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The Graded Motor Imagery HandbookG. Lorimer MoseleyDavid S. ButlerTimothy B. BeamesThomas J. Giles

References

1/ Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial., Moseley, G.L., Pain 2004

2/ Is successful rehabilitation of complex regional pain syndrome due to sustained attention to the affected limb? A randomised clinical trial. Moseley, G.L., Pain 2005

3/ Graded motor imagery for pathologic pain: A randomized controlled trial. Moseley, G.L., Neurology 2006

4/ Does evidence support physiotherapy management of adult Complex Regional Pain Syndrome Type One? A systematic review. Daly, A. E., Biolocerkowski, A. E., European Journal of Pain, 2008.

“CONCLUSIONS: Graded motor imagery should be used to reduce pain in adult CRPS-1 patients. Further, the results of this review should be used to update the CRPS-1 clinical guidelines.”

Graded Motor Imagery

GMI is an individually tailored treatment process which has successfully been used for persistent and complex pain states 1,2,3,4. It aims to give flexibility and creativity back to the brain via graded exposure.

The Graded Motor Imagery Handbook, Moseley GL, Butler DS, Beames TB, Giles TJ. Noigroup Publications, Adelaide, Australia, 2012

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What is ‘normal’? Broad guidelines are:

• You don’t know you are mentally moving

• Premotor cells modify primary motor cells without activating them

• Less likely to activate the pain neurotag

Implicit Motor Imagery (left/right judgements)

ReferencesParsons LM., Integrating cognitive psychology, neurology and

neuroimaging. Acta Psychologica 2001;107:155-81.

Schwoebel J, Coslett HB, Bradt J, et al. Pain and the body schema: effects of pain severity on mental representations of movement. Neurology 2002;59:775-7.

Wallwork S, Butler DS, Darmawan I, et al., Motor Imagery of the neck. Age, gender, handedness and image rotation affect performance on a left/right neck rotation judgement task. Submitted 2012.

Bowering J, Butler DS, Fulton I, et al., Implicit motor imagery in people with a history of back pain, current back pain, both or neither. Submitted 2012.

• Aim for accuracy of 80% and above

• Similar results for left and right (no bias)

• Aim for response time (speed) of 1.6 seconds +/- 0.5 seconds for necks and backs

• Aim for response time (speed) of 2 seconds +/- 0.5 seconds for hands and feet

• Consistent over a period of at least a week

B - Acute left hand injury looking at left hand

Resp

onse time

Resp

onse time

Accuracy

Accuracy

L

L

L

L

R

R

R

R

Wrong choice, start again

Wrong choice, start again

X

X

Acu

te L

EFT

hand injury looking at RIGHT hand

Acu

te L

EFT

hand injury looking at LEFT hand

Chro

nic

LEFT

hand injury looking at RIGHT hand

Chro

nic

LEFT

hand injury looking at LEFT hand

Acute

Chronic

A - Acute left hand injury looking at right hand

C - Chronic left hand injury looking at right hand

D - Chronic left hand injury looking at left hand

A

B

C

D

Difficult decision, Safest to presume it’s LEFT hand because

my LEFT hand is injured choose

LEFT hand

Mentally move LEFT hand

Mentally move RIGHT

handCorrect!

Correct!

Mentally move LEFT hand

Difficult decision, Safest to presume

it’s LEFT hand because my LEFT

hand is injured choose LEFT hand

Difficult decision, Safest to presume it’s RIGHT hand

because my LEFT hand is in trouble

and I’m protecting it by not focusing on it

Mentally move RIGHT hand

Correct!

Difficult decision, Safest to presume it’s RIGHT hand

because my LEFT hand is in trouble

and I’m protecting it by not focusing on it

Correct!

Mentally move LEFT

hand

Mentally move RIGHT hand

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• Where do I practice explicit motor imagery? At home, work, school, on the bus, in the bath?

• Do I keep my eyes open or closed during motor imagery?

• What position do I adopt during imagery? Sitting, standing, lying?

• Do I think of myself moving (first person) or someone else moving (third person)?

• How long should I perform imagery for and how many times a day?

• What is the task complexity and intensity and how does it tie in with grading my exposure?

• What words should the therapist use to describe or talk through the process?

• What words should the user think of when going through the process?

• What cues can be used to heighten the process? Sounds, memories, smells?

• Should there be prior demonstration of the movement by another person (therapist, family member)?

• Do I use relaxation or meditation in conjunction?

• How much do I know about the changes in the brain that I can achieve with imagery?

