Graded motor imagery protocol for CRPS

Hi Joe,
How many patients have you used this protocol on? What outcome measure do you use and what scores have you got? I only get a few CRPS a year so I would be interested to generalise. Does it work for central post stroke pain, phantom limb or other condition where a central reorganisation needs to be facilitated? I have tried mirrors on these groups with very variable success.
Kind thoughts,

Hey Steve,
I have used this on probably 10-12 individuals over the past year with rather good success. I have only used it in individuals with CRPS but I would suspect anyone who is in a process of central sensitization to have some success. I stay very strict to this protocol in conjunction with pain education. I do not include any other activities (or modalities—thermal stimuli actually can make the condition worse) until the 6 weeks have been completed and limit their physical activities during this time. You do not want to just do mirror-box interventions without first attempting to have an effect on the pre-motor cortices through the planning of painfree movements through laterality and imagined movements.

I measure all patients using the recognise app for iphone to measure laterality (i used the online version prior to the app from the noigroup), use a tampa scale for kinesiophobia, pain catastrophizing scale, and VAS. I also ask their perceived expectations that their condition will improve pre- and post- pain education. Expectation for improvement is key. If they do not have expectations, help set them through education as well as possible mentorship w/individuals who have been successfully treated for this condition.

Cheers Joe,
Great advice and it is well recieved. I particularly like the choice you make to measure expectation for improvement. I agree and suspect that this expectation represents a state of mind that indicates that the brain is willing. Willing to risk the threat of a pain experience. To revisit high risk areas. And following the protocol as stated would be a zero added pain experience which would build on their willingness. Nice.
I suspect that expectation would be proportional to belief (in the neurophysiological model you teach) and trust (in you).
Kind thoughts.
Steve

Hi,
thanks for your post. I, too have practiced this protocol w/ CRPS clients. However, I haven’t had the outcomes you describe.
1) Are the CRPS patients you treat fairly acute or in the chronic stage ?
2) Are you only progressing the patient if they make improvements on their laterality recognition ?
3) what if they don’t have any improvement with their laterality ? do you still progress them to the 2nd phase ?
Thanks,
Renee, PT

Thanks for your suggested protocol. I was wondering how you might approach graded motor imagery in a patient with bilateral symptoms, particularly when it comes to using the mirror box. Do you simply put their most affected/worst hand inside the box? Or is this form of therapy inappropriate? Looking forward to your thoughts.
Katrina

Hey guys,
I would say by the time they are in my office they would be classified as “chronic” but I hate using the terms acute/chronic. I prefer to classify patients in pain as nociceptive, peripheral neuropathic or central sens.

I have seen patients improve in their laterality measures (using recognise) but like I posted before, this is all they do for 2 weeks. Laterality exercises become their life. If there were no improvements, I would continue to attempt to improve laterality before progressing.

In terms of patient with bilateral symptoms or symptoms that are spreading, I still do laterality and graded motor imagery but I do not do mirror-box. The success of these individuals is much lower, from my antedoctal experience, but I would be interested to see if they would take ownership or tolerate treatment of a realistic, prosthetic limb. There has been some literature to support healthy individual can gain sensation in prosthetic limbs, but more research needs to be done to look at applicabiltiy in individuals with CRPS.