Atlas›Domain IX · Biomedical, neuro & digital›Guide 060
Guide IX-060

Mirror therapy (Ramachandran)

V. S. Ramachandran, Rogers-Ramachandran1996
A 22 · L 56 · M 2217 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the original mirror box procedure of Ramachandran and Rogers-Ramachandran (1996) for phantom limbs; mirror therapy after stroke as summarised in the Cochrane review by Thieme et al. (2018); mirror visual feedback and graded motor imagery (GMI) as listed in the Royal College of Physicians UK CRPS guidelines (2nd edition, 2018) and described in NHS patient leaflets. The guide is written for a psychotherapist working alongside the rehabilitation team, not for delivering the physical treatment.

What it is. Mirror therapy (also called mirror visual feedback) places a mirror between the limbs so that the person sees the reflection of the intact or less affected limb where the missing, painful or paretic limb should be. Ramachandran and Rogers-Ramachandran built a cardboard "mirror box" for ten upper-limb amputees. They reported that watching the reflection let some patients feel their phantom move, and that four of five patients with painful clenching spasms got relief when they used the mirror to "open" the phantom hand. The authors said pain relief would need double-blind testing before the procedure could be called a treatment. [source: Ramachandran & Rogers-Ramachandran 1996] The method was later used in stroke rehabilitation, mainly to improve motor function [source: Thieme et al. 2018 Cochrane], and in complex regional pain syndrome (CRPS) [source: RCP 2018]. Graded motor imagery is a related, staged programme associated with G. Lorimer Moseley. It moves from left/right limb recognition, to imagined movement, to mirror work. [source: EKHUFT GMI leaflet; Moseley 2004 trial not verified [uncertain]]

Core idea of change (as sources state it). For CRPS, NHS leaflets explain that seeing a normal-looking reflection may lead the brain to treat the painful limb as normal and gradually recalibrate pain signals, so that movement and touch stop triggering excessive pain. [source: NHS Ayrshire & Arran leaflet; EKHUFT leaflet] For stroke, the proposed mechanisms (mirror-neuron/action-observation pathways, attention and self-awareness, recruitment of ipsilateral pathways, changes in motor-cortex excitability) are hypotheses, not established mechanisms. [source: Gandhi et al. 2020]

Who delivers it. Mirror therapy and GMI are delivered by physiotherapists, occupational therapists, hand therapists and pain teams. In the UK, physiotherapists and occupational therapists are regulated by the Health and Care Professions Council (HCPC) and their titles are protected by law. "Psychotherapist" is not an HCPC-protected title, although practitioner psychologist titles are. [source: HCPC, The professions] The RCP guidelines ask that physiotherapy and occupational therapy for CRPS be given by therapists competent in chronic pain and/or CRPS, with hand therapy preferred for upper-limb CRPS. [source: RCP 2018] In the US, physical and occupational therapists are licensed by states, and APTA and AOTA are their professional associations [uncertain: not verified]. The mirror itself is simple equipment. The sources cited do not describe any device regulatory status [uncertain].

Evidence status in brief. Stroke: the 2018 Cochrane review found moderate-certainty evidence that mirror therapy improves motor function, motor impairment and activities of daily living. For pain the evidence was low certainty, and the benefit was not significant once CRPS-only trials were removed. For visuospatial neglect the effect was not significant. [source: Thieme et al. 2018] NICE published an evidence review on mirror therapy as part of its 2023 stroke rehabilitation update. The final recommendation wording is not verified [uncertain]. [source: NICE evidence review 26, draft April 2023] Phantom limb pain: a patient charity leaflet endorsed by the Walton Centre pain team calls mirror feedback "still experimental, but has helped in some cases" [source: Pain Relief Foundation]. A 2023 meta-analysis rated the certainty "very low" and found no difference from sham comparisons [source: Canadian Journal of Pain 2023, abstract]. CRPS: the RCP guidelines list mirror visual feedback and GMI among recommended rehabilitation approaches. A footnote says the techniques in that box had not been tested individually in randomised trials (as reported). [source: RCP 2018]

