1. CRPS and Graded Motor Imagery Programme
Emma J Mair
November 2012
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.

2. Tonight- an overview Aetiology Pathophysiology UK Guidelines Diagnosis
Treatment
Graded Motor Imagery
programme
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.

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
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.

4. Cause Unknown 45% following fracture 18% following sprains
12% following surgery
<10% spontaneous
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.

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
Typically we always reported CRPS in Types.
One for crps after injuries and

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
Two for after definate nerve injury.

7. 1 + 2 = CRPS
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.

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
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. 8

9. Sensory abnormalities Autonomic dysfunction Neurogenic inflammation
Contralateral cortical changes
Reorganisation of sensory
maps in S1*
Reorganisation of motor
maps in M1†
↓Inhibition and ↑excitation
in M1 and SMA
Ipsilateral cortical changes
↓Inhibition and ↑excitation in M1
↓Endogenous pain control
Pain
Central sensitisation
Allodynia, hyperalgesia, secondary
hyperalgesia, and wind-up
Sympathetic–afferent coupling
Pain
↓Sympathetic outflow
Vasodilation (early stage)
Sensory abnormalities
Autonomic dysfunction
Neurogenic inflammation
Motor abnormalities
Sensitisation
Central reorganisation
Endothelial dysfunction
↓NO and ↑ET-1
Impaired circulation (chronic stage)
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.
• Swelling
• Glossy skin
• Increased nail and
hair growth
• Hyperaemia‡
Peripheral sensitisation
↑IL-1β, IL-6, TNFα, NGF, CGRP,
substance P, and bradykinin
Pain, vasodilation of the
skin, and oedema 9

10. Risk Factors ACE inhibitors Asthma Migraine Immobilisation ? Genetic
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 )
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. 10

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:
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.

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:
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.

13. B The patient has at least one sign in two or more of the categories
A The patient has continuing pain which is disproportionate to any inciting event
B The patient has at least one sign in two or more of the categories
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 symptoms
All A-D must apply
Category
Sign (you can see or feel a problem)
Symptom (the patient reports a problem)
1. SENSORY
Allodynia (to light touch and/or temp sensation and/or deep somatic pressure and /or joint movement) and/or hyperalgesia (to pinprick)
Hyperesthesia does also qualify as a symptom
2. VASOMOTOR
Temperature asymmetry and/or skin colour changes and/or skin colour asymmetry
Temp asymmetry must be >1°C
3. SUDOMOTOR/ OEDEMA
Oedema and/or sweating changes and/or sweating asymmetry
4. MOTOR/ TROPHIC
Decreased range f motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair/nail/skin)
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.

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.
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

15. Vasomotor Temperature asymmetry Skin colour changes
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

16. Sudomotor / Oedema Oedema Sweating changes or asymmetry
Reports of edema and/or sweating changes and/or sweating asymmetry
Evidence of edema and/or sweating changes and/or sweating asymmetry

17. Motor / Trophic Decreased range of movement and/or
Motor dysfunction (weakness, tremor, dystonia) and/or
Trophic changes (hair, nails, skin)
Motor/Trophic:
Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes
(hair, nail, skin)
Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes

18. Body Perception Disturbance
DISLIKE
DISOWNERSHIP
DESIRE TO AMPUTATE
DISTORTED MENTAL VISUALISATION
The 4 D’s
% report disturbances in body perception.
Thoughts about the painful limb:
Hate it
Refer to it in the 3rd 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 18

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
Diagnosis___________________________ Date of symptom onset____________
Body part affected: 1)_________________________
2)_________________________
3)_________________________
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?
Very aware = 0__ 1__2__3__4__5__6__7__8__9__10 = Completely unaware
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
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
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?
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
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____________________
General Screening:
Targeted questioning
Emotions
Sense of belonging
Perceived size
Simple observation of position of 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.

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
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

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
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

22. Primary Care Physiotherapy & Occupational Therapy
I’ve split this into the primary care physio and OT as in the guidelines

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
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.

24. Rehabilitation Algorithm
Consider yellow flags
Are suggesting 4 weeks of no change the patients should be referred on to MDT specialist services.

25. Pain Medicine and Interdisciplinary Specialist Rehabilitation Programmes
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.

26. Four Pillars of Treatment
Physical and vocational rehabilitation
Pain relief (medication and procedures)
Psychological interventions
Patient information and education to support self- management

27. Engagement: education and information 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
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!

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. Pain Medicine Guideline Recommendations
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
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.

