Mirror Therapy for Hemiparesis Following Stroke: A Review

  • Kasondra Hartman
  • Eric L. AltschulerEmail author
Stroke Rehabilitation (G.E. Francisco, Section Editor)
Part of the following topical collections:
  1. Stroke Rehabilitation


Purpose of Review

Ramachandran (Nature 377:489–490, 1995) showed that in amputees, phantom limb pain described as a spasming or immobile phantom limb can be alleviated by watching their reflection of the intact limb in a parasagittally placed mirror while moving the intact limb and the phantom simultaneously. This suggested that therapy via mirror visual feedback—mirror therapy—might be considered for other diseases and conditions characterized by poor mobility. We were the first to show that mirror therapy might be beneficial for hemiparesis following stroke. There have now been numerous case reports and studies of mirror therapy for hemiparesis following stroke.

Recent Findings

Overall, the majority of studies done thus far on patients with hemiparesis in the subacute or chronic phase following stroke find mirror therapy to be more beneficial than control treatments. Even when mirror therapy is not superior to control therapy, the reason for this is there are similar improvements in both groups. There have not been adverse effects in patients that perform mirror therapy for hemiparesis following stroke.


There appears to be a benefit of mirror therapy for hemiparesis following stroke in the subacute and chronic phase. Trial of mirror therapy for hemiparesis may be warranted. Further study of mirror therapy for hemiparesis following stroke will be welcomed; in particular, it would be important to study different groups of patients given the heterogeneity of stroke.


Mirror therapy Stroke rehabilitation Visual feedback Physical rehabilitation Hemiparesis Review 


Compliance with Ethics Guidelines

Conflict of Interest

Kasondra Hartman and Eric L. Altschule declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Recently published papers of particular interest have been highlighted as: • Of importance •• Of major importance