2. Framework

Mirror therapy is a rehabilitation technique, not a psychotherapy. The phases below describe the care pathway as the psychotherapist meets it. Session numbers, frequency and length are set by the treating physiotherapist or OT and are deliberately not given here. The sources show that they vary widely across trials and services, and NHS leaflets include a treatment-plan box the therapist fills in for each patient. [source: Thieme et al. 2018; NHS Ayrshire & Arran leaflet]

Phase 0: Referral and assessment by the rehabilitation team. Goal: confirm the diagnosis (phantom limb pain, post-stroke paresis, CRPS) and decide whether mirror work or GMI fits. In CRPS, the RCP describes four equally important pillars delivered by an integrated team: education, pain relief, physical rehabilitation and psychological intervention. [source: RCP 2018] Hagenberg and Carpenter's expert panel found that contraindications were set according to how confident each practitioner felt about managing adverse effects, so selection is not uniform across services. [source: Hagenberg & Carpenter 2014, abstract] Psychotherapist's task: share relevant psychological information (with consent), such as distress, trauma linked to the injury, grief, or a strong aversion to the limb.

Phase 1: Preparation. Goal: the person understands the rationale and expected sensations, agrees to try it, and has a plan for unusual or upsetting experiences. NHS guidance says to start only after a consultation with the physiotherapist, and suggests having someone present the first time the mirror is used. [source: NHS Ayrshire & Arran leaflet]

Phase 2: Active programme. Goal: graded exposure to seeing, imagining and then moving the limb. In GMI the order is laterality recognition, then explicit motor imagery, then mirror visual feedback. The treating therapist decides when to advance, and patients move on once imagined movement becomes easier. [source: EKHUFT GMI leaflet] In stand-alone mirror therapy, the person first looks at the reflection at rest. Then both limbs move slowly in the same way, or the person imagines the affected limb moving if pain prevents movement. [source: NHS Ayrshire & Arran leaflet] Moving-on criteria: set by the treating therapist. The RCP advises therapists to refer on if there is no improvement within four weeks, and to seek advice from an experienced colleague when unsure. [source: RCP 2018]

Phase 3: Integration into function. Goal: carry gains into everyday tasks (self-care, work, sleep). Pain-service therapists address function, teach pacing and relaxation or mindfulness, and liaise on vocational support. [source: RCP 2018] In stroke, task-based or home-based mirror programmes are among the published variants. [source: Gandhi et al. 2020]

Phase 4: Ending and follow-up. Goal: close the programme, plan for flare-ups and arrange continued psychological care if needed. The sources cited give no formal ending criteria [uncertain]. The psychotherapist's ending work is [synthesis].

3. Guiding principles

  • The rehabilitation team owns the physical treatment. Practical meaning: never set, change or add mirror or imagery exercises. Route all questions about technique, frequency or progression to the treating physiotherapist or OT. [source: NHS Ayrshire & Arran leaflet; RCP 2018; synthesis]
  • Psychological care is one of four equal pillars in CRPS. Practical meaning: your work is part of the treatment plan, not an add-on. Coordinate with the team, and remember that the RCP names the GP as the coordinator of consistent advice. [source: RCP 2018]
  • CRPS is not a psychological disorder. Practical meaning: the RCP states that pre-existing psychological problems do not cause CRPS but should be treated when present. Never frame the pain as "in the head". [source: RCP 2018]
  • Unusual sensations are expected and usually short-lived. Practical meaning: prepare clients for feelings of heaviness or lightness, warmth or cold, numbness, "floating" or an extra limb, which usually pass within seconds or minutes. [source: NHS Ayrshire & Arran leaflet]
  • Emotional reactions are a recognised adverse effect. Practical meaning: expert practitioners report emotional reactions, increased pain, sensory changes, a "frozen" phantom, dizziness and sweating. Make it safe to report these. [source: Hagenberg & Carpenter 2014, abstract]
  • Seeing the limb can be loaded. Practical meaning: in CRPS, negative feelings towards the limb, a wish for amputation, or feeling detached from the limb can affect engagement. Treat these as clinical information to share with the team (with consent), not as resistance. [source: RCP 2018; EKHUFT leaflet]
  • Honest expectations. Practical meaning: describe the evidence as the sources state it (moderate certainty for stroke motor outcomes, very low certainty for phantom limb pain), so that a non-response is not experienced as personal failure. [source: Thieme et al. 2018; Canadian Journal of Pain 2023; synthesis]
  • Match the plan to the person. Practical meaning: expert practitioners concluded that different treatment plans suit different patients and practitioners. Encourage clients to tell their therapist what is not working. [source: Hagenberg & Carpenter 2014, abstract]
  • Adapt for cognition, attention and mood after stroke. Practical meaning: attention-dependent techniques call for assessment of cognition and depression. People with neglect did much less mirror practice in one trial. [source: Gandhi et al. 2020]
  • Describe without prescribing. Practical meaning: no session durations, repetition counts or progression rules come from you. Those belong to the treating clinician. [synthesis]

