Graded Motor Imagery

I use Graded Motor Imagery commonly for a range of painful conditions including CRPS. In essence, GMI is brain training that targets mechanisms that we know are involved in ongoing pain states. Here is David Butler talking about GMI, mirrors and neuroscience.

Part 1

Part 2

Part 3

Part 4

Mirror Therapy

Neurodynamics and neuroscience

For more information about treatment of CRPS and other chronic and complex pain states, visit

Imagery & mirrors

Many readers will know about mirror box therapy for CRPS and other painful conditions. The Graded Motor Imagery Programme that we use at Specialist Pain Physio is sequential training that starts with laterality, progressing to imagined movements and then to mirror therapy. There is some really good data for the programme and CRPS but it can also be effective with other chronic pains. Interestingly we are now seeing components of GMI being used and written about in the popular press, most recently for Parkinson’s disease and arthritis.

Brain training for pain

A brief article in New Scientist describes the Parkinson’s research by David Linden at Cardiff University. 10 subjects were asked to think about movement for 45 minutes whilst they were having brain scans. Five of the subjects were given feedback that showed them how they were activating the brain and all were asked to practice the imagery at home. Two months later rigidity and tremor had reduced some 37% in the feedback group. The thinking is that there is cortical change underpinning this improved function that is feasible.

Mirror therapy for pain

At The Society for Neuroscience annual meeting 2011 a small study was performed with arthritis (OA & RA) patients used mirror therapy. Subjects observed the moving reflection of the researcher’s hand in the mirror whilst producing the same movement themselves with their hidden hand. After 1 minute it was noted that the subjects pain improved. This was reported in The Guardian today.

For details on our treatment programmes including imagery, mirror therapy, graded motor imagery and other neuroscience-based techniques, come and see our website at or call 07518 445491. Our clinics are based in London and Surrey

Great books to understand brain and pain

I love reading. Books, blogs, articles and papers. The written word can have a such a powerful effect, sometimes enhanced with images. Clearly the spoken word can also have a stimulating effect, both postive and negative. Think about some of the words spoken about your pain by doctors, therapists and friends that continue to echo through your mind as examples. Are they true? Do you know that they are true? Or are they unhelpful thoughts that continue to be bothersome?

Below I have listed some of my favourite books that are great resources for developing an effective understanding of pain. To really understand pain is to be able to use the information practically. This includes enhanced coping with painful periods so that they are decreasingly impacting upon lifestyle, being able to make effective choices when faced with painful problems and ultimately reducing the threat value of the painful situation. This last point is fundamental in any painful condition. Reduce the perceived threat, reduce the pain-or increase the pain threshold physiologically.

I regularly use these books with patients and recommend them for reading to really create an opportunity for deeper learning.

Explain Pain - also available as a e-book (great on the ipad)

To order call NOI UK on

'Does what it says on the tin'






Painful Yarns - L Moseley

Understand pain with stories

The Challenge of Pain - R Melzack & P Wall
The classic book by the originators of pain medicine, Melzack and Wall

The classic pain text

The Brain That Changes Itself – N Doidge
Tell-Tale Brain - VS Ramachandran
A story of how

CRPS, Pain and Brain Research update November Part 1

Welcome to the first November research update.

Specialist Pain Physio Clinics, London

J Pain 2011 Oct 25. [Epub ahead of print]

Pain-Related Fear, Perceived Harmfulness of Activities, and Functional Limitations in Complex Regional Pain Syndrome Type I.


Department of Rehabilitation, University Hospital Maastricht, Maastricht, The Netherlands; Department Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands.


