Here is a note from a NOI instructor:
Patients often have a way of knowing what they need, without realizing why. How often do they demonstrate a relieving position or observation?
Recently I received an email from a patient who I had just started seeing. She had presented with a diagnosis and symptoms of CRPS of the right foot following an ankle injury. Note the intriguing comments about using her left side to massage and stretch the right. I have some thoughts about what is going on, but would be intrigued to hear of similar findings and also what the scientists might think.
“I have a question I hope you don’t mind answering, as I’m not seeing you until next week. My foot is going great – I’ve walked an incredible amount this week and seeing gradual increased function all the time. I’m getting heaps of pain with all the use through and quite a lot of puffy swelling around my achilles in both feet, but especially the bad one. The pain is fine, but I want to know what you suggest for my ankles when this happens? It does seem to go away eventually, but worries me a lot as this problem has debilitated me in the past.
Also, I’ve discovered something new and interesting that I wanted to share. I’m pretty sure that doing massage / exercises / specific activities that involve my left side interacting with my right foot, have a more positive impact than having my right side only involved! For instance, if I massage my foot with my left hand, do sensation training or stretching exercises using my left hand rather than my right hand on my foot, I seem to get better results! Also, exercises that involve one side crossing over to the other, like twisting-type stretches or diagonal-cross sit-ups, seem to improve my general RH side coordination heaps! Very cool, and I bet there is a physiological explanation for it:)”
Have you ever encountered something like this?
What is the science behind this?
Thankyou to Brendon and your patient for sharing this most interesting story! Well the first thing that this brings to mind is the research that shows that when someone with hand CRPS crosses their arms over, the effected side (normally cooler) warms up and the healthy (warmer) side cools down (see Moseley et al. 2008 below). This suggest 1. that some of the symptoms associated with CRPS are mediated by the central nervous system and 2. that these central nervous system processes relate not to the hand but ‘the space/side in which the hand normally resides’. Further research has shown that deficits in tactile processing also relates to the space in which the hands are in rather than the hand itself (see Moseley et al. 2009 below). Thus is is likely that some of the other symptoms described here are also ‘space based’.
My best hypothesis for now is this: That perhaps by association with the healthy side (i.e. bringing the ‘healthy space’ into the ‘disrupted space’), the disrupted side is once again represented in the brain as healthy thereby resulting in a healthier foot.
Do you know whether the client massaged their foot by bringing the right foot onto the ‘left space’ of the body or by taking the left arm into the ‘right space’?
I would certainly welcome other ideas or additions. Many thanks.
Moseley, GL., Gallace, A., Spence, C., (2009) ‘Space-based, but not arm-based, shift in tactile processing in complex regional pain syndrome and its relationship to cooling of the affected limb’, Brain.
Moseley GL., Olthof N., Venema A., Don S., Wijers M., Gallace A., et al. ‘Psychologically induced cooling of a specific body part caused by the illusory ownership of an artificial counterpart’ Proc Natl Acad Sci USA 2008a; 105: 13169–73.
PhD Candidate, BodyinMind research group
p.s. hope to see you all at UniSA’s ‘ride for pain’
and ‘Pain Adelaide’
Isn’t this similar to the concept used in therapeutic knitting? There is evidence that knitting (or any activity that involves crossing over the midline with the affected limb) will lead to improved proprioception, function, etc in chronic pain. This website might be useful: http://www.stitchlinks.com/research1.html.
Thanks for those comments, this is the direction that I was hoping for when including my patient’s experience. To give some further information regarding her spatial positioning, her experiences were most noticeable when the foot crossed midline to meet the hand, but was still significant in difference when the hand went to meet the foot when compared to the same sided hand.
This has me asking questions from two different perspectives
Is it by having contact with the opposite hand that this naturally results in the affected foot then being more towards or across midline so that it is more easily brought into contact with the other side, where maximal effect was noted. Is the effect of crossing midline actually about personal/body space of the other side, or is it also that there have not been the same experiences in this crossed midline position so there is then less disposition towards symptoms. By having less experience is it more receptive to new inputs?
Is it demonstrating that perhaps the representation of the opposite hand is more organized than the affected side hand, so therefore the information being fed into the brain about the foot is more reliable, clear, organized, less threatening and makes more sense, compared to the “blind leading the blind” when it is done by the same side.
Has the person effectively started to shut down input loops with regards to the affected side in an effort to minimize pain experiences, but contributing to further sensitization.
Going further, is this an example of true “laterality” bias towards the left hand dominance – is she naturally better organized, more efficient with this body part, and is information received from it usually given precedence or priority over other information.
In hindsight, as well as testing laterality recognition ability on recognize of the feet on initial assessment (of which there was a significant deficit), should I perhaps also have done this for the hands, would this show a recognition ability discrepancy, if so, where does this end, should we look at trunks, necks, etc?
Again, thanks for your comments,
Thanks, Brendon, for posting this. After reading it, I suggested that my niece, who has had CRPS for 6 months, try something like it. She crossed her affected foot over to the unaffected side, and then applied lotion to the affected foot with her unaffected hand. When she did, they noticed a significant improvement of skin color and temperature within only 2 minutes! In addition, however, she had the unpleasant surprise of her unaffected foot (which I assume had crossed the midline over to the affected side) starting to hurt.
Since she was starting to “fall off the wagon” with her gmi exercises, this served as a wake up call to illustrate that the brain had significant power over what is happening to cause her pain. I am hoping to use that to help her to dive into gmi, and for her family to support that.
Hi Carol – falling off the GMI wagon is a problem and we have had a number of calls for help in this area in the last week. I will start a “falling off the GMI wagon” thread soon, but in the meantime can we help you here?
David at NOI