Michael Sullivan, PT, MSPT Presents Physical Rehabilitation for CRPS at RSDSA Conference

Michael Sullivan of the Bay Area Pain and Wellness Center

Michael Sullivan, PT, MSPT is the Director of Rehabilitation Services at the Bay Area Pain and Wellness Center. Mr. Sullivan's lecture deals with one of the many issues that people with Complex Regional Pain Syndrome struggle with--that movement is painful, to the point where individuals with CRPS don't feel they have the choice to be active. The lecture also talks about neuroplasticity, graded motor imagery, mirror box therapy, and virtual reality. His guiding principle is that if you can do tomorrow what you did today, you are heading in the right direction.

Transcript

00:09
who's Michael Sullivan at first I met
00:12
Michael when we came out here to meet
00:14
with the staff of the Bay Area pain and
00:16
Wellness Center and I also had a
00:17
privilege of seeing him speak at the
00:19
American Academy of Integrative pain
00:23
management and Michael was just
00:25
extraordinary and he really talks about
00:27
a movement based brain plasticity and
00:31
and really helping people without pain
00:34
go through the physical and occupational
00:36
therapy and in what struck me so much it
00:40
was first time I heard him speak about I
00:42
don't move people I convinced them to
00:45
move and that for me was just was
00:49
epiphany and and I think that's so often
00:52
I hear that I say have you gone to good
00:54
therapists well been through therapy
00:55
well you really have to vet who is who's
00:58
going to treat you and who's gonna help
00:59
you try to get better so Michael
01:02
Sullivan is a doctor of physical therapy
01:05
he started working at part as a
01:07
interdisciplinary pain management team
01:09
in 1997 with a focus on helping people
01:12
with chronic pain in general and CRPS in
01:14
particular to live more active lives
01:17
he's director the functional restoration
01:19
program at the Bay Area pain and
01:20
Wellness Center and it's really a
01:22
pleasure to have him speak today thank
01:25
you my purpose in life is to change the
01:28
way that you think about your pain and
01:31
to help you to recognize that the
01:35
experiences that we've had in the past
01:37
the formative experiences that have
01:40
trained us and have taught us what pain
01:43
means are no longer always serving us
01:47
well because the way that our brains
01:49
change the neuroplasticity
01:51
that dr. debauchee was talking about
01:53
those types of changes can lead our
01:56
brain to give us incorrect information
02:00
it's our reality it governs what's
02:03
happening with our body but it's not
02:05
always serving us well and what we want
02:08
to do is we want to find ways that we
02:11
can change our pain experience and a big
02:14
part of that is that we need to be able
02:16
to redefine what does pain mean because
02:21
when we talk about pain
02:22
terms of harm it hurts we're essentially
02:26
equating pain wood tissue damage and
02:29
that's not what pain is pain is our
02:33
early warning system it's there to
02:35
protect us when the nervous system is
02:37
functioning properly pain protects us
02:41
when the nervous system is no longer
02:44
functioning properly as what happens
02:46
with CRPS our pain is no longer
02:49
protecting us it's giving us lots of bad
02:52
information so when we go into treatment
02:57
with our CRPS patients the foundation of
03:01
everything we do what comes first pain
03:05
neuroscience education is our key
03:08
because we're gonna be asking you to do
03:12
things that hurt and I want you to think
03:15
about we're gonna be asking you to do
03:17
things that are painful but not harmful
03:20
we want to rephrase the conversation but
03:23
everyone says but Michael that hurts
03:26
yeah I totally totally understand that
03:29
but we're not going to damage tissues
03:32
and we can fall back on our common sense
03:36
oftentimes and go when I touch my hand
03:39
like this it burns but you look at your
03:42
hand and you know that there's nothing
03:44
burning your hand your brain doesn't
03:46
know that as far as your brain is
03:49
concerned you've activated a thermal
03:52
pathway that's sending information up
03:54
there that's saying something's burning
03:56
my hand something's burning my hand okay
03:59
and we know that it's not but it feels
04:02
exactly the same way so how do we move
04:05
how do we move past that and there's a
04:07
number of things that we do from the
04:10
treatment standpoint to help people work
04:13
through that but starting with our pain
04:17
neuroscience education number one pain
04:20
and tissue damage are not synonymous
04:23
okay number two we all have the ability
04:28
to modulate our pain level we can turn
04:31
the volume up or we can turn the volume
04:33
down a lot of the things that dr. Bai
