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Title The Effectiveness of Using Mirror Therapy in Improving Upper
Extremity Function Among Individuals Post-Stroke
Author Kays Fihakhir, OTS; Katy Gallagher, OTS; Mackenzie Hess, OTS;
Date Reviewed Kate Jordan, OTS; Simon Komar, OTS

Date Reviewed: September 2018

Key Points for Clinical Application
Purpose/General ● Mirror therapy supposes that visual stimuli, sent to the brain
Information through observation of the unaffected body part movements,
can improve the function of the affected limb. Essentially
mirror therapy is a comparative treatment strategy aimed at
improving the function of the affected side by having the
patient observe the movements of the unaffected side.
● Mirror therapy involves placement of a one-sided mirror in the
midsagittal plane between both limbs with the mirror facing the
unaffected limb. The reflection of the unaffected limb is
superimposed on the affected limb producing the illusion of the
affected limb moving in synchrony with the unaffected limb
(Deconinck, Smorenburg, Benham, Ledebt, Feltham &
Savelsbergh, 2015)
● Even when patients have regained strength and coordination in
their shoulder and elbow joints, the functions of their fingers
and hands often have not recovered, which continue to limit the
activities of daily living. Therefore, recovery of finger and
hand dexterity is a critical component of rehabilitation in
chronic hemiplegia patients.
● Mirror therapy can increase neuroplasticity and promote
increased function in the affected upper extremity, which can
increase independence in daily activities.
Clinical Bottom Line ● Studies have shown that mirror therapy can be effective in
individuals with both sub-acute and chronic stroke (Pérez‐
Cruzado, Merchán‐Baeza, González‐Sánchez & Cuesta‐Vargas,
2017).
● Some evidence supports combining task-oriented approaches
with mirror therapy rather than using task-oriented approaches
by itself (Lim, Lee, Yoo, Yun & Hwang, 2016).
● Emerging evidence demonstrates that using task-oriented
approaches with mirror therapy is more effective than mirror
therapy by itself (Paik, Kim, Lee, Jeon, 2014).
● There are multiple outcome measures that can be used to record
the effectiveness of mirror therapy. Clinicians should use their
judgement to determine which measure to use based on their
client’s goals.
● Future research should conduct the studies on larger samples of
stroke patients to improve generalizability of results. Further,
future studies should also conduct follow-up assessments to
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determine the long-term effects of these therapies and assess
their effects on ADL.
FITT Principle Inpatient Setting (Lim et al., 2016), (Cruzado, 2017)
● F: 5 times a week for 4 weeks
● I: 20 reps and 3 sets per movement/activity (Lim et al., 2016)
● T: 20 minutes
● T: motor control, neuroplasticity

Home/Outpatient Setting
● F: 5 times a week for 4 weeks
● I: minimum of 150 repetitions (Bondoc et al., 2018)
● T: 20 minutes
● T: motor control, neuroplasticity
Intervention Specific Inpatient Setting (Lim et al., 2016)
Parameters ● Patients will imitate the reflection of the unaffected upper limb
in the mirror and then will attempt to move the affected limb in
the same way as the unaffected limb.
● Therapists provided verbal assistance to ensure that patients
were concentrating on the movements being performed by the
affected hand.
Outpatient Setting (Paik et al., 2014)
● For non task-oriented mirror therapy, patients will perform five
different movements: (a) forearm pronation and supination, (b)
wrist flexion and extension, (c) finger flexion and extension,
(d) finger numbering, and (e) opposition. Conduct movements,
in order, using the unaffected side, and each movement was
repeated 10 times.
● For task-oriented mirror therapy, the patients will perform
ADL movements (grasping and releasing balls, pinching tongs,
using a spray bottle, kneading putty, pinching coins, using a
spoon, lifting a heavy can, and wiping a table with a towel).
Frequency Inpatient Setting
● 5 times a week
● [Post-Stroke Within 6 Months, Mean Age = 65.3 years old
(Lim et al., 2016)]

Home/Outpatient Setting
● 5 times a week
● [Post-Stroke at least 3 months, age >21 years old (Bondoc et
al., 2018)]
Duration of Inpatient Setting
Treatment ● 4 weeks
● [Post-Stroke Within 6 Months, Mean Age = 65.3 years old
(Lim et al., 2016)]

