We get heaps of requests for help here at NOI and much of it is in the area of graded motor imagery (GMI). A frequent call for help is about how to help people with heightened sensitivity imagine movement in a body part. If we follow the broad protocol, better outcomes with the mirror will occur if you have the skill to imagine a body part in the first person i.e. actually experience yourself moving even though you are not.
Frequently the person can imagine themselves moving the non-painful/affected side but not the other. Left right discrimination abilities are usually OK and we are assuming a part disembodiment. Recent calls for help have been with a burnt hand and CRPS,
We have a few ideas, but there are many people out there with great skills in imagery.
We would enjoy some thoughts on how to help people achieve this skill or as I like to say – “get some good templates for movement”.
David Butler
www.noigroup.com
Hi, I am a chronic pain sufferer who has found imagined movement helpful.
If you mean imagined movement is difficult because it triggers pain, then try imagining the opposite movement. e.g. if raising your knee is the problem then imagine slowly lowering it, as if releasing the muscles. ie using the same muscles but not in the same direction that has become associated with causing pain, I believe this is called eccentric movement.
If you find it difficult to visualise the movement, imagine interacting with something. e.g. for a hand imagine a feather floating down and imagine straightening out your finger to reach it, so there is a reason for the imagined movement.
I also imagine doing things that I know well. I played a lot of sport so I imagine running in a place I loved running, or reliving particular goals I scored. This has the added bonus that it makes you feel happy! However, it is sometimes so vivid that something more gentle is best to start with.
I used to use imagined movement when I was fit to try to improve my hockey skills between matches and it was very effective then too.
Thanks Caroline,
These are really perceptive comments and we are delighted to include them here. You may be more intuitive than many clinicians. Imagining the opposite movement is great (another example – if walking forward is a problem try walking backwards – this change of context will “exercise” the brain neurosignatures related to problem forward walking in a slightly differetn and perhaps nonpainful way.
I also like the idea of imagining for a reason and delving back in time for older perhas non affected brain pathwsys and memories. Its all about context.
Some of our patients may not be in pain but simpy can’t imagine the part.
All the best
David
Caroline and Dave, you both bring up really useful imagery tools for those with significantly altered body schema. i am having difficulty at the moment with a patient who is unable to imagine anything without a verbal assist from someone reading an imagery ‘dialogue’ to assist in the imagination process. At this point i am considering including 2-point discrimination training on the unaffected side to see if we can get a little closer to the involved body part. Any feedback or reflection would be welcomed.
I have borrowed a phrase from Richard Wiseman called ‘As If’ thinking. I say to patients to look a the reflection in the mirror ‘as if’ it is the affected limb/part moving. Think this is really importnat as I ‘think’ it helps them emobdy the reflection as if it is their affected side moving.
Another plea for help.
I have a patient at present who has bilateral leg pain where with a central driver for her pain. Her main problem is walking.
She has normal laterality scores for all her back and lower limb parts.
However she cannot imagine walking, she is able to manage a few steps then something strange happens where she either walks with the same leg going forward all the time or other odd and strange patterns.
We are now trying to break the pattern down and have looked at imagery with backward walking, walking up steps, walking sideways and just single leg raises.
Anyone got any other ideas how to break the pattern down further or any other jems to re-engage the walking representation in the brain.
Hi Dave,
What about using emotional cues, like imaging walking towards someone she cares deeply for, who is walking towards her to embrace her?
Or if she is someone who has an affinity and / or familiarity with water, imagining paddling in the pool, and then grading up to imaging feeling the ground beneath her tip toe-ing and then walking into more shallow water?
Maybe imaging cycling her legs in deep water will help with fluidity of movement as a progression to a walking pattern.
Hope this helps and all the best!
Jacquie Pohl
Hi Dave,
My feeling is that lots of people have a real sense of disconnection with the body and particularly with the part that is in pain, so getting them to imagine that part moving is a bit like jumping ahead to mirror therapy in GMI. They need to practice actually getting a ‘felt sense’ for the body first. This is of course coming from my mindfulness background, so I may be biased here, but a conceptual sense of the body is very different from the perceptual and I really think that needs to be established before moving on to imagined movements. This can take some time and often daily practice of simple things like actually feeling the body either sitting or lying down, even things like noticing where the body is making contact with the floor or chair, noticing all of the sensations, even if the sensation is neutral or not really much at all, gets people to tune into the feeling world of the body. Imagined movements seem to come much more easily once this is established.
Marelle Wilson
oooh…. good stuff marelle. I concur that the sense of the body part is most important if one is to move forward, and beyond, in many pain states. Your description of the client/patient needing to catch on to a ‘felt sense’ of the body part is a great way to frame it. To me, that is also imagery, but the static observation of the part, not the dynamic ‘imagined’ movement we all want our patients to get to…. i have found this piece of the GMI spectrum to be the most difficult to transcend, and yet also the most important and powerful if further progress is to occur.
If anyone has other useful ways to assist patients to more easily ‘catch’ or get a sense of their body parts as part of the imagery process then get on the noijam blog and share them…. i can use them!
As part of a mindfulness meditation style body scan, I get people to scan through the body, part by part initially, with no expectation of feeling anything special. There may be sensations there, but there may equally be not much at all, perhaps a feeling of numbness, or not being able to see or feel the part, but that’s OK , even if it’s a feeling of nothingness.. and then move on. Its not the sensations themselves that are important, but developing the capacity to pay attention to what exactly is there. So perhaps, noticing where a better sense of being able to imagine the body actually kicks in again-is there a sharp border/edge, or more a gradual transition between the two areas? If they can’t see/or feel the body part, are they able to connect with something more abstract, like a colour or shape? Or on the other hand, the sensations may be so strong, there is the tendency to ‘not want to look or feel’ and so just noticing those thoughts too. At the end though (this could last from 10-30 minutes, depending on the patient), the thing is to then get a sense of the body as a whole, so moving from the body as separate bits, to perhaps the whole right side, or both arms at the same time, then moving to feeling more wholeness. For the purposes of the exercise, its also useful to explain that just for a short time, its OK to let go of any expectation for things to be different than what they are. A bit tricky to explain in this forum and best experienced! Takes practice and lots of repetition, like anything else.
really useful replies, thanks people.