CRPS and Graded Motor Imagery


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Lecture given to the West of Scotland Pain Group on Wednesday 28th November 2012 by Emma Mair, Specialist Physiotherapist in Pain Management about Complex Regional Pain Syndrome (CRPS) and its treatment with Graded Motor Imagery (GMI).

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  • So for those who do not know me my name is Emma Mair. I am a clinical specialist physio here at the New Victoria Hospital and I have a specialist interest in CRPS and that’s why its me here speaking to you tonight.
  • Its going to be a bit of a whistle-stop-tour as those who know me I can talk and I could talk for crps and do for hours on end so I’ll just crack on and hopefully we can cover some of the newer information coming out of the guidelines and also explain a bit more about graded motor imagery and why I’m often seen wandering over the hospital with a big mirror as you can see its clearly not that I’m completely vain.
  • I had old information which quoted 1 in 50 of us got CRPS, with a 1 in 32 for women and 1 in 119 in men but that seemed an awful high rate so I’ve never been able to find my source so I’m secretly glad as my odds in 26 in 1 hundred thousands sounds so much better. Increases with age, More in the upper limb but I wonder at times if that is just more reported and researched 15% will continue to have symptoms 2 years on, I maybe a bit skewed by that data as obviously I see a lot of chronic CRPS patients and not always the early ones but I would have thought that would be a bit higher.
  • So the cause is unknown but the majority of patients are after injuries such as sprains and strains and those spontaneous onset unfortunately also have a much worse prognostic factor.
  • Typically we always reported CRPS in Types. One for crps after injuries and
  • Two for after definate nerve injury.
  • To be honest there was a lot of discussion regarding dropping these terms but it was decided to keep them but other than in nerve injuries which may require surgery crps 1 and 2 equal crps when it comes to diagnosis and treatment.
  • We know that the actual cause of CRPS is unknown but there is multifactorial pathophysiology including both the Peripheral and Central nervous system. Current thoughts are on an inflammatory overload which doesn’t switch off and theres a lot of studies re genetic predisposition and other factors. There is no current definition of recovery so it makes it defficult in research and I think it’s a term that sticks even when a patient no longer has alloydnia and hyperalgesia they sometimes report their pain as CRPS which it no longer would be diagnosed as such, but we can come on to that later. The guidelines say these patients should still be termed ‘CRPS-NOS’ (not otherwise specified). We absolutely know that crps is not a result of psychological problems although that doesn’t mean there is a host of psychological distress that goes along with crps.
  • Figure 4: Clinical features and proposed pathophysiological mechanisms of CRPS Although these pathophysiological mechanisms have all been identified in CRPS, they might occur independently of each other. The absence of such fixed relations explains the clinical heterogeneity that is often encountered in this condition. *Reorganisation of contralateral primary somatosensory cortex is associated with spontaneous CRPS pain and mechanical hyperalgesia. This reorganisation might also explain altered sensations (eg, perceptual disturbances and referred sensations). Reorganisation of contralateral Primary motor cortex is associated with motor dysfunction (ie, tapping). However, these changes might be secondary to the symptoms rather than being a cause of the symptoms. Perception of threat- smashed window, flight/fright reaction different systems working causing causes not only in physical sensations but thoughts and feelings… this ongoing changes the nervous system not exactly technically correct but it starts to highlight to the patient the multi systems involved and then ongoing to further pain explanations.
  • ACE inhibitors inhibit the breakdown of substance P obviously involved within sensitisation Coexisting medical conditions –osteoporosis, recent h/o menstrual cycle related problems and pre-existing neuropathies The association with asthma and migraine favours existing ideas of neurogenic inflammation involvement with CRPS (de Mos et al. 2008 ) Studies on immobilisation, people even without fractures who were immobilised high percentage started to show signs of CRPS so it should be something that people who are casted are given advice to monitor for changes etc. the guidelines gives a handout template for use in ortho clinics.