  1. 1.
    • Ramachandran VS, Hirstein W. The perception of phantom limbs. The D. O. Hebb lecture. Brain. 1998;121:1603–30. Review of phantom limbs and cortical remapping.CrossRefPubMedGoogle Scholar
  2. 2.
    •• Ramachandran VS, Rogers-Ramachandran D, Cobb S. Touching the phantom limb. Nature. 1995;377:489–90. This paper reports the discovery and the first use of mirror therapy. Google Scholar
  3. 3.
    Kim SY, Kim YY. Mirror therapy for phantom limb pain. Korean J Pain. 2012;25(4):272–4.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Weeks SR, Tsao JW. Incorporation of another person’s limb into body image relieves phantom limb pain: a case study. Neurocase. 2010;16(6):461–5.CrossRefPubMedGoogle Scholar
  5. 5.
    • Chan BL, Witt R, Charrow AP, Magee A, Howard R, Pasquina PF, et al. Mirror therapy for phantom limb pain. N Engl J Med. 2007;357:2206–7. The first randomized controlled trial of mirror therapy for phantom limb pain. Google Scholar
  6. 6.
    The Centers for Disease Control and Prevention. Stroke (2015). Retrieved from
  7. 7.
    Altschuler EL. Motor rehabilitation in a stroke patient using a mirror. Poster session (24.1408) presented at the annual meeting of the Society for Neurosciences, Los Angeles, CA (1998).Google Scholar
  8. 8.
    • Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DME, et al. Rehabilitation of hemiparesis after stroke with a mirror. Lancet. 1999;353:2035–6. The first study of the use of mirror therapy for hemiparesis following stroke. Google Scholar
  9. 9.
    • Sathian K, Greenspan AI, Wolf SL. Doing it with mirrors: a case study of a novel approach to neurorehabilitation. Neurorehabil Neural Repair. 2000;14:73–6. A case report of significant benefit of mirror therapy in a patient with hemiparesis following stroke. Google Scholar
  10. 10.
    Stevens JA, Stoykov ME. Using motor imagery in the rehabilitation of hemiparesis. Arch Phys Med Rehabil. 2003;84:1090–2.CrossRefPubMedGoogle Scholar
  11. 11.
    Stevens JA, Stoykov ME. Simulation of bilateral movement training through mirror reflection: a case report demonstrating an occupational therapy technique for hemiparesis. Top Stroke Rehabil. 2004;11:59–66.CrossRefPubMedGoogle Scholar
  12. 12.
    ∙ Sütbeyaz S, Yavuzer G, Sezer N, Koseoglu BF. Mirror therapy enhances lower-extremity motor recovery and motor functioning after stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2007;88:555–9. The first randomized controled trial of mirror therapy for the lower extremity in patients with hemiparesis following stroke. Google Scholar
  13. 13.
    ∙ Yavuzer G, Selles R, Sezer N, Sütbeyaz S, Bussmann JB, Köseoğlu F, et al. Mirror therapy improves hand function in subacute stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2008;89:393–8. The first randomzied controled trial of mirror therapy for the upper extremity in patients with hemiparesis following stroke. Google Scholar
  14. 14.
    McCabe CS, Haigh RC, Ring EF, Halligan PW, Wall PD, Blake DR. A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology (Oxford). 2003;42:97–101.CrossRefGoogle Scholar
  15. 15.
    ∙ Cacchio A, De Blasis E, Necozione S, di Orio F, Santilli V. Mirror therapy for chronic complex regional pain syndrome type 1 and stroke. N Engl J Med. 2009;361(6):634–6. A randomized controled trial of mirror therapy for patients with complex regional pain syndrome and hemiparesis following stroke. Google Scholar
  16. 16.
    Pervane Vural S, Nakipoglu Yuzer GF, Sezgin Ozcan D, Demir Ozbudak S, Ozgirgin N. Effects of mirror therapy in stroke patients with complex regional pain syndrome type 1: a randomized controlled study. Arch Phys Med Rehabil. 2016;97(4):575–81.CrossRefPubMedGoogle Scholar
  17. 17.
    Altschuler EL, Hu J. Mirror therapy in a patient with a fractured wrist and no active wrist extension. Scand J Plast Reconstr Surg Hand Surg. 2008;42:110–1.CrossRefPubMedGoogle Scholar
  18. 18.
    Rosén B, Lundborg G. Training with a mirror in rehabilitation of the hand. Scand J Plast Reconstr Surg Hand Surg. 2005;39:104–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Rostami HR, Arefi A, Tabatabaei S. Effect of mirror therapy on hand function in patients with hand orthopaedic injuries: a randomized controlled trial. Disabil Rehabil. 2013;35(19):1647–51.CrossRefPubMedGoogle Scholar
  20. 20.
    Ramachandran VS, Altschuler EL. The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain. 2009;132(Pt 7):1693–710.CrossRefPubMedGoogle Scholar
  21. 21.
    ∙ Holmes NP, Crozier G, Spence C. When mirrors lie: ‘visual capture’ of arm position impairs reaching performance. Cogn Aff Behav Neurosci. 2004;4:193–200. An excellent study in normal study which elucidates the mechanism of action of mirror visual feedback. Google Scholar
  22. 22.
