Download The Graded Motor Imagery Handbook, 2012

DESENSITIZATION & CORTICAL
REMODELING: USING A GRADED
MOTOR IMAGERY APPROACH TO
TREAT CRPS
Elizabeth Gaffron, MOTR/L
RIC, Center for Pain Management
AAPM&R, 2015
I have no actual or potential conflict of
interest in relation to this presentation.
LEARNING OBJECTIVES
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Understand the motor/autonomic pain mechanism &
rational for top-down treatment approach for CRPS.
Establish what assessments & clinical features may
direct clinical rational to use Graded Motor Imagery
(GMI) in the treatment of CRPS.
Why do we use pain physiology education to reconceptualize pain experience in combination with
GMI?
Define the components of graded motor imagery &
establish it’s value in the treatment CRPS.
CRPS – MOTOR/AUTONOMIC PAIN
MECHANISM
Alterations in central & peripheral modes of pain reception
Inflammatory
Mechanisms
Autonomic/vasomotor
dysfunctions
Cortical, neuroplastic
changes
CRPS – TREATING A PROCESS, NOT ANATOMY
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Maladaptive cortical reorganization reinforcing pain &
symptoms
Limb positioned outside of visual field – protective
guarding, neglect & disuse
Disturbance in perceived body part relative to shape, size,
temperature, orientation, positional sense
“My arm doesn’t feel like my own”
Conflict between sensory-motor cortical processing
networks
Lewis & McCabe, 2010; McCabe, 2011; Harden et al., 2013
TOP DOWN – BRAIN TO BODY
• Individuals with central deficits
related to body image or movement
beliefs require retraining of sensory
& motor function in the primary
somatomotor cortex
• Training the brain representation to
promote body function
• Establish fear hierarchy relative to
movement, contexts, & meaning
A World of Hurt, A Guide to Classifying Pain, 2015
TREATMENT PATHWAYS
- ASSESSMENTS
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Bath CRPS Body Perception Disturbance Measure
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Proprioception: limb position sense
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Sensory: 2-point discrimination testing, localization &
precision testing
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Left/Right discrimination testing: signs of cortical
representation
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FAB-Q, TSK, PHODA: kinesiophobia, fear-avoidance,
catastrophic thinking patterns
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Canadian Occupational Performance Measure:
functional deficits
“ KNOW PAIN ”
• Pain is a protective
mechanism influenced by
multiple factors
• Pain is an “OUTPUT” of the
brain
• Use of metaphors may help to
reframe unhelpful thoughts
about pain experience
• Understanding basic pain
physiology can diminish
threat, improve compliance &
progression of treatment,
change movement
performance, promote client’s
active role in goal setting &
problem-solving.
RE-CONCEPTUALIZE PAIN BELIEFS
NEUROTAGS – INTERCONNECTED NEURONS
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Activation of neurotags produces an OUTPUT
When the neurotag network for pain is activated,
it produces the pain experience
The Graded Motor Imagery Handbook, 2012
NEUROTAGS - INPUTS
Thoughts
 Movements
 Sensations
 Noises
 Memories
 Emotions
 Vision
 Balance
 Blood pressure
 Nerve messages
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NEUROTAGS –PERSISTENT PAIN, CRPS
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Sensitization
- Increased excitability, more easily activated
- Allodynia & Hyperalgesia
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Disinhibition
- Loss of precision, activation of additional neurons
- Pain spreads, moves, defies anatomical
structures
The Graded Motor Imagery Handbook, 2012
TRAINING THE BRAIN REPRESENTATION TO
PROMOTE BODY FUNCTION
RE-CONCEPTUALIZING PAIN – GRADED
MOTOR IMAGERY (GMI)
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GMI was developed as a treatment strategy to engage
sensory & motor networks without triggering the protective
pain response.
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Desensitizing neurotags using graded brain exercise.
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Graded Motor Imagery (GMI) is a graded exposure program
grounded in three paradigms:
Biopsychosocial (Engle, 1977)
Neuromatrix (Melzack, 1989)
 Pain Mechanisms (Gifford & Bulter, 1997)
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Priganc &Strakla, 2011; Bowering et al., 2013; The Graded Motor Imagery Handbook, 2012
“Self-generated
representation
(neurotag) in the
brain of a
movement or
posture without
actually performing
the movement or
posture” (Timothy
Beams, The Graded
Motor Imagery Handbook,
2012)
The Graded Motor Imagery Handbook, 2012
Mirror Therapy
Identifying Right vs.
Left using pictures
of limbs in postures
or during ax to help
establish accurate
representation of
the body.
Motor Imagery
Left/Right Discrimination
GMI – Three Components
Normalizing neural
networks by
diminishing
sensorimotor
discrepancies &
prioritizing visual
feedback. Brain
begins to adjust how
it perceives &
processes sensation
& position of the limb.
GMI – EVIDENCE
 K. Jane Bowering, Neil E. O’Connell, Abby Tabor, Mark J.
Catley, Hayley B. Leake, G. Lorimer Moseley, and Tasha R.
Stanton (2013) The Effects of Graded Motor Imagery and Its
Components on Chronic Pain: A Systematic Review and MetaAnalysis. J. of Pain 14(1):3-13.
