546134

research-article2014
NNRXXX10.1177/1545968314546134Neurorehabilitation and Neural RepairDeconinck et al

Clinical Research Article

Neurorehabilitation and

Reflections on Mirror Therapy:

Neural Repair
2015, Vol. 29(4) 349­–361
© The Author(s) 2014
A Systematic Review of the Effect of Reprints and permissions:
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Mirror Visual Feedback on the Brain DOI: 10.1177/1545968314546134

nnr.sagepub.com

Frederik J. A. Deconinck, PhD1,2, Ana R. P. Smorenburg, PhD3,

Alex Benham, PhD4, Annick Ledebt, PhD5, Max G. Feltham, PhD6,
and Geert J. P. Savelsbergh, PhD5

Abstract
Background. Mirror visual feedback (MVF), a phenomenon where movement of one limb is perceived as movement of
the other limb, has the capacity to alleviate phantom limb pain or promote motor recovery of the upper limbs after
stroke. The tool has received great interest from health professionals; however, a clear understanding of the mechanisms
underlying the neural recovery owing to MVF is lacking. Objective. We performed a systematic review to assess the
effect of MVF on brain activation during a motor task. Methods. We searched PubMed, CINAHL, and EMBASE databases
for neuroimaging studies investigating the effect of MVF on the brain. Key details for each study regarding participants,
imaging methods, and results were extracted. Results. The database search yielded 347 article, of which we identified 33
suitable for inclusion. Compared with a control condition, MVF increases neural activity in areas involved with allocation
of attention and cognitive control (dorsolateral prefrontal cortex, posterior cingulate cortex, S1 and S2, precuneus). Apart
from activation in the superior temporal gyrus and premotor cortex, there is little evidence that MVF activates the mirror
neuron system. MVF increases the excitability of the ipsilateral primary motor cortex (M1) that projects to the “untrained”
hand/arm. There is also evidence for ipsilateral projections from the contralateral M1 to the untrained/affected hand as a
consequence of training with MVF. Conclusion. MVF can exert a strong influence on the motor network, mainly through
increased cognitive penetration in action control, though the variance in methodology and the lack of studies that shed light
on the functional connectivity between areas still limit insight into the actual underlying mechanisms.

Keywords
systematic review, sensorimotor control, visual feedback, mirror, hemiparesis, stroke, cerebral palsy

