Topics

Manual Edema Mobilization (MEM) was first described in the late 1990’s as way of stimulating the lymphatic system to treat sub-acute or chronic edema found in the orthopedic population (Artzberger, 1997; Artzberger, 2000; Artzberger, 2002). Historically, many edema treatment techniques were developed with the rationale that the technique stimulated the venous and lymphatic systems, giving the impression that one technique would affect both systems equally. However, current literature now describes differences between how the venous and lymphatic systems remove excess fluid (Chikly, 2002), thereby lending credence to the fact that not all edema reduction techniques work for all types of edema.

Theoretical Foundation

Manual edema mobilization is built upon the same theoretical foundation as manual lymphatic therapies. These theoretical premises are highlighted below.

• Stimulation of the lymphatic system is necessary to decrease high-protein edema (Casley-Smith & Casley-Smith , 1988; Chikly, 2002).
• Plasma proteins that leak into the interstitium are too large to permeate the venous system (Chikly, 2002; Mortimer, 1998) and need to be disposed of through the lymphatic system (Villeco, 2002; Guyton, 2000), as the primary role of the lymphatic system is to dispose of matter that is too large for the venous system (Chikly, 2002; Mortimer, 1998; Villeco, 2002; Guyton, 2000).
• Following an injury...
  • The lymphatic system may be damaged or overloaded, which can hinder its ability to dispose of these larger plasma proteins (Chikly, 2002; Foldi, 1989).
  • If these plasma proteins remain in the interstitium, the colloid osmotic pressure, which is “the pressure to diffuse exerted by proteins and macromolecules” (Chikly, 2002), of the interstitial fluid increases (Guyton, 2000).
  • This increase in the interstitial colloid osmotic pressure subsequently draws more fluid into the interstitial spaces (Casley-Smith & Casley-Smith , 1988; Reed & Zarro, 1990; Reed, 1988; Leduc, 1989).
  • If these proteins remain in the interstitium, the edema will persist due to the pull of fluid into the interstitium (Foldi, 1989).
  • This prolonged stagnation of plasma proteins in the interstitium leads to chronic inflammation (Casely-Smith & Gaffney, 1981).

See diagram below.

