Graded Motor Imagery in Hand Therapy

The 3 Stages of Graded Motor Imagery 

graded motor imagery

We’ve all heard of mirror box therapy, but do you know the details of how it works? There’s actually 3 stages involved that exercise the brain and take advantage of its plasticity.  There is a great deal of evidence supporting these three stages and you can use them with confidence. It should be noted that all 3 stages must be used in sequence to be effective. 

Stage 1:  Laterality 

graded motor imagery

Laterality is the ability to identify if a body part as being left or right sided when shown an image of the body part. For example if a patient is experiencing pain in their hand, you would show them pictures of hands and have them identify if the hand shown is a left hand or a right hand. This is  important for recovery from pain and improved mind-body awareness. Limb laterality recognition activates premotor (association) cortices, not the primary motor cortex. This is a precursor to the other two steps and prepares the brain for further association processes. 

graded motor imagery

Images of left and right hands can be presented to the patient on flashcards, online, or through free Apps on your phone (orientate). The more the better. 

Stage 2:  Explicit Motor Imagery 

This stage involves imagining movements without actually moving.  Much like an athlete envisioning the movements before they do them, your patient will imagine movements of the affected hand without moving it. This activity activates the premotor cortex as well as the motor cortex, allowing the basis for graded motor imagery progression. Mirror neurons in the brain are a clear target during this activity. For example you might ask your patient to imagine their hand doing a specific activity or to imagine manipulating a certain object.  Visualization of motor movements without pain improves the body’s ability to move in the same pattern without perceived pain.

Stage 3: Mirror Therapy

graded motor imagery

The final stage is to use a mirror to present the reverse image of a limb to the brain, thus “tricking” the brain. Some common mirror progressions may include:

  • Looking at the hand
  • Turning the hand up and down via the arm
  • Flatten the hand
  • Move individual fingers
  • Thumb to fingers
  • Tapping fingers
  • Tool usage

A lot of research has been done to show the effectiveness of graded motor imagery on CRPS. You may also find this technique to be useful for stroke patients, phantom limb pain,  and other neurologically based phenomena. 

You can check out our video “How to Make a Mirror Box” for details on making a low cost mirror box for your clinic. 

Leave a Comment





More To Read

Ways to Improve HEP Compliance  in Hand Therapy 

April 17, 2022

Ways to Improve HEP Compliance  in Hand Therapy  By: Dalton Busch  One of the most important ways we see our patient’s progress is by assuring they are compliant with their prescribed home exercise program (HEP). Our patients are always encouraged to adhere to their prescribed program but compliance is easier said than done. Reminding patients…

Read More

The Role of Sensory Re-education After Nerve Injury

May 9, 2021

Priya, B. A. (2012). Effectiveness of Sensory Re-education after Nerve Repair (Median or Ulnar Nerve) at the Wrist Level. Indian Journal of Physiotherapy & Occupational Therapy, 6(3), 62–68. The Skinny  The human nervous system is incredibly complex and, once damaged, requires significant time to repair. A previous study (Bentzel, K 2002)  identifies that with peripheral…

Read More

Comparing IP and MCP joint splinting for Trigger Finger

August 8, 2021

Teo, S. H., Ng D. C., Wong, Y.K.(2018).  Effectiveness of proximal interphalangeal joint blocking orthosis vs metacarpophalangeal joint blocking orthosis in trigger digit: A randomized clinical trial. Journal of Hand Therapy, 1-7. The Skinny- This study compared PIP joint immobilization via an Oval-8TM with a custom MCP blocking orthosis in the treatment of trigger finger. …

Read More
Envelope_1

Sign-up to Get Updates Straight to Your Inbox!

Sign up with us and we will send you regular blog posts on everything hand therapy, notices every time we upload new videos and tutorials, along with handout, protocols, and other useful information.