Introduction reflection of the limb in front of the mirror is superimposed

Often a source of fascination, or perhaps frustration, optical
illusions have captivated people since ancient times. For
instance, curved surfaces and the absence of right angles in
archaic Greek temples suggest that its architects attempted
to optically correct the illusion of slanted columns or curved
tympanums; however, others believe these features may
serve engineering purposes or reflect aesthetic preference.1
As much as they are a source of excitement, for neuroscien-
tists optical illusions are considered a backdoor into peo-
ple’s mind and provide an excellent way to study the neural
mechanisms underlying perception and action.2
Interestingly, although optical illusions are known to
deceive the individual, the false reality may fool the brain,
such that the outcome is beneficial. One such an illusion is
the mirror illusion, which has been found to have therapeu-
tic benefits over the past 2 decades. When a mirror is placed,
along the midsagittal plane in between the 2 limbs, the
on the contralateral limb. Any motion of the limb in front of
the mirror induces the illusion of 2 synchronously moving
limbs. After Ramachandran and his colleagues found that
this illusion could alleviate phantom pain in a proportion of
the patients,3 mirror visual feedback (MVF) was introduced
as a neurorehabilitation tool to treat other unilateral pain
1
Ghent University, Ghent, Belgium
2
Manchester Metropolitan University, Manchester, UK
3
Burke-Cornell Medical Research Institute, White Plains, NY, USA
4
Bradford Institute for Health Research, Bradford, UK
5
VU University, Amsterdam, Netherlands
6
University of Birmingham, Birmingham, UK
Corresponding Author:
Frederik J. A. Deconinck, Ghent University, Faculty of Medicine and
Health Sciences, Department of Movement and Sports Sciences,
Watersportlaan 2, Gent 9000, Belgium.
Email: Frederik.Deconinck@UGent.be
350 Neurorehabilitation and Neural Repair 29(4)
disorders, such as complex regional pain syndrome (CRPS).
In addition, the paradigm is now used to promote motor
recovery (eg, in hemiparetic patients or after hand
surgery).
Despite its widespread use in neurorehabilitation and
the claims that MVF therapy would lead to neuroplastic
changes, there is no consensus about the underlying mech-
anism and speculation often lacks the neuroscientific proof.
The aim of this review is therefore to bring together current
knowledge on the effect of MVF on the brain as has been
described in neuroimaging studies, in order to explore
potential processes underlying the beneficial clinical
effects of MVF. To acquaint the reader with MVF and its
current applications, we will first revisit Ramachandran’s
rationale for MVF, followed by a narrative review of the
clinical neurorehabilitation research that followed in his
footsteps. At the end of this section, we introduce 3 hypoth-
eses that have been proposed to explain the positive effects
related to MVF. Part 2 provides a systematic review and
discussion of studies that examined the effect of MVF on
brain activation patterns using neuroimaging or electro-
physiological techniques. Finally, in Part 3 we discuss the
findings of the systematic review in relation to the hypoth-
eses introduced in Part 1 and we identify where further
research is required.
Part 1: Mirror Therapy—Background,
Current Applications, and Potential
Mechanisms
The idea of using MVF for the management of phantom
limb pain was inspired by early findings on the integration
of perception and action, in particular the principle of reaf-
ference.4,5 Reafference is afferent sensory information
caused by a motor command (eg, signals from muscle spin-
dles in M. biceps brachii when the arm is actively flexed),
as opposed to exafferent information, which results from
factors outside the individual (eg, signals from muscle spin-
dles in M. biceps brachii when the arm is flexed passively).
To distinguish between these 2 sensory stimuli, it is main-
tained that the generation of a motor command is accompa-
nied by a parallel signal, termed efference copy, which
contains the sensory feedback to be expected due to this
command. Comparison of all afferent signals with the effer-
ence copy provides a way to separate signals that originate
from bodily movements and those from outside the indi-
vidual. As a consequence, motor commands that are not
instantaneously followed by the expected reafferent feed-
back will be modified in an attempt to evoke the expected
sensory afference.5 It is this conflictive state that, according
to some,6,7 may evolve into a form of “learned paralysis”
accompanied by a feeling of painful spasms,* as experi-
enced by a proportion of patients who have had an arm or
leg amputated. The goal of MVF is to restore the efference–
afference loop that has been interrupted. MVF of the intact
limb deceives the individual and elicits the awareness that
the amputated limb is still intact, not at least due to the dom-
inance of the visual system over other modalities.8,9 Indeed,
when the illusion was tested in arm amputees with com-
plaints of “clenching spasms” and phantom limb pain, the
spasms were eliminated and the pain was relieved immedi-
ately after exposure to MVF in a proportion of the
sample.3
The novelty and simplicity of the idea, in combination
with the far-reaching potential of MVF, prompted clinicians
and researchers to replicate the initial findings of
Ramachandran and colleagues. Consistent with the earlier
observations, follow-up studies have confirmed that MVF
treatment has the capacity to reduce phantom limb pain
intensity and duration.10,11 Moreover, the notion that many
neurological disorders with unilateral pain and motor symp-
toms may be (partly) caused by maladaptive cortical reorga-
nization involving a disruption of the efference–afference
loop, led others to apply MVF to a wide range of conditions.
Hemiparesis after stroke is perhaps the most striking exam-
ple. In a proportion of the patients the paresis is thought to
be a form of “learned paralysis” due to a nonpermanent
blocking of corticofugal fibers by swelling after the
trauma.12 A recent Cochrane Review exploring the effec-
tiveness of MVF therapy in patients after stroke (13 ran-
domized controlled trials, 506 patients) concluded that
mirror therapy indeed might be more effective in promoting
motor function than a control intervention† when used as an
adjunct to conventional therapy.13 Furthermore, the meta-
analysis indicated that the effects were retained, up to 6
months after the intervention, and that MVF therapy had a
significantly greater effect than control interventions on
activities of daily living and on pain, though the latter was
found only in a subgroup with CRPS after stroke.
To date, MVF is administered to treat various unilateral
pain and/or motor disorders, including CRPS,14-18 hemipa-
resis after stroke,19,20 reduced mobility after wrist fracture,21
and spastic hemiparetic cerebral palsy (SHCP).22,‡ The find-
ings of these studies tend to corroborate the initial work,
that is, a reduction in pain and improvement in motor func-
tion. Still, it should be noted that publication bias toward a
*In their recent review article, Ramachandran and Altshuler9 rec-
ognize that the origin of phantom pain is still poorly understood
and may be related to other factors, for example, persistence of
preamputation pain and pathological “remapping” among others
(see also Ramachandran and Hirstein6). The rationale to use MVF,
however, is based on the notion of a mismatch between motor out-
put and visual and/or proprioceptive feedback.
†
The effect of MVF therapy was significantly larger than control
interventions.
Deconinck et al 351
selection of positive results may be likely and additional
placebo-controlled studies are needed for all conditions or
symptoms. In this respect, it is worth mentioning that
Brodie et al found that the attenuating effect of MVF on
pain was not stronger than a control condition in lower limb
amputees.23
Despite the fact that there appear to be parallels in the
pathophysiology of unilateral pain and motor disorders as
described by Ramachandran and Altschuler,12 the 2 phe-
nomena should be considered separately, hence the focus of
this review will be on the effects of MVF on sensorimotor
control. To fully exploit the potential of MVF, a better
insight into the processes that underlie the beneficial effects
on motor function is required. Not only would this knowl-
edge advance our theoretical understanding of the brain, it
may also provide guidelines as to when MVF may be useful
and how it should be applied.
When the individual is required to perform bilateral,
symmetrical motor tasks, MVF therapy may be considered
a special form of bilateral training, and hence exploit simi-
lar mechanisms (see Cauraugh and Summers for a
review24). However, in search of the added value of MVF
researchers have invoked 3 (not mutually exclusive)
hypotheses to account for the positive effects of MVF on
motor recovery. A first hypothesis relates to the mirror
neuron system.17,19,20 Mirror neurons fire both when an
individual observes an action and when he/she performs a
similar action. The network, including the premotor cor-
tex, supplementary motor area, inferior frontal gyrus, and
inferior parietal lobule of the brain, is thought to play an
important role in action recognition and motor learning or
rehabilitation.25 An observation/execution matching
mechanism, whereby action observation activates crucial
parts of the motor system, is hypothesized to induce motor
learning.25,26 It is known that action observation facilitates
the corticospinal pathway and this paradigm is already
used in neurorehabilitation as mental practice aimed at
improving motor function.27 According to this hypothesis,
a “mirror box” is a means to facilitate action observation
and therefore MVF is thought to activate the mirror neu-
ron system in a similar way to action observation
(Hypothesis 1). In line with this is the notion that MVF
may elicit or enhance motor imagery,28 that is, internal
simulation of movement without overt action. Just like
action observation motor imagery has been attributed ther-
apeutic capacities because it activates neural circuits
involved in motor control.29
‡
See Ramachandran and Altschuler9 for a list of clinical cases
where the use of MVF has been observed informally but has not
been described in the literature.
Second, MVF might promote recruitment of ipsilateral
motor pathways.30 These motor pathways, originating in the
unaffected hemisphere and projecting ipsilaterally to the
paretic body-side, have been attributed a nontrivial role in
the restoration of motor function in hemiparesis.31-34 It is
hypothesized that MVF might facilitate the unmasking of
“dormant” ipsilateral projections, which are normally inhib-
ited (Hypothesis 2).
Finally, MVF or the associated illusion is thought to
increase an individual’s (spatial) attention toward the
unseen (affected) limb.35 It is known that hemiparetic
patients may end up in a state of “learned nonuse,” by con-
tinuously avoiding the use of the paretic hand or by patho-
physiological disruption of the efference–afference loop.36
In keeping with the rationale for using constraint-induced
movement therapy,36 the increased attention toward the
affected limb, mediated by the illusory image of a “healed”
paretic limb, may activate motor networks (Hypothesis 3).
In sum, an increasing body of evidence underpins the
potential of MVF to facilitate recovery of motor function.
Still, the neural mechanism of MVF, whether the behavioral
effect is accompanied by neuroplastic changes, and what
this reorganization would involve is unclear. The hypothe-
ses invoked to explain MVF effects are based on known
concepts in neurorehabilitation, but they remain specula-
tive. Recent experimental neuroimaging research has begun
to reveal the extent of brain activation during movement
with MVF, and its modulatory effects on brain processes
compared with normal visual conditions. In the following
part of this article, the findings of these studies will be sys-
tematically reviewed. This will serve as a validity test of the
proposed hypotheses.
Part 2: The Neural Correlates of
Mirror Visual Feedback
Purpose
The purpose of this systematic review was to identify the
areas in the brain that are differentially affected or modu-
lated by MVF compared with a condition with normal or
without visual feedback.
Literature Search
A literature search using the electronic databases PubMed,
CINAHL, and EMBASE (1972 to January 2014) was con-
ducted. Search terms included “mirror therapy” or “mirror
visual feedback” combined with “functional magnetic reso-
nance imaging (fMRI),” “positron emission topography
(PET),” “transcranial magnetic stimulation (TMS),” “mag-
netoencephalography (MEG),” “electroencephalography
352 Neurorehabilitation and Neural Repair 29(4)