Numerous studies have shown that pain-related fear is one of the strongest predictors of pain disability in patients with chronic musculoskeletal pain, and there is evidence that the reduction of pain-related fear through an exposure treatment can be associated with restoration of functional abilities in patients with complex regional pain syndrome type I (CRPS-I). These findings suggest that pain-related fear may be associated with functional limitations in neuropathic pain as well. The aim of the current study was to test whether the debilitating role of pain-related fear generalizes to patients with CRPS-I. The results of 2 studies are presented. Study I includes a sample of patients with early CRPS-I referred to an outpatient pain clinic. In Study II, patients with chronic CRPS who are members of a patients’ association were invited to participate. The results show that in early CRPS-I, pain severity but not fear of movement/(re)injury as measured with the Tampa Scale for Kinesiophobia was related to functional limitations. In patients with chronic CRPS-I, however, perceived harmfulness of activities as measured with the pictorial assessment method significantly predicted functional limitations beyond and above the contribution of pain severity. Not fear of movement/(re)injury in general, but the perceived harmfulness of activities appears a key factor that might be addressed more systematically in the clinical assessment of patients with CRPS-I. These results support the idea that pain-related fear might be a promising concept in the understanding of pain disability in patients with neuropathic pain. PERSPECTIVE: This is the first study showing that perceived harmfulness of activities contribute to the functional limitations in CRPS-I. The current findings may help clinicians customizing cognitive-behavioral treatments for patients with chronic neuropathic pain.


Clin J Pain. 2011 Oct 13. [Epub ahead of print]

Effect of Immunomodulating Medications in Complex Regional Pain Syndrome: A Systematic Review.


Erasmus MC, Rotterdam, The Netherlands.



Different mechanisms are involved in a complex network of interactions resulting in the painful and impairing disorder, complex regional pain syndrome (CRPS). There is convincing evidence that inflammation plays a pivotal role in the pathophysiology of CRPS. Immunomodulating medication reduces the manifestation of inflammation by acting on the mediators of inflammation. Therefore, as inflammation is involved in the pathophysiology of CRPS, immunomodulating medication in CRPS patients may prove beneficial.


To describe the current empirical evidence for the efficacy of administering the most commonly used immunomodulating medication (ie, glucocorticoids, tumor necrosis factor-α antagonists, thalidomide, bisphosphonates, and immunoglobulins) in CRPS patients.


PubMed was searched for original articles that investigated CRPS and the use of one of the abovementioned immunomodulating agents.


The search yielded 39 relevant articles: from these, information on study design, sample size, duration of disease, type and route of medication, primary outcome measures, and results was examined.


Theoretically, the use of immunomodulating medication could counteract the ongoing inflammation and might be an important step in improving a disabled hand or foot, leading to further recovery. However, more high-quality intervention studies are needed.


PLoS One. 2011;6(10):e26010. Epub 2011 Oct 13. Click here for article

Brain morphological signatures for chronic pain.


Department of Physiology, Northwestern University, Chicago, Illinois, United States of America.


Chronic pain can be understood not only as an altered functional state, but also as a consequence of neuronal plasticity. Here we use in vivo structural MRI to compare global, local, and architectural changes in gray matter properties in patients suffering from chronic back pain (CBP), complex regional pain syndrome (CRPS) and knee osteoarthritis (OA), relative to healthy controls. We find that different chronic pain types exhibit unique anatomical ‘brain signatures’. Only the CBP group showed altered whole-brain gray matter volume, while regional gray matter density was distinct for each group. Voxel-wise comparison of gray matter density showed that the impact on the extent of chronicity of pain was localized to a common set of regions across all conditions. When gray matter density was examined for large regions approximating Brodmann areas, it exhibited unique large-scale distributed networks for each group. We derived a barcode, summarized by a single index of within-subject co-variation of gray matter density, which enabled classification of individual brains to their conditions with high accuracy. This index also enabled calculating time constants and asymptotic amplitudes for an exponential increase in brain re-organization with pain chronicity, and showed that brain reorganization with pain chronicity was 6 times slower and twice as large in CBP in comparison to CRPS. The results show an exuberance of brain anatomical reorganization peculiar to each condition and as such reflecting the unique maladaptive physiology of different types of chronic pain.