Whether it’s addressing general levels of fitness, reducing levels of pain, increasing limb function or working on preventing or reducing muscle contractures, physiotherapy plays an important role in the treatment and management of Complex Regional Pain Syndrome (CRPS).
Physiotherapists along with Occupational Therapists form the ‘physical therapy’ team that CRPS sufferers encounter during multi-disciplinary pain management programmes, usually working in conjunction with pain doctors and psychologists. However, many CRPS sufferers develop an ongoing relationship with a physiotherapist as part of the longer term management of their condition.
Physiotherapy encompasses a large number of different techniques. However, the two techniques most often utilised in the management of CRPS are:
For those in severe pain, getting any exercise at all, let alone regular exercise, is understandably difficult. Fatigue, muscle weakness and an instilled need to protect the affected part or parts of the body can create a serious barrier to exercise. Physiotherapists therefore work with a patient in order to ascertain which exercises work best for them and, crucially, how to know when to stop exercising. They will also work on techniques to use in order to deal with exacerbations of pain caused by exercise.
Perhaps the most difficult issue to address is mobilisation of the affected part of the body itself. However, this is crucial in order to maintain at least some function and to help prevent or reduce contractures of the muscles and/or joints. I am still haunted by the image some years ago of a client whose upper limb contractures were so severe that her fingers had clawed to the extent that her fingernails were growing into the palm of her hand. Physiotherapists will manage contractures through gentle bending and stretching exercises often referred to as ‘passive and active movements’.
Graded Motor Imagery
Graded Motor Imagery (GMI) is a series of techniques used by specialist pain therapists to train the brain to re-connect to the part of the body affected by pain.
The brain of somebody suffering CRPS treats the part of the body in pain as a threat rather than as a hand or a foot, effectively disowning it. When the brain recognises a threat, it produces pain as a defence mechanism like an alarm going off. In people suffering CRPS that alarm does not switch off when the threat goes away.
GMI works on those parts of the brain that deal with movement and sensation. By helping the brain to re-connect to the affected part of the body, levels of pain can be reduced. GMI involves three stages, the first two of which do not actually involve movement of the affected limb:
Stage 1 – a person is shown a series photographs and is asked to quickly identify whether the image shows a left or right limb;
Stage 2 – while the affected limb remains still, the person is asked to imagine moving the limb into the position shown in a photograph;
Stage 3 – involves Mirror Box Therapy where the person is asked to exercise an unaffected limb in front of a mirror, while watching the reflection, giving the appearance of the affected limb performing the exercise.
In a study in 2009*, it was concluded that GMI resulted in a greater pain reducing benefit than conventional physiotherapy. However, the study also highlighted a lack of high quality research on the role of physiotherapy in the treatment and management of CRPS.
On a related point, it is of course wise to take pain medication in good time prior to commencing any form of physical therapy. However, both the therapist and the patient must remain alert to ensure that any temporary dampening down of pain caused by the medication does not result in the patient being pushed too far, too soon.
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