Interview with Diane Jacobs - Part III

Part I is here.
Part II here.

Matthias:
"Gandevia and others have shown that by displacing skin - for example at the fingers - gives the patient the illusion that the finger has moved. The same thing happens when you vibrate tendons - depending on the context people think their limbs start moving. It seems from this line of research that our brain constructs a Virtual Reality Simulation of the body - a virtual body as it is often called. Do you think that the brain regards the virtual body being real and that problems in the real body (only) arise because of discrepancies between the virtual and the real body? What I mean by this is: the brain tries to adjust the real body so that it fits the virtual body?"

Diane:
That is a good testable treatment construct, I think. Butler has been thinking along these lines as well.

Matthias:
"What can patients do on their own to keep their virtual body flexible and healthy? What are some of the things you yourself do in everyday life to keep it fit?"

Diane:
Well, everyone knows that pain can arise when the real body gets impacted, jolted, injured as in a car accident, etc. Most people do not realize pain can arise through ordinary daily habits. I usually ask patients what their "default" positions are, the positions they adopt while being sedentary.

These positions often leave lasting impressions on the nervous system. For example, most people relax in the evening, sit with a leg crossed over the other. Many people always cross the same leg, have for years, never the other. Or they will pick a corner of the couch to watch TV from, and tuck their legs up to the side - always the same direction. Or lean on one elbow - always the same elbow.

I once treated a woman who had an enormous dint in the side of her leg from her other knee pressing in. You can learn to spot the sedentary habits from the impressions they leave on the actual body! But think what this must also do to their virtual bodies after awhile.

I make people aware of the need to observe themselves at home, become aware of their default positions, change them. I explain it simply - let them know that nerves need fed evenly from all sides or eventually they'll set up a distress call.

I don't teach "exercise" anymore, instead I teach sensory awareness, i.e., anything that will change sensory discriminative input into the neuromatrix. Change the relationship to gravity - lie down on the floor. Attend to breathing. Stay focused on the breathing and lengthen out an arm along the floor, see how it feels.

Do telescoping movements instead of stretching. Shorten and lengthen. Breathe. Feel what parts are trying to help and which ones feel as though they don't help, or resist. And don't worry about trying to make them do anything they can't seem to. Stop trying to override everything, just notice things, let them be, let them change by themselves, but keep checking on them periodically.

Do not cause more pain.
Practice moving without pain, practice what you can inside the comfort zone - there's lots to work on without trying to push the boundaries. Wait. Do small amounts frequently. Think of this work as feeding the nervous system.

Like a very young and cranky baby, it cannot absorb very much at a time. It needs your help and caregiving and attentiveness and feeding, but it needs small amounts frequently to turn itself around and thrive. A big "meal" once a day would be counterproductive, to say the least.

I use the example of learning to ride a bike - here's a complex motor skill that requires about three days to learn. All that's required is repeated exposure to the task, practice. Nothing is going to happen until that exposure has made its way all through every part it needs to go.
Patience and repeated exposure is all that is required.

Suddenly, on about day three or four, the task is accomplished - suddenly, the brain has figured out how to help your body achieve balance and coordination sufficient to ride a bike, and it's without effort. It's the same for learning to move without pain.

Matthias:
Diane – thank you very much for sharing these fascinating insights!

I hope more people will be inspired by your example.

Interview with Diane Jacobs - Part II

The first part of the interview is here.

Diane:

From that point on I became an ectodermalist. I deliberately gave up worrying about muscle function, joint alignment, posture, all that stuff. I became mainly interested in helping people downregulate pain, manually, but since then I've focused my efforts on learning all I can about that first layer that is contacted in manual therapy, about how it reads contact from another nervous system.

This has taken me into learning about the brain faster than anything ever did previously. I've read all I can lay hands on about pain, how the brain works, how it evolved, how it produces movement, pain, and perception as output, how it "feels" its environment, how it constructs strategies for its own survival and for that of its "organism". As fast as I can learn, more info is being produced. Is it possible to ever know enough?

I've learned about the cutis-subcutis layer, how it regulates homeostasis, about the importance of the cutaneous nervous system in this regard, how although it doesn't innervate "muscle" it is still "motor" in that it has autonomic efferent function as well as afferent sensory function.

