graded motor imagery
TRANSCRIPT
![Page 1: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/1.jpg)
David ButlerUniversity of South AustraliaNOI Australasiawww.noigroup.com
Graded Motor Imagery
“working deep into the neuromatrix”
![Page 2: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/2.jpg)
Lecture Aims
Introduce the science and clinical applications of the graded motor imagery programme
An example of taking novel science, paradigms and technique into physiotherapy
![Page 3: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/3.jpg)
Graded Motor Imagery (GMI) Definitions
Laterality : the ability to identify a body part as left or right, or a body part moving to the left or the right
Motor imagery: watching or imagining a body part in a certain position or motion
Mirror therapy: use of a mirror to present a reverse body part image to the brain
An emerging evidence based sequence of strategies to manage known pathoanatomical
brain based obstacles to rehabilitation.
![Page 4: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/4.jpg)
Laterality reconstruction
Motor imagery
Mirror therapy
Graded Motor Imagery (GMI)
•The sequence is important •“graded” because of the sequence requirements and the need of graded exposure principles
![Page 5: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/5.jpg)
GMI – targets?
CRPS 1Phantom limb pain
Research currently underway for CTS, OA, whiplash and face pain
If CRPS1 and phantoms can be helped??
Anecdotally, many chronic and some acute pain disorders may benefit from aspects of the programme
Moseley GL 2006 Neurology 67: 1-6, Daly A 2008 Eur J Pain doi:10.1016/j.ejpain.2008.05.003
![Page 6: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/6.jpg)
• Do part of movement but no painful part
• Do part of movement with painful part
• Do more• Increase number• Increase strength• Add equipment
Rehab 101. Task Progression – break movement down
![Page 7: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/7.jpg)
• Laterality reconstruction(premotor association areas)
• Watch static posture• Imagine static posture• Watch movement• Imagine movement
(Mirror neurone complexes)• Mirror
(“Smudged” brain areas)• Do part of movement but no painful part• Do part of movement with painful part• Do more• Increase number• Increase strength• Add equipment
Rehab 201……. Task Progression
![Page 8: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/8.jpg)
Some underpinning science
Two gifts from neuroscience
•Mirror neurones•Neuromatrix paradigm
![Page 9: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/9.jpg)
• Starting a pee?• Sportspeople who excel?• Learning guitar?• Children learning?• pornography• Treated necks all day and gone
home with neck pain?
Neuroscience Gift 1. Mirror neurones
![Page 10: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/10.jpg)
• The legend of the discovery
• Zillions of them
• Fire to watching and imagining movement?
• Fire to nonvisual stimuli
• Emotional mirror neurones
Neuroscience 1 Mirror neurones
Iacoboni, B. and e. al. (2005). "Grasping the intentions of others with one's own mirror system." PLos Biology 3: 529‐535.Rizzolatti, G., L. Fogassi, et al. (2006). "Mirrors in the mind." Scientific American 295: 30‐37.
![Page 11: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/11.jpg)
• Don’t hang around with idiots
• Be carefull who you cross the road with
• “it hurts when I think of moving”
• Demonstrating exercise• Emotional burnout in pain
management• Manage workplace issues
early • An anatomical target of
GMI
Neuroscience 1 Mirror neurones & the clinic
![Page 12: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/12.jpg)
• GMI reliant on the neuromatrix paradigm. It doesn’t make sense without it.
Neuroscience Gift 2. Neuromatrix paradigm
![Page 13: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/13.jpg)
Some essentials of the neuromatrix paradigm
Neuromatrix = coding space
Neurosignature = representation= event space
Neurosignatures like pain love, anger are distributed and parallel.
•Key parts smudge or shrink
![Page 14: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/14.jpg)
The brain activity which occurs when a particular person with chronic low back pain experiences pain during an attempt at an abdominal contraction
A pain neurosignature
![Page 15: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/15.jpg)
GMI Part 1. Laterality
![Page 16: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/16.jpg)
GMI Laterality – the practicalities
1.A critical premotor association signature
2.Known losses in CRPS1 and phantom limb pain. Anecdotally, lost in many ongoing pain states
3.Also altered in ongoing motor perturbations
4.Evolutionary biology perspective5.Laterality training known to involve
premotor, not motor areas(e.g Nico D et al 2004 Brain 127: 120; Moseley GL 2004 Neurology 62: 2186
![Page 17: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/17.jpg)
Premotor influences
![Page 18: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/18.jpg)
Optimal motor output
![Page 19: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/19.jpg)
Optimal motor output
![Page 20: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/20.jpg)
GMI Laterality – the practicalities
1.A critical premotor association signature2.Known losses in CRPS1 and phantom
limb pain. Anecdotally, lost in many ongoing pain states
3.Also altered in ongoing motor perturbations
4.Enhanced in acute states5.Evolutionary biology perspective6. fMRI studies show laterality training
known to involve premotor, not motor areas
(e.g Nico D et al 2004 Brain 127: 120; Moseley GL 2004 Neurology 62: 2186)
![Page 21: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/21.jpg)
•Recognise on line
•Flash cards
•“zoo” and “who”
•Other techniques
Laterality assessment/reconstruction
![Page 22: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/22.jpg)
Recognise online
www.noigroup.com
![Page 23: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/23.jpg)
Recognise online
Left and right body parts are presented randomly in predetermined:
• numbers • time •Context (vanilla to context variable to abstract)•Image or movie
![Page 24: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/24.jpg)
venstre eller højre?
