Clinical Reasoning // Education //

Reflect on Movement

Taking Graded Motor Imagery to a more global scale seems to be an interesting field and reading the work from Wand and colleagues (Wand et al, 2012) seems to demonstrate some interesting points. The study looked to determine whether visualization of the back influenced parameters of movement related pain in people with chronic nonspecific low back pain.

This got me thinking, why do I sometimes see my 9 year old and 5 year old watching themselves move in front of a mirror, whether it is dancing, pulling faces or watching their hands or feet move…..maybe I just have strange children..! However, when we consider motor learning, perception of movement, motor efficiency and maybe why we move in certain way’s, we can look to see and maybe begin to understand movement, whether we are in pain or not. Is global visualization deeper engrained in our development as a child and does visualizing movement when we are in pain evoke a memory of movement that was free from care, pain or emotion…?

In essence, Wand and colleagues team hypothesized that pain would increase less, and settle more quickly, when movements were performed with visual feedback than when movements were performed without visual feedback. Patients reported significantly less increase in pain and recovered significantly faster when they were able to visualize their back during the performance of repeated spinal movements.

Consistent with their hypotheses, patients reported significantly less increase in pain and recovered significantly faster when they were able to visualize their back during the performance of repeated spinal movements within the mirror..!

I wonder how the geography of our cortical map as we develop impacts rehabilitation and influences pain and will be blogging on this in another edition.

Now here comes the science stuff that floats my boat…! Stick with it and check out the references for more detail….

A number of physiological responses to viewing oneself in a mirror have been reported, such as changes in the perceived location of the body part, increases in excitability of motor pathways and modification of sensory experiences; however, the exact mechanisms by which Mirror Visual Feedback (MVF) relieves pain are uncertain (1). A commonly offered explanation is that MVF works by restoring congruence between motor output and sensory input. It has been proposed that movement related pain may arise if there is discordance between motor intent and sensory feedback associated with movement (2). When a motor command is created, the central nervous system makes predictions of the sensory consequences of the movement and monitors the congruence between predicted and actual sensory feedback (3). If incongruence is detected, it is hypothesized that pain may arise to warn of an error in information processing (4). The visual feedback afforded by the mirror may improve sensory acuity of the affected area and help reestablish congruence between sensory feedback and motor intention (3,4). This proposal is supported by data that suggests that a wide range of sensory disturbances, including pain and discomfort, can be provoked when mirrors are used to artificially induce a state of conflict between motor intent and visual feedback (6, 7). Disruption of the cortical somatosensory representation of the painful body part and distortion of body perception are considered possible mechanisms underpinning the production of sensorimotor incongruence in clinical populations (2,4,9) and these processes might be occurring in people with chronic nonspecific LBP. There is evidence that patients with chronic nonspecific LBP exhibit significant alterations in the brain structure and function,(10) including degeneration and reorganization in cortical areas that are thought to subserve the perception of the back (12, 13, 14).

If you really want to get into the detail, then the references are here for you, but hopefully I have broken it down enough for you to use in clinical practice and have a basic understanding of why this may be beneficial to you and your patients.


  1. Moseley GL, Gallace A, Spence C. Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain. 2008;138:7–10.
  2. Harris AJ. Cortical origin of pathological pain. Lancet. 1999;354:1464–1466.
  3. Frith CD, Blakemore SJ, Wolpert DM. Abnormalities in the awareness and control of action. Philosophical Transactions of the Royal Society of London B, Biol Sci. 2000;355:1771–1788.
  4. McCabe CS, Blake DR. Evidence for a mismatch between the brain’s movement control system and sensory system as an explanation for some pain-related disorders. CurrPain Head- ache Rep. 2007;11:104–108.
  5. McCabe CS. Mirror visual feedback therapy. A practical approach. J Hand Ther. 2011;24:170–178.
  6. McCabe CS, Haigh RC, Halligan PW, et al. Simulating sensory-motor incongruence in healthy volunteers: implications for a cortical model of pain. Rheumatology. 2005;44:509–516.
  7. McCabe CS, Cohen H, Blake DR. Somaesthetic disturbances in fibromyalgia are exaggerated by sensory-motor conflict: implications for chronicity of the disease? Rheumatology. 2007;46:1587–1592.
  8. Daenen L, Roussel N, Cras P, et al. Sensorimotor incon- gruence triggers sensory disturbances in professional violinists: an experimental study. Rheumatology. 2010;49:1281–1289.
  9. McCabe CS, Cohen H, Hall J, et al. Somatosensory conflicts in complex regional pain syndrome type 1 and fibromyalgia syndrome. Curr Rheumatol Rep. 2009;11:461–465.
  10. Wand BM, Parkitny L, O’Connell NE, et al. Cortical changes in chronic low back pain: current state of the art and implications for clinical practice. Man Ther. 2011;16:15–20.
  11. Schmidt-Wilcke T, Leinisch E, Ganssbauer S, et al. Affective components and intensity of pain correlate with structural differences in gray matter in chronic back pain patients. Pain. 2006;125:89–97.
  12. Flor H, Braun C, Elbert T, et al. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neurosci Lett. 1997;224:5–8.
  13. Lloyd D, Findlay G, Roberts N, et al. Differences in low back pain behavior are reflected in the cerebral response to tactile stimulation of the lower back. Spine. 2008;33:1372–1377.
  14. Tsao H, Galea MP, Hodges PW. Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain. Brain. 2008;131:2161–2171.

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