Complete Guide To Graded Motor Imagery (GMI) For CRPS
Graded Motor Imagery is one of two treatments for Complex Regional Pain Syndrome or CRPS that have shown to be effective and to have good outcomes. The second treatment considered effective is Mirror Therapy also known as Mirror Visual Feedback (O’Connell, N.E. et al 2016).
Complex Regional Pain Syndrome (CRPS) is a complex and difficult condition not only to diagnose but also to treat, therefore finding a treatment that can help every CRPS patient is extremely difficult as all CRPS patients are individuals where their CRPS signs and symptoms are concerned. Graded Motor Imagery is just one of a range of CRPS management options that have been included in the Complex Regional Pain Syndrome (CRPS) guidelines from the Royal College of Physicians in the UK.
We’ve previously written an article on How To Use Mirror Therapy as a CRPS treatment however this current article focuses on the Graded Motor Imagery Programme (GMI) for CRPS.
Graded Motor Imagery (GMI) was first developed by Professor Lorimer Moseley and is an up to date rehabilitation programme that has been based on clinical trials and the latest science. GMI is seen as a cost-effective and noninvasive treatment with limited adverse effects and complications (Limakatso, K. et al 2016).In a 2016 systematic review of interventions (O’Connell, et al 2016) that was aimed at reducing pain, disability, or both, in patients with complex regional pain syndrome (CRPS), Graded Motor Imagery or GMI was found to may be effective for pain and function when compared with the usual CRPS treatment options. Johnson, S. 2013 concluded that Graded Motor Imagery is an approach used for the rehabilitation of patients with chronic pain; it aims to activate the cortical networks involved in sensory-motor processing. The GMI or Graded Motor Imagery Programme for Complex Regional Pain Syndrome (CRPS) is a 3 stage treatment that aims to gradually engage cortical motor networks without triggering the protective response of pain.(Bowering, K. et al 2013)
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What Tools Are Involved In Graded Motor Imagery (GMI) for CRPS?According to the Ranelli, S. (2013) GMI uses 2 main tools including:
- Flash cards – which are a random collection of pictures of hands and feet in different postures and position and doing different tasks. They are used to help re-train the ability to recognise where the body or body part is in space
- A computer programme OR App called ‘Recognise’
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Recognise™ AppThe Recognise™ app has been developed and released by the NOI Group™ and is available for both iPhones/iPads and Android. The app uses the same pictures as in the flash cards and also assesses your accuracy (how many of the positions and postures you recognise correctly as left or right side) and the time it took for you to record your response. This means that you can take a step-by-step approach to improving your recognition ability and this is usually associated with a decrease in pain and an improvement in your function. It is available for the following areas of the body:
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Features of the Recognise™ AppThere are a number of features as part of the Recognise™ app and according to the NOI Group™’s app description, these are:
- ‘Memory’ and ‘Speed Match’ tools to take your training to the next level
- Graded difficulty levels and personal best challenges
- Detailed onscreen results and graphs to map your progress
- Powerful clinical integration tools – export and email your results directly to your clinician or therapist
- Capture your own images on your phone or table and use them in your training
- Comprehensive explanation of the science behind left/right discrimination and Graded Motor Imagery
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Stages of Graded Motor Imagery (GMI)The GMI treatment programme involves 3 progressive stages that are designed to exercise the brain in different ways. These techniques or stages are delivered sequentially but this is flexible and can be moved forwards, backwards or sideways by the clinician to completely suit the patient. If symptoms occur in one of the sequential steps, the clinician may go back to the previous step to decrease the unwanted symptoms.Those stages are:
- Left/Right discrimination – Identify left or right images of their painful limb or body part
- Explicit motor imagery – Thinking about moving without actually moving
- Mirror therapy – This is mentioned in a separate article – How To Use Mirror Therapy for CRPS
What Is Left/Right Discrimination or Laterality?This is the first stage of the GMI programme and this stage is the ability to identify left or right images of the patient’s painful body part(s). This stage is also called laterality recognition task or simply ‘laterality.’ Research indicates that people with ongoing pain lose the ability to accurately discriminate between left and right body parts, or movements to the left or right as well as decreased speed in discriminating between left and right. This task stimulates the representation of the body part in the brain, and due to neuroplasticity, causes changes in this representation.
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How Is This Stage Undertaken?Using flash cards, magazine pictures or the ‘Recognise’ programme (or app), this stage will challenge patients to quickly identify images as showing left or right body parts or left or right movements. If you don’t have the Recognise app or the flash cards you could also use magazine pictures or photos for this stage. Patients will usually do this stage of the GMI five (5) times per day for 5 minutes, however the health professional will decide on the plan for each patient after establishing a baseline beforehand.