MEM consists of four treatment concepts

1. Diaphragmatic breathing: All MEM sessions begin with deep, diaphragmatic breathing to empty the thoracic duct thus creating a vacuum (space) to move lymph from the periphery.
   • Why have patients perform diaphragmatic breathing?
     This concept is based on the premise that respiration changes tissue pressure (Kubik, 2003). Because changes in tissue pressure allows fluid to flow into the initial lymphatics by opening the interendothelial gaps (Kubik, 2003; Casley-Smith & Casley-Smith, 1997), there is speculation that diaphragmatic breathing influences the initial lymphatics.
2. Light skin-traction massage: A light skin traction massage is a massage to the skin that is so light that no blanching or indentation of the skin occurs yet it is firm enough to move the skin thereby preventing the hand from sliding on the skin. The light skin traction massage technique involves a light, rhythmical massage that follows lymphatic pathways so that fluid can flow through the lymphatic system.
   • Why massage?
     The light skin-traction massage influences the lymphatics on a superficial level. The initial lymphatics are small lymphatic channels that create a mesh-like network (Kubik, 2003; Casley-Smith & Casley-Smith, 1997) throughout the dermo-epidermal layer of the skin (Chikly, 2002). Attached to these small lymphatic channels are anchoring filaments, which connect these cells to the surrounding tissues. Between these cells are junctures known as interendothelial gaps (Chikly, 2002). As tissue pressure changes, the anchoring filaments assist in opening these interendothelial gaps (Chikly, 2002; Kubik, 2003) to allow for an adequate amount of fluid within the interstitial spaces to enter the lymphatic system (Zuther, 2005). Therefore, any mechanism that changes interstitial pressure ultimately stimulates lymphatic flow, and massage is one of those variables reported to change tissue pressure ( Casley-Smith & Casley-Smith, 1997; Xuijan, 1990).
   • Why keep the massage light?
     Because the initial lymphatics are considered “feather fine” fragile vessels (Chikly, 2002), firm pressure can collapse them. Therefore, the MEM massage technique is light, just enough to move the skin without blanching it.
3. Exercise: Active and/or passive exercise is an integral part of MEM. The MEM exercise routine normally begins with trunk exercises immediately after the diaphragmatic breathing. The active/passive exercises then move to the periphery and correlate with the area on the body recently massaged.
   • Why exercise?
     Similar to light massage, muscle contractions also influence tissue pressure, allowing fluid to flow into the initial lymphatic system by opening the interendothelial gaps. Additionally, after the fluid enters the initial lymphatics, it then travels through deeper lymphatic vessels, the collector lymphatics (Chikly, 2002; Kubik, 2003; Casley-Smith & Casley-Smith, 1997). At the level of the collector lymphatics, the lymphatic system has muscular units known as lymphangions. Simultaneous muscle activity has been found to stimulate the deeper layers of the lymphatic system (Casley-Smith & Casley-Smith, 1997) as the lymphangions have a higher rate of contraction or “pumping” during exercise (Zuther, 2005), and lymphatic flow can increase by 10—30 times through the lymphangions with exercise (Chikly, 2002; Weissleder H, Schuchhardt , 1997). Exercise then stimulates the superficial lymphatics by altering tissue pressure and stimulates the deeper lymphatics which aids in propelling the lymph through the deeper vessels (Kubik, 2003).
4. Pump point stimulation: Pump points are areas of concentrated lymphatic bundles or lymphatic nodes found throughout the body. Following the light skin-traction massage, simultaneous massaging of these pump points is performed as part of the MEM treatment routine. There is speculation that simultaneously massaging two pump points can create a proximal vacuum by creating a negative pressure gradient within the lymphatics, thereby draining the lymphatic system distally (Artzberger, 2002; Artzberger & Rodrick, 2002).
   • Why utilize pump points?
     Although the lymphatic literature does not address the use of pump points to decrease edema, partial support for pump point stimulation lies in the concept of pressure gradients. The circulatory system, which includes the lymphatic system, functions on pressure gradients; meaning that substances diffuse across cell membranes from areas of higher concentration to areas of lower concentration. This diffusion is known as Starling’s Forces or Starling’s Equilibrium (Chikly, 2002). The permeability of membranes and changes in hydrostatic and colloid osmotic pressure (either in the capillaries or the surrounding tissue) influence how fluids diffuse across the capillaries (Casley-Smith & Casley-Smith, 1997). It is known that the interendothelial gaps open when total tissue pressure is low and close when total tissue pressure is high (Casley-Smith & Casley-Smith, 1997). Therefore, it is plausible that creating a negative pressure gradient throughout the lymphatic system could entice fluids to flow from the tissues (the area with a higher pressure gradient) into the lymphatic system (the area with a lower pressure gradient). Through clinical observation, it has been noted that simultaneously massaging pump points reduces edema, although the exact mechanism for this clinical observation is yet to be determined.

Summary Statement

MEM is designed for the orthopedic patient. For example, the patient that sustained a distal radius fracture and has significant, persistent edema throughout the hand and wrist. Or, the patient that sustained a crushing injury to his/her hand. It is not designed for people with lymphedema.

The overall theory of lymphatic therapies, including MEM, is to remove plasma proteins from edematous areas by stimulating the lymphatic system, which subsequently enables these proteins to leave the interstitial spaces and enter the lymphatic structures. Manual edema mobilization is a new way to think about treating edema.