4. Intervention inventory

Part A describes how the rehabilitation team delivers the treatment, at a descriptive level only, so you can explain it and support the client. Part B covers the psychotherapist's own interventions. No exercise doses, durations or progression rules are given. Those come from the treating therapist.

A1. The original mirror box (phantom limb, Ramachandran 1996)

  • Purpose: to create the visual impression that the phantom limb is present and moving, in order to change phantom movement, painful spasms and referred sensations. [source: Ramachandran & Rogers-Ramachandran 1996]
  • How it was done (descriptive): a vertical mirror stood in a box with its top and front removed. The intact hand went on one side and the phantom was "placed" on the other. The patient lined up the reflection with the felt position of the phantom and tried mirror-symmetric movements, first with eyes closed and then while watching the reflection. One patient practised at home over several weeks and later reported that the phantom arm had partly "disappeared", leaving the fingers at the stump. [source: Ramachandran & Rogers-Ramachandran 1996]
  • Example language (illustrative): "Your physio's mirror lets your brain see a hand where it feels one. Some people feel the phantom move or loosen, some notice nothing, and a few find it odd or upsetting. All of those are worth telling them about."
  • Watch for: the authors recorded frustration in patients who got no movement or relief, and a "painful tugging sensation" when the reflected posture was impossible for a real hand. Some pain, such as burning pain, did not change. [source: Ramachandran & Rogers-Ramachandran 1996] Later expert practitioners also report emotional reactions, increased pain, a frozen phantom, dizziness and sweating. [source: Hagenberg & Carpenter 2014, abstract]

A2. Mirror therapy after stroke

  • Purpose: to improve motor function and everyday activities of the paretic arm or leg. [source: Thieme et al. 2018]
  • How it is delivered (descriptive): the mirror is positioned so that movement of the unaffected limb appears in place of the affected limb, which is hidden in a box or behind a 2-D mirror frame. Programmes use either movements of the unaffected limb alone or symmetrical movements of both limbs, from simple graded movements and reaching to task-based activities. Settings include inpatient, outpatient and home-based care, mostly under direct supervision. Variants include mirrored video and virtual-reality reflection. Because it relies on vision, it is reported as usable even in people with complete or severe paralysis. [source: Thieme et al. 2018; Gandhi et al. 2020] Delivered by physiotherapists and occupational therapists. Session prescriptions vary widely between trials and are set by the treating team. [source: Thieme et al. 2018]
  • Example language (illustrative): "This is mostly about getting your arm working again. Concentration matters, so let's think about times of day when your mood and energy are best for it."
  • Watch for: occasional short-lived fatigue, soreness or swelling in the paretic limb. Attention and neglect problems can reduce how much practice gets done, and cognition and depression are worth assessing. No serious adverse effects were reported in the trials reviewed. [source: Gandhi et al. 2020]

