Breaking the Cycle of Pain: The Role of Graded Motor Imagery and Mirror Therapy in Complex Regional Pain Syndrome.

Background: Complex Regional Pain Syndrome (CRPS) is a chronic condition characterized by severe pain and functional impairment. Graded Motor Imagery (GMI) and Mirror Therapy (MT) have emerged as potential non-invasive treatments; this review evaluates the effectiveness of these therapies in reducing pain, improving function, and managing swelling in CRPS patients. Methods: A systematic review was conducted including randomized controlled trials (RCTs) that investigated GMI and MT in CRPS patients. This review was registered in PROSPERO (CRD42024535972) to ensure transparency and adherence to protocols. This review included searches of PubMed, Cochrane, SCOPUS, and Web of Science databases. Out of 81 studies initially screened, 6 were included in the final review. Studies were assessed for quality using the PEDro and RoB-2 scales. The primary outcomes were pain reduction, functional improvement, and swelling reduction. Results: Graded Motor Imagery (GMI) and Mirror Therapy (MT) reduced pain by an average of 20 points on the Neuropathic Pain Scale (NPS) and resulted in functional improvements as measured by the Task-Specific Numeric Rating Scale (NRS). GMI also contributed to some reduction in swelling. MT, particularly in post-stroke CRPS patients, showed significant pain reduction and functional improvements, with additional benefits in reducing swelling in certain studies. However, the included studies had small sample sizes and mixed designs, which limit the generalizability of the findings. The studies varied in sample size and design, with some risk of bias noted. Conclusions: Graded Motor Imagery (GMI) and Mirror Therapy (MT) have proven to be effective interventions for managing Complex Regional Pain Syndrome (CRPS), with significant improvements in pain reduction and functional recovery. These non-invasive treatments hold potential for integration into standard rehabilitation protocols. However, the small sample sizes and variability in study designs limit the generalizability of these findings. Future research should focus on larger, more homogeneous trials to validate the long-term effectiveness of GMI and MT, ensuring more robust clinical application.

Feasibility study of a home-based graded motor imagery intervention (GraMI protocol) for amputees with phantom limb pain.

INTRODUCTION: Phantom limb pain affects 64% of amputees. Graded Motor Imagery comprises three consecutive application techniques designed to reorganize maladaptive changes that have occurred after the amputation. OBJECTIVE: To assess the feasibility of a home-based Graded Motor Imagery intervention, the GraMI protocol, for amputee people with phantom limb pain. METHODS: Twenty individuals over 18 years of age with upper or lower limb amputation, experiencing phantom limb pain, who were pharmacologically stable, and had been discharged from the hospital were recruited. The experimental group followed the GraMI protocol. Primary outcomes included study processes, such as recruitment time and rate, adherence, compliance, and the acceptability of digital technologies as a treatment tool. Secondary outcomes assessed the impact on phantom limb pain, quality of life, functionality, and depressive symptoms. RESULTS: On average, seven participants were recruited monthly over a three-month period. No losses were recorded throughout the nine weeks of intervention. Treatment adherence averaged 89.32%, and all participants demonstrated familiarity with the usability of digital technologies. No significant differences were observed between groups (p = .054). However, within the experimental group, intragroup analysis revealed a significant (p = .005) and clinically relevant reduction (>2 points) with a large effect size (0.89) in phantom limb pain. CONCLUSION: Conducting a multicenter study with a home-based intervention using the GraMI protocol is feasible. Future clinical trials are needed to verify its effectiveness in managing phantom limb pain.

Complex regional pain syndrome type II localized to the index finger. A case report translating scientific evidence into clinical practice.