  • So most of the information about the diagnosis is from the new UK guidelines which were published earlier this year, although like anything its knowing they are there. There is a concise guideline then a more detailed guideline which is categories into different areas.
  • The main thing with diagnosis is that usually it is the physios who are seeing these patients early on so they really are at the best place to recognise and identify CRPS, as long standing some areas of medicine will still require a medical practitioner to “signoff” that diagnosis especially within medico-legal claims so it is always beneficial to discuss with the cons/GP. The guidelines have now all been compressed into what is known as the Budapest criteria which is still based on signs and symptoms. Obviously differential diagnosis needs to be considered but they is little confirmatory investigations for CRPS other than thermography but we don’t have them lying around and later stages MRI and x-ray changes.
  • So the budapest criteria is based on signs and symptoms in 4 areas: Sensory Vasomotor Sudomotor/ oedema Motor/ trophic changes Which I will go through quickly. To confirm a diagnosis the patient has to have a continuing pain which is disproportionate to any injury, They must have at least one sign( you can see it) in two or more of the categories And the patient reports at least one symptom in 3 or more of the categories. For research, diagnostic decision rule should be at least one symptom in all four symptom categories and at least one sign (observed at evaluation) in two or more sign categories.
  • Sensory Reports of hyperesthesia and/or allodynia Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or temperature sensation and/or deep somatic pressure and/or joint movement
  • Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry Usually hot crps initially and develops to “cold” crps Vasomotor: Evidence of temperature asymmetry (>1°C) and/or skin color changes and/or asymmetry
  • Reports of edema and/or sweating changes and/or sweating asymmetry Evidence of edema and/or sweating changes and/or sweating asymmetry
  • Motor / Trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin) Motor / Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
  • The 4 D’s 54.4-84% report disturbances in body perception. Thoughts about the painful limb: Hate it Refer to it in the 3 rd person Foreign / alien to them Don’t want to think about it Feeling of amputation (early onset) Lack of attention to the limb (think, look, touch) Poor limb/digit position awareness and performance Perceptual changes in limb size and shape Perceptual mismatch in temp, pressure and weight Perceptual distortions in mental representation of the limb
  • Targeted screening to the patient about how the limb feels to them, does it feel apart of them and does it feel bigger, smaller to what they know it to be. Often pateints with body perception dysfunction will position the limb differently, round the back of a chair or give the area much more space. We now use the Bath body perception scale as an outcoem measure as I think this is also a way for us to report changes in these patients with treatment.
  • Because of Body perception dysfunction you need to be mindful of the treatment environment. It will be my CRPS patients who will tell me how drafty the new department feels whereas I had never noticed it or they often give me into trouble about speaking with my hands as I would be creating a change in pressure and at times the feeling of coming to close to them. It is worth noting as it can make a huge different to the patient
  • The guidelines suggests the main aims of treatment are: Reduce pain Preserve or restore function Enable the pateint to manage the condition and Improve quality of life… If it was so simple as that these patients wouldn’t be coming to pain clinics and you all certainly wouldn’t be giving up your time to talk about it. Luckily there is a bit more guidance
  • I’ve split this into the primary care physio and OT as in the guidelines
  • All the expectation is that you are aware of crps, the diagnosis and early input. If things aren't improving knowing where to get advice and/ or referral on.
  • Are suggesting 4 weeks of no change the patients should be referred on to MDT specialist services.
  • Some of the guidelines are based also on PMPs which I think is based on the Bath CRPS service model but early patients wouldn't go to the PMP here in Glasgow.
  • Just like in any complex and pain condition understanding is key. Explaining pain and crps is really a bit of a soap box theme for me. This isn't exclusive to crps either!
  • Intravenous regional sympathetic blocks with guanethidine should not be routinely used as 4 RCTs have not demonstrated any benefit. Immunoglobulin trials SCS- evidence shows that scs benefit generally declines over time. Baclofen- within input from specialised centres and when side effects out weigh within dystonia crps.