04:36
she was talking about things that turn
04:38
the volume up on your pain level
04:40
catastrophic thinking stress okay even
04:45
more so with CRPS because with CRPS
04:48
patients the stress pain connection
04:51
actually gets stronger than it is than
04:54
it normally is such that stress has a
04:57
much greater response or a much greater
04:59
impact on your body okay so we want to
05:03
change the way that we respond to those
05:05
stresses as well which thankfully I work
05:09
as part of a bigger team and my team is
05:14
key for me because they do a lot of the
05:17
education of how do we calm down the
05:19
nervous system because when we develop
05:22
skills to calm down our nervous system
05:24
we change some of that hypersensitivity
05:27
that we experience okay
05:29
the other key for us is that you
05:32
understand first how does the normal
05:35
nervous system function okay and there's
05:37
a concept of people tend to think about
05:42
well yeah I've got this pain signal
05:45
coming up to my brain and in reality we
05:48
don't it's it's not pain until we
05:51
process it in our higher centers so
05:54
there can be an event down here that
05:58
activates a no susceptor and this
06:00
nociceptors that event gets changed into
06:04
an electrical signal which travels up a
06:06
nerve goes to my spinal cord my spinal
06:10
cord can do some processing and then
06:12
that signal gets sent up to my brain and
06:14
my brains got to decide how important is
06:18
this information or really the question
06:22
that's asking itself is how dangerous is
06:25
this and if your brain decides that what
06:28
you're experiencing is very dangerous it
06:30
dials up the pain and it's a survival
06:33
response people who don't sense pain
06:36
there's congenital disorders of people
06:39
who don't sense pain they don't live
06:41
very long because they ignore all of
06:44
this very important survival information
06:46
so one of the biggest challenge
06:49
is we've gone through life and what
06:52
we've learned is that pain helps me to
06:54
survive pain helps to keep me safe it's
06:58
telling me something's wrong I need to
07:00
avoid all those things if we didn't if
07:02
there were no negative consequences to
07:05
me putting my hand on a hot burner I
07:07
would never stop putting my hand on that
07:09
well no problem I'll just grab that pot
07:12
right off the stove right so our brain
07:15
teaches us things that we shouldn't do
07:17
if we want to stay safe and survive and
07:20
now what I'm saying is you need to
07:22
override all of that right so we're
07:25
talking about it a huge challenge okay
07:28
so information comes up there's no
07:31
susceptible to my brain and my brain
07:34
says how dangerous is this and it stands
07:37
all of all sorts of things in my brain
07:39
it past experiences if I ever felt
07:42
something like this before
07:43
and if I did what happened what were the
07:45
consequences okay cultural beliefs can
07:49
be important in how we process pain how
07:52
are we raised we're where our early
07:55
experiences with pain handled a certain
07:59
way or handled a different way little
08:01
kids running across the playground falls
08:03
down skins is neat mom goes running over
08:06
and goes oh poor baby you poor baby
08:08
are you okay and then the next time the
08:11
little kid goes running down the
08:12
playground skins his knee and looks up
08:14
oh there's mom right we get trained
08:20
subconsciously to respond to pain in
08:22
certain ways okay and we want to we want
08:25
to be aware that we have the ability to
08:29
change that we have the ability to
08:31
retrain our brain so that all of these
08:34
past experiences okay okay can be
08:38
reframed in a different way are we we're
08:42
not going to get it okay I'll just keep
08:44
going
08:44
so once we do that little search and our
08:49
brain decides how dangerous is this for
08:52
us then we're into the modulation phase
08:55
of how we manage her pain okay so yeah I
08:58
feel something like this every time I
09:00
run my my quads hurt
09:03
I get a little stitch in my gut not a
09:04
big deal we'll turn the volume down
09:07
we're not gonna pay attention to it it's
09:08
not providing any useful information so
09:12
we don't process it okay oh my god the
09:15
last time I felt that I couldn't stand
09:17
up straight or walk on my foot for like
09:19
six months
09:20
well turning the volume way up on your
09:23
pain okay this works really well with
09:28
acute pain and we talked about acute
09:31
pain as being adaptive pain our response
09:36
to acute pain is essential to our
09:38
survival okay with complex regional pain
09:43
syndromes we're talking about chronic
09:45
pain chronic pain is what we refer to as
09:48
maladaptive pain it's no longer serving
09:52
a purpose okay I use with my patients
