OT MIRROR

THERAPY
PROGRAM

Lower Extremity – Mirror Therapy Treatment Plan

Basic Motor Exercises Do 3 sets of the following exercises for 15 repetitions.

• Point toes away from you (hold

3 seconds), then bring toes up
towards knees (hold 3
seconds).

• Spread toes apart (hold 3

seconds), flex toes together
(hold 3 seconds).

• Ankle rolls clockwise and

counter-clockwise.

• Bend knee up, extend knee

out.

Basic Sensory Exercises Try providing sensory input (light touch, tapping, hot/cold, vibration, etc.)
to both Right leg and to Left residual limb.
• Have someone provide resistance during motor exercises
• Push foot against bed footboard/floor/foot rest on w/c

Functional Exercises • Putting on sock in the mirror

(using objects) • Picking up objects w/ toes
• Bed-bath w/ long-handled sponge on Right leg/foot using mirror

Mental Practice/Imagery • Imagine stretching and repositioning Right leg in attempt to reposition
Left phantom limb/sensations and to relieve pain.
 OT MIRROR
THERAPY
PROGRAM

Self-Reflection Record for Mirror Therapy – Lower Extremity:

• TODAY’S DATE: _______________________ TIME OF MIRROR THERAPY: _______________________

• HOW IS YOUR PHANTOM PAIN TODAY/RIGHT NOW? (circle below)

1 2 3 4 5 6
• CAN YOU DESCRIBE WHERE THE PAIN IS? (circle below - be specific if possible)

Hip Thigh Knee Calf /Shin Ankle Foot Toes

On Top On Bottom All Sides

Constant Pain -OR- Periodic Pain Shooting Pain Aching Throbbing Cramping

§ Additional Comments:

• HOW LONG DID YOU DO MIRROR THERAPY TODAY? (circle below)

Did not attempt <5 mins 5-10 mins 10-20 mins >20 mins

• DID YOUR MIRROR THERAPY FEEL EFFECTIVE TODAY? (circle below)

YES NO Hard to Say… Only while doing the therapy.

§ Additional Comments:

• WHAT DID YOU DO IN MIRROR THERAPY TODAY?

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