BACKGROUND: Complex regional pain syndrome type II (CRPS-II) is a rare condition associated with peripheral nervous system lesions. Its localized distribution in the fingers is unique, and its treatment is unclear. CASE DESCRIPTION: A 56-year-old male presented to the emergency department with a saw-cut index finger injury with associated tendon and nerve injuries. After surgery, he was admitted to physical therapy (PT) with persistent pain, joint stiffness, allodynia, and trophic changes compatible with CRPS-II localized in the index finger. The diagnosis was confirmed after applying the Budapest Criteria, and PT was progressive and individualized according to the patient's needs, including graded motor imagery, mobilizations, exercises, and education. OUTCOMES: After 12 weeks of PT, a clinically significant decrease in pain intensity and improvements in mobility and index finger and upper limb functionality was observed, reducing CRPS symptomatology. DISCUSSION: This report provides information about a unique case of a localized form of CRPS-II. After reviewing the literature on clinical cases of both CRPS-II and localized forms of CRPS, we highlight that the clinical features of this patient and his positive therapeutic response support the importance of translating the scientific evidence on CRPS into clinical practice.

Implicit Motor Imagery for Chronic Pelvic Pain: A Cross-Sectional Case-Control Study.

Implicit motor imagery (IMI), with an image laterality discrimination (LD) task, has been proposed as a useful therapeutic tool to restore body schema in patients with chronic pelvic pain (CPP). The aim of this study was to analyse the existence of differences between patients with CPP and healthy individuals in order to justify the use of IMI. An observational, cross-sectional study with non-probabilistic sampling was designed as a one-to-one matched case-control study. Through a web link designed for this purpose, a total of 40 abdominoperineal images were shown to 130 participants during the laterality task. Outcome measures were pain intensity (visual analogue scale, VAS), accuracy, response time (RT), and CPPQ-Mohedo score (Chronic Pelvic Pain Questionnaire-Mohedo). This was an observational, cross-sectional study with a total of 64 CPP patients and 66 healthy individuals. The comparative analysis between groups revealed significant differences in accuracy, CPPQ-Mohedo and VAS (p < 0.001), but not in RT; in patients with CPP, accuracy was correlated with a lower CPPQ-Mohedo score and RT and, the greater the pain intensity, the higher the CPPQ-Mohedo score and RT, and the lower the accuracy. In the LD task, the patients with CPP made more mistakes than the healthy individuals. IMI could be a useful and complementary tool in the therapeutic approach for patients with CPP.

Does graded motor imagery benefit individuals with knee pain: A systematic review and meta-analysis.

OBJECTIVE: Evaluate how Graded Motor Imagery (GMI) may be used in those with knee pain, if individuals with knee pain present with a central nervous system (CNS) processing deficit, and if GMI is associated with improved outcomes. METHODS: An electronic database search was conducted of PubMed, SPORTDiscus, CINHAL, MEDLINE, Google Scholar, and Sports Medicine Education Index using keywords related to GMI and knee pain. This review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Out of the 13,224 studies reviewed, 14 studies were included that used GMI for knee pain. Effect sizes were reported with standardized mean differences (SMD). RESULTS: Individuals with knee osteoarthritis demonstrated poor performance with correctly identifying images of left or right knees, and GMI improved performance. In contrast, individuals with an anterior cruciate ligament injury demonstrated no evidence of CNS processing deficit and mixed outcomes with GMI. Meta-analysis was limited to individuals post total knee arthroplasty showing low certainty that GMI can improve quadriceps force production [SMD 0.64 (0.07,1.22)], but evidence of no effect to reduce pain or improve Timed up and Go performance and self-reported function. CONCLUSIONS: Graded motor imagery may be an effective intervention for individuals with knee osteoarthritis. However, there was limited evidence that GMI was effective for an anterior cruciate ligament injury.

The effect of graded motor imagery training on pain, functional performance, motor imagery skills, and kinesiophobia after total knee arthroplasty: randomized controlled trial.