  • Suffering Fear Anxiety Anger Depression Failure to cope Behavioural illness
  • Individualised management - clinical reasoning +++ Little and often All hands on deck (MDT approach) Believe patient’s pain Gain trust It will hurt but not harm Function, function, function (valued) Emphasis on self management Be creative and compassionate Liaise and Refer to specialised MDT services
  • But can you be an official GMI practitioner? I don’t think so. It’s a constantly developing umbrella concept encompassing the neuromatrix paradigm, mindfulness, problem solving and most importantly is an individually tailored part of treating pain. Reduces threat of the movement as well as graded activation of different neuronal populations and cortical networks
  • GMI reduces pain intensity by a clinically relevant amount and this is maintained for up to 6 months (Daly and Bialocerkoswski 2009) Physiotherapy treatment for CRPS is not underpinned by any research
  • Pain physiology ed alters brain activity during task performance. We do not know why some people get CRPS and others don’t We DO know that
  • is a sequential process of rehabilitation where the therapeutic targets are synapses in the brain Laterality reconstruction Motor Imagery Mirror Therapy
  • These pictures above you all would have looked at them and made a decision about what you thought you saw and then perhaps knowing they are illusions investigated further to decide what else lies within the picture and these basic principles of visual perception. Not exactly the same as recognising laterality of an image but similar as, as I said when one looks at an image we initially make a guess and then mental rotate this image to confirm and reject our initial decision, best way to explain this is to give you a go. I’m going to show you an image and I want you to tell me if it is right or left sided. Just shout out right or left.
  • Quite often, people with painful limb problems lose the ability to recognise left or right images which can obstruct a successful recovery. The good news is the brain is plastic, and changeable, if given the right stimuli for long enough. So with a little bit of work, patience and persistence it is possible to reconstruct the brain’s feature of laterality, which would have existed prior to the limb problem. Laterality is the ability to select whether a presented image is right or left sided. A response requires initial selection of a right or left side then mental spatial transformation to confirm the choice i.e. we mentally rotate our own limb in our mid to confirm the choice. As such this requires an intact body schema. Body schemas are representations of the body within the spinal cord, thalamic and cortical structures which have a role in the guidance of imagined and actual movements. Melzack’s neuromatrix describes the self distinct identity from others and the world. This may be a genetic basis sculptured by life experiences, i.e. nature versus nurture. Modified by observation of others and modified by tool use- increases influence of body, modified by experience- skill acquisition such as musical instruments and using braille increases the representation of the hand. Nociceptive barrage also alters the representation in S1 and S2. The body schema can be fooled- rubber hand illusion Cognitive psychologists used laterality to investigate body schema Studies have shown that reaction times for recognition in laterality recognition can be reduced in CRPS and in phantom limb pain, however in acute experimental pain and expectation of pain there is delayed recognition in the opposite limb with no change to the affected limb. Researchers such as Moseley have shown that this change in reaction time in chronic pain are therefore unlikely to be due to nociceptive input, and in acute experimental pain there is unlikely to be a disruption to body schema. It also does not evoke protective premotor processes likely to be present with a problem which is perceived as threatening, i.e. volunteers know the pain will go away. Laterality tasks activates premotor cortices, not primary motor cortex, whereas imagined movements activate both allowing a basis for the GMI progression.
  • Motor imagery- the result of conscious access to the neurosignatures representing intention, preparation, carrying out and evaluation of a movement. There is a high degree of overlap in brain regions involved in actual movements or imagined movements. Essentially imagining movements and postures. This is kinaesthetic activation not a visual activation meaning the patient must imagine themselves doing the movement, not as an observer watching themselves do the movement.
  • Motor imagery- the result of conscious access to the neurosignatures representing intention, preparation, carrying out and evaluation of a movement. There is a high degree of overlap in brain regions involved in actual movements or imagined movements. Essentially imagining movements and postures. This is kinaesthetic activation not a visual activation meaning the patient must imagine themselves doing the movement, not as an observer watching themselves do the movement.
