REP 6: HOW MIGHT WE GET PATIENTS MOVING WHO ARE IMMOBILIZED BY THEIR PAIN?
In my office, I have a collection of articles that I love to add to. They cover a range of systems and conditions that have been shown to improve when an individual engages in some form of exercise or activity. Lately, my interest in patient engagement in exercise has found its way into the classroom as I teach students in our clinical program what I consider different ‘access points’ into an exercise program (by this, I mean how we can set up the first exercise program so that the person will be successful and be able to progress).
One focus of my research is considering how we get people who are in pain to exercise, which I think is a huge hurdle for new physiotherapists to overcome. Indeed, it may take every clinical skill we have, and more, for physiotherapists to address these issues at any stage in their career!
The big idea
Consider a patient for whom movement causes a significant amount of pain – pain so strong that it makes activity and exercise almost impossible. When I was practicing, I remember working with people immobilized by pain, after whipla1sh for example, and sometimes it felt completely pointless for them to be in the clinic. Yet, they needed assistance to get moving again. I wish now that I had tried using motor imagery as an access point to exercise and rehabilitation.
My take on things…
There is a growing body of knowledge that looks at the effect of motor imagery on the nervous system, and physiotherapists can easily tap into this. Results from studies in basic science where participants are briefly immobilized, as well as stroke and elite athlete research, have been mounting. The Neuro Orthopaedic Imaging Group’s Graded Motor Imagery Handbook includes an extensive review of literature that applies to painful conditions such as complex regional pain syndrome and phantom pain, and describes some of the progressive steps that can be used to gradually expose people to movement: from watching someone else move, to thinking about their own body moving, to mirror therapy.
Motor imagery has been shown to activate the same areas of the motor cortex that are activated when the physical movement is actually carried out.
Motor imagery, i.e., vividly imagining your own body moving through some kind of pattern without actually moving is known as motor imagery. It is a technique that has been used by athletes for a very long time and has been shown to activate the same areas of the motor cortex that are activated when the physical movement is actually carried out (more about thathere and here). People who practice motor imagery without performing the movement (for example, when immobilized in a cast) have been found to have less muscle atrophy as compared to those with the same immobilization but who do not practice motor imagery. In fact, in a recent study (unfortunately not open access) where the participants had a wrist/hand immobilization for four weeks, those who practiced motor imagery for approximately 12 minutes, 5 times per week had a 50% attenuation of muscle strength loss as compared to those who did not practice motor imagery. (Here are two additional non-open access papers that further investigate these concepts: Yue; Zijdewind)
A graded motor imagery approach offers an access point to the exercise progression continuum. If practiced, it has been reported that gradually an individual experiencing pain on movement can advance to other ways of getting moving, such as mirror therapy. A systematic review and meta-analysis concluded that graded motor imagery and mirror therapy are effective at reducing pain.
Take it back a step…
Believe it or not, just thinking about moving can be painful for some people. As described above, the phenomenon is believed to be that motor imagery activates the motor cortex as well as other interconnected parts of the brain including those associated with pain. This results in the perception of pain (the neuromatrix concept). Researchers have found that getting a person to watch someone else move can get the motor cortex activated without the experience of pain, providing an access point to exercise and activity. After practicing, and once they could watch someone else move without experiencing pain, they would progress to thinking about moving their own body part.
Another way of tapping into this visual/motor system is through the use of mirror therapy. The mirror therapy approach uses the illusion that a body part is moving when it isn’t. If a mirror is placed in front of a person such that their right hand is visible in the reflection and the true left hand is hidden, it looks like there are two hands (see image). Move the right hand, and it appears that both hands are moving. It has been reported that watching this kind of illusion results in decreased pain (associated with stroke, phantom limb and complex regional pain syndrome) in the limb that is not actually moving.
How does this happen?
Have a look at this YouTube video of the Rubber Hand Illusion. It demonstrates the connectivity between visual and motor functions that can be capitalized on to enhance rehabilitation – and the effect can happen very rapidly. In an experiment with the Rubber Hand illusion, it took as little as 11 seconds for people to begin agreeing with statements such as: “It felt as if the rubber hand was my hand” or “I found myself looking at the dummy hand thinking it was actually my own”.
