Tag Archives: #teaching

The Basics of Graded Motor Imagery

Below is a blog post I wrote for the American Academy of Orthopedic Manual Physical Therapists. I am the Fundraising Chair for the Student Special Interest Group, and one of our duties is to compose relevant material for the group’s blog.

https://aaomptssig.wordpress.com/

The Basics of Graded Motor Imagery

 

Depending on how far along you are in your curriculum, you have probably heard words like “cortical reorganization,” “central sensitization,” and “mirror training.” You may have had some lectures that addressed pain, central sensitization and graded exposure to activities. You may have even seen the wonderful G.L Moseley’s research into Graded Motor Imagery (GMI) and its application to patient’s with CRPS, phantom limb pain, and chronic pain. If you are like me, however, you never got the full picture of how to clinically apply GMI to a live patient with real, chronic, centrally mediated pain.

 

We are probably all familiar with Penfield’s homunculus and its simplification of cortical representation in the both the motor and somatosensory cortex.

image1

Research has shown that in chronic pain states, the cortical representation of the affected body area becomes “smudged” and the brain has a distorted view of the area. Even small activation of these areas can be very painful for patient. This plays heavily into the manner that patients with chronic pain typically describe their pain. “Diffuse,” “poorly located,” “has a mind of its own.”

 

This knowledge of cortical reorganization becomes important when educating patients with chronic pain in that their pain is not necessarily related to any tissue damage. It is a hard concept to get your patient to understand, and I often heard “Oh, so the pain is all in my head.” I highly recommend getting your “pain talk” down so that patients are able to digest this information without feeling like their pain is somehow not real.

 

GMI was designed specifically to address this cortical reorganization and other processes of chronic, centrally mediated pain. According to the Neuro Orthopaedic Institute (NOI), “GMI is a sequence of strategies including laterality restoration (being able to identify left and right limbs), motor imagery and use of a mirror box.”1 It is rooted in biopsychosocial theory and addresses how pain is “lived.”

 

The first step to GMI is laterality training. The cortical reorganization involved in chronic pain leads to a distorted view of the limb. Laterality training determines how easily a patient can judge left/right images of their affected body part. Additionally, laterality training does not activate the motor cortex.

 

The training is broken down below:

 

  • How?
    • Recognise App/online
    • Flash Cards
    • Magazines
  • Dosing:
    • IT DEPENDS!
    • Start with 20 images with 10 seconds of time
    • The patient CANNOT MOVE their hands to guess the position
    • Try to get them to respond as quickly as possible
    • Gauge symptoms
      • It’s ok to be sore as long as you are safe
    • Try to have the patient practice 4-5x per day without flare up
    • Rough baseline for advancement
      • 2 weeks
      • Looking for roughly 80% accuracy
      • 1.6s +/- .5s for neck and backs
      • 2.0s +/- .5s for feet and hands

 

Once a patient has reached the above criteria, they are ready to start with explicit motor imagery or in easier terms, imagined movements. If you are having a hard time digesting this one, let me help. If you are in a room with a door, imagine yourself walking through that door. No problem, right? Now imagine that door is open just enough to squeeze your body through. Now try to get through the door. Did you feel yourself slide between the door and the frame? Did you maybe “feel” the brush of the frame against your back? That is explicit motor imagery. Explicit motor imagery WILL activate the primary motor cortex.

 

The criteria are similar to laterality training and are below:

  • How?
    • Start with a movement that the patient is not afraid of
    • Break it down into steps
    • Have the patient try it in a quiet spot
    • Gauge the reaction
    • If it’s painful, take a step back to left/right images or find a different movement
  • Dose
    • 4-5x/day for 2 weeks without flare up

 

After achieving the above, it is time for the fun stuff! Mirror training is the last piece of the GMI puzzle. This activates the primary motor cortex almost as much as actual movement, which is why it is the last piece.