Background: The aim was to investigate the effect of graded motor imagery (GMI) added to rehabilitation on pain, functional performance, motor imagery ability, and kinesiophobia in individuals with total knee arthroplasty (TKA). Methods: Individuals scheduled for unilateral TKA were randomized to one of two groups: control (traditional rehabilitation, n = 9) and GMI (traditional rehabilitation + GMI, n = 9) groups. The primary outcome measures were the visual analogue scale and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcome measures were knee range of motion, muscle strength, the timed up and go test, mental chronometer, Movement Imagery Questionnaire-3, lateralization performance, Central Sensitization Inventory, Pain Catastrophizing Scale, and Tampa Kinesiophobia Scale. Evaluations were made before and 6 weeks after surgery. Results: Activity and resting pain were significantly reduced in the GMI group compared to the control group (P < 0.001 and P = 0.004, respectively). Movement Imagery Questionnaire-3 scores and accuracy of lateralization performance also showed significant improvement (P = 0.037 and P = 0.015, respectively). The Pain Catastrophizing Scale and Tampa Kinesiophobia Scale scores were also significantly decreased in the GMI group compared to the control group (P = 0.039 and P = 0.009, respectively). However, GMI did not differ significantly in WOMAC scores, range of motion, muscle strength, timed up and go test and Central Sensitization Inventory scores compared to the control group (P > 0.05). Conclusions: GMI improved pain, motor imagery ability, pain catastrophizing, and kinesiophobia in the acute period after TKA.

The Efficacy of Graded Motor Imagery and Its Components on Phantom Limb Pain and Disability: A Systematic Review and Meta-Analysis.

Introduction: Graded Motor Imagery (GMI) is a non-invasive and inexpensive therapy used to treat Phantom Limb Pain (PLP) by sequentially activating motor networks in such a way that movement and pain are unpaired. The objective of this systematic review was to critically appraise relevant data on the efficacy of GMI and its components for reducing PLP and disability in amputees. Methods: We searched 11 electronic databases for controlled trials investigating GMI and its components in amputees with PLP from inception until February 2023. Two reviewers independently screened studies and extracted relevant data. Study-level data were entered using the inverse variance function of the Review Manager 5 and pooled with the random effects model. Results: Eleven studies with varying risk of bias were eligible. No eligible study considered left/right judgement tasks in isolation. Studies showed no effect for imagined movements, but positive effects were seen for GMI [weighted mean difference: -21.29 (95%CI: -31.55, -11.02), I2= 0%] and mirror therapy [weighted mean difference: -8.55 (95%CI: -14.74, -2.35, I2= 61%]. A comparison of mirror therapy versus sham showed no difference [weighted mean difference: -4.43 (95%CI: -16.03, 7.16), I2= 51%]. Conclusion: Our findings suggest that GMI and mirror therapy may be effective for reducing PLP. However, this conclusion was drawn from a limited body of evidence, and the certainty of the evidence was very low. Therefore, rigorous, high-quality trials are needed to address the gap in the literature and inform practice.

Contexte: L'imagerie motrice graduelle (IMG) est un traitement non invasif et peu coûteux utilisé pour traiter la douleur du membre fantôme par activation séquentielle des réseaux moteurs de manière à ce que le mouvement et la douleur soient dissociés. L'objectif de cette revue systématique était d'évaluer de manière critique les données sur l'efficacité de l'IMG et de ses composantes pour réduire la douleur du membre fantôme et l'invalidité chez les amputés.Méthodes: Nous avons effectué des recherches dans 11 bases de données électroniques afin d'y repérer des essais contrôlés portant sur l'utilisation de l'IMG et de ses composantes auprès des amputés atteints de douleur du membre fantôme depuis le début jusqu'en février 2023. Deux évaluateurs indépendants ont examiné les études et extrait les données pertinentes Les données au niveau de l'étude ont été saisies à l'aide de la fonction de variation inverse de Review Manager 5 et regroupées selon un modèle à effets aléatoires.Résultats: Onze études présentant un risque de biais variable ont été retenues. Aucune étude admissible ne se penchait sur les tâches de jugement gauche/droite de manière isolée. Les études n'ont montré aucun effet pour les mouvements imaginés, mais des effets positifs ont été observés pour l'IMG [différence moyenne pondérée : -21,29 (IC à 95 % : -31,55, -11,02), I2 = 0 %] et la thérapie miroir [différence moyenne pondérée: -8,55 (IC 95% : -14,74, -2,35, I2 = 61%]. La comparaison de la thérapie miroir à une thérapie factice n'a montré aucune différence [différence moyenne pondérée : -4,43 (IC à 95 % : -16,03, 7.16), I2 = 51 %].Conclusion: Nos résultats indiquent que l'IMG et la thérapie miroir peuvent être efficaces pour réduire la douleur du membre fantôme. Cependant, cette conclusion a été tirée à partir d'un ensemble limité de données probantes, et la certitude de ces dernières était très faible. Par conséquent, des essais rigoureux et de haute qualité sont nécessaires pour combler les lacunes dans la littérature et éclairer la pratique.

