Introduction to Graded Motor Imagery: Reducing Phantom Limb Pain

by Kerstin Baun, MPH, OTR/L, on Aug 31, 2020 2:59:11 PM

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Graded Motor Imagery may sound a bit mysterious. Simply stated, it's a non-invasive treatment option that can help decrease phantom limb pain and improve myo-electric prosthetic control in people with upper limb amputations. Graded Motor Imagery consists of three stages:

  1. Laterality Reconstruction (left/right discrimination exercises)
  2. Motor Imagery
  3. Mirror Therapy

How does it work? The brain has "maps" of the body and when an amputation happens, those maps no longer match the sensory and motor signals from the body. This has been proposed as a primary cause of phantom limb pain. Research has shown that Graded Motor Imagery training techniques may allow the neural pathways that have been affected to return to how they were before the amputation. Because of this, it is theorized that using these techniques may assist with decreasing pain and improving control of the muscles that are used for operation of a myo-electric prosthesis. When regularly practiced, they have the potential to greatly improve the overall daily function of someone who has experienced an upper limb amputation.

Consulting a therapist who is knowledgeable and experienced in using Graded Motor Imagery techniques and can help guide you through the three stages is recommended. If you would like help in finding an occupational or physical therapist to get started, please contact us.

Laterality Reconstruction

Laterality reconstruction is essentially a training program that targets the neurologic connections between the brain and the missing limb by having you identify body (in this case arm/hand) images as either left or right. In this article, we will discuss laterality reconstruction. We have articles about the next stages, motor imagery and mirror therapy, if you're ready to learn more about those.

To get started with laterality reconstruction, you can download apps to a cell phone or tablet: you may want to purchase an application called Recognise or download the free application called Orientate. These applications are used for testing and training the ability to identify the left and right sides of the body, which is what laterality reconstruction is all about. Recognise may also be purchased for use on a computer or in flashcard form.

If using the Recognise or Orientate App, follow the instructions that accompany the program. Use the programs frequently (several times a day) until you can consistently achieve 90% or greater accuracy and speeds of approximately two seconds or less per image.

If you are not able to download the applications Recognise or Orientate, you may want to search "hands" using a search engine like Google. After searching, click the Images option under the search bar. Find images that are left hands and find separate images that are right hands. We recommend printing at least 20 images so that you can use them as flashcards. You may need to ask for someone to help you identify which hands are left and which are right. Then mark the back of the flashcards to indicate whether the image is a photo of a right or left hand. Then do the following:

  1. Go through the flashcards frequently (several times a day perhaps after breakfast, lunch and dinner) until you can consistently achieve 90% or greater (9 out of 10 or 18 out of 20) right and left accuracy in under ~ two seconds per image. The nice thing about flashcards is that you can take them with you and do the exercises whenever you have a free moment.
  2. Once you achieve the goal of 90% or greater accuracy, you may move onto the Motor Imagery techniques that we will describe in our next article. However, from time to time, return to laterality reconstruction to determine if your laterality is still intact.
  3. Apply your laterality ability to real life situations by looking at people’s hands at home, on the bus, in the store, at work, etc. and try to determine if the hand you see is a right or left hand.

By practicing this technique, your brain uses its movement planning areas to start normalizing messages between the brain and body. The goal of laterality reconstruction is to help prepare your brain for the next steps of motor imagery and mirror therapy. Keep in mind that laterality reconstruction exercises are not a "test" they can actually be fun! Try your best to not become frustrated if you are not a pro at this exercise in the first few days. Recovery takes time and is not linear. Go easy on yourself and know that you are working toward mitigating your pain.

If you are ready to move on from laterality reconstruction, you should be working with a physical or occupational therapist during the next steps of motor imagery and mirror therapy. Please reach out to us if you are looking for a therapist to work with. If you have tried laterality reconstruction and would like to tell your peers about your experience with it, please leave a comment below.

Topics:Arm Dynamics TeamUpper Limb LossProfessional AdvicePainPhantom Limb PainGraded Motor Imagery

About the Upper Limb Library

Arm Dynamics is the most experienced upper limb prosthetic care provider in the world. Our Upper Limb Library is our community space for articles for and by those with an upper limb difference. Read on to learn all about issues that affect those who have had an amputation, and be sure to leave a comment letting us know what topic you’d like to know more about!

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