Applications of Graded Motor Imagery in a Patient with Chronic Upper Extremity Pain. Following Multiple Thoracic Outlet Surgeries: A Case Report

Transcription

1 Applications of Graded Motor Imagery in a Patient with Chronic Upper Extremity Pain Following Multiple Thoracic Outlet Surgeries: A Case Report Brianna DeBiasi Student Physical Therapist Department of Physical Therapy University of Illinois at Chicago 1919 West Taylor Street Chicago, IL 60612

2 Abstract Background and Purpose In a clinical setting, the most challenging patients can be those with chronic pain. Chronic pain is associated with disruptions in the somatosensory and motor cortices and is difficult to treat with typical therapeutic interventions. Graded Motor Imagery (GMI) is a series of interventions aimed at reorganization of these areas and has been used to successfully treat chronic pain conditions such as chronic regional pain syndrome and phantom limb pain. Case Description A 46 year-old female with a history of multiple thoracic outlet surgeries has been receiving physical therapy for 13 months following her most recent surgery in order to restore function, address residual chronic pain in the right upper extremity and chronic headaches. Previous interventions included desensitization techniques, manual therapy, shoulder strengthening and stretching, aquatic therapy and fine motor tasks. GMI was integrated into the previous interventions and is currently being continued. Outcomes Symptoms were assessed at each treatment and were quantified with the Verbal Numeric Rating Scale (VNRS). Manual Muscle Testing, Range of Motion and grip strength were evaluated at initial evaluation and Weeks 1 and 9 of the intervention. The patient verbally reported the nature and duration of symptoms throughout intervention. The patient s headaches decreased in duration, intensity and frequency. Her typical right shoulder pain decreased from 5-7/10 to 2-3/10 on the VNRS; however, elbow

3 hyperalgesia, 4 th and 5 th digit fingertip numbness and pain persisted, and she had a decrease in right upper extremity range of motion. Discussion These outcomes suggest that GMI may be successful with chronic pain management after surgery; however, more research is needed on the most effective way to incorporate GMI in a clinical setting. [Word Count: 275] Word Count:

4 Background and Purpose Approximately 100 million Americans suffer from chronic pain. 1 Over 20 years of research in chronic pain has revealed that it is directly tied to disrupted cortical representations of the body in the brain and plastic changes in the spinal cord. Moreover, there is evidence of disrupted somatopic and spatial representation resulting in disrupted stimuli supplied to healthy body parts in the area, abnormal perception of the size of the body part and poor volitional movement. 2 As a result, GMI was developed specifically to address these cortical disruptions with its foundations in graded exposure and a biopsychosocial approach to pain. In addition to these cortical disruptions, central sensitization is linked with chronic pain. Central sensitization is associated with plastic changes occurring in neurons in central nociceptive pathways. According to Woolf, peripheral nerve injuries can trigger increased excitability in spinal cord neurons, which can greatly change the gain of the somatosensory system. 3 Central sensitization is marked by two major changes in the somatosensory system: increased excitability of pain pathways and decreased inhibition of pain signals. Woolf goes on to say the markers of central sensitization are hyperalgesia, which is an exaggerated response to noxious stimuli, allodynia, which is a noxious response to stimuli that are not typically noxious and secondary hyperalgesia, which is an expansion in the receptive field that allows non-injured tissue to produce pain. 3 People suffering from chronic pain are subjected to heightened responses in every aspect of the pain process from peripheral nerves to cortex. In fact, a pain signature arises in the brain that is tied to the patient s perception of painful

5 movements. 4 As a result pain arises not in accordance to the condition of the involved tissue or the activity in nociceptive fibers, but rather the perceived threat to tissues and the need for the individual to respond. 5 Because chronic pain is so rarely related to tissue damage, it can be difficult for both therapist and patient to grasp. Conservative physical therapy interventions for chronic pain often fall short because they fail to respect the deep-seated changes in the nervous system. GMI employs a multiple-step process that gradually activates the involved cortices without exacerbating the patient. There is limited evidence that GMI and mirror therapy alone may be effective for treatment of chronic pain, but for treatment of pathological pain syndromes there is evidence to suggest that GMI can reduce pain and disability in patients. 2,6 A challenge for many clinicians is incorporating a biopsychosocial-based intervention into their typical treatment. Explaining GMI to a patient can be difficult given the intangibility of the body parts involved; however, patient education is the first step in beginning GMI. The patient has to be able to understand the science behind their pain in order to find value in GMI. It has been found that education about pain can lead to improvements in perceptions about general health and physical functioning. 7 Although there is an increasing amount of research studying the efficacy of GMI, there are few studies indicating its incorporation into a traditional therapy program in the clinic. The purpose of this case report is to demonstrate how GMI was applied in a clinical setting as an adjunct to standard physical therapy in a patient with chronic pain. Case Description: Patient History and Systems Review

