Rehabilitation Service - Hand Therapy - Graded Motor Imagery

Introduction

Graded motor imagery consists of a set of treatments aiming at helping reduce pain and improve the ability to move the hand, wrist, arm. It can also be used for any other part of the body affected by persistent or wide-spread pain.

In some cases of pain wide-spread pain, traditional therapy treatments to help with movement such as exercise and joint mobilisation may be too painful to tolerate. Graded motor imagery is a gentler way to help improve movement whilst also reducing pain.

Understanding pain

Pain can be complex to understand as it involves many different aspects. When we sprain our ankle, this pain can be useful as it protects the leg until it heals, but on rare occasions this pain can become longstanding (chronic), meaning it continues after the injury has healed and is therefore not useful. Longstanding pain can be felt when the nerves that sense pain are irritated, but it is also affected by activity in many different parts of the brain. Each person has a different pain ‘circuit’ in the brain which is activated by different factors.

As pain persists, this circuit in the brain can become over-sensitive and easily activated. For some people, just the thought of moving can activate the pain circuit and cause pain to be felt. A little bit like a fire alarm, which can go off if there is a fire, however it may also go off if there is smoke from a toaster. Pain does not always mean that is harmful to move.

When the hand or arm is painful it can become difficult to touch, move or use. The brain also has a memory or ‘map’ of different body parts and how these feel, move and function in day-to-day activities. If the hand or arm is not touched, moved, or used this map starts to change and can begin to disappear. Fortunately, the brain map can be changed and re-built. Graded motor imagery helps with this process.

You may not need to complete all the treatments described below. Your therapist will advise on the appropriate treatments for you.

Treatment needs to be completed regularly to be effective. You may experience pain differently depending on the time of the day, the place you are, among other circumstances. It may therefore be useful to consider when and where you complete your treatment to reduce the chance of you experiencing pain during the treatment.

The ideal sequential progression of the different elements of graded motor imagery

1. Watching movements

2. Left/right discrimination

Is this left or right movement?
Is this a left or a right side?
Backs and necks are twisting which way?

3. Explicit motor imagery

Imagine moving, touching and feeling
Am I standing on a balance beam, in tall grass or on the beach?
How do my clothes feel on my skin?

4. Mirror Therapy

Enriching my experience by using a mirror, different moods, circumstances, places
By using mirrors, I can trick my brain

5. Regain function

Laterality

Laterality is about recognising if an image is of the right or left hand side of the body. When the brain maps begin to change because of lasting pain, the ability to distinguish right from left can be affected. The purpose of this exercise is to begin to re- build the brain map, by looking at a number of images of hands in different positions and trying to identify if they are left or right hands. If you find this task difficult, complete this stage before progressing to the next stages of graded motor imagery:

Start with a few pictures of hands in simple positions which are easy to identify as left or right. You can look on magazines picturing people or browse images of hands on the internet, alternatively use the images provided by your therapist (see last page of this leaflet)
When you can consistently identify simple pictures correctly, progress to pictures in more complex positions. You should be able to repeatedly identify the more complex pictures before progressing to the next stage of graded motor imagery

You can also complete this treatment using the app Recognise™. Recognise™ measures the ability to recognise left and right body parts and movements and can be used to train left/right discrimination as part of a complete rehabilitation programme.

Imagined movements

This exercise refers to thinking about doing a movement without actually doing the movement. This exercise uses the same parts of the brain as doing a movement but to a smaller degree and so it is less likely to produce pain. This is a technique used by elite athletes to help improve performance in their sports.

Sit comfortably or lay down, try with the eyes closed as it may help. Do not actually move your hands during this exercise:

Begin with imagining your hands in static positions
If you feel pain when imagining putting your own hand in the position in the images below, you can imagine someone else moving their hand first
When you feel ready and pain free completing the first step, progress to imagining your hands doing different activities. Think about how it would feel to do certain day-to-day activities, such as stroking a pet, picking up a knife to butter a slice of bread or peeling and eating an orange. Think of a very explicit scenario, imagine the room you’re in, the weight, shape and texture of the objects you are holding, of the how your clothes feel on your skin, the noises you may hear and the smells you are experiencing. Also think about the exact actions your fingers and wrist need to do to complete each task

There is a free podcast you can download called “Saebomind” where you can find mental practice exercises for the upper limb.

Mirror Therapy

The third stage involves looking at the reverse image of your non-painful hand in a mirror. The reflection in the mirror then appears as the affected hand. This aims to ‘trick’ the brain into thinking that the painful hand now feels and moves as normal:

Place a mirror upright on a table or other surface. A free- standing mirror is ideal. You can also use a bigger mirror if you can sit comfortably
Place your pain free hand in front of the mirror where its reflection can be clearly seen in the mirror. Place your painful hand behind the mirror and out of view. Ensure that any jewellery is removed from either hand before the treatment so that both hands are the same
Start by just looking at the image of the still hand in the mirror. Make sure that both hands are placed in the same position. You can use different positions each time you complete the treatment, but you should attempt the same position with both hands
Once you can look at the mirror image without feeling pain you can begin to move the hands
Start with a small amount of movement in the least painful direction. Ensure both hands move at the same time in the same direction. Gradually try to increase the amount of movement as you progress through your treatment sessions
Once you can complete a movement or movements consistently without pain, progress to the next most painful movement or movements until all movements can be done with minimal pain

Remember

These activities can help reduce your pain; however, you must do them consistently and regularly for them to be beneficial. If when doing any of these exercises your pain increases, stop immediately, return to an activity that does not increase pain and discuss this with your therapist at your next appointment.

Continuing treatment is important to help to achieve the changes we want to occur.

Your pain is real. It is a result of the nerves becoming oversensitive and the brain changing. We can begin to reverse them with treatment, but it takes time, commitment and effort.

Use the following pictures to imagine your hand in each position (as guided by your therapist). This encourages rebuilding of the area of your brain which may be struggling to receive normal messages.
Hand exercises