Those who came to the recent NOI neuroscience festival in Adelaide will have noted more education and research devoted to Graded Motor Imagery. The Graded Motor Imagery Handbook is now available. Due to popular demand, the next two NOI Notes are devoted to the topic of Graded Motor Imagery from the clinical viewpoint.
Graded Motor Imagery as a toddler
Lorimer and I have always been very wary of clinical implementations of GMI. We used to call it embryonic for years. It is increasingly becoming popular and we want it to be done as best as you can. This means using clinical reasoning to tailor it for individual patients (no recipe books here!), linking it to education, making it a part of a package that deals where possible with all relevant contributing issues to a person’s problem and being prepared to grade, adapt and move along the scale of therapies in GMI (see Figure 1 below from The Graded Motor Imagery Handbook which shows where GMI ‘sits’ in overall management). It’s no magic cure – it’s hard work in a patient group with problems that, in many cases, are harder to treat than some cancers.
Figure 1: GMI as part of an overall rehabilitation process
Part of the growing up process of a proposed treatment strategy is to see what pain states may benefit and to keep an eye on what is happening in basic sciences. While the relevance of Graded Motor Imagery in neuropathic pain states such as CRPS is supported, what about other pain states, including some that may be “not so neuropathic”?
How scientific is that categorisation!!! But the clinicians will know what I am referring to.
Post ankle fracture stiffness – is it all in the ankle?
A friend of mine asked me to see her husband. He had fractured/dislocated his left ankle 5 weeks previous. The ankle had been internally fixated and he had been given a moonboot and told not to weight-bear. Little information was provided post-surgery and he had the moonboot on all day and night, even the same post-surgical dressings. He said the ankle was going red – it was super stiff and with a history of RA. He was very concerned about the future. Notably, he said “he didn’t like the foot, especially with screws in it?” and “it didn’t feel like his”.
The ankle was very stiff but my original fears of CRPS were quickly dispelled. This of course is basic rehabilitation – start weight-bearing, graduated stretching and strengthening, balance and education. But I also tested the speed and accuracy of left/right foot discrimination via Recognise.
Anybody can sign up for a free 5 login trial account to test left/right discrimination at http://noigroup.com/recognise/createaccount.
There were differences. He was inaccurate identifying left feet compared to the right and generally slow (around 3 seconds – ‘normals’ are around 2 seconds). With practice (around 150 tests over 6 days) they resolved quickly (left accuracy = right, and times were 2 seconds and under). This is a glorious anecdote of course – there may have been regression to the mean (extreme variations are inevitably followed by average variations), there may have been the effects of multiple treatments – perhaps just getting going and using the foot is enough to restore any left/right discrimination issues, and we all probably suffer a bit of confirmation bias as we look for what we want to believe. But the questions raised from this anecdote include:
- Is there a place for exercise of neurosignatures of immobilised parts?
- Could it offer some protection against CRPS?
- Are clues such as “my foot doesn’t feel like mine” indicative of changes of representation in the brain?
Figure 2: Results in Accuracy and Speed from Recognise
As you can see the general accuracy improved but still there was far more 100% results compared with the left foot and there was a general decrease in speed of recognition. The speed results at the end of 6 days are regarded as normal.
Love and the foot
I took something else from the clinical encounter. My friend who is very perceptive said to me as I left after the second visit “you just got him to love his foot again didn’t you?” Well, love wasn’t something I had planned with his foot (still in its original dressing) but I reflected on what was essentially a basic treatment focussing on an unloved body part with its laterality not quite discriminated in the brain suggesting foot representational changes in the brain.
I can go with the notion of ‘loving the foot’ as a broad direction to reintegrate/restore brain representation of the part. The integrative activity of multiple sensory inputs such as vision, motor, touch and proprioception plus the ‘welcoming back’ emotions and cognitions would seem enough to activate micro and macroglia keeping an eye on and re-embellishing the synapses which truly belong to the best functioning foot for that person. Mind you, the neuroscientists don’t quite say this directly (yet) but you feel as though they are itching to! Check out one of a number of reviews on the immune system and plasticity.
Suggestions for clinicians
We enjoy and learn from feedback about graded motor imagery. We call it ‘learning from the shadows' – contact us at firstname.lastname@example.org if you’ve had similar findings with Recognise testing.
The online Recognise software is free for anybody to use as a trial for 5 logins, so give it a go in a pain state. If you get these Notes you’re already a member so use your Noigroup membership email and password to sign in at http://www.noigroup.com/recognise or to set up a new account, go to http://www.noigroup.com/recognise/createaccount.
Next month we will take a closer look at left/right discrimination. – David
1. Moseley, G.L., et al., The Graded Motor Imagery Handbook 2012, Adelaide: Noigroup.
2. Moseley, G.L., Graded motor imagery for pathologic pain. Neurology, 2006. 67: p. 1-6.
3. Yirmiya, R. and T. Goshen, Immune modulation of learning, memory, neural plasticity and neurogenesis Brain, behaviour and immunity, 2011. 25: p. 181-213.
A bit more reading
Here is a brilliant article by Jonah Lehrer, published in The New Yorker in 2010, about The Decline Effect.
Last Notes on Brain Food
Download the bite sized recipe book from our last edition, Brain Food. Congratulations to Ewa from Australia for your delicious, simple, fresh and healthy grilled piece of oily fish. In keeping with the NOI philosophy, we loved the adaptability of the ‘recipe’ as much as the healthy ingredients suggested. You now have a copy of Explain Pain and a box of Haighs dark chocolate coming your way in the post.
…A grilled piece of an oily fish such as salmon or tuna, a side of fresh green salad (preferably straight out of the garden), dressed with parsley, raspberries and avocado dressed with a good cold pressed olive oil and balsamic vinaigrette on top, with a side of some whole grain such as brown rice/quinoa/barley for the hungry person, this could have some very lightly toasted slithered almonds and walnuts mixed through with a light drizzle of olive oil again.
Fish / Salad greens (from the garden) / Parsley / Raspberries / Avocado / Good olive oil & balsamic / Whole grains (brown rice/quinoa/barley) / Toasted almonds and walnuts
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That’s all for now. Please stay in touch and we look forward to seeing or hearing from you in the near future!
Cheers from the Noigroup team