Tim Beames - GMI 1

Hi, my name is Tim Beames.
I'm a physio.

I've got an interest in persistent pain,

also interested in bodily perception and
how that changes in pain states.

So, what I'm going to do is take you through a
brief introduction of graded motor imagery.

So, what exactly is Graded Motor Imagery?

I've just very simply summarised it as
a treatment approach

that aims to grade the exposure of
movement to the brain.

So it's a baby of Lorimer Moseley’s,

and he would say that it's taking the principles
from traditional rehabilitation

and taking it towards brain and
brain networks.

So it’s graded, is graded in the sequence,

and it's also graded in the exposure within each sequence
as well, and it consists of three different stages.

The first stage is an implicit
motor imagery stage.

So the important aspect of this stage, for me anyway,
is the fact that it’s implicit.

It means that it should be out of
your awareness.

So you can do, you can measure it,
and you can train this

in a number of different ways – mostly by identifying
left and right pictures of body parts,

so that's called a left/right judgement task
or a left/right discrimination task.

Is also being called laterality.

So many people will have learnt this
as a laterality stage.

So implicit motor imagery consists of
running movements in you,

in your brain, but without knowing how you're
running that movement within you.

The next stage of the sequence
is explicit motor imagery.

So the important part here, obviously
being explicit,

so now you do know that you're
running movement.

You know how you're taking yourself
through that movement.

Most people would refer to this as
imagine movement.

And a third stage is called mirror
therapy.

So mirrors have been used in number
of different ways

but the way the mirror therapy is traditionally used with
graded motor imagery is it’s placed on your midline,

you’re looking into the mirror,

and you're seeing a reflection of a body part as if you're
seeing the body part that is hidden behind the mirror.

So they are the three different stages.

As a summary of the difference,
the difference between those stages,

it's thought that there's a sequential activation
of cortical pre-motor and motor networks,

where the implicit stage of the graded motor
imagery process activates the premotor regions,

there’s slightly more activation than in the primary
motor cortex in the explicit motor imagery,

and then the mirror therapy stages.

Importantly though there's graded exposure within each
sequence of the graded motor imagery treatments.

So you can perform implicit motor imagery
with more or less challenge or threat,

be more or less meaningful change the
context within that part of the process.

So someone can be performing implicit
motor imagery at quite a difficult level,

quite a challenging level, and the
suggestion here,

is in this stepwise process, that the original
research and the protocol for the research was

that you would perform two weeks of
implicit motor imagery training,

then when you finish with that you would
move on to the explicit motor imagery.

The reality is that many people maintain the implicit
motor imagery part of their treatment

as they then start to incorporate explicit
motor imagery training,

and that will be true for the mirror
therapy as well.

There are changes also that they may not
be as easy as that it being a stepwise process.

So the original research was a 2-week stage so,
2 weeks of implicit motor imagery,

2 weeks of explicit more imagery,
2 weeks of mirror therapy.

In reality, so pragmatically, this may
not be as easy as the research set out.

There may be people who need to spend
a lot longer going through each stage

or 1 stage and may not necessarily respond that
well to one or other of the stages as well.

But the important part of graded motor
imagery, as we would said it out,

is the fact that graded exposure is integral to the
treatment as a as a part of a rehabilitation process.

And rehabilitation doesn't stop at
mirror therapy,

but also might start before implicit
motor imagery.

So there, it should be a part of a grounded
in traditional rehabilitation process.

People might do more of an observational
approach,

so this would be referred to as motor
empathy

and it’s simply just watching someone
move or watching pictures of people move,

but equally you could take any of these
stages into more of a performance level,

so both occupational and sport performance,

and certainly explicit motor imagery would
be the most well-known,

where we see people in sport perform
explicit motor imagery.

Usain Bolt, for instance, at the start of 100m
would run his race in his head.

So mentally, he's taken himself
through his race.

So, there's nothing to be said that this
should only be used in people with pain,

or people who are incapacitated or much
more disabled.

These are all parts of treatment that could be used within
rehabilitation at a much later or a high performance level.

Where does graded motor imagery come from?

I've got two different pictures here.

The first is from a paper by
Rama Chandran.

So talking to Lorimer, he was influenced
greatly by Rama Chandran,

who wrote an interesting book,
“Phantoms in the Brain” in the mid-90s.

And this is a picture of a paper of his,

where he was mapping out the sensory
perception of upper limb amputees.