6 The patient is a 46 year-old female with a diagnosis of recurrent right neurogenic thoracic outlet syndrome who is now status post right supraclavicular thoracic outlet decompression including anterior scalenectomy and brachial plexus neurolysis and right pectoralis minor tenotomy in March She had previous surgeries on the right upper extremity including a right transaxillary first rib resection in 1998 and a revision in 2008 due to recurrent symptoms. The patient works as a Senior Claims Adjuster for an insurance company, but she has been unable to return to work since surgery. She drinks an average of 5 drinks per month and is a former smoker who has not smoked in 19 years. Her prior medical history is unremarkable other than the surgeries mentioned above. At the time of re-evaluation in May 2014, her complaints are decreased cervical and right upper extremity range of motion as well as a burning sensation and numbness throughout the right upper extremity. She is unable to tolerate wearing heavier fabrics due to pain and experiences anxiety when performing activities of daily living involving her right upper extremity. Her right arm pain is typically 5-7/10 and neck pain is 2/10 on the VNRS. At the time of evaluation, she was taking the following medications: Roboxin daily, Lyrica 75mg twice a day and 600mg Ibuprofen nightly. Her primary goals were to restore sensation and pain-free range of motion in her right upper extremity in order to return to independence in activities of daily living as well as return to work. Clinical Impression #1 The patient s subjective reports of intolerance to donning heavier fabrics as well as hypersensitivity throughout the right upper extremity indicate central sensitization.

7 She has decreased endurance in her right upper extremity due to pain. Her subjective reports, history of brachial plexus impingement and multiple surgeries indicate she will be a good candidate for the application of GMI to her current physical therapy. There is no gold standard for diagnosis of central sensitization 10 ; further examination should include right upper extremity range of motion, manual muscle testing and grip strength in order to gauge changes in related function. Sensitivity to light touch is often tested for people with neuropathic pain 10 and should also be assessed based on the patient reports of decreased sensation in the involved area. Examination Range of Motion Active range of motion was assessed with the subject seated in a chair. A standard goniometer was used to measure shoulder flexion, abduction, elbow flexion and extension, wrist flexion and extension as well as radial and ulnar deviation. Shoulder internal rotation was assessed using the thumb to highest spinous process behind the back method and similarly external rotation was assessed using the thumb behind the head to the lowest spinous process. (See Table 1) Manual Muscle Testing Manual muscle testing was performed in the seated position. Shoulder external and internal rotators were tested with the elbow in 90 of flexion with the arm at the side. All other manual muscles tests were taken in accordance with standards published by Reese. 11 (See Table 1) Grip Strength Brianna DeBiasi 3/21/2015 2:21 PM Formatted: Indent: First line: 0.5"

8 Grip strength was assessed with the patient seated in a chair using a Jamar Hand Dynamometer. The elbow was flexed to 90 and positioned at the patient s side. (See Table 1) Light Touch Sensitivity to light touch was assessed by lightly touching a cotton ball to the upper extremity and asking the patient to accurately describe the location and quality of the touch in comparison with the uninvolved extremity. The patient was unable to tolerate light touch in certain areas of the right upper extremity due to pain and testing was aborted due to unreliability. < Insert Table 1 Here> Clinical Impression #2 Examination findings support the initial impression of central sensitization as she demonstrated allodynia during attempts to test sensitivity to light touch. Her limitations in range of motion were due to pain. Although the patient has made gains in range of motion since surgery, (See Table 1) she is still lacking in shoulder flexion, shoulder abduction, wrist flexion and extension. Based on the data in the first clinical impression and the objective data above, the patient is experiencing central sensitization of her right upper limb and would be a good candidate for GMI. Given that GMI is typically administered in 3 2-week stages, the patient should experience a decrease in elbow tenderness and numbness over 6 weeks. She would experience an increase in pain-free range of motion in the right upper extremity as well as increased grip strength. Her headaches should also decrease in intensity, frequency and duration. Given the complexity of chronic pain, it is difficult to determine how much

