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Complex Regional Pain Syndrome

and Graded Motor Imagery

Lauren Wu, SPT
Central Michigan University 2018
Special Tree Rehabilitation Fall 2017
Understand what Chronic Regional
Goals of Pain Syndrome (CRPS) is

In-service Understand want Graded Motor

Imagery (GMI) is

Understand how GMI can be used to

treat CRPS
Chronic Regional
Pain Syndrome
What is CRPS?1
● Also known as Reflex Sympathetic
Dystrophy (RSD)
● Chronic pain condition (>6 mo)
● Abnormal response to injury
● Disproportionate pain relative to injury
● Typically affects one limb
● Considered biopsychosocial disorder

1. National Institute of Health

Causes2 Incidence2
● Fractures, immobilization in cast ● Rare (26.2 persons out of 100,000)
● Nerve injury ● Women > Men (3x more)
● Burns, cuts, bruises ● 40-60 y/o most common
● Sprains, strains ● Upper extremity > Lower extremity (3:2)
● Smokers, psychological factors, SES

2. Goh EL, Chidambaram S, Daqing M. Burns Trauma. 2017

How does CRPS occur?
● Peripheral and Central Nervous Systems damage/malfunction
○ Can’t regulate the affected area

● Cortical structure changes3,4

○ Changes in representation
○ Disturbances in perception
○ Sensory and motor homunculus are “smudged”
○ Referred pain

● Immune system response2

○ Increased inflammation
○ Sensitivity is increased to guard and protect body part

3. Swart CMA, Stins JF, Beek PJ. Eur J Pain, 2009

4. Thieme H, Morkisch N, Rietz C, Dohle C, Borgetti B. J Pain. 2016
Graded Motor
Imagery (GMI)
What is GMI?
● Graded exposure
to movement
● 3 sequential
○ Laterality
○ Explicit motor
○ Mirror therapy
How can GMI help to treat CRPS?
● Retraining the brain3
○ Remap sensory and motor homunculus
○ Reduce sensory-motor mismatch
● Desensitize and reidentify body part
● Tricking the brain with visual input
● Decrease pain4,5
● Increase function

5. Smart KM, Wand BM, O’Connell NE. Cochrane Database Syst Rev, 2016
● Identifying left and right sides
○ Pre-motor cortices6
● Upper or lower extremity (face atypical)
● Speed and accuracy

6. Moseley GL. Pain, 2004

Mental Imagery
● Imagining performing the movement
○ Primary motor cortices6
● Mental rehearsal of repeated movement
● Accuracy
● Improve physical function
Mirror Therapy
● Affected side behind mirror
● Unaffected side in front of mirror
● Watching unaffected side
perform movements
○ Tricking the brain
○ Affected side is “exercising”
● Accuracy
Upper extremity
Example protocol: Moseley (2004)
2 weeks of laterality recognition
● 84 possible photos in bank; 56 randomly selected photos, presented in random order.
● Patients pressed button as quickly as possible to identify right or left
● Speed and accuracy emphasized

2 weeks of mental imagery

● 28 randomly selected photos, presented in random order
● Deliberately imagine moving own hand to adopt same posture 3 times
● Perform task every waking hour (about 15 minutes)
● Accuracy, not speed, emphasized

2 weeks of mirror therapy

● 20 randomly selected photos of unaffected hand
● Slowly and smoothly adopt posture in each picture with both hands, with affected hand concealed in
mirror box and unaffected hand’s reflection observed
● Perform task 10 times every waking hour
● Pain science education
● GMI is a gradual process and requires a lot of time
● Gives patient more control over treatment
● Safe, cost-effective
The Efficacy of Movement Representation Techniques for Treatment
of Limb Pain—A Systematic Review and Meta-Analysis.4
● High quality evidence regarding movement
representation techniques to treat different types
of limb pain
○ CRPS, post-stroke, phantom limb pain/amputation
● Outcomes: pain, disability, quality of life
● 2 studies including CRPS, 2 studies including CRPS
● For CRPS, GMI/mirror therapy recommended to
decrease pain and disability
● Positive but non-significant effect on quality of life
Physiotherapy for pain and disability in adults with complex regional
pain syndrome (CRPS) types I and II.5
● Systematic review of physiotherapy interventions
○ Manual therapy, therapeutic exercise, electrotherapy,
education, cortically directed sensory-motor rehabilitation
● Outcomes: pain intensity, functional disability
● 2 studies including GMI/mirror therapy
● GMI recommended to reduce pain intensity and
1. Complex Regional Pain Syndrome Fact Sheet. National Institute of Neurological Disorders and Stroke.
ct-Sheet. Accessed November 1, 2017.
2. Goh EL, Chidambaram S, Daqing M. Complex regional pain syndrome: a recent update. Burns Trauma. 2017;5:2. doi:
3. Swart CMA, Stins JF, Beek PJ. Cortical changes in complex regional pain syndrome (CRPS). Eur J Pain.
2009;13(9):902-907. doi: 10.1016/j.ejpain.2008.11.010
4. Thieme H, Morkisch N, Rietz C, Dohle C, Borgetti B. The efficacy of movement representation techniques for treatment
of limb pain--a systematic review and meta-analysis. J Pain. 2016;17(2):167-180. doi: 10.1016/j.jpain.2015.10.015
5. Smart KM, Wand BM, O’Connell NE. Physiotherapy for pain and disability in adults with complex regional pain
syndrome (CRPS) types I and II. Cochrane Database Syst Rev. 2016;24(2). doi: 10.1002/14651858.CD010853.pub2
6. Moseley GL. Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised
controlled trial. Pain. 2004;108(1-2):192-198. doi: 10.1016/j.pain.2004.01.006