Graded Motor Imagery is rehabilitation programme used to treat patients with altered nervous systems based on principles from the bio-psychosocial model and neuro-immune science. It is most commonly used for treating chronic conditions with neuropathic pain the main three conditions the research has focused on is stroke, phantom limb and CRPS. Ok, so it sounds complex and seems like a random thing for me to write about on my blog but this is where you are wrong.
Graded motor imagery is a 3 step programme that I used in my recovery from CRPS without the help and explanation this programme offered me I don’t know where I would be now. Honestly this was one of the key reasons I am now in remission and I truly believe in this course was one of the main reason why. I believe to the point where I went on their course and now can offer it to my own patients.
A Bio-psychosocial approach just means you are looking at the disease and injury as a whole, it has been proven that pain isn’t as simple as just you have damaged the area in question. It also is influenced by other aspects including what the area means to you, previous injuries, other people experiences of pain in the same area.
What is Graded Motor Imagery?
It is a three-step rehab programme:
- Left/Right discrimination
- Explicit motor imagery
- Mirror therapy
The ‘programme’ is not set in stone its more of a guideline and how long it takes to complete can completely vary on the individual Education is also central to this treatment with a big emphasis put on actually understanding pain and why you have it and using that as a basis in getting better. Knowledge is very powerful it has the ability to be de-threatening and give meaning to the situation that often stems from the question why me. Its important to understand that pain doesn’t have to correlate to the amount of tissue damage that has occurred it often has very little to do with it. Also, your pain is not in your head no matter what anyone says it is an output of threat from your brain if your brain thinks something is a threat no matter how small or irrational it is, it will cause you pain. Therefore more often than not it is ok and ‘safe’ to do activities that actually cause some pain as especially with neurological pain. Its more to do with the changes with how your nervous system is processing the pain rather than the physical anatomy of that area. Therefore you’re not actually damaging that area at all.
It may seem silly but research has shown that people in pain especially chronic so when you have had it for more than 12 weeks have difficulty identifying the difference between left and right body parts of the painful area. Often when you’re in pain you tend to disassociate yourself from it, ignore it try to pretend its not there. In my case it got pretty extreme to the point where I didn’t even count below my knee on my left side as part of me anymore. This may seem odd and crazy but I am not alone loss of laterality recognition has been found in other patients with CRPS and phantom limb in numerous studies including Nico et al 2004 and Schwoebel et al 2002. I mean the situation just seemed a bit ridiculous in my head, I was meant to be this fit healthy 18 year old girl who loved running and yet I was in so much pain I couldn’t walk or stay conscious, it didn’t seem like me at all!!
Thankfully the brain is very clever and can change these misconceptions that naturally build up when you’re in long-term pain. It can take a lot of work but your brain isn’t hardwired you can teach old dogs new tricks. It takes practice so this stage is about looking at pictures and without thinking too much identifying whether the body part is left or right you can do this with flashcards, online or on an app. Its actually quite fun and seems a bit of game. When I first did it took me twice as long to notice my left side and I made more mistakes in identifying the pictures as well. Generally in a normal person you should get 80% correct and it should take about 2 seconds to identify a left or right hand or foot and most importantly they should be equal between the two sides.
Explicit Motor Imagery
Explicit movement just means just thinking about movements like imagining going on your tiptoes for example. It is based on a similar principle to why athletes imagine their fight sequence, getting out the blocks at the start or scoring that slam-dunk. I know it seems a bit odd but when I would think about running again and actually imaging me doing it or even wearing heels it would cause me pain or start a tingling sensation in my foot.
So why does it hurt just to imagine well to imagine a movement? When you think of the movement even though you aren’t actually doing it you activate around 25% of the neurones (brain cells) involved in if you were actually going to do the exercise. It’s a way of exercising your brain and preparing you to do the movements even if you’re in too much pain to do them at that point in time. The neurones can be called ‘mirror neurones’ as imagining or watching the movements rather than doing the movement activates them. These neurones have been also been identified on functional MRI scans. (Gallese et al. 1996) The more detail you think about the movement or sensation the more beneficial it is. This includes not just the movement itself but what it feels like, emotions, sounds, smells and the sensations of the whole situation.