  • The use of the mirror to present the reversed image of a limb to the brain, illusion. Graded contextural activities
  • The Prism Glasses are a medical device created to help treat patients suffering from phantom limb pain and help rehabilitation of patients following a stroke. The Prism Glasses also have applications in the treatment of visual neglect syndrome and other chronic pain conditions such complex regional pain syndrome.
  • Based Phantom Limb Pain Research Moseley and Butler Daly & Bialocerkowski (2009) systematic review Clinical Evaluation- Bath / Liverpool experience Clinical site not clinician? CRPS conference
  • CRPS and Graded Motor Imagery

    1. 1. CRPS and Graded Motor Imagery Programme Emma J Mair November 2012
    2. 2. Tonight- an overview Aetiology Pathophysiology UK Guidelines Diagnosis Treatment Graded Motor Imagery programme
    3. 3.  European Incidence rate of 26/100,000 person-years Incidence with age till 70 60% in upper limb, 40% in lower limb Approximately 15% of sufferers will have unrelenting pain and physical impairment 2 years after CRPS onset
    4. 4.  Cause Unknown 45% following fracture 18% following sprains 12% following surgery <10% spontaneous
    5. 5. CRPS-1 Type 1: sympathetically maintained pain can start for no apparent reason but most commonly follows distal radial fracture. Characterised by pain which is disproportionate to inciting event, swelling, autonomic and motor disturbances, changes in skin blood flow
    6. 6. CRPS-2 Type 2: Onset develops after injury to a major peripheral nerve. May occur immediately or be delayed for several months Most commonly involved are the median and sciatic nerves Allodynia and hyperalgesia occur but not limited to the territory of one single peripheral nerve
    7. 7. 1 + 2 = CRPS
    8. 8. Pathophysiology Multi-factorial Other factors: environmental, genetic, psychological The stereotyped stages are now obsolete A definition of recovery has not yet been agreed CRPS is not associated with a history of pain preceding psychological problems, or with somatisation or malingering
    9. 9. Contralateral cortical changes Ipsilateral cortical Reorganisation of sensory changes maps in S1* ↓Inhibition and Reorganisation of motor ↑excitation in M1 maps in M1† ↓Inhibition and ↑excitation in M1 and SMA ↓Endogenous pain control Pain Central sensitisation Allodynia, hyperalgesia, secondary hyperalgesia, and wind-up Sympathetic– ↓Sympathetic outflow afferent coupling Vasodilation (early stage) •Sensory abnormalities Pain Endothelial dysfunction •Autonomic dysfunction ↓NO and ↑ET-1 Impaired circulation (chronic stage) •Neurogenic inflammation •Motor abnormalities •Sensitisation • Swelling • Glossy skin •Central reorganisationPeripheral sensitisation • Increased nail and↑IL-1β, IL-6, TNFα, NGF, CGRP, hair growthsubstance P, and bradykinin • Hyperaemia‡Pain, vasodilation of theskin, and oedema
    10. 10. Risk Factors ACE inhibitors Asthma Migraine Immobilisation ? Genetic
    11. 11. UK Guidelines Published April 2012 Recommendations for assessment and management Speciality Guidelines:  Primary Care  Physio & OT  Orthopaedic Practice  Rheumatology, neurology and neurosurgery  Dermatology  Pain Medicine  Rehabilitation Medicine  Long-Term support in CRPS Available from: pain-syndrome-concise-guideline
    12. 12. Diagnosis Physio’s probably best equipped to identify a patient with CRPS Confirmation of diagnosis based on Budapest guidelines Confirmation with GP/cons Differential diagnosis Diagnosis tool:
    13. 13. A The patient has continuing pain which is disproportionate to any inciting event All A-D must B The patient has at least one sign in two or more of the categories apply C The patient reports at least one symptom in three or more of the categories D No other diagnosis can better explain the signs and symptomsCategory Sign (you can see or Symptom (the feel a problem) patient reports a problem)1. SENSORY Allodynia (to light Hyperesthesia does touch and/or temp also qualify as a sensation and/or symptom deep somatic pressure and /or joint movement) and/or hyperalgesia (to pinprick)2. VASOMOTOR Temperature Temp asymmetry asymmetry and/or must be >1°C skin colour changes and/or skin colour asymmetry3. SUDOMOTOR/ Oedema and/orOEDEMA sweating changes and/or sweating asymmetry4. MOTOR/ Decreased range fTROPHIC motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair/nail/skin)
    14. 14. Sensory Alloydnia – pain due to a stimulus which does not normally cause pain. E.g. touch and temperature Hyperalgesia– increased response to stimulus that is normally painful Hyperesthesia– increased sensitivity to stimulation Hyperpathia- a state of exaggerated and very painful response to stimulation especially repetitive stimulus Hypoesthesia- a reduced sense of touch or sensation, or a partial loss of sensitivity to sensory stimuli sensory.