I've done a dissection of the arm, to learn how the underlying cutaneous nerves (which run parallel to the skin) send off many mechanosensitive disseminating twigs that embed into skin from below, via tubular skin ligaments. I was allowed to photograph this work, about which I'm currently writing an article.

All this sensitivity built into skin is adaptive, and can be construed as the brain's own sensors, feelers, into the environment. Touch skin in a therapeutic context and it is as if you are touching someone's brain, on many levels. Knowing the levels and knowing how to help them downregulate themselves properly is the whole knowledge base that helps manual therapy make more sense.

I'm involved in a study to determine the effects of a completely nervous system based form of treatment, which I have called "dermoneuromodulation", on pain. It considers the cutaneous nervous system closely, tries to move it carefully according to the principles of neurodynamics.

I am still in the process of de-programming myself from all the mesodermalist learning I took on, but have made a lot of progress. Instead of viewing manual therapy as something I do "to" someone's body, I see it now as interaction "with" someone's nervous system.

Matthias:
"From what we heard so far - it seems that your approach could be described as helping people heal/help themselves - pointing their brain in the right direction. It seems to me that this dermoneuromodulation is different from other treatment methods because you emphasize downregulating much more than others which are more about adding strength here, increasing mobility there and so on and so forth. Your treatment is more about removing obstacles so that the brain/body can heal itself. Would you agree with this assessment?"

Diane:
I would agree with you in general, especially the part about obstacle removal. But I wouldn't say my treatment does this - when the brain is ready to change its output, it does. That's all.
The whole illusion that I, the therapist, create change in someone else's nervous system, is fantasy. I like to think of my work as pointing out possibilities to the patient's brain.

I feel like I just hold up a flashlight while the patient's brain gets busy fixing the "problem". :) I think my presence is necessary so the nervous system can get a good "read" or "fix" on some body part, but it does all the heavy lifting - my role is to feel the changes as they occur.

Matthias:
"It sounds to me that by using skin and it's cutaneous nerve system you are in a way talking directly with the patients brain - trying to establish “first contact” so to speak. What role does the patient play during this treatment process? What are your instructions to them? Should they try to move the part of their body that is being treated? Should they just observe?"

Diane:
The patient plays an observing role, but it's a lot bigger than it sounds: I ask them to let me know immediately if they experience any discomfort. Most people willingly take this task on - it not only gives them a tiny, manageable, focused task to do, it reminds them that they have charge of that all important "locus of control" - they become treatment manager/gate keeper, in a way.



Several other important objectives are met. They immediately realize they must be engaged in the process, mentally. They came in thinking it was I who would do all the work and they would just lay there, but now they realize it's about them focusing, breathing, staying in the process. All this from just one simple instruction - "I can't 'feel" your body the same way you can.

I want you to tell me if you experience any discomfort, because there is no point in reinforcing any pain pathways - that would be completely counterproductive - and besides, if you are experiencing discomfort it will be harder for you to relax and let your nervous system change itself."

Then I ask them to feel their breath go past their nose, on the way in, and on the way out. If I have a rapid or shallow breather to deal with, I ask them to breathe out for twice as long as they breathe in. That's about all.

It's like learning to meditate. The outward mechanics are rather simple, but a lot of processing goes on. I let them figure out how to do that themselves. Our connection is through the skin, and they've been instructed to tell me about any discomfort they might feel. Some people go for complete silence immediately. Others like to stay in more verbal contact.

I let them decide what level of engagement with the process they want - it's up to them, and I realize they need to establish rapport with me in their own time. As long as they can process something, dip in and out of the process even, it will be fine. Lots of people give me a running commentary of what they are sensing.

A useful metaphor is skin diving. Skin diving is the process. On one level it looks like I'm the one "doing" the skin diving, but in reality, I'm the one left on the boat managing the lines, staying alert to danger, and the patient is the one doing the dive, for the first time perhaps, diving right into their own processes, sometimes scary, sometimes wonderful, but it is they who have to do the "work", exploring, bringing up the sunken treasure - which turns out to be a fleeting realization that they can in fact move some part without pain, if they like.

