Learning from the shadows

When clinicians go about their daily practice, they will often hear odd complaints and encounter weird findings and anomalies. Most are forgotten but sometimes the findings happen again and again and may well become researchable. For example, many patients with chronic pain complain of sensitivity to cold and following research, cold sensitivity is now an established part of the pattern of central sensitisation. We call this “learning from the shadows” [1] i.e. knowledge hidden in the clinical darkness which makes its way out of the shadows via good clinical behaviours  and which can eventually be put to scientific scrutiny. This is a great example of developing clinical practices driving new research, and complements the other direction of research driving clinical practice.NOI as astonishing anecdote central
At NOI we get about 30 GMI associated requests for help with patients every week, and it allows us to collect a rich narrative about what is happening “out there”, especially in the area of left right discrimination. It’s quite exciting as it often includes success stories such as the person who had severe pain after an eye was surgically removed – left right discrimination tasks hurt , she had to start with the foot and eventually could do ‘vanilla’ hands as her pain eased right back.

Other stories include: consistent loss of left right discrimination in dyslexia, the rare freak-outs when a person with a severely painful and dysfunctional right hand is asked whether a picture of a right hand is left or right, instant reversal of left right discrimination scores in a day, but still some who won’t change, the regular loss of left right discrimination and difficulty imagining movement in osteoarthritic knees. Some stories engender a sense of awe – we have had repeated narrative about spread of pain post whiplash treated with spinal left right discrimination (perhaps keeping central sensitisation in check?) and of young people with CRPS whose left right discrimination scores flipped while attempts at painful desensitisation were made (they seem to think the left is the right and vice versa – a powerful attempt at protection?).

GMI and neurological damage
We are hearing more regular anecdotes from therapists and patients with injured or diseased nervous systems and also how the GMI process can be integrated into management.

Here is an anecdote from NOI instructor Brendon Haslam:

I was recently referred a man who was 4/52 post surgery from removal of a meningioma, following an 8 month history of worsening leg weakness and numbness.  He had previously been a very keen tennis player and runner.  At his first appointment, he walked in reporting feelings of poor hip control both in stepping and stance.  He had no active left dorsiflexion or toe extensors, and said he had the feeling of a ‘flicker’ of calf activity in the past week.  His surgeon had told him he was confident in the results of the surgery. Reassured by this, he saw any improvements as a bonus, but was understandably keen to get to the highest functioning level possible.

He described having weird feelings in his foot, a mild lack of ownership (“it’s just not quite right”), but denied having any pain. We discussed the notion of utilising GMI in addition to use of hands on facilitatory techniques to try and gain extra awareness of movement. He was happy to try anything, and followed the reasoning explained to him about how GMI could help. We initially used Recognise Online (vanilla feet) with good results within the session, scoring >90% accuracy and reaction times just over 1 second after initial trial ‘learning’ run.  Feeling confident with such good Recognise results, we then went straight to mirror therapy (using an upright mirror in sitting). Instantly he felt a sense of ownership of the reflected image of his leg and foot, and got very excited at this. Starting with some basic PF/DF, he felt as if was getting some activation left foot and calf, and noted flickers of tib ant and antigravity calf were visible within a couple of minutes. He then rested, and repeated the task, with further improvements with some slight antigravity dorsiflexion/inv (but no toe extension). We then took the mirror away so he could see the active movement he was now performing.  He was blown away by this and keen to keep going.

The session then changed tact a little bit to try and get some more unilateral movement without relying on the mirror or the good leg, and so utilised some PNF lower limb patterns in supine, with a further increase in active movement throughout leg, and the distal component coming in repeatedly. This was progressed into free active patterns (with no operator) on the plinth, with the mirror on the affected side (at the side of the plinth) so he could see the active movement occurring at all areas (trying to get visual reinforcement for extra sensory input, as well as the feel good factor).

At the end of the session, I discussed the option of setting up a home upright mirror to enable him to recreate the movements performed at home, in addition to some easy visualization activities to perform during the day.

He returned 5 days later feeling great. He had not only consolidated his active movement gains, but progressed them. He was able to consistently recruit dorsiflexion (inversion biased), and had even tried some gentle hits of tennis!  Within this second session, he was able to recruit toe extensors (gt toe> others) with firing of EDB as well. He reported increased balance skills and confidence, doing more outdoors and genuinely excited about where he’s going. He then asked the question “why wasn’t this started sooner?” and informed me that he is thinking of flying overseas in a few weeks providing he gets the okay from his surgeon! I’m due to see him again today for his third session, and can’t wait to see where it goes. Clearly there has been that underlying potential there for a while, it was just a matter of finding the right ‘switch’ to create an opportunity to tap into it.”

More please!
We are expecting more stories, especially as we are about to begin a new course called Pain, Plasticity and Rehabilitation where we introduce GMI strategies to the neurologically damaged patients. Chronic  pain is common and attempts to treat it are often not attempted.

Keep the ‘stories from the shadows’ coming in. We will give a copy of The Graded Motor Imagery Handbook to the story that makes us reflect the deepest on “what is going on here”. Submit your story to info@noigroup.com 
Search for and enquire about NOI courses here 



  1. diSessa, A.A., A bird’s-eye view of the “pieces” vs “coherence” controversy., in International Handbook on Research on Conceptual  Change S. Vosniadou, Editor. 2008, Routledge: New York.
  2. Moseley, G.L., et al., The Graded Motor Imagery Handbook 2012, Adelaide: Noigroup.

Recent conferences

A big hooroo and thank you to the people who visited the NOI stands at IFOMT2012, Quebec City, Canada, and also the AHTA conference in hometown Adelaide.

El Administrao
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Cheers, from noigroup team

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