Home/Outpatient Setting
● 4 weeks
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● [Post-Stroke at least 3 months, age >21 years old (Bondoc et
al., 2018)]
Time each Session Inpatient Setting
● 20 minutes
● [Post-Stroke Within 6 Months, Mean Age = 65.3 years old
(Lim et al., 2016)]

Home/Outpatient Setting
● 20 minutes
● [Post-Stroke at least 3 months, age >21 years old (Bondoc et
al., 2018)]
Intensity Inpatient Setting
● 20 reps for 3 sets per movement/activity
● [Post-Stroke Within 6 Months, Mean Age = 65.3 years old
(Lim et al., 2016)]

Home/Outpatient
● minimum of 150 repetitions
● [Post-Stroke at least 3 months, age >21 years old (Bondoc et
al., 2018)]
Progression ● Progress from simple movements (looking at reflection,
forearm pronation/supination, wrist extension/flexion, finger
flexion/extension, tapping, opposing) to simple tasks (picking
up a coin or bean, flipping a card, putting a block in a bucket)
to complex tasks (pegboard, drawing coloring) (Lim et al.,
2016).
Appropriate patients ● Individuals with acute, subacute and chronic stroke who
present with upper extremity disorders after stroke resulting in
weakened or stiff muscles, imbalance, hypertonia, and sensory
disturbances; amputees with phantom limb pain.
● Exclusion criteria: musculoskeletal conditions, neglect, major
visual deficits and cognitive deficits.
Evidence for Effectiveness Based on Level I/III/IV Evidence
Level I Evidence
● When comparing a task-oriented mirror therapy group with a
control group, both groups demonstrated an increase in
significant functional recovery in the hemiplegic upper
extremity after therapy, but the degree of recovery was greater
for the mirror therapy group. The Fugl-Meyer Motor
Assessment (FMA) scores and Modified Berthel Index (MBI)
scores significantly increased for both groups, but the degree of
recovery for the mirror therapy group was greater (Lim et al.,
2016).
● A systematic review, comparing the effectiveness of mirror
therapy with conventional rehabilitation, demonstrated that a
combination of both mirror therapy and conventional
rehabilitation is more effective in improving upper extremity
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motor function and gross manual dexterity. 20-minute sessions
of mirror therapy demonstrated a greater carry over effect than
90-minute sessions. Authors recommend mirror therapy to be
performed for 20 minutes/day, 5 days a week (Perez-Cruzado
et al., 2017).

Level III Evidence

● All participants demonstrated clinically meaningful
improvements in arm and hand function based on FMA scores
and performance of tasks within their chosen occupations
based on PSFS scores (Bondoc et al., 2018).

Level IV Evidence (Paik et al., 2014).