Search of bibliographic databases:

PubMed, CINAHL, EMBASE
+
Personal database

Outcome N = 347
Databases: N = 341 records
Personal databases: N = 6 records
Main reasons for exclusion:
1st stage screening of titles - Methodology did not
and abstracts by 2 involve MVF
independent reviewers - Methodology did not
involve neuroimaging
N = 41 records
Main reasons for exclusion:
2nd stage screening of full - Neuroimaging only for
texts by 2 independent diagnostic purposes, not
reviewers for measuring effect MVF
(N = 2)
Final selection: - Effect of MVF on pain or
N = 33, including 12 fMRI, 9 TMS, 5 MEG, 4 EEG, 2 tactile perception, not
PET, and 2 NIRS motor control (N = 4)
- See Supplementary
Material for details.

Figure 1.  Flow diagram of the article selection process.

(EEG),” or “near infra-red spectrometry (NIRS).” In addi- Results

tion, we checked our personal database and the reference
list of included articles. Our search was restricted to peer-
reviewed full articles written in English.
Inclusion criteria were the following:
•• Experimental studies or clinical trials
•• Normal and/or motor-impaired human participants
•• Use of neuroimaging techniques (fMRI, PET, MEG,
EEG, NIRS) or TMS to study the effect of MVF* on
cortical activation (and related motor performance or
perceptual measures)
Exclusion criterion was the following:
•• Studies that do not assess effect of MVF on senso-
rimotor control, but focus on pain and/or tactile
perception.
The records identified by this search were screened inde-
pendently by 2 authors of this systematic review (FD and
AS) in 2 stages: a first stage screening of titles and abstracts
and a second stage using the full text of the remaining
article. The lists of eligible articles identified by the indepen-
dent reviewers were compared, and any disagreements were
resolved through discussion (and referral to the text of the
articles in question).
The electronic database search yielded 347 unique articles,
of which 33 were deemed eligible for this systematic review
(see Figure 1 for an overview of the selection process).
Across the selected articles, the most commonly used scan-
ning technique was fMRI (12 studies).37-47 MEG was the
neuroimaging modality in 5 article,48-52 EEG in 4,53-56 PET
in 2,57,58 and NIRS in 2.59,60 Nine studies investigated the
effect of MVF on cortical activation with TMS47,61-68; 1
study used both TMS and fMRI.47 In Tables 1 to 4, the
included articles and their methodologies are listed accord-
ing to modality. The majority of the studies (n = 27) exam-
ined immediate modulatory effects when exposed to MVF,
of which 22 focused on healthy individuals and 5 on stroke
patients (Tables 1-3). In 16 studies, MVF was provided in
a bilateral fashion, that is, not obscuring the active hand.
Six studies assessed neuroplastic changes in response to a
bout of practice or an intervention in healthy individuals (n
= 3) or stroke patients (n = 3). Here, bilateral MVF was
used in all but one study (Table 4 and Supplementary
Material). The variance in methodology and motor task,
which may be unilateral or contralateral, complicates the
overall interpretation of the observations. A factor that
*Mirror visual feedback could be induced by a real mirror or using
a virtual reality environment.
Deconinck et al 353

