Being individual

Many people are now asking for advice on graded motor imagery. Here are some very broad suggestions.

Back to the patient
A 30 year old female who has a four year history of Complex Regional Pain Syndrome (CRPS), post right wrist fracture. Her pain has also spread into her right lower limb.

This patient is now being managed by a physiotherapist.

The clinician writes…
“I saw the patient today to begin the graded imagery program. She was obviously very excited and a very willing participant. Based on the protocol laid out by Moseley, I have her doing either the Recognise computer program or the flash cards 3 times per day for at least 10 minutes per session. She will do that for two weeks and then return with the data collected by the programme. While in the office I had her perform 4 trials of the computer based programme and no matter what images she used for the upper extremity she consistently scored 70-75%. I was able to score 90% but am not sure what that means. Is there any normative data about people with CRPS and how well they do using recognise online or the flash cards vs. those who do not? Should there be a goal we achieve with the program i.e. 85% before we consider it a success and move onto the visualization (mirror) portion of the protocol?”

These are good questions
These questions expose (a) the amount of evidence available and (b) the need for management which is individualised for patients.

There is no normative data on laterality, although we are presently conducting a large scale study. We will post any research outcomes as soon as they are available on the graded motor imagery website. For this patient, it would help to have information on differences between left and right laterality accuracy and speed in both hand and feet. If there are differences, then it would be worth continuing the programme, thus ‘exercising’ those laterality association neurones influencing the patient’s motor responses. The consistent scores of 75% may well be quite normal for that person, and the patient may have little or no laterality deficits and can progress towards motor imagery strategies and mirror therapy. They could well also continue the laterality exercises while doing motor imagery and mirror therapy. But as mentioned elsewhere, before you can imagine a limb movement, the brain must first be able to pick whether it is a left or right limb.

If the patient continues to use laterality training, here are some thoughts:

  • Laterality problems may be exposed by grading use of RecogniseTM online. For example, shorter time between images, use more images, use the contextual and abstract images and videos. Maybe even use the programme in an uncomfortable position.
  • Use of the RecogniseTM flash cards can be made more difficult as well. There are progressively more difficult games that can be played.
  • I suggest between 1-2 hours a day (broken into sessions) of laterality exercises could be performed. It can be done through the day i.e. looking at people and saying “that’s left, that’s right.”
  • Get a trashy celebrity magazine with lots of pictures of people and go through it and circle the left or right limbs, which ever is painful.
  • Make up laterality games.
  • In this person it may be that improving foot laterality will improve hand laterality and vice versa.

Always contact us with your clinical queries about using the graded motor imagery programme.

Your turn
Send in a story of individualised assessment and treatment to go in the running for a Graded Motor Imagery pack.

Last month’s notes on nerve flossing
Thanks for the great stories on nerve sliding and gliding, especially to Kara for her neurodynamics DVD and handbook winning tale. Read on here for the rest of Kara’s and the others’.

“I took over the management of a young man one year after he had cut his thumb (over the distal palmar surface) at work. The cut subsequently became infected and took a long time to heal.  He developed mild stiffness in the DIP joint however his main complaint was pain with any kind of gripping activity, and this pain had somehow spread into the elbow…”

Assess and address with Recognise™

Set your patient up in the clinic with a free, 7 day trial of RecogniseTM online with the new Clinician’s Version. If upon assessment there is a laterality deficit present the trial can be upgraded to a 12 month license while retaining the trial period results to thoroughly track progression.



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