Graded Sensory Motor Imagery for Chronic Low Back Pain Occupational Therapy Management

Introduction to GMI

Graded motor imagery (GMI) has been used as a treatment for people with chronic low back pain.[1]Bowering KJ, O’Connell NE, Tabor A, et al. The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis. J Pain. 2013;14:3-13. … Reference List Chronic pain is pain that lasts longer than three months. GMI is thought to work for pain by facilitating cortex reorganization. GMI consists of three stages:

  1. Left vs. right discrimination
  2. Explicit motor imagery (EMI)
  3. Mirror therapy

2022 Study: Intervention Similar to GMI

The researchers asked the question, “What is the effect of a graded sensorimotor retraining intervention on pain intensity for adults with chronic low back pain?” Their findings were that in this randomized clinical trial that included 276 participants, a graded sensorimotor retraining intervention, compared with a sham procedure and attention control, resulted in a statistically significant improvement in pain intensity at 18 weeks (estimated mean difference, 1.0 point on an 11-point numeric rating scale [range, 0-10 points]).[2]Bagg MK, Wand BM, Cashin AG, et al. Effect of Graded Sensorimotor Retraining on Pain Intensity in Patients With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA. 2022;328(5):430–439. … Reference List

Graded Sensorimotor Retraining Protocol for LBP

  1. Pain education using Explain Pain book and RESOLVE web-platform that was individualized to the participant’s experience. Methods of instruction included graphical,  audio (podcast), video, narrative, and metaphorical. Consisted of pain neuroscience-based education.
  2. Sensory precision training included tactile localization and discrimination of sharp/dull on the back using a sharpened chopstick (sharp end) and pencil eraser (blunt end). Stimuli were presented in a grid pattern and participants progressed to more points being added e.g, 9 to 16, and a decreased distance between points.
  3. Participants performed the same sensory precision training at home (homework, carryover).
  4. Graphasthesia: recognizing letters on the back, then simple words, and finally simple mathematical calculations, e.g., sums. The activity was also graded up by decreasing the size of the stimuli of drawn letters and numbers.
  5. Mental rehearsal (imagery) of movements with progression using more complex images and decreased time allowed to answer. Homework was provided using an App for the same exercises.
  6. Motor empathy training: passive watching videos of others performing lower back movements. Training was graded up with increased complexity of movements and activities of video models.
  7. Explicit motor imagery involved the application of active imagination of themselves performing the movements in the videos. Complexity could be graded up the same way such as complexity, weight of load, and more relevant tasks.
  8. Mastering of smooth fluid movements in the lower back and at the hips using visual and proprioceptive feedback. Attention was focused on non-noxious aspects of the exercise, e.g., not pain.
  9. Part-practice was completed using components of functional movements that were painful at baseline with intragration of the previous stage. Focus is still on precision with feedback.
  10. Final stage involved performing functional movements that are relevant and meaningful to the patient and their goals in an environment that can still provide feedback.[3]Bagg MK, Wand BM, Cashin AG, et al. Effect of Graded Sensorimotor Retraining on Pain Intensity in Patients With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA. 2022;328(5):430–439. … Reference List

Traditional GMI Interventions

Stage 1 consists of correctly identifying left vs right images or videos. In the case of low back pain (LBP), the person would identify whether a person is turning left or right with their back exposed. Solutions such as Recognize by the Neuro Orthopaedic Instutute can help patients to discern the laterality of the back. Research say that left/right judgements should not be used in isolation as a stand-alone treatment for chronic pain.

Stage 2 involves imagination of movements without pain.[4]Sawyer EE, McDevitt AW, Louw A, Puentedura EJ, Mintken PE. Use of pain neuroscience education, tactile discrimination, and graded motor imagery in an individual with frozen shoulder. J Orthop Sports … Reference List For example, the patient can imagine performing painful movements at baseline such as lumbar flexion without physically doing it to avoid experiencing pain. This step requires multiple real and fictitious imaginations of situations – preferably meaningful client-centered activities. The more situations imagined the better. A good duration is 5 minutes daily.

Stage 3 mirror therapy for LBP can be for example with patients standing between two large mirrors facing each other. The mirrors should be placed so that there is a clear view of the patient’s own back. The therapist can mark landmarks such as the spinous processes in order to enhance visual feedback as the patient performs forward bending, extension, or side (lateral) bending.[5]http://www.aptei.ca/library-article/mirror-therapy-for-back-pain/ Why mirror therapy works is still uncertain, but this visual feedback  may play a role in reducing the fear and anxiety related to painful movements.

Occupational Therapy Interventions

Besides these 3 stages, it is important that the patient become educated in pain neuroscience. The patient can be educated on how the central nervous system processes pain. Pain education can also serve to answer questions and dispel myths, perspectives, and misunderstandings about pain.

After stage 3, patients can progress towards graded exposure and therapeutic exercise or participation. The patient can progress and perform prior painful motions such as lumbar flexion. They can progress their goals such as gradual increases in degrees of range of motion.[6]Iglar, L., Mansfield, C. J., Bleacher, J., & Briggs, M. (2021). Monkey See, Monkey Do—Using Graded Motor Imagery in the Management of Chronic Low Back Pain: A Case Report. JOSPT Cases, 1(1), … Reference List To incorporate participation in meaningful occupations, patients are encouraged to work towards performing these same movements in the real-world environment and activity.

GMI Study Limitations

  • Small sample sizes
  • Bias risk
  • Limited studies
  • Publication bias[7]Bowering, K. J., O’Connell, N. E., Tabor, A., Catley, M. J., Leake, H. B., Moseley, G. L., & Stanton, T. R. (2013). The effects of graded motor imagery and its components on chronic pain: a … Reference List

References

References
1 Bowering KJ, O’Connell NE, Tabor A, et al. The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis. J Pain. 2013;14:3-13. https://doi.org/10.1016/j.jpain.2012.09.007
2, 3 Bagg MK, Wand BM, Cashin AG, et al. Effect of Graded Sensorimotor Retraining on Pain Intensity in Patients With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA. 2022;328(5):430–439. doi:10.1001/jama.2022.9930
4 Sawyer EE, McDevitt AW, Louw A, Puentedura EJ, Mintken PE. Use of pain neuroscience education, tactile discrimination, and graded motor imagery in an individual with frozen shoulder. J Orthop
Sports Phys Ther. 2018;48:174-184. https://doi.org/10.2519/jospt.2018.7716
5 http://www.aptei.ca/library-article/mirror-therapy-for-back-pain/
6 Iglar, L., Mansfield, C. J., Bleacher, J., & Briggs, M. (2021). Monkey See, Monkey Do—Using Graded Motor Imagery in the Management of Chronic Low Back Pain: A Case Report. JOSPT Cases, 1(1), 61-67.
7 Bowering, K. J., O’Connell, N. E., Tabor, A., Catley, M. J., Leake, H. B., Moseley, G. L., & Stanton, T. R. (2013). The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis. The journal of Pain, 14(1), 3-13.
Jeff is a licensed occupational therapist and lead content creator for OT Dude. He covers all things occupational therapy as well as other topics including healthcare, wellness, mental health, technology, science, sociology, and philosophy. Buy me a Coffee on Venmo.