And what he notices, as he was mapping out touch on
the face is that they felt both the touch on their face

but also on the phantom of the same time.

For me one of the most revelationary
findings that he discovered was

that if he just held ice cube against
the cheek of the amputee,

they would feel the ice roll down the cheek and at the
same time feel it roll down their phantom as well.

The suggestion here is it may, there must be
cortical involvement to this perception.

The other picture we've got here is some
of the original data,

looking at the altered representation within the
brain of the affected body part in amputees,

and this is a paper by Herta Flor.

The suggestion being that in amputees,
the affected body parts,

as it's represented in the brain,
shrinks or moves.

Some people have called this as smudging.

So Lorimer was, in particularly, he was
interested in people in pain.

He was interested in the cortical
involvement in different pain states.

Another thing that he was interested in is that there were
people taking through traditional rehabilitation,

where just, for instance, imagining
movement would be painful.

So for those people, where do you go
with our traditional thinking,

where do you go with traditional
rehabilitation techniques

and this is really the crux of graded
motor imagery.

It was offering people the chance
to do something

and do something actively when previously
just imagining moving may have been painful.

So who, who is it for?

The original research was performed in people with
complex regional pain syndrome, following wrist fractures.

I've got a picture here on the on the left-hand
side of the screen of one of my patients,

and you can probably tell that her right foot
has lost a little bit of the temperature,

so there's a significant difference in the
appearance of the left and the right.

CRPS has been used in research for GMI, and the reason
it's been used is it's such an enigmatic condition.

And what I mean by that is that there is evidence
of both peripheral and central changes,

and the traditional treatment approaches
have been far from successful.

So if we can help someone with CRPS,
not any CRPS;

other any enigmatic conditions that have been
explored, are things like phantom limb pain,

so pain where there's no longer a limb, pain
after brachial plexus, avulsion injuries as well.

So if we can help these people who traditionally have
been very difficult to be able to offer our help to,

then hopefully we can also offer people
with the more simple pain states.

How might graded motor imagery work?

There's a number of different thoughts
about graded motor imagery

and quite simply we don't know as yet
how it may work.

The traditional view is that it allows reorganizing
of altered sensory and motor maps.

So a study by Christian may often demonstrated
the normalisation of cortical representation

of the affected body part after
successful treatment.

It could be that it reverses learned
disuse of a limb.

This may fit with elements of pseudoneglect or a
pseudoneglect-like presentation that people have.

So they start to connect to or embrace that body part,
starts to be a part of them again.

It may be that there's a sequential
activation of cortical networks

associated with the affected movement
without evoking pain.

So by practicing, training, rehearsing this
a number of times,

it becomes less likely that that movement
will be associated with pain in the future.

It's almost as though you’re learning to be able
to do something without the association of pain,

so you’re unlearning the association of movement
and pain.

And that's the last of them,

the main theories behind our graded motor
imagery work isn't the normalisation

of the difference between sensory feedback
and the motor command.

And this fits with the sensory and
congruence theory of Harris.

So parts of the treatments, particularly
mirror therapy now,

you can see the combination of both the movement
and the sense of the feeling of that movement,

and perhaps giving her a more normal
balance between expectation

of what it should feel like as you're
moving.

Does it work?

So graded more imagery’s been explored all
be in very small numbers at the moment.

Lorimer’s original data explored complex
regional pain syndrome,

phantom limb pain, brachial plexus,
as well other aversion injuries,

all people who've been suffering
for many months.

And compared it with a treatment as
usual group, so a control group,

and the data here looks at the change in the baseline
measures immediately following treatment.

So at 6 weeks, and then at a 6-month
follow-up.

And the important findings are that for all of the
groups who performed graded motor imagery,

there’s a significant improvement in both
their pain,

and also in the perceived functions,
as well.

So the patients’ specific functional scales
were measured

and we’re seeing improvements following
the treatment at 6 weeks.

Interestingly, we see the improvement
increase at 6 months,

so it's almost as though they've taken
onboard this message,

this treatment, and they run with it,
and they’ve grown from it as well.

Jane Barring looked at graded motor
imagery,

compared it with a number of different
approaches in isolation,

so left/right discrimination task as a treatment, motor
imagery as a treatment, mirror therapy as a treatment.