>>FOUND THIS TOPIC INTERESTING? FIND A COURSE HERE

References

1. Griffin J et al: Reduction of chronic posttraumatic hand edema: a comparison of high voltage pulsed current, intermittent pneumatic compression, and placebo treatments. Physical Therapy 1990; 70:279.
2. Miles W: Soft tissue trauma. Hand Clin 1986; 2:33-27.
3. Sorenson MK: The edematous hand. Phys Ther 1989; 69:1059-1065.
4. Chikly B: Silent Waves: Theory and practice of lymph drainage therapy, 2nd ed., Scottsdale AZ, International Health and Healing, 2002.
5. Artzberger S: Edema control: new perspectives. Phys Disabil Special Interest Section Quarterly March, 1997; 20: 1-4
6. Artzberger, S: Manual edema mobilization for the hand and arm. 2000; Symposium conducted through Hand Therapy Consulting Services, Portland, ME.
7. Casley-Smith JR, Casley-Smith JR: Modern treatment for lymphoedema, 5th ed, Adelaide, Australia, The Lymphoedema Association of Australia., 1997.
8. Artzberger S: Manual edema mobilization: treatment for edema in the subacute hand. In Mackin EJ et al,(eds): Rehabilitation of the hand and upper extremity, 5th ed, St. Louis, Mosby, 2002, pp 899-913.
9. Casley-Smith JR, Casley-Smith JR: The pathophysiology of lymphoedema and the action of benzo-pyrones in reducing it. Lymphology 1988; 21:190.
10. Villeco. J., Mackin, E et. al: Edema: Therapist’s management. In Mackin EJ et al,(eds):Rehabilitation of the hand and upper extremity, 5th ed, St. Louis, Mosby, 2002, pp 183-193.
11. Guyton A, Hall J: Textbook of medical physiology, 9th ed, Philadelphia, WB Saunders, 2000.
12. Reed B, Zarro, V: Inflammation and repair and the use of thermal agents. In Michlovitz S (ed.), Thermal agents in rehabilitation, 2nd ed., Philadelphia, F.A. Davis,1990, pp 3-17.
13. Reed. B: Effect of high voltage pulsed electrical stimulation on microvascular permeability to plasma proteins. Physical Therapy 1988; 68(4): 491-495.
14. Mortimer P: The pathophysiology of lymphedema. Cancer 1998; 83(Suppl. 1): 2798-2801
15. Foldi E et al: The lymphedema chaos: a lancet. Ann Plast Surg 1989; 22:505-515.
16. Leduc O et al: The physical treatment of upper limb edema. Cancer 1989; 15:83: 2835-2839.
17. Casley-Smith JR, Gaffney RM: Excess plasma proteins as a cause of chronic inflammation and lymphedema quantitative electron microscopy . J Pathol 1981;133:243-272.
18. Weissleder H, Schuchhardt C: Lymphedema diagnosis and therapy, 2nd ed. Bonn, Kagerer Kommunikation, 1997.
19. Kubik S: Anatomy of the lymphatic system. In Foldi M., Foldi E, Kubik, S (eds): Textbook of lymphology for physicians and lymphedema therapists, 1st. ed, Munich Germany; Elsevier, 2003, pp 2-164.
20. Huntley, N: Cardiac and pulmonary disease. In C. Trombly & M. Radomski (eds.), Occupational Therapy for Physical Dysfunction, 5th ed., Baltimore, MD:Lippincott, Williams, & Wilkens, 2002, pp. 1071-1089.
21. Matthews, M.: Cardiac and pulmonary diseases. In L. Pedretti & M. Early (eds):Occupational Therapy: Practice skills for physical dysfunction, 5th ed., St. Louis, MO, Mosby, 2001, pp. 966-980.
22. Zuther, J :Lymphedema management: the comprehensive guide for practitioners. New York, Thieme Medical, 2005.
23. Xujian, S.:Effect of massage and temperature on the permeability of initial lymphatics. Lymphology 1990; 23: 48-50.
24. Miller GE, Seale J: Lymphatic clearance during compressive loading. Lymphology 1981; 14:161-166.
25. Eliska O, Eliskova M: Are peripheral lymphatics damaged by high pressure manual massage? Lymphology 1995; 28:21: 21-30.
26. Zuther, J :Lymphedema management: the comprehensive guide for practitioners. New York, Thieme Medical, 2005.
27. Artzberger S, Rodrick J: Manual edema mobilization: A new concept in sub-acute hand edema reduction. The Israel Journal of Occupational Therapy 2002; 11(2), E37-E63.

