Graded Motor Imagery (GMI)
Information for patients from the Orthopaedic Hand Service
Graded Motor Imagery exercises are not suitable for patients who have dyslexia or for children.
You have been referred to the Orthopaedic Hand Service, as you are feeling pain when you move. After discussing your symptoms with you, your therapist has suggested that Graded Motor Imagery (GMI) may be able to help you.
This leaflet explains the following.
Why you have been referred for GMI.
What central sensitisation is, and what the symptoms are.
What GMI is, and how it can help.
We hope this leaflet answers some of the questions you may have. If you have any further questions or concerns, please speak to your therapist.
Why have I been referred for Graded Motor Imagery (GMI)?
Your therapist has suggested that you do GMI exercises, as your pain response is stronger than we would expect. This is known as Complex Regional Pain Syndrome (CRPS). For example, you have pain caused by simple joint movement or pain from a light touch. With CRPS pain continues after the original injury has healed.
With CRPS two things are happening to your body.
The nerves in your painful limb (arm or leg) are being overactive or sensitised.
The ‘sensory-motor’ area in your brain is altered, causing a ‘mismatch’ in information. This is called central sensitisation. This sensory-motor area deals with how your body feels when it is moved or stimulated.
More information is available in the following leaflets.
What is central sensitisation?
Pain is an unpleasant feeling that your brain produces to prevent or lessen damage to your body. Central sensitisation can be thought of as your brain trying to protect your limb unnecessarily. This creates excessive pain, as your brain mistakenly believes your body is at risk of damage.
In people affected by CRPS, brain scans can see the following during special studies.
The brain’s over-reaction to touch and movement.
Changes in the sensory-motor area.
This shows that CRPS pain is real.
What are the symptoms of central sensitisation?
Central sensitisation can include some or all the following symptoms. Remember everyone is different, so you may have other signs as well.
Pain triggered by the idea of movement and touch.
Feeling detached from your limb (your limb is not part of your body).
Feeling that your limb is not the shape and size it actually is (it feels swollen when it’s not).
Having strong negative feelings towards your limb.
Skin discolouration.
Increased swelling and stiffness, plus one or more of the symptoms listed above.
Any of these symptoms are worrying. However, studies have shown that GMI exercises can help you correct the changes in your sensory-motor area. GMI exercises can even help after many years of suffering from the problem.
What is Graded Motor Imagery?
GMI exercises aim to ‘train your brain’, so that movement and touch no longer trigger a pain response stronger than you should expect. GMI aims to restore your altered sensory-motor area and lessens central sensitisation. This needs time and regular practice by you.
Graded. Step-by-step introduction of movement, without triggering a pain response. This is done by starting with the area of your brain that only prepares for movement. Like sneaking in through the back door.
Motor. A word used to describe our body’s system for joint movement. This includes the brain, nerves, skeleton, joints, and muscles.
Imagery. Using your imagination to think about and move both your painful and unaffected limb. To only imagine the movement, not actually move your painful limb.
How is Graded Motor Imagery done?
A GMI program has three stages of exercises.
To begin with, you must do these exercises exactly how your therapist tells you to. Once you are used to them, you can do them as you feel necessary.
Your therapist will tell you when to move on to the next stage.
Stage 1: Laterality exercise
Laterality is our ability to recognise left and right sides. We look at our own limbs or other people’s limbs and try to identify which is the left side or which is the right side. To do this, we use the area of our brain involved in movement planning, not movement execution (actually moving). It is thought that the movement planning area of our brain is less likely to be sensitised and send pain messages. This is the back door.
For specific exercise instructions, please ask a member of staff for a copy of the Trust’s Laterality exercise leaflet.
Stage 2: Explicit motor imagery
Explicit motor imagery is imagining movement. When we imagine movement we activate both:
the movement planning; and
some of the movement execution area of our brain, without actually moving our body.
The purpose of this is to teach the sensitised areas of your brain that movement is not a threat. That you can move and not cause yourself pain.
To start with you may find you feel pain by imagining movement. With practice, it may be possible for you to activate the movement execution area of your brain without triggering a pain response.
When you can more easily imagine moving your painful limb, it is time for stage 3.
For specific exercise instructions, please ask a member of staff for a copy of the Trust’s Explicit motor imagery or imagined movement leaflet.
Stage 3: Mirror Visual Feedback
In this exercise a mirror is used to reflect your unaffected limb. Your painful limb is behind the mirror. The idea is to:
‘trick’ your brain into thinking that your affected limb is being moved freely and normally,
whilst your unseen affected side moves in the same way but with smaller, controlled, and ‘non-threatening’ movement.
For full instructions, please ask a member of staff for a copy of the Trust’s Mirror visual feedback leaflet.
Further information
Please feel free to keep asking questions.
Please discuss your concerns and symptoms with your therapist, no matter how strange they may seem.
Please remember, everyone feels pain differently. So, although these exercises have been proven to help, it may take you more / less time to see the benefits.
Your therapist will see you regularly. They will guide your treatment and provide you with support.
If you have any questions, please speak to your therapist.
Ask 3 Questions
There may be choices to make about your healthcare. Before making any decisions, make sure you get the answers to these three questions:
What are my choices?
What is good and bad about each choice?
How do I get support to help me make a decision that is right for me?
Your healthcare team needs you to tell them what is important to you. It’s all about shared decision making.
What do you think of this leaflet?
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Patient Voice Team
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