The final blog in this 3-part series introduces Graded Motor Imagery (GMI) and its role in treating pain and movement dysfunctions. The introduction is used to help create a focus on a key principle of GMI: making patients think. Engaging a patient’s mind during daily clinical practice can be challenging, but in doing so there may be a vast untapped potential waiting to be discovered.
What is Graded Motor Imagery?
GMI is considered a first line, non-threatening assessment and treatment regimen targeting primary somatosensory cortex and primary motor cortex smudging in cases of persistent pain, phantom pain, and complex regional pain syndrome. GMI has been shown to create healthy neuroplastic shifts in unhealthy somatosensory and motor cortexes through novel “brain exercises” (here). GMI brain exercises are purposed to engage thinking and thoughtful consideration of a painful body part and its neighbors without moving the painful part.
Traditional GMI includes assessment and treatment of laterality (left and right discrimination); motor imagery/movement visualization; sensory discrimination (localization, two point discrimination, graphesthesia, stereognosis); and mirror therapy. While the order of these treatments can vary, the above sequence is a common order for their application in the persistent pain population. If treating someone with significant persistent pain, the order matters and a deeper understanding of these treatments is essential. However, discussing the depths of GMI is not the purpose of the blog.
I have heard many therapists pose the question, “If GMI works for complex pain, why would its principles not have the potential to benefit common pain and movement dysfunction?”
The widely accepted notion that all pain is “an output of the brain” should lead one to ponder the possibilities that exist for using GMI principles each day in the clinic.
Living deep within the heart of GMI is the principle of engaging the mind to think about and consider the existence of pain and movement in different ways. It is this principle that may enhance daily clinical practice.
Discovering hints that a patient may need to be challenged to think about their pain can often be found through listening during the subjective exam (here) and (here). It is new and foreign for many patients to have to think about why pain is present, why it still hurts, what is believed about the pain, and what activities might resume if the pain were gone. Instead many just know it hurts and do not want it to hurt any longer. The patient may look perplexed or annoyed as you ask questions that make them think. What a patient may think initially is, “get along with it you silly therapist and just fix it you nitwit”. But I have learned to love those looks! I now have the patient’s attention in a new way. Replying with something like, “thank you for being patient with me and my questions, you are really helping me understand what you are feeling and why you hurt”, helps progress along allowing more time to engage thoughts. It is often around this time that a patient remembers something that they had forgotten about their pain experience and shares a valuable piece of information.
Classic objective examination procedures create another ideal opportunity for challenging patients to think.If you find yourself flying through the objective exam and getting lots of solid objective data, but have not engaged patient thinking, you have missed a potential opening for positive neuroplasticity.
A “patient thinking” objective exam is slower, compares lots of involved and non-involved sides, and gives time for patients to consider questions like:
-What does that feel like compared to the right side?
– Does it hurt more here or here?
-What do you think might help that part feel better?
-How does that feel if I do this?
-What do you notice if I push here compared to here?
-Is that your pain or just stiffness?
It can be a slow dance of asking, thinking, and giving time for a response.Making a patient think with an objective exam can help make a problem feel known, create perceived value in the quality of the exam, build trust and create better explanations for why the pain exists.
As is often the case, objective testing turns into the treatment. The treatments should have a similar goal: encourage thinking about what is happening, where it is happening, and how it feels. Thinking treatments, whether the outcome is better or worse, puts the patient in the driver’s seat with a potentially better ability to understand why the change happened.
Stimulating and inspiring a patient to think during an exam and treatment will make the process slower and will leave less time to do other things. Though that is the cool paradox of it all.The things you decide to do may create an environment for igniting neuroplastic shifts that ultimately require you to do less. There are no right or wrong ways to make patients think. Do it in your own style and within what you already do. But at the end of the day ask yourself, did I make my patients think or did I just tell them what to do?
––– Comments
Jarrod
Commented • September 25, 2017
Thank you Debbie for reading and your comments. I like how you say touch and manual therapy are "putting the body part back in the brain". The essence of treating the whole person requires both peripheral and central considerations. I fully agree that using our hands, at the right times, can influence the CNS in a positive way as we nudge all patients toward exercise, movement, and function. Getting the right combinations of these components is the art and skill of what we do. I think it is part of what makes our job both rewarding and challenging. It keeps us on our toes and always hopeful that we can help the next person that walk through the door. Thanks again. Jarrod
Debbie Rico
Commented • September 21, 2017
Thank you Jarrod for your great insightful series. It is a wonderful thing to have a patient tell you their problem, they don't quite know where it is...it is in their neck. You ask which side, they say, "the whole thing". So you examine, touch them, ask them questions and they begin to open up. They ask, "How did you know where to push?" " That is it, that is my pain!" I think what we are doing more than moving a joint or tissue, is putting that body part back in the brain. Yes, there is something happening locally, but also centrally. We cannot forget our manual skills, but we need to learn more and understand how we influence the central nervous system through our hands. Physical Therapy is a contact sport. Then we take them and exercise. Allowing the brain to activate those tissues and joints in a non-painful way. It is really cool when that occurs.
Jarrod
Commented • September 20, 2017
Thanks for reading Jessie. I appreciate your response. I totally agree that all that the potential to heal and improve lives within all patients we see. Especially when a patient is exposed to tools that help their individual system to protect less. I am learning that one of the best ways to nudging them along, as you say, is by challenging their capacity to think about their problem in a new way. When this is done in a caring, motivating,and encouraging environment the sky is the limit. For many this is the cornerstone of positive change to move forward and live a better life. Thanks again! Jarrod
Jessie Podolak
Commented • September 19, 2017
"Did I make my patients think, or did I just tell them what to do?" That is so well said, Jarrod! It gets to the heart of what truly fosters change in people. For so long, I just told patients what to do, and when they didn't improve, I felt defeated. But now, as I ask better questions and ultimately put more ownership on them, the results are much different! I am convinced that the vast majority of those we serve have everything it takes within themselves to achieve healing. They just need some skillful nudging from us to help discover and access the tools that will bring about deep and lasting change. Great post, and great series! Thank you!!