Benefits of the Modified Graded Motor Imagery Protocol in the Treatment of Patients With Complex Regional Pain Syndrome Type I and Type II

摘要

Introduction: The abnormal prolongation of pain, dystrophic events, autonomic dysfunction, microvascular abnormality, localized atrophy, and functional impairment constitutes complex regional pain syndrome (CRPS).It could appear after trauma or surgery. New information regarding cortical changes in patients with chronic pain has prompted a reevaluation of the type of treatment. Graded Motor Imagery (GMI) is one of the treatment techniques from the “top-down” paradigm designed to treat chronic pain. The aim of this study was to evaluate the functional results of the occupational therapy treatment in patients with CRPS type I and type II including the Modified GMI Protocol. Methods: Fifteen patients of both sexes with CRPS type I and type II as a complication of various pathologies of the upper extremity were evaluated. They were treated from November 2014 to January 2016. Patients who were diagnosed with CRPS type I or type II by the physician (hand surgeon or rheumatologist) and underwent a minimum of 10 treatment sessions were included. Patients were assessed with goniometry of the wrist and thumb opposition, distance to the distal palmar crease, visual analogue scale (VAS), and Patient-Rated Wrist/Hand Evaluation (PRWHE). GMI consisted of 3 stages: recognition of hand laterality, imagined hand movements, and mirror therapy. The execution time for these was based on the performance of the patient. Together with the Modified GMI Protocol, other activities such as global and functional range of motion of the upper extremity, sensory reeducation, and edema treatment were developed. Results: Active wrist flexion increased to 61% and the extension to 76.6% in comparison with the first evaluation. Six patients did not achieve the complete opposition of the thumb to the base of the fifth metacarpal in an average of 1.3 cm (range, 1-3 cm). Five patients were able to make the active full fist to the distal palmar crease, the remaining patients had an average deficit of 2.20 cm. Pain decreased in an average of 3/10 (range, 0-7) in the VAS. The PRWHE showed that the patients presented an average of 18.13/50 of difficulty in the Function subscale (specific activities and usual activities). Conclusions: The results obtained in this study suggest that the inclusion of the Modified GMI Protocol has significant advantages, decreasing pain, increasing the active mobility of the affected hand, as well as facilitating its performance in daily activities. We have noted that the protocol can be performed by devoting less time to the stages of laterality and imagined movements if the patient has no difficulty in performing them. Nevertheless, it is important to do the 3 steps in order to allow cortical reorganization of the body scheme and the movements of the affected limb.