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{ 14 comments… read them below or add one }
Dear Lorimer and David,
I have been working with several CRPS in a unilateral upper extremity with quite severe and easily exasperated symptoms. I have had to limit the number of images seen at each session. In trying discern what was provoking their increase, two of the patients stated that as they moved their eyes to focus on the image, their pain increased. With each of these patients I then tested unidirectional repetitive eye motions. Eye motions, without head movement, toward the side of pain would rapidly provoke the symptoms within a few reps. other motions did not provoke the symptoms and the same movement with eyes closed did not provoke the symptoms. I have started patients on non symptom productive movements and symptom provoking directions with eyes closed. I also used palpation of the side of the face below symptoms. I have seen improvements in thier tolerance of eye movement in the past 10 days and some tolerance for other activities. Do you have any insight ( no pun) on what may be going on here?
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Lorimer Reply:
December 10th, 2009 at 11:40 am
Great work John. I am particularly interested in symptoms in CRPS that seem to be related to space. what i mean by this is we know that people with chronic CRPS seem to neglect the space in which their limb normally resides [see our recent Brain paper: space-based but not arm-based shift...]. I don’t know why this happens. It seems feasible to me that, for some patients, that whole side of space becomes ‘dangerous’. If so, it would seem sensible to prevent oneself from having anything to do with it. The best way to do this would seem to be to make it painful. That is, perhaps even looking in that direction is regarded as dangerous by the brain and hence increases brain.
I love your clinical response to this. I would love to be kept in the loop of how it goes and I encourage you to take good notes.
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I’ve just been introduced to Painful Yarns through my husband attending intensive rehabilitation for his back at Salisbury Hospital, Wiltshire, UK. Whilst pondering the tales in the book in relation to my husband’s experience of pain (not necessarily easy as an interested bystander – perhaps that’s another book for you), I wondered if you thought that the same might be true of people who experience emotional pain. In that, historical experience/tangible examples of a lot of emotional pain would result in someone lacing situations with a greater amount of emotional content and therefore reacting in a more extreme manner than others might. And so, rather than learned behaviour and mimicing others, the brain’s evaluation of ‘emotional danger’ delivers an emotional wound which then leads the individual to display more extreme emotions than a situation warrants.
Just a thought….
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Lorimer Reply:
December 10th, 2009 at 3:41 pm
Hi Diane. Nice thoughts. Your wondering seems sensible to me – there is no doubt that our brain remembers anything that is important to our survival. That said, I dont make a distinction between physical and emotional pain. I reckon that if it hurts somewhere in the body then it is pain. If it doesn’t, then it is not. I am very comfortable with the idea of, for example, an aching heart, but if one doesn’t feel the ache then it is probably most accurately called something else, for exmaple anguish, grief, despair etc etc. this sounds simply semantic but I think it is important if we are to accept that pain is produced by the brain and doesn’t need input from the body even though it feels exactly like there is. Anyway, that is a Cab Sav conversation, which is a conversation best had while sharing a bottle of south Australian, preferably Coonawarra, Cabernet Sauvignon. I am not sure if you can get them in Wiltshire.
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Many thanks for your response, that is most helpful. Good news! Coonawarra, Cabernet Sauvignon is available in Wiltshire, sadly we’ve a bit too much weather at the moment for the ideal situation, but I could light a fire…………
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The 2009 non pain study by Mizuguchi et al (Influence of touching an object on corticospinal excitability during motor imagery) showed that the excitability of the corticospinal pathway can be increased during ‘ball squeezing imagery’ if real touch of the ball is also involved during this imagery exercise. Furthermore, this increased excitement occurred along the corticospinal pathway (including the primary motor cortex), and not along the afferent pathway to the primary somatosensory cortex.
This raises a possibility that graded motor imagery (GMI) and actual touch of the imagined object (‘combination GMI and touch therapy’) may be an alternative for CRPS treatment, instead of GMI treatment alone?
Studies may be warranted to determine whether ‘combination GMI and touch therapy’ results in increased activity along the efferent corticospinal pathway. If yes, this may result in increased benefits for some CRPS patients, and may even benefit CRPS patients that may not respond to GMI therapy alone.
Neuroimaging may be useful to confirm any increased activity along the efferent motor pathway in CRPS patients.
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HI Lorimer
My personal good friend always challenge me to give her more scientific evidence that her lower back is not the typical chronic lower back pain that other patients have (we both work in rehab where we see chronic back pain patients). SHE believed and argued with me that her pain is purely “physical”. She had spondolysis and had 2 back surgery to stabilise the joints from slipping forward. She tried everything under the “medical” sun. She is a Yoga teacher and believed that when she is doing her yoga, she is in no pain, extremely flexible and mobile. But when it comes normal standing, she needs to use her sit/stand stick. So …using all the bible text including Explain Pain, Painful Yarns and the Brain that Change itself….eetc…to illustrate to her that pain is in her brain and she can change her mind about believing that her pain is purely physical and that nothing works for her…any suggestions please? She’s a good friend and I feel like I am arguing with her. But she has a point. It is physical isn’t it?