09:56
the example of a car alarm my car alarm
09:58
goes off in the middle of the night I
10:00
jump out of bed and I run outside and I
10:02
look around and well the car is fine
10:04
it's still locked there's no one there I
10:06
go back to bed thirty minutes later my
10:08
car alarm goes off again I run outside
10:11
of look around nothing yeah turn it off
10:14
go back to bed thirty minutes later my
10:16
car alarm goes off again and I go oh I
10:19
tried outside I reset it eventually I
10:23
need to figure out that my car alarm
10:24
doesn't work it's not providing a useful
10:27
information and wouldn't it be nice if
10:29
we could just turn off the non useful
10:32
information that our brain is processing
10:35
but that's that's where our challenge
10:37
lives okay so there's been a lot of
10:42
studies in the last 10 to 12 years on
10:45
different ways to approach the physical
10:48
rehabilitation of a complex regional
10:51
pain syndrome so once you understand hey
10:53
this is how my normal nervous system
10:56
works then we want to talk in context of
10:59
your specific symptoms how does your
11:02
nerve how is your nervous system
11:04
functioning differently okay
11:06
some people have sympathetic changes not
11:10
everybody does which is why they don't
11:11
call it RSD anymore okay some people
11:15
some people don't
11:16
some people have warm dry red hands
11:20
some people have cold sweaty blue hands
11:23
okay because some people have not enough
11:26
sympathetic activity some people have
11:28
too much sympathetic activity okay
11:31
some people have allodynia dr. bocce
11:35
mentioned that pain with non painful
11:37
stimuli light touch shouldn't cause pain
11:40
the wind blowing on my ankle shouldn't
11:43
make my ankle burn what's happening
11:46
there our nervous system when it's
11:49
getting bombarded with no susceptable
11:52
this information about potential harm
11:56
nociceptors information isn't related to
11:59
just actual harm my nervous system gets
12:02
bombarded by that it starts to get
12:03
sensitized it gets sensitized at the
12:06
spinal cord level whereby the the
12:10
stimulus creates a response that's in
12:13
much greater intensity and lasts for a
12:17
longer duration than what we want it to
12:19
that's called central wind-up and then
12:22
it'll send messages back down to the
12:24
receptors of themselves and start to
12:26
change the receptor thresholds such that
12:29
things that shouldn't be painful have
12:32
the ability to activate that same system
12:34
because the thresholds are no longer
12:37
accurate okay and then this information
12:40
goes up and it bombards my brain and it
12:43
starts to create maladaptive changes in
12:46
my brain so when we talk about
12:48
neuroplasticity it can go both ways we
12:51
could get great growth in
12:52
interconnectivity or we can get
12:55
alterations that are negative to have
12:57
negative consequences for how we
12:59
function and what we focus on the most
13:02
with our physical rehabilitation is the
13:05
somatosensory cortex the somatosensory
13:08
cortex is a map in your brain that
13:10
receives all of this information and we
13:13
can see in functional magnetic resonance
13:15
imaging studies if I push a pin and your
13:18
finger a little spot will appear of
13:21
activity in that area of the map and the
13:23
brain where the finger is represented
13:25
after the brain gets bombarded would
13:28
nurse gnosis have
13:29
information for long periods of time the
13:32
somatosensory cortex starts to change it
13:34
starts to smudge is the word that they
13:37
use for it that area of representation
13:39
for the finger starts to get bigger and
13:41
now it's the hand and in some cases
13:44
because of the way the maps laid out
13:46
it's not just the hand but I start to
13:48
feel stuff in my face itches sensations
13:51
because they're next to each other on
13:53
the map that's one of the ways that our
13:55
pain can spread okay it also leads us to
13:59
lose find discrimination we're no longer
14:02
able to feel things in our hands
14:05
properly anymore I can't pick up a
14:07
marble it doesn't feel right okay
14:10
dr. bocce spoke a little bit about
14:13
changes in our body perception okay
14:16
when our somatosensory cortex gets
14:19
impaired and starts to have this process
14:22
going on it no longer provides us
14:25
accurate information about what state
14:28
our body is in and I'll have patients go
14:30
look how swollen my hands are when I
14:33
look at them I'm like wow they look fine
14:36
you know I don't I don't see these
14:37
falling that's not what their brains
14:39
telling them their brain is telling them
14:41
that my limb is heavy and swollen and we
14:44
do a little experiment where I say hold
14:46
your hand like this and what I want you
14:48
to do is touch as close as you can to it