Table 1.  Outline of the Methodology, Type of MVF, Measures to Avoid Systematic Variation in Movement Across Conditions, and
Known Potential Confounds in All Experimental Studies Using fMRI Included in the Systematic Review.
Outline of Experimental Methodology Relevant to (a) Measures to Avoid Systematic
Study Reference Participants This Review Type of MVF Variation (b) Potential Confounds

Diers et al (2010)37 9 healthy individuals aged
51.9 ± 6.9
Dohle et al (2004)38 6 healthy individuals aged
29.0 ± 1.5
Fritzsch et al (2013)39 15 healthy individuals aged
22-56
Matthys et al (2009)46 18 healthy individuals aged
22-48
Merians et al (2009)47 3 healthy individuals aged 26.8 and
1 stroke patient aged 70.0
Michielsen et al (2011)40 18 stroke patients aged
54.7 ± 9.9
Shinoura et al (2008)41 5 healthy individuals aged 21-57 and
2 patients with brain tumor aged
47 and 67
Wang et al (2013)42 15 healthy individuals aged
22-56
Wang et al (2013)43 15 healthy individuals aged 22-56
and 5 stroke patients aged 50-72
Repetitive clenching of the fist at dominant side Bilateral (a) Metronome paced
with (1) normal VF, (2) MVF of active hand, or (b) No statistical comparison
(3) during motor imagery between conditions
Static condition vs finger-thumb opposition with Unilateral (a) Metronome paced
(1) virtual VF of hand; (2) virtual MVF of hand
Unilateral index finger-thumb opposition of either Unilateral (a) Metronome paced
left or right hand with (1) virtual VF, (2) virtual
MVF
Tapping right index finger with (1) VF active hand; Bilateral (a) None
(2) MVF active hand
Finger tapping right hand with (1) virtual VF active Unilateral (a) None
hand; (2) virtual MVF active hand (b) Lack of control condition
Unimanual (nonaffected hand) and bimanual Bilateral (a) Metronome paced
clenching movement with (1) VF; (2) MVF
Unimanual and bimanual clenching of hand(s) with Bilateral (a) None
(1) eyes closed; (2) MVF of (one of the) active (b) No statistical comparison
hand(s) between conditions
Movement performance task: Unilateral index Unilateral (a) Number of repetitions
finger-thumb opposition of either left or right counted post hoc
hand with (1) virtual VF, (2) virtual MVF.
Movement observation task: Observation of
similar action on video
Unilateral index finger-thumb opposition of either Unilateral (a) Number of repetitions
left or right hand with (1) virtual VF, (2) virtual counted post hoc
MVF

Abbreviations: MVF, mirror visual feedback; VF, normal visual feedback. Bilateral MVF, active hand and its mirror reflection; Unilateral MVF, MVF of active hand only. MVF
was generated by a mirror placed in between the arms in the sagittal plane, except when stated otherwise.

adds to this difficulty is the absence of a standard control
condition. In some studies, MVF is contrasted with normal
full vision of the 2 limbs, whereas in others visual feedback
of the active or static limb only is used as a control.
Furthermore, to isolate the effect of MVF on brain activa-
tion it is crucial to keep the movement (range, frequency,
intensity) constant across MVF and control conditions,
which a number of studies have failed to do or to control
for (see Table 1-4 for details).
Instant Neuromodulatory Effects of MVF.  The neuromodula-
tory effects of MVF refer to changes in activity or excitation
that are evoked by MVF, that is, revealed by direct compari-
son of MVF with a control condition (listed in Table 5).
MVF evokes a conflict between expected and actual feed-
back (cognitive conflict) and between visual and kinaes-
thetic feedback (perceptual conflict). This conflict is most
obvious when performing unimanual or asymmetric biman-
ual tasks, although even during symmetric bimanual actions,
the perfect interlimb symmetry is perceived as surreal. In
this latter case, MVF is accompanied with an increase of
activity within the superior parietal lobe (precuneus [bilat-
eral] and superior posterior parietal cortex [contralateral]40),
the posterior cingulate cortex,58 and ipsilateral lateral sul-
cus51,52 compared to a condition with full vision of the 2
hands.
MVF inducing a more extreme conflict (during uniman-
ual actions) stimulates activity within primary visual and
somatosensory areas, as well as higher order processing
areas in the occipital and parietal cortex ipsilateral to the
moving limb.38,39,42,43,46,60 In fact, the mirror inverts the lat-
eralization that is normally associated with the presentation
of a right or left hand in these regions. Note, however, that
these observations stem from studies that contrasted virtual
MVF of the active hand with virtual VF displayed in the
frontal plane (on a screen or onto MRI-compatible goggles).
Other studies show increased activation in the right dorso-
lateral prefrontal cortex (DLPFC),58 the contralateral sec-
ondary sensory cortex (SII),51 the ipsilateral superior
temporal gyrus (STG),46 and the contralateral insular
cortex.52,57
Finally, MVF modulates activity of the primary motor
cortex, both ipsilateral and contralateral to the active hand
reflected into the mirror, though the findings are somewhat
inconsistent. The majority of the studies suggest an increase
in ipsilateral M1 excitability or increased ipsilateral activa-
tion as indicated by a change in laterality index (vs a control
condition).47,53,55,56,63,65-68 Hadoush et al claim that this
effect is more prominent for unimanual MVF, that is, when
the active hand (reflected into the mirror) is covered.48
Others show that the increase in excitability is observed
particularly when MVF and motor imagery are com-
bined.66,68 Investigation of the potential mediators of this
effect suggests that MVF has the capacity to neutralize the
(interhemispheric) inhibition from contralateral to ipsilat-
eral hemisphere. Still, it should be noted that a number of
354 Neurorehabilitation and Neural Repair 29(4)