    Holmes NP, Snijders HJ, Spence C. Reaching with alien limbs: Visual exposure to prosthetic hands in a mirror biases proprioception without accompanying illusions of ownership. Percept Psychophys. 2006;68:685–701.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Holmes NP, Spence C. Visual bias of unseen hand position with a mirror: spatial and temporal factors. Exp Brain Res. 2005;166:489–97.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Lundquist CB, Nielsen JF. Left/right judgement does not influence the effect of mirror therapy after stroke. Disabil Rehabil. 2014;36(17):1452–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Nilsen DM, DiRusso T. Using mirror therapy in the home environment: a case report. Am J Occup Ther. 2014;68(3):e84–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Romano D, Sedda A, Dell’aquila R, Dalla Costa D, Beretta G, Maravita A, Bottini G. Controlling the alien hand through the mirror box. A single case study of alien hand syndrome. Neurocase. 2014;20(3):307–16.CrossRefPubMedGoogle Scholar
  27. 27.
    Ramachandran VS, Altschuler EL, Hillyer S. Mirror agnosia. Proc Biol Sci. 1997;264(1382):645–7.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Ramachandran VS, Altschuler EL, Stone L, Al-Aboudi M, Schwartz E, Siva N. Can mirrors alleviate visual hemineglect? Med Hypotheses. 1999;52(4):303–5.CrossRefPubMedGoogle Scholar
  29. 29.
    ∙ Ng MJ, Singh P, Pandian JD, Arora R, Kaur P. Mirror therapy in unilateral neglect after stroke (MUST trial): a randomized controlled trial. Neurology. 2015;84(12):1286. A randomized controled trial demonstrating the benefit of mirror therapy in patients with hemineglect following stroke. Google Scholar
  30. 30.
    Nojima I, Oga T, Fukuyama H, Kawamata T, Mima T. Mirror visual feedback can induce motor learning in patients with callosal disconnection. Exp Brain Res. 2013;227(1):79–83.CrossRefPubMedGoogle Scholar
  31. 31.
    Schuster-Amft C, Henneke A, Hartog-Keisker B, Holper L, Siekierka E, Chevrier E, Pyk P, Kollias S, Kiper D, Eng K. Intensive virtual reality-based training for upper limb motor function in chronic stroke: a feasibility study using a single case experimental design and fMRI. Disabil Rehabil Assist Technol. 2015;10(5):385–92.CrossRefPubMedGoogle Scholar
  32. 32.
    Shiri S, Feintuch U, Lorber-Haddad A, Moreh E, Twito D, Tuchner-Arieli M, Meiner Z. Novel virtual reality system integrating online self-face viewing and mirror visual feedback for stroke rehabilitation: rationale and feasibility. Top Stroke Rehabil. 2012;19(4):277–86.CrossRefPubMedGoogle Scholar
  33. 33.
    Yang YR, Chen YH, Chang HC, Chan RC, Wei SH, Wang RY. Effects of interactive visual feedback training on post-stroke pusher syndrome: a pilot randomized controlled study. Clin Rehabil. 2015;29(10):987–93.CrossRefPubMedGoogle Scholar
  34. 34.
    Diers M, Kamping S, Kirsch P, Rance M, Bekrater-Bodmann R, Foell J, Trojan J, Fuchs X, Bach F, Maaß H, Cakmak H, Flor H. Illusion-related brain activations: a new virtual reality mirror box system for use during functional magnetic resonance imaging. Brain Res. 2015;12(1594):173–82.CrossRefGoogle Scholar
  35. 35.
    Michielsen ME, Smits M, Ribbers GM, Stam HJ, van der Geest JN, Bussmann JB, Selles RW. J The neuronal correlates of mirror therapy: an fMRI study on mirror induced visual illusions in patients with stroke. Neurol Neurosurg Psychiatry. 2011;82(4):393–8.CrossRefGoogle Scholar
  36. 36.
    Mehnert J, Brunetti M, Steinbrink J, Niedeggen M, Dohle C. Effect of a mirror-like illusion on activation in the precuneus assessed with functional near-infrared spectroscopy. J Biomed Opt. 2013;18(6):066001.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Wang J, Fritzsch C, Bernarding J, Krause T, Mauritz KH, Brunetti M, Dohle C. Cerebral activation evoked by the mirror illusion of the hand in stroke patients compared to normal subjects. NeuroRehabilitation. 2013;33(4):593–603.PubMedGoogle Scholar
  38. 38.
    Hamzei F, Läppchen CH, Glauche V, Mader I, Rijntjes M, Weiller C. Functional plasticity induced by mirror training: the mirror as the element connecting both hands to one hemisphere. Neurorehabil Neural Repair. 2012;26(5):484–96.CrossRefPubMedGoogle Scholar
  39. 39.
    Fritzsch C, Wang J, Dos Santos LF, Mauritz KH, Brunetti M, Dohle C. Different effects of the mirror illusion on motor and somatosensory processing. Restor Neurol Neurosci. 2014;32(2):269–80.PubMedGoogle Scholar
  40. 40.
    Lee YY, Hsieh YW, Wu CY, Lin KC, Chen CK. Proximal Fugl-Meyer assessment scores predict clinically important upper limb improvement after 3 stroke rehabilitative interventions. Arch Phys Med Rehabil. 2015;96(12):2137–44.CrossRefPubMedGoogle Scholar
  41. 41.
