"My patient developed what appeared to be early stage CRPS in his right hand " "It's my feeling that mirror box therapy had a significant impact on this patient's recovery." M. Cole, PTA, Oregon MORE...
If you are unfortunate to suffer from Complex Regional Pain Syndrome (CRPS) or Reflex Sympathetic Dystrophy (RDS) you need to try mirror box therapy as it has been clinically proven to assist in the rehabilitation of the condition.
CRPS is a very pain full condition. Modern practice is to encourage rehabilitation of the hand in a fashion that is as comfortable as possible.
It may seem bizarre that something as simple as a mirror can be used to get your hand going again but it's true. It is becoming apparent that some of the underlying problems causing CRPS arise from the initial immobility of the hand following the injury. The immobility is thought to reduce the efficiency of the communication between your brain and your hand. In order to rehabilitate your hand, you need to turn back "on" the wiring between your brain and your hand. Mirror therapy is an aid to this rehabilitation and provides a visual feed back that is thought to encourage your wiring system to both get moving again and to activate spare or sleepy parts of the wiring system that have previously been uninvolved, to contribute to your recovery.
How it's used.
The patient places the effected limb in side the mirror box and their unaffected limb in front of the mirror. Seeing the reflection of the unaffected limb and performing simple tasks such as unclenching of the fist or circular motion the patient thus receives artificial visual feedback from the unaffected limb in a mirror, though it appears they are moving their affected limb. In addition, patients should imagine that they are moving their affected limb and move it from a potentially painful position.
Improvements come with repeated exercises. This is why a portable, collapsible and lightweight Mirror box is an invaluable tool in your recovery, allowing you to do your rehabilitation exercises wherever and whenever you wish. Watch Video
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Mirror therapy can be used as a key aid to this rehabilitation and provides a visual feed back that is thought to encourage your wiring system to both get moving again and to activate spare or sleepy pathways that have until then been dormant, to contribute to your recovery.
CRPS / RSD rehabilitation focuses on restoring normal function through graded exercise programmes. This work is the "bread and butter" of physiotherapy and occupational therapists. Our deepening understanding of why some patients have difficulty rehabilitating their limbs following CRPS RSD development has revealed that co-ordination between the somatosensory cortex and the motor cortex is key. Further more input from vision and mirror visualisation techniques can play a very helpful and significant role in speeding up and increasing the effectiveness of physiotherapy routines, which can easily be undertaken using the mirror box mirror. This approach has been described in the literature in anecdotal evidence, case reports and clinical trial work. The evidence is building that using mirror therapy particularly with hand following injury be it accidental or post surgery can have a beneficial effect on rehabilitation.
Definition of CRPS
Complex Regional Pain Syndrome has been defined by the International Association for the Study of Pain using the following diagnostic criteria (Boas 1996). CRPS describes a variety of painful conditions that usually follow injury, occur regionally, have a distal predominance of abnormal findings, which exceed in both magnitude and duration the expected clinical course of the inciting event, often result in significant impairment of motor function and show variable progression over time .
CRPS Type I (formerly known as RSD)
Follows an initiating noxious event.
Spontaneous pain and/ or allodynia and hyperalgaesia occur beyond the territory of single peripheral nerve(s), and is disproportionate to the inciting event.
There is or has been evidence of oedema, skin blood flow abnormality, or abnormal sudomotor activity, in the region of the pain since the inciting event.
The diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain or dysfunction .
CRPS Type II (formerly known as Causalgia)
This syndrome follows nerve injury. It is similar in all other respects to CRPS Type I.
Is a more regionally confined presentation about a joint or area, associated with a noxious event.
Spontaneous pain and/ or allodynia and hyperalgaesia are usually limited to the area involved but may spread variably distal or proximal to the area, not in the territory of a dermatomal or peripheral nerve distribution.
Intermittent and variable oedema, skin blood flow change, temperature change, abnormal sudomotor activity, and motor dysfunction, disproportionate to the inciting event are present in the area involved.
Patients with CRPS typically complain of a very painful extremity which may not of suffered a significant injury, the limb is described as, hot or cold, burning sweating, flushing alternatively hot and cold, itching, very sensitive to touch, weak, incredibly painful to move and unbearable. The pain is invariably unresponsive to over the counter medications and simple analgaesics. Patients may be suicidal.
What causes CRPS?
The truth is we do not yet know the answer to this question.
The current thinking suggests that CRPS is a result of dysfunction of both the peripheral and central nervous systems. Associated with this dysfunction is often a maladaption and malfunction of the autonomic nervous system to these changes. Recent fMRI work has also suggested that within the higher centres (brain), the integration of the motor pathways to the limb along with somatosensory cortex integration play an important role in the pathophysiology of the process. In other words the bits of your brain that integrate movement control of the limb and sensory appreciation of the limb go awry. It is precisely at this point that mirror visualisation techniques or mirror box therapy works .
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Treatment Strategies .
There is unfortunately no single therapy that has been shown in clinical trials to be of overwhelming superiority in the management of CRPS.
Treatment goals are to improve pain relief alongside allowing gradual mobilisation of the affected limb in a paced and goal oriented way. There is a consensus view now that in the long term gradually exercising and using the limb achieve best results. Views differ on quite how tough the therapist needs to be to achieve this.
In order to achieve the above patients may be trialled on any or all of the following.
Neuropathic medications such as anticonvulsants, tricyclic antidepressants and opioids analgaesics.
Topical Therapies such as DMSO cream and capsaicin.
Stimulation therapies such as TENS or Spinal Cord Stimulation.
Physiotherapy and Occupational Therapy
There is growing evidence from both clinical trial work, anecdotal case reports and fMRI work that mirror box therapy and visualisation techniques have a significant effect on assisting in the rehabilitation of the limb .