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One of the tools used in modern stroke rehabilitation work has become a mirror box. Mirror Box Therapy originally was developed from research into chronic pain and phantom limb pain – a painful condition where an amputated limb gives pain as if the limb were still present.
Neurologist and neuroplastician, V.S. Ramachandran, discovered from reviewing and examinations of many amputees that before amputation all of them had had their arms immobilised in a sling or plaster casts for a long period before the limb was amputated.
Under normal conditions, when the brain sends out a motor command to move the arm, it gets feedback from various sensory systems to confirm the order has been carried out. However when the brain of a person with an amputation sends that message to move the brain never gets the sensory information back to tell it the order has been executed because there are no motion sensors or arm to provide the information, so the brain thinks the arm is still frozen, since the immobilisation has changed the brain map to represent the arm as immobile. When the arm is removed there is no new information given to the brain so the brain retains its, now outdated, knowledge that the arm is frozen. This is similar to what is known as “learned paralysis” in stroke.
As the brain is getting no feedback and it increases its signals to move, this causes the “clenching” seen in a stroke patients hand. Phantom limb pain can feel as though the fingernails are digging into the hand. This combination of extreme contraction and pain associate themselves in memory.
Ramachandran asked the question of whether this paralysis and pain could be unlearned and this question led him to inventing the mirror box.
The original mirror box was a large box with two compartments, one for each arm to easily slide into. On one side of one of the compartments was a mirror. With each arm in the compartments (or imagined to be in the case of the amputated limb), they move the hands, as best they can, or imagine doing so, whilst looking at the unaffected hand moving in the mirror. This fools the brain into thinking that the affected arm/hand is moving normally and eventually new brain maps are stimulated to form for movement of the limb. It is thought that the mirror box works by altering the perception and relationship of pain and body image.
Ramachandran went on to research mirror box use with chronic “learned pain” in a disorder called reflex sympathetic dystrophy – type 1 chronic pain, and found mirror box work to be helpful in this problems too. From there he looked at paralysis and had equally promising results.
The mirror box in action takes the form of exercising in it every day for at least 10 minutes, although an optimum use would be two or three separate ten minute sessions each day. Normal physiotherapeutic exercises will suffice but any movement will be effective. The work is slow and requires daily use for results – results show sometimes as quickly as two weeks up to two months (sometimes there is an initial improvement and then a standstill before another improvement – the key is to keep on going).
Mirror boxes can either be made at home (there are internet sites with instructions), or bought on the internet (www.mirrorboxtherapy.com). However, the bought ones although very neatly designed to fold away, are fitted with a plexiglass mirror: latest research is showing much better results with a proper mirror rather than plexiglass.
For stroke rehabilitation work I have found that mirror box work enhances, and is enhanced by, threading and pegging exercises, plus (as the hand improves) ordinary everyday tasks like learning to fold clothes, pick up and beginning to relearn the use of kitchen utensils, making drinks, pouring, mixing etc. (and, yuck, even washing up!). Eventually, beginning to pick up a pencil and making marks etc can be utilised as ways of relearning. To make the mirror box work more fun it can be useful to put on some cheerful music and do the exercises either in time to, or with the energy of, the music.
But the most important thing of all, for the long and often frustrating work of stroke rehab, is the determination and tenacity to get well. There are many many instances (on the net) of stroke patients (not victims) recovering when it seemed as if they never would – and they all have the same thing in common – they worked hard, every day, and knew they could, and would, do it.
Gill Eardley
Life You Choose
952 030 927
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