![Page 25: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/25.jpg)
![Page 26: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/26.jpg)
![Page 27: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/27.jpg)
![Page 28: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/28.jpg)
![Page 29: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/29.jpg)
![Page 30: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/30.jpg)
![Page 31: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/31.jpg)
![Page 32: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/32.jpg)
![Page 33: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/33.jpg)
![Page 34: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/34.jpg)
![Page 35: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/35.jpg)
![Page 36: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/36.jpg)
![Page 37: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/37.jpg)
![Page 38: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/38.jpg)
![Page 39: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/39.jpg)
![Page 40: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/40.jpg)
![Page 41: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/41.jpg)
![Page 42: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/42.jpg)
![Page 43: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/43.jpg)
![Page 44: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/44.jpg)
![Page 45: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/45.jpg)
![Page 46: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/46.jpg)
![Page 47: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/47.jpg)
![Page 48: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/48.jpg)
Any body part can be used
![Page 49: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/49.jpg)
![Page 50: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/50.jpg)
![Page 51: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/51.jpg)
![Page 52: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/52.jpg)
![Page 53: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/53.jpg)
![Page 54: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/54.jpg)
![Page 55: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/55.jpg)
![Page 56: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/56.jpg)
![Page 57: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/57.jpg)
![Page 58: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/58.jpg)
![Page 59: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/59.jpg)
![Page 60: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/60.jpg)
![Page 61: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/61.jpg)
![Page 62: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/62.jpg)
![Page 64: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/64.jpg)
![Page 65: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/65.jpg)
![Page 66: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/66.jpg)
The “who and zoo” technique, adapted as necessary
![Page 67: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/67.jpg)
![Page 68: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/68.jpg)
![Page 69: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/69.jpg)
Digital cameras are great
![Page 70: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/70.jpg)
GMI Part 2 Motor Imagery
•Watching and imagining postures, movements and activities•Mirror neurons are targets•Imagery is not visual, more kinaesthetic
This part of GMI can also be graded:
•Watching to imagining•Static to moving to context enriched
![Page 71: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/71.jpg)
• Watch another person’s body part in a certain posture• Consider what it might feel like to have a body part
in a certain position
• Watch another person move• Consider what it might feel like to have a body part
doing a certain movement
• Consider what it might be like to manipulate an object (or watch another person)
• Consider what it is like to move like a certain person
Part 2 Motor Imagery
Magazines, movies, on the bus, at work, home, clinic, recognise, flash cards etc.
![Page 72: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/72.jpg)
McCabe S et al 2003 Rheumatology 42:97
Moseley GL 2005 Pain 114:54
GMI Part 3 Mirror therapy
![Page 73: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/73.jpg)
• Box construction• Beer cartons• Good quality perspex
mirror• Collapsible to take home
Practicalities –the mirror box
![Page 74: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/74.jpg)
• Prepare the patient• Sit “evenly”• No jewellery• Forget hand in the box
initially
Practicalities –the mirror box
![Page 75: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/75.jpg)
Graded hand activity examples
– Looking at the hand – Turning hand up and down (elbow movement not hand movement)– Flattening out the hand– Flattening the hand and taking some weight thought it– Moving individual fingers– Finger thumb opposing– Tapping fingers– Add increasing muscle activity to each movement– Use tools (screwdriver, nailcutters, pen scissors etc. – make appropriate
to the left or right hand)– Introduce clinicians’ hand– Touch the face in the mirror
Practicalities –the mirror box
![Page 76: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/76.jpg)
• Place (safe to feared places)• Emotion• Time of day• Try movements distracted (eg while balancing on a
chair)• Music (play a song in your brain) play an external song.• Sitting, standing, lying• Use metaphors (eg. Open hand to free a bird, play
spiders with the fingers on the mirror)• Add different smells and noises
Practicalities –the mirror box
Context change
![Page 77: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/77.jpg)
• Some move it as well• Asynchyria• Move hand in the box as treatment for many handpains
What about the hand in the box?
![Page 78: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/78.jpg)
![Page 79: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/79.jpg)
2 weeks x 2hrs laterality, 2 weeks by 2hrs imagery 2 weeks x 2hrs mirrors (Moseley 2006).
CRPS1 and phantom limb pain group.
Some don’t have a laterality deficitMany progress fasterModalities can be mixed“around 20% CRPS1 no shift”
How much, how many, how long?
![Page 80: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/80.jpg)
The clinical reasoning, compliance, goal setting and support essential
Laterality lost in dyslexiaCricketers have superb laterality, but
injury may offset itLaterality deficits may be severe enough
to use the foot for the hand and vice versa
Mirrors used for all hand painsMirrors for out of plaster stiffnessGMI could be pre-emptiveMirrors may be a life time pain
management tool for some
Some clinical anecdotes
![Page 81: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/81.jpg)
Research projects on line
Get a trial version
Share anecdote
Please help in these embryonic therapies which show so much promise for neuropathic pain.
![Page 82: Graded Motor Imagery](https://reader033.vdocuments.net/reader033/viewer/2022051616/553c94b3550346b94f8b4a01/html5/thumbnails/82.jpg)
Conclusions