The Joint Mobilizations for the Upper Extremity course taught by Karen Westervelt, MS, PGDipHSc, PT, OCS, ATC and Sonya Worth, PGDipHSc, OCS, PT is absolutely worth taking if you are interested in learning very specific joint mobilization techniques that you can immediately use on your patients. Karen and Sonya teach a dynamic lab based course that begins with a fresh approach of using your knowledge of physiological range of motion and joint end feels to learn the specifics of how to safely and effectively perform joint mobilizations for all the upper extremity joints.

They will cover topics such as accessory movement techniques to allow you to better assess how much motion is available at the joint and specifically which motions are painful and or restricted. Then they will teach you exactly how to do joint mobilizations for all the upper extremity joints. You will learn Maitland Grades of Movement to know how much force to use with your joint mobilizations and what effect this has on the tissues. You will also learn the Concave Convex Rule to allow you to know specifically what direction you need to apply your joint mobilization to be most effective. This course will enable you to make the most of your treatment time with patients knowing that you are applying your joint mobilization in the direction that will help your patient to gain range or reduce pain instead of just providing general joint motion in every direction.

Joint mobilization with movement

For those therapists interested in practicing Evidence Based Medicine you really will benefit from the final section of this course devoted to Joint Mobilizations with Active Movement. Did you know that according to the current literature it is more effective to treat “Tennis Elbow” or lateral epicondylalgia with joint mobilizations with movement and exercise than with cortisone injections or patient education? (Bisset L., Beller E., Jull G., Brooks P., Darnell R., and Vicenzino B). Click here to read more.

• Why?
  Joint mobilizations with active movement are believed to correct a 'positional fault' and therefore reduce a patient’s pain almost immediately. A 'positional fault' may be a new term to some therapists, but it simply is malalignment of the joint surfaces, more subtle than a joint subluxation. If the olecrenon is not in correct alignment in the olecrenon fossa than a joint mobilization can restore proper alignment and reduce pain. Once the pain is reduced active movement and strengthening can be initiated to strengthen the wrist extensor tendons. We are seeing patients tolerate strengthening much earlier in the rehabilitation program than when tennis elbow is treated without joint mobilizations.

The highlighted study by Bisset et al compared mobilizations with movement and exercise, corticosteroid injection, and wait-and-see for people with tennis elbow. Researchers concluded that people who received corticosteroid injections had short term pain relief but after 6 weeks had a high recurrence rate (47/65) and poorer outcomes in the long term. In contrast, people who were treated with mobilizations with movement and exercise had better pain relief than the wait-and-see group in the first 6 weeks but not the steroid injection group. However, after 6 weeks the mobilization with movement and exercise group had better pain relief, a more successful outcome, and sought less additional treatment then the corticosteroid injection group.

Summary statement

You will learn joint mobilization with active movement techniques, taping techniques, and home exercise programs for upper extremity conditions including: Tennis elbow, Golfers elbow (Medial epicondylalgia), glenohumeral impingement syndrome, status post Colles fractures and more. Overall this is a dynamic laboratory based course that anyone who practices in orthopedics will not want to miss!