14:51
without actually touching your skin and
14:54
people who have intact body maps intact
14:57
body schema will be just a hair away
15:00
from touching themselves and then our
15:02
CRPS patients will go
15:06
because as far as their limb their brain
15:09
is concerned that's how big their limb
15:11
is that it's giving inaccurate
15:14
information
15:14
there's series tons of great experiments
15:18
that have demonstrated we have the
15:20
ability to trick the brain into
15:22
believing things that aren't true and in
15:26
doing so we have the ability to induce
15:29
pain with non painful experiences we can
15:33
make it worse or we can make it better
15:35
based on how we process that information
15:37
so we know tricking the brain is
15:40
something that's possible okay so what
15:43
are we gonna do for treatment we want to
15:46
trick the brain in a good way okay we
15:49
want to stimulate that somatosensory
15:52
cortex in a way that helps us to
15:55
function better so all of my information
15:58
about how I move my premotor cortex
16:01
which plans movement for me gets
16:04
feedback from my somatosensory cortex it
16:07
gives me information about the state of
16:09
my body what position am i in I don't
16:12
need to look at my arms to know they're
16:13
straight out at my sides okay my brain
16:16
gets that information if I got CRPS nope
16:19
not anymore okay that can be can become
16:22
affected which then means my movement
16:24
plan is no longer accurate my brain
16:27
thinks I've got a heavy limb and doesn't
16:29
know what position my joint is in my
16:31
somatosensory cortex gets separated
16:35
there's a incongruence between the way
16:39
my body is the way my brain thinks my
16:42
body is and then that affects my ability
16:44
to plan movement okay that could be
16:46
manifested as tremors when I try and do
16:49
things loss of motor control dystonia
16:53
all sorts of movement patterns can get
16:56
messed up through that process yeah so
16:59
we use a program called graded motor
17:02
imagery and this was started in 2000
17:07
well part of it was started in 2005 the
17:10
neural orthopaedic Institute
17:12
Lorrimer Moseley in particular was doing
17:15
most of the research at that time and he
17:17
was working with David Butler who's an
17:19
educator
17:20
and they put together a program of how
17:22
do we deal with these pain problems and
17:24
graded motor imagery it has three parts
17:26
to it
17:27
it starts off with what's called
17:29
left/right discrimination it's a
17:31
laterality task you look at pictures I
17:33
look at a picture of a left hand
17:35
I got identified as the left hand I look
17:37
at a picture of a right hand I have to
17:39
identify it as a picture of a right hand
17:40
I need to do this quickly and I need to
17:42
do it accurately and what we see is with
17:44
people who've got changes in that area
17:46
of their brain they can they're great
17:49
with the right hands are awful with the
17:51
left hands because their right hands at
17:52
the affected extremity they're great
17:54
with the left foot they're awful with
17:56
the right foot because they're their
17:58
right foot is their affected extremity
17:59
so changes in that area of the brain
18:03
start to create this incongruence and
18:07
when we retrain laterality that area the
18:11
brain starts to get healthier and
18:12
they've shown that the smudging in the
18:15
somatosensory map actually starts to
18:18
change okay in a in a positive way it
18:22
starts to revert back to normal and what
18:24
happens when that happens we have less
18:26
pain so extensive review of the
18:30
literature best way to the the best
18:34
technique for CRPS and pain reduction is
18:37
graded motor imagery okay so after the
18:42
laterality tasks we go into imagined
18:45
movements okay so there's a series of
18:48
images again you look at the image and
18:50
you imagine your hand being in that
18:53
position or you imagine your foot being
18:55
in that position and as part of that
18:57
exercise you're actually rotating
19:00
pictures in your brain which is almost
19:03
like rotating limbs in your brain and we
19:06
see just as much activity in the
19:09
premotor in the motor cortex as if you
19:12
were actually moving okay without the
19:16
negative consequences of moving which
19:18
for most people is increase pain I have
19:22
more pain when I move okay we want to
19:24
change that experience
19:26
so these imagined movements then go from
19:28
just stimulating the sensory areas to
19:32
stimulating the sensory
19:33
and motor areas and then our third one
19:36
is mirror therapy and mirror Thamar
19:40
therapy was actually started and I think
19:43
it's 1995 by Ramachandran and what they
19:49
were doing was working with amputees
19:51
working with stroke patients and it
19:54
