Tim Beames is NOI UK’s most experienced instructor and co-author of The Graded Motor Imagery Handbook. Tim is also possibly the world’s most experienced GMI clinician, having been there right from the start. He’s taking his knowledge and experience and is teaming up with NOI USA’s most experienced instructor, Robert Johnson, for a special one-off, two day Graded Motor Imagery course in Chicago on May 20-21 2017.
For easy online registration and payments for this course just click here
Tim is the co-founder of Pain and Performance, London, providing treatment for people with persistent and complex pain problems, support and guidance for clinicians dealing with complex pain patients and delivering bespoke courses for departments and organisations on pain related topics
Robert is co-owner and clinical director of Achieve Orthopedic Rehab Institute in Chicago, Illinois. Bob has been teaching with David Butler and the NOI team since 1999. As a true allrounder, he teaches Explain Pain, Graded Motor Imagery and Mobilisation of the Nervous System, courses.
To mark this special event, we’ll be revisiting some of Tim Beames’ NOIjam posts, like this one:
Jumping into a protective force field
Having a ‘protective force field’ around the painful side of the body is a reasonably understandable response for someone with complex regional pain syndrome (CRPS). Why would you want someone to come near, let alone touch an extremely sensitive part of your body?
I have come across this phenomenon with some consistency in people with CRPS. They may be acutely aware that they don’t want you to come into or invade their space or their body language infers this.
Traditional therapeutic evaluation of a painful limb i.e. jump straight into a physical assessment of the affected body part, essentially flies in the face of the desires of the person in pain. So, are there other more empathetic ways of elucidating useful information regarding their pain experience? (And avoid flaring-up an easily provoked pain problem).
I recently saw a teenager in my clinic that displayed a ‘protective force field’ over the right side of her body. When she used the Recognise app on a smart phone, she leant even further away from her right side than she already was and held the phone over her left knee with both hands, quickly navigating through the images. We picked up a small deficit in the accuracy for her affected (right) side of 88%, compared with 100% on the left. Here response times were very quick, both at 0.9 seconds.
I asked her to repeat the test on a couple of occasions whilst leaning over her right knee/side of space (i.e. her painful side), which she was happy to do. On these occasions the accuracy remained at 100% on her left side but dropped on the right/affected side to between 75-80%.
Interestingly there was also an accompanying change in her response times for her right side. They slowed to between 1.3-1.6 seconds, whereas her left side remained at 0.9 seconds.
I think this is an important change. There is a reflection here of a processing bias away from her right side (shown in the slowing of times) when performing the test in her right-sided space. There is also a reduction in her online body schema for her right foot whilst performing this in her right-sided space.
I am pretty sure that there are a number of factors that could be considered when interpreting these interesting, empirical observations. What this and previous clinical experiences have taught me is that there are obvious strengths when being a little more creative in our assessments to inform and add further individual, context-based creativity to treatment. It is liberating to know that we don’t have to jump straight into a protective force field in order to gain a better understanding of a person’s pain experience.
To secure your place at the special Graded Motor Imagery Event with Tim Beames and Bob Johnson click here for easy online registration and payment
Tim, do you have any idea which cutaneous receptors might be involved in establishing and maintaining the force-field (= peri-personal space)? How is the force-field mapped dynamically by the brain?
Different Tim, but Giando Iannetti has done some great work on peri-personal space (I’m sure you’re aware of it John, but for the others playing along at home – his lab’s website has many of his papers available as PDFs – http://www.iannettilab.net/products/a2016/).
Perhaps your question is a red herring, as it seems that the defensive peripersonal space (DPPS) is modulated by many factors including cognitions, vision, and proprioception. Giando has also shown that the ‘shape’ of the DPPS is dynamically altered by gravitational cues (i.e.. whether we are upright, supine or sideways).
Thanks Tim. Am I correct in my understanding that the peri-personal space is not dependent upon the availability of visual information? If this is so, my question may not be a red herring.
This is where i think it gets a bit tricky. The Hand Blink Reflex is often used as a proxy to ‘measure’ the DPPS and Giando has shown that blind individuals can display a similar HBR as sighted individuals regardless of the age that blindness occurred. But individuals with last onset blindness also display a ‘far-near’ effect such that as the hand gets closer to the face, the evoked HBR is increased. One interpretation of this is that DPPS and associated defensive repossess are learned during a critical period of developing visuo-spatial integration (3-7years old) with vision being crucial during this time.
Missing, of course, in all of these papers is any exploration or discussion of the phenomenology of DPPS – in either sighted or blind individuals. Is there anything that it is like for a blind individual to have a threat enter their DPPS (but not touch their body) if they can’t see it?
A long winded way to answer your question, which would have been equally well answered with “i don’t know’!
Perhaps Tim Beames might like to comment?