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Use of GRADED MOTOR IMAGERY

In Treating Complex PainAnne Huffington-Carroll, MPTLead Therapist, Orthopedic and Sports Teams

Providence NE Rehabilitation

Rehab Persistent Pain Team

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Persistent pain is a complex issue

• Pain is an output that is the result of input from multiple areas of the brain:

• Thalamus and Hypothalamus: stress response, autonomic regulation,

motivation

• Amygdala: fear, fear conditioning

• Prefrontal and frontal cortex: makes sense out of the situation.

• Cingulate cortex: concentration and focus, affected by attention to pain

• Cerebellum: Perception of movement

• Hippocampus: memory, spatial cognition, fear conditioning

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Persistent pain is a complex issue:

• Sensory homunculus:

• Receives input from the body and localizes the source.

• This can become blurred and “smudged” with changes in movement habits

• Premotor and Primary motor cortex:

• Organizes and prepares for movement.

• Affected by fear of hurting oneself

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• In the presence of persistent pain the nervous system undergoes changes which help perpetuate the presence of pain.

Neuromatrix

• All of the connections in the brain

make up a bodyself neuromatrix.

• This self representation is

constantly evolving; being sculpted

by life.

• The “coding space” of all events of

the brain.

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19th Century engraving ofGoethe’s Faust and the Homunculus

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Neurotag

• The self-generated representation in your brain of a movement or posture

without actually performing the movement or posture.1

• Activation in multiple areas of the brain results in the activation of a neurotag.

• There is an activation threshold required to produce an output of a neurotag,

similar to a single neuron.

• The output defines the neurotag.

• Each movement has its own neurosignature.

• Pain also has its own neurosignature.

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Mosley, Butler, Beames, Giles. The Graded Motor Imagery Handbook. Noigroup Publications: Adelaide, 2012

Central Sensitization • Sensitization

• Increase in excitability of the member brain cells of a neurotag lowers the activation threshold.

• In a pain neurotag this results in pain that is more easily produced.

• Disinhibition• Decrease in the inhibition of non-member brain cells surrounding the

neurotag.• In the presence of disinhibition neurotags lose their precision • Disinhibition of movement neurotags manifests as imprecise movements or

perhaps in extreme dystonia• Disinhibition of pain neurotags results in poorly localized pain. • Result in altered sensory perception of a body part.

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Graded Motor Imagery

• This treatment method has evolved out of a growing understanding of the

neurobiology of complex pain due to central sensitization.

• It exercises the brain through a stepwise progression of activities to improve synaptic

health in a graded fashion, taking advantage of neuroplasticity.

• The process of graded motor imagery serves to guide the sensory and motor

cortexes through activities without activating the pain neurotag associated with

movement.

• The goal is uncoupling the link between the movement neurotag and pain neurotag

by reshaping the movement experience, resulting a different the output with the

activation of the neurotag

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•Some of the common diagnoses treated:

• Complex Regional Pain Syndrome (CRPS)

• Phantom Limb Pain

• Pain related to Spinal Cord Injury (SCI) or Stroke

• Persistent Neck, back, or extremity pain

• Pain following peripheral nerve injury

• Possible use for Pain Prevention

• Amputation

• Fracture

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Step process

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Motor/functional empathy (watching)

Implicit Motor Imagery (L/R

judgments)

Explicit Motor Imagery (imagining L/R movements)

Mirror Therapy (tricking the brain with a mirror)

Motor/Functional Exposure (real movements)

Occupational/higher functional exposure (back to work)

Adapted from Mosley, Butler, Beames, Giles. The Graded Motor Imagery Handbook. Noigroup Publications: Adelaide, 2012

Techniques

• Left/right discrimination (Implicit Motor

Imagery)

• Imagined motion (Explicit Motor Imagery)

• Mirror Therapy

• Graded Exercise Exposure

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Baseline level

•It is important to establish the level of activity (or thinking

about an activity) that can be accomplished without pain.

•This must be established before starting training in order to

begin the process of disassociation of pain and an activity or

movement.

•This allows the patient and the clinician to establish criteria

for success and when it is appropriate to change the activity.

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Sequence of Treatment

• The order of treatment is important.

•Mirror Therapy was not affective in decreasing pain when

used as the first intervention.5

•Graded Motor Imagery done in this order was found to

decrease pain in patients with CRPS16

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Step 1

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Motor/functional empathy (watching)

Implicit Motor Imagery (L/R judgments)

Explicit Motor Imagery (imagining L/R movements)

Mirror Therapy (tricking the brain with a mirror)

Motor/Functional Exposure (real movements)

Occupational/higher functional exposure (back to work)

Adapted from Mosley, Butler, Beames, Giles. The Graded Motor Imagery Handbook. Noigroup Publications: Adelaide, 2012

Left/Right Discriminationor Laterality

• The process of identifying one side of the body as distinct from the other.