One of the important findings that he
found in the systematic review

and meta-analysis of graded motor imagery
was that there was a significant improvement

compared with treatment as usual for the
graded motor imagery group,

who demonstrated this enigmatic pain states
of the neuropathic pain states so we've discussed.

As other evidence,

at the moment the trials of fairly small and one trial
using modify graded motor imagery approach

in non chronic complex regional pain syndrome
type 1 of the upper limb

and they demonstrated a reduction of pain
intensity, improving in grip strength.

A 4-week graded motor imagery treatment
of stroke,

demonstrating improvement of the upper
limb function.

And one case study that demonstrates
altered cortical activity

as a result of beneficial graded motor
imagery treatments.

But at the moment we really are left with
a lack of evidence.

More work needs to be done and its
underway at the moment.

There's obviously evidence against graded motor
imagery and it would be remiss to avoid this.

Other results by a group led by Johnson
were unable

to replicate the results that Moseley
demonstrated,

and had difficulty in implementing graded
motor imagery

in a pragmatic way across the two centres
with a special interest in pain.

So it may be that there are difficulties offering
graded motor imagery as a treatment.

What are these difficulties were the
pragmatic difficulties

that we come across and can we account
for them going forward?

So what I'd like to do is just take you through
the stages of graded motor imagery,

starting with implicit motor imagery.

So we going to see Nil's being taken
through

the use of the recognised app which
is available through Noi.

So he's going to guess left and
right hands.

So he's going to do it as quick
as you can,

as if he’s guessing, and the important part
here is that he's not giving the time

to think about how to go through that
movement.

Hence, it’s implicit.

So the important part of a left-right judgement
task is the fact that it's performed at speed.

We get several bits of data back through
this task;

we get data regarding their response time, the speed,
the response time is thought to reflect attention.

Now, the bias of attention both towards
or away from the affected limb.

The original data demonstrates a shift of attention
away from the affected body part in chronic CRPS.

But in an acute experimental pain situation the shift
is towards the affected limb painful body parts.

So in patients as I've seen,
this is only my patients,

my feedback from my patients, is not as simple as
someone coming to you with a persistent pain state

and always been out to predict that they’re going
to be slower on their affected body part.

Sometimes they're not, sometimes there's
no change in the speed.

Sometimes we see changes of the affective
body part relative

to the unaffected body parts or body
sides as well.

So there's a complexity to interpreting the data.

And the research originally focus very much on the
response time, more recently the accuracy rate.

So how many someone was able to get
right or wrong

has been more of a part of understanding
the results of the implicit motor imagery.

And the accuracy is thought to reflect the
precision of someone's bodily representation.

So, the bodily representation is also referred
to as someone's body scheme,

and this is all the understanding that
they have regarding their body,

without them having to consciously access
their understanding of their body.

So if you were to reach forward, pick up a glass,
take the glass to your lips, take a sip.

You're not having to think about
how you perform that task,

you're not having to mentally think how
am I going to reach forward with my hand,

how much force am I gonna use,

how strong do I have to be to
lift a glass up to my lips.

This is something that should
be done out of your control.

So body scheme is an important part of
the process of graded motor imagery,

and what we think we can help with,

identifying the patients is an important
part of graded motor imagery.

And picking up the changes in body scheme,

there may be certain words that they use, ways
of describing themselves, the use of it,

so it's almost like this, they've created a disembodiment
towards that body part or the affected body parts.

So there are a number of different cues
that may suggest

that you should test left/right discrimination
as a part of your assessment.

You could also use this as a part of the way of ruling
out the more simple mechanical perhaps problems.

Here's a quick video of one of my patients
performing left/right discrimination.

It's not unusual for people to shout out,
say left, right, move their heads,

trying to orientate themselves in relation to the
pictures that have been presented to them.

But we are possible, as a therapist,
we need to try and limit that,

perhaps that's more likely to be an
explicit task if they're really trying

to figure out how to mentally suss out what
they're viewing as a picture of a body part.

There are a number of studies just
looking at left/right discrimination,

left/right judgement task, as a part
of an assessment process.

This is certainly not an exhaustive list but just running
through some of the more seminal studies,

complex regional pain syndrome in the arm
greater than 3 months has been measured.

Complex regional pain syndrome, one of the wrist,
obviously Moseley's were upper limb amputees,

focal hand dystonia, chronic arm or
shoulder pain, chronic leg or foot pain,

back pain, painful osteoarthritis of the knee,
carpal tunnel syndrome,

complex regional pain syndrome,
and phantom limb pain, to name a few.

