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PPP Management How to help PPP patients.

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Old 02-10-2011, 11:07 AM   #1
antony112
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Default Mirror therapy in treating OA?

Hi

I’m a 3rd year physio student from the UK. I have just started my dissertation which is to design a research proposal that will explore the effects of mirror therapy in reducing pain in the wrist and hand in patients who suffer from chronic OA.

Its early days right now and I am reading around previous studies using mirror therapy and some of the concepts surrounding chronic pain states. Previous mirror therapy studies that I have found all focus on the treatment being used in PLP, CRPS and stroke. I understand these conditions have different mechanisms of pain than a mechanical pain such as OA and obviously mirrors will have no effect on the mechanical characteristics of OA

I am basing the research proposal on mirror therapy possibly having a desensitising effect on the affected areas by correcting changes that may have occurred in the somatosensory cortex as a result of long term OA, possibly making the condition more manageable.

I have a basic understanding of the somatosensory cortex at best and just wondered if anybody knew of any good resources that might be helpful in understanding how chronic pain can change the somatosensory cortex, treating and remapping the somatosensory cortex and any good research on mirror therapy (especially if there have been any previous studies on mirror therapy in OA, I can’t find any!)

There seem to be a few people on here that are very knowledgeable in chronic pain conditions and treatments and I would appreciate any input whatsoever especially if you can see any major flaws in what I’m proposing as I am pretty new to this

Thanks

Antony
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Old 02-10-2011, 01:59 PM   #2
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When you say mirror therapy, do you mean mirror therapy in isolation or as part of the graded motor imagery protocol?

Becareful in defining OA pain as mechanical. OA in itself does not suggest a pain mechanism. But good luck with your study, great that you are looking into this kind of thing. Where in the uk are you studying?
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Old 02-10-2011, 02:19 PM   #3
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Dave's right, mechanical deformation as an origin isn't, to my knowledge, greater in cases of OA then in anything else. You seem to be assuming this and if you do I see problems ahead. You seem to be identifying a cause or source, both, in my opinion, deadends.

Mechanical deformation as an origin is simply characterized by pain that is altered with position and/or use - not with an x-ray finding.
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Old 02-10-2011, 04:44 PM   #4
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Hi

Thanks for pointing that out, I am have obviously misunderstood the term mechanical pain. I guess the I should be describing OA pain as nociceptive where as the pain from PLP and CRPS would be neuropathic pain (I think, although I could well be misunderstanding that as well!!)

I plan on putting the proposal through as mirror therapy in isolation, I have read a little about graded imagery protocols but I struggled to find information about the amount of time spent in the different stages and if there are any objective markers that indicate that a patient is ready to move on to the next stage of the programme.

I do intend to include a discussion within the proposal about graded imagery protocols just to show that I’m aware that they are out there and the effect this may have on the results of the proposed study as essentially I would be jumping patients forward to the last stage of the programme.

Im studying at Hallam Dave. We haven’t done much around pain concepts and mechanisms but it’s an area I find interesting and well worth learning more about. I thought doing a dissertation in this subject would be a great opportunity to invest some time studying this area. I’m just hoping it’s not all a little over my head!

Thanks for your responses
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Old 02-10-2011, 05:26 PM   #5
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Antony,

You should consider studying mirror therapy in isolation with caution, since, as Dave has already suggested, this is part of a graded motor imagery program (GMIP) treatment progression for patients with persistent pain problems where central sensitization is a predominant feature.

The epidemiology research on OA clearly shows that many people have radiological evidence of disease, but little if no pain; therefore, if you assume that you're studying mechanical pain in patients with OA, then you may be inadvertently perpetuating one of the myths that we are trying to debunk here- which is that connective tissue "abnormalities" (including radiological findings) correlate with having a mechanical pain problem.

If your inclusion criteria only allows those with inflammatory signs and symptoms in presence of positive radiological findings, then now you are studying something different that what you described above. However, just because you have inflammation and pain doesn't necessarily mean that the patient is going to be highly centrally sensitized, and therefore be a candidate for GMIP.

You see why it's so hard to study human beings who have pain!

If you haven't already, you should read all of Lorimer Moseley's work in this area. Also, the review by Nijs et al published in Manual Therapy in 2010 is an excellent resource for better understanding the clinical manifestations of central sensitization with abundant references.
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Old 02-10-2011, 05:38 PM   #6
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In sheffield! Thats great.

I see a few pitfalls for you. Is your study for an MSc?

There has been a RCT by Lorimer Moseley on GMI and CRPS. In that there is pretty clear guidelines to the protocol. I think it was 2 hours a day at each stage.

How are you going to diagnose OA and what will your inclusion criteria be? If possible I would try to get away from OA and talk about centrally driven pain.

As for mirror therapy in isolation, what do you think the mirror will do, and how will it work? There is some data out there (i'll try and find it later) that suggests that mirror therapy in isolation can increase peoples symptoms in CRPS.