They realize they have an option. It's a lot like mirror therapy I think. Instead of accessing a visual part of the cortex to convince the motor map that movement is possible, the kinesthetic sensing part of the cortex (or perhaps subcortical maps as well) are accessed somehow. And most patients will choose freedom to move over pain.

A space opens up, an opportunity to move without pain, and the patient accepts the possibility as their new reality. This decision-making is done well back of their "ordinary" decision-making capacities - it's quite automatic, although they get to be aware of it in the moment.

Certainly they are free to move in the moment if they would like, but usually I ask them to sit up periodically to move, see if they can move more easily. Most of the "movement" during treatment is palpable to me - it feels like physiology - little pulses start up then fade away, elongations occur, muscles twitch or feel as though they gently writhe,... small things that signal something rather large and non-conscious is happening below the surface.

Interview with Diane Jacobs - Part I

Some of you might already be familiar with Diane Jacobs from her blog Humanantigravitysuit or from the Teamblog Neurotonics where we share our views on certain topics.

I asked Diane a while ago if she would like to do an interview – and I’m happy to say she agreed.

She has over 35 years of hands-on experience, reads everything she can get her hands on and is a devoted student of the human body and it’s inner workings.

She has developed her own approach to treating pain and movement dysfunction – called Dermoneuromodulation.

By showing how she developed her style and treatment over the years I hope others will find some inspiration.

Here’s Part one:

Matthias:
Diane, glad you agreed to do this interview.

Please tell us how you came into the profession and what factors shaped your career:

Diane:

I entered PT school (a diploma program at U. of S.) in 1968, at age 17. I entered into the program hoping to be taught how to use my hands to help people rid themselves of pain. Three years later, I was a graduate with a license, and lots more growing to do. The hands were trained for a lot of things, but helping to relieve pain somehow had escaped inclusion in the curriculum.

The first decade out of school was mostly about growing up, learning to be independent. I worked in hospitals, took university classes frequently, figured my adult self out. I played by the rules and enjoyed life. I still wanted to learn to use my hands to help relieve pain, but hope was fading that I'd ever learn to do this within the profession of PT.

Around 1983 I went to a workshop taught by an osteopathic physician. There, I learned techniques for handling spinal dysfunction and other kinds of pain, muscle energy technique and positional release. I thought I was the luckiest person on the planet, bumping into this teacher.

Based on this single workshop, I pulled up my life in Saskatchewan, moved to BC, to be closer to the manual therapy school he taught at. For the next 20 years, on and off, I attended his school and became very good at using the techniques taught there. I began attending orthopaedic training workshops taught within the PT community, but dropped out, having lost interest - they were about learning to manipulate joints, and I was decidedly uninterested in pursuing that direction. The osteopathic techniques were more clinically interactive and very helpful to people.

By now I had my own practice, successfully treating all manner of patients with these gentle techniques. There was still something missing however - the treatment constructs were very biomechanical, and I was ready for more understanding.

Enter David Butler in 1998. He spoke a new fresh (to me) language - suddenly I was hearing all about physiology and brain and peripheral nerves. Peripheral nerves? They can "hurt"? This new layer of information and the emphasis on careful handling compared very favorably with the techniques I'd been using - I realized that all along, they had been "neurodynamically" friendly without the originators' ever having known the first thing about neurodynamics or any other concept about the physicality or structure or preferences or sensitivities of nerves in the body.

The techniques had simply been developed in concert with patients with treatment constructs tacked on after the fact, treatment constructs that didn't make any real sense because they were (archaic to me now) bio-mechanical, joint-based, structure-based (e.g., bones, fascia) - if they involved consideration of the nervous system at all it was a convoluted construct involving some sort of influence of treatment on muscle innervation, as if skin didn't exist at all.

Matthias:

Please explain why skin is so important in the approach you developed?:

Diane:

I realized no one seemed to care about skin. No one cared about the fact that all manual techniques are applied through skin. That the cutaneous system reads every kind of handling first. That the brain reads every kind of handling first. Practitioners only seem to care about what is underneath skin. This suddenly seemed ludicrous to me.

Then something else clunked into place, cognitively - a lot of detailed study of embryology. I remembered that skin came from ectoderm and so did the brain. At the manual therapy school all this embryology was taught, yet the techniques themselves were taught from a mesodermal or structural perspective, not from a nervous system perspective.