>>FOUND THIS TOPIC INTERESTING? FIND A COURSE HERE

References

Adapted from the Mulligan Concepts Research List

• Abbott, JH. (2001). Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia. Manual Therapy, 6(3), 170-177.
• Abbott, JH. (2001). The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Manual Therapy, 6(3), 163-169.
• Abbott, JH. (1998). The effect of elbow mobilisation with movement on shoulder impairment and functional limitation: A case report. Journal of Manual and Manipulative Therapy, 6(4), 208.
• Backstrom, KM. (2002). Mobilization With Movement as an Adjunct Intervention in a Patient With Complicated De Quervain's Tenosynovitis: A Case Report. Journal of Orthopaedic and Sports Physical Therapy, 32(3), 86-94.
• Bisset L., Beller E., Jull G., Brooks P., Darnell R., and Vicenzino B. (2006) Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. British Medical Journal 333(4) 939-945 link.
• Carson, PA. (1999). The rehabilitation of a competitive swimmer with an asymmetrical breastsroke. Manual Therapy, 4(2), 100-106.
• Colloca CJ, Keller TS, Gunzberg R. Neuromechanical characterization of in vivo lumbar spinal manipulation. Part II. Neurophysiological response. J Manipulative Physiol Ther 2003; 26(9):579-91.
• Davies GJ, Ellenbecker TS. Focused exercise aids shoulder hyopmobility. J Biomech. 1999;6:77-81.
• Folk, B. (2001). Traumatic thumb injury management using mobilization with movement. Manual Therapy, 6(3), 178-182.
• Hsieh, CY. (2002). Mulligan's mobilization with movement for the thumb: a single case report using magnetic resonance imaging to evaluate the positional fault hypothesis. Manual Therapy, 7(1), 44-49.
• Kochar, M. (2002). Effectiveness of a specific physiotherapy regimen on patients with tennis elbow. Physiotherapy, 88(6), 333-341.
• Moulson A, Watson T. (2006). A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population. Manual Therapy 11(3), 214-224.
• Mulligan, BR. (2003). The painful dysfunctional shoulder. A new treatment approach using ‘Mobilisation with Movement’ The New Zealand Journal of Physiotherapy 31 (3) 140-142 link
• Paungmali, A. (2003). Hypoalgesic and Sympathoexcitatory effects of Mobilization with Movement for lateral epicondylalgia. Physical Therapy, 83(4), 374-383.
• Paungmali, A. (2004). Naloxone fails to antagonize initial hypoalgesic effect of a manual therapy treatment for lateral epicondylalgia. Journal of Manipulative and Physiological therapeutics, 27, 180-185.
• Slater, H. (2006) Effects of a Manual Therapy technique in experimental lateral epicondylalgia. Manual Therapy 11 (2) 107-117.
Teys P, Bissett L, Vicenzino B. The initial effects of a Mulligan’s mobilization with Movement technique on range of movement and pressure pain threshold in pain-limited shoulders. Manual Therapy 13 (2008) 37-42.
• Vermeulen HM, Rozing PM, Obermann WR, et al. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized control trial. Phys Ther. 2006;86:355-368.
• Vicenzino, B. (2001). Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia. Manual Therapy, 6(4), 205-212.
• Vicenzino, B. (1995). Effects of a novel manipulative physiotherapy technique on tennis elbow: a single case study. Manual Therapy, 1, 30-35.

Related books:

• Dutton M. Orthopaedic Examination, Evaluation, and Intervention second Edition McGraw-Hill Companies. 2008
• Hall, TM. (2003). A chronic case of mechanics elbow. In M. Jones & D. Rivett (Eds.), In Clinical reasoning for physical therapists: Churchill Livingstone.
• Kisner C, Cobly LA. Therapeutic Exercise 5th edition. FA Davis Company, Philadelphia. 2007.
• Maitland GD. Peripheral Manipulation 3rd Edition. Butterworth-Heinemann Ldt, 1991.
• Mulligan, BR. (1994). SNAGS: Mobilisations of the spine with active movement. In G. Grieve (Ed.), In Modern Manual Therapy (2nd ed., pp. 733-743). Edinburgh: Churchill Livingston.
• Mulligan, BR. (2003). Manual Therapy NAGS SNAGS MWMS etc. 5th Edition. Plane View services Ltd. New Zealand.
• Mulligan, BR. (2003). Self Treatments for Back, Neck and Limbs. Plane View Services Ltd. New Zealand.
• Mulligan BR. Manual Therapy NAGS, SNAGS, MWMS, etc. Firth Edition. Plane View Services Ltd, New Zealand. 2006.
• Reese NB and Bandy WD. Joint Range of Motion a Muscle Length Testing. WB Saunders Company. 2002.
• Wilson, E. (2002). The Mulligan Concept: NAGs, SNAGs, MWMs, etc. In L. Chaitow (Ed.), In Positional Release Techniques (2nd ed.). London: Churchill Livingstone.

