2

N
e
u
r
o

O
r
t
h
o
p
a
e
d
i
c

I
n
s
t
i
t
u
t
e

|

w
w
w
.
n
o
i
g
r
o
u
p
.
c
o
m
w
w
w
.
g
r
a
d
e
d
m
o
t
o
r
i
m
a
g
e
r
y
.
c
o
m
The
Graded Motor Imagery
Handbook
G. Lorimer Moseley
David S. Butler
Timothy B. Beames
Thomas J. Giles
References
1/ Graded motor imagery is effective for long-standing
complex regional pain syndrome: a randomised controlled
trial., Moseley, G.L., Pain 2004
2/ Is successful rehabilitation of complex regional pain
syndrome due to sustained attention to the affected limb?
A randomised clinical trial. Moseley, G.L., Pain 2005
3/ Graded motor imagery for pathologic pain: A randomized
controlled trial. Moseley, G.L., Neurology 2006
4/ Does evidence support physiotherapy management of adult
Complex Regional Pain Syndrome Type One? A systematic
review. Daly, A. E., Biolocerkowski, A. E., European Journal
of Pain, 2008.
CONCLUSIONS: Graded motor imagery should be used
to reduce pain in adult CRPS-1 patients. Further, the results
of this review should be used to update the CRPS-1 clinical
guidelines.
Graded Motor Imagery
GMI is an individually tailored treatment process which has successfully been
used for persistent and complex pain states
1,2,3,4
. It aims to give exibility and
creativity back to the brain via graded exposure.
The Graded Motor Imagery Handbook,
Moseley GL, Butler DS, Beames TB, Giles TJ.
Noigroup Publications, Adelaide, Australia, 2012
2

N
e
u
r
o

O
r
t
h
o
p
a
e
d
i
c

I
n
s
t
i
t
u
t
e

|

w
w
w
.
n
o
i
g
r
o
u
p
.
c
o
m
w
w
w
.
g
r
a
d
e
d
m
o
t
o
r
i
m
a
g
e
r
y
.
c
o
m
What is normal?
Broad guidelines are:
You dont know you are
mentally moving
Premotor cells modify
primary motor cells
without activating them
Less likely to activate the
pain neurotag
Implicit Motor Imagery (left/right judgements)
References
Parsons LM., Integrating cognitive psychology, neurology and
neuroimaging. Acta Psychologica 2001;107:155-81.
Schwoebel J, Coslett HB, Bradt J, et al. Pain and the body
schema: effects of pain severity on mental representations of
movement. Neurology 2002;59:775-7.
Wallwork S, Butler DS, Darmawan I, et al., Motor Imagery
of the neck. Age, gender, handedness and image rotation
affect performance on a left/right neck rotation judgement
task. Submitted 2012.
Bowering J, Butler DS, Fulton I, et al., Implicit motor imagery
in people with a history of back pain, current back pain,
both or neither. Submitted 2012.
Aim for accuracy of 80% and above
Similar results for left and right (no bias)
Aim for response time (speed) of 1.6 seconds
+/- 0.5 seconds for necks and backs
Aim for response time (speed) of 2 seconds
+/- 0.5 seconds for hands and feet
Consistent over a period of at least a week
B - Acute left hand injury
looking at left hand
R
e
s
p
o
n
se time
R
e
s
p
o
n
se time
A
c
c
u
racy
A
c
c
u
racy
L
L
L
L
R
R
R
R
Wrong choice,
start again
Wrong choice,
start again
X
X
A
c
u
t
e