Table 2.  Outline of the Methodology, Type of MVF, Measures to Avoid Systematic Variation in Movement Across Conditions, and
Known Potential Confounds in All Experimental Studies Using TMS Included in the Systematic Review.
Study Reference
63
Carson and Ruddy (2012)
Fukumura et al (2007)68
Funase et al (2007)64
Garry et al (2005)65
Kang et al (2011)66
 
Kang et al (2012)67
 
Merians et al (2009)47
Participants
12 healthy individuals aged
21.5 ± 3.4
6 healthy individuals aged
20-39
12 healthy individuals aged
19-40
8 healthy individuals aged
39.6 ± 14.5
30 healthy individuals aged
28.0 ± 2.4 and 30 stroke
patients aged 66.0 ± 11.0
18 healthy individuals aged
30.9 ± 2.2 and 18 stroke
patients aged 61.3 ± 11.6
1 healthy individual
(a) Measures to Avoid
Systematic Variation
Outline of Experimental Methodology Type of
Relevant to This Review MVF (b) Potential Confounds
Exp 1: Flexion-extension of left wrist with Bilateral (a) Metronome paced,
(1) VF of nonmoving right hand; (2) MVF of EMG recording
moving left hand; (3) no VF
Flexion-extension of left wrist with (1) VF Bilateral (a) Metronome paced
left hand; (2) VF left + motor imagery right
hand; (3) MVF left hand; (4) MVF left +
motor imagery right hand; (5) MVF left +
passive movement right hand; (6) MVF +
passive movement and motor imagery right
hand
Flexion-extension left hand or left index finger Bilateral (a) Metronome paced
and wrist with (1) VF left side; (2) MVF left
side
Finger-thumb opposition with (1) VF active Bilateral (a) Metronome paced,
hand; (2) VF inactive hand; (3) neutral VF; EMG recording
(4) MVF active hand
Thumb abduction/adduction with (1) VF active Bilateral (a) Metronome paced
hand + motor imagery; (2) MVF active hand
+ motor imagery inactive hand; (3) MVF
active hand + motor imagery of asymmetric
movements inactive hand
Passive task with (1) motor imagery of right  
hand; (2) AO other hand + motor imagery
own right hand; (3) MVF + motor imagery
other hand
Exp 1: TMS across nondominant/affected Bilateral (a) Metronome paced
hemisphere during unilateral flexion-
extension of the dominant/unaffected wrist
with (1) MVF, (2) virtual MVF, or during (3)
relaxation
Exp 2: TMS across nondominant/affected  
hemisphere during unilateral flexion-
extension of the dominant/unaffected
wrist with (1) continuous virtual MVF, (2)
intermittent virtual MVF
Finger tapping right hand with (1) virtual VF Bilateral (a) None
active hand; (2) virtual MVF active hand

Abbreviations: MVF, mirror visual feedback; VF, normal visual feedback; AO, action observation; Exp, experiment. Bilateral MVF, active hand and its mirror reflection;
Unilateral MVF, MVF of active hand only. MVF was generated by a mirror placed in between the arms in the sagittal plane, except when stated otherwise.

studies could not find changes in activity within the ipsilat-
eral M1 evoked by MVF.39,60,64
Neuroplastic Effects Due to Practice or Intervention With
MVF.  Six studies have examined the effect of a bout of prac-
tice or treatment with MVF on motor function while also
measuring the change in brain activity pre and post training
(see Table 4 for details).44,45,54,61,62,69 Consistent with earlier
reports training with MVF resulted in a gain in motor func-
tion of the untrained or affected hand in all studies. This
gain seems to be related to an enhanced excitatory function
of the (contralateral) corticospinal pathway projecting to
this hand (ie, decrease in motor threshold and intracortical
inhibition within M1 ipsilateral to the trained hand).61,62
After training the activation balance when moving the
affected hand has shifted toward M1 of the affected hemi-
sphere, indicating increased activation of the affected side
and/or decreased activation of the contralesional side.45,54,69
This would imply a reestablishment the hemispheric bal-
ance that was disrupted by the insult. Another study sug-
gests, however, that the improvement of untrained hand is
related to the establishment of a functional connection
between this hand and the ipsilateral motor cortex (ie, M1
contralateral to the trained hand).44 Dynamic causal model-
ing and functional connectivity analysis further indicates
that this reorganization is mediated by enhanced connectiv-
ity between the premotor cortices (both left and right) and
the ipsilateral supplementary motor area.
Deconinck et al 355