An emerging rehabilitation approach for people with chronic pain, including those with CRPS, is the utilization of a graded motor imagery program (MIP) incorporating mirror visual feedback (MVF) as a technique to decrease pain (Berthelot, 2006). This graded motor imagery program has developed during the last decade (Moseley, 2004; Moseley, 2005), during which time researchers have identified..

• Changes in the cortex and cortical reorganization in people with chronic pain (Juottonen, Gockel, Silen, Hurri, Hari, & Forss, 2002; Maihofner, Handwerker, Neundorfer, & Birklein, 2003; Moseley, Zalucki, Birklein, Marinus, van Hilten, Luomajoki, 2008)
• A relationship between this observed cortical reorganization and pain intensity, (Maihofner, Handwerker, Neundorfer, & Birklein, 2003)
• A reversal in the cortical changes as pain reduces (Pleger, Tegenthoff, Ragert, Forster, Dinse, Schwenkreis, Nicolas, & Maier, 2005; Maihofner, Handwerker, H., Neundorfer, B., & Birklein, F, 2004).

Such discoveries have sparked an interest in addressing this cortical disorganization as a treatment approach for people with CRPS, with the thought that if normality is restored in the cortex, pain would decrease. Although this treatment technique is still in its infancy, evidence is mounting advocating its benefits (Daly & Bialocerkowski, 2009).

Graded Motor Imagery:
A comprehensive program that involves 3 steps:

Laterality Training:

Laterality training is the first step in a graded motor imagery program. Laterality training involves having the patient identify pictures of right and left hands in various positions (Moseley, 2004), in an attempt to reestablish left and right concepts in the brain.

The underlying premise for laterality training is that the ability to discriminate between right and left depends on an intact body schema (Moseley, Sim, Henry, Souvlis, 2005). It has been noted that patients with chronic CRPS take longer to identify right versus left, leading to speculation that body schema is affected in patients with CRPS (Schwoebel, Friedman, Duda, Coslett, 2001; Schwoebel, Coslett, Bradt, Friedman, Dileo, 2002).

Laterality training is designed to help patients identify right and left in an attempt to reinstate an accurate body schema.

Imagined Hand Movements

Imagined hand movements are performed through visualization. Imagined hand movements involve asking the patient to visualize moving his or her hand to match a picture (Moseley, 2005). Emphasis is on imagining that one is actually performing the movement (Moseley, 2006), but not actually doing the movement.

It has also been found that just thinking about movement can increase pain in people with chronic arm pain (Moseley, Zalucki, Birklein, Marinus, van Hilten, & Luomajoki, 2008). Therefore, the second step in the graded motor imagery program to have the patient work on visualizing normal, pain-free motion so that they are comfortable with the movement.

Mirror Visual Feedback:

Mirror visual feedback is the final step in MIP. Mirror visual feedback involves using a mirror box, which can be either purchased or created at home by placing a mirror on one side of a cardboard box. The patient is instructed to place the affected hand in the box so it is occluded from the visual field. The patient is instructed to perform movement patterns with both hands, keeping the affected hand concealed and watching the movement patterns with the unaffected hand in the mirror (Daly & Bialocerkowski, 2009; Moseley, Gallace, & Spence, 2008; Moseley, 2004).