And universally, people have picked up
changes in either or both accuracy

and the response time exploring
these problems.

So we think about osteoarthritis or
carpal tunnel syndrome,

where they've been traditionally thought of
as problems relating to tissue change,

I suspect people may find it unusual to to
think that left/right judgement tasks

are found to be changed and altered
in the population as well.

A more recent study exploring back pain and
left/right judgments led by Jane Barring again,

it’s shown very interesting results.

So just taking us through this diagram, we've got
on the left-hand side an 80% accuracy rate

for normal population who have never
experienced back pain.

When Nils went through his left/right
judgement task, he’s got about 80%

so he should feel quite happy about that.

The next demonstrates the results for
people with an acute onset of back pain

and there's a wild variation here,
a wide variation.

So some people score incredibly accurately,
some people's accuracy is lost.

The next we see people who've had back pain
in the in the past but have actually improved,

so they no longer have back pain and what
we see here is that the accuracy rate

is fairly similar to those who've recovered
for a who's never had back pain.

And the last, and the one that's most significantly
different from the other results

is people who've had persistent back pain.

Now there's a huge amount of work to be done here
and we don't know whether there's correlation

in the shift in someone’s left/right judgement
task for their implicit motor imagery ability

and whether or not they are going to
improve from their episode of back pain,

but it does look like something that's
interesting for people to explore.

So, if someone improves from their
current pain states,

does that also correlate with having improvement
in the implicit motor imagery ability?

Or is it important to improve their implicit motor
imagery ability to improve their pain state?

Left/right judgment task has been offered
as a way of being able

to help original people who, by just
imagining movement, would be painful.

What I've just shown here is Lorimer’s
work again,

where they explored motor imagery in people
with chronic arm pain and in both groups

they demonstrated both an increase in pain
and an increase in the finger circumference,

so a swelling of the fingers, whilst
performing motor imagery task.

So for those people with the more
sensitised pain states,

left/right judgement tasks may give
them somewhere to go.

And perhaps this is because they're
activating their premotor regions

without the activation of primary motor cortex, that
may be an important part of the pain state for them.

So here we have results.

Just looking at the activation of
cortical networks,

so doing left/right judgement task activates brain areas
involved in high-order aspects of motor output,

so premotor cortices, but without
activation of the primary motor cortex.

At the moment that's an important part of the
theory that underpins graded motor imagery.

Here's a simple picture for most of you.

Just trying to guess whether that's
a left or right will be fairly easy.

This is slightly different, perhaps
a little bit more difficult for you to get in,

and clearly then we might find
correlation between them the ease

by mechanically of adopting position
shown as well.

So depending on the rotation and complexity
of the picture that you show,

there will be a shift in someone's
ability to identify it,

in regards to both speed and their accuracy.

And the moment people are starting to explore,

whether or not pictures presented in the first person
perspective versus a third person perspective,

is important in a pain state.

They may be important regarding gender,

they may be important regarding ethnicity
as well when we are identifying pictures

and quite simply we don't know what
they are at the moment.

What we do know is that there are top-down
influences on someone's judgement tasks.

So by taking the pictures and asking someone to
analyse how much pain they would expect to be in

if they adopted those positions, we find as
a correlation between the expectation

and the speed of guessing left/right
judgement for people with chronic CRPS.

So for me, if I I'm interested in the
notion that by doing a task,

it's an unbiased filter on some of the top-down
influences on someone's pain states.

So we've discussed their attentional bias, we've
discussed their representation of the body part,

and there may also be an element of expectation
that we're measuring here as well.

Moving onto explicit motor imagery.

This is an important part of a bit of
work here by Henrik Ehrsson.

In this study they’re scanning people as
they’re imagining doing movement.

What they are imagining doing is they’re imagining,
bending, and straightening their fingers,

or their toes, or waggling their tongue
side to side.

And the important finding here is that
the areas of their brain activated

correlates somatotopically to the part of the body
that is being moved or imagined being moved.

So, what we can take from this is
that someone,

when they imagine doing movements, the areas of the brain
activated some the networks of the brain being activated

when they're imagining doing the movement,

are the same as those that you would expect
when they're actually doing the movements,

so when they go through executing
that movement.

Looking at motor imagery in isolation as a treatment,
there's fairly contrasting results.

There are studies that have demonstrated
that motor imagery make people worse.