Table 3.  Outline of the Methodology, Type of MVF, Measures to Avoid Systematic Variation in Movement Across Conditions, and
Known Potential Confounds in All Experimental Studies Using PET, MEG, EEG, and NIRS Included in the Systematic Review.
Study Reference Modality
57
Dohle et al (2011)
Fink et al (1999)58
Hadoush et al (2013)48
Tominaga et al (2009)49
Tominaga et al (2011)50
Wasaka and Kakigi
(2012)52
Wasaka and Kakigi
(2012)51
Praamstra et al (2011)55
Touzalin-Chretien et al
(2008)56
Touzalin-Chretien et al
(2010)53
Imai et al (2008)59
Mehnert et al (2013)60
(a) Measures to Avoid
Systematic Variation
Outline of Experimental Methodology
Participants Relevant to This Review Type of MVF (b) Potential Confounds
PET 10 healthy individuals Unilateral circular movement of left or right Unilateral (a) Metronome paced
aged 19-42 arm with (1) VF; (2) virtual MVF
PET 10 healthy individuals Luria’s bimanual circle drawing task: (1) Bilateral (a) None
aged 20-73 in-phase with VF; (2) in- phase with MVF;
(3) out-of-phase with VF; (4) out-of-phase
with MVF
MEG 10 healthy individuals Index finger extension with MVF of active Bilateral (a) None
aged 22-35 hand, (1) with VF of active hand or (2)
without VF of active hand
MEG 11 healthy individuals Stimulation of right median nerve at wrist Unilateral (a) N/A
aged 19-34 while holding a pencil with (1) MVF of right
hand; (2) VF of right hand; (3) MVF of left
hand; (4) VF of left hand
MEG 13 healthy individuals Stimulation of right or left median nerve at Unilateral (a) N/A
aged 19-34 wrist while holding a pencil with (1) MVF
of right hand; (2) VF of right hand; (3) MVF
of left hand; (4) VF of left hand
MEG 10 healthy individuals Stimulation of left median nerve at wrist Bilateral (a) None
aged 24-46 while flexing-extending left thumb
repetitively or at rest with (1) MVF of
stationary right hand; (2) VF of both hands
MEG 10 healthy individuals Stimulation of left median nerve at wrist Bilateral (a) None
aged 28-46 while flexing-extending left and right
thumb repetitively symmetrically or
asymmetrically with (1) MVF of right hand;
(2) VF of both hands
EEG 9 healthy individuals aged Extension-flexion right or left index finger Unilateral (a) Set number of trials,
32 ± 11 with (1) VF active finger; (2) MVF active EMG recording
finger
EEG 11 healthy individuals Key press with right hand [except (4)] with Unilateral (a) Set number of trials,
aged 27.7 (1) VF of right hand; (2) MVF of right hand; EMG recording
(3) MVF of right hand in a frontal mirror;
(4) VF of left hand
EEG 8 healthy individuals aged Key press with right hand [except (2)] with Unilateral (a) Set number of trials,
32.2 (1) VF of right hand; (2) VF of left hand; (3) EMG recording
MVF of right hand; (4,5) MVF of right hand
with left hand in incongruent position; (6)
MVF of right hand in a frontal mirror
NIRS 5 healthy individuals aged Unilateral grasping movements with right or Bilateral (a) Metronome paced
21.1 ± 1.1 left hand with (1) VF of nonmoving hand,
(2) with MVF of moving limb
NIRS 22 healthy individuals Unilateral index finger-thumb opposition of Unilateral (a) Metronome paced
aged 21-40 either left or right hand with (1) virtual VF,
(2) virtual MVF

Abbreviations: MVF, mirror visual feedback; VF, normal visual feedback; PET, positron emission topography; MEG, magnetoencephalography; EEG, electroencephalography;
NIRS, near infrared spectrometry.

Discussion draw firm conclusions. In addition, a large number of stud-

This systematic review aimed to identify instant and long-
term neuromodulatory effects associated with MVF. The
findings of the 33 articles indicate that MVF engages a dis-
tributed network within the brain, including regions related
to perceptual, motor, and higher cognitive functions, though
it is important to acknowledge a number of limitations.
Clearly, the variety of methodologies impedes the ability to
ies had relatively small sample sizes (N ≤ 10 in 17 out of 33
studies) and a number of studies fail to meet all method-
ological requirements, for example, equal performance
across experimental manipulations or adequate control
intervention (see Tables 1-3 and Supplementary Material).
These limitations highlight that future research should pri-
marily focus on isolating the effect of MVF from the
356 Neurorehabilitation and Neural Repair 29(4)

Table 4.  Outline of the Methodology in All Clinical or Training Studies Included in the Systematic Review.
Outline of Experimental Methodology
Study Reference Modality Participants Nature of Training Frequency and Duration Relevant to This Review

Bae et al (2012)54
Bhasin et al (2012)69
Hamzei et al (2012)44
Laeppchen et al (2012)61
Michielsen et al (2011)45
Nojima et al (2012)62
 