Virtual McKenzie extension exercises for low back and leg pain: a prospective pilot exploratory case series.

INTRODUCTION: Current evidence supports the inclusion of directional preference exercises for a subgroup of patients with low back (LBP) and leg pain. Recent pain neuroscience strategies have suggested that cortical restructuring associated with movement activating the body map representation in the brain might account for the observed improvement with the directional preference approach. OBJECTIVES: To explore whether or not a motor imagery directional preference approach would result in any changes in patients with LBP and leg pain. METHODS: A consecutive convenience sample of patients with LBP and leg pain were recruited at two outpatient physical therapy clinics. Measurements of LBP, leg pain, fear-avoidance beliefs (FABQ), pain catastrophizing (PCS), active lumbar flexion, and straight leg raise (SLR) were compared before and immediately after a virtual (motor imagery) directional preference exercise. RESULTS: Statistically significant differences for LBP, FABQ, PCS, active lumbar flexion, and SLR were observed, but only SLR changes met or exceeded the minimally clinically important difference (MCID). CONCLUSIONS: A brief virtual motor imagery extension treatment yielded some immediate positive shifts in patients presenting to physical therapy with LBP and leg pain. Our results indicate that randomized comparison trials are needed to determine the effect of this intervention on the short- and longer-term outcomes in patients with LBP and leg pain.

Clinical and Neurophysiological Effects of Progressive Movement Imagery Training for Pathological Pain.

Movement limitation is a common characteristic of chronic pain such that pain prevents the very movement and activity that is most likely to promote recovery. This is particularly the case for pathological pain states such as complex regional pain syndrome (CRPS). One clinical approach to CRPS that has growing evidence of efficacy involves progressive movement imagery training. Graded Motor Imagery (GMI) targets clinical and neurophysiological effects through a stepwise progression through implicit and explicit movement imagery training, mirror therapy and then functional tasks. Here we review experiences from over 20 years of clinical and research experience with GMI. We situate GMI in terms of its historical underpinnings, the benefits and outstanding challenges of its implementation, its potential application beyond CRPS. We then review the neuropathological targets of GMI and current thought on its effects on neurophysiological biomarkers. PERSPECTIVE: This article provides an overview of our experiences with graded motor imagery training over the last 20 years focussing on the treatment of CRPS. It does both cover the theoretical underpinnings for this treatment approach, biomarkers which indicate potential changes driven by GMI, and experiences for achieving optimal treatment results.

Effectiveness of graded motor imagery in subjects with frozen shoulder: a pilot randomized controlled trial.

