Thursday, May 10, 2012

"The Graded Motor Imagery Handbook" a much anticipated addition to NOI Group's "Explain Pain".

 This new Noigroup publication is born of a firm conviction that, as Lorimer Moseley says, "people in pain do better if they are given the resources to master their situation". To this end The Graded Motor Imagery Handbook builds on and extends much further the knowledge that  Explain Pain began. A persistent theme is that treatment requires patience and persistence, courage and commitment. I have to agree with that. Lorimer sums this up beautifully on page 37.

The book is divided into five sections - knowledge, background, treatment, stories and tool boxes.
David Butler in the first section tells us about this exciting new era in rehabilitation powered by the neuroscience revolution of which Graded Motor Imagery is an important part. David explodes some myths and builds on the plain common sense of Explain Pain. He offers suggestions and encouragement, including encouragement to share your experience and thoughts. This open mindedness is refreshing.
David explains that Graded Motor Imagery (GMI), unlike a program is not preset. It's a series of novel treatment strategies which remind us that representation of body in the brain should be considered in all patients. Importantly he says that patients cannot be just passive recipients of treatment. They need to self manage and understand that gaining knowledge is part of treatment - knowledge is power - knowledge can be therapy. "If you have knowledge of GMI you have skills to know why it hurts so much today and how to deal with it."

In the second section of The Graded Motor Imagery Handbook Lorimer Moseley gives us the science underpinning the concept of Graded Motor Imagery. He also explains such things as delayed reaction time in left/right hand judgements and why sometimes even imagined movements make some feel pain. He gives a great explanation of possible mechanism of spreading pain which can manifest as imprecise movements or dystonia. Lorimer explains the pattern of primary sensory cortex (outermost layer of brain) activation caused by stimulating different points on the skin. Using this method of brain activation a representation of the body in the brain has been drawn called sensory humunculus (humunculus means little man). Page 27 has a simplified 2D  illustration of the body in the brain. The picture looks grotesque, out of shape. This is due to the richness of innervation of different body areas.  As I actually gained remission finally twice from Yamamoto New Scalp Acupuncture I was excited to learn that it utilizes this same sensory homunculus. Curiouser and curiouser.

Interestingly Dr Moseley (page 50) describes comparison between patients who used imaginary and mirror therapy with those who used the three step Graded Motor Imagery approach (that is left/right judgements followed by imagined movements and then mirror therapy). In his results with ungraded motor imagery "patients tended to get worse in those phases but improved when left/right judgements were used and then further improved when the next steps were followed. " I'm putting this here because what I like about this book is that the authors don't pretend to know it all. I did not have the benefit of left/right judgement before I began mirror work, nor did I know anything about imagined movements as therapy. I read about mirror therapy, worked out what might work and experimented. With persistence, a very little and often over a long period I improved. I suspect that keeping the training very short prevented worsening of symptoms as described. The important message here is that beyond doubt, pain can be reduced by brain retraining methods. 

Tim Beames authors the third and no less important section on treatment. He goes much further into the practical aspects of treatment, the stages, adaptive techniques, how to use Recognise, implicit and explicit motor imagery and on to mirror therapy This is a valuable section for clinicians as many examples are given. Telling photos of mirror therapy in practice will be an asset for both therapists and patients. There's a great "how to mirror therapy" table on page 89. Each section is clearly summarized and on page 92, Timothy brings it all together and encourages us to be creative and "not be satisfied with just managing pain." I like his attitude.

David takes the fourth section to a new level. I like the way he cuts to the chase, a no nonsense approach explaining how stories and metaphors can "get us through". He has a great knack of keeping it simple and really getting his message across. I like too the analogy on page 114 of our brain being "our own drug cabinet". I agree with what he says at the end, "Basically, knowledge is the greatest pain liberator of all. The key is in your hands."

Now to the final section written by Thomas Giles. I'll call him Tom. Tom describes himself as the nerdy one. It's one thing to tell us what, but he's the one who shows us how to access and use the tools to make it work. It's refreshing to see this depth of information and practical support. From system requirements and connecting to Recognize to making your own resources, Tom explains it all simply and logically. He encourages us to share our ideas. Just contact NOI Group. Many people with CRPS contact me asking where they can find out more, who can help them, where there's someone in their area.  Now I can suggest they go to their local clinician. If the clinician/physical therapist is unfamiliar with Graded Motor Imagery this link and this wonderful book will provide the answers. Ignorance of something new isn't a problem. It's an opportunity.

At the end of his section Dr Moseley asks "Does Graded Motor Imagery work?" I'm reviewing this book because I know this works. I believe The Graded Motor Imagery Handbook  is a great resource for patients but I consider it is a must for those who treat people in pain. I add my encouragement for clinicians who use it to document what you do and add to the growing body of evidence by sharing your results and experience. This book gets a big thumbs up from me.

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