 

  • How?
    • Start slowly with the affected hand/body part in a static position behind the mirror
    • Place the opposite hand/body part in front of the mirror and perform movements while focusing on the reflection of the hand in the mirror
    • Start in a quiet place
    • Start with 1-2 minutes and progress from there up to 5-10min daily
    • As usual, take a step back in the case of flare-ups!

 

Here is a great progression of mirror training.

mirror-box-tips-for-progression-diagram

 

Those are the basics of GMI and here are some things to keep in mind.

 

  • It’s ALL individualized for the patient
  • You can start with any of the three progressions, but don’t get greedy!
  • You may need to start with an uninvolved limb if the patient is really sensitized
  • Have your patients practice in as varied as settings as possible as they progress. GRADE IT.
  • Dial it back if you have flare ups and be able to make suggestions to keep moving forward
  • A patient cannot harm themselves with imagery, but flare ups can only further sensitize
    • “It’s ok to be sore as long as you are safe”

 

For more reading, I recommend the NOI website at http://www.noigroup.com/en/Home. If you really want to become better at applying GMI, the Graded Motor Imagery Handbook and Explain Pain are both available on the NOI website.

 

As novice clinicians, patients in chronic pain states will most likely be our biggest challenge, but this is where it all starts. In my first clinical, I brought GMI to my CI and treated several patients with aspects of it. I challenge and encourage you to do the same.

 

Brianna DeBiasi

UIC SPT 2015

 

References:

  1. Available at: http://www.noigroup.com/documents/noi-gmi-evidence. Accessed December 26, 2014.
  2. Moseley GL, Butler DS, Beames TB, Giles TJ. The Graded Motor Imagery Handbook. . Adelaide Australia. Noigroup Publications. 2012

 

Humboldt Park Diabetes Empowerment Center

Matt Currier and I had the opportunity to aide a community near Matt’s apartment in Humboldt Park. Humboldt Park is densely Hispanic, particularly Puerto Rican, and many community centers and groups revolve around the Hispanic culture.

Unfortunately, diabetes also has found its way into Hispanic lifestyles. One study showed that the prevalence for type II diabetes is 18.1 percent in people of Dominican and Puerto Rican descent versus 10.2 in non-Hispanic whites.

In order to address the disease prevalence, the Humboldt Park Diabetes Empowerment Center was established. After contacting the center, Matt and I were asked to design a simple powerpoint to address exercise and injury in people with diabetes.

diabeetus

 

Above is a sample slide from the powerpoint. Our goal was to get the pertinent information in an easily digestible format so people would be able to apply the information to their lives easily especially since all of the material would be translated to Spanish.

This was a great opportunity to provide a continually used resource with evidence-based research incorporated, so that the people using the information could be well-informed and empower themselves.

The Student Becomes the Teacher

One of the most beneficial aspects of my first year of PT school was having hour long reviews led by the second years. It was comforting to have them guiding us along and revealing the subtle nuances to each professor’s teaching style. In some ways, they were the most influential experiences I have had simply because there was no fear in being wrong or asking dumb questions. It was simply students helping each other.

I had grandiose thoughts of leading as many review sessions as I could, but, second year of PT school has a way of clobbering you in the subtlest ways. Unfortunately, I was only able to lead 6 review sessions covering anatomy and kinesology. Despite only leading 6 reviews, I put almost 10 hours of prep time into the actual sessions.

It was extremely helpful to write material for these because it further implanted the foundation sciences we imbibed in our first year. It also allowed me to further mentor the first year students and give them the opportunity to vent and ask questions the way I was able to the year before.

One of the most important skills in our program is palpation and identification of important landmarks. Kinesology has 3 palpation check-offs throughout the semester: upper extremity, lower extremity, and spine. Having a good guide can help immensely when navigating these landmarks for the first time.

Below is one that took me over 3 hours to perfect and finish.  Review if you need!

