Successful Graded Mirror Therapy in a Patient with Chronic Deafferentation Pain in Whom Traditional Mirror Therapy was Ineffective: A Case Report.

A 43-year-old man had deafferentation pain in his right upper extremity secondary to brachial plexus avulsion from a traffic accident 23 years previously. On our initial examination, he had severe tingling pain with numbness in the right fingers rated 10 on the numerical rating scale. The body perception of the affected third and fourth fingers was distorted in the flexed position. Although he performed traditional mirror therapy (TMT) for 4 weeks in the same methods as seen in previous studies, he could not obtain willed motor imagery and pain-alleviation effect. Therefore, we modified the task of TMT: Graded mirror therapy (GMT). GMT consisted of five stages: (1) observation of the mirror reflection of the unaffected side without imagining any movements of the affected side; (2) observation of the mirror reflection of the third and fourth fingers changing shape gradually adjusted from a flexed position to a extended position; (3) observation of the mirror reflection of passive movement; (4) motor imagery of affected fingers with observation of the mirror reflection (similar to TMT); (5) motor imagery of affected fingers without mirror. Each task was performed for 3 to 4 weeks. As a result, pain intensity during mirror therapy gradually decreased and finally disappeared. The body perception of the affected fingers also improved, and he could imagine the movement of the fingers with or without mirror. We suggested that GMT starting from the observation task without motor imagery may effectively decrease deafferentation pain compared to TMT.