A3. Mirror visual feedback in CRPS

  • Purpose: to reduce pain and make movement easier by giving the brain a normal-looking image of the painful limb. [source: NHS Ayrshire & Arran leaflet; RCP 2018 Box 3]
  • How it is delivered (descriptive): only after consultation with a physiotherapist, in a quiet room, seated or lying with the back supported. The mirror faces the unaffected limb and the painful limb is hidden behind it. The person first looks at the reflection without moving, then slowly moves both limbs in the same way, or imagines the painful limb moving if movement hurts too much. The physiotherapist may add specific exercises and writes the personal plan (how often, how long, when to stop). Sessions are kept short because concentration drops. [source: NHS Ayrshire & Arran leaflet]
  • Example language (illustrative): "If a strange feeling comes up, like the hidden arm feeling heavy, floating or not yours, your physio's leaflet says to stop and look at both arms without the mirror. It usually passes quickly. Let's practise noticing that moment calmly."
  • Watch for: if pain or stiffness becomes a problem, the leaflet advises going back to looking with both limbs at rest. If a sensation is uncomfortable or disturbing, stop and look at both limbs without the mirror. [source: NHS Ayrshire & Arran leaflet] The RCP's general caution is that excessive mobilisation that strongly worsens pain is contraindicated. [source: RCP 2018]

A4. Graded motor imagery (GMI)

  • Purpose: a staged programme for CRPS (also studied in phantom limb pain) that aims to activate movement networks in the brain step by step, without triggering pain. [source: EKHUFT GMI leaflet; Canadian Journal of Pain 2023]
  • How it is delivered (descriptive): (1) Laterality recognition: identifying pictured limbs as left or right, which engages movement-planning areas without moving. (2) Explicit motor imagery: imagining movements of the painful and unaffected limbs without moving. (3) Mirror visual feedback, as in A3. Delivered by a hand therapist or physiotherapist, who sees the person regularly, provides detailed stage leaflets and decides when to advance. The local leaflet states it is not suitable for children or people with dyslexia. [source: EKHUFT GMI leaflet] The RCP lists GMI as a CRPS-specific rehabilitation technique. [source: RCP 2018 Box 4] Moseley's NOI Group publishes GMI training and materials. [uncertain: not verified]
  • Example language (illustrative): "Imagining the movement can hurt at first. The leaflet warns about that. It doesn't mean you're doing it wrong, and it's something to tell your therapist."
  • Watch for: pain when imagining movement early on [source: EKHUFT GMI leaflet]. Frustration with the slow pace, and self-criticism about speed or accuracy on laterality tasks [synthesis].

A5. Body-perception strategies in CRPS

  • Purpose: to address body perception disturbance, meaning negative feelings towards the limb and altered ownership, size or shape perception. [source: RCP 2018]
  • How it is delivered (descriptive): the RCP lists strategies that involve looking at, touching and thinking about the affected limb, mental visualisation for altered size and shape, and self-administered tactile and thermal desensitisation to normalise touch. Body perception can be assessed with the Bath CRPS body perception disturbance scale (items not reproduced here). [source: RCP 2018]
  • Example language (illustrative): "You said your hand feels like it doesn't belong to you. That's a recognised part of CRPS, and your therapist will want to know. Would it help to talk about what looking at it brings up?"
  • Watch for: disgust, a wish for amputation, or dissociation from the limb. The RCP says amputation decisions need a multidisciplinary team that includes a pain-specialised psychologist or liaison psychiatrist. [source: RCP 2018]

Part B: the psychotherapist's interventions. Except where a source is cited, the steps below are [synthesis]: general good practice for psychological care alongside rehabilitation, not taken from Ramachandran, Moseley or the guideline authors.