● Box block tests (BBT) showed that patients who engaged in
simple mirror therapy improved upper extremity function, with
a slight reduction in BBT score during Baseline 2. However,
patients engaged in task-oriented mirror therapy showed
improvements in upper extremity function that were
maintained or further improved during Baseline 2.
● Cube carry tests showed that patients who engaged in simple
mirror therapy improved ability to reach and move the upper
extremity, but the score was reduced during Baseline 2.
However, patients engaged in task-oriented mirror therapy
improved the ability to reach and move the upper extremity and
this improvement was maintained or increased further during
Baseline 2.
● Card turning tests showed that patients who engaged in simple
mirror therapy showed an increase in speed of upper extremity
movement, but the speed decreased during Baseline 2. Patients
who engaged in task-oriented mirror therapy increased the
speed of upper extremity movement during the intervention
phase and this speed was further increased during Baseline 2.
● FMA scores showed that upper extremity function improved
for all patients- both those undertaking the simple task mirror
therapy test and the task-oriented mirror therapy test. But
significantly, the average scores of the simple task patients
increased by 14 points, whereas the task-oriented patients’
scores increased by 20.5 points
Mechanisms of Recovery
● Mirror therapy creates an illusion that the affected limb is
functioning within normal limits through visual sensory input.
The reflection of the unaffected arm replaces the lost
proprioceptive sense and assists in the reconstruction of the
motor cortex and stimulation of whole-body activity (Lim et
al., 2016).
● Evidence shows that mirror therapy activates visuomotor
neurons and aides in motor recovery and allows the patient to
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observe, imagine and attempt to execute movements.
● Mirror therapy does not involve movement of the affected
limb, but it is thought to have a similar neurological effect and
produce results similar to those associated with bilateral
movement. The optical illusion that the patient is moving the
affected side is thought to activate mirror neurons (neurons that
trigger when one acts or observes contralateral actions) and
induces movement of the affected side behind the mirror.
● Hypothesized that parts of three different areas of the brain
contribute to changes in perceptuo-motor control processes
when using mirror therapy. All hypotheses show promise, but
further research is necessary (Deconinck et al., 2015):
a. Greater activation in the superior posterior parietal
cortex and posterior cingulate cortex indicates that
participants’ brains were activating the areas that
cognitively control behavior and movement in response
to increased activation and awareness of visuospatial
stimuli to resolve the perceptual incongruence.
b. Increased activation in areas of the mirror neuron
system, including the superior temporal gyrus and
premotor cortex, results in enhanced ability to imitate
movement and acquire motor skills.
c. Reduced intracortical inhibition increases the
corticospinal output to the affected side of the primary
motor cortex in individuals with stroke.
● Unilateral mirror therapy mostly affects primary and secondary
visual processing areas. Bimanual mirror therapy, in contrast,
seems to engage more frontal and parietal regions related to
higher cognitive functions like attention and monitoring.
Outcome Measures & Demonstrations
Outcome measures ● Fugl-Meyer Motor Assessment, Modified Berthel Index, Motor
Activity Log, Patient-Specific Functional Scale, Box Block
Test, Card Turning Test, and Cube Carry Test.
Video ● https://www.youtube.com/watch?v=xh8Pc6v7KAg
demonstrations
Documentation Tips ● Various CPT codes can be utilized such as therapeutic exercise
or therapeutic activity depending on the nature of the
intervention
● Document length of sustained attention to mirror therapy
tolerated each session to show tolerance building.
● Clearly document relationship between mirror therapy and
function.
● To show patient progress, document number of exercise/task
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repetitions and quality of movement each session.
● Chose a functional outcome measure assessment to monitor
progress.

Category Intervention Diagnosis Stroke

Sub Category Contemporary Motor Article https://docs.google.com/sp
Control Approach Summaries readsheets/d/1i8yWNeEh6
RZLEKXQR28fmy7qf3OC0
k_bLgo5oHntbMU/edit#gi
d=0

Bondoc, S., Booth, J., Budde, G., Caruso, K., DeSousa, M., Earl, B., Hammerton, K., &
Humphreys, J. (2018). Mirror therapy and task-oriented training for people with a paretic
upper extremity. American Journal of Occupational Therapy, 72, 7202205080.
https://doi.org/10.5014/ajot.2018.025064

Deconinck, F. J. A., Smorenburg, A. R. P., Benham, A., Ledebt, A., Feltham, M. G., &
Savelsbergh, G. J. P. (2015). Reflections on mirror therapy: a systematic review of the
effect of mirror visual feedback on the brain. Neurorehabilitation and Neural Repair,
29(4), 349–361. https://doi.org/10.1177/1545968314546134

Lim, K. B., Lee, H. J., Yoo, J., Yun, H. J., & Hwang, H. J. (2016). Efficacy of mirror therapy
containing functional tasks in poststroke patients. Annals of rehabilitation medicine,
40(4), 629-636. https://doi.org/10.5535/arm.2016.40.4.629

Paik, Y.R., Kim, S.K., Lee, J.S., & Jeon, B.J. (2014). Simple and task-oriented mirror therapy for
upper extremity function in stroke patients: a pilot study. Hong Kong Journal of
Occupational Therapy, 24, 6-12. http://dx.doi.org/10.1016/j.hkjot.2014.01.002

Pérez‐Cruzado, D., Merchán‐Baeza, J. A., González‐Sánchez, M., & Cuesta‐Vargas, A. I.

(2017). Systematic review of mirror therapy compared with conventional rehabilitation in
upper extremity function in stroke survivors. Australian Occupational Therapy Journal,
64(2), 91-112. doi:10.1111/1440-1630.12342