CRPS and Graded Motor Imagery Programme Emma J Mair Emma.Mair@ggc.scot.nhs.uk 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.

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.

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.

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.

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

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.

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.

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

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

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. 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. 10

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: http://www.rcplondon.ac.uk/resources/complex-regional-pain-syndrome-concise-guideline 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.

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: http://www.trendconsortium.nl/diagnosis/ 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.

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.

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

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

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

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

Body Perception Disturbance DISLIKE DISOWNERSHIP DESIRE TO AMPUTATE DISTORTED MENTAL VISUALISATION The 4 D’s 54.4-84% 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

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 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.

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

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

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

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.

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

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.

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

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!

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

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.

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

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

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

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

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

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

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

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

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

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

Graded Motor Imagery

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

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

Limb Laterality

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

Right or Left?

Right or Left?

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.

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

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

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

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

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

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

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

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

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

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

Motor Imagery

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

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

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

The What? Patient Explanation Food Back pain & bending

The How? Prompts: Shape Skin Colour Digits Movement

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

Mirror Therapy

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

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

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

Mirror therapy for the 21st century? Prism Glasses www.prismglasses.co.uk 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.

Brain Training Educate Desensitise Habituate Develop Function 70

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

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

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