involves putting your affected limb in a
19:56
box where you can't see it and the first
20:00
thing we do is we look at if this was my
20:03
affected limb and it's in the box I'm
20:05
looking at a mirror reflection of my
20:08
good limb and it looks normal and my
20:11
brain goes man my right hand looks good
20:14
because it can't see it okay that
20:17
without movement at all can help to
20:21
change that somatosensory cortex and
20:24
then when we add movement on top of it
20:27
and we always start with are there any
20:29
movements you can do that don't hurt
20:31
yeah I can I can do this but I can't do
20:36
this well we're not going to do this
20:39
okay we're gonna start with this and
20:41
you're gonna look at it and you're going
20:43
to see all this movement the this is a
20:47
sequential process laterality leads to
20:51
imagine movement leads to mirror therapy
20:53
but it doesn't always work that way for
20:56
everybody okay
20:58
we actually have lucrat see it's got a
21:00
table set up
21:01
in the back we have these tools if you
21:03
want to look at them we've got a mirror
21:05
box back there we've got some laterality
21:07
tasks they're not toys they can make
21:11
your pain worse
21:12
okay there's there's a lack of agreement
21:17
on how do we do if it were if it were
21:21
cookie cutter if it was following a
21:23
recipe everybody could do the same thing
21:26
and get better but as you know we
21:28
everybody's got different symptoms
21:30
everybody's got a different experience
21:33
and so the treatment needs to vary based
21:36
on what you need so some people will say
21:39
never let this hand move when that one
21:42
the hidden one isn't because in about
21:44
15% of the population
21:47
including people with healthy nervous
21:48
systems if I put them in the box and I
21:52
have them do this for five minutes their
21:54
hand will start to hurt a hand that
21:56
doesn't have any pain because I've now
21:59
I've now created an incongruent between
22:02
my movement system and my sensory system
22:04
because my brains not getting feedback
22:06
that my hands moving but my brains being
22:09
told that my hands moving and that in
22:11
congruence can create pain okay so there
22:14
isn't one right way to do it it's for
22:18
everybody a little bit different how do
22:20
we find a progression that's going to
22:22
help you okay
22:24
desensitization activities and kind of a
22:29
focus on textures can help to reduce
22:32
allodynia through decreasing the
22:36
hypersensitivity in those nerve endings
22:38
and those nociceptors and creating some
22:41
changes in the somatosensory cortex so
22:44
we start with like cotton but it burns
22:47
okay what do I do if it hurts well my
22:52
answer to that is if an hour after you
22:54
stop doing it your pain hasn't changed
22:57
then we did too much okay or if you
23:02
can't do tomorrow what we did today then
23:06
you did too much so what we want to
23:10
avoid is so this is a centralized pain
23:14
syndrome for everybody
23:15
there's centralized changes allodynia is
23:18
the hallmark of centralized pain
23:21
syndromes so that means we got changes
23:23
in the spinal cord in the brain with
23:25
these things we don't want to aggravate
23:29
that we don't want to get it wound up
23:32
because if we wind it up it runs longer
23:36
so what we want to do and what we
23:39
encourage people to do at home and it
23:41
doesn't fit really well with the
23:42
standard physical therapy model I want
23:45
you to do activities five minutes a day
23:47
eight to ten times a day I don't care
23:51
what the activity is I don't care if
23:53
you're doing laterality and then your
23:55
next five minutes is going to be mirror
23:56
box and your next five minutes is going
23:59
to be working on your range of motion
24:00
okay but in short spells we can retrain
24:05
our bodies okay so other other things
24:11
that we can do aerobic exercise is key
24:15
dr. Bochy talked about the glial cells
24:18
Oh
24:18
glial cells in particular micro grid
24:21
gulia are very important with the health
24:24
of our nervous system a little bit - the
24:26
good thing too much very bad thing
24:29
and with CRPS patients there's two
24:32
common genetic markers that we see that
24:35
lead to huge amounts of glial cell
24:38
active microglia activation that we
24:41
don't want okay the only thing in
24:43
physical therapy that we can do about
24:45
that aerobic exercise early animal
24:49
studies demonstrate that aerobic
24:51
exercise will down-regulate microglial
24:54
activity the doctors will tell you other
24:56
things there's other tools to do this
24:58
it's probably the forefront of new
25:01
therapies coming out how do we change
25:03
this microglial activity right now the
25:05
only thing I got for you aerobic
25:07
exercise if your disease is in your feet
25:10
