David ButlerUniversity of South AustraliaNOI Australasiawww.noigroup.com

Graded Motor Imagery

“working deep into the neuromatrix”

Lecture Aims

Introduce the science and clinical applications of the graded motor imagery programme

An example of taking novel science, paradigms and technique into physiotherapy

Graded Motor Imagery (GMI) Definitions

Laterality : the ability to identify a body part as left or right, or a body part moving to the left or the right

Motor imagery: watching or imagining a body part in a certain position or motion

Mirror therapy: use of a mirror to present a reverse body part image to the brain

An emerging evidence based sequence of strategies to manage known pathoanatomical

brain based obstacles to rehabilitation.

Laterality reconstruction

Motor imagery

Mirror therapy

Graded Motor Imagery (GMI)

•The sequence is important •“graded” because of the sequence requirements and the need of graded exposure principles

GMI – targets?

CRPS 1Phantom limb pain

Research currently underway for CTS, OA, whiplash and face pain

If CRPS1 and phantoms can be helped??

Anecdotally, many chronic and some acute pain disorders may benefit from aspects of the programme

Moseley GL 2006 Neurology 67: 1-6, Daly A 2008 Eur J Pain doi:10.1016/j.ejpain.2008.05.003

• Do part of movement but no painful part

• Do part of movement with painful part

• Do more• Increase number• Increase strength• Add equipment

Rehab 101. Task Progression – break movement down

• Laterality reconstruction(premotor association areas)

• Watch static posture• Imagine static posture• Watch movement• Imagine movement

(Mirror neurone complexes)• Mirror

(“Smudged” brain areas)• Do part of movement but no painful part• Do part of movement with painful part• Do more• Increase number• Increase strength• Add equipment

Rehab 201……. Task Progression

Some underpinning science

Two gifts from neuroscience

•Mirror neurones•Neuromatrix paradigm

• Starting a pee?• Sportspeople who excel?• Learning guitar?• Children learning?• pornography• Treated necks all day and gone

home with neck pain?

Neuroscience Gift 1. Mirror neurones

• The legend of the discovery

• Zillions of them

• Fire to watching and imagining movement?

• Fire to nonvisual stimuli

• Emotional mirror neurones

Neuroscience 1 Mirror neurones

Iacoboni, B. and e. al. (2005). "Grasping the intentions of others with one's own mirror system." PLos Biology 3: 529‐535.Rizzolatti, G., L. Fogassi, et al. (2006). "Mirrors in the mind." Scientific American 295: 30‐37.

• Don’t hang around with idiots

• Be carefull who you cross the road with

• “it hurts when I think of moving”

• Demonstrating exercise• Emotional burnout in pain

management• Manage workplace issues

early • An anatomical target of

GMI

Neuroscience 1 Mirror neurones & the clinic

• GMI reliant on the neuromatrix paradigm. It doesn’t make sense without it.

Neuroscience Gift 2. Neuromatrix paradigm

Some essentials of the neuromatrix paradigm

Neuromatrix = coding space

Neurosignature = representation= event space

Neurosignatures like pain love, anger are distributed and parallel.

•Key parts smudge or shrink

The brain activity which occurs when a particular person with chronic low back pain experiences pain during an attempt at an abdominal contraction

A pain neurosignature

GMI Part 1. Laterality

GMI Laterality – the practicalities

1.A critical premotor association signature

2.Known losses in CRPS1 and phantom limb pain. Anecdotally, lost in many ongoing pain states

3.Also altered in ongoing motor perturbations

4.Evolutionary biology perspective5.Laterality training known to involve

premotor, not motor areas(e.g Nico D et al 2004 Brain 127: 120; Moseley GL 2004 Neurology 62: 2186

Premotor influences

Optimal motor output

Optimal motor output

GMI Laterality – the practicalities

1.A critical premotor association signature2.Known losses in CRPS1 and phantom

limb pain. Anecdotally, lost in many ongoing pain states

3.Also altered in ongoing motor perturbations

4.Enhanced in acute states5.Evolutionary biology perspective6. fMRI studies show laterality training

known to involve premotor, not motor areas

(e.g Nico D et al 2004 Brain 127: 120; Moseley GL 2004 Neurology 62: 2186)

•Recognise on line

•Flash cards

•“zoo” and “who”

•Other techniques

Laterality assessment/reconstruction

Recognise online

www.noigroup.com

Recognise online

Left and right body parts are presented randomly in predetermined:

• numbers • time •Context (vanilla to context variable to abstract)•Image or movie

venstre eller højre?

Any body part can be used

Recognise online

tom@noigroup.com

Free trial version to play with

The “who and zoo” technique, adapted as necessary

Digital cameras are great

GMI Part 2 Motor Imagery

•Watching and imagining postures, movements and activities•Mirror neurons are targets•Imagery is not visual, more kinaesthetic

This part of GMI can also be graded:

•Watching to imagining•Static to moving to context enriched

• Watch another person’s body part in a certain posture• Consider what it might feel like to have a body part

in a certain position

• Watch another person move• Consider what it might feel like to have a body part

doing a certain movement

• Consider what it might be like to manipulate an object (or watch another person)

• Consider what it is like to move like a certain person

Part 2 Motor Imagery

Magazines, movies, on the bus, at work, home, clinic, recognise, flash cards etc.

McCabe S et al 2003 Rheumatology 42:97

Moseley GL 2005 Pain 114:54

GMI Part 3 Mirror therapy

• Box construction• Beer cartons• Good quality perspex

mirror• Collapsible to take home

Practicalities –the mirror box

• Prepare the patient• Sit “evenly”• No jewellery• Forget hand in the box

initially

Practicalities –the mirror box

Graded hand activity examples

– Looking at the hand – Turning hand up and down (elbow movement not hand movement)– Flattening out the hand– Flattening the hand and taking some weight thought it– Moving individual fingers– Finger thumb opposing– Tapping fingers– Add increasing muscle activity to each movement– Use tools (screwdriver, nailcutters, pen scissors etc. – make appropriate

to the left or right hand)– Introduce clinicians’ hand– Touch the face in the mirror

Practicalities –the mirror box

• Place (safe to feared places)• Emotion• Time of day• Try movements distracted (eg while balancing on a

chair)• Music (play a song in your brain) play an external song.• Sitting, standing, lying• Use metaphors (eg. Open hand to free a bird, play

spiders with the fingers on the mirror)• Add different smells and noises

Practicalities –the mirror box

Context change

• Some move it as well• Asynchyria• Move hand in the box as treatment for many handpains

What about the hand in the box?

2 weeks x 2hrs laterality, 2 weeks by 2hrs imagery 2 weeks x 2hrs mirrors (Moseley 2006).

CRPS1 and phantom limb pain group.

Some don’t have a laterality deficitMany progress fasterModalities can be mixed“around 20% CRPS1 no shift”

How much, how many, how long?

The clinical reasoning, compliance, goal setting and support essential

Laterality lost in dyslexiaCricketers have superb laterality, but

injury may offset itLaterality deficits may be severe enough

to use the foot for the hand and vice versa

Mirrors used for all hand painsMirrors for out of plaster stiffnessGMI could be pre-emptiveMirrors may be a life time pain

management tool for some

Some clinical anecdotes

Research projects on line

Get a trial version

Share anecdote

Please help in these embryonic therapies which show so much promise for neuropathic pain.

Conclusions