There's some studies that showed
no difference.

There's also some studies demonstrating
significant improvements as well and importantly,

analysing the data, there are significant
problems, risk of bias.

One issue is that the follow-up periods,

that they’re analysing data so their follow-up’s
perhaps not long enough into the future.

So there's a lot more work to be done on
motor imagery as a part of treatment in pain.

We're gonna go through an imagery
exercise now.

So what I want you to do:

Picture a glass of water in front of you.

Imagine reaching to pick it up.

Now, imagine taking a sip of that water.

Put it back down on the table.

Which arm did you use?

And when you went through it, did you feel
yourself moving towards the glass?

Did you see your arm moving?
Or was it a combination of the two?

I'll show you a picture

What I want you to do is imagine adopting
the posture shown in the picture.

And I want you to imagine it in a smooth
and pain free manner.

I want you to go through this twice and I want
you to imagine yourself actually doing it,

so feel yourself doing it, not just watch
yourself doing it.

So the pictures’ gonna come up, take yourself
through this twice in your own time.

My experience of taking people through this
is that some people are much more visual.

Some people are more kinaesthetic,
they have a feeling of it.

Some people have a combination of the two.

The data, the protocol as it was set out
originally by Lorimer,

ask people to go through the task
as I've said it out here.

It may be important for some people to alter
the context of the task as you go through it.

So some people like to close her eyes.
Some people like to have their eyes open.

What we do know is if the position that
you are in, or your phantom is in,

is totally different to the position
that you’re asked to adopt,

then it's significantly more difficult to
take yourself through this process.

So for those of you who do work with people
who have painful phantom limbs,

it is important to to work to begin with something
that conforms to the position of the phantom limb.

Moving onto mirror therapy.

Got a picture here of someone taking
themselves through mirror therapy,

and on the right hand side there's data
of Herta Flor's group.

Taking people through three parts of the
graded motor imagery process, 3, 2 parts of it,

but what they're doing is they’re
imagining moving,

they're moving using mirrors so they’re giving themselves
that feedback as we see in the picture,

or they’re actually executing the movements
and there's three different groups.

On the top that’s people with phantom
limb pain, in the middle,

people with phantom limb but without pain in the phantom
limb, and at the bottom, are the healthy controls.

I'm interested in a two things here.

The first is that if you take someone
through the use of mirrors,

both on nonphantom limb pain and the healthy
controls, what we see is as they're using the mirrors,

so if this is the mirror and they're looking
at the reflection of this arm here,

we would expect the contralateral
hemisphere,

in the primary motor cortex for instance,
to be activated.

But as they're seeing the reflection
moving in the mirror,

we also see activation on the ipsilateral
hemisphere to the arm that is moving.

So the important thing here is that the brain is being
activated in the way that it would

if that person was actually moving the
arm that's hidden in the mirror.

The second interesting point here is the difference
in cortical activation in the three groups.

The main difference here

is a lack of that ipsilateral activation of the primary
motor cortex in the people with phantom limb pain.

So clearly there is a difference now
and what exactly that difference is,

I'm not sure, but what we do know is that
there is a difference in the way

that the brain is activated going through
this task or going through these tasks.

Using mirror therapy in isolation’s been
shown to be quite beneficial.

The only in small groups so can the Margate
caves group has demonstrated some benefit

in the use of mirrors, particularly
in CRPS following stroke,

people who have acute painful states but
less so in other states.

And Jane Barring’s work demonstrates
that, sorry, going back,

Lorimer’s appraisal of mirror therapy is that it's probably
no better than motor imagery for immediate pain relief,

although it's arguably more interesting and might
be helpful if used over an extended period.

Rama Channon’s original work looked
at the use of mirror therapy

to give someone back the feeling that
limb was present again

and the original paper went through
a series, 5 case series,

5 people using mirrors to give them back
a sense that their arm was present again.

In one of those people they took the
mirror with them,

they ran with it, and they got a significant benefit
from the use of mirrors – mirror therapy.

What you often lose in the date of the clarity is it there
were people who responded quite negatively as well.

And the important part of the use of
mirror therapy, for me,

is that it is the therapy that's had the
most immediate change,

both in a positive but also in
a negative direction.

What do patients think about graded
motor imagery?

I think this is an important part
of the process.

So I've asked a couple of patients what their
beliefs are regarding graded motor imagery

and the thoughts regarding the theory
of graded motor imagery.