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Lorimer Reply:
January 4th, 2010 at 4:53 pm
Tricky. Except that ALL pain is of the brain. I can’t tell you if you should argue with her or not – it sounds like she is quite the formidable opponent – however, i can tell you that it is, ultimately, her call. If she believes she is human (which clearly you believe she is) and that she is not a freak of humankind (which you clearly think she is not), then the fact remains that her back wouldn’t hurt if her brain didn’t make it hurt and her brain will make it hurt if her brain thinks it in her best interests and her brain almost certainly considers more than spinal input in high threshold neurons when it makes this call. If your friend believes that the only determinants of her back pain are the forces, chemicals and temperature fluctuations that are occurring at particular tissues of her back, then i think she should apply exactly the same principles to training it that one would always apply – remove those factors and then gradually expose the tissues to those things again. This is, as it sounds, probably impossible. If one was to abide that hypothesis of course, then one would have to deal with the sticky issue of why larger forces, more concentrated chemicals and bigger temperature fluctuations don’t necessarily hurt. We are, i am convinced, fearfully and wonderfully complex…….
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lloyd Reply:
February 3rd, 2010 at 9:38 am
hi Alice and Lorimer,
interesting. your friend is so like me. i’ve an L5 spondylolithesis caused by doing a particular yoga extension pose that i used to rest in for 10 minutes at a time regularly over a period of 18 months almost 10 years ago now. buttock and lateral shin pain with standing any sort of prolonged time.i’m not a longe lizard for nothing.about 3weeks ago i went again to see a consultant re a fusion cause i was fed up with the pain and limitations felt there was nothing i could do to solve it feeling very like what you described for your friend. Interestingly since i’ve now got 4 months till surgery i decided that i’d better get serious cause i’d be well cheesed if i fused it and then discovered a couple of years later that there were processes i could have used. i’m now using a combination of feldenkraise type exercises meditation and yoga and reading Anat Baniels fab book- the nine esentials for lifelong vitality. basically trying to enrich the cortical realistate that relates to my back and body, the way it moves and feels. in the process i’m beginning to uncover all sorts of ways my nervous system needs to increase its sensitivity , relax ,increase its activation. the breath shows up alot of old fight and flight patterns stored with in this nervous system.
i still had a bunch of pain doing the washing up this evening but i’m not so bothered because i see a way forward and am excited by my discoveries. we’ll see over the next couple of months but i’m not going to get a fusion. if i can get the surgeon to decompress the root without stabalizing i might go for that.they automatically think the segments unstable and needs fusing. i can deal with the degenerative symtoms. i maybe i can live with the “nerve” pain in a better way
anyway.it is very difficult when you percieve probably very rightly that there are major nocioceptive drivers present and the reality of a graded exposure approach when you have a complex life to lead just seems ridiculous.
Lorimer i hope to catch you at the nottingham gig. i’ll try not to get to flustered by the presence of such a megastar and relate to you as a person ok!
i presume that would work better for you as well.
regards
lloyd
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Hi Lorimer,
I am an Occupational Therapist in Green Bay, Wisconsin/US. I have been reading some of your articles for Graded Motor Imagery, and have tried out the 3 phase program with 3 participants (2 are active patients). I am looking for clinical guidelines with developing our program. I meet with participants once a week but have them completing the program mostly through home program. It looks as though the research suggests 3 times an hour, but was wondering if you see results still with reduced frequency. (My patients are struggling with getting the program in this frequently). Also, I am going to be creating laminated pictures for them to use, and plan to do Right/Left and Male/Female, but how many images would you suggest to be effective but as cost effective as possible for us to make?
I really appreciate your input as I try to complete Evidenced Based Practice, but also make it as practical as possible to fit in with patient’s daily routines.
One more question: do you think that the limb laterality recognition would also work by identifying right and left on people around them (instead of paper copy?). I have a hair dresser that has little time with the pictures, but states she is constantly observing her clients hand postures and mentally identifying Right/Left.
I find your work fascinating!!!
Thank you,
Jamie
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admin Reply:
January 28th, 2010 at 11:19 am
G’Day Jamie- noigroup already sells laminated pictures of hands and feet i think. Check them out – http://www.noigroup.com. Re guidelines – we are a bit short of that but that is where we would like to go. These things take time and much effort. Re your idea about observing on others – GREAT! Makes complete sense according to cognitive neuroscience but, of course, we haven’ tested it in a clinical trial! Thanks for your support and input.
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Hi Lorimer
I have watched a very good DVD from Discovery Channel production regarding Pain and chronic pain. I used it in my Pain Management workshop with my patients from all sorts of ethnic background. They seems to understand the concept more so in a video format than in a written format (partly due to language but also i guess it’s pretty boring to talk about pain, isn’t it? Of course, you always makes chronic pain topic so much more interesting and intriguing.). In the video, they interviewed Dr Mackay’s research regarding using fMRI scan to retrain the brain to reduce the “volume” of pain. What do you think about that? Is that something we can have in Australia at some stage for those pain patients who are willing to use their brain power to control pain? Interested in your views about that.