30. Psychosocial and behavioural management
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
Suffering
Fear
Anxiety
Anger
Depression
Failure to cope
Behavioural illness

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. It may also include specialised techniques to address altered perception and awareness of the limb, for example:
Self administered 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. Activities of ADL and societal participation
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. Overview Understand Recognise Prompt diagnosis Educate Early treatment
MDT approach
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 34

35. CRPS Treatment Explain & Educate Mindfulness / Awareness
Problem Solving
Reducing Threat
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 35 35

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
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

37. Educate, educate, educate
We do not know why some people get CRPS and others don’t
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
About CRPS
About Pain
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 37

38. Movement versus Pain Remember pain science and pathophysiology
Sensitisation of CNS
More harm than good?!

39. Desensitisation Activities of daily living Washing and dressing
Sensory Discrimination
Two-point discrimination
Electrical Stimulation 39 39

40. Graded Motor Imagery

41. is a sequential process of rehabilitation where the therapeutic targets are synapses in the brain
Laterality reconstruction
Motor Imagery
Mirror Therapy

42. 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

43. Limb Laterality

44. What do you see?
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. 44

45. Right or Left?

46. Right or Left?

47. 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!
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.

48. Limb Laterality Recognition
Pain affects the brains ability to recognise laterality of images of limbs
Information processing bias
Working body Schema

49. “Normal Scores” Accuracy of 80% and above
Speed of hands and feet ~ 2 seconds
Accuracies and RT should be equal

50. Differences in Speed Identifies problems with Information processing
… but what does that mean?

51. Acute Pain Acute LEFT hand injury looking at RIGHT hand
Mentally move LEFT hand
Mentally move RIGHT
hand RT
R>L
Difficult decision, safest to presume its LEFT hand because my LEFT hand is injured, chose LEFT hand.
Acute LEFT hand injury looking at RIGHT hand X
Wrong choice, start again
correct
Accuracy
L=R
Mentally move LEFT hand
Difficult decision, safest to presume its LEFT hand because my LEFT hand is injured, chose LEFT hand.
Acute LEFT hand injury looking at LEFT hand
correct
Acute Pain

52. Chronic Pain Chronic LEFT hand injury looking at RIGHT hand
Mentally move RIGHT
hand
Mentally move LEFT
hand RT
L>R
Difficult decision, safest to presume its RIGHT hand because my LEFT hand is in trouble and I’m protecting it by not focusing on it.
Chronic LEFT hand injury looking at RIGHT hand X
Wrong choice, start again
correct
Accuracy
L=R
Mentally move RIGHT hand
Difficult decision, safest to presume its RIGHT hand because my LEFT hand is in trouble and I’m protecting it by not focusing on it.
Chronic LEFT hand injury looking at RIGHT hand
correct
Chronic Pain

53. 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

54. Differences in Accuracy
Difference in accuracy suggests issues with the working body schema

55. Why? Cortical reorganisation
Easier access to painful working body schema?

56. Laterality Reconstruction
Hands, Feet, Neck/Shoulder
Vanilla, Abstract, Context
Online and Flash cards
Recognise Phone Apps
Other methods:
Shadow Puppets
Digital cameras
Magazines

57. Recognise Recognise online: http://recognise.noigroup.com/recognise/57

58. Motor Imagery

59. Motor Imagery Sports Performance Neuro-Rehabilitation
Cognitive Psychology
Graded Motor Imagery

60. Motor Imagery Observing and Imagining movements
Imagining yourself doing the movement not imagining observing themselves doing 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. 60 60

61. The Why?
If you can’t feel it, how can you use it?

62. The What?
Patient Explanation
Food
Back pain & bending

63. The How?
Prompts:
Shape
Skin
Colour
Digits
Movement

64. Motor Imagery Awareness of body part Imagining movements
Imagining functional activities
Flash cards and online images can be used as prompts
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. 64 64

65. Mirror Therapy

66. The Why?
Illusion
Tricking the brain
Motor Cortex / S1
Mirror Neurons

67. The How? Observation De-sensitisation Movement
Context- emotional, threat
Weight bearing
Functional rehab
The use of the mirror to present the reversed image of a limb to the brain, illusion.
Graded contextural activities 67

68. 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

69. Mirror therapy for the 21st century?
Prism Glasses
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.

70. Brain Training
Educate
Desensitise
Habituate
Develop Function 70

71. Bilateral synchronised movements in a mirror Mirror visual feedback
? Physical rehabilitation approaches
Rehearse motor imagery
Limb Laterality
Limb Laterality programme
Sensory discrimination
Electrical or manual
Concurrent medical and psychological support
Imagined movement of affected limb
Can’t Perform

72. Resources & Research Based Phantom Limb Pain Research
Moseley and Butler
Daly & Bialocerkowski (2009) systematic review
Clinical Evaluation- Bath / Liverpool experience
Clinical site not clinician?
CRPS conference

73. Questions from you and from me?
How do we support our primary & secondary care clinicians treating this condition?
Specialised Pathways and Clinics required?