For me, cutaneous innervation became the transition; it is still structure, but helped me bridge the techniques I loved to do into a context that made much more sense as to why on earth they seemed so helpful. I realized they were brain-friendly - that when performed expertly, with attention in the moment to every detail in the moment, not in any zombie-like or mechanical fashion, but slowly, with feeling, they helped the brain down-regulate pain.

Matthias:

I hear you!

The focus – at least here in Germany – is still very much tissue based.
Neuroscience isn’t mainstream yet.
I want to point out to all the therapists out there who read this that they don’t have to give up their favorite techniques – just that they have to look at what they are doing based on the bigger picture.

If you are manually mobilizing a joint – you have to touch the patient – there is no other way to do it. This fact is sadly overlooked in most approaches.
By thinking in terms of altering nervous system input you can achieve miracles since the brain takes care of the rest.

Again: use what you have learned – but change your thinking about why you apply it and how!

Play As If Your Life Depends On It

That's the title of a book I bought recently. I haven't read it yet - but the title alone is worth it's weight in gold. ;-)

I don't know if there is a proper definition of play and playful out there - but here is mine:
"Play is the joyful exploration of oneself and one's surroundings/environment" (this also includes interaction with said environment).

I want to stress the joyful aspect of it here. If you are doing things because you love to do them - then that's one of the strongest and best motivators out there. And motivation means that the sky's the limit. ;-)
(Fear by the way is an equally strong motivator - unfortunately accompanied by a lot of detrimental side effects).

Why are babies and children able to learn so much so quickly?
Because they are motivated, hardwired to learn and have fun exploring everything around them.

If they are interested they focus intensely on one thing - and one thing only. They have no problem whatsoever trying hundreds (?) of different ways to interact with objects in their environment. They are exploring things from perspectives we - as adults - would never think about.

Who would voluntarily go inside a closet and pull the door closed behind them?
Who would sit under a table and declare it to be a cave?
Who would insist on wanting to lie in the trunk of the car on the way home? (I did once - and my wish was granted) ;-)

By not doing things like that - even simply lying on the floor reading a book for example - we forgo certain experiences. Our interaction with the environment becomes "dulled down" and repetitive.

Once you try a couple of new things you suddenly realize how "liberating" and refreshing they actually can be.

Give it a try - lie down on the floor and read a book down there. Or draw something - anything.
Compare that to your favorite spot on the couch or in your favorite chair and see how much more feedback the floor provides.

I'm not saying that this particular exercise is joyful - in most cases it even hurts a little because you are simply no longer accustomed to it.
But it's one of the best ways to get quick feedback from your body.

Now think of you going to the gym every week - doing the same exercises over and over again.
Not really inspiring isn't it?

Try to adopt a playful attitude here too: do the exercises differently - with your eyes closed for example. You'd be surprised how different things can become when you change them even a little bit.

There are restaurants now that have no lights. The staff are blind and the food is served - and eaten - in total darkness.

Since taste is integrated with our sense of vision the food tastes completely different.
Shake things up to keep them interesting and fresh. Brains like novelty!

As for chronic pain: in order to re-wire the brain you need attention and motivation. Those two ingredients are the best recipe for quick changes.

So find movements that you like, ways to do things that you like - set the mood - and go play!

Mirror Box Therapy - Part VII

F.A.Q.

This section tries to cover any question you might have and should serve as an additional resource so that the experiences people have with this kind of therapy can be recorded and shared.

1) Are there any known side effects?

None have been reported yet.
Things that can happen - depending on the condition are:
Lorimer Moseley reported a patient that was so distressed seeing the amputated limb move again that he had to withdraw from treatment.
Another interesting phenomenon is Dysynchiria - if you touch the unaffected limb and watch the reflection pain is felt in the affected limb.

2) How long should the sessions last?

Since you have to focus your attention on the treatment 10 minutes at a time are sufficient. Try to repeat it several times a day for a few weeks.
There are huge differences between individuals regarding how fast they respond.

3) Are there commercial suppliers of mirror boxes?

Yes - you can order them here and here for example.
Or you can make your own by following these instructions.

4) What do I do during the session?

