Left and Right – take care with the hype

As producers of the materials and investors in some of the research behind Graded Motor Imagery, it is our hope that users will utilise it as well as possible. Questions from patients and clinicians pour in daily, although The Graded Motor Imagery Handbook has eased some of the pressure. These Notes look at the most common questions and issues around stage 1 of GMI – left right discrimination. The main reference for all the answers is The GMI Handbook and particularly research by Sarah Wallwork and Jane Bowering at the University of South Australia and Lorimer Moseley at numerous institutions.

First – Left right discrimination – what is it?
Left right discrimination (LRD) or ‘laterality’ is the ability to identify an image of a body part as left or right or in the case of the spine, to identify if the person in the image is turning (leaning/rotating) to the left or right side.

Is this a left or right hand?  
Is this person turning (leaning/rotating) to the left or right?  

LRD is known to be altered in a number of neuropathic pain states such as CRPS and phantom pain and we have repeated anecdotal evidence of left right discrimination changes in a variety of states ranging from post spinal cord injury pain, fibromyalgia, carpal tunnel syndrome, limb immobilisation and dyslexia. We would not be surprised to observe changes in any neuropathic pain state nor would we be surprised if left right discrimination ability was intact.

See the section on ‘tools’ below for information about getting a free Recognise trial and low cost downloads of the Recognise Apps (hands or feet) for the next 5 days.

“What is normal?”
Everyone asks us this. I am not sure I know what a normal human being is, but here are a few suggestions from the studies so far.
Our broad suggestions for normal responses to a left right discrimination test are:

  • Accuracy of 80% and above, but why not aim for more!
  • A speed of 1.6 seconds +/- 0.5sec appears quite normal for necks and backs. Hands and feet are a little slower with an average speed of 2 seconds +/- 0.5 seconds
  • Accuracies and response times should be reasonably equal left and right
  • The above figures should be quite stable, i.e. they don’t fade out with stress and are consistent for at least a week.
  • A judgement will also be needed on the personal relevancy of the responses. For example, minor left right discrimination changes may not be so relevant in a person who has a severe pain related incapacity, whereas they may be more relevant in a person with a much more minor problem. This is a clinical reasoning judgement.

“But it’s not working – the scores don’t seem to change!!”
Now that is a good question. You may need to remember that you may have a patient with unrelenting neuropathic pain for 10 years, untouched by any therapy who can’t begin to comprehend that the problem may be in their brain. Give 1 in 10 of such a patient significant relief and you will be doing better than the most powerful drugs on the market.

My typical advice for when LRD scores no longer improve:

  • Has it been done enough? (might need up to 2 hours a day)
  • Has it been done for long enough? (might need weeks or months)
  • Has it been done in different contexts and with different tools? (use the online program, flashcards, apps, magazines, photo albums in safe and non-safe places and in different moods)
  • Is it being done properly? (a quick but relaxed and automatic decision)
  • Has it been embedded in a favourable education context? (can they engage their brains or is it off limits?)
  • Is there an existing brain injury? (perhaps it was never going to change much)

“My patient is faster on the sore side”
Maybe your patient is a rabbit? In acute experimental states, it has been noted that participants are faster on the sore side. That kind of makes sense if you want to protect a sore part you can make an evaluative bias. In a chronic state – whenever that is (is it a few weeks or a few months?) – it appears that they get slower. It’s one of those things – all output systems seem to vary over time as the self seeks homeostasis.

“Does being left or right handed make a difference to scores?”
No, there is nothing special about being a leftie.

“Does age make a difference?”
No, we oldies are pretty slick. Nor is there any gender effect and I guess you wouldn’t expect there to be.

Why are there rotated images?
We have had a few queries about the rotated images. The reason for rotation is to push the brain that little bit more. An image which is upside down (rotated by 180 degrees) will always take longer, or is more difficult, to judge as left or right than if it was upright or on its side.

Some of the GMI tools available
There are always plenty of GMI tools at your fingertips. Run through your Facebook photos or dust off the albums and pick out all the left hands. Use a magazine to do the same. Try turning it upside down!

We have also built some easy to use and accessible tools. Recognise is the computer program and anybody can sign up for a free 5 login trial to test their LRD or do motor imagery exercises.

Apps are available as ‘Recognise hands’ and ‘Recognise feet’ for iPhones and Androids. Go to the iTunes App store (iPhones) or Google Play (Androids) to get the App for an unusually low price over the next 5 days! This offer ends July 18, 2012.

Flash cards are available as sets of 48 pictures (24 lefts and 24 rights) in Hands, Feet, Necks, Shoulders and Backs. Play games like ‘fish’, ‘snap’ or ‘memory’. Build a fear hierarchy based on the different postures and work through them gradually.

The NOI Mirror Box is also useful for progression through the stages in GMI.

Write to us
We love hearing about any experiences you’ve had (good or bad) using GMI. Your feedback helps us to direct research, develop tools and share anecdotes. Get in touch on recognise@noigroup.com.

Links
What is patient empowerment?
How a bee’s brain can change with new tasks
New findings: Blaming the brain for chronic pain
The Pain Toolkit
Does evidence support physiotherapy […] in CRPS-1. A systematic review, 2009.

Hot NOI courses in the next 2 months!
14 – 15 Jul Mobilisation of the Nervous System, London, UK
16 – 17 Jul Mobilisation of the Nervous System, Derby, UK
27 – 28 Jul Schmerzen Verstehen, Burgau, DE
5 – 6 Aug Schmerzen Verstehen, Bremen, DE
18 – 20 Aug Das Sensitive Nervensystem, Hamburg, DE
18 – 19 Aug Mobilisation of the Nervous System, Jaipur, IN
25 – 26 Aug Mobilisation of the Nervous System, Pune, IN
8 – 9 Sep Explain Pain, Chicago IL, US
14 Sep Graded Motor Imagery, Arnhem, NL
15 – 16 Sep Explain Pain, *CLOSED COURSE**, US
15 – 16 Sep Schmerzen Verstehen, Bremen, DE
15 – 17 Sep Mobilisation des Nervensystems, Zurzach, CH

Search for and enquire about NOI courses here

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