flip the image on the screen. We quickly found out however that that wasn't necessary at all.
Simply being able to see one's own back had a big effect on pain and the ability to move it.

Mirror Therapy in this case is used as a tool so that the patient can quickly learn how to move the back in a natural and fluid way. Not as guarded and stiff as they usually do when that part of the body hurts.

It's a "re-learning motor-control" approach as the first step of a comprehensive rehabilitation regimen. When proper motor control is established, the patient then can start functional exercises, weight training and so on and so forth.

But how are you going to train and strengthen muscles that aren't working properly because they are actively inhibited by the nervous system? Doesn't work.

In the clinic you don't have to use the high tech approach using a laptop. In this video I show you how I do it with my clients using 2 mirrors:

Since we have the space available at our clinic I like to use a mirror wall and a big mirror behind the patient. For home use you can also use 2 smaller mirrors - just set them up in such a way that you are able to see your lower back - ideally the left and the right side.

Since it's a treatment that's aimed at re-learning/re-training motor control you can move the unaffected side to see how it looks and feels. Then try it on the symptomatic side.

A lot of patients describe that when you show them a movement, they have no idea of how to do it themselves. They have lost the ability to mentally process movements that they see or do mental imagery movements themselves. This is normal, and mirror therapy is a great way to remove that "mental blockage" pretty quickly.

You can also touch the back while looking at it in the mirror. The brain doesn't care how it get's feedback from the body - just that there is some feedback to work with. ;-)

However: a combination of vision and touch is a great way to normalise maladaptive changes in the brain.
As you can see in the videos I start of the session with the patient sitting on a swiss ball. The movement I'm going for is a small lateral flexion of the lumbar spine (since that is what the low back does during walking).
The curvature of the ball helps make it easier to see and feel the back moving. After that we try the same thing while standing on an unstable surface.

I also used a pen to draw 2 lines on the back - again to make it easier for the patient to see what it should look like when he moves the spine. The lines have to go up and down just a little.

Have fun giving it a try! Questions and comments are welcome!