Graded Motor Imagery for Women at Risk for Developing Type I CRPS Following Closed Treatment of Distal Radius Fractures: Protocol and Case Example

Purpose: Distal radius fractures (DRF) account for nearly one-fifth of all fractures in older adults with women sustaining them at a rate of 5 to 1 relative to their male counterparts. The majority of DRF occur as a result of low impact injuries to the wrist with the hand being outstretched and are most often managed via closed treatment and cast immobilization The aftereffects of these injuries include pain, distal upper limb immobility, distal sensorimotor changes, hand weakness, edema, and type I complex regional pain syndrome (CRPS) development. Women, those sustaining lowforce injuries, and those who undergo closed treatment and cast immobilization of the DRF, are at increased risk for developing type I CRPS. Given that alterations in the brain's somatosensory strip likely influence CRPS development, a newer intervention, graded motor imagery, is being used to restore the affected limbs cortical representation to its typical state. Beyond pain reduction, the implications of this type of approach also include restoring sensorimotor function to the affected limb. Evidence supports that these interventions can impact CRPS symptoms as well as motor impairment but only after they've developed. To date, there is no literature exploring how these techniques, specifically graded motor imagery, can be applied to prevent or mitigate the aforementioned aftereffects of DRF in women. Methods: Design: Case Study; pre-post design. Participant: Right hand dominant 61-year-old female who sustained a right comminuted extra-articular DRF and ulnar styloid fracture (USF) after a FOOSH. In ER, participant underwent closed reduction and was placed in sugar-tong splint. One week later, participantwas evaluated by orthopaedics, placed in fiberglass cast, and referred to occupational therapy. Slight ulnar positive variance was noted by ortho at that time. Client was evaluated by OT within 1 week of casting. A preventative protocol including graded motor imagery was implemented by OT during cast immobilization phase. Her cast was removed 1-month post referral. Instruments: Pain subscale of the patient rated wrist evaluation (PRWE) and Veldman CRPS diagnostic criteria were primary outcomes. PRWE was administered by primary therapist upon initial evaluation and within 1 day of cast removal. Total, pain subscale and function subscale scores were calculated. Goniometry of the wrist and forearmwas also performed as a secondary measure at 10 weeks post injury so as to compare to those reported for persons with concomitant DRF and USF [Daneshvar et al. (2014)]. An adherence chart and interview were used to informally assess protocol feasibility and perceived benefits/limitations. Procedure: Participant was enrolled in a 4 week early-intervention protocol which included AROM to all non-immobilized joints of the affected extremity, elevation, and GMI during cast-immobilization phase. Client participated in four weekly 1 hour sessions where the focus was on assessing readiness for and instructing on the progression of GMI protocol, education, and home program review. Participant completed weekly adherence chart where she reported home program performance frequency, symptomology, and feedback on the experience. Home programwas performed for 15 minutes 3x/daily and the participant was provided with 50 custom-made wrist/hand/forearm specific GMI cards and a 12x12" mirror box for use during such (Figs. 1 and 2). Following cast removal, participant engaged in standard care occupational therapy services at a frequency of 1x/week. Results: Total, pain, and function PRWE scores improved by greater than its published MCID and MDC. Although baseline total and pain scores were similar to those reported in a descriptive study by MacDermid et al. (2003), participant's pain score at 6 weeks post injury (PRWE pain = 7) was greater than 1 SD below those reported by MacDermid et al [21.0 (11.0)] at 8 weeks. Total PRWE score at 6 weeks (Total = 45) was similar to average scores reported at 8 weeks [43.3(23.0)] by MacDermid et al and were approaching those reported at 12 weeks by Daneshvar et al. [38(no SD reported)]. Diagnostic criteria for CRPS were not met. Goniometric values at 10 weeks were consistent with those reported by Daneshvar at 12 weeks for wrist flexion, and extension however exceeded the mean pronation value by greater than 1 SD. At 10 weeks, the participant's supination score was less than 1 SD below that which is reported at 6 months. See table 1 for details. Participant reporting participating in 100% of all home program sessions and progressed through the GMI program at a rate of 1 phase/week. When asked to describe her experiences using GMI, the participant stated, "I felt like a had a sensation in the R arm, like it was tingling. When I moved the L hand while looking in the mirror I felt "sensations" in the R arm, like it wanted to move but it didn't. It felt relaxing too." No adverse events were reported. Conclusions: We present a novel protocol and case study to illustrate the potential benefits of this early intervention approach for women with DRF. Although dealing with a concomitant USF, this participant experienced clinically meaningful changes in wrist pain and function within a 4-week period of cast immobilization. Most notable was the participant's low PRWE pain score at 6 weeksrelative to published averages at 10. The participant's wrist and forearm supination AROM were consistent with average AROM measurements of those with DRF and USF at 12 weeks and 6 months respectively and her pronation AROM appeared to be greater than 1 SD above average at 12 weeks. Although we had expected better motor outcomes, these were likely impacted by the presence of the USF and reported positive ulnar variance. The protocol appeared to be manageable for this participant however, given the many limits to rigor associated with this study design, a larger sample is required to better understand the protocol's feasibility. Beyond the issue of sample size is the need for a comparison group to better study the intervention effects as well as the use of additional sensorimotor outcomes such as wrist joint position sense and grip strength. The addition of these outcomes will assist in better understanding if sensorimotor changes, in addition to pain and functional changes, exist following the implementation of this early intervention approach.