Thinking about moving without actually moving – imagined movements.There are many different ways to go through the process and the most common method used in GMI is a first person perspective of feeling your own movement and postures. Graded activation of the brain through observation, imagining movements and actual movements.

Explicit Motor Imagery

ReferencesEhrson HH., et al,. Imagery of voluntary movement of fingers,

toes, and tongue activates corresponding body-part-specific motor representations. J Neurophysiol. 2003 Nov;90(5):3304-16.

Ideas board

Observing movement

Imagining movement

Performing movement

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Using a mirror boxIn this situation the problematic limb is hidden in the box. Looking at the mirror image of the left limb gives the illusion of seeing the hidden right limb.

Therapist as illusionistMirror therapy means looking into a mirror to see the reflection of the limb or body part in front of it. The mirror will effectively give the illusion that you are looking at the limb that is hidden. Brain activation during mirror therapy is less than actual movement but slightly more compared with imagining the same movement.

Mirror Therapy (1)

ReferencesDiers M., et al. Mirrored, imagined and executed

movements differentially activate sensorimotor cortex in amputees with and without phantom limb pain. Pain 2010

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Tips and examples of progression for using a mirror box

Mirror Therapy (2)

Keep the hand still/resting in a comfortable position Keep the hand still/resting in the same position as the hand in the box – just observe the reflection

INSIDE THE BOX OUTSIDE THE BOX

More sensitive

Rotate the handKeep the hand still/resting

Oppose each finger separatelyKeep the hand still/resting

Bend the wrist up and down through its full range of movementBend the wrist up and down within the limit of pain

Oppose the fingers and press with some force togetherOppose the fingers and gently touch together

Make a fist and squeeze in repetitionsMake a fist, pushing into some discomfort. Then repeat in time with the hand outside the box

Copy the hand in the box through a full range of movementRotate the hand and wrist fully

Copy the hand in the boxMove both hands fully and include some extra tasks, e.g., squeezing a ball or writing

Copy the hand in the boxInclude tools that are more threatening such as a knife

Less sensitive

Make a fist then slowly relax; repeatKeep the hand resting with a slight bend in the fingers

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A graded approach for treating pain It appears necessary that GMI is offered in a sequential manner. A strong grounding in the science underpinning GMI is essential for all users to be able to decide best when to move forwards, sideways or backwards through the treatment process.

The ideal sequential progression of the different elements of graded motor imagery:

GMI: a graded approach (1)

Left/right discrimination

Explicit motor imagery

Mirror therapy

Regain function

Watching movements

Is this a left or right

movement?

Imagining moving, touching

and feeling

Enriching my experience by using

a mirror, different moods, circumstances,

places

Am I standing on a balance beam, in tall grass or on the

beach?

Using mirrors I can trick my

brainHow do my

clothes feel on my skin?

Backs and necks are twisting – which way?

Is this a left or a right side?

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GMI: a graded approach (2)

Left/right judgements

Hands and feet

2 minutes every waking hour

Left/right judgements

Feet only

1 minute every waking hour

Watching

Sitting in a cafe watching the other diners

Increase 1 minute per day

~

Piano movies, sister typing, Indian dancing

5 minutes x 5 per day

Left/right judgements

Hands and feet

10 images / hour

Increase by 1 image every day

Explicit motor imagery

Hands and feet

10 images/hr

Increase by 1 image per day

Mirror therapy

Hands and feet

5 minutes/hour

Increase by 1 minute every day

0

1

2

3

4

5

6

7

8

9

10

0 - 2 weeks 3 - 4 weeks 5 - 11 weeks 12 - 14 weeks 15 - 17 weeks 18 - 20 weeks

Pain on movement

Resting pain

A case studyLucy Loo presented with marked CRPS affecting her arm, leg and face. We treated her with GMI for two minutes every waking hour for the first two weeks. Her pain worsened. You can see this by the slightly upward trajectory of the diamonds, which reflect pain on movement of her thumb, and the circles, which reflect pain at rest.

We then reduced her training and worked on GMI of the feet instead. Two weeks later – no worse but really no better. We then did some motor empathy – we asked her to watch movies of people playing on the piano, watching her sister’s hands as she typed at the computer, and to watch other movements. She clearly began to improve.

We progressed that, spending more time and watching more functional activities, for seven weeks. Then we tried GMI again and this time she responded.

It took another nine weeks to get through the GMI programme, but at 20 weeks after the initial appointment, Lucy started functional exposure. Six months later she had only a small amount of pain when she worked with her hands for half an hour or so.

The trick with her? We had to get under the radar by abandoning GMI and starting instead with motor and functional empathy.