mirrorbox

The Graded Motor Imagery Handbook – a review


I love getting presents, and I love books, so what could be better than getting a book to review as a present!

Graded motor imagery (GMI) has become incredibly popular in pain management, especially for people with unilateral pain.  It’s a treatment that is intensive for patients/participants, but is non-invasive, means the person with pain develops self management skills, and has level B1 evidence.  For those who don’t know – level B1 evidence means there are several RCT’s, and at least one meta-analysis showing support for this approach.

Back to the book.  Like all the NOI books it’s an unusual size, has groovy graphics and an easy-to-use layout. It’s a spiral bound book of over 140 pages with a great index (yay!), logical layout and has room for notes.  The illustrations and photographs are clear and provide excellent guidance for clinicians.  Chapters divide the book into sections of background info including theory and evidence; how to conduct treatment with GMI (clinical reasoning); metaphors (David Butler’s favourite teaching tools); and a whole chapter on how to use the materials available from NOI to support GMI treatment.   Each chapter can stand alone, and it’s not necessary to read from beginning to end – but of course, it does help!

This book isn’t for beginner therapists working in pain management. There are some assumptions about the level of clinical reasoning required and patient selection that are not fully explored, and true psychosocial aspects of managing pain – and the translation into the “real world” – are omitted. This is fine as long as clinicians are aware of the need to identify people who will benefit from the approach and as long as clinicians work within an interdisciplinary team environment.

Patients/participants need to be motivated, committed, and relatively psychologically well, without complex psychosocial contexts such as family/relationship issues, litigation, personality disorders, drug/alcohol problems or other cognitive impairment.  GMI has best application in people with unilateral pain such as CRPS and phantom limb pain – although it has been extended to other pains.  These factors may influence the degree of engagement and time required to carry out GMI, and may influence the outcome.

Back to the book again!   I love the chapter written by Lorimer Moseley on the neuroscience underpinning GMI.  His writing is clear and provides an excellent scientific basis for the approach.  He doesn’t extend his writing into psychological aspects of pain beyond the concepts of what he calls “neurotags”, or “interconnected neurones … that produce an output”.  Neurotags involve areas across the whole brain and, when activated, produce, for example, the experience of a whiff of fresh bread (along with the scent, the associated emotions and cognitions from past learning and the anticipation of future action).  I have learned these associations as just that – associations between various aspects of learning and anticipation, and have called them the neuromatrix – but NOI have used the term neurotag, and I guess it’s as good a name as any.

The chapter on conducting GMI treatment written by Tim Beames is extremely clear and well written.  While it’s possible to use this as a sort of cook-book to treatment, with the information from other chapters such as Lorimer’s neuroscience, and Butler’s metaphors, it becomes far more flexible.  I like this.  It is a chapter that I think many clinicians will turn to regularly – but as is emphasised throughout this handbook, patients/participants should read this stuff too.

Worth getting? Yes, I think so. 

My caution lies in over-interpreting the application of GMI beyond the evidence-base.  If you intend to try it with a patient/person with pain, please explain that this is an experiment that you and the person are conducting to see how this treatment works for him or her.  Select patients appropriately, checking for motivation, factors that could distract from engagement in treatment, and type of pain.  Record a baseline. Monitor progress. And involve the other members of your treatment team (particularly occupational therapists) to help transfer what is practiced out into the wide, wide world.  After all, the most complex context of all is being engaged in occupations like grocery shopping, driving, cooking a meal, playing a sport – where the environment is always changing, contains all those triggers, and where the brain is involved in multiple decisions moment-by-moment.

Where to get it? Go here – and let ’em know I sent you.

Friday Funnies – and some great links


Oh no, the Friday Funnies, full of cringe-making ‘funnies’.  Try to enjoy them – they’re there to help you prepare for your weekend (you know you’ll need a drink after looking at them!)

I recently posted a list of ‘doctor’ or health care rules courtesy of Dr Rob of Musings of a Distractible Mindthis is a link to the accompanying patient rules, I thought they might be useful.

For a tasty snack, probably designed to make sure you remain healthy of spirit and soul while less so of artery and heart…take a look at this recipe for shortbread from Borealnz’s blog

The brilliant Ben Goldacre never ceases to amaze me with his wry comments on both his Twitter feed and his Bad Science blog. He’s never shy of taking on the misinformed or the shonky – and his sense of humour is great.  This is a good example. Voices of the Ancients, debunking mystic nonsense published in British newspapers.

Last but not least.  Let it never be said that I shied away from promoting the hardy souls who toil in the world’s largest island (or is that the smallest continent).

First up is NOI Group, or Neuro Orthopaedic Institute, with the colourful David Butler who sports more pairs of groovy glasses than anyone I’ve ever seen.  This is the site for mirrorbox, laterality and Explain Pain.

And next is the loquacious Lorimer Moseley who, along with a few others, blogs on Body in Mind.  His blog features not only some of his most up-to-date research carried out on pain, but also promotes new PhD’s by publishing a brief summary of their research too.  You can follow them on Twitter as well (and I believe there is a Facebook page or group to join also).

The last, but not an Australian, is the wonderful Diane Jacobs, who is a most prolific reader and linker on Twitter under the name @dfjpt, and also on Facebook with the group ‘Neuroscience and Pain Science for Manual Physical Therapists’

Well, that should leave you with a few thoughts links for the weekend – enjoy!