    15. 15. Vasomotor Temperature asymmetry Skin colour changes
    16. 16. Sudomotor / Oedema Oedema Sweating changes or asymmetry
    17. 17. Motor / Trophic Decreased range of movement and/or Motor dysfunction (weakness, tremor, dystonia) and/or Trophic changes (hair, nails, skin)
    19. 19. Body Perception Disturbance The Bath CRPS Body Perception Disturbance Scale* Developed by Jennifer S. Lewis, The Royal National Hospital for Rheumatic Diseases Bath, England. v2. ©2008. All rights reserved. Patient name ________________________ Date ________ Assessment no. 1 2 3 4 5 General Screening: Diagnosis___________________________ Date of symptom onset____________ Body part affected: 1)_________________________ 2)_________________________ 3)_________________________  Targeted questioning 1) On a scale of 0-10 how much a part of your body does the affected part feel? Very much a part = 0__1__2__3__4__5__6__7__8__9__10 = Completely detached 2) On a scale of 0-10 how aware are you of the physical position of your limb? Emotions Very aware = 0__ 1__2__3__4__5__6__7__8__9__10 = Completely unaware 1. 3) On a scale of 0-10 how much attention do you pay to your limb in terms of looking at it and thinking about it? Full attention = 0__ 1__2__3__4__5__6__7__8__9__10 = No attention 2. Sense of belonging 4) On a scale of 0-10 how strong are the emotional feelings that you have about your limb? Strongly positive = 0__ 1__2__3__4__5__6__7__8__9__10 = Strongly negative 5) Is there a difference between how your affected limb looks or is on touch 3. Perceived size compared to how it feels to you in terms of the following: Size yes no Comment ________________________ Temperature yes no Comment ________________________ Pressure yes no Comment ________________________ Weight yes no Comment ________________________ 6a) Have you ever had a desire to amputate the limb? Yes No 6b) If yes, how strong is that desire now? Simple observation of Not at all = 0__ 1__2__3__4__5__6__7__8__9__10 = Very strong Desired amputation site________________________________ 7) With eyes closed describe a mental image of your affected and unaffected position of limb body parts (drawn by assessor during patient description then verified by the patient) This is an accurate account of my image of my affected body part. Signature __________________________________ Date____________________
    20. 20. The Environment Therapy environment – breezes, open windows, fans Lighting Invasion of personal space Therapist movement and language (“your” vs “it”) Other people nearby Noise Privacy
    21. 21. Treatment Prompt diagnosis and early treatment are considered best practice Aims of treatment:  Reduce pain  Preserve or restore function  Enable patients to manage their condition  Improve quality of life
    22. 22. Primary Care Physiotherapy &Occupational Therapy
    23. 23. Best practice recommendations Be aware of CRPS and identify the clinical signs Be aware of the Budapest criteria for diagnosing CRPS Initiate treatment as early as possible Provide patient education about the condition Know of the nearest MDT pain service or CRPS centre Recognising non-resolving or moderate symptoms for onward referral
    24. 24. Rehabilitation Algorithm Identify CRPS signs and symptoms Consider Meet Budapest Confirm DiagnosisDifferential Diagnosis criteria Via GP or consultant Consider Mild/Moderate yellow flags Moderate/ severe symptoms symptoms Educate, commence Educate, refer via GP treatments To specialist pain clinic Failing to respond Pain Management to treatment in 4 weeks programme Noticeable response to Treatment within 4 weeks And ongoing improvement
    25. 25. Pain Medicine andInterdisciplinary SpecialistRehabilitation Programmes
    26. 26. Four Pillars of Treatment Physical and vocational rehabilitation Pain relief Psychological (medication and interventions procedures) Patient information and education to support self- management