Motor imagery is another tool physiotherapists can easily incorporate into their practice. Perhaps experimenting with access points to activity that use the visual system would give you, as a clinician, new ideas for patients who experience so much pain that activity or exercise is very hard.
Did you enjoy this topic? Want to read more? Here are the full citations for the papers I referred to in this Rep. Unless noted otherwise, all are open access:
Bowering K, O’Connell N, Tabor A, Catley M, Leake H, Moseley G, et al. The Effects of Graded Motor Imagery and Its Components on Chronic Pain: A Systematic Review and Meta-Analysis. J Pain. 2013 Jan;14(1):3-13.
Cacchio A, De Blasis E, Necozione S, Di Orio F, Santilli V. Mirror therapy for chronic complex regional pain syndrome type 1 and stroke. New Engl J Med. 2009;361(6):634-6.
Chan B, Witt R, Charrow A, Magee A, Howard R, Pasquina P, et al. Mirror therapy for phantom limb pain. New Engl J Med. 2007;357(21):2206-7.
Clark B, Mahato N, Nakazawa M, Law T, Thomas J. The power of the mind: the cortex as a critical determinant of muscle strength/weakness. J Neurophysiol. 2014 Dec 15;112(12):3219-26. (NOT open access)
Decety J. Do imagined and executed actions share the same neural substrate? Cognitive Brain Research. 1996 Mar;3(2):87-93.
Decety J. The neurophysiological basis of motor imagery. Behav Br Res. 1996 May;77(1-2):45-52.
Mahoney M, Avener M. Psychology of the elite athlete: An exploratory study. Cogn Ther Res. 1977;1(2):135-41.
Melzack R. From the gate to the neuromatrix. Pain. 1999;6(Suppl):S121-S126.
Michielsen M, Selles R, Van Der Geest J, Eckhardt M, Yavuzer G, Stam H, et al. Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: A phase II randomized controlled trial. Neurorehabilitation and Neural Repair. 2011;25(3):223-33.
Moseley G, Butler DS, Beames T, Giles T. The Graded Motor Imagery Handbook. Adelaide: Noigroup Publications; 2012.
Moseley G, Gallace A, Spence C. Bodily illusions in health and disease: Physiological and clinical perspectives and the concept of a cortical ‘body matrix’. Neuroscience & Biobehavioral Reviews. 2012 Jan;36(1):34-46.
Moseley G. Imagined movements cause pain and swelling in a patient with complex regional pain syndrome. Neurology. 2004;62(9):1644.
Moseley G. Is successful rehabilitation of complex regional pain syndrome due to sustained attention to the affected limb? A randomised clinical trial. Pain. 2005;114(1-2):54-61.
Ranganathan V, Siemionow V, Liu J, Sahgal V, Yue G. From mental power to muscle power-gaining strength by using the mind. Neuropsychologia. 2004;42(7):944-56.
Yue G, Cole K. Strength increases from the motor program: comparison of training with maximal voluntary and imagined muscle contractions. J Neurophysiol. 1992 May 1;67(5):1114-23. (NOT open access)
Zijdewind I, Toering S, Bessem B, van der Laan O, Diercks R. Effects of imagery motor training on torque production of ankle plantar flexor muscles. Muscle Nerve. 2003 Aug 1;28(2):168-73. (NOT open access)
Do you think that there might be merit in using some of these techniques with patients immobilized with pain to get moving?
About Katherine Harman
Katherine Harman is an Associate Professor with Dalhousie University’s School of Physiotherapy. After her B.Sc. (PT) at Univ. of Toronto, she completed an M.Sc. (Anatomy / Neuroscience) and a Ph.D. (Psychology / Neuroscience). She teaches about pain to M.Sc. (Physiotherapy) students and her research program currently focuses on the therapeutic relationship and patients experiencing pain. Find articles in Physiotherapy Canada, Physiotherapy Practice and the Pain Sciences Division newsletter.
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