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Moseley,GL (2006) Graded motor imagery for pathologic pain – a
randomised controlled trial. Neurology 67: 2129-34
Moseley,GL (2004) Graded motor imagery is effective for longstanding complex regional pain syndrome – a randomised
controlled trial. Pain 108(1-2): 192-198
BRAIN TO PERIPHERY – GMI
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Implicit motor imagery used for relearning cognitive &
planning components of movements
Explicit motor imagery & mirror visual feedback are used
to retrain the brain for basic motor skills by focusing on
non-painful movements
Coordinated, controlled movements provide example for the
brain to reset circuitry that modulates voluntary movement
Desensitizing neurotags by winding down the nervous
system
Re-inhibiting neurotags for precision & definition
LEFT/RIGHT DISCRIMINATION TRAINING
IMPLICIT MOTOR IMAGERY
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Pre-motor skill required for
coordinated execution of movement
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Unconscious mental movement
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Less likely to activate the pain
neurotag
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Activation occurs in the premotor
cortex – planning movement
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Decreasing sensitization and
normalizing inhibition
The Graded Motor Imagery Handbook, 2012
LEFT/RIGHT DISCRIMINATION TRAINING –
WHAT’S MY BRAIN DOING?
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Make a spontaneous judgment - dependent on the
processing speed of CNS & attention to body part
Mentally move our own matching limb to mimic the
posture of the limb- requires an intact working body
schema & it’s integration of premotor processes
Confirm or deny the initial judgment –dependent on the
processing speed of the CNS
Moseley, 2004; Moseley & Flor, 2012
MOTOR IMAGERY – EXPLICIT MOTOR
IMAGERY
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Observing or imagining movements by
creating the sense of doing the activity or
position without movement of the body
Provides insight into the function of motor
planning pathways
Increase likelihood of activating pain
neurotag
Activation in the pre- & primary motor cortex
– execution of movement
McCabe, 2011; The Graded Motor Imagery Handbook, 2012
EXPLICIT MOTOR IMAGERY – WHAT’S MY
BRAIN DOING?
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Activation of primary motor cortex cells, which
may activate the neurotags for movement
Initiates the neural hardware for both movement
& sensation
The Graded Motor Imagery Handbook, 2012
MIRROR VISUAL FEEDBACK
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Restoring a pain-free relationship between sensory
feedback & motor intention.
Corrective visual representation of the affected
limb may help to normalize the body schema.
Increase attention of affected limb, improving
ownership and emotional attachment to the limb.
Activation of “movement areas” of the brain – more
likely to activate neurotag.
The Graded Motor Imagery Handbook, 2012; McCabe, 2011; Lewis & McCabe, 2010
MIRROR VISUAL FEEDBACK - TRAINING
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Mirror placed so the reflective surface is facing the
unaffected limb & occluding the affected limb
Person must establish & sustain ownership of reflected limb
Visual input overrides absent or poor proprioception of the
affected limb
McCabe, 2011, Moseley, et al., 2012, Ramachandran &
Rogers-Ramachandran, 1996
MIRROR VISUAL FEEDBACK CONTRAINDICATIONS
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Reports of increased pain
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Motor extinction
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Exacerbation of movement disorders – tremor or
dystonia
Inability to establish and sustain ownership of
reflected limb
Lewis & McCabe, 2010; McCabe, 2011; Harden et al., 2013
“ You move more easily, function better and your
brain has less need to make pain when you know
what is going on with your body.”
(David Butler, The Graded Motor Imagery Handbook, 2012)
REFERENCES
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Harden, NR, Oaklander, AL, Burton, AW, Perez, RSGM, Richardson, K, Sawn,
M,Barthel et al. Complex regional pain syndrome: Practical diagnostic and
treatment guidelines, 4th edition. Pain Medicine 2013; 14: 180-229
Kolski, MC & O’Connor, A. A world of hurt, a guide to classifying pain. St. Louis,
MO: Thomas Land Publishing, 2015
Lewis, J & McCabe, C. Body perception disturbance in CRPS (BPD). Practical Pain
Management, 2010; 60-66
Louw, A, Puentedura, E, & Mintken, P. Use of an abbreviated neuroscience
education approach in the treatment of chronic low back pain: A case report.
Physiotherapy Theory & Practice, 2011; 00(0): 1-13
McCabe, C. Mirror visual feedback therapy. A practical approach. Journal of Hand
Therapy, 2011; April-June; 170-179
Moseley, GL. Unraveling the barriers to reconceptualization of the problem in
chronic pain: The actual and perceived ability of patients & healthcare
professionals to understand neurophysiology. Journal of Pain, 2003 (C) 4: 184-189
Moseley, GL, Nicholas, MK, & Hodges, PW. A randomized controlled trial of
intensive neurophysiology education in chronic low back pain. Clinical Journal of
Pain, 2004; 324-330
Moseley, GL. Why do people with CRPS take longer to recognize their affected
hand? Neurology, 2004; 62:2182-2186
REFERENCES
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Moseley, GL, Butler, DS, Beams, TB, & Giles, TJ. The graded motor imagery
handbook. Adelaide: NOIgroup Publishing, 2012.
Moseley, GL & Flor, H. Targeting Cortical Representations in the treatment of
chronic pain: A review. Neurorehabilitation & Neural Repair, 2012;1-7
Prignac VW& Stralka, SW. Graded motor imagery. Journal of Hand Therapy,24:
164-168