Graded motor imagery

1. Implicit motor imagery (left/right judgement task)

Moseley (2004) Pain; 108: 192-8;

Moseley (2005) Pain 114;54-61

Moseley (2006) Neurology 67 2129-34

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Graded motor imagery, as it has been tested in clinical trials, involves three stages. The first stage involves practicing the left/right limb judgment task. For this, the patient sits in front of a computer which displays left and right hands in a variety of different positions. The patient responds to each according to whether they perceive the pictured hand as a left or right hand, by pressing one of two buttons.

Is this a left or a right hand?

One image is shown at a time

Software is online and via CD

“Recognise” www.noigroup.com

Objectives:

- Equal reaction times for left & right

- >80% accuracy

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These are examples of the sort of pictures that can be used. The recognise program has a range of pictures including pictures in which the hand is doing a functional task. I think that they are great, but we haven!t done any experiments on them and we didn!t use them in the clinical trials. In reality, we progress from this stage to stage 2 when patients reach performance targets, not in two weeks. Importantly, I am very confident that for patients to make gains, they have to practice very often. In the clinical trials we had compliance of about 75% for hourly

practice sessions (not while they sleep of course!) We enhanced it by sending SMS messages and emails, and phoning them and telling them they were champions.

Graded motor imagery

1. Implicit motor imagery (left/right judgement task)

2. Explicit motor imagery (imagined movements)

Moseley (2004) Pain; 108: 192-8;

Moseley (2005) Pain 114;54-61

Moseley (2006) Neurology 67 2129-34

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Stage 2 of the graded motor imagery also involves looking at pictures of hands on a computer monitor, but now the patient imagines adopting the position shown in the picture.

Imagined limb movements

One image is shown at a time

Software is online and via CD

“Recognise” www.noigroup.com

“Imagine adopting this posture with your

own hand and then returning it to where

it is. Imagine a pain-free, smooth

movement”.

Objectives:

- Little or no symptom provocation

- Task is easy or boring

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Again, I think it is critical that patients practice a little, alot!

Graded motor imagery

1. Implicit motor imagery (left/right judgement task)

2. Explicit motor imagery (imagined movements)

3. Mirror movements

Moseley (2004) Pain; 108: 192-8;

Moseley (2005) Pain 114;54-61

Moseley (2006) Neurology 67 2129-34

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This stage again involves a large amount of practice and pretty much follows the ideas described by McCabe et al in Bath. We use the Recognise photos and instruct patients to slowly move both hands into the posture shown. They look at their ‘good’ hand in the mirror while they do it.

Mirror movements

“Gently adopt the posture shown with

both hands, while watching the mirror

image of your good hand”.

Objectives:

-Little or no symptom provocation

-Movement is not dystonic

-Movement L & R similar in range and

speed

- Task is easy or boring

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Time (weeks)

Neuropathic pain scale

50

20

0 2 4 6 12 18 24

Rec

ogni

tion

Imag

ined

Mirr

or

MIP MIP

Moseley(2004) Pain; 108: 192-8;

Crossed over

Single

blind RCT

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These are the results of the first clinical trial. The citation is shown. All patients had chronic CRPS that began with a wrist fracture. A score of 40 on the neuropathic pain scale would equate to about 6-7 out of 10 on a 10 point NRS. Here, the measure refers to average pain over the last two days. The dark circles denote the group of CRPS patients who were randomly allocated to the MIP. The control group, who were under the usual care of a GP, showed a similar response when they were crossed over.

• CRPS of arm or leg• 18-75 years old• No other diagnoses• English-proficient• Presented to GP,

physiotherapy, Pain

management or

neurology

Single blind RCT

Moseley (2006) Neurology 67 2129-34

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This is the most recent clinical trial, which included CRPS patients regardless of duration or initiating event, and patients with phantom limb pain after either brachial plexus avulsion injury (the brachial plexus is ripped out of the spinal cord, most commonly in a motorcycle accident), or amputation.

Moseley (2006) Neurology 67 2129-34

Single

blind RCT

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This is the consort diagram - note that all but one (in the control group) completed the trial. Also note that 20% of the CRPS patients did not fulfill the diagnostic criteria for CRPS, set out by the IASP.

Moseley (2006) Neurology 67 2129-34

NNT to get a 50%

reduction in pain

Post-MIP = 3 (2-6)

6 months = 2 (1-5)

NNT to get a 4/10 point

increase in function

Post-MIP = 4 (2-11)

6 months = 3 (2-4)

Single

blind RCT

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The results of this clinical trial: a dodgy figure - sorry. The key information is in the box. NNT = number needed to treat, in this case to get a 50% reduction in pain, for one patient to get that response that they wouldn’t not get in the control group. Some important caveats here: 1. practice 2. practice 3. practice!