Mirror movement disorder rehabilitation after epilepsy: A case report and video presentation

ABSTRACT

Mirror movement disorder is defined as the involuntary involvement of contralateral homologous muscles during voluntary movements, and its rehabilitation is a labor-intensive process. In this case report, we described a 12-year-old male patient with epilepsy who developed mirror movements in the upper extremities. The patient underwent hand-arm bimanual intensive therapy including the lower extremity for 20 days and 50 h. The Woods-Teuber evaluation score, which was high before treatment, was lower after treatment. During the three-month follow-up, the patient’s condition continued to improve.

Mirror movement disorder syndrome is a symmetrical movement disorder that occurs involuntarily on the opposite side of the limb that a patient wants to use voluntarily. Although this condition can also be observed in healthy children, it disappears over time as the central nervous system matures. The persistence of this movement pattern is considered pathological. The condition may be congenital or associated with a disease, such as attention deficit hyperactivity disorder, multiple sclerosis, amyotrophic lateral sclerosis, Parkinson’s disease, corpus callosum abnormality, and hemiparetic cerebral palsy.^{[1, 2]} Although the pathophysiology of the disease has not been clearly elucidated, some studies suggest that genetic mutations and abnormalities in the corticospinal pathways may cause this condition.^{[3, 4]} Individuals with this disease may experience difficulties with functional movements that are essential for activities of daily living and in jobs requiring bimanual coordination. Evidence indicates that treatment options are limited. Botox injection is one invasive treatment that can help patients.^[5] Among the noninvasive treatment methods, rehabilitation plays an important role in the lifelong control of the disease. Of note, studies on mirror movement disorder syndrome and its rehabilitation are few, and the available studies have mostly focused on children with unilateral cerebral palsy.

To the best of our knowledge, the reported number of patients with mirror movement disorder after epilepsy diagnosis is small, and rehabilitation information regarding this disorder is limited. This case report aimed to contribute to the literature and further understanding of mirror movement disorder after epilepsy. In this study, we described a patient who was followed for mirror movement disorder after epilepsy and the rehabilitation process using pre- and posttreatment video recordings.

CASE REPORT

A 12-year-old male patient, born at term with no history of disease, drug use, or surgery, was referred to the pediatric neurology department for investigations and follow-up after two epileptic episodes. The patient was admitted and observed for two weeks, and medication was prescribed. Electroencephalography, brain, cervical, and thoracic magnetic resonance imaging, and blood tests were performed. No pathology was observed in the imaging or blood test results. However, during follow-up, mirror movements in the upper extremities were noted. The patient was referred to the physical medicine and rehabilitation department for the recommended rehabilitation. Written informed consent was obtained during the patient’s consultation and before the video recordings from the patient’s parents. The patient and family were informed that all recordings taken from the case would be used for medical and academic information purposes, with personal information kept confidential.

On admission, the patient’s range of motion and motor examination findings were normal. The patient did not exhibit any spasticity. Blood tests revealed 25-hydroxyvitamin D deficiency, and 600 IU of vitamin D once daily was prescribed. Significant mirror movements in the upper extremities continued. The mirror movements were evaluated using the Woods-Teuber scale before, after, and at three months. In contrast, no pathological movement was observed during the lower extremity examination.

The patient was informed of the diagnosis, and a rehabilitation plan was implemented (Table 1). As per the literature, the patient was started on hand-arm bimanual intensive therapy including the lower extremity (HABIT-ILE), which involved both upper and lower extremities. The HABIT-ILE has been successfully used in children with cerebral palsy. For our patient, one-to-one HABIT-ILE was planned for 50 h in 20 days. The patient’s mother was instructed on the at-home exercise program to be performed and the arrangements that could be made in daily life. The patient was followed up regularly once a week. At the three-month follow-up, significant improvements in the upper extremity mirror movements was observed. Consequently, follow-up was adjusted to monthly.

TABLE 1. Rehabilitation process.

-	Method	Frequency	Duration (h)	Application
Week 1	Functional movements of the upper limbs, while the lower limbs are actively in use, at least 10 repetitions	Approximately 2.5 h, 7 days a week	17	Individual accompanied by physiotherapist
Week 2	Functional and task-specific movements of the upper limbs. The series of movements forced all four extremities to work in coordination, at least 10 repetitions, gradual change	Approximately 2.5 h, 7 days a week	17	Individual accompanied by physiotherapist
Week 3	Functional and task-specific movements of the upper limbs. The series of movements forced all four extremities to work in coordination, at least 10 repetitions, gradual change	Approximately 2.5 h 6 days a week	16	Individual accompanied by physiotherapist