Pictures are from Trail Guide to the Body: A hands-on guide to locating muscles, bones and more. Biel A. and Palpation Techniques: Surface Anatomy for Physical Therapists. Reichert B.

Landmark Palpation Tips
Hip Bony Structure
ASIS
  1. Place hands on hips with fingers in front and thumbs behind. Feel the tip of the pelvis that sticks out anteriorly.
  2. Make sure you are inferior of the umbilicus
PSIS IMAG0638
  1. Place your hands on the iliac crests
  2. Follow the crests around posterior hip. They will descend medially
  3. They are not as pronounced as ASIS
  4. Also can be visibly identified by the dimples at the base of the low back.
Iliac Crest
  1. Slide your hands down lateral abdomen to iliac crest.
Iliac Tubercle
  1. 2 Inches posterior of ASIS
  2. Feel the thickening of the iliac crest
Greater trochanterGreater Trochanter
  1. Locate the middle of the iliac crest
  2. Slide your fingers inferiorly 4-6” along the lateral thigh until you reach the superficial mass
  3. You should feel a wide, knobby surface.
  4. Medially and laterally rotate the leg and feel the trochanter move back and forth over under your fingers
Ischial Tuberosity Ischial Tuberosity
  1. Use your palm to find the prominent point under the gluteal fold
  2. On yourself, find your “sit bones” while seated.
  3. Stand up and continue while palpating.

 

 

 

Hip Soft Structures
Piriformis Muscle
  1. Halfway between PSIS and ischial tuberosity.
Inguinal Ligament
  1. Extends from ASIS to pubic tubercle in a diagonal direction
  2. Find these landmarks and palpate in the middle. “Strumming” transversely
  3. You should feel a cordlike structure beneath your fingers
Knee Bony Structures
Femoral Epicondyles
  1. Locate patella
  2. Slide directly lateral from the patella to outside of knee.
  3. Slide medially from center of patella.
  4. The medial epicondyle is just superior to the tibiofemoral joint.
Adductor tubercle (superior medial epicondyle )
  1. Located proximal to the medial epicondyle.
  2. Slide superiorly along the medial side of the femur.
  3. The femur will drop off into soft tissue.
  4. It is usually very tender to the touch.
Medial tibial plateau and Lateral tibial plateau
  1. Both medial and lateral plateaus are located on the proximal end of the tibia.
  2. Flex the knee
  3. Place your thumbs on either side of the patella
  4. Slide inferiorly and feel your fingers sink into the joint space
  5. Just inferior are the plateaus
Tibial Tuberosity
  1. Partner seated with knee flexed. Locate patella.
  2. Slide your fingers 3-4” inferior from patella
Gerdy’s TubercleGerdys Tubercle
  1. This area of roughness can be found on the anterolateral side of the tibia slightly inferior to the joint space.

 

Head of fibula
  1. Located on lateral side of leg.
  2. Locate the tibial tuberosity
  3. Slide your fingers laterally 3-4” toward lateral side of tibia.
  4. Palpate the knobby head of the fibula.
Patella (base and apex)
  1. Shift the patella from side to side.
  2. Feel for base, apex and lateral and medial sides.
  3. Remember the apex is inferior and the base is superior
Trochlear groove
  1. Slide just inferior to the apex of the patella
Joint line
  1. Palpate medially and laterally from the apex of the patella
  2. Move the tibia to confirm you are in the joint space

 

Knee Soft Structures
Patellar ligament
  1. Start at the apex of the patella.
  2. Slide inferior to find the patellar ligament
Medial collateral ligament
  1. Flex the knee and locate the medial epicondyle.
  2. Slide distally to the joint space
  3. Strum your fingertip along this space

 

 

 

Lateral/Fibular collateral ligament
  1. Flex the knee.
  2. Locate the head of the fibular and the lateral epicondyle
  3. Slide your finger between these points and gentle strum this cord like structure

 