• The brain is mentally manipulating the body part, but we are not aware.

• When a person looks at an image:

• The response should be immediate, spontaneous, and unconscious

• This is a mental movement- maneuver body part in your mind

• This process will use parts of a neurotags that create movement

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Left/Right Discriminationor Laterality

•Body schema is created through input from the spinal cord, thalamic

tracts and cortical structures.

•Recognizing a body part moving requires an intact body image.

• In the presence of complex, persistent pain body image becomes

distorted. 7, 8

•There is a bias in tactile processing away from the painful body part. 1

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Left/Right Discriminationor Laterality

• Implicit motor imagery does not light up the Primary Motor Cortex

(M1), but does activate the Pre-motor Cortex, the area where

planning movement occurs.

• Activation of the Pre-motor Cortex through implicit motor imagery

can result in a change in the activation threshold of the neurotags

• It also can increase inhibition of neighboring non-member cells.

• This helps restore precision to the neurotag in sensory and motor

issues.

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Tools forImplicit Motor Imagery

•RecogniseTM App •Available on iTunes for IOS and Android•Feet, knees, hands, necks and backs

•Flash Cards•Easy to use in different contexts

•Magazines•Ones you like, ones you don’t like

•Creativity and Imagination

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Implicit Motor Imagery(left/right judgements)

You don’t know you are mentally moving

Premotor cells modify primary motor cells without activating them

Less likely to activate the pain neurotag

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RECOGNISETM App

• Establish a baseline for activity

without pain production.

• Suggested trial:

• 20 images

• 5 seconds/image

• Quick test or basic

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Response times

• Response Time

• 1.6 sec +/- .05 sec = necks and backs

• 2.0 sec +/- .05 sec = hands and feet

• Accuracy of Judgments

• 80% or above

• Side to Side Difference

• Response time and accuracy should be equal

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Flash Cards• NOI has cards for hands, feet, necks, backs

and shoulders.

• Make them with a digital camera

• Can be used in a variety of settings (i.e. on the bus, at work)

• Can play games:

• Tic Tac Toe

• Sorting into R/L piles

• Memory

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Magazines

• Initially look through the magazine.

• Identify body parts

• Identify the direction a neck or back is turned or side bent.

•Rotate the picture to increase the difficulty.

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If implicit motor imagery causes pain?

• Results should be stable in various contexts (i.e under stress or varied environments) and consistent for at least 1 week before progressing activity

• If pain is increased when the images progress, look for a pattern, is there a specific image that triggers pain. Then break down the image into parts (i.e. holding a hammer, etc.)

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Implicit Motor Imagery Lab•Recognise App•Flash Cards•Right left discrimination•Tic-tac-toe

•Magazine•Flip through the pages and identify a body part•Which side of the body?•Is the neck or trunk turning right or left? •Side bending right or left?

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Step 2

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Motor/functional empathy (watching)

Implicit Motor Imagery (L/R judgments)

Explicit Motor Imagery (imagining L/R movements)

Mirror Therapy (tricking the brain with a mirror)

Motor/Functional Exposure (real movements)

Occupational/higher functional exposure (back to work)

Adapted from Mosley, Butler, Beames, Giles. The Graded Motor Imagery Handbook. Noigroup Publications: Adelaide, 2012

Imagined movement

•“The self-generated representation (neurotag) in your brain of a movement without actually performing the movement or posture”1

•Has been widely used by athletes to improve performance.9

•Engages the sensory cortex as well as the motor cortex.

•This process helps to train inhibition of non-member brain cells and improve precision with the sensory system

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Explicit Motor Imagery(Imagined Motions)

You know you are mentally moving

Primary motor cells activated

More likely to activate the pain neurotag

Imagined Movement• 1st Person Exercise: Imagine the feeling of doing an activity, rather than seeing the

performance.

• Imagined motions can cause pain and swelling on a patient with CRPS1

• If this is too painful, the exercise can be done in 3rd person, “watching” themselves do the movement or activity.

• If someone has persistent pain they may have difficulty visualizing the body part.• They can:• Visualize the opposite side.• “Watch” themselves• Watch others• Start proximal and work toward the affected area

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Explicit Motor Imagery Lab

•Find a partner

•Pick a script on the table.

•Take turns guiding each other through the activity.