The Woods-Teuber scale was applied to rate mirror movements. The patient was asked to perform three basic movements. These were (i) repetitive tapping of the index finger on the thumb, (ii) alternating supination and pronation of the hand, and (iii) repetitive alternating touching of each fingertip. Afterward, variants of the tasks were administered (e.g., fist opening, clenching, and finger tapping on a table). While the patient was performing these movements, the movements in the other hand were scored as (0) no clear imitative movements, (1) barely discernible repetitive movements, (2) slight mirror movements or stronger but briefer, repetitive movements, (3) strong and sustained repetitive movements, and (4) movements equal to those observed in the active hand.^[6] The patient’s right hand was dominant. Before treatment, the left hand scored 9 points during right-sided movements, and the right hand scored 12 points during left-sided movements. After 50 h of the rehabilitation program, when the same evaluation was performed, both sides scored 3 points. At the three-month evaluation, both hands scored 3 points. The patient’s evaluations, before and after treatment, were video recorded. (Video 1, Video 2).

DISCUSSION

Although mirror movement disorder syndrome may accompany many neurological diseases, it is not well known to most clinicians. In particular, there is limited visual or video content in the literature that assists in scoring or evaluating mirror movements.

The mechanisms underlying the pathophysiology of this disease suggest that pathologies in the corticospinal pathway may be involved. Mirror movements disorder syndrome mostly affects the upper extremities and may increase during voluntary movement of the nondominant hand.^{[7, 8]} This condition may affect many vital aspects of children’s well-being, from their quality of life to school success. Therefore, timely management and rehabilitation are crucial.

We reviewed the literature to guide the patient’s treatment process. Current evidence indicates that mirror movement disorder rehabilitation has mostly been applied to patients with cerebral palsy. The results of the different rehabilitation techniques were also observed in this patient group. Importantly, a review of studies on children undergoing constraint-induced movement therapy reported that the evidence quality of this rehabilitation method is low.^[9]

In the early 2000s, studies conducted with children with unilateral cerebral palsy mirror movements introduced hand-arm bimanual intensive therapy (HABIT) and HABIT-ILE, in which spontaneous lower extremity exercises were added to HABIT.^{[10, 11, 12]} This rehabilitation method applies an individualized model consisting of bimanual exercise activities with increasing motor difficulty, and the commands also involve the lower extremities. These studies have shown that patients’ mirror movements and hand skills improve, and functional goals and activities of daily living increase with activities, games, and home studies offered to children. However, the optimal frequency and duration of rehabilitation remain controversial. In a study of patients with unilateral cerebral palsy who exhibited signs of continued well-being for three months, a significant improvement in well-being was observed after HABIT-ILE treatment for 9 h daily and 90 h in total (85 h of individual work and 5 h of group work) lasting for two weeks, depending on the intensity of the patient’s rehabilitation program.^[13] In our patient, a significant improvement was observed with 50 h of individual professional rehabilitation and at-home exercises, and the improvement continued during the three-month follow-up. To date, consensus regarding frequencies and duration of rehabilitation is not available, and patients are followed up with different rehabilitation frequencies and durations in different studies, particularly in children with cerebral palsy.^{[10, 13]}

A 2024 study of children with cerebral palsy who underwent a 90-h HABIT rehabilitation program reported that functional independence improved due to improvements in hand performance but not in mirror movements.^[14] In our study, a significant improvement was observed in the patient’s mirror movements, after a 50-h HABIT-ILE rehabilitation program. Although the changes in the patient’s mirror movements were carefully evaluated, hand performance was not evaluated. This is a limitation in our evaluation during this rehabilitation process.

The current literature includes only a limited number of cases involving mirror movement disorders following an epilepsy diagnosis,^[15] and the rehabilitation data is insufficient. Furthermore, the standardized evaluation methods and treatment programs lack visual documentation and a detailed protocol. The cohort of patients monitored for post-epileptic mirror syndrome remains small, and no established rehabilitation guidelines exist for this specific patient group.

In conclusion, we described a 12-year-old male patient with epilepsy who developed mirror movements, a rare occurrence that is rarely mentioned in the literature. An improved well-being was observed after 50 h of rehabilitation over three months. Based on experience, the HABIT-ILE is an innovative rehabilitation method. This approach presents challenges owing to varying opinions on treatment duration, intensity, and frequency, as well as its applicability across different neurological conditions. Despite the complex and demanding nature of the rehabilitation process, evidence suggests that patients can achieve significant benefits through a well-structured treatment plan and close monitoring.

Supplementary Materials

Video 1

https://www.youtube.com/watch?v=7moLpURXfdI

Video 2

https://www.youtube.com/watch?v=n-0L_1124_o