Does GMI rewire the brain?
Here's one person’s thoughts.

“Yes, it must do! I get far less peculiar reactions:
a reduced dry mouth,

less weird floaty feelings, everything feels more normal.”

“I'm not noticing differences nearly as much.”

“Things don't stand out as being unusual
anymore.”

“Little by little, slowly increasing
things is the best way to do it.”

So she’s setting out her thoughts
regarding graded motor imagery

and what was noticeable in terms
of her changes,

but also the fact that it's an important part
of our processes that it’s repetitive,

it takes time, it may be quite slow for
some people.

How does the brain change?

“I think it causes the brain to plasticise, offering
alternative routes to the same destination,

drawing attention away from the fixed
destructive pathways that only lead to pain,

that are being reinforced each time they
are stimulated.”

It certainly fits with our thoughts of
the association of movement and pain.

“Like a pile up on the motorway, there's no point trying to
force your way through, you have to find an alternative route.”

To me, that sums graded motor imagery
up well.

It offers people a place to go when traditionally,
therapy hasn't been successful,

or has made them worse in many cases, and I think what's
nice listening to these comments of patients and will be

at least a people who've been taken through a significant
amount of the graded motor imagery process,

is their thoughts about graded motor imagery fit very
well what our thoughts are regarding the theory,

but also the design of a treatment.

So the fact that it should be graded, it should be something
that is repeated over a number of times.

So Lorimer’s original work at significant
commitment on our patients,

they have to repeat their treatments
every waking hour,

10 minutes every waking hour he was asking for and
remarkably they are able to achieve around 77% of that,

so it's a huge ask on that patient.

That needs to be a buy in from them

as a commitment from them to the to be a
part of this treatment approach,

this ongoing part of their lives as well
as like a full time job.

There are clearly difficulties using graded motor imagery.
There is some equipment needed.

Although you can make your own equipment,
it does take time.

I've done it with my patients in the past
where we've cut pictures out of magazines,

laminated those pictures before we even had
access to recognise this as an online program.

We've made a number of mirrors in the past as well,
gone down to IKEA,

or a hardware store, and just back some mirrors
onto some hard board or cardboard.

So you can make your own mirrors,
it doesn't need to be an expensive mirror,

just make sure that the mirror doesn't
make the limb look distorted.

It’s difficult to replicate the
experimental protocol.

Both the time devoted to it, and the fact
that it should be completed in 6 weeks.

There was some quite stringent inclusion and
exclusion criteria in Lorimer’s original work.

For my patients I've been unable to take
someone through a process in a 6-week period.

I have had people that have improved
significantly in a short period of time

but mostly it's people who need to work
over a number of months on this process

and I've got people who’ve reported significant improvements
and wanted to carry on a part of a treatment process

for a number of months because they feel that’s such an
integral part of them improving in the long term as well.

One lady that I saw this morning, she finds
that's going through an imagery process

is the most beneficial part of the graded
motor imagery process for her,

and originally when she was taking herself through this
she was able to feel, visualise, sense her affected leg.

It took us 6 months training herself
to be able to walk, and then run,

and cycle her bike, and feel that the left and
the right sides were intimate parts of her.

She was truly connected with her
left leg again.

The last point I have is on it's own it's just
not enough. You may need education.

I think you need to do appropriate education
to just sell a treatment approach.

There are other techniques that go alongside it,
sensory discrimination techniques for instance,

but there may be a number of different
treatment techniques

that should sit well with a graded motor
imagery process.

It may be important to maintain the order
that was said out in the original research.

Although this research was done in a fairly homogenized
groups, so CRPS1 following wrist fracture,

but what Lorimer’s research demonstrated is that the
improvements were more significant in the group

that followed the GMI order,

and also those improvements were maintained over a
6-week period following the end of the treatment with GMI.

So the order of implicit, followed by
explicit motor imagery,

followed by mirror therapy, may be an
important part of a process.

Anecdotally, the use of mirror therapy isn't so
successful for people who are unable to

mentally imagine themselves or mentally
imagine the affected body parts.

So just that setting up process may be
important even if you decided

to forego some parts of the graded motor
imagery process.

So, thanks very much for listening! If you'd like a little
bit more information, then you can visit my website.

You can visit the NOI website as a graded
motor imagery website.

And on Lorimer’s blog site,
the bodyinmind.org

You'll be able to find articles to help you.

Thanks very much!