EEG MG: 10 stroke patients MG: bilateral movements 4 weeks, 5 sessions/ Observation of hand movements
aged 55.2 ± 8.5 with MVF week, 30 minutes/ during rest, while measuring µ-
CG: 10 stroke patients CG: unilateral session rhythm across left (C3), right (C4)
aged 52.6 ± 11.2 movements of paretic and (Cz) central fissure prior to and
side with VF of 2 limbs after training
fMRI MG: 20 stroke patients Bilateral hand exercises 8 weeks, 5 sessions/ Repetitive clenching/extension of fist
aged 28-62 with virtual MVF on week, 30-60 minutes/ at the affected side without VF pre-
laptop screen session and posttraining
fMRI MG: 13 healthy MG and CG: 5 4 days, 20 minutes/day fMRI during (1) AO of grasping
individuals aged 23.9; unimanual skills (RH movement during rest, (2) active
CG: 13 healthy only) with MVF or VF imitation of grasping movement
individuals aged 25.5 of RH only with left or right hand, pre- and
posttraining
TMS MG and CG: 10 MG and& CG: 5 4 days, 20 minutes/day Test of TMS parameters (MT, ICI,
healthy individuals unimanual skills (RH ICF, IHI left hemisphere) pre- and
aged 24.1 only) with MVF or VF posttraining
of RH only
fMRI MG: 9 stroke patients MG and CG: bimanual 6 weeks, 5 sessions/ fMRI during clenching movement with
aged 51.9 ± 9.3 exercises with MVF or week, 60 minutes/day affected hand without VF pre- and
CG: 7 stroke patients VF of 2 hands posttraining
aged 59.0 ± 10.4
TMS Exp 1. MG and CG: 10 MG and CG: unimanual 10 sets of 30 minutes Test of TMS parameters (MT, ICI, IHI)
healthy individuals (RH only) ball handling each pre- and postpractice
(young adults) task with MVF or VF of
2 hands
Exp 2. MG1 and MG2: MG1 = MG2: unimanual 10 sets of 30 minutes Similar to Exp 1. Practice was followed
8 healthy individuals (RH only) ball handling each by cTBS over M1 (MG1) or occipital
(young adults) task with MVF cortex (MG2)

Abbreviations: EEG, electroencephalography; fMRI, functional magnetic resonance imaging; TMS, transcranial magnetic stimulation; MG, mirror group; CG, control group;
MVF, mirror visual feedback; VF, normal visual feedback; Exp, experiment; AO, action observation; MT, motor threshold; ICI, intracortical inhibition; ICF, intracortical
facilitation; IHI, interhemispheric inhibition; cTBS, continuous theta burst stimulation. MVF was generated by a mirror placed in between the arms in the sagittal plane,
except when stated otherwise.

Table 5.  Brain Areas Differentially Activated With Mirror Visual Feedback (MVF) Compared to Control Conditions, Corresponding
Brodmann Area (BA) Where Known, Side of Activation Listed According to Populationa,b.

Population Area BA Side MVF Network

58
Healthy Dorsolateral prefrontal cortex 9/46 Right Bi Attention
  Precentral gyrus (M1) 4 Ipsi41,47,63,65-68 Uni and Bi Motor
  Postcentral sulcus, posterior wall (S1/S2) 2 Contra52 Uni and Bi Attention
  Lateral sulcus, upper wall (S2) Contra51,52 Bi Attention
  Superior posterior parietal cortex 7 Ipsi58 Bi Attention
  Precuneus (V6) 7 Ipsi38,42,43,60 Uni and Bi Attention
  Superior temporal gyrus 39 Ipsi46 Bi MNS
  Cuneus/Lingual gyrus (V1/V2) 17/18 Ipsi38,42 Uni Attention
  Superior/Middle occipital gyrus (V2, 3, 5) 19 Ipsi38,42,46 Uni and Bi Attention
  Fusiform gyrus (V4) 37 Ipsi38,42 Uni Attention
  Insular cortex, posterior region Contra57 Uni Attention
Stroke Precentral gyrus (M1) 4 Ipsi66,67 Bilateral Motor
  Precuneus (V6) 7 Contra40, Ipsi40,43 Uni and Bi Attention
  Posterior cingulate cortex 30 Contra40 Bi Attention

Abbreviation: MNS, mirror neuron system.