    Lee YY, Lin KC, Wu CY, Liao CH, Lin JC, Chen CL. Combining afferent stimulation and mirror therapy for improving muscular, sensorimotor, and daily functions after chronic stroke: a randomized, placebo-controlled study. Am J Phys Med Rehabil. 2015;94(10 Suppl 1):859–68.CrossRefPubMedGoogle Scholar
  42. 42.
    Wu CY, Huang PC, Chen YT, Lin KC, Yang HW. Effects of mirror therapy on motor and sensory recovery in chronic stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2013;94(6):1023–30.CrossRefPubMedGoogle Scholar
  43. 43.
    Kim K, Lee S, Kim D, Lee K, Kim Y. Effects of mirror therapy combined with motor tasks on upper extremity function and activities daily living of stroke patients. J Phys Ther Sci. 2016;28(2):483–7.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    In TS, Cha YR, Jung JH, Jung KS. Effects of visual feedback with a mirror on balance ability in patients with stroke. J Phys Ther Sci. 2016;28(1):181–5.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Kim H, Shim J. Investigation of the effects of mirror therapy on the upper extremity functions of stroke patients using the manual function test. J Phys Ther Sci. 2015;27(1):227–9.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Cho HS, Cha HG. Effect of mirror therapy with tDCS on functional recovery of the upper extremity of stroke patients. J Phys Ther Sci. 2015;27(4):1045–7.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Choi M, Yoo J, Shin S, Lee W. The effects of stepper exercise with visual feedback on strength, walking, and stair climbing in individuals following stroke. J Phys Ther Sci. 2015;27(6):1861–4.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Kim JH, Lee BH. Mirror therapy combined with biofeedback functional electrical stimulation for motor recovery of upper extremities after stroke: a pilot randomized controlled trial. Occup Ther Int. 2015;22(2):51–60.CrossRefPubMedGoogle Scholar
  49. 49.
    Lee D, Lee M, Lee K, Song C. Asymmetric training using virtual reality reflection equipment and the enhancement of upper limb function in stroke patients: a randomized controlled trial. J Stroke Cerebrovasc Dis. 2014;23(6):1319–26.CrossRefPubMedGoogle Scholar
  50. 50.
    Selles RW, Michielsen ME, Bussmann JB, Stam HJ, Hurkmans HL, Heijnen I, de Groot D, Ribbers GM. Effects of a mirror-induced visual illusion on a reaching task in stroke patients: implications for mirror therapy training. Neurorehabil Neural Repair. 2014;28(7):652–9.CrossRefPubMedGoogle Scholar
  51. 51.
    Michielsen ME, Selles RW, van der Geest JN, Eckhardt M, Yavuzer G, Stam HJ, Smits M, Ribbers GM, Bussmann JB. Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial. Neurorehabil Neural Repair. 2011;25(3):223–33.CrossRefPubMedGoogle Scholar
  52. 52.
    Arya KN, Pandian S, Kumar D, Puri V. Task-based mirror therapy augmenting motor recovery in poststroke hemiparesis: a randomized controlled trial. J Stroke Cerebrovasc Dis. 2015;24(8):1738–48.CrossRefPubMedGoogle Scholar
  53. 53.
    Arya KN, Pandian S. Effect of task-based mirror therapy on motor recovery of the upper extremity in chronic stroke patients: a pilot study. Top Stroke Rehabil. 2013;20(3):210–7.CrossRefPubMedGoogle Scholar
  54. 54.
    Rodrigues LC, Farias NC, Gomes RP, Michaelsen SM. Feasibility and effectiveness of adding object-related bilateral symmetrical training to mirror therapy in chronic stroke: a randomized controlled pilot study. Physiother Theory Pract. 2016;32(2):83–91.CrossRefPubMedGoogle Scholar
  55. 55.
    Colomer C, Noè E, Llorens R. Mirror therapy in chronic stroke survivors with severely impaired upper limb function: a randomized controlled trial. Eur J Phys Rehabil Med. 2016.Google Scholar
  56. 56.
    Ji SG, Kim MK. The effects of mirror therapy on the gait of subacute stroke patients: a randomized controlled trial. Clin Rehabil. 2015;29(4):348–54.CrossRefPubMedGoogle Scholar
  57. 57.
    Kim H, Lee G, Song C. Effect of functional electrical stimulation with mirror therapy on upper extremity motor function in poststroke patients. J Stroke Cerebrovasc Dis. 2014;23(4):655–61.CrossRefPubMedGoogle Scholar
  58. 58.
    Yoon JA, Koo BI, Shin MJ, Shin YB, Ko HY, Shin YI. Effect of constraint-induced movement therapy and mirror therapy for patients with subacute stroke. Ann Rehabil Med. 2014;38(4):458–66.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Lee MM, Cho HY, Song CH. The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients. Am J Phys Med Rehabil. 2012;91(8):689–96, quiz 697–700.Google Scholar
  60. 60.
    Guo F, Xu Q, AboSalem HM, Yao Y, Lou J, Huang X. The neuronal correlates of mirror therapy: a functional magnetic resonance imaging study on mirror-induced visual illusions of ankle movements. Brain Res. 2016;1639:186–93.CrossRefPubMedGoogle Scholar
  61. 61.