•For the “clinician” speak slowly as you give the instructions.

•For the “patient” concentrate on the directions, focus on

feeling the body part.

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Step 3

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Motor/functional empathy (watching)

Implicit Motor Imagery (L/R

judgments)

Explicit Motor Imagery (imagining L/R movements)

Mirror Therapy (tricking the brain with a mirror)

Motor/Functional Exposure (real movements)

Occupational/higher functional exposure (back to work)

Adapted from Mosley, Butler, Beames, Giles. The Graded Motor Imagery Handbook. Noigroup Publications: Adelaide, 2012

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Mirror Therapy

• Goal is to perform an activity with both sides of the body, but view the

uninvolved side as though it was the involved side.

• This tricks the brain into thinking that the limb visualized in the mirror is the

affected limb.

• Activation of primary Motor Cortex both for the moving limb and the hidden

limb.

• More activation than imagined movement

• More success with patients who have the ability to imagine moving the

effected limb.11

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Mirror TherapyTools:

Mirror Box or tall mirror

• A good mirror won’t

distort body parts

• Make it believable –

take off jewelry,

watches, cover tattoos

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Threat Value Inside the Box Outside the box

Static PostureKeep the hand still/resting in a

comfortable position

Keep the hand still/resting in the same position as the hand in the box-observe

the reflection

Keep the hand still Rotate the hand

Keep the hand still Oppose each finger separately

Keep the hand resting with a slight bend in the fingers

Make a fist, then slowly relax; repeat

More threateningBend the wrist up and down within

the limit of painBend the wrist up and down, through its

full range of movementOppose the fingers and gently touch

togetherOppose the fingers and press with some

forceMake a fist, pushing into some

discomfortMake a fist and squeeze in repetitions

Move both hands full and include tasks such as squeezing a ball or

writingCopy the hand in the box

Most ThreateningInclude tools that are more threatening, such as a knife

Copy the hand in the box

Reproduced from the Graded Motor Imagery Course Manual, NOI 2012

Contextual changes as part of a graded progression

•Location

•Noise

•Vision

•Emotion

•Gravity

•Time of day

•Distraction

•Expectations

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In summation

•With persistent pain cortical changes result in functional changes

•The nervous system can be retrained, BUT this is difficult work that takes patience and persistence over time.

•There will be flare ups, but reinforce this is a protective strategy of the body, not a sign of injury.

•Stick to the plan.

•Don’t push beyond on a good day.

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Thank you!

Questions?

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References1. Mosley, Butler, Beames, Giles. The Graded Motor Imagery Handbook. Noigroup Publications: Adelaide, 2012

2. Ramachandran, V.S., Rogers-Ramachandran, D., Cobb S. 1995 “Touching the Phantom Limb.” Nature 377: 489-490

3. Ramachandan, V.S., Rogers-Ramachandran, D. 1996b. “Synaethesia in the Phantom Limbs Induced with Mirrors.” Proc R Soc London, 263:

377-386

4. Stevens, J.A. Interference effects demonstrate distinct roles for visual and motor imagery during mental reprensation of human activion.

Cognition, Volume 95, Issue 3, April 2005; 329-350

5. Moseley GL, Gallace A, Spence C. Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain 2008; 138:7-10

6. Moseley GL. Graded Motor Imagery is effective for long-standing complex regional pain syndrome: a randomized controlled trial. Pain 2004; 108: 192-8

7. Moseley GL. I can’t find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain 2008; 140: 239-243

8. K. Jane Bowering, David S. Butler, Ian J. Fulton and G. Lorimer Moseley (2014). Motor Imagery in People With a History of Back Pain, Current Back Pain, Both, or Neither Clin J Pain 30:1070–1075.

9. Feltz, DL. and Landers, DM (1983) The effects of mental practice on motor skill learning and performance: A meta-analysis. Journal of Sports Psychology 5: 25-57.

10.Moseley, G.L. (2004b) Imagined movements cause pain and swelling in a patient with complex regional syndrome. Neurology, 62, 1644-1647

11.Sumatani M, Miyauchi S, McCabe CS, et al. Mirror visual feedback alleviates deafferentation pain, depending on qualitative aspects of the

pain: a preliminary report. Rheumatology 2008; 47: 1038-43

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19th Century engraving ofGoethe’s Faust and the Homunculus

Homunculus

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Experiences, Beliefs, Knowledge, body Image, Culture, motor Pattern etc..Tissue

Environment

adapted from material from Brendon Haslam: Pain, Plasticity and Rehabilitation course material 2014

• Persistent pain is a complex issue.

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