Graded Motor Imagery
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Transcript of Graded Motor Imagery
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
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