Background: Subjects with frozen shoulder (FS) might not be comfortable with vigorous physical therapy. Clinical trials assessing the effect of graded motor imagery (GMI) in FS are lacking. The aim of this study was to determine the effect of GMI as an adjunct to conventional physiotherapy in individuals with painful FS. Methods: Twenty subjects aged 40-65 years having stage I and II of FS were randomly divided into two study groups. The conventional physiotherapy group (n = 10) received electrotherapy and exercises while the GMI group (n = 10) received GMI along with the conventional physiotherapy thrice a week for 3 weeks. Pre- (Session 1) and post- (Session 9) intervention analysis for flexion, abduction, and external rotation range of motion (ROM) using a universal goniometer, fear of movement using the fear avoidance belief questionnaire (FABQ), pain with the visual analogue scale, and functional disability using the shoulder pain and disability index (SPADI) was done by a blinded assessor. Results: Statistically significant difference was seen within both the groups for all the outcomes. In terms of increasing abduction ROM as well as reducing fear of movement, pain, and functional disability, the GMI group was significantly better than control group. However, both groups were equally effective for improving flexion and external rotation ROM. Conclusions: Addition of GMI to the conventional physiotherapy proved to be superior to conventional physiotherapy alone in terms of reducing pain, kinesiophobia, and improving shoulder function for stage I and II of FS.

Development and Validation of a Graded Motor Imagery Intervention for Phantom Limb Pain in Patients with Amputations (GraMI Protocol): A Delphi Study.

BACKGROUND: Phantom limb pain can be defined as discomfort or pain in a missing part of the limb. The aims of this study were to develop and validate, through a Delphi methodology, a graded motor imagery protocol in order to reduce phantom limb pain. METHOD: Physiotherapists and/or occupational therapists with experience in research and a minimum clinical experience of five years in the field of neurorehabilitation and/or pain were recruited by part of a group of experts to assess the intervention. The study was conducted through an online questionnaire, where experts assessed each aspect of the intervention through a Likert scale. As many rounds as necessary were carried out until consensus was reached among experts. RESULTS: A total of two rounds were required to fully validate the intervention. During the second round, the relative interquartile range of all aspects to be assessed was less than 15%, thus showing a consensus among experts and with good concordance (Kappa index of 0.76). CONCLUSION: Experts validated a graded motor imagery intervention of phantom limb pain in patients with amputations (GraMi protocol). This intervention can help to homogenize the use of graded motor imagery in future studies and in clinical practice.

Sequential neural activity in sensorimotor area and mirror neural system for graded mirror therapy with imagined hand movements.

BACKGROUND: Graded motor imagery (GMI) therapy is a neural rehabilitative physiotherapy that has been shown to alleviate the severity of complex regional pain syndrome, phantom limb pain and disability. OBJECTIVE: To identify neural networks associated with the use of graded mirror therapy (MT) while imagining hand movements. METHODS: We made a block-design functional magnetic resonance imaging study of MT included three experiments: (1) immobile unimanual MT (IU-MT), in which the right hand flexed and made a fist, which then remained immobile; (2) mobilization unimanual MT (MU-MT), in which the right hand performed a flexion-extension movement; and (3) mobilization bimanual MT (MB-MT), in which both hands performed a flexion-extension movement. When subjects started their hand movements, they gazed at the mirror and imagined the same movement behind the mirror. RESULTS: We discovered that the sensorimotor area of the left brain, superior temporal gyrus/middle temporal gyrus (STG/MTG) of the right brain and visual areas were activated by IU-MT. In MU-MT, only the STG/MTG was activated. Furthermore, MB-UT mostly activated the sensorimotor area and STG of the right brain. However, there were no brain areas activated by MU-MT compared with IU-MT or MB-MT; but, MB-MT activated more motor areas than IU-MT. Importantly, we determined that the level of mirror imagery was negatively correlated with signals in the mirror neuron system (MNS) and positively related with the signals in the sensorimotor areas. CONCLUSIONS: We suggest that graded MT might be a sequential therapeutic program that can enhance the sensorimotor cortex. The MNS might have an initiating role in graded MT. Thus, there is the possibility that graded MT is a helpful treatment strategy for the rehabilitation of dysfunctional patients.

Modifications in fMRI Representation of Mental Rotation Following a 6 Week Graded Motor Imagery Training in Chronic CRPS Patients.