If you have pain in your arms, hands or fingers try moving them in any way possible. Pick things up, count coins, do whatever you can. Vary the movements from simple to complex. And above all: watch what works best for you.
Jeiseas Blog is a great resource - see how she uses it. What works for her might also be good for you.

5) Which therapist should I see for mirror box treatment?

This is a tough one.
The treatment was developed by a Neurologist and is used (and expanded) by Physiotherapists, MD's, Psychologists and other professions.
In effect the treatment belongs to you - the person in pain.
Any attempt to bring it under the domain of only one profession is - in my view - completely nuts!
By explaining it in this series I hope you are able to give it a try yourself.

6) Which conditions can be treated?

First the obvious ones: phantom limb pain, CRPS, RSI.
Then the not so obvious one: central pain in paraplegia.
And last but not least those problems that can be treated by applying the principles of feedback therapy: low back pain, tinnitus, anorexia (?!), fibromyalgia.

Mirror Box Therapy - Part VI

or: Outlook - Possibilities - Thoughts

OK - our brains are built to predict the future - let's see if I can help that along. ;-)

Blakeslee - in her excellent book - has reported that there are preliminary results that viewed the problem of Anorexia from a body map disorder point of view. What if people with anorexia "just" have a different body map - one that is much much thinner than their real bodies.

Easy: they feel extremely uncomfortable in their own bodies. I imagine it like your whole body being numb (think of the effect you feel after you visited your dentist - now only include your whole body).

The only way to make the felt image and the actual image fit is to starve yourself - in 20% of cases even to death. That's how strong this urge is.

The thing we have to recognize about emotions and the urges they produce is that they are strong motivators - they "make us do things". And only when we have satisfied whatever the emotion tells us does the urge go away. Viewing pain as an emotion like hunger and so on makes it much easier to grasp what's it all about.

My best guess is that eventually all body dismorphic disorders will be recognized to really be "body map" disorders and be treated accordingly.

(I know that pain is not a real emotion - it's much more than that. But some of the effects it has on us and on our behavior are very similar which makes it easier to talk about it.)

Another very frequent condition where feedback therapy shows good results is tinnitus.
Again - peripheral thinking (i.e. in terms of damaged structures) hasn't amounted to much progress being made.

Now - thanks to brain imaging we can see that tinnitus is the same as phantom limb pain only for our sense of hearing. The auditory cortex where sounds are mapped becomes disorganized - creating random noise. By re-training the auditory cortex - as Herta Flor and Colleagues have done - having the patient distinguish different frequencies and so on - the symptoms can be markedly reduced.

Another treatment that is able to alleviate such symptoms is TMS (transcranial magnetic stimulation) which shows even better results.
One clinic in Germany at Regensburg University is working with this technique. And on a sad side note - largely unnoticed by the medical establishment as yet.

Migraines - with aura - are yet another field where neuroscience has found an identifiable cause - quickly spreading cortical depression. And the easiest way to describe treatment I have to think of the term "re-booting". It seems that a few neurons go haywire - causing others to join in. By zapping those neurons - which are located in the visual cortex - you can stop the effect from spreading.

A handheld device is currently undergoing final tests and should be on the market soon.

As for other frequent conditions:
focal dystonias, writers cramp, jips in golfers, RSI, .... are all due to some form or other of the map areas becoming deformed, fused or altered in some unintended way. Treatment as I stated before has to re-establish normal maps, creating congruence between the VR program and the actual sensory information.

If you don't suffer from any of these conditions count yourself lucky.

Not only was treatment unavailable till now - since no real cause could be found sooner or later people were accused of the symptoms being all in their heads - which in a way they were - but as real physiological manifestations - not some unexplained "psychological" phenomenon.

Don't get me started on the harm that was done to these people by so-called medical professionals who are too lazy to pick up a book or medical journal once in a while and are too arrogant to question their own knowledge.

A much more common problem everyone has to deal with sooner or later is aging and it's accompanying aches and pains.
The best term for this combination is sensori-motor amnesia - which - as far as I can tell - comes from Thomas Hanna who built on the work of Feldenkrais.

What do "old" people have in common?
Their posture, their way of walking, their difficulty in looking over their shoulders (which makes driving a car dangerous), and so on and so forth.

Yet - with a little hands on treatment - they are able to regain a lot of their mobility within minutes.