    27. 27. Engagement: education andinformation for the patient &family Understanding pain and CRPS Learning self management principles Self efficacy- the patient remains responsible and involved Empowering the patient and the family
    28. 28. Medical Management Investigation and confirmation of diagnosis Pharmacological intervention to provide a window of pain relief Reassurance that PT and OT are safe and appropriate Provide medical follow up Support any litigation/ compensation claim
    29. 29. Pain Medicine GuidelineRecommendations No drugs are licensed to treat CRPS in the UK Neuropathic drugs should be used in according to NICE & IASP guidelines Pamidronate (single 60mg intravenous dose) should be considered in suitable patients with less than 6mths duration as a one off treatment Intravenous regional sympathetic blocks with guanethidine should not be routinely used Other additional drugs demonstrate efficacy but a lot of the evidence is still preliminary Spinal Cord Stimulators
    30. 30. Psychosocial and behaviouralmanagement Psychological intervention is based on individualised assessment, to identify and proactively manage any factors which may perpetuate pain or disability/ dependency including:  Mood evaluation- management of anxiety and depression  Internal factors, eg counter productive behaviour patterns  Any external influences or perverse incentives It usually follows principles of CBT delivering:  Coping skills and positive thought patterns  Support for family/carers
    31. 31. Physical Management Emphasis should be on restoration of normal function and activities through acquisition of self management skills, with the patients actively engaged in goal setting The programme may include elements of chronic pain management including:  General body re-conditioning through graded exercise, gait re-education, postural control  Restoration of normal activities, including self care, recreational physical exercise and social/ leisure activities  Pacing and relaxation strategies  Vocational support
    32. 32.  It may also include specialised techniques to address altered perception and awareness of the limb, for example:  Selfadministered desensitisation with tactile and thermal stimuli  Functional movement to improve motor control and limb position awareness  Graded motor imagery, mirror visual feedback, mental visualisation  Management of CRPS- dystonia
    33. 33. Activities of ADL and societalparticipation Support graded return to independence in ADLs and clear functional goals Assessment and provision of appropriate specialist equipment to support independence Adaptation of environment Extend social and recreational activities in and outside the home Workplace assessment/ vocational re-training
    34. 34. Overview Understand Recognise Prompt diagnosis Educate Early treatment MDT approach
    35. 35. CRPS Treatment Mindfulness /Explain & Educate Problem Solving Reducing Threat Awareness
    36. 36. Treatment- what are the options? Based on evidence based practise, guidelines and innovative clinicians Good quality evidence for graded motor imagery(GMI) combined with pharmacological management is the most effective
    37. 37. Educate, educate, educate  We do not know why some people get CRPS and About CRPS others don’t About Pain  We DO know that it is not because of psychological frailty or abnormality  Several important changes in the brain seem to accompany CRPS  To normalise these changes, we have to identify ALL combinations to perceived threat and train the brain
    38. 38. Movement versus Pain Remember pain science and pathophysiology Sensitisation of CNS More harm than good?!
    39. 39. Desensitisation Activities of daily living Washing and dressing Sensory Discrimination Two-point discrimination Electrical Stimulation
    40. 40. Graded Motor Imagery
    41. 41.  Sequential activation of cortical pre-motor and motor networks Laterality and Imagery = pre motor Mirror Therapy = Primary Motor Cortex and S1 cortices ?reversal of cortical reorganisation
    42. 42. Limb Laterality
    43. 43. What do you see?
    44. 44. Right or Left?
    45. 45. Right or Left?
