SPORTS MEDICINE TIBIAL FRACTURE

however the VAS for this dropped to 4/10 for ankle pain. This MVF treatment combined with active movement

STEP 3 MIRROR THERAPY STEP 2 MOTOR IMAGERY

Figure 4: Main steps of graded motor imagery (GMI)

and imagery was undertaken over the course of 1 week. Daily sessions lasting 20 minutes were carried out each morning immediately following a conventional session of physiotherapy. The patient also recevied instruction about the use of motor imagery and was asked to utilise these techniques to “run” an imagined, elegant pattern of normal movement in the left leg during “walking” and the “single-leg hop test”. This work was integrated into the weekly programme of intensive rehabilitation (which also included strength and conditioning, soft tissue therapy, physiology and conventional physiotherapy sessions).

Outcome STEP 1 LATERALITY RECONSTRUCTION

her right foot, presented randomly via photographic cards. She demonstrated a good ability at this task, so the intervention comprised a modified regimen of both imagined movement and mirror movements of her unaffected limb (2). A standard 50 cm by 200 cm wall mirror was placed

between her legs, with the mirror side facing her unaffected lower leg. The affected left lower limb was covered over. From this position the patient was able to see a complete mirror image of her unaffected right lower limb. She was then instructed to spend some time looking at “both legs” before undertaking small gentle movements of the foot, ankle and knee of her unaffected leg, primarily in the sagittal plane. The response to this initial session was profound. The

player was “amazed” that she now had “two normal legs again” and no longer had a “cankle” (her definition of a thickened ankle the size of a calf). After 15 minutes of mirror movement training, her gait was tested again and another single-leg hop test was performed. There was marked improvement in her stride length and cadence during gait, and the patient reported a sensation of being better “balanced” and having “less of a limp”. The single-leg hop test remained a challenge for her due to poor force attenuation on landing,

Affected leg

Figure 5: Typical set-up for motor graded imagery using mirror visual feedback

Reflection of normal leg

perceived by patients to be be ‘normal’ affected leg

At the end of 1 week the player was asked to repeat the Lower Limb Tasks Questionnaire. Her score had improved by 5 points to 19 out of 40. A a 4-point shift is considered a significant improvement (8). Left dorsiflexion in weight- bearing became – 7.5 cm toe to wall, which represents an increase of 3.5 cm. Her gait continued to improve with a longer stride length on the left, and more balanced weight bearing during the stance phase. The single-leg hop test remained challenging although the VAS for her ankle pain diminished to 2 or 3 out of 10. Of particular interest was a marked improvement in the appearance of her left leg, which improved in colour and the temperature of the skin decreased. The hyperaesthesia that had been evident earlier that week also improved, with almost no allodynia to light touch, and less discomfort on digital pressure testing. Undoubtedly this multidisciplinary intensive rehabilitation programme helped to improve the markers around her recovery. However the patient identified the mirror therapy and motor imagery as having a significant impact both on her psychological beliefs and physical achievements during her initial week at the IRU. This positive experience then set the tone for progress in her other sessions, which is essential in a residential rehabilitation environment. The patient subsequently remained under the close supervision of the team physiotherapist, incorporating the motor imagery and mirror therapy into her regular home routine. She returned for a further three 1-week blocks of intensive rehabilitation, with a graduated return to training and impact. Some 11 months after the initial injury she returned to full competitive rugby at an international level – a true testament to her dedication and single-mindedness during the rehabilitation period.

Mirror Normal unaffected leg www.sportEX.net

DISCUSSION Although physiotherapists have been using mirrors as a means of visual feedback for many years, it is only relatively recently that the underlying neurophysiology of this intervention has been understood (1). Early work by Ramachandran (9,10), McCabe (11,12), Moseley (13) and others (14) has looked at MVF as a treatment intervention for various clinical conditions, including phantom limb pain following amputation, complex regional pain syndrome (type 1), and hemiparesis following stroke. The results of these studies demonstrate a significantly beneficial response when this treatment is added to a conventional approach in a well- defined subset of patients (2). The challenge for therapists working in the musculoskeletal field is to understand when MVF could be used to add value to a treatment approach, especially when a condition appears to be a purely physical

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