Complex regional pain syndrome (CRPS) is a neuropathic pain condition that is difficult to treat. For behavioral interventions, graded motor imagery (GMI) showed relevant effects, but underlying neural substrates in patient groups have not been investigated yet. A previous study investigating differences in the representation of a left/right hand judgment task demonstrated less recruitment of subcortical structures, such as the putamen, in CRPS patients than in healthy controls. In healthy volunteers, the putamen activity increased after a hand judgment task training. In order to test for longitudinal effects of GMI training, we investigated 20 CRPS patients in a wait-list crossover design with 3 evaluation time points. Patients underwent a 6 week GMI treatment and a 6 week waiting period in a randomized group assignment and treatment groups were evaluated by a blinded rater. When compared to healthy matched controls at baseline, CRPS patients showed less functional activation in areas processing visual input, left sensorimotor cortex, and right putamen. Only GMI treatment, but not the waiting period showed an effect on movement pain and hand judgment task performance. Regression analyses revealed positive associations of movement pain with left anterior insula activation at baseline. Right intraparietal sulcus activation change during GMI was associated with a gain in performance of the hand judgment task. The design used here is reliable for investigating the functional representation of the hand judgment task in an intervention study. PERSPECTIVE: Twenty chronic CRPS patients underwent a 6 week GMI intervention in a randomized wait-list crossover design. functional MRI was tested pre and post for the hand lateralization task which improved over GMI but not over WAITING. Performance gain was positively related to right parietal functional MRI activation.

Client buy-in: An essential consideration for graded motor imagery in hand therapy.

STUDY DESIGN: This is a cross-sectional survey research. INTRODUCTION: Current evidence provides efficacy of graded motor imagery (GMI) in chronic pain conditions but also reveals barriers to its implementation. PURPOSE OF THE STUDY: The purpose of this study was to describe current utilization of GMI in hand therapy practice. METHODS: Survey tool, informed by literature and Revised Neurophysiology of Pain Questionnaire (NPQ) was electronically distributed to members of the American Society of Hand Therapists. RESULTS: 132 therapists completed the survey. 65.2% reported they would always or very likely use GMI in clients with central sensitization, but no relationship between the likelihood of therapists using GMI to score achieved on the NPQ was found. Lack of patient buy-in, was the main barrier cited. "Sell it well" with pain neuroscience education the most cited strategy. DISCUSSION: GMI is frequently used in clients with central sensitization but requires client buy-in. CONCLUSIONS: Understanding and explaining pain mechanism is essential for implementing GMI.

The Short-term Effect of Graded Motor Imagery on the Affective Components of Pain in Subjects with Chronic Shoulder Pain Syndrome: Open-Label Single-Arm Prospective Study.

OBJECTIVE: To determine the short-term effect of graded motor imagery (GMI) on the affective components of pain and range of motion in subjects with chronic shoulder pain syndrome. DESIGN: Open-label single-arm prospective study. SETTING: The Physical Therapy Laboratory, Universidad de las Americas. SUBJECTS: One hundred seven patients with chronic shoulder pain syndrome. METHODS: The subjects received a six-week GMI program based on laterality training, imagined movements, and mirror therapy. We assessed pain intensity using a visual analog scale (VAS), fear of movement was assessed using the Tampa Scale of Kinesiophobia (TSK), and catastrophizing was assessed using the Pain Catastrophizing Scale (PCS). The patient's flexion active range of motion (AROM) was also recorded. RESULTS: At the end of treatment, the VAS showed a decrease of 4.2 cm (P < 0.001, Cohen's d = 3.3), TSK showed a decrease of 17.0 points (P < 0.001, Cohen's d = 2.8), catastrophizing showed a decrease of 19.2 points (P < 0.001, Cohen's d = 3.2), and shoulder flexion AROM showed an increment of 30.3º (P < 0.000, Cohen's d = 1.6). CONCLUSIONS: We conclude that a short-term GMI program improves the affective components of pain and shoulder flexion AROM in patients with chronic shoulder pain syndrome.