L
E
F
T
h
a
n
d
in
jury looking a
t R
IG
H
T
h
a
n
d
A
c
u
t
e

L
E
F
T
h
a
n
d
in
jury looking a
t L
E
F
T
h
a
n
d
C
h
r
o
n
i
c

L
E
F
T
h
a
n
d
in
jury looking
a
t R
IG
H
T

h
a
n
d
C
h
r
o
n
i
c

L
E
F
T
h
a
n
d
in
jury looking
a
t L
E
F
T
h
a
n
d
Acute
Chronic
A - Acute left hand injury
looking at right hand
C - Chronic left hand injury
looking at right hand
D- Chronic left hand injury
looking at left hand
A
B
C
D
Difcult decision,
Safest to presume its
LEFT hand because
my LEFT hand is
injured choose
LEFT hand
Mentally move
LEFT hand
Mentally
move RIGHT
hand
Correct!
Correct!
Mentally move
LEFT hand
Difcult decision,
Safest to presume
its LEFT hand
because my LEFT
hand is injured
choose LEFT hand
Difcult decision,
Safest to presume
its RIGHT hand
because my LEFT
hand is in trouble
and Im protecting it
by not focusing on it
Mentally move
RIGHT hand
Correct!
Difcult decision,
Safest to presume
its RIGHT hand
because my LEFT
hand is in trouble
and Im protecting it
by not focusing on it
Correct!
Mentally
move LEFT
hand
Mentally move
RIGHT hand
2

N
e
u
r
o

O
r
t
h
o
p
a
e
d
i
c

I
n
s
t
i
t
u
t
e

|

w
w
w
.
n
o
i
g
r
o
u
p
.
c
o
m
w
w
w
.
g
r
a
d
e
d
m
o
t
o
r
i
m
a
g
e
r
y
.
c
o
m
Where do I practice explicit motor imagery?
At home, work, school, on the bus, in the
bath?
Do I keep my eyes open or closed during
motor imagery?
What position do I adopt during imagery?
Sitting, standing, lying?
Do I think of myself moving (rst person) or
someone else moving
(third person)?
How long should I perform imagery for and
how many times a day?
What is the task complexity and intensity
and how does it tie in with grading my
exposure?
What words should the therapist use to
describe or talk through the process?
What words should the user think of when
going through the process?
What cues can be used to heighten the
process? Sounds, memories, smells?
Should there be prior demonstration of the
movement by another person (therapist,
family member)?
Do I use relaxation or meditation in
conjunction?
How much do I know about the changes in
the brain that I can achieve with imagery?
Thinking about moving without actually moving imagined movements.
There are many different ways to go through the process and the most common method used in GMI is a
rst person perspective of feeling your own movement and postures. Graded activation of the brain through
observation, imagining movements and actual movements.
Explicit Motor Imagery
References
Ehrson HH., et al,. Imagery of voluntary movement of ngers,
toes, and tongue activates corresponding body-part-
specic motor representations. J Neurophysiol. 2003
Nov;90(5):3304-16.
Ideas board
Observing
movement
Imagining
movement
Performing
movement
2

N
e
u
r
o

O
r
t
h
o
p
a
e
d
i
c

I
n
s
t
i
t
u
t
e

|

w
w
w
.
n
o
i
g
r
o
u
p
.
c
o
m
w
w
w
.
g
r
a
d
e
d
m
o
t
o
r
i
m
a
g
e
r
y
.
c
o
m
Using a mirror box
In this situation the problematic limb is hidden in the box.
Looking at the mirror image of the left limb gives the illusion
of seeing the hidden right limb.
Therapist as illusionist
Mirror therapy means looking into a mirror to see the reection of the limb or body
part in front of it. The mirror will effectively give the illusion that you are looking
at the limb that is hidden. Brain activation during mirror therapy is less than actual
movement but slightly more compared with imagining the same movement.
Mirror Therapy (1)
References
Diers M., et al. Mirrored, imagined and executed
movements differentially activate sensorimotor
cortex in amputees with and without phantom
limb pain. Pain 2010
2

