Graded Motor Imagery

Lorimer Moseley is the lead author of the textbook Graded Motor Imagery (GMI). He began using imagery exercises with his physical therapy patients while he was working on his PhD, in the early 2000’s. He found that many of his patients improved with this form of treatment.

How is this possible?

There is a part of the brain called the primary motor cortex that is active when we move.  Activity in this part of the brain can also stimulate the pain process associated with movement. It is also active when we imagine movements. So imagining movements can activate the primary motor cortex with a decreased chance of triggering pain .

Unfortunately, Dr. Moseley found that many of his patients also experienced increased pain while imagining movements, therefore this method of treatment was unsuccessful for some. So here is another question… Why would imagining movements trigger pain? Remember the section on the memory of pain regarding neurotags and neurosignatures? Actual movement as well as imagined movement can trigger a pain neurotag thus increasing pain.

He later found that people experiencing pain can also have difficulty distinguishing the right and left side of the body at the subconscious level.  He realized that brain exercises can improve this deficit and was important to perform before imagining movements because practicing the ability to distinguish the right and left side stimulated the primary motor cortex without activating it.  Thus decreasing the pain neurotag.

Was that confusing??? Don’t Worry, all you need to know for now is that imagining movements and brain exercises involving left and right judgements can help improve the neurological components of neurosignatures or memories of pain. The third component of GMI utilizes mirror therapy to promote positive changes within the nervous system and will be discussed later.

Lorimer Moseley now leads a group of physical therapists and scientists in treating and researching pain.  Graded Motor Imagery has turned out to be a novel treatment component for general pain conditions as well as specific conditions such as phantom limb pain and complex regional pain syndrome (formerly called RSD).

To see if you may benefit from GMI, please answer the following questions:

1. Do you experience pain when you see someone move in a way you feel painful? For example, do you experience back pain if you see someone carry a heavy object?
2. Do you experience pain when you imagine yourself doing something is typically is painful?
3. Do you experience pain when you think about doing an activity?
4. Do you have difficulty distinguishing the right and left side?
5. Does your pain seem to be excessive or disproportionate to the level of your activity?

If you answered “yes” to any of the questions above, GMI may be worth a try. Even if you answered “no” to the questions you should still give GMI a try! If you are experiencing chronic pain, you will never know if you would benefit if you didn’t give it a chance.

Here is the LINK to the graded motor imagery website to read more about it.

They offer a start up package for self-treatment to take control of your pain. The start up package (graded motor imagery pack) includes the following items and is offered at 144.50 AUD (Australian Dollars). The GMI pack can be found HERE and includes the following items:

1 x Graded Motor Imagery Handbook
1 x 2 month RecogniseTM subscription – to perform left and right brain exercises online. Your performance is graded and can be sent to your clinician if they have a membership.
1 x NOI Mirror Box (perspex mirror)
1 x RecogniseTM Flash Cards for hands (the package comes with flash cards for the hands but you can request any body part) You would use these cards to practice graded motor imagery exercises at your leisure

There are three steps involved with GMI. There are no rules written in stone and you can go forward and backwards to any step depending on your response.

Step 1: Left and Right Discrimination
Step 2: Explicit Motor Imagery
Step 3: Mirror Therapy

If you are not sure about spending the money, you can test yourself and progress brain exercises using a modified version of GMI  on your own with a few magazines.

Step 1:  Left and Right Discrimination

Grab a magazine that has a lot of people in it. If you have right arm pain, flip through the magazine as fast as you can and circle the right arm on each person. Remember to do this as fast as you can in order to stimulate the  automatic and subconscious part of right and left discrimination functionality in your brain.  If you do this activity slowly and give yourself time to think which is the right or left side, this exercise will not be helpful because you are using your cognitive (thinking) part of the brain rather than the automatic portion. In the GMI text book, it is stated that a goal would be to spend 1.8 to 2 seconds or less to distinguish the right or left side.

