Many interesting comments were made on my posts about graded motor movements and Dr. Lorimer Moseley’s interview about his research.  I’ve asked Dr. Moseley 2 questions as follow-up.  (As always, do not undertake this treatment, nor any other, without first consulting with your doctor.)

1. Nickie asks, “I’m visually impaired and have CRPS/RSD. Could this technique ever be adapted for someone without sight?”

Dr. Moseley:  This is a most intriguing question, isn’t it?!  It’s not the first time I’ve been asked that question.  I think it’s important that the brain is ‘moving’ the limb to some extent, so it would seem feasible for a blind person to imaging doing things with her limbs. However, if this isn’t sufficiently conservative (i.e. if it increases pain when done, -HTCWP), then perhaps she could ‘look’ at others doing things (in her head).  This would require that she wasn’t always blind.  Otherwise it’s up to the creative investigative work of the clinician and patient perhaps - does she play an instrument perhaps?  If so, she could answer questions like, “What does the left hand do in Ornithology by Charlie Parker?” or similar.

HTCWP: So the answer would be that the technique would be modified so that you wouldn’t look at pictures, but figure out how to get your brain to go through the same steps.  Left/Right hand and foot pictures could be imagined, then imagining moving your own hand and feet to the position, then actually moving.  3-D models of R/L hands and feet could also conceivably be made, or use dolls, stuffed animals, etc.  Dr. Moseley raised the possibility of imagining hand positions when playing music.  Any activity could be tried, e.g. sewing, cooking.

2. I asked Dr. Moseley his thoughts about what is being accessed in the brain in his 3-part sequence of graded motor movements - versus - what is being accessed in mirror image work (we’ll learn more about this in future posts).  The first 2 steps of the graded motor movements seem to be “preparatory” for the actual movement.  Mirror image work seems to be comparable to the second and last step in graded motor movement, i.e. somewhere between imagining movement and the actual movement.  Both seem to access a “movement’s ok” network.  Any thoughts?

Dr. Moseley: Yeah, I have many thoughts on this - primarily because I’ve only ever gotten really good results with the mirror in acute patients, and those findings are clouded by the possibility of spontaneous recovery.  My clinical experience was that mirror therapy seldom yielded better than transient results.  A published trial by McCabe et al suggests it doesn’t help patients with chronic CRPS.  I actually think we need some tight rct’s (”randomised controlled trials” -HTCWP) to know whether mirror therapy alone really works.

There are several theories about why mirror therapy might work, but none of them, in my view, have been substantiated, despite the popularity of the technique.  Your call that it seems to be accessing the “movement is ok” network is as good as any, and it’s probably the most intuitively sensible at the moment.

I agree that the first 2 stages seem to be preparatory, but they seem to be important too.  You probably read the paper that did them in different orders - that was a bit of a surprise finding actually - it was very clear from the data that patients didn’t respond to mirrors unless they had already done the other 2 steps.

Thanks to Dr. Moseley, and to all who commented and shared their experience about this treatment.  We’ll await more news about this exciting development.

And, for those of you who enjoy subtle humor, this was an automated reply on Dr. Moseley’s email…  “This is an automated reply.  Not completely automated because I had to type this in in the first place.  Manually.  Regardless, you have been sent this manually-assisted reasonably automated-ish reply because I won’t read your email until Tuesday. Sorry about that.”  Funny guy, and smart too!  -HTCWP

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