The effectiveness of graded motor imagery for reducing phantom limb pain in amputees: a randomised controlled trial.

OBJECTIVE: To investigate whether graded motor imagery (GMI) is effective for reducing phantom limb pain (PLP) in people who have undergone limb amputations. DESIGN: A single-blinded randomised, controlled trial. SETTING: Physiotherapy out-patient departments in three secondary level hospitals in Cape Town, South Africa. PARTICIPANTS: Twenty-one adults (≥18 years) who had undergone unilateral upper or lower limb amputations and had self-reported PLP persisting beyond three months. INTERVENTIONS: A 6-week GMI programme was compared to routine physiotherapy. The study outcomes were evaluated at baseline, 6 weeks, 3 months and 6 months. OUTCOME MEASURES: The pain severity scale of the Brief Pain Inventory (BPI) was used to assess the primary outcome - PLP. The pain interference scale of the BPI and the EuroQol EQ-5D-5L were used to assess the secondary outcomes - pain interference with function and health-related quality of life (HRQoL) respectively. RESULTS: The participants in the experimental group had significantly greater improvements in pain than the control group at 6 weeks and 6 months. Further, the participants in the experimental group had significantly greater improvements than the control group in pain interference at all follow-up points. There was no between-group difference in HRQoL. CONCLUSION: The results of the current study suggest that GMI is better than routine physiotherapy for reducing PLP. Based on the significant reduction in PLP and pain interference within the participants who received GMI, and the ease of application, GMI may be a viable treatment for treating PLP in people who have undergone limb amputations. CLINICAL TRIAL REGISTRATION NUMBER: (PACTR201701001979279).

The clinical application of pain neuroscience, graded motor imagery, and graded activity with complex regional pain syndrome-A case report.

BACKGROUND: Chronic Regional Pain Syndrome (CRPS) is a condition that physical therapists may encounter in an outpatient orthopedic setting. In physical therapy (PT) treatment of CRPS addresses pain and the changes observed in the brain through the use of graded motor imagery (GMI). CASE DESCRIPTION: A 57-year-old female presented to an outpatient PT clinic with CRPS type 1. Complicating psychosocial factors such as kinesiophobia and catastrophization were present. The patient engaged in a treatment plan including GMI: pain neuroscience education (PNE), laterality training, motor imagery, and mirror training. As symptoms improved, graded functional exposure and functional restoration occurred. OUTCOMES: The patient was seen for a total of 26 visits over a 9-month period. FAAM measures exceeded reported clinically important change that was sustained at two-year follow-up. Long term outcomes showed no functional deficits related to her foot or ankle and minimal to no catastrophizing and fear avoidance behaviors. DISCUSSION: This case report showcases the use of GMI with a patient with CRPS type 1 in an outpatient orthopedic clinic. Clinicians may consider the use of GMI to progress a patient toward maximal functional gains.

Mental imagery training for treatment of central neuropathic pain: a narrative review.

Mental imagery is a quasi-perceptual experience in the absence of external stimuli. This concept has intrigued psychologists, sportspersons, neurologists and other scientists for over a decade now. Imagery has been used in rehabilitation and the results have been promising. Researchers refer to this as healing the body through the mind. However, the challenge is lack of standardized protocols, homogeneity and consistency in application of mental imagery in different populations. The purpose of this review is to discuss and understand the role of mental imagery in the treatment of central neuropathic pain (CNP). Treatment options of CNP are inadequate and their benefits are short lived. We conducted an extensive search on various databases using combinations of different keywords and reviewed the available literature in this area. We were able to finalize twelve studies where mental imagery was used for treating CNP in spinal cord injury (SCI), stroke and multiple sclerosis. However, the methodology and techniques of mental imagery training used in these studies were non-homogeneous and inconsistent. This review provides a guiding framework to further explore the different techniques of mental imagery and their roles in treating CNP.