Alice
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admin Reply:
January 28th, 2010 at 11:16 am
Hi Alice – Sean Mackey does some really groovy stuff and i reckon the real time biofeedback using fMRI is cool+++. Will it be something we use clinically any time soon? I don’t think so because there is a large amount of research – clinically and experimentally – that we would have to do first. As well as that – the gear is really really expensive. My final thought on that one is that i can’t see that it solves the problem. I guess it could address it in some form because patients would realise that their brain is the main player, not their body. Still, I am open minded about these things – it certainly is very groovy research.
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Sorry. It’s Dr Mackey’s research.
http://paincenter.stanford.edu/press/video_discovery.html
Alice
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Hi Lorimer
Just finished reading my new book for my little one on Brain by Rita Carter. Got me also reading her book on mapping the mind. I know she is a medical writer not a researcher but found her book easy to read and explain quite nicely how the brain is so powerful in controlling so many things including pain and chronic pain. Just thought you might have met her somewhere in your career paths?
Alice
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I’m treating a patient at the moment who has developed CRPS in her hand post colles fracture.I have been treating her for two months now and her PIP joints of the 2-4th digits are held in fixed flexion ~ – 40 degrees extension which is irreversible with a passive stretch. I was wondering if anyone has any clinical tips for treatment or how long such can take to resolve? Thanks
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Lorimer Reply:
February 11th, 2010 at 2:28 pm
Hi Maria –
I am not sure i understand the exact nature of the motor pattern, but that it affects passive and active range is consistent with a fixed motor dystonia. The best people in the world on that stuff are in The Netherlands – look up Bob (Jacob) van Hilten and the Trend Consortium. I will pass on your thingie to Bob as well in case he can comment on it with more than i can. Anyone else out there feel free to suggest something to Maria…
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Lorimer:
Big fan of you & David Butler. I have read many of your articles, etc. but my favorite?? …..“Painful Yarns ”… what a hoot! Anyway, I’ve had CRPS type symptoms for 15 years or so. My PT and myself are going to engage on graded motor imagery path, using NOI Groups cards, etc… I have a question:
…. I have never seen a visual image in my “mind’s eye” in my life. I just cannot visualize. Do you have any recommendations concerning how to try to kinesthetically imagine movements without actually engaging the neuromuscular system?……….
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Lorimer Reply:
February 15th, 2010 at 5:55 pm
Gday Tim – thanks a million for posting, and for your encouragement – much appreciated indeed! I am not sure of the answer to your question – however, the good news is that the idea of graded motor imagery is, after the initial phase of left/right recognition, to NOT imagine what it looks like but just imagine doing it. Does that make sense? That is, you don’t visualise the movement, you just imagine doing it. I will have an ask around and if i find something will let you know.
thanks again Tim, Lorimer
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Gday Lorimer…
thank YOU a million for a reply!!
you said, “the idea of graded motor imagery is, ….. to NOT imagine what it looks like but just imagine doing it. Does that make sense?
Frankly — no — this does not make sense to me.
How do people imagine? I think most people when they imagine trying to visualize don’t they?? When people ask me to imagine… I really can’t… because I can’t visualize.
I maybe can think about moving my arm, but I’m wondering if that actually engages the mind and the nervous system a little bit and if that is good or bad???
So, ‘m still confused.
I checked out some definitions of, imagine….. and they all say something like this:
Imagine: To form in the mind a notion or idea of; to form a mental image of; to conceive; to produce by the imagination.
Most definitions of imagine use the word root, imagine, in its definition or refer to visual mental images….
Still treading water…
Timv
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Lorimer Reply:
February 20th, 2010 at 12:41 pm
hey Tim – I don’t think that imagine means ‘visualise’, but i am v. open to being a dufus on that front. I think we should try to feel what it feels like, not what it looks like. perhaps this is illustrated by imagining you have chocolate in your mouth – you don’t visualise that because you don’t know what it looks like (presumably….). make sense?
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l’m the dufus. so, What I’m understanding is that the “motor imagery” part of “Graded Motor Imagery” does not involve any visualization, I should just simply watch others do motions that are painful for me (or look atRecogniseTM cards etc) and just concentrate on what is happening………… nothing else. The mirror neurons et. al. will do their work..
thanks for taking the time to respond to me. I think the word “imagery” leads to confusion with me ( and probably others). Please keep on posting!! some of us find it your work as interesting as you do!
timv
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this is a facinating conversation. its so interesting to hear ?? you say?? that lorimer
but i have to say i feel like a dufus.
i always thought of imagine as visualise as well
but have to say i like imagine the feeling more than the image
and really engaging activly your mirror neurons whilst watching someone else do something that is difficult or painful for me is absolutly brillant
nice one tim
what a bunch of dufus’s
high regards and peace
llolyd
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