After you attempt to circle the right arm for a few pages, turn the magazine sideways to exercise your brain in a different vantage point. Then turn the magazine sideways again to give your brain an upside down perspective as your circle the right arm. Keep rotating the magazine after a few pages. After you have completed the magazine, look to see how many right arms and left arms you circled.

You should continue with this exercise if you had to think which is the right or left side, took time circling the correct side, or circled the incorrect side. You can also focus on the vantage point that was most difficult.

RecogniseTM is an online program that  will measure your accuracy and response time which can indicate when you can go to the next step. If you do not purchase the program, I would suggest that you go onto the next step if you feel your responses are quick and accurate.

Step 2: Part 1 Motor Imagery – Visualizing yourself move

It is time to try the next step of GMI after you are able to make right and left judgements very quickly and accurately. Let’s get starting by making a list of activities that will increase pain and place them in the following categories minimal, moderate, or severe with each activity.

For example, if you experience pain in the lower back region your list may be like this:

1. Activities that may increase pain to a minimal level: standing for 10 minutes, washing dishes, putting on shoes, walking to the bathroom
2. Activities that may increase pain to a moderate level: picking up light objects from the floor, doing laundry, lying on your stomach, grocery shopping
3. Activities that may increase pain to severe levels: picking up a heavy box, mowing the lawn, vacuuming, jumping, running, moving furniture

Let’s start from the activities that increase pain to a minimal level. Close your eyes and imagine yourself doing one of the activities in your list. Do not continue if you begin to experience pain. You can visualize any of the activities that you listed, but it might be a good idea to begin with activities that are not associated with severe pain to minimize protective mechanisms.

If you were injured at work, try visualizing work activities at home, then slowly grading your imagery into your work environment. You can do the same thing for injuries on the playing field. You can also physically go to the location of injury to  see if you have a different response to your imagery exercises.

You can imagine yourself as if you are doing it or as if you see yourself doing it, as if you were watching yourself on a video. Dr. Moseley states that either way is beneficial. So you can try both and perhaps you will find one method that is better than the other.

Step 2: Part 2 Motor Imagery –  Looking at pictures

If visualizing yourself move was not tolerable, you can try looking at pictures of activities that increase pain. You can also watch people move in ways that trigger your pain. Just be careful not to stimulate your protective mechanisms.

Step 3: Mirror Therapy

If you would like an introduction of mirror therapy by David Butler, one the leading pain researchers in the world, check out this video on YouTube here: https://www.youtube.com/watch?v=hMBA15Hu35M

This last step involved with GMI can be used for anyone who is experiencing pain. Keep in mind that if you have right hand pain, move it to a degree that does not increase pain. The left side will move through its full range of motion.  Just keep practicing to change your brain and nervous system. I have seen patients who had dramatic results in a short period of time and others had to keep working on it. Everyone is different and  responses to graded motor Imagery will be variable.

References:

Moseley GL. Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology. 2006 Dec 26;67(12):2129-34. Epub 2006 Nov 2. PubMed PMID: 17082465

Moseley, GL, Butler DS, Beames TB, Giles TJ. The Graded Motor Imagery Handbook. Adelaide, Australia: NOI group Publications; 2012

Schuster C, Hilfiker R, Amft O, Scheidhauer A, Andrews B, Butler J, Kischka U, Ettlin T. Best practice for motor imagery: a systematic literature review on motor imagery training elements in five different disciplines. BMC Med. 2011 Jun 17;9:75. doi: 10.1186/1741-7015-9-75. Review. PubMed PMID: 21682867; PubMed Central PMCID: PMC3141540.

Schwoebel J, Friedman R, Duda N, Coslett HB. Pain and the body schema: evidence for peripheral effects on mental representations of movement. Brain. 2001 Oct;124(Pt 10):2098-104. PubMed PMID: 11571225.

One comment

  1. How do I find a P. T. Who is trained in GMI? I have Crps, and they want me to jump right into mirror therapy. They don’t want to hear from their patient, I’m not ready for that.

    Like

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