Movement representation techniques: it’s a fuzzy name, but it might just work!

A systematic review and meta-analysis has just come out in The Journal of Pain looking at the efficacy of “movement representation techniques” for people with limb pain. Now, you might ask “what is a movement representation technique”? Well, according to the authors of this review, a movement representation technique can encompass any therapy that uses the imagination or observation of a pain-free movement. Identified therapies included were mirror therapy, motor imagery and action observation.

The review was limited to randomised controlled trials. Fifteen studies were included –with 397 participants in total. Pain conditions were complex regional pain syndrome (CRPS – type I and II), phantom limb pain, post-stroke pain, and non-pathological pain. The majority of interventions were mirror therapy, a handful were motor imagery, a couple with graded motor imagery, and one action observation study. Outcome measures were pain ratings, disability and quality of life.

The main conclusions was that there was some evidence supporting movement representation techniques to reduce limb pain. Interrogating the specific pain groups and therapies – the main effect was mirror therapy and graded motor imagery to reduce CRPS limb pain. The authors made an argument that graded motor imagery includes mirror therapy, and perhaps the effect is due to mirror therapy alone, although this seems unlikely as the order of graded motor imagery seems to be important (as reported in Moseley 2005). Pain was also reduced in people with non-pathological pain (acute). Interestingly, what this means is that this technique was beneficial in people with acute and chronic pain. Regarding other outcomes, disability was reduced after treatment and effects on quality of life were not significant.

Unfortunately there were substantial differences in treatment duration between studies, with some studies limiting their treatment duration to 5 days, whereas others were as long as 6 weeks. Methodological quality was generally fair, with 11 out of 15 studies scoring 6-8 out of 10, although one study scored as low as 1. There is a substantial potential for publication bias and overall, the strength of the evidence in this review seems fairly weak.

One thing that I thought was neat about this review, is that it was not isolated to chronic pain. They had a bunch of studies under the banner of ‘non-pathological limb pain’ – including ankle sprain, knee replacement, anterior cruciate ligament repair and rotator cuff injury.  Not too many studies look at acute pain and chronic pain when it comes to these therapies, so this made for an interesting addition. Surprisingly (to me at least) there was no mention of left/right judgments fulfilling the criteria of a ‘movement representation technique’. Any thoughts on this?

 About Sarah Wallwork

Sarah WallworkSarah is in the final stages of her PhD at BiM Adelaide. Her interest is in defensive peripersonal space, threat identification and reflexes. Sarah has been around here for a while – finishing her Honours thesis in 2010 in normative left/right neck rotation judgments. We’re looking forward to seeing what she gets up to next.

References:

Thieme, H, Morkisch, N, Rietz, C, Dohle, C, Borgetto, B, 2015, The efficacy of movement representation techniques for treating limb pain – a systematic review and meta analysis, The Journal of Pain, In Press. DOI: 10.1016/j.jpain.2015.10.015

Moseley, G.L. 2005, Is successful rehabilitation of complex regional pain syndrome due to sustained attention to the affected limb? A randomised clinical trial. Pain, 114(1), 54-61

Comments

  1. I found mirror therapy only worked in my acute stage I continued in chronic stage but stopped as opposite non injured hand development carpal tunnel mirror box was worsening to the pain …I have crps type 2

  2. Lesley Singer says

    I am wondering if people who are more “in tune “with their bodies have a better ability to do this. I think this would be something we might notice clinically but I am not looking for research on this just a question I think about

  3. Excellent. Just a few thoughts if you don’t mind. For me mirror therapy works brilliantly for acute pain http://youtu.be/FM1DKhKehfI
    Re left/right recognition. In my case recognition results are proportional to pain. Reduce pain, improve results. Any increase in pain eg add a migraine will worsen results. Believe it is not a case of can’t recognise bbut more that processing time slows considerably with raised pain levels.

  4. Hi Sarah

    Really interesting study. What strikes me is that you are starting to get close to identifying “embodiment” as a critical factor in your research. I find this regularly in my practice where wounds, operations, breaks etc are not healing. The problem is almost always corrected (and the body repairs itself quickly) once the person ceases to be frightened or antipathetic to the body part and injury and “owns” their body once more and fully inhabits it with their awareness/consciousness.

    This is essentially a form of partial somatic dissociation. They are always unaware that they have done this because the reduction in conscious connection is an absence. I find that people who have adopted a strategy of screaming at their body to control it are for the most part unhelpable for as long as they are not prepared to enter the more compassionate mindset necessary to re-establish a better quality of conscious embodiment. People who are terrified of the pain (and their body) are also quite difficult, but often their perception can be re-framed as soon as they find a part of their body that is comfortable. The main problem is getting them through the clinc door in the first place if they are locked in a pain minimisation avoidance strategy.

    Amongst other approaches, I have been using a simple body awareness script for some time – see http://www.hummingbird-one.co.uk/pdf/body_int.pdf – this is quite old now and I have changed my working script and am currently re-writing this document, but it’s a good start. I’ve had a couple of people through the clinic with severe chronic pain lasting over 10 years who ONLY needed to re-inhabit their body and the pain completely went. Most people also require some manual treatment to attain full recovery.

    Your current PhD research also ties in with this territory – I’ll email you a link to some work I have been doing over the past 10 years that specifically applies proxemic alarm zones in some of these cases.

    The usefulness of trying to be aware of a specific part of the body depends on whether its ANS content is primarily sympathetic or parasympathetic. If the emergency parasympathetic response dominates, then placing attention on that part directly will simply increase the somatic dissociation. This might not appear relevant, because emergency parasympathetic dominant states are usually blank/numb rather than painful. However, my experience is that where there is severe chronic pain there is sometimes also something somewhere connected to the pain zone that is blank/numb – and until that body part is reintegrated the painful area will not usually reintegrate. There are lots of ways to deal with this, but I hadn’t considered using the movement representation techniques you describe above, so thankyou again.