    46. 46. Laterality Recognition Make a quick decision about the laterality then you mentally rotate mental representation of the limb into the position viewed to confirm initial selection!
    47. 47. Limb Laterality Recognition Pain affects the brains ability to recognise laterality of images of limbs Information processing bias Working body Schema
    48. 48. “Normal Scores” Accuracy of 80% and above Speed of hands and feet ~ 2 seconds Accuracies and RT should be equal
    49. 49. Differences in Speed Identifies problems with Information processing … but what does that mean?
    50. 50. Mentally Mentally move move RT LEFT RIGHT R>L hand hand Difficult decision,Acute LEFT hand safest to presume Xinjury looking at its LEFT hand correct because my LEFT WrongRIGHT hand hand is injured, choice, chose LEFT hand. start Accuracy again L=R Mentally Difficult decision, move safest to presume LEFTAcute LEFT hand its LEFT hand handinjury looking at because my LEFT hand is injured,LEFT hand chose LEFT hand. correct Acute Pain
    51. 51. Mentally Mentally move move RT RIGHT LEFT L>R hand Difficult decision, hand Chronic LEFT safest to presume its RIGHT hand X hand injury because my LEFT correct Wronglooking at RIGHT hand is in trouble choice, and I’m protecting it hand by not focusing on it. start Accuracy again L=R Mentally Difficult decision, move Chronic LEFT safest to presume RIGHT its RIGHT hand hand hand injury because my LEFTlooking at RIGHT hand is in trouble correct and I’m protecting it hand by not focusing on it. Chronic Pain
    52. 52. Why? Incorrect selection leads to longer reaction time as need to repeat mental rotation of limb to confirm laterality choice Pain & information processing, patients wrongly select
    53. 53. Differences in Accuracy Difference in accuracy suggests issues with the working body schema
    54. 54. Why? Cortical reorganisation Easier access to painful working body schema?
    55. 55. Laterality Reconstruction Hands, Feet, Neck/Shoulder Vanilla, Abstract, Context Online and Flash cards Recognise Phone Apps Other methods:  Shadow Puppets  Digital cameras  Magazines
    56. 56. RecogniseRecognise online:
    57. 57. Motor Imagery
    58. 58. Motor Imagery Sports Performance Neuro-Rehabilitation Cognitive Psychology Graded Motor Imagery
    59. 59. Motor Imagery Observing and Imagining movements Imagining yourself doing the movement not imagining observing themselves doing the movement
    60. 60. The Why? If you can’t feel it, how can you use it?
    61. 61. The What? Patient Explanation  Food  Back pain & bending
    62. 62. The How? Prompts:  Shape  Skin  Colour  Digits  Movement
    63. 63. Motor Imagery Awareness of body part Imagining movements Imagining functional activities Flash cards and online images can be used as prompts
    64. 64. Mirror Therapy
    65. 65. The Why? Illusion Tricking the brain Motor Cortex / S1 Mirror Neurons
    66. 66. The How? Observation De-sensitisation Movement Context- emotional, threat Weight bearing Functional rehab
    67. 67. Mirror Therapy Practical:  Try bilateral movements with the mirror  Try asynchronous movements whilst watching your limb in the mirror  Get someone to tap or stroke the unaffected limb whilst looking at the reflected limb
    68. 68. Mirror therapy for the 21st century? Prism Glasses
    69. 69. Brain Training Educate Desensitise Habituate Develop Function
    70. 70. Can’t Perform Bilateral synchronised Mirror visual feedback movements in a mirror ? Physical rehabilitation Can’t Perform approaches Can’t Perform Imagined movement of Rehearse motor imagery affected limbCan’t Perform Can’t Perform Limb Laterality Limb Laterality programmeCan’t Perform Can’t Perform Sensory discrimination Electrical or manual Concurrent medical and psychological support
    71. 71. Resources & Research
    72. 72. Questions from you and fromme? How do we support our primary & secondary care clinicians treating this condition? Specialised Pathways and Clinics required?