Mirror therapy for Complex Regional Pain Syndrome (CRPS)—A literature review and an illustrative case report
Authors: Sayegh Samaa Al , Filén Tove , Johansson Mats , Sandström Susanne , Stiewe Gisela , Butler Stephen 
Published: July 2013

Abstract

Background and purpose
This case of a 42 year old woman with lower extremity Complex Regional Pain Syndrome (CRPS) after a twisting injury of the ankle, effectively treated with the addition of mirror therapy to a rehabilitation programme, prompted a literature review of both CRPS and mirror therapy. Mirror therapy is a newer adjunct to other forms of pain control and functional restoration for treatment of CRPS as well as other difficult clinical problems. This was a required group project as part of a university based course in chronic pain for healthcare workers.

Materials and methods
The PubMed database up to September 26,2012 was reviewed using four search word groups: “CRPS mirror therapy”, “mirror CRPS”, “reflex sympathetic dystrophy OR Complex Regional Pain Syndrome AND mirror” and “reflex sympathetic dystrophy OR Complex Regional Pain Syndrome AND mirror + RCT”. Nine studies from PubMed met the criteria that this working group had chosen for inclusion in the analysis of mirror therapy as treatment. These references were supplemented by others on CRPS in order to generate an adequate review of both the syndrome CRPS and mirror therapy itself. Some references were specific for mirror therapy in the treatment of CRPS but others described mirror therapy for the treatment of phantom limb pain, brachial plexus avulsion pain, for physical rehabilitation of stroke related paresis and for rehabilitation after hand surgery.

Results
Criteria for the diagnosis of CRPS including the International Association for the Study of Pain criteria and the Budapest criteria are reviewed with an emphasis on the specificity and sensitivity of the various criteria for clinical and research purposes. The signs and symptoms of CRPS are a part of the criteria review.
The main treatment strategy for CRPS is physical rehabilitation for return of function and mirror therapy is one of many possible strategies to aid in this goal.
The patient in this case report had failed many of the adjunctive therapies and rehabilitation had been unsuccessful until the addition of mirror therapy. She then could progress with physical rehabilitation and return to a more normal life. Mirror therapy techniques are briefly described as part of a discussion of its success with relationship to signs and symptoms as well as to the duration of CRPS (and other syndromes). Some discussion of the theories of the central effects of both CRPS and phantom limb pain and how these are affected by mirror therapy is included.
An analysis of the 9 most relevant articles plus a critique of each is present in table form for review.

Conclusions
There appears to be a clear indication for the use of mirror therapy to be included in the multidisciplinary treatment of CRPS types 1 and 2 with a positive effect on both pain and motor function. There is also evidence that mirror therapy can be helpful in other painful conditions such as post stroke pain and phantom limb pain.

Implications
CRPS is often overlooked as an explanation for obscure pain problems. Prompt diagnosis is essential for effective treatment. Mirror therapy is a newer technique, easy to perform and can be a useful adjunct to aid physical rehabilitation and decrease pain in this population. Much further prospective research on mirror therapy in CRPS is ongoing and is needed to systematize the technique, to clarify the effects and to define the place of this therapy in the multidisciplinary management of CRPS.