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Mirror Training
2 Dec 2015
2 Dec 2015
by Megan Davis, Psychologist

Graded Motor Imagery and its role in recovery from injury and pain.

A well planned graded exercise program is critical to recovery from most injuries. The use of Graded Motor Imagery has been shown to enhance recovery from a number of chronic pain conditions, and may have a role in improving return to function in a range of other rehabilitation processes.

It is useful to consider pain as an output of the brain, and a protection mechanism.

When damage occurs in the body, the damaged area sends ‘warning’ or ‘threat’ signals to the brain. The brain responds by outputting pain, as a way of protecting the individual. For most people, the desire to avoid pain will result in appropriate behavioural modifications, which limit further damage to the body, and enhance healing.

In the case of persistent or chronic pain conditions, this relationship between damage, warning, pain and behaviour becomes complex. When emotional factors (current or historical) such as fear, anger, trauma, or a sense of helplessness feed into the perception of threat the brain may increase the protection, and therefore the experience of pain. This need for protection may continue even after the body has healed.

Pain pathways become habituated. Once established, pain can be produced in response to a whole range of physical triggers, including movement, light touch, and temperature variations. Pain can also be triggered by emotional factors (often fear or anger), by prediction of pain, and by circumstances or environment. This does not mean the person is making up the pain, or the pain is ‘all in their head’. Pain caused by habituated nerve pathways is real and often severe.

The good news is that this pain is very treatable, though continued focus on looking for or treating damaged tissue may be counter-productive. There are four main steps in treating chronic pain:

  1. Education – patients need to come to the understanding that there is not something ‘broken’ in their body, even though they have very real pain (and often other symptoms). Education can go a long way to removing fear of pain and further damage.
  2. Behavioural challenge – patients need to develop trust and confidence in their body’s capacity to move safely.
  3. Emotional counselling – the stressors which led to the establishment of the chronic pain condition need to be worked with. This may include past trauma or stress.
  4. Lifestyle change – often people with a history of emotional stress have established emotional avoidance behaviours, which allowed them to ‘not stop and look’ at their emotions. In some cases major stressors still exist in the person’s environment.

In this article I will discuss behavioural challenge, and the role Graded Motor Imagery has in this step toward recovery.

Whist most practitioners understand the value of a gradually increasing movement program, many people with complex pain conditions are unable to tolerate even small amounts of movement and exercise. Their posture and behaviour becomes very protective, and a 10 minute walk, for example, causes a ‘flare up’ of their symptoms. Even thinking about moving can cause pain.

GMI offers an alternative approach, where the brain is retrained and ‘exercised’ in conjunction with the physical program.

GMI is broken down into three distinct stages.

  1. 1. Left-right discrimination. Research indicates that people with ongoing pain lose the ability to accurately discriminate between left and right body parts, or movements to the left or right. This seems to be due to a ‘smudging’ in the way the body part is represented in the brain. ‘Recognise’ is an on line program which challenges people to quickly identify pictures as showing left or right body parts or left/right movements. This step could also be done with pictures from magazines, or photos. The task stimulates the representation of the body part in the brain, and due to neuroplasticity, causes changes in this representation.

  2. 2. Explicit motor imagery. When we watch someone else move, or imaging moving ourselves, we activate mirror neurons in the brain. This technique is often used by athletes, both in learning new skills, and in rehearsing performances. Imagery trains the brain’s representation of the movement, and builds confidence, without creating as much threat as actual movement. In conditions such as CRPS and fibromyalgia, even imagining movement can cause an increase in symptoms, so this stage should be approached carefully.

  3. 3. Mirror therapy. Using a mirror to reflect movement of unaffected body parts creates the illusion that the painful body area is moving without pain or restriction. This changes it’s representation in the brain. Once again, this exposure to movement should be done in a graded way so as not to trigger the protection habit of the brain.


Brain training should stay ‘one step ahead’ of physical challenges. We need to build confidence in movement, and take fear and prediction out of the pain cycle before the brain will allow the movement physically.

Response to this program will be very individual, and patients should be aware and ready to move back a step if pain increases. Pushing through or fighting pain will always be counter-productive. Current life stressors and triggers should also be considered when moving through the stages of GMI.

Graded Motor Imagery is gaining solid empirical support in treatment of CRPS and Phantom Limb Pain. Evidence is growing for efficacy in treatment of a range of ongoing pain conditions such as Carpal Tunnel Syndrome, arthritic conditions, back and neck pain.

Interest is growing in the use of this technique to reduce the loss of skill and function following acute injury, particularly where immobilisation is required. There may be a role for GMI in the future in treatment of athletic injury and post-operative rehabilitation.


Further reading:

Moseley, G.L; Butler, D.S; Beames, T.B. Giles T.J. (2012).The Graded Motor Imagery Handbook.

Sarno, J.E. (1991) Healing Back Pain: The Mind-Body Connection.

Schubiner, H. (2010). Unlearn your pain.

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