How come?
Well - I see daily life as a constant struggle between adaptive and (cumulative) maladaptive learning.

Babies learn all day long. They learn a language or two or three, they learn social norms and customs by imitation, they learn how to move their bodies in thousands of different ways. After a while they become school children - and learning takes on more of a purely "mental" form - the memorization of knowledge. "Body learning", i.e. different types of movement aren't explored any more.

Now you might say that during the teenage years most people pick up a sport - and you'd be right. But it is one sport - with one specialized way of moving - and not a great variety of things.

After that you have a job - and if you are really unlucky it either involves sitting or doing the same repetitive tasks over and over again.

What happens when you either have to little movement (sitting) or too much small movements is that your body maps change. Add to that that the tissue becomes hypoxic and you have a recipe for disaster:
this body map change is accelerated by the presence of pain.

Now - before pain becomes "felt" there is already nociceptive information being sent to the brain which uses reflex responses to automatically adjust posture and such. Just watch people at the cinema - they are constantly shifting position to distribute the pressure from sitting over a wider area of the body.

Only when those mechanisms don't suffice to change the nociceptive input pain is produced.

These two examples give you an idea about what aging is:
it is the slow accumulation of changes in our body maps with the effect that we un-learn how to move bit by bit. This process is accelerated/aided by sub-conscious pain and automatic reflex responses (reflexes are stereotypical - that's why old people "all" have the same posture).

It's not because our bodies can't move freely anymore - the brain simply has forgotten how to send the appropriate motor commands.

The solution: life-long body learning. Feldenkrais, Somatics, Yoga, .... - all build on this.

It's a bit more difficult to incorporate this into daily life - but things like the Nike Free are a good way to start.

Those shoes really do help your feet to become alive again.

What are you waiting for?
Go do something now or I will send them after you: ;-)

Mirror Box Therapy - Part V

or: Resources

I love the Internet - plain and simple.
All my life I knew there was something missing - till broadband came along and changed everything. ;-)

This collection of links is an ongoing project - feel free to suggest additional links, blogs, websites, ... in the comments or by email to matthias.weinberger(at)gmail.com

Medical Databases and Search Engines:
- PubMed
- HubMed - a much better interface than PubMed
- Google Scholar

Recommended Journals:
- Pain
- Neuroscience Letters
- Experimental Brain Research
- Neurology
- Brain
- Journal of Applied Physiology
- Journal of Neurophysiology

Videos:
- YouTube
- SciVee

People:
- Ramachandran
- Herta Flor
- Lorimer Moseley
- Candy McCabe

Products:
- NOI
- Mirrorboxtherapy.com

Blogs:
- Diane Jacobs
- Neurotonics
- Howtocopewithpain - including a monthly pain blog carnival
- Psychology of Pain
- David Butler's blogs: one, two, three
- Michael Merzenich
- Deric Bownds`MindBlog
- BPS Research Digest
- MindHacks
- Mixing Memory
- The Frontal Cortex
- Healthskills
- Jeisea

Books:
- V.S. Ramachandran "Phantoms in the Brain"
- Sandra Blakeslee "The Body has a mind of it's own"
- Herta Flor "Psychobiologie des Schmerzes"
- David Butler, Lorimer Moseley "Explain Pain"
- Patrick Wall, Ronald Melzack "Textbook of Pain", "Pain"
- Alain Berthoz "The Brains Sense of Movement"
- Michael Gazzaniga "The Mind's Past"
- Jeffrey Schwartz "The Mind and the Brain"

Forums:
- NOI - the forum closed some time ago - but the archive is still there
- SomaSimple

Podcasts:
- Brain Science Podcast
- All in the Mind
- TED Talks

I thought about including a section about the most important scientific papers - but there simply are too many out there.
For those who want to dig into this stuff: start here.

Mirror Box Therapy - Part IV

Feedback.

That's what the treatment of chronic pain boils down to: you have to send feedback - be it visual, tactile, auditory, ... to the brain so it can update the VR model. Only if the model and the corresponding motor command generated by it and the information from the external sensors matches up will the pain stop - very rapidly as several studies have shown.

Now - the really great thing about any type of feedback therapy is that the corresponding map which was altered in a maladaptive way starts to get reorganized while doing the therapy. That's what the studies report: during the first few training sessions the pain diminishes very rapidly - but comes back after a short amount of time (15 minutes,...).