Each action has a ‘neurotag’ a network or pattern of neurones that when activate tell your brain a step-by-step guide to how to do that action works. In this section we are trying to activate the neurotag for the movement or situation enough to produce the experience of the movement without actually going through with it. The cortical activation that occurs in your brain when you think about a movement is actually very similar to when you actually do it. It can actually cause some minor activation in the muscles themselves even without causing any movement in the muscles.
Now this is the part of the programme that people may have heard about before, it’s the part that has received the most amount of press attention and has even been in programmes like House. Its mirror box therapy where you use the mirror to trick you brain into thinking the reflection of your ‘good’ side is actually your bad side. This means that the reflection you see seems like your ‘bad’ side is actually able to do movements that normally it wouldn’t be able to do or if it did would normally really hurt. However because your not actually moving the painful body part it doesn’t actually hurt, again its another way of activating the pathway enough to make a difference but not enough to cause any pain. Obviously because it is more interactive as you are seeing your body part move and getting feedback from that area of the brain.
When you do this part of the programme you want to make sure that you don’t have an jewellery on, or anything that will make you associate yourself with which side of the body it is. You want to be able to trick your body into believing that the reflection really is your painful limb. The idea is to trick the movement area of that of the brain enough to activate the area and believe it is actually moving but not enough to cause pain as your not actually doing the movement. Also you want to make sure that you are comfortable and that the movements are small and simple like opening and closing your hand. You want to keep the movements basic but relevant to what your goals are functionally, for example if you want to walk or run then pointing your toes up and down is a simple starting movement. You can develop it to the point where your painful limb also starts to join in with the movement seven though you cant see it, this is obviously dependant on your pain levels.
What is the evidence for Graded Motor Imagery?
So the NOI (neuro-orthopedic Institute) group that set this up, is run by some very smart people the main founder is Lorimer Moseley which might not mean much to most people but he one of the leading figures in pain science. The different stages are focused around treating central sensitisation which simply put, is when your brain gets very sensitive and goes into overdrive. When they are sensitised in this way it means that the neurone or brain cells can fire off prematurely and can get activated even if they shouldn’t be, like when someone fall starts in a race.
You start to feel pain and often extreme pain with less and less provocation to the point in extreme cases where you can get pain from things that shouldn’t hurtm like cotton wool touching the skin Ingraham (2016). This happened to me, I ended up having to sleep in a plaster cast as the touch of blankets caused too much pain for me to get to sleep. These changes occur in the central nervous system and how your brain and spinal cord process/reorganise the pain as well as the function of that part of your body. Neurologist have identified central sensitisation as one of the most dominant aspects of chronic pain and not surprisingly also one of the hardest things to treat. The symptoms of central sensitisation tend to get more severe as you have the condition for longer. Woolf (2010)
Therefore there has been extensive research hat has gone into each step of the programme as well as the process in general. Therefore it is important to do the steps in order, the time you spend on each one is dependant on the individual but Moseley, 2006 research shows the order is very important. However as I have said previous there has been a lot of evidence including from McLachlan et al, 2004 and McCabe et al, 2003 into mirror box therapy and research does show that just using that alone can be advantageous. The most beneficial results from GMI is for CRPS both types of the condition and phantom limb. (Moseley, 2005:Moseley, 2004). Honestly there is so much research into the beneficial results and how it can help different conditions. Some of the other pain conditions research has shown beneficial results for include: overuse and repetitive strain injuries, cumulative trauma disorders, osteoarthritis, lower back pain and other arthritic conditions.
GMI Tools Summary: http://www.noigroup.com/documents/noi_gmi_tools_information.pdf
McCabe CS, Haigh RC, Ring EFR, et al. A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology (Oxford) 2003;42:97-101.