Graded motor imagery for women at risk for developing type I CRPS following closed treatment of distal radius fractures: a randomized comparative effectiveness trial protocol.

BACKGROUND: Distal radius fractures (DRF) account for nearly one-fifth of all fractures in older adults, and women experience them 5× as often as men. Most DRF occur with low impact injuries to the wrist with an outstretched hand, and are often managed via closed treatment and cast immobilization. Women sustaining a DRF are at risk for upper limb immobility, sensorimotor changes, edema and type I complex regional pain syndrome (CRPS). Since CRPS onset is likely influenced by alterations in the brain's somatosensory region, a rehabilitation intervention, Graded Motor Imagery (GMI), aims to restore cortical representation, including sensory and motor function, of the affected limb. To date, there are no studies on the use of GMI in reducing risk of or preventing the onset of type I CRPS in women with DRF treated with cast immobilization. Due to a higher likelihood of women with this injury developing type I CRPS, it is important to early intervention is needed. METHODS/DESIGN: This article describes a six-week randomized comparative effectiveness trial, where the outcomes of a modified GMI program (mGMI) + standard of care (SOC) group (n = 33) are compared to a SOC only control group (n = 33). Immediately following cast immobilization, both groups participate in four 1-h clinic-based sessions, and a home program for 10 min three times daily until cast removal. Blinded assessments occur within 1 week of cast immobilization (baseline), at three weeks post cast immbolization, cast removal, and at three months post cast removal. The primary outcomes are patient reported wrist/hand function and symptomology on the Patient Rated Wristand Hand Evaluation, McGill Pain Questionnaire, and Budapest CRPS Criteria. The secondary outcomes are grip strength, active range of motion as per goniometry, circumferential edema measurements, and joint position sense. DISCUSSION: This study will investigate the early effects of mGMI + SOC hand therapy compared to SOC alone. We intend to investigate whether an intervention, specifically mGMI, used to treat preexisiting pain and motor dysfunction might also be used to mitigate these problems prior to their onset. If positive effects are observed, mGMI + SOC may be considered for incorporation into early rehabilitation program. TRIAL REGISTRATION: This trial is registered at ClinicalTrials.gov with identifier NCT02957240 (Approval date: April 20, 2017).

Management of long-term complex regional pain syndrome with allodynia: A case report.

STUDY DESIGN: Case report. INTRODUCTION: Conventional rehabilitation alone may not be effective in reducing symptoms in some patients with complex regional pain syndrome. PURPOSE OF THE STUDY: This case report portrays the benefits of a new tailored rehabilitation program for a 39-year-old patient suffering from upper limb complex regional pain syndrome with severe touch-evoked pain (static mechanical allodynia). METHODS: This patient had previously received conventional rehabilitation for a year and a half including physical and nonsurgical medical interventions that did not improve symptoms or function. In the search for an alternative, this patient was referred to occupational therapy to try a tailored rehabilitation program, drawing on multiple strategies used sequentially according to the patient's tolerance and symptom evolution. During this 22-month program, the following methods were added (listed chronologically): somatosensory rehabilitation of pain method, graded motor imagery, pain management modalities, active mobilizations, strengthening exercises, and task simulation. The patient successively showed resolution of mechanical allodynia, decreased pain, reduction of tactile hypesthesia and improvement in active range of motion, strength, and function. These improvements allowed him to return to work. DISCUSSION: This suggests that a tailored rehabilitation program combining somatosensory rehabilitation of pain method, graded motor imagery and more conventional approaches could improve symptoms and functional status in patients with upper limb complex regional pain syndrome, even with persistent refractory symptoms. CONCLUSION: The addition of the somatosensory rehabilitation of pain method and the graded motor imagery approach to conventional therapy could be considered in cases of complex regional pain syndrome that do not respond to conventional rehabilitation alone.