9 pain-free range of motion and strength she will gain and what time frame would be adequate to expect change. Approach The physical therapy intervention consisted of minute sessions over the course of 9 weeks. The patient came to therapy twice a week and attended aquatic therapy once a week. Specific treatments included GMI, manual trigger point release, scar tissue mobilization, bilateral shoulder strengthening, stretching, desensitization techniques, fine motor tasks and pain education. The patient was given stretching and shoulder exercises to perform at home. After the introduction to GMI, the patient s treatment was split into hard days on Mondays in order to increase exercise tolerance and light days on Tuesdays to mitigate any exacerbation of symptoms on the hard days. (See Table 2) <Insert Table 2> Education: The patient was educated on the theories of GMI and its role in pain management. The patient was also educated on central sensitization, peripheral sensitization and their respective roles in chronic pain. Face-to-face sessions of education with written materials has been found to be effective for changing pain perceptions in people with chronic pain. 7 Most of the educational material provided was directly from The Graded Motor Imagery Handbook and a sample can be seen in Figure 1. The education was given over the course of the 9 weeks and the patient verbalized understanding. < Insert Figure 1 Here>

10 Graded Motor Imagery Graded motor imagery consists of 3 stages and is advanced based on time or a decrease in symptoms. The first stage called laterality training involves daily, if not hourly, left/right judgments of the involved limb using pictures or the Recognise application. The second stage uses imagined movements and the third stage involves mirror therapy, after which exposure to graded functional movement is undertaken. 5 The stages are performed on more of a continuum than a linear progression. For instance, the patient in this case report continued laterality training and explicit motor imagery exercises in conjunction with mirror training. Throughout the training, it is imperative that a patient does not experience an exacerbation of symptoms and if she does, the treatment should be scaled back to avoid another incident. In this case, the patient was instructed not to exceed a 4/10 rating of pain on the VNRS while performing GMI. To ensure proper application to the protocols, the patient performed each stage at least 2 times during a therapy session and continued to perform the stages at home. Laterality training is based on research finding that many people with chronic pain have a distorted view of their affected limb due to cortical changes. Following the graded theme, laterality training is found to activate premotor cortices and not the primary motor cortex. Additionally, people in chronic pain states have a strong association between pain and motor output so that even pre-movement commands may cause pain. 8 In patients with chronic pain, activating the primary cortex can be quite painful and ineffective as treatment. Previous research indicates the three stages of GMI are introduced according to the patient s symptoms. The patient was introduced to laterality first and based on her performance, (see Table 3) continued for 3 weeks until

11 her time and accuracy reached the suggested levels in The Graded Motor Imagery Handbook. (see Table 3) <Insert Table 3 here> The Recognise application was used to display images of plain Vanilla Hands in various positions and the patient was given 20 seconds to determine if it was a left or right hand. To progress the program, the Recognise application also has images of hands with objects or Context Hands and Abstract Hands to continue to challenge the patient after initial parameters are met. Immediate pain and sensation response to all stages is gauged to insure the training is engaging the patient without producing an exaggerated response. After performing the Recognise application for the first time in session, the patient reported that her right hand felt like it had been writing pages. Based on this response, the patient was asked to perform the Recognise program once per day on her personal ipad. The patient was able to achieve the suggested outcomes in laterality training after 3 weeks and moved on to explicit motor imagery, but continued using laterality training throughout treatment. Explicit motor imagery is the next graded process in GMI. Where laterality training does not activate the primary motor cortex, explicit motor imagery activates the premotor and primary motor cortices; however, the activation in the primary motor cortex is less than that of mirror training or actual movement. The patient was given the following instructions: find a movement you are not afraid to perform, break the task down into steps, find a quiet spot, imagine your body performing the movement and then gauge your reaction. If the patient had a poor reaction to the task, the task was

12 changed or the patient would discontinue motor imagery and continue laterality training until she can perform the imagery without pain. In her first attempt, the patient imagined playing golf and experienced a severe headache the next day. The patient was educated to try a more graded task such as reaching for a golf club. She was able to tolerate 3 to 4 minute bouts of imagery before bed every night and gradually progressed to 10-minute bouts and more challenging upper extremity movements. After 3 weeks, she progressed to mirror training, but continued laterality and motor imagery concomitantly. Mirror training is the final stage of GMI and continues to involve the primary motor cortex, but at a intensity lower than actual movement. Much like explicit motor imagery, the patient is instructed to start in a quiet place and perform active contralateral hand movement in front of a mirror while the involved limb remains stationary behind the mirror. A progression of mirror training from The Graded Motor Imagery Handbook can be seen in Figure 2. <Insert Figure 2> The patient started with 2 minutes of mirror training with her right hand still behind the mirror. She was able to increase to 10 minutes of mirror training during sessions, but was unable to progress to moving her right hand behind the mirror. Over 4 weeks, she experienced progressive burning in her right hand despite scaling back mirror training. She discontinued mirror training, but continued explicit motor imagery. Desensitization Use of desensitization techniques was the primary treatment method for patients with chronic regional pain syndrome or chronic pain before GMI was conceived. The

