Graded Motor Imagery – Step 1: Left Right Discrimination

Left-Right Discrimination – step 1 in Graded Motor Imagery (GMI) Training.

Ever have a patient that had a stroke, try mirror therapy with them and wonder “why am I doing this?” because it never seemed to work?🙋

I have (more times than I’d like to admit)!

It’s super frustrating, especially since the evidence shows that mirror therapy can have a positive effect on motor function, buuuut after years of courses (thanks Medbridge!) and trying different techniques in the clinic, I basically realized I was doing it all wrong. 😁

Not actual video of patient performing mirror therapy…😹

I wasn’t teaching the the actual mirror therapy techniques incorrect per se, but I wasn’t applying the entire Graded Motor Imagery continuum into my patient’s treatment plan.

Basically, I was putting the horse 🐎 before the cart.

Graded Motor Imagery is a set of 3 different, sequential (but flexible) treatment techniques using “top down” cortical central processing to improve movement difficulties or complex pain.

Let’s start with the basics.

What is Graded Motor Imagery?

Graded motor imagery is a process that trains and retrains the brain and its myriad connections, and it may be used to help with chronic pain. A recent systematic literature review on graded motor imagery for CRPS1 supports the use for reducing pain (Daly AE, Bialocerkowski AE, 2008). In recent RCTs, the graded motor imagery protocol has demonstrated good evidence of outcomes (reduced pain and disability) in complex regional pain syndrome1 (CRPS1) (Moseley, 2004a, 2005) and in CRPS1 and phantom limb pain (Moseley, 2006).

You might also find graded motor imagery helpful in stroke patients, for phantom limb pain, and other neurologically-based phenomena. The generation and perception of motor actions recruits shared parts of the brain (Blakemore & Decety, 2001; Grezes & Decety, 2001), which allows the imagery to act as a neuronal training method within the graded program. Visualizing a pain-free motor action enhances a persons ability to move through a similar pattern without perceiving pain.

Further progress in this stage allows for actual movements in affected body parts without pain. The occupational therapy practitioner will assess the patients pain condition before moving them through each new stage.

Graded motor imagery may provide further benefits to motor function of the upper extremities of patients with chronic stroke while performing conventional exercises. A home-based GMI program could be an effective complement to usual rehabilitation to enhance upper limb function in patients with chronic stroke. Implementation of graded motor imagery program-based stroke rehabilitation at-home interventions has led to beneficial outcomes in motor function in the upper extremity.

Further studies are needed to identify the stroke type that is best suited for the GMI training, as well as to evaluate the neurophysiological changes in the brain. It is helpful to understand that graded motor imagery is not a preset program, but is instead a guideline to advance a motion treatment using motor imagery.

Evidence of graded motor imagery use comes from both basic science (neuroscience) and clinical trials. GMI is helpful in treating conditions like complex regional pain syndrome (CRPS), reflex sympathetic dystrophy (RSD), chronic back pain, chronic neck pain, phantom limb pain, and certain cases of dystonia. The Graded Motor Imaging (GMI) curriculum provides up-to-date information on basic science, clinical trials, and clinical applications of the program.

The Steps of Graded Motor Imagery Include:

1️⃣ Laterality Training (aka Left/Right Discrimination)

2️⃣ Explicit Motor Imagery Exercises (aka Imagery)

3️⃣ Mirror Therapy (see how I used to just skip the 1st two steps and expect amazing results?!?)

The intervention modalities involves using computers, flashcards, imaginary movements, and mirror visual feedback. I have given step-by-step instructions and supporting research on how to complete both Explicit Motor Imagery Training and Mirror Therapy in the OT Flourish Membership but I am going to dig into and share with you what you need to do to get started in step 1 ⬇️⬇️

Laterality Training (aka Left/Right Discrimination)

What is Left-Right Discrimination (aka Laterality Training)?

Left-right discrimination helps us be able to identify one side of our body from the other, as well as determine if our body part is moving to the right or the left.

If I have my eyes closed, can I tell that I am turning my head to the right?

Or if I have my eyes closed and someone externally rotates my right arm, can I identify that it has been moved to the right?

Or even can I look at a picture and determine which is left/right or turning which direction?

What Should You Have Your Patient Do to Perform Left Right Discrimination?

✅ Look through magazines, identifying body parts and what direction they are in

✅ Have the patient download and use the Recognise™ app (good for metrics, but is a little limited on pictures)

Graded motor imagery app: utilize this with your patients that have had a stroke in step 1: left-right discrimination

✅ Use body part flash cards and play games

When I do this activity with my patients that have hemiplegia, I always give these cards to them for homework, having them do the arm, shoulder, neck and trunk flashcards as well as this makes for holistic intervention (the other body part cards, instructions & how to grade can be accessed in the OT Flourish Membership).