But after the 5th or 6th session most people are able to get more lasting pain relief - and after just 3 weeks of daily practice most people can stop doing mirror box therapy altogether because the pain doesn't return.

This is all due to the positive effects of brain plasticity: the brain is able to re-organize very very quickly - provided it has the right incentive to do so.

As yet there are no long terms studies out that show how people with phantom limb pain that were treated with mirror box therapy have done over the years - this method is simply to new. I expect the first big trials to show up in the next 5 years or so in the wake of the studies done now at Walter Reed Medical Hospital with Veterans of the Iraq War.
That should give us an even better picture about what causes the process of maladaption in the first place.

My best guess is that initial pain (a painful limb that hurts before amputation) is the single most important factor - the brain learns the pain.
That's why amputations done where the limb was anaesthesized first show much better outcomes than traumatic amputations.

If you look at the case of CRPS - and to some extent after a stroke - you see another interesting thing:
the immobilization phase you have to go through after breaking a bone or suffering from a stroke tells your brain that - despite it sending motor commands to your limb - there is no proprioceptive feedback from the sensors in that limb.
If you can't move your hand because it's in a cast it can't send enough feedback to the brain.

So gradually over the weeks the hand map is adjusted - resulting in a limb that actually can't be moved even after the cast is removed. The brain has un-learned that the hand can move a great deal. And since the VR simulation in our brains is the basis for our actual perceptions and thoughts and feelings and everything else a lot of people describe their afflicted hand as no longer belonging to them.

An even more extreme example with different causes is the so called Alien Hand syndrome in which people don't recognize the hand being theirs at all.

What happens with the hand during CRPS - the swelling, osteoporosis and all the other stuff is secondary to the changes in the brain!

By using a mirror to give the brain visual feedback of an intact, healthy and freely movable limb re-organizes the map and symptoms vanish very quickly.
There are some preliminary results that show that even in stroke - at least part of the paralysis that results is not "real" paralysis - but learned paralysis - the brain just thinks that one side can't move any longer.

And even if that only accounts for say 20% - every bit of function you are able to regain after a stroke is better than nothing.

What sets CRPS apart from other chronic pain syndromes is that in addition to the hand map becoming distorted is that people aren't able to distinguish between a picture of a left hand and a right hand. They loose the sense of laterality.

This could be due to the fact that the brain uses the representations of the hands in it's internal model to construct laterality in the first place.

This would amount to the loosing of one of the models of the physical world that was established during childhood. Imagine yourself loosing your sense of gravity - one could no longer throw things accurately because you wouldn't be able to plan a parabolic trajectory - you would think that things always just fly in straight lines.

The NOIgroup Institute has developed a set of cards and a computer program with which you can re-learn this basic first step called Recognize.

If CRPS is in full swing however and sort of movement might aggravate pain.
That's why in severe cases you have to wait a little before you can do visual feedback therapy (mirror box).

The treatment in these cases starts by doing imaginary movements.
Those activate the same brain areas as actual movements - after all the brain does the same while running the VR program - the only thing that's missing is the actual motor command which is actively inhibited.

That way you can train the neuronal/mental circuitry which later will be activated for real.

As for areas of the body that have no limb like features - like the back:
you could have the patient lie down and point a video camera at his back and show him the image on a monitor.

But - as a few clever scientists have found out long ago - visual and tactile feedback are treated as equal in the brain.
Here finally the hands of the therapist come into play. ;-)

By touching the skin over the area you want the patient to move you can facilitate the whole process.
Once he has established motor control over that area again he is instructed to activate the muscles in that area every day so that the brain receives proprioceptive information from that area on a constant basis.
I advise some variation of primate grooming for home use: back rubs, brushes, whatever is available.

Regardless of which type of condition you have or want to treat:
the basis is always to send feedback about a limb or another part of the body to the brain (the comparator).

Feedback in daily life is important: remember how hard you had to hit the keys on an old typewriter?



Today's keyboards - especially the new one's from Apple are awesome!
Touch screens however are tricky because they don't provide any feedback. If the manufacturers were clever they'd introduce a very slight vibration - that would do the trick.