IT BandIT Band This flat, wide, firm-elastic structure crosses over the knee joint to attach to Gerdy’s Tubercle.
Common peroneal nerve
  1. With the partner in prone, flex the knee and located the biceps femoris tendon and head of the fibula.
  2. Roll your thumb from side to side and explore the region just distal to biceps tendon.
  3. Distinguish the nerve from the gastroc by having your partner slightly flex the knee. The nerve should remain soft and mobile.
Popliteal artery
  1. Partner should be in supine. Flex the knee.
  2. It is situated deep in the back of the knee.
Gastrocnemius
  1. Palpate the large mass on the posterior aspect of the leg.
Ankle and Foot
Cuneiforms
  1. Locate the base of the first met
  2. Glide proximally to the skinny ditch of the first tarsometatarsal jt.
  3. Continue proximally to the surface of the medial cuneiform.
  4. Continue laterally along the dorsal surface of the foot.
Navicular
  1. Navicular is sandwiched between the medial and middle cuneiforms and talus.
  2. Locate the base of the first met.
  3. Slide along the medial foot to the cuneiform. And then slide off to the joint.
Talus: Head, neck, dome Head:

  1. Locate the navicular tubercle.
  2. Slide proximally off the tubercle to the head of the talus.
  3. You should feel a depression in comparison to the tubercle.
  4. Passively invert and evert the foot.
  5. The navicular tubercle will become more prominent in inversion.
  6. The talar head will become more prominent in eversion.

Neck:

  1. Head to the anterior aspect of the medial malleolus.
  2. Move just anterior and plantarflex the foot so the neck pops into your hand.

Dome:

  1. Passively invert and plantar flex the foot.
  2. Draw a horizontal line connecting the malleoli and drop inferiorly off the center of the line. The dome will be deep to the underlying tendons.

 

Medial Mallelous
  1. It’s that big bump on your medial inferior tibia.
Sustentaculum TaliSustentaculum Talo
  1. Palpate 1cm inferior from inferior tip of medial malleolus
  2. You should feel a bony eminence on the calcaneus that protrudes in the medial direction
Lateral Malleolus
  1. It’s that big bump on your inferior fibula.
Calcaneus
  1. Grab your heel
  2. That’s it.
Cuboid Cuboid
  1. The cuboid lies between the lateral malleolus and the base of the fifth met.
Peroneal Tubercle
  1. Dorsiflex the foot and locate the lateral malleolus
  2. Slide about an inch inferior to the trochlea.

 

Ankle Soft Tissue Structures
Spring Ligament
  1. Passively invert the foot.
  2. Locate the sustentaculum tali
  3. Locate the navicular tubercle.
  4. The ligament is in between these landmarks.
Deltoid Ligament
  1. Locate the medial malleolus and the sustentaculum tali.
  2. Strum horizontally.
  3. Slide distally from the medial malleolus at a 45˚ angle.
Posterior Tibial Artery
  1. Locate medial malleolus.
  2. Using 2 fingerpads, slide posterior to the malleolus and feel for pulse of the artery.
Dorsal Pedal Artery
  1. Located between first and second metatarsal
  2. Use gentle pressure to find the pulse
Lateral Collateral Ligaments:
Anterior Talo-fibular
  1. This ligament is not very distinguishable, but its near the anterior aspect of the lateral malleolus.
  2. Slide your thumb an inch toward the head of the talus

 

Calcaneal Fibular
  1. This ligament runs obliquely between the lateral malleolus and the lateral aspect of the calcaneus and passes posterior to the peroneal tubercle.
Posterior Talo-Fibular
  1. Start at the posterior aspect of the lateral malleolus.
  2. Continue around the malleolus posteriorly.
  3. The ligament is in between the malleolus and the calcaneal tendon.
Achilles Tendon
  1. Palpate the posterior/inferior aspect of the leg.
  2. Plantar flex the foot to feel the taut band of the Achilles Tendon