B1. Recognising when to suggest referral or review

  • Purpose: to make sure psychological and physical needs reach the right team.
  • Steps: (1) Listen for the RCP's psychosocial "yellow flags" such as fear-avoidance, anxiety or depression, and litigation stress [source: RCP 2018 Box 2]. (2) If pain-related distress or disability is significant, even when pain is mild, suggest the client asks their GP about referral to a multidisciplinary pain clinic, as the RCP advises [source: RCP 2018]. (3) For a suspected but undiagnosed CRPS or a new symptom, advise a medical review rather than interpreting it yourself. (4) With consent, write to the treating physiotherapist or OT.
  • Example language (illustrative): "The way the pain is spreading and changing colour is something a doctor should look at. Would you be willing to book with your GP this week?"
  • Watch for: clients who have been told "it's psychological" and avoid medical follow-up.

B2. Psychoeducation that matches the team's explanation

  • Purpose: to reduce confusion and fear by repeating the rationale in the same terms the team uses.
  • Steps: (1) Ask the client what their therapist told them. (2) Fill gaps with the published rationale: the brain's map of the limb, sensitisation, and seeing a normal-looking limb [source: NHS leaflets]. (3) Name the expected sensations and their usual short duration [source: NHS Ayrshire & Arran leaflet]. (4) Give an honest view of the evidence (see Section 1).
  • Example language (illustrative): "The idea is that your brain's alarm system has become over-protective, and the mirror is a gentle way of showing it a limb that looks fine."
  • Watch for: clients who take "brain-based" to mean "imaginary". Keep saying clearly that the pain is real.

B3. Supporting informed consent and shared decision-making

  • Purpose: to help the client make an informed choice about starting, continuing or declining the programme, and to make sure that choice stays with them and their treating team.
  • Steps: (1) Explore what the client hopes for and fears. (2) Help them list questions for the therapist, such as what the exercises involve, what to do if it hurts, how long before they review progress, and alternatives. (3) Reflect ambivalence without pushing either way. (4) Respect a decision to decline and tell the team, with consent.
  • Example language (illustrative): "It sounds like part of you wants to try and part of you dreads looking at the arm. Shall we write down what you'd want to ask your physio before you decide?"
  • Watch for: consent given out of pressure to be a "good patient".

B4. Preparing for and processing unusual sensations and emotional reactions

  • Purpose: to make the documented adverse experiences (emotional reactions, pain increase, sensory changes, frozen phantom, dizziness, sweating) manageable and reportable [source: Hagenberg & Carpenter 2014, abstract].
  • Steps: (1) Before the first session, rehearse the leaflet's stop rule: stop and look at both limbs without the mirror [source: NHS Ayrshire & Arran leaflet]. (2) Teach a brief grounding routine the client can use afterwards (orienting to the room, slow breathing). (3) In the next session, review what happened, what the client felt and what it meant to them. (4) Encourage reporting "no matter how strange" the sensation seemed [source: EKHUFT leaflet], and pass on anything persistent to the team.
  • Example language (illustrative): "When the hidden hand felt like an extra limb, what went through your mind?"
  • Watch for: panic, depersonalisation, or intrusive memories of the injury, the amputation or the stroke.

B5. Grief and loss work after amputation

  • Purpose: seeing a "restored" limb in the mirror, or feeling the phantom move, can bring up grief, longing or shock. This is an inference from the emotional reactions practitioners report. [synthesis; source for emotional reactions: Hagenberg & Carpenter 2014]
  • Steps: (1) Ask about the circumstances of the amputation (trauma, illness, choice) and the client's relationship with the phantom. (2) Normalise grief and mixed feelings. (3) Work with loss using your usual grief or trauma-informed approach, paced separately from the mirror sessions. (4) If watching the reflection reliably triggers acute grief or traumatic intrusions, help the client tell the physiotherapist so the plan can be adjusted (for example covering the limb, which practitioners describe as a way to fine-tune the experience) [source: Hagenberg & Carpenter 2014, abstract].
  • Example language (illustrative): "Seeing two hands again was a shock. It makes sense that it brought back the loss."
  • Watch for: prolonged grief, PTSD symptoms related to the injury, and depression.

