Back to the patient: a 30 year old female who has a four year history of Complex Regional Pain Syndrome (CRPS), post right wrist fracture. Her pain has also spread into her right lower limb.
This patient is now being managed, as I write, by a physiotherapist. I will collect more information about the patient as I go along.
The clinician writes….."I saw the patient today to begin the graded imagery program. She was obviously very excited and a very willing participant. Based on the protocol laid out by Moseley, I have her doing either the computer program or the flash cards 3xs per day for at least 10 minutes per session. She will do that for two weeks and then return with the data she collected from the computer. While in the office I had her perform 4 trials of the computer based program and no matter what program she used for the upper extremity she consistently scored 70-75%. I was able to score 90% but am not sure what that means. Is there any normative data about people with CRPS and how well they do using the computer program or the flash cards vs. those who do not? Should there be a goal we achieve with the program i.e. 85% before we consider it a success and move onto the visualization portion of the protocol?”
These are good questions which expose (a) the amount of evidence available and (b) the need for management which is individualised for patients.
There is no normative data on laterality, although I am aware that this is now being done and we will post any research outcomes on this blog. For this patient, it would help to have information on differences between left and right laterality accuracy and speed in both hand and feet. If there are differences, then it would be worth continuing the programme, thus “exercising” those laterality association neurones influencing the patient’s motor responses (next blog will be on the neuroscience of laterality deficits). The consistent scores of 75% may well be quite normal for that person, and the patient may have little or no laterality deficits and can progress towards motor imagery strategies. They could well continue the laterality exercises while doing motor imagery. But as mentioned elsewhere, before you can imagine a limb movement, the brain must first be able to pick whether it is a left or right limb.
If the patient continues to use laterality training, here are some thoughts: 1)laterality problems may be exposed by grading use of the CD. For example, make images come up faster, use more images, use the contextual and abstract images. Maybe even use the programme in a position that hurts a little bit. 2)Use of the flash cards can be made more difficult as well. There are progressively more difficult games that can be played 3)I suggest that at least 2 hours a day (broken into sessions) of laterality could be performed. It can be done through the day i.e. looking at people and saying “that’s left, that’s right” 4)Get a magazine such as “who” with lots of pictures of people and go through it and circle the left or right limbs, which ever is painful. 5)Make up laterality games.