or inflammatory-driven pain presentation. Some recent case studies have begun to explore this concept. A patient described by Altschuler and Hu (15), who sustained a fracture of the distal radius without any tendon or neurovascular involvement, required internal fixation and immobilisation of the wrist. The presentation of severe stiffness, loss of joint range, pain in the wrist and tingling in the hands echoed the findings of our elite rugby player patient (albeit in her lower limb). MVF was instigated at an early stage as a treatment modality alongside conventional physiotherapy plus muscle stimulation over a 3-month period. While there was no “control” in their case study, it was reported that MVF training helped to over-ride the aberrant sensory input from the injured hand so that the paraesthesias that had been initially described subsided, and normal function could return with therapeutic input. Other reports in the literature (1,2) suggest that the use of MVF to help reverse cortical reorganisation also results in an immediate effect on modulating pain. This was demonstrated across several clinical presentations, such as phantom limb pain, complex regional pain syndrome, and trigeminal neuralgia, and was a feature of the mirror intervention in our patient. Further evidence of physiological changes resulting from the use of MVF were demonstrated by McCabe and Haigh (12) who used this treatment in a group of eight patients presenting with less than 3 years of lower-limb complex regional pain syndrome (type 1) symptoms. Although this was a pilot study, it had a robust design in which all eight subjects went through two control phases of “no-device” and “use of a non-reflective surface” before being treated with the mirrored intervention device in MVF. These patients were instructed to view their unaffected limb in the mirror, thus “tricking” their brain into believing they had two normally functioning legs. Lower limb movements were then undertaken, within the limits of pain. The outcome measures were VAS and vasomotor changes measured by infrared thermography. They showed significant, immediate and surprising improvements in the patients with early complex regional pain syndrome (of less than 8 weeks’ duration), and these improvements lasted through to a 6-week follow-up.

These studies strongly support the hypothesis that disruption of central sensory processing can occur across a range of different clinical presentations (12). It is possible that this cascade of abnormal afferent sensory information up to the brain causes a degree of maladaptive reorganisation of the sensory homunculus within the parietal cortex (1). By moving the unaffected limb in front of a mirror, cortical reorganisation occurs (16) and a reprogramming or reorganisation is thought to take place in this “virtual body” (3). This in turn helps to restore the balance between sensory input and motor output, thus moderating the pain a patient feels (3). All of this suggests that the connections in the adult human brain which, while complex, are extraordinarily malleable (1). Finally, the work undertaken by Moseley (13) suggests that the sequence of carrying out the intervention is important. Limb laterality training should be a precursor to imagined movements, followed lastly by MVF training. The rationale behind this is to activate pre-motor and motor networks in the brain prior to adding a barrage of sensory and motor feedback relating to movements with the MVF treatment.

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SUMMARY

The use of a graded motor imagery programme including the use of MVF should be considered in injured athletes who present with sensory disturbances. This intervention has been found to be most effective in the earlier stages of rehabilitation, and may be used as an integral component of a multifaceted treatment approach.

Conflicts of interest

The author can confirm there are no conflicts of interest. The patient provided full consent for publication.

FURTHER INFORMATION For more on graded motor imagery (GMI) see http://www.gradedmotorimagery.com/

References 1. Ramachandran VS, Altschuler EL. The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain 2009;132:1693–1710 2. Moseley GL. Graded motor imagery for pathologic pain. Neurology 2006;67:2129–2134 3. Moseley G L. A pain neuromatrix approach to patients with chronic pain. Manual Therapy 2003;8:130–140 4. Sutbeyaz S, Yavuzer G, Sezer N, Koseoglu BF. Mirror therapy enhances lower-extremity motor recovery and motor functioning after stroke: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2007;88:555–559 5. Catagni MA, Ottaviani G, Maggioni M. Treatment strategies for complex fractures of the tibial plateau with external circular fixation and limited internal fixation. Journal of Trauma Injury, Infection and Critical Care 2007;63:1043–1053 6. Cavenagh J, Good P, Ravenscroft P. Neuropathic pain: Are we out of the woods yet? Internal Medicine Journal 2006;36:251–255 7. Janig W, Baron R. Complex regional pain syndrome: Mystery explained? Lancet Neurology 2003;2:687–697 8. McNair PJ, Prapavessis H, Collier J. The lower-limb tasks questionnaire: An assessment of validity,reliability, responsiveness, and minimal important differences. Archives of Physical Medicine and Rehabilitation 2007;88(8):993–1001 9. Ramachandran VS, Rogers-Ramachandran D, Cobb S. Touching the phantom limb. Nature 1995;377:489–490 10. Ramachandran VS, Rogers-Ramachandran D. Phantom limbs and neural plasticity. Archives of Neurology 2000;57:317–320 11. McCabe CS, Haigh RC, Halligan PW, Blake DR. Referred sensations in patients with complex regional pain syndrome (type 1). Rheumatology 2003;42:1067–1073 12. McCabe CS, Haigh RC, Ring EFR, Halligan PW, Wall PD, Blake DR. A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology 2003;42:97–101 13. Moseley GL. Is successful rehabilitation of complex regional pain syndrome due to sustained attention to the affected limb? A randomised clinical trial. Pain 2005;114:54–61

THE AUTHOR Greg

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Greg Retter PGDip Manip MCSP is a chartered physiotherapist specialising in manipulative physiotherapy. He is currently rehabilitation manager of the Intensive Rehabilitation Unit at

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the British Olympic Medical Institute, based at Bisham Abbey National Sports Centre. He heads up a team of rehabilitation specialists covering specialisms in sports medicine, physiotherapy, rehabilitation science, physiology, psychology, nutrition and soft tissue therapy. He has worked extensively with a number of sports teams and has attended four Olympic Games and three Commonwealth Games as a headquarters physiotherapist.

sportEX medicine 2010;45(Jul):13-16