13 theory behind the techniques lies in reintroducing the tissue into different sensations and habituating the nerves to the stimulation in an effort to normalize the response to the stimulus. Outcome Following the 9-week intervention, the patient verbally reported a decrease in intensity, frequency and duration of headaches. Her typical right shoulder pain decreased from 5-7/10 to 2-3/10 on the VNRS. She was able to tolerate progressively more involved exercises on her hard day routine and she started a Pilates class in 9 weeks into treatment indicating increased activity tolerance. She was able to decrease her Roboxin usage to as needed instead of daily. The patient stated that her biggest takeaway from GMI was that the GMI really made me recognize the dial it back theory...meaning when I m doing an activity, to notice when I start to feel pain and then in my mind dial back the activity until the pain lessens. I hate headaches!! ( communication December 2014) Despite these positive changes, her manual muscle test scores and grip strength remained unchanged from the first week of intervention, and she had a decrease in shoulder and wrist range of motion. (See Table 1) Discussion This case describes the application of GMI to a 46-year-old woman with chronic right upper extremity pain secondary to multiple surgeries. She presented with allodynia, hyperalgesia, decreased activity tolerance, decreased range of motion in the right upper extremity and chronic headaches. Through GMI, she was able to increase

14 her activity tolerance, reduce her headaches and manage her symptoms throughout the day using GMI. While the singular application of GMI has been researched in a clinical setting, there is little suggestion for how GMI can be successfully integrated into traditional orthopedic practice. Using the theories of a gradual activation of the involved cortices as well as progressing the program based on patient reaction, a tailored program was developed for the patient. The primary limitation in this case report the lack of standardized outcomes used. While subjective data was obtained at every visit, there was little objective data to support the successful application of GMI. The McGill Pain Questionnaire, Disabilities of the Arm, Shoulder and Hand and the Global Rating of Change Scale all would have been applicable outcome measures to use for this patient to assess pain-free function. Two other measures, the Pain Sensitivity Questionnaire and the Central Sensitization Inventory screen for central sensitization and would have been helpful assessing her level of sensitization. 10 In some aspects, GMI was successfully applied to the patient. For instance, the patient had a much better idea of how to grade her activities of daily living so as not to exacerbate her symptoms, but she also experienced a gradual decrease in functional right upper extremity range of motion and no change in elbow or fingertip pain and numbness. This was puzzling due to gains made elsewhere and her adherence to the GMI program. One suspected reason for this was the flare-ups she experienced after hard days. They likely negated some of the progress the patient made in addressing the peripheral and cortical changes that were targeted during GMI. Another suspected

15 reason is that a recent EMG of her right brachial plexus indicated recurrent impingement from scar tissue. She is currently scheduled for surgery February ( correspondence December 2014) She plans to restart GMI after surgery and hopes to fully gain functional movement of her right arm. Future research should focus on GMI and a more standard protocol for its integration into standard orthopedic physical therapy

16 Acknowledgements Todd J Wallace OCS, DPT for his guidance and willingness to try different treatment methods. The patient, BF, for her patience, determination, and courage throughout her life. Cary Physical Therapy for providing a environment in which a student physical therapist can practice, learn and be supported throughout a clinical affiliation.

17 References 1. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, Bowering KJ et al. The Effects of Graded Motor Imagery and Its Components on Chronic Pain: A Systematic Review and Meta-Analysis. The Journal of Pain. 2013:14(1): Woolf CJ. Central Sensitization: Implications for the diagnosis and treatment of pain. Pain. 2011;152:S2-S Nijs J et al. How to Explain Central Sensitization to Patients with 'Unexplained' Chronic Musculoskeletal Pain: Practice Guidelines. Manual Therapy. 2011: Moseley GL, Flor H. Targeting Cortical Representations in the Treatment of Chronic Pain: A Review. Neurorehabilitation and Neural Repair. 2012;26(6): Moseley GL. Graded Motor Imagery for pathologic pain: A Randomized Controlled Trial. Neurology. 2006;67: Oosterwijck JV et al. Pain Physiology Education Improves Health Status and Endogenous Pain Inhibition in Fibromyalgia: A Double Blind Randomized Controlled Trial. Clin J Pain. 2013;29:

18 Moseley GL. Graded Motor Imagery Is Effective for Long-Standing Complex Regional Pain Syndrome: A Randomised Controlled Trial. Pain. 2004;108: Moseley GL, Butler DS, Beames TB, Giles TJ. The Graded Motor Imagery Handbook. Adelaide Australia. Noigroup Publications Njis J et al. Applying Modern Pain Neuroscience in Clinical Practice: Criteria for the Classification of Central Sensitization of Pain. Pain Physician. 2014;17: Berryman Reese N. Muscle and Sensory Testing. Saunders; 2011

19 Tables Table 1. Range of Motion, Manual Muscle Testing and Grip Strength on Initial Evaluation, Week 1 of Intervention and Week 9 of Intervention Action Tested Initial Evaluation 13 months Prior to Intervention Right UE ROM MMT Week 1 of Intervention Right UE ROM MMT Week 9 of Intervention Right UE ROM MMT Shoulder Flexion 90 4-/5 157 * 5/5 145 * 5/5 Shoulder Abduction 72 4-/5 160 * 4/5 95 * 4/5 Shoulder Internal Rotation Shoulder External Rotation HBB to Hip Not Tested 4 - /5 4 - /5 HBB to T9 HBH to T4 4 + /5 HBB to T9 HBH to T1 Elbow Flexion / / /5 Elbow Extension / / /5 Wrist Flexion 50 4-/ / /5 Wrist Extension / /5 50 * 4 + /5 Ulnar Deviation 20 4-/5 35 5/5 25 5/5 Radial Deviation 10 4-/5 22 5/5 22 5/5 4 + /5 4 + /5 4 + /5 367 Grip Strength R L R L R L Elbow Flexed to 90 at 38lbs 50lbs 38lbs 50lbs 38lbs 50lbs Side : Hand behind back. :Hand behind head. *:Pain with movement. ROM: Range of Motion. MMT: Manual Muscle Test Score

20 Table 2 Interventions Used Before Introducing GMI and in Conjunction with GMI PRE-GMI THERAPY Techniques Soft Tissue Massage Upper Trapezius Stretch in Chair Parameters Bilateral Upper Trapezius, Right Scalenes, Right Pectoral Area for 10 minutes 3 times for 30 seconds Desensitization Techniques Supine Foam Roll Exercises with Yellow Theraband Fine Motor Tasks HARD DAYS Techniques Warm-Up on Airdyne Bike Wartenburg Pinwheel, Towel rubs over the affected for 2 times for 30 seconds Shoulder Flexion, Angels, External Rotation, Sash Pulls 10 repetitions Grasping objects in a rice bag, putty manipulation for 2 minutes, dealing playing cards Parameters 5 Minutes Therapist administered Bilateral Scalene Stretch in supine Upper Limb Neural Tension Desensitization Techniques Supine Foam Roll Exercises with Yellow Theraband Fine Motor Tasks 3 times for 20 seconds Right Median and Ulnar Nerves for 10 repetitions or to tolerance Wartenburg Pinwheel, Towel rubs over the affected area for 2x30 seconds Shoulder Flexion, Angels, External Rotation, Sash Pulls 10 repetitions Grasping objects in a rice bag, putty manipulation, dealing playing cards for 3 minutes each

21 LIGHT DAYS Techniques Soft Tissue Massage Cervical Mobilizations Trigger Point Release Parameters Bilateral Upper Trapezius 375 Right Scalenes Right Pectoral Area for 10 minutes 376 Grade II Central Posterior to Anterior Mobilization at C7, T1, T2 for 3 minutes 377 each segment Grade II upglide mobilization to C4-C5 378 Right mid-thoracic region for 5 minutes Table 3. Suggested Parameters of Laterality Training 9 and Patient s Score on 1 st Attempt. Suggested Parameters Feet & Hands Accuracy Time >80% 2.0s ±.5s 382 Patient s First Attempt R Hand 33% 2.5 s L Hand 70% 1.5 s

22 Figure Headings Figure 1. The Twin Peaks Model of Pain used to describe a typical pain response to tissue strain and a chronic pain response to tissue strain. (from Explain Pain p.119) The Twin Peaks model is a useful educational picture that can help a patient understand why small innocuous movements may cause them pain. Figure 2. There are several ways to start with mirror training exercises. This figure (from The Graded Motor Imagery Handbook p.89) demonstrates an easy to follow graded movement plan. 393

23 394 Figures 395 Figure Figure 2.