What Is The Goal Of This Stage?The goal of this stage of GMI is to show improvement in accuracy of identification, as well as speed of identification. Swart et al reported that left and right identification focuses on the premotor cortex and motor imagery focuses on the primary motor cortex, both of which are integral parts of priming the system. (Swart et al 2009). However it doesn’t activate the primary somatosensory and motor cortices (Cocksworth & Punt, 2013). Avoidance of early activation of motor cortices was considered important because movement execution commands are known to readily trigger pain responses (Melzack, 1990; Moseley, 2004a) in patients with conditions similar to CRPS (e.g. phantom limb pain). Moreover, laterality recognition tasks may be considered less threatening to patients than imagined movement or mirror therapy (Heeger, G et al. 2017 Commentary)
What Are The Response Times?As mentioned above, a baseline must first be established before starting the GMI Programme. This baseline is the level of activity (or thinking about an activity) that can be accomplished without pain. Here are the response times that are seen as correct for this stage:
- 6 sec +/- .05 sec (Backs and Necks)
- 0 sec +/- .05 sec (Hands and Feet)
- Accuracy of Judgments – 80% or above
- Side to Side Difference – Response time and accuracy should be equal
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Explicit Motor ImageryThe Explicit Motor Imagery is the second stage of Graded Motor Imagery (GMI). In this second stage of GMI, the patient will imagine the limb in a position and then imagines the limb moving in specific illustrated positions or completing an activity with the limb. It is important that this phase is started by imagining the limb is a stationery position before imagining the limb moving. Whenever we watch someone else’s movements we activate mirror neurons in the brain. This technique is often used by athletes, when they learn new skills, and also when they are rehearsing performances. This Motor Imagery phase of GMI is a way to exercise the brain before the rest of the body. Imagery trains the brain’s representation of the movement. It also builds up confidence levels without creating as much threat as actual movement. In patients with complex chronic conditions like CRPS, even imagining movement can cause an increase in symptoms including anxiety. Information from several research studies have suggested that mental imagery may be very helpful, but they’ve indicated that more studies are needed. It has been discussed that explicit motor imagery can help activate neural pathways in preparation for movement (Moseley, 2005). However, the use of explicit imagery without a preliminary laterality task may result in increased pain and swelling in some adult patients with CRPS (Moseley, 2004b).
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Mirror TherapyThe mirror therapy phase is the third stage of the GMI programme and it uses a mirror to reflect the movement of a patient’s unaffected body part that will create an illusion that the painful body area is moving freely without any pain and other symptoms. This changes its representation in the brain. Just as in Stage 2, the Explicit Motor Imagery, this exposure to movement should be done in a graded way so as not to trigger the protection habit of the brain and cause the patient to have a flare up of their CRPS symptoms. This Mirror Therapy Stage of the GMI programme uses the same principles as the stand alone treatment – Mirror Therapy or Mirror Visual Feedback. It is thought that mirror therapy helps to reconcile sensory feedback to motor output. Here is an video by the NOI group and that shows you the Recognise programme in use:
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How Could Graded Motor Imagery (GMI) Help CRPS?Davis, M (2015) said that
“GMI offers an alternative approach, where the brain is retrained and ‘exercised’ in conjunction with the physical program.”We are already aware that the brain in CRPS patients perceive any touch no matter how soft or hard as painful. The idea behind both mirror therapy and GMI as a for Complex Regional Pain Syndrome (CRPS) treatment is to help ‘retrain the brain’ to not be painful and in recent studies it has been shown to be effective in reducing pain levels and also improving function. GMI is focusing on training the brain to re-connect to the body part affected by the Complex Regional Pain Syndrome (CRPS) pain. In other words, GMI aims to activate the cortical networks involved in sensory-motor processing. (Johnson, S et al 2012) In the research study by Johnson, R. (2014) he explains more about the pain that is produced by Complex Regional Pain Syndrome:
“When you have CRPS in one part of your body, your brain “disowns” the body part, recognising it as threat, instead of your hand or foot. When your brain recognises a threat to your survival, it produces pain to protect you. It is an alarm system that goes off so you can treat the injured area. However, in cases of CRPS, this alarm system is faulty.” [/quote] After the research from McCabe, C. et al. (2003) that found that mirror therapy was ineffective in chronic CRPS, it was then considered that chronic CRPS patients might benefit from a sequence initially involving hand laterality recognition and pure motor imagery before receiving actual mirror therapy. (Maihöfner, C. & Speck, V. 2012) Moseley proposed (Moseley, GL. 2005) that imagined or mirror movements not preceded by hand laterality recognition have a poor effect on symptoms because these movements activate per se cortical networks involved in pain processing (Decety et al., 1994; Decety, 1996). Therefore using this knowledge and research, the GMI programme consists of hand laterality recognition training, motor imagery and mirror therapy, and aims at consecutive activation of the cortical premotor and motor networks, which are relevant to the planning, selection and execution of actions (Moseley, 2004b).Brain training should stay ‘one step ahead’ of physical challenges. Confidence in movement has to be built up first and take fear and prediction out of the pain cycle before the brain will allow the movement physically. (Davis, M 2015) Another systematic review of physical therapies for CRPS Type 1 concluded that there is good evidence that GMI is effective in adults with CRPS Type 1 and that GMI should be employed as part of good clinical practice (Daly and Bialocerkowski, 2009). In the research by Moseley, G.L. 2004, it also concluded that there is evidence that a six-week program of Graded Motor Imagery rehabilitation for CRPS patients does result in the improvement of both CRPS symptoms and function. However in the multi-Centre prospective audit research by Johnson, S et al (2012), it was concluded that although results of Graded Motor Imagery (GMI) obtained within the context of clinical trials were encouraging, fundamental differences exist in clinical practice. This meant that the ‘real-world’ implementation of GMI failed to identify a reduction in pain intensity after treatment. For those health professionals who are using Graded Motor Imagery for CRPS it is important to remember and be aware of the fact that GMI may be potentially ineffective or may even lead to an increase in pain in a patient. Therefore it is crucial to carefully consider the individual feedback from the patient.TO THE TOP
Does Graded Motor Imagery (GMI) For CRPS Work?Everyone with Complex Regional Pain Syndrome is an individual and everyone will react differently to Graded Motor Imagery (GMI) just as in every other CRPS treatment. A systematic review of interventions aimed at reducing pain, disability, or both, in patients with Complex Regional Pain Syndrome (CRPS) (O’Connell, 2013) identified that GMI may be effective for pain and function when compared with usual treatments for the condition. The Cochrane Review (Smart, K. M. et al 2016) rated the evidence for GMI as very low quality that GMI plus medical management may be more effective at reducing pain and improving function than conventional physiotherapy plus medical management in the treatment of CRPS I of the upper limb. (Smart, KM et al 2016) However the Cochrane Review did conclude that their findings did suggest that: “GMI may provide clinically meaningful medium and long-term improvements in both pain and disability in CRPS I, although the results from these trials were not consistent.”
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Final Words On Graded Motor ImageryAs you can see from our article above on the Complete Guide To Graded Motor Imagery (GMI) for CRPS, more work needs to be done in bringing GMI out of a clinical trial setting and into actual clinical practice. You can also see that there are a few RCTs for GMI showing a mixture of conclusions including the Cochrane Review (Smart, K 2016) that found there was low evidence for GMI. Unfortunately for Graded Motor Imagery, the evidence is limited and analysis are not independent between the different types of CRPS, as all the evidence available is aimed towards CRPS Type I rather than both types of CRPS. Graded Motor Imagery (GMI) is a treatment for Complex Regional Pain Syndrome (CRPS) that has to be individually tailored to the patient and cannot exist as a stand-alone treatment without patient education and interdisciplinary care. Patients’ responses and feedback to GMI will therefore be very individual, and patients should be made aware of this. If a patient finds their pain increases during the GMI programme, they should be ready to move back a step. Pushing through or fighting the pain will always be counter-productive, therefore Pacing is the key. Life stresses and triggers should also be considered when moving through the stages of GMI. Patients and professionals should realise that not every patient will find Graded Motor Imagery (GMI) for their CRPS, an effective treatment. It is important that practitioners/physiotherapists should build up a patient’s confidence in movement, and to remove fear and prediction out of the pain cycle before the brain will allow the movement physically. For the mirror therapy section of the Graded Motor Imagery as a stand alone CRPS treatment as discussed in our other article – How to Use Mirror Therapy for CRPS, there are a mixture of reviews and thoughts from the available research. Please feel free to share our Complete Guide To Graded Motor Imagery (GMI) for CRPS or make comments below. How do you think GMI has worked for you either as a CRPS patient or medical professional? Let us know your thoughts. P.S. Have you seen our other blogs on 18 Tips Preparing For Your Pain Appointment or our Complete Guide to the Dorsal Root Ganglion Stimulation for Complex Regional Pain Syndrome (CRPS)? Don’t forget to take a look!
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