N
e
u
r
o

O
r
t
h
o
p
a
e
d
i
c

I
n
s
t
i
t
u
t
e

|

w
w
w
.
n
o
i
g
r
o
u
p
.
c
o
m
w
w
w
.
g
r
a
d
e
d
m
o
t
o
r
i
m
a
g
e
r
y
.
c
o
m
Tips and examples of progression
for using a mirror box
Mirror Therapy (2)
Keep the hand still/resting in a comfortable position Keep the hand still/resting in the same position as
the hand in the box just observe the refection
INSIDE THE BOX OUTSIDE THE BOX
More
sensitive
Rotate the hand Keep the hand still/resting
Oppose each fnger separately Keep the hand still/resting
Bend the wrist up and down through its full range of movement Bend the wrist up and down within the limit of pain
Oppose the fngers and press with some force together Oppose the fngers and gently touch together
Make a fst and squeeze in repetitions Make a fst, pushing into some discomfort.
Then repeat in time with the hand outside the box
Copy the hand in the box through a full range of movement Rotate the hand and wrist fully
Copy the hand in the box Move both hands fully and include some extra tasks,
e.g., squeezing a ball or writing
Copy the hand in the box Include tools that are more threatening such as a knife
Less
sensitive
Make a fst then slowly relax; repeat Keep the hand resting with a slight bend in the fngers
2

N
e
u
r
o

O
r
t
h
o
p
a
e
d
i
c

I
n
s
t
i
t
u
t
e

|

w
w
w
.
n
o
i
g
r
o
u
p
.
c
o
m
w
w
w
.
g
r
a
d
e
d
m
o
t
o
r
i
m
a
g
e
r
y
.
c
o
m
A graded approach for treating pain
It appears necessary that GMI is offered in a sequential manner. A strong grounding in the
science underpinning GMI is essential for all users to be able to decide best when to move
forwards, sideways or backwards through the treatment process.
The ideal sequential progression of the different elements of graded motor imagery:
GMI: a graded approach (1)
Left/right
discrimination
Explicit
motor imagery
Mirror
therapy
Regain
function
Watching
movements
Is this a left
or right
movement?
Imagining
moving, touching
and feeling
Enriching my
experience by using
a mirror, diferent
moods, circumstances,
places
Am I standing on
a balance beam, in
tall grass or on the
beach?
Using mirrors
I can trick my
brain
How do my
clothes feel on
my skin?
Backs and necks
are twisting
which way?
Is this a left or
a right side?
2

N
e
u
r
o

O
r
t
h
o
p
a
e
d
i
c

I
n
s
t
i
t
u
t
e

|

w
w
w
.
n
o
i
g
r
o
u
p
.
c
o
m
w
w
w
.
g
r
a
d
e
d
m
o
t
o
r
i
m
a
g
e
r
y
.
c
o
m
GMI: a graded approach (2)
Left/right
judgements
Hands and feet
2 minutes every
waking hour
Left/right
judgements
Feet only
1 minute every
waking hour
Watching
Sitting in a cafe watching the
other diners
Increase 1 minute per day
~
Piano movies, sister typing,
Indian dancing
5 minutes x 5 per day
Left/right
judgements
Hands and feet
10 images / hour
Increase by 1 image
every day
Explicit motor
imagery
Hands and
feet
10 images/hr
Increase by 1
image per day
Mirror therapy
Hands and feet
5 minutes/hour
Increase by 1
minute every day
0
1
2
3
4
5
6
7
8
9
10
0 - 2 weeks 3 - 4 weeks 5 - 11 weeks 12 - 14 weeks 15 - 17 weeks 18 - 20 weeks
Pain on movement
Resting pain
A case study
Lucy Loo presented with marked CRPS
affecting her arm, leg and face. We treated
her with GMI for two minutes every waking
hour for the rst two weeks. Her pain
worsened. You can see this by the slightly
upward trajectory of the diamonds, which
reect pain on movement of her thumb, and
the circles, which reect pain at rest.
We then reduced her training and worked
on GMI of the feet instead. Two weeks later
no worse but really no better. We then
did some motor empathy we asked her
to watch movies of people playing on the
piano, watching her sisters hands as she
typed at the computer, and to watch other
movements. She clearly began to improve.
We progressed that, spending more time and
watching more functional activities, for seven
weeks. Then we tried GMI again and this
time she responded.
It took another nine weeks to get through
the GMI programme, but at 20 weeks
after the initial appointment, Lucy started
functional exposure. Six months later she
had only a small amount of pain when she
worked with her hands for half an hour or so.
The trick with her? We had to get under
the radar by abandoning GMI and starting
instead with motor and functional empathy.