B6. Body-image and limb-ownership work

  • Purpose: to address disgust, alienation or a wish to be rid of the limb (CRPS), or self-image after stroke or amputation, alongside the team's body-perception strategies [source: RCP 2018].
  • Steps: (1) Gently assess how the client thinks and feels about the limb and its appearance. (2) Use acceptance- and compassion-based or cognitive work on body image [synthesis]. (3) Coordinate timing with the team's looking, touching and visualisation tasks so they reinforce rather than compete with each other. (4) Treat any wish for amputation as something to raise with the multidisciplinary team, including a pain-specialised psychologist or liaison psychiatrist [source: RCP 2018].
  • Example language (illustrative): "What would you say to the hand if it could hear you?"
  • Watch for: self-harm aimed at the limb, or covering and neglecting it.

B7. Pain psychology alongside

  • Purpose: the RCP places psychological care within group-based multidisciplinary pain management programmes for those who need them. People with significant distress may need individual therapy first. Approaches often follow CBT principles, though other methods also show efficacy. [source: RCP 2018]
  • Steps: (1) Assess fear-avoidance, catastrophising, mood and sleep using validated measures, as the RCP recommends where possible [source: RCP 2018]. (2) Deliver your pain-psychology approach (CBT, ACT or similar) with goals agreed with the team. (3) Support the pacing and relaxation or mindfulness skills the pain-service therapists teach, without contradicting their instructions [source: RCP 2018]. (4) Link values-based goals to the functional goals of rehabilitation.
  • Example language (illustrative): "What would you be doing more of if the pain shouted a bit less?"
  • Watch for: boom-and-bust cycles around home practice.

B8. Adherence and ambivalence conversations

  • Purpose: to explore barriers to home practice without ever changing the programme.
  • Steps: (1) Ask open questions about what gets in the way (boredom, pain, fear, low mood, fatigue, attention). (2) Use motivational interviewing to explore ambivalence. (3) Problem-solve routines such as cues, timing and support. (4) Any change to how often, how long, or which exercises: "That's one for your physio".
  • Example language (illustrative): "Your plan sheet says what your therapist wants. If it isn't working, let's think about how to tell them."
  • Watch for: guilt and shame about not practising, and clients making up their own longer sessions.

B9. Monitoring and passing on warning signs

  • Purpose: to make sure problems reach the treating team quickly.
  • Steps: (1) Agree consent and a route (phone, letter, shared record) for contacting the physio or OT and the GP. (2) Pass on: sustained pain flare after sessions, persistent disturbing sensations, emotional reactions that stop practice, new or spreading CRPS signs, mood deterioration. (3) Record what you passed on and when.
  • Example language (illustrative): "I'd like to let your physio know the sessions have been leaving you dizzy and tearful. Is that OK?"
  • Watch for: relying on the client to pass on information when their distress, cognition or aphasia makes that hard.

B10. Crisis and safety planning

  • Purpose: chronic pain, CRPS, amputation and stroke can all bring depression and suicidal thinking. Standard risk-assessment practice applies.
  • Steps: (1) Ask directly about suicidal thoughts when mood drops or hopelessness about the pain appears. (2) Build a written safety plan: warning signs, coping strategies, people and services to contact, and lethal-means safety such as secure storage of medicines in liaison with the GP or pharmacist. (3) Escalate urgent risk through local crisis pathways. (4) Tell the rehabilitation team when the risk level changes, with consent or as safeguarding requires.
  • Example language (illustrative): "When pain is this relentless, some people start to think about not wanting to be here. Has that crossed your mind?"
  • Watch for: a sudden wish for amputation or giving up on rehabilitation as possible signs of despair.

B11. Stroke-specific adaptation

  • Purpose: to make psychological support usable when attention, cognition, language or mood are affected. Gandhi et al. call for cognitive and depression assessment with attention-dependent techniques [source: Gandhi et al. 2020].
  • Steps: (1) Liaise with the OT or speech and language therapist on communication aids [synthesis]. (2) Use short sessions, written summaries and family involvement [synthesis]. (3) Screen for post-stroke depression and anxiety and refer for review as needed [synthesis].
  • Example language (illustrative): "Let's use the picture card to rate how today's practice felt."
  • Watch for: neglect and attention problems that reduce practice [source: Gandhi et al. 2020].