What is seen is the ‘mirrored’ hand, and patients are typically instructed to perform normal, pain-free movements while looking in the mirror. Mirror visual feedback alone, without the motor imagery program, has been found to decrease pain in people with acute CRPS (McCabe, Haigh, Ring, Halligan, Wall, & Black, 2003). However, for people with long-standing CRPS, the entire graded motor imagery program is advocated.

Click here to see pictures of other mirror boxes

• http://www.reflexpainmanagement.com
• http://www.gradedmotorimagery.com/

Summary Statement

Graded motor imagery is designed to sequentially activate the cortical motor networks (Moseley, 2005), and there is speculation that it is the pattern of training that systematically activates the cortical systems in a pattern that allows for cortical reorganization to occur. According to Moseley (2005) “…it may be important to sequentially activate pre-motor and motor networks prior to reconciliation of sensory feedback and motor output via mirror movements” (p. 59). The graded motor imagery program is an attempt to improve cortical organization by stimulating and activating cortical pathways in an attempt to restore normality.

The exact mechanism as to why the graded motor imagery program decreases pain is not yet fully understood (Moseley, 2006). It is thought that the program ‘trains the brain,’ although this is speculation at this point in time (Moseley, 2006).

Several studies have examined MIP and MVF (McCabe, Haigh, Ring, Halligan, Wall, & Blake, 2003; Moseley, 2004; Moseley, 2005; Moseley, 2006) in people with CRPS and have yielded promising results and quality evidence (Daly & Bialocerkowski, 2009). However, much research is still needed to definitively state whether or not motor imagery and mirror visual feedback are effective in decreasing pain and improving normal movement patterns in those with chronic pain (Birklein & Maihofner, 2006; Moseley, Gallace, & Spence, 2008). This exciting and emerging area of research may produce innovative treatment techniques for this patient population.

>>FOUND THIS TOPIC INTERESTING? Want to host this course? Click here for information on how to host a course

References

1. Berthelot, J. Current management of reflex sympathetic dystrophy syndrome (complex regional pain syndrome type I). Joint Bone Spine 2006; 73, 495-499.
2. Moseley, G. Graded motor imagery is effective for long-standing complex regional pain syndrome: A randomised controlled trial. Pain 2004; 108, 192-198.
3. Moseley, G. Is successful rehabilitation of complex regional pain syndrome due to sustained attention to the affected limb? A randomised clinical trial. Pain 2005; 114, 54-61, p. 59.
4. Juottonen, K., Gockel, M., Silen, T., Hurri, H., Hari, R., Forss, N. Altered central sensorimotor processing in patients with complex regional pain syndrome. Pain 2002; 98, 315-323.
5. Maihofner, C., Hermann,O., Handwerker, H., Neundorfer, B., Birklein, F. Patterns of cortical reorganization in complex regional pain syndrome. Neurology 2003; 61, 1707-1715.
6. Moseley, G., Zalucki, N., Birklein, F., Marinus, J., van Hilten, J., Luomajoki, H. Thinking about movement hurts: The effect of motor imagery on pain and swelling in people with chronic arm pain. Arthritis & Rheumatism 2008; 59(5), 623-631.
7. Pleger, B., Tegenthoff, M., Ragert, P., Forster, A., Dinse, H., Schwenkreis, P., Nicolas, V., Maier, C. Sensorimotor returning in complex regional pain syndrome parallels pain reduction. Ann Neurol 2005; 57, 425-429.
8. Maihofner, C., Handwerker, H., Neundorfer, B., Birklein, F. Patterns of cortical reorganization in complex regional pain syndrome. Neurology 2004; 63, 693-701.
9. Daly, A., Bialocerkowski, A. Does evidence support physiotherapy management of adult complex regional pain syndrome type one? A systematic review. European Journal of Pain 2009; 13, 339-353.
10. Moseley, G., Sim, D., Henry, M., Souvlis, T. Experimental hand pain delays recognition of the contralateral hand – evidence that acute and chronic pain have opposite effects on information processing? Cognitive Brain Research 2005; 25, 188-194.
11. Schwoebel, J., Friedman, R., Duda, N., Coslett, H. B. Pain and the body schema: Evidence for peripheral effects on mental representation of movement. Brain 2001; 124, 2098-2104.
12. Schwoebel, J., Coslett, H. B., Bradt, J., Friedman, R., Dileo, C. Pain and the body schema: Effects of pain severity on mental representation of movement. Neurology 2002; 59, 775-777.
13. Moseley, G. Graded motor imagery for pathologic pain: A randomized controlled trial. Neurology 2006; 67, 2129-2134.
14. Moseley, G., Gallace, A., Spence, C. Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain 2008; 138, 7-10.
15. McCabe, C., Haigh, R., Ring, E., Hallian, P., Wall, P., Blake, D. A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology 2003; 42, 97-101.

