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38 m a s s a g e & b o d y w o r k j a n u a r y / f e b r u a r y 2 0 1 5 then matches motor intent and proprioception. With repetition, this pathway is reinforced, and ultimately the phantom limb pain may subside. The key players, according to Ramachandran, are motor neurons located in the frontal and parietal lobes called mirror neurons. These cells, which by some accounts comprise up to 20 percent of our motor neurons, are activated when we observe someone else's movements. That is to say, when we watch someone walk or dance, mirror neurons in our own brains that could stimulate similar movements fire a signal. When we watch someone smile or laugh, the same thing happens. Under normal circumstances, these motor impulses are inhibited by other CNS signals before we act on them, but pain and paralysis are not normal circumstances, so these inhibitors may be bypassed. And, amazingly, when we watch someone get hurt (remember the action movie hero?), mirror neurons seem to convey a sensation of pain as well. So, the theory goes, mirror therapy works by using mirror neurons to essentially re-establish functional pathways to connect visual messages, proprioception, and motor and sensory perceptions in a pain-free way. This theory is supported by fMRI tests before and after mirror therapy. 2 Truthfully, the link between mirror neurons and the success of mirror therapy is only partially established. Ramachandran and others strongly suspect mirror neurons to be involved, but laboratory testing has not confirmed all the details. In the meantime, however, we are learning a great deal about how the brain works with pain, and that knowledge may be beneficial to a very wide audience. WHEN DOES MIRROR THERAPY WORK? The research on mirror therapy has yielded mixed findings. It appears to work better for some people than for others, but it can be difficult to predict who is most likely to benefit. It is successful more often for upper limb dysfunction than for lower limb problems, but some people with leg and foot problems derive significant benefit, too. Several specific mirror therapy protocols have been developed, and one program called "graded motor imagery" uses it as part of a progression of motor challenges in paralyzed people, with significant success. 3 One small study of six individuals for whom typical movement-centered mirror therapy was unsuccessful may be of special interest to massage therapists. In this study, a researcher added gentle stroking (that is, massage) of the healthy arm to the standard protocol. This additional element reduced pain for five of the six participants. 4 lucky, longer if she's not—sensation in the phantom limb may change. The cramping feeling may release, and the sense of being twisted may let go. This might take a while; 40–60 minutes a day for several days is not unusual. But the payoff is huge: for a while, at least, the PLP is resolved. And the next time it arises, she has an easy home-care protocol to deal with it. Similar applications have been used with CRPS patients, spinal cord injury patients, and stroke survivors. In many patients, using a mirror to reflect a healthy limb allowed them to increase their range of motion and to decrease pain—without drugs or surgery. 1 This approach, called mirror therapy, arises mainly from the work of neurologist V. S. Ramachandran. In 1996, he and his team published a paper on using mirrors to alter phantom limb pain. They went on to study mirror therapy in the context of stroke-induced paralysis, CRPS, and several other conditions. The results, while not universal, were successful often enough that mirror therapy is now a commonly employed strategy for physical and occupational therapists. HOW DOES MIRROR THERAPY WORK? The principal theory behind mirror therapy is that the mirror creates a visual perception of the limb, which Resources Moseley, L. "The Mirror Cure for Phantom Pain." Scientific American. April 16, 2008. Accessed December 2014. www.scientificamerican.com/article/the-mirror-cure. Samuel, J., S. Buxton, and W. Walker. "Mirror Therapy." Accessed December 2014. www.physio-pedia.com/Mirror_Therapy. Thieme, H., et al. "Mirror Therapy for Improving Motor Function After Stroke." Cochrane Database Systematic Reviews 14, no. 3 (March 2014): CD008449. Accessed December 2014. www.ncbi.nlm.nih.gov/pubmed/22419334.