I'm happy to meet you near Hallam and throw some ideas about over a coffee.
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Old 02-10-2011, 07:28 PM   #7
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Hi John

Yes the inclusion criteria would be patients diagnosed with OA in the hand and/or wrist who have been suffering with pain symptoms. They would have had these symptoms for a certain amount of time. I don’t know how long you have to suffer with a condition before it is deemed chronic, it is something I will have to look up. It would also have to be unilateral.

I was going forward under the Idea that if an individual has suffered from a long term nociceptive pain, in this case OA of the hand/wrist then a some degree of that pain would be due to central sensitisation. In this case I thought that a prolonged nociceptive pain stimulus would alter the somatosensory cortical map making the hand larger and therefore more sensitive and susceptible to pain. So if anything I wasn’t trying to support the myth that connective tissue abnormalities correlate with a mechanical pain problem, more the opposite really.

I thought the mirror would provide the illusion that the affected hand can be moved without pain providing a visual stimulus to help rearrange the somatosensory cortical map, reducing the size of the hand and decreasing any central sensitisation that may have occurred. This would aim to reduce pain making the patient’s condition easier for them to manage.

I know that all pretty crude and basic but that’s my interpretation of the information that I have seen so far.

Dave I really appreciate the offer to meet up and discuss, and I would be more than happy to take it up. My study is for the BSc hons course although I wish it was for the MSc as that means I would have already done it and passed. Im on placement at the moment and I work weekends so I would have to meet you one evening if that’s OK. PM me when your available and we can arrange something from there.

Once again thanks to everyone for your input
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Old 02-10-2011, 08:34 PM   #8
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Quote:
I was going forward under the Idea that if an individual has suffered from a long term nociceptive pain, in this case OA of the hand/wrist then a some degree of that pain would be due to central sensitisation.
This idea of yours is inaccurate, I'm afraid, because you're equating having OA with having nociceptive pain. You're making an assumption that cannot be justified based on current research showing the high prevalence of asymptomatic OA.
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Old 02-10-2011, 09:15 PM   #9
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I think OA flare-ups are likely of chemical origin. The inflammation in the joint activates the nervous system and initiates the nociceptive process. Patients might also then get some mechanical type symptoms and get to thinking the joint is the issue.

I remember an article that supported inflammatory markers being able to detect meniscal tears better than the physical exam and MRI.

Food for thought.

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Old 02-10-2011, 09:59 PM   #10
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I'd have to agree with john and gary. I think your jumping a bit ahead of yourself with some assumptions.

I understand what you want to look at but i'd try and make it a lot simpler. Now the term OA in itself is a nightmare to study because your not defining a pain mechanism.

I'd bring it back a bit. Two of the ways of measuring central changes are two point discrimination and the laterality test.

For a 3rd year study you need something quite simple. Two point discrimination and laterality are easy and reliable to measure. Is there a way of testing a group of chronic hand pain patients (who may have the label of OA, but not CRPS) for laterality or 2pd. I have no idea if this has been done yet. I know it has for the lower back, its getting done for the neck and i think the knee.

Give me a pm and i'll give you my email to arrange a coffee.
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Old 03-10-2011, 12:17 AM   #11
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Anthony

As others have, I would also suggest considering the whole GMI rather than just mirror therapy. It might be worth getting in contact with NOI as they have software to measure laterality scores which you could use as either inclusion/exclusion or an outcome depending on how your study goes. If you mention it's for your degree they may even give you a deal on the equipment - worth an ask.

If you PM me your email, I have some articles and info on mirror therapy I can send you.

Roly
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Old 14-11-2011, 10:18 PM   #12
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Just saw this: Mirror therapy may help to reduce the pain of arthritis.
Candice McCabe involved.
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Old 14-11-2011, 10:43 PM   #13
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Hmmm...The study sounds like something that would have been designed by an undergrad. 8 subjects, 2 totally seperate diagnoses (which may or may not have pain as a symptom), outcomes compared only with a pain scale and an intervention which hasn't been validated to be effective in isolation. I wouldn't hold my breath to see this published. The authors need some design assistance...and if they are reading this thread, pm me.
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Old 15-11-2011, 03:07 AM   #14
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'The Brain that Changes Itself' by Norman Doidge is a great book with reference to mirror box therapy and the info you are seeking. I also recall some info about neuroplasticity and pain in 'Pain-The Science of Suffering' by Patrick Wall
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Old 15-11-2011, 03:29 AM   #15
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The writer of the article sounds quite muddled about pain; it comes from the brain with central sensitisation - but from the joint if it's peripheral????
Doubt if it would get past peer review.

Nari

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Old 15-11-2011, 11:14 AM   #16
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Even though it's great that the brain is getting attention I'm not sure articles like this are particually helpful. Mirror therapy in isolation hasn't been proved to be useful in treating pain. It can even flare up some nasty pain states. But I think people get confused between mirror therapy and graded motor imagery. GMI takes a massive investment in time by the patient, an hour a day in some cases, the RCT on it was 2 hours a day. A few minutes infront of a mirror a day makes the whole process sound easy and a quick fix. It's not.
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