Mirror Box Therapy / Mirror Visual Feedback

Mirror Box therapy

Mirror box Published with the kind permission of 23NLPeople.com

Mirror Box Therapy (or Mirror Visual Feedback (MVF)) was originally developed to help people deal with phantom limb pain, particularly in cases where a patient imagined that an amputated arm or leg was stuck in an uncomfortable position. It works by using the reflection of your good hand or leg to fool your brain into thinking that your missing hand or foot is moving. Similarly, with paralysis or muscle weakness (hemiparesis) after a stroke, looking at the reflection of your working limb may stimulate movement in your weak or paralysed limb.1Developed by VS Ramachandran, mirror box therapy is based on the idea that the brain is ‘plastic’ and able to change and reorganise itself after a serious injury. As you watch the mirror image of your movements, your brain begins to create new connections and map out new pathways. With practice, this therapy can, in some cases, stimulate movement in a paralysed hand, reduce the pain that remains after a leg has been amputated, and increase mobility in a limb weakened by stroke.2

The treatment is easy to set up. You can use a household mirror, or buy a mirror box. You sit at a table and hide your weak hand behind the mirror or inside the mirror box. You then move your good hand or foot in front of the mirror, so that it looks like your weak limb is moving. It is important not to look at the weak limb while you are doing this. Over time, your brain will try to restructure itself so that your injured limb moves at the same time as your good limb. Typically, you would practise this for a minimum of 10 minutes per day. Mirror box therapy is designed to complement an ongoing programme of treatment and should not replace any existing therapy.

  • Possible benefits of Mirror Box Therapy for stroke

    In some cases, paralysis and muscle weakness after a stroke have a psychological element. A stroke survivor may ‘neglect’ part of his or her body, or have an unconscious negative reaction to a damaged limb. It can be difficult to tell if there is a psychological aspect to the deficit left by a stroke. In 2005, a pilot study of mirror box therapy showed that it could speed up recovery for some people. Sathian et al studied a group of stroke survivors six months after their assault:

    ‘Six months post stroke the patient was given MVF for 2 weeks and there was a striking recovery of grip strength and other useful movements (e.g. opening a lock) in the paretic [partially paralyzed] arm.’3

    There have been numerous studies on the effectiveness of mirror box therapy.4 The majority of these have shown good results for a significant number of participants. For example, in 2008 in a high-quality study, 40 patients with an average age of 62 were tested within a year of their stroke. The study showed that ‘patients who received mirror therapy in addition to conventional therapy showed significant improvement’ in specific tests that measure the recovery of movement. Participants were randomly broken into two groups. Both groups continued their standard therapy, in addition to extra wrist and finger exercises. One group used a mirror while exercising; the other group used the un-reflective side of the mirror:

    ‘The treatments were carried out through a period of 4 weeks with a follow-up at 6 months (both real and placebo mirror treatments were 30 minutes per day, and standard therapy was 5 days per week, 2-5 hours per day). …  Immediately following treatment, patients who received mirror therapy in addition to conventional therapy showed significant improvement in scores of the Brunnstrom stages for the hand and upper extremity as well as in the FIM self-care score (all p<.01). The above measures also showed statistical significance in favour of the mirror group for between-group differences measured from post treatment to 6 months follow-up (all p <.05).’5

  • Arguments against using Mirror Box Therapy for stroke

    Mirror box therapy is effective where there is a psychological element to the paralysis or weakness. While this may be the case for many stroke survivors, it is not the case for everyone. Therefore, mirror box therapy does not work in every case. However, it might be hard to tell whether someone could benefit from the treatment or not until they have gone through a trial period. It has also been speculated that the success of the treatment depends, in part, on the exact location of the lesion and duration of paralysis following a stroke. If these variables are better understood, it might be possible to administer mirror box therapy to those patients who are likely to benefit most.6

    We did not find any reports suggesting that mirror box therapy could cause damage or harm to the user. This treatment costs little or nothing and can be carried out at home with minimum help from a therapist. The simplicity and lack of danger in the procedure have led doctors to suggest that it should be implemented routinely alongside other therapies.7

  • Case histories

    Mirror Box and Phantom Limb Pain #1

    This video shows how to use a mirror box for stroke and phantom limb pain:
    Video permission courtesy of www.mirrorboxtherapy.com. More parts of this video can be found here


  • Notes and references
    1. This short article describes a case where mirror box therapy was show to improve recovery after a stroke. ‘Doing It with Mirrors: A Case Study of a Novel Approach to Neurorehabilitation’ by K Sathian, Arlene I. Greenspan, and Stephen L. Wolf. In Neurorehabilitation and Neural Repair 2000;14:73-76
    2. ‘Plasticity and functional recovery in neurology’. College Lectures by VS Ramachandran. In Clinical Medicine vol 5 no 4 July 2005
    3. ‘Plasticity and functional recovery in neurology’. College Lectures by VS Ramachandran. In Clinical Medicine vol 5 no 4 July 2005
    4. ‘The use of visual feedback, in particular mirror visual feedback, in restoring brain function’ by V.S. Ramachandran and Eric L. Altschuler. In Brain 2009 132(7):1693-1710
    5. ‘Mirror Therapy Improves Hand Function in Subacute Stroke: A Randomized Controlled Trial’ by Yavuzer G., Selles R., et al. In Archives of Physical Medicine and Rehabilitation, 2008 89, 393-398.
    6. ‘The use of visual feedback, in particular mirror visual feedback, in restoring brain function’ by V.S. Ramachandran and Eric L. Altschuler. In Brain 2009 132(7):1693-1710.
    7. ‘The use of visual feedback, in particular mirror visual feedback, in restoring brain function’ by V.S. Ramachandran and Eric L. Altschuler. In Brain 2009 132(7):1693-1710

Aviva Cohen is the author and CEO of Neuro Hero