The interactive on-line learning we offer provides a flexible venue to learn about concepts related to the field of hand therapy. The interactive on-line courses we offer are unique. There is active participation between the ‘live’ instructor and the participants, which creates a wonderful, engaging, and rich dialogue of various hand therapy concepts. The interactive on-line courses attract people with varied backgrounds and expertise from around the country, enabling participants to not only learn from the instructor, but learn from each other. Although the courses run for a set period of time (typically 4-weeks), there is flexibility within that time frame, so that people can participate at a time convenient for them.

Tips for successful on-line learning

Self-directed learning http://www.selfdirectedlearning.com/index.html

Self-directed learning is a critical attribute of professionals if one is to stay apprised of new material and offer the best products/practice patterns to their clients. Self-directed learning attributes are described as taking the initiative to learn, which may include identifying what needs to be learned, obtaining learning resources, and evaluating learning outcomes. These attributes are beneficial when participating in on-line learning, as a large part of on-line learning is taking the initiative to learn.

The following websites offer some self-exploration activities regarding self-directed learning. You may enjoy browsing these websites and exploring your strengths, weaknesses, and learning styles as they relate to self-directed and life-long learning.

Activities

A fun SDL website to explore:

• Self-Directed Learning - If you have time, try Activity 2 and Activity 4 on this website. These two activities are self-exploration activities.

Two interesting articles to read regarding SDL:

• Article 1
• Article 2
• If you have time, read some of the questions. Did any of your answers surprise you?

Other tips for on-line learning

• Take an active role as a team member and provide meaningful comments not something like "good job" or "I agree".
• Please use the conventions of online etiquette/netiquette.
• Please understand that the written text does not allow for body language and tone of voice. As such, make sure you are considerate in your postings and respectful of others.
• It will be helpful if you have up to date anti-virus software as a protection to your computer!
• If you have an emergency or other unforeseen event that will prevent you from posting, please let the speaker know as soon as possible.

What is needed for on-line learning

You need to have basic technology skills and access to an Internet connection to take the on-line course.

Basic computer skills include the ability to:

• Create and save documents;
• Manage and organize documents (files) and folders;
• Upload and download files;
• Send and receive email;
• Navigate to web sites using web addresses;
• Perform basic Web searches

Your computer should have the following:

• Windows 95, 98, 2000 or XP or MacOSX(10)
• 128 MB of RAM is highly recommended and is essential for using MS Office XP
• 1 Gigabyte of free disk space
• Internet Explorer - free download version 5.5 or higher or
• Netscape - free download version 4.78 or higher
• A 56K or faster modem
• Virus protection

Hardware and software required to use Blackboard, the online learning platform

• An e-mail account is required
• Go to: http://mail.yahoo.com for a free account

Interested in taking an interactive on-line course? Click here to find a course