    Thieme H, Bayn M, Wurg M, Zange C, Pohl M, Behrens J. Mirror therapy for patients with severe arm paresis after stroke—a randomized controlled trial. Clin Rehabil. 2013;27(4):314–24.CrossRefPubMedGoogle Scholar
  62. 62.
    Invernizzi M, Negrini S, Carda S, Lanzotti L, Cisari C, Baricich A. The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial. Eur J Phys Rehabil Med. 2013;49(3):311–7.PubMedGoogle Scholar
  63. 63.
    Radajewska A, Opara JA, Kucio C, Błaszczyszyn M, Mehlich K, Szczygiel J. The effects of mirror therapy on arm and hand function in subacute stroke in patients. Int J Rehabil Res. 2013;36(3):268–74.CrossRefPubMedGoogle Scholar
  64. 64.
    Samuelkamaleshkumar S, Reethajanetsureka S, Pauljebaraj P, Benshamir B, Padankatti SM, David JA. Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial. Arch Phys Med Rehabil. 2014;95(11):2000–5.CrossRefPubMedGoogle Scholar
  65. 65.
    Pandian JD, Arora R, Kaur P, Sharma D, Vishwambaran DK, Arima H. Mirror therapy in unilateral neglect after stroke (MUST trial): a randomized controlled trial. Neurology. 2014;83(11):1012–7.CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Mirela Cristina L, Matei D, Ignat B, Popescu CD. Mirror therapy enhances upper extremity motor recovery in stroke patients. Acta Neurol Belg. 2015;115(4):597–603.Google Scholar
  67. 67.
    Brunetti M, Morkisch N, Fritzsch C, Mehnert J, Steinbrink J, Niedeggen M, Dohle C. Potential determinants of efficacy of mirror therapy in stroke patients—a pilot study. Restor Neurol Neurosci. 2015;33(4):421–34.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Radajewska A, Opara J, Biliński G, Kaczorowska A, Nawrat-Szołtysik A, Kucińska A, Lepsy E. Effectiveness of mirror therapy for subacute stroke in relation to chosen factors. Rehabil Nurs. 2016.Google Scholar
  69. 69.
    Yun GJ, Chun MH, Park JY, Kim BR. The synergic effects of mirror therapy and neuromuscular electrical stimulation for hand function in stroke patients. Ann Rehabil Med. 2011;35(3):316–21.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Mohan U, Babu SK, Kumar KV, Suresh BV, Misri ZK, Chakrapani M. Effectiveness of mirror therapy on lower extremity motor recovery, balance and mobility in patients with acute stroke: a randomized sham-controlled pilot trial. Ann Indian Acad Neurol. 2013;16(4):634–9.CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Yeldan I, Huseyınsınoglu BE, Akıncı B, Tarakcı E, Baybas S, Ozdıncler AR. The effects of very early mirror therapy on functional improvement of the upper extremity in acute stroke patients. J Phys Ther Sci. 2015;27(11):3519–24.CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Lee HM, Li PC, Fan SC. Delayed mirror visual feedback presented using a novel mirror therapy system enhances cortical activation in healthy adults. J Neuroeng Rehabil. 2015;11(12):56.CrossRefGoogle Scholar
  73. 73.
    Numata K, Murayama T, Takasugi J, Monma M, Oga M. Mirror observation of finger action enhances activity in anterior intraparietal sulcus: a functional magnetic resonance imaging study. J Jpn Phys Ther Assoc. 2013;16(1):1–6.CrossRefPubMedPubMedCentralGoogle Scholar
  74. 74.
    Zult T, Goodall S, Thomas K, Solnik S, Hortobágyi T, Howatson G. Mirror training augments the cross-education of strength and affects inhibitory paths. Med Sci Sports Exerc. 2016;48(6):1001–13.CrossRefPubMedGoogle Scholar
  75. 75.
    Sehm B, Perez MA, Xu B, Hidler J, Cohen LG. Functional neuroanatomy of mirroring during a unimanual force generation task. Cereb Cortex. 2010;20(1):34–45.CrossRefPubMedGoogle Scholar
  76. 76.
    Byblow WD, Stinear CM, Smith MC, Bjerre L, Flaskager BK, McCambridge AB. Mirror symmetric bimanual movement priming can increase corticomotor excitability and enhance motor learning. PLoS ONE. 2012;7(3):e33882.CrossRefPubMedPubMedCentralGoogle Scholar
  77. 77.
    de Almeida Oliveira R, Cintia Dos Santos Vieira P, Rodrigues Martinho Fernandes LF, Patrizzi LJ, Ferreira de Oliveira S, Pascucci Sande de Souza LA. Mental practice and mirror therapy associated with conventional physical therapy training on the hemiparetic upper limb in poststroke rehabilitation: a preliminary study. Top Stroke Rehabil. 2014;21(6):484–94.Google Scholar
  78. 78.
    Cusmano I, Sterpi I, Mazzone A, Ramat S, Delconte C, Pisano F, Colombo R. Evaluation of upper limb sense of position in healthy individuals and patients after stroke. J Healthc Eng. 2014;5(2):145–62.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science + Business Media New York 2016

Authors and Affiliations

  1. 1.The Commonwealth Medical CollegeScrantonUSA
  2. 2.Department of Physical Medicine and RehabilitationLewis Katz School of Medicine Temple UniversityPhiladelphiaUSA

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