a
The 2 final columns indicate the type of MVF that elicits this observation and the network to which specific areas are considered to belong.
b
Contralateral (contra) and ipsilateral (ipsi) are defined with respect to the (moving) limb that is reflected in the mirror. MVF indicates the type of MVF
(unilateral or bilateral) that elicits this observation.
Deconinck et al 357
mechanisms associated with bilateral training. Despite
these limitations, this first systematic review of the effect of
MVF on the brain reveals useful information with respect to
the underlying mechanisms of MVF for both researchers
and practitioners in neurorehabilitation.
Overall, the findings suggest that MVF may affect per-
ceptuo-motor control processes via (parts of) 3 functional
networks. First, the increase in activity in primary and sec-
ondary visual and somatosensory areas suggests a rise in
attentional resources to resolve the perceptual incongru-
ence.51,52 This is associated with conscious awareness of
sensory feedback or control of agency, as observed in the
activity within the insular cortex,70 and enhanced monitor-
ing of the movement, as found in the involvement of the
right DLPFC.58,71 Furthermore, greater activation of the
posterior aspect of the parietal and cingulate cortex sup-
ports the notion of greater attentional demands. The poste-
rior cingulate cortex, highly interconnected with various
brain regions, is considered a hub for information exchange72
and a prominent role in the cognitive control of behavior is
attributed to this region.73 The nearby superior posterior
parietal cortex and its medial extension (precuneus) are
known to be involved in visuospatial information process-
ing and directing spatial attention, especially during biman-
ual coordination tasks.74,75 This probably explains why the
effect of MVF on the precuneus is primarily observed in
studies that use virtual MVF of the hand in the frontal
plane.38,39,42,43,60 Notably, a number of studies have shown
that the precuneus is particularly active during motor imag-
ery,76 which may account for the combined effect of imag-
ery and MVF.
Second, MVF seems to cause increased immediate acti-
vation of STG46 and elevated engagement of PMC44 after
training. Both areas have been associated with the mirror
neuron system. STG is often linked to its neighboring supe-
rior temporal sulcus and is involved in the visual identifica-
tion of biological motion.77 Combined with the PMC, it
forms a network that subserves the imitation of biological
motion and the acquisition of motor skills.25,78,79 The activa-
tion of PMC, especially at the side of the lesion, is in keep-
ing with earlier research that has attributed a prominent role
to this region in motor recovery after stroke.80,81
A third functional network on which MVF appears to
exert a modulatory effect is the motor network. The primary
motor cortex (M1) ipsilateral to the active (reflected) hand,
that is, M1 projecting to the unseen hand behind the mirror,
is considered the final common pathway for the beneficial
effect of MVF according to various studies. A complete
reversal of lateralization when moving a limb that is
reflected by a mirror (ie, the ipsilateral side taking over con-
trol), as put forward by some,53,56,59 is unlikely; however,
there is accumulating evidence that MVF decreases the
motor threshold and enhances corticospinal output of the
ipsilesional M1 in stroke patients.55,63,65-68 This is probably
mediated through a reduction in interhemispheric inhibition
(from contralateral/lesional to ipsilateral/lesional)63 and/or
a reduction of intracortical inhibition.61 In view of the
notion that functional recovery is correlated with the extent
of involvement of the ipsilesional (here: contralateral)
motor network,82 this seems a promising therapeutic effect
of MVF. Other findings in healthy adults, however, indicate
that improved motor skill of the untrained hand is achieved
by establishing a functional connection with the ipsilateral
motor cortex via MVF, a mechanism that has been associ-
ated with poorer motor recovery compared with normaliza-
tion of the hemispheric balance.83 This discrepancy might
reflect 2 stages in the recovery process or a population-spe-
cific response and warrants further investigation.
The effect of MVF on brain activation is likely depen-
dent on the specific nature of the feedback. In this respect it
is remarkable that the effect on primary and secondary
visual processing areas is primarily related to unilateral
MVF. Bimanual MVF, in contrast, seems to engage more
frontal and parietal regions related to higher cognitive func-
tions like attention and monitoring (see Table 5).
Finally, it is noteworthy that the findings for individuals
with stroke are in accordance with those for healthy people,
insofar as the limited number of studies allows this com-
parison (see Table 5). There is evidence of increased activa-
tion of higher order areas involved with attentional processes
(precuneus and posterior cingulate cortex) and the ipsilat-
eral M1.
Part 3: Summary and Future
Directions
Convergent evidence suggests that MVF may be used as a
tool to promote functional recovery in patients with unilat-
eral motor impairments. A systematic review of neuroimag-
ing research was conducted to test the validity of the 3
hypotheses proposed to explain the positive effects associ-
ated with MVF. The findings of this review, suggesting sub-
stantial overlap between MVF-related activity and regions
subserving attention-related processes, confirm that MVF
activates a broad network dedicated to attention and action
monitoring (Hypothesis 3). This is consistent with known
motor learning principles, which attribute success of motor
practice to attentional focus and cognitive processing.
Furthermore, the positive effect on motor function is associ-
ated with facilitation of M1 contralateral to the affected or
untrained hand (here: referred to as ipsilateral to the moving
hand that is mirrored). However, there is also evidence to
support a mechanism that exploits ipsilateral control of the
affected limb, which has been associated with suboptimal
recovery after other therapeutic interventions (Hypothesis
2). Regions that have been linked with the mirror neuron
system (PMC, STG) may play a mediating role in connect-
ing perceptual and motor areas (Hypothesis 1). Still, the
358 Neurorehabilitation and Neural Repair 29(4)
current evidence indicates that MVF therapy is certainly not
a substitute for observational therapy or motor imagery,
given that MVF activates only isolated parts of the MNS.
Future research using recent advances in graph theory may
elucidate functional connectivity within and between the
involved networks.84
To date the majority of evidence stems from studies in
healthy adult individuals and the few studies that have
examined a patient population only considered people
who survived a stroke. It remains unclear to what extent
these hypotheses may be valid for other clinical conditions
for which MVF has been suggested an adjunct to conven-
tional therapy (eg, SHCP22,85-87 and CRPS14-18). The find-
ing that MVF may have an impact on multiple functional
networks may mean it can serve as a versatile tool to pro-
mote motor recovery, of which the actual mechanism is
dependent on the specific condition or damage. Large-
scale clinical trials that include measurement of brain
function and structure are to examine the efficacy and the
underlying mechanisms of MVF in different populations,
and potential differences between them. Although further
research is warranted to fully understand and exploit the
potential of MVF in neurorehabilitation, it is indisputable
that MVF can exert a strong modulatory influence on the
motor system.
Acknowledgments
The authors wish to thank Prof Karen Caeyenberghs and two
anonymous reviewers for their advice and suggestions.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
work was partly supported by a research grant from Sparks, regis-
tered charity 1003825 (England & Wales), to Geert Savelsbergh
and Frederik Deconinck (Grant 09MMU01).
Supplementary Material
Supplementary material for this article is available on the
Neurorehabilitation & Neural Repair Web site at http://nnr.sage-
pub.com/content/by/supplemental-data
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