Graded Motor Imagery and how it can help people with chronic pain

1. Copyright Lorimer Moseley 2009
Graded motor imagery
1. Implicit motor imagery (left/right judgement task)
BodyInMind.com.au
Moseley (2004) Pain; 108: 192-8;
Moseley (2005) Pain 114;54-61
Moseley (2006) Neurology 67 2129-34
Graded motor imagery, as it has been tested in clinical trials, involves three stages. The first stage involves practicing the left/right limb judgment task. For
this, the patient sits in front of a computer which displays left and right hands in a variety of different positions. The patient responds to each according to
whether they perceive the pictured hand as a left or right hand, by pressing one of two buttons.

2. Is this a left or a right hand?
Copyright Lorimer Moseley 2009
One image is shown at a time
Software is online and via CD
“Recognise” www.noigroup.com
Objectives:
- Equal reaction times for left & right
- >80% accuracy
BodyInMind.com.au
These are examples of the sort of pictures that can be used. The recognise program has a range of pictures including pictures in which the
hand is doing a functional task. I think that they are great, but we haven!t done any experiments on them and we didn!t use them in the clinical
trials. In reality, we progress from this stage to stage 2 when patients reach performance targets, not in two weeks. Importantly, I am very
confident that for patients to make gains, they have to practice very often. In the clinical trials we had compliance of about 75% for hourly
practice sessions (not while they sleep of course!) We enhanced it by sending SMS messages and emails, and phoning them and telling
them they were champions.

3. Copyright Lorimer Moseley 2009
Graded motor imagery
1. Implicit motor imagery (left/right judgement task)
2. Explicit motor imagery (imagined movements)
BodyInMind.com.au
Moseley (2004) Pain; 108: 192-8;
Moseley (2005) Pain 114;54-61
Moseley (2006) Neurology 67 2129-34
Stage 2 of the graded motor imagery also involves looking at pictures of hands on a computer monitor, but now the patient imagines adopting the position
shown in the picture.

4. Imagined limb movements
Copyright Lorimer Moseley 2009
One image is shown at a time
Software is online and via CD
“Recognise” www.noigroup.com
“Imagine adopting this posture with your
own hand and then returning it to where
it is. Imagine a pain-free, smooth
BodyInMind.com.au
movement”.
Objectives:
- Little or no symptom provocation
- Task is easy or boring
Again, I think it is critical that patients practice a little, alot!

5. Copyright Lorimer Moseley 2009
Graded motor imagery
1. Implicit motor imagery (left/right judgement task)
2. Explicit motor imagery (imagined movements)
3. Mirror movements
BodyInMind.com.au
Moseley (2004) Pain; 108: 192-8;
Moseley (2005) Pain 114;54-61
Moseley (2006) Neurology 67 2129-34
This stage again involves a large amount of practice and pretty much follows the ideas described by McCabe et al in Bath. We use the Recognise photos and
instruct patients to slowly move both hands into the posture shown. They look at their ‘good’ hand in the mirror while they do it.

6. Mirror movements
Copyright Lorimer Moseley 2009
“Gently adopt the posture shown with
both hands, while watching the mirror
image of your good hand”.
Objectives:
-Little or no symptom provocation
BodyInMind.com.au
-Movement is not dystonic
-Movement L & R similar in range and
speed
- Task is easy or boring

7. Single
Copyright Lorimer Moseley 2009
n
blind RCT
it io
d
ine
gn
or
ag
co
irr
Im
Re
M
MIP MIP
50
Neuropathic
pain scale
BodyInMind.com.au
Crossed over
20
0 2 4 6 12 18 24
Moseley(2004) Pain; 108: 192-8; Time (weeks)
These are the results of the first clinical trial. The citation is shown. All patients had chronic CRPS that began with a wrist fracture. A score of 40 on the
neuropathic pain scale would equate to about 6-7 out of 10 on a 10 point NRS. Here, the measure refers to average pain over the last two days. The dark
circles denote the group of CRPS patients who were randomly allocated to the MIP. The control group, who were under the usual care of a GP, showed a
similar response when they were crossed over.

8. Copyright Lorimer Moseley 2009
Single
blind
• CRPS of arm or leg RCT
• 18-75 years old
• No other diagnoses Moseley (2006) Neurology 67 2129-34
• English-proficient
• Presented to GP,
physiotherapy, Pain
BodyInMind.com.au
management or
neurology
This is the most recent clinical trial, which included CRPS patients regardless of duration or initiating event, and patients with phantom limb pain after
either brachial plexus avulsion injury (the brachial plexus is ripped out of the spinal cord, most commonly in a motorcycle accident), or amputation.

9. Single
Copyright Lorimer Moseley 2009
blind RCT
BodyInMind.com.au
Moseley (2006) Neurology 67 2129-34
This is the consort diagram - note that all but one (in the control group) completed the trial. Also note that 20% of the CRPS patients did not fulfill the
diagnostic criteria for CRPS, set out by the IASP.

10. Single
Copyright Lorimer Moseley 2009
blind RCT
NNT to get a 50%
reduction in pain
Post-MIP = 3 (2-6)
6 months = 2 (1-5)
BodyInMind.com.au
NNT to get a 4/10 point
increase in function
Post-MIP = 4 (2-11)
6 months = 3 (2-4)
Moseley (2006) Neurology 67 2129-34
The results of this clinical trial: a dodgy figure - sorry. The key information is in the box. NNT = number needed to treat, in this case to get a 50%
reduction in pain, for one patient to get that response that they wouldn’t not get in the control group. Some important caveats here: 1. practice 2. practice 3.
practice!