you're going to exercise with your arms
25:11
if your diseases in your arms you're
25:13
gonna exercise with your feet okay
25:15
anything that gets your heart rate up
25:17
counts anything all right
25:20
so aerobic activity is good big
25:26
take-home message we're treating two
25:28
different things we're treating the
25:30
changes in your central nervous system
25:31
as a result of the disease and then we
25:35
need to treat the orthopedic problems
25:37
that are a result of your injury or a
25:40
result of the immobility as a result of
25:43
your disease okay if we ignore the
25:46
orthopedic problems what ends up
25:49
happening is as our disease process gets
25:51
better and we get in better control and
25:53
we're able to modulate it and I'm ready
25:55
to move again now I got a hand that
25:57
won't move anymore because I've got
25:59
worth Pedic restrictions
26:02
unfortunately most physical therapists
26:06
start with the orthopedic problems it
26:09
doesn't work you need to have some
26:11
success with tools to help to deke
26:14
crease your pain before we ask you to do
26:16
things that we know that are gonna
26:18
really hurt okay and that's where for us
26:21
the whole team comes into play is you're
26:25
learning how do I calm down my nervous
26:28
system how do I change the way I think
26:29
about my pain relaxation meditation
26:32
exercises yoga activities all of these
26:35
things play a role in this calming down
26:38
the nervous system because when our
26:39
nervous system quiets down we have less
26:41
discomfort okay but not moving is not an
26:45
option if we don't move our joints don't
26:49
get good joint lubrication okay
26:52
they don't which means they don't get
26:54
good nutrition and they can develop all
26:56
kinds of contractures whereby then when
26:59
we're able to move our joints are going
27:01
to be like nope not going to go there
27:02
our muscles get weaker which means
27:05
they're easier to overload which means
27:07
they're eat they're more likely to cause
27:09
pain and if we don't use them they can
27:11
get fibrotic and we can get permanent
27:14
changes in our muscles that oh that
27:16
muscles not going to link them anymore
27:17
okay so all kinds of changes the Spanish
27:23
Inquisition 700 years ago they got
27:26
really good at torturing each other
27:28
people did in the name of certain
27:31
beliefs okay one of the most powerful
27:36
forms of torture was to tie people up
27:39
into a position where they couldn't move
27:42
that was it that's all you had to do a
27:44
day later they wouldn't it to killing
27:46
their mother if she was sitting right
27:47
there in the room okay because not
27:49
moving is incredibly painful anyone
27:54
who's ever had a cast on or been
27:55
immobilized knows that you get pain in
27:59
joints that weren't injured and areas
28:01
that weren't injured as a result of
28:03
immobilization but when it everything
28:05
hurts we immobilize ourselves great for
28:09
an acute pain problem because it gives
28:11
our body time to heal really bad for a
28:15
chronic pain problem because it actually
28:17
leads to increased sensitization
28:20
increased pain and negative consequences
28:24
for all the tissues in our body so I
28:26
want to encourage you to
28:28
first find some things that help you to
28:30
manage well the grated motor imagery is
28:32
a great start look at the neural
28:34
orthopaedic Institute look at the rsd a
28:37
yes a website all kinds of great
28:40
resources on there Laura more Mosley's
28:42
done piece for them there's all sorts of
28:45
good stuff on their doctoral bocce's
28:47
book is great you can buy a graded motor
28:51
imagery book but be careful find
28:54
somebody with it so the next time you're
28:56
getting ready to do physical therapy ask
28:58
them hey are you familiar with graded
29:01
motor imagery if they say yeah you're
29:03
probably in a good place right off the
29:05
bat because they're on top of what's
29:07
been going on okay sorry I didn't have
29:09
any pictures for you thank you for your
29:12
time yeah so Jim asked if if it's okay
29:25
to do mirror box therapy with bilateral
29:29
CRPS and I'm gonna probably jump through
29:36
the mirror box at you and say virtual
29:40
reality is going to be the way to go so
29:43
virtual reality is like mirror box on
29:46
steroids because you're watching your
29:49
hand reach out and do things that your
29:53
hand can't do and so instead of having
29:56
two affected limbs and not one to mirror
30:01
off of we've got a healthy limb and it
30:04
may actually be a representation of our
30:06
own healthy limb that we can look at and
30:09
use that to trick the brain and there's
30:12
actually someone here today who's got a
30:14
virtual reality platform and I think
30:18
it's I do think it's going to be a
30:19
future of a lot of the things that we do