Giving hope to pain sufferers without smoke and mirrors

CAROLINE Gill spends a lot of time looking in the mirror. She’s not checking whether her lipstick needs touching up or obsessing about whether new wrinkles have appeared since she last checked. In fact, she is not even focusing on how she looks.

Ms Gill is using the mirrors in a bid to control the excruciating pain she suffers as a result of complex regional pain syndrome (CRPS).

CRPS - formerly known as reflex sympathetic dystrophy - is a rare condition that causes debilitating pain.

It can arise after surgery, stroke, heart attack or bone fracture. It can also develop after a less serious insult such as a sprain, and cause pain disproportionate to the original injury.

The slightest brush against cloth, or even a drop of water on an affected area, can cause excruciating pain.

Early symptoms include severe burning pain, local swelling, temperature changes, mottling of the skin, muscle spasms and intolerance to heat or cold.

Why and how this illness develops is little understood, and it can go into spontaneous remission as unexpectedly as it began. However, for many patients, this is not the case, and it can devastate their lives.

Ms Gill, 43, is no stranger to pain. She has suffered from rheumatoid arthritis for 19 years and the disease affects much of her body including knees, hips, shoulders, elbows and jaw. She has undergone hip and knee replacements. It was after recent surgery on her hands and wrist that she began to suffer CRPS.

"I felt like a puppet whose strings had been pulled too tight," she says of the pain caused by CRPS, which she says is very different to the pain she suffers from arthritis.

Pain specialists have tried to help CRPS sufferers with pain-killers, nerve-block injections alongside physiotherapy, hydrotherapy, TENS machines, spinal-cord stimulators, morphine pumps or alternative therapies such as hyperbaric oxygen, acupuncture or reflexology. But for many, these therapies have little or no effect.

However, David Blake, a professor of rheumatology at the Royal National Hospital for Rheumatic Disease (RNHRD) in Bath, is achieving promising results in CRPS pain relief with his radical treatment - mirror therapy.

Prof Blake believes CRPS occurs when there is a mismatch between how the body sees itself and the sensations it actually experiences.

His mirror therapy is designed to trick the brain into thinking it is watching a limb which is affected by CRPS carrying out a movement which it is not in fact performing.

Prof Blake developed his theory after he read about mirror therapy being employed to treat phantom limb pain in amputees. A pain specialist at the University of California in San Diego suspected patients felt pain in their absent limb due to a disruption in the normal intention to move a limb and the absence of nerve feedback.

The American researcher thought that an image of the affected limb, moving as a normal limb, would provide a visual feedback which would interrupt the pain cycle, and used a mirror image to create this effect. A total of 50 per cent of patients who underwent trials with this therapy found it effective. The same researchers also found that mirror therapy was helpful in the rehabilitation of patients with paralysis following stroke.

It occurred to Prof Blake that the pain associated with CRPS might be caused by a similar mechanism and that it might be reversed by providing patients with visual feedback. He says: "We understand how pain is created when we hit ourselves with a hammer. The nervous system is disrupted, setting off alarm bells in the brain, which sends signals to the affected area, causing you to withdraw from the thing causing the pain. The question was: is it possible that pain can be generated from activity in the brain, when there is no injury?"

Prof Blake proposes this might happen when there is a mismatch between the intention to move the affected limb and the nerve feedback to the brain and draws an analogy with what happens in motion sickness. He said: "If you are on a boat, your eyes tell you the horizon is in one place, but the vestibular system which controls balance in the ear tells you that you are somewhere else. Your brain has two contradictory inputs telling you where you are in space which results in two reflexes, namely nausea and vomiting. We then wondered: if pain is a reflex, is it possible that not only just pain, but an inflammatory reaction created by the nerves themselves is a secondary reflex similar to vomiting?"

Ms Gill is one of the patients who has benefited from Blake’s mirror therapy. In her case, the therapy means she places the one-sided looking glass between her arms, so that her right arm is the reflected image. She focuses her gaze on the right arm, and its reflection. Her left arm remains out of sight.

She then performs a few minutes of basic exercises with her right arm.

She says: "I jumped at the chance of trying the mirror therapy; after all the surgery I have undergone, I was quite happy to try any therapy which didn’t involve something invasive.

"Initially when I tried it, I was doing the exercises three or four times a day for as long as I could. I have a very arthritic right shoulder so couldn’t last as long as ten minutes, so I tried to do several short bursts of a few minutes.

"What I have found is that pain relief is not instantaneous, but by the end of five minutes my fingers are connected into the exercise and gradually over time there has been increased movement in two out of the four fingers."

According to Sister Candy McCabe, a lecturer in rheumatology nursing who has carried out a study of mirror therapy, this is a disease frequently missed or misdiagnosed by GPs. She says: "The problem is that the severity of the pain experienced by patients is often disproportionate to the initial insult which started it off. Often patients are disbelieved by health practitioners who have never heard of CRPS. Early diagnosis is critical to prevent movement problems and the disease spreading to other parts of the body."

Prof Blake’s study, published last year in the journal Rheumatology, found that mirror therapy was helpful in patients with early or intermediate disease, but made no difference to patients who had long-standing disease. One problem is that patients with intractable CRPS find that trying to move the affected limb causes intolerable pain. A group in Queensland, Australia has tried to get round this by giving a group of chronic CRPS sufferers a series of pictures to look at on a screen of right and left hands. This was then followed by imagining adopting the positions of a random selection of pictures. and finally trying to adopt hand postures in the pictures using the mirror technique. The study, published in this month’s edition of the medical journal Pain, found that six weeks after starting this treatment, half of the patients no longer fulfilled the diagnostic criteria for CRPS.

The best endorsement is from the patients who have benefited. As Ms Gill says: "Mirror therapy has improved my quality of life - not just by improving the pain and increasing movement, but by giving me hope."