Utilizing a modified graded motor imagery program to treat CRPS-1

Complex regional pain syndrome (CRPS) is an often disabling condition that is characterized as having pain which is disproportionate in time and intensity compared to the inciting event.  It is classified as a neuropathic pain disorder and the diagnosis of CRPS-1 is made when a nerve lesion cannot be identified (as compared to CRPS-2 which has an identifiable nerve lesion).  90% of cases are classified as CRPS-1.
One of the leading researchers of CRPS is Lorimer Moseley.  Moseley has made major contributions toward the treatment of CRPS through a combination of mirror therapy and motor imagery, which we call Graded Motor Imagery (GMI).  GMI is a program designed to sequentially activate cortical motor networks and improve cortical organization.  It simply “trains the brain” and is based upon the understanding that pain is an output from the brain.  GMI routinely consists of three phases: 1. Limb Laterality Recognition 2. Motor Imagery (imagined limb movements) 3. Mirror Therapy.  You can read more about the original protocol here.
A recent case series published in the International Journal of Rehabilitation Research attempted to “tweek” Moseley’s GMI protocol by making two major changes to the existing three phases for the treatment of upper extremity CRPS-1.  First, these authors believed integration of mirror therapy should take place in phase. Second, different levels of mirror therapy were introduced (versus one phase).   Here is the modified protocol:
Phase 1: Identification of hand laterality.  I recommend doing this using Recognise by the noigroup.
Phase 2: Imagined hand movements.  The patient would watch the reflection of the unaffected limb in the mirror, and they would imagine performing the movement presented, in a program such as Recognise, and returning to rest.
Phase 3: Mirror therapy with mobilization of the unaffected hand.  During this phase, the patient would execute movements demonstrated, on a program such as Recognise, by moving the unaffected limb while looking in the mirror.
Phase 4: Mirror therapy with mobilization of both hands.  The patient would execute movements of both hands, mimicking the positions demonstrated by the software.
The participant performed the therapy at home for 10 min sessions, three times a day, 6 days per week.  Phases were progressed every 2 weeks.
The results of this modified program showed effectiveness in pain reduction and improved grip strength in patients with non-chronic CRPS-1.  There was not a clinically significant difference in perceived disability.
The results of this study are promising but we must be cautious because it only included seven participants.   BUT being that it was a case series, this low power is not unusual.  The authors explain that this was a pilot study and that they are continuing to study this modified GMI protocol in a larger controlled clinical trial.  We must always be weary in using premature protocols in clinical practice, but the theoretical constructs of this protocol make sense and I expect the RCT to demonstrate similar results
Lagueux E, Charest J, et al. Modified graded motor imagery for complex regional pain syndrome type 1 of the upper extremity in the acute phase: a patient series. International Journal of Rehabilitation Research 2012: 35; 138-145.

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