B12. Integration before, during and after the programme

  • Purpose: to make psychological work and rehabilitation fit together over time.
  • Steps: Before: prepare (B2–B4). During: brief check-ins on each block of practice, and coordinate timing so that heavy trauma or grief work does not land on the same day as demanding mirror sessions. After: review gains, plan for flare-ups that fit the team's advice, and continue grief, body-image or pain-psychology work as needed.
  • Example language (illustrative): "As the physio sessions finish, what do you want to keep working on here?"
  • Watch for: a sense of abandonment when rehabilitation ends, and relapse into avoidance.

5. Handling problems

Unless a source is cited, the responses below are [synthesis].

  • Distressing phantom sensations or a "frozen" phantom during mirror work. Practitioners report these as adverse effects [source: Hagenberg & Carpenter 2014, abstract]. Response: use the stop-and-ground plan (B4). Help the client report the experience to the physiotherapist, who may adapt the setup, for example by covering the limb [source: Hagenberg & Carpenter 2014]. Explore what the sensation meant to the client.
  • Grief, shock or traumatic memories triggered by the reflection. Response: slow the psychological pacing, offer grief or trauma-focused work separately from the rehabilitation sessions, and, with consent, ask the team whether the timing of mirror work can fit around it. Do not advise stopping the programme yourself.
  • Pain flare after sessions. The leaflet advises going back to looking with both limbs at rest, and the RCP warns against mobilisation that strongly worsens pain [source: NHS Ayrshire & Arran leaflet; RCP 2018]. Response: validate, separate catastrophic interpretations from the facts, and route all questions about the exercises to the therapist.
  • No response ("it doesn't work for me"). The evidence for phantom limb pain is very low certainty, and expert practitioners differ in how long they wait before calling someone a non-responder [source: Canadian Journal of Pain 2023; Hagenberg & Carpenter 2014]. Response: work on self-blame, and support the client to ask the team about alternatives. For CRPS, the RCP advises that therapists refer on if there is no improvement within four weeks [source: RCP 2018].
  • Stuck or bored with slow GMI stages. Response: link the practice to valued goals, use small rewards and routines, and help the client tell the therapist about the boredom.
  • Resistance to looking at or touching the limb (CRPS). This is part of body perception disturbance, not wilfulness [source: RCP 2018]. Response: use a graded, compassionate approach to feelings about the limb (B6) and coordinate with the team.
  • Belief that the pain is "all in my head". Response: explain the RCP position that CRPS is not caused by psychological problems [source: RCP 2018], and frame brain involvement as part of a real pain condition.
  • Non-adherence with home practice. Response: use MI-style exploration (B8). Problem-solve barriers, and never change the prescription.
  • Overwhelm after stroke (fatigue, cognitive load, aphasia). Response: use short, concrete sessions with carers involved, and pass concerns about attention or neglect to the OT [source for attention issues: Gandhi et al. 2020].
  • Rupture with the rehabilitation team (the client feels blamed or dismissed). Response: repair within your own relationship first, then help the client prepare questions for, or a joint meeting with, the team. Avoid taking sides.
  • Wish for amputation (CRPS). Response: explore it seriously, assess risk, and make sure it reaches the multidisciplinary team, which should include a pain-specialised psychologist or liaison psychiatrist [source: RCP 2018].
  • Children or people with dyslexia offered GMI. A local NHS leaflet states GMI is not suitable for these groups [source: EKHUFT leaflet]. Response: raise questions with the treating team. Whether other services apply this restriction is [uncertain].
  • Do-it-yourself mirror use from online videos. Response: encourage the client to start only after consultation with a physiotherapist, as NHS guidance says [source: NHS Ayrshire & Arran leaflet], and to have support available the first time.

Sources

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