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Graded Motor Imagery

working deep into the neuromatrix

David Butler University of South Australia NOI Australasia www.noigroup.com

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


An emerging evidence based sequence of strategies to manage known pathoanatomical brain based obstacles to rehabilitation.
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

Graded Motor Imagery (GMI)


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

Laterality reconstruction

Motor imagery

Mirror therapy

GMI targets?
CRPS 1 Phantom 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

Rehab 101. Task Progression break movement down


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


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

Some underpinning science

Two gifts from neuroscience


Mirror neurones Neuromatrix paradigm

Neuroscience Gift 1. Mirror neurones


Starting a pee? Sportspeople who excel? Learning guitar? Children learning? pornography Treated necks all day and gone home with neck pain?

Neuroscience 1 Mirror neurones


The legend of the discovery Zillions of them Fire to watching and imagining movement? Fire to nonvisual stimuli Emotional mirror neurones
Iacoboni,B.ande.al.(2005)."Graspingtheintentionsofotherswithone'sownmirrorsystem."PLosBiology 3:529535. Rizzolatti,G.,L.Fogassi,etal.(2006)."Mirrorsinthemind."ScientificAmerican 295:3037.

Neuroscience 1 Mirror neurones & the clinic


Dont 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 Gift 2. Neuromatrix paradigm

GMI reliant on the neuromatrix paradigm. It doesnt make sense without it.

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

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

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 perspective 5. 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 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. Enhanced in acute states 5. Evolutionary biology perspective 6. 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)

Laterality assessment/reconstruction

Recognise on line Flash cards zoo and who Other techniques

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 hjre?

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

Part 2 Motor Imagery


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

GMI Part 3 Mirror therapy

McCabe S et al 2003 Rheumatology 42:97 Moseley GL 2005 Pain 114:54

Practicalities the mirror box


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


Context change 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

What about the hand in the box?

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

How much, how many, how long?


2 weeks x 2hrs laterality, 2 weeks by 2hrs imagery 2 weeks x 2hrs mirrors (Moseley 2006). CRPS1 and phantom limb pain group.

Some dont have a laterality deficit Many progress faster Modalities can be mixed around 20% CRPS1 no shift

Some clinical anecdotes


The clinical reasoning, compliance, goal setting and support essential Laterality lost in dyslexia Cricketers have superb laterality, but injury may offset it Laterality deficits may be severe enough to use the foot for the hand and vice versa Mirrors used for all hand pains Mirrors for out of plaster stiffness GMI could be pre-emptive Mirrors may be a life time pain management tool for some

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

Research projects on line Get a trial version Share anecdote

Conclusions