Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction/Background

Chronic low back pain is complex and often not explained by a structural pathology alone. Modern pain neuroscience suggest that persistent pain may be due to maladaptive neuroplastic changes. In this article, the authors introduce Graded Motor Imagery (GMI). GMI is a three-stage neurorehabilitation approach (left/right discrimination, explicit motor imagery, mirror therapy) designed to treat chronic pain by altering the central nervous system processing.

Methods

A 67-year-old female with a 30 year history of chronic LBP participated in the study. Her pain significantly impacted her quality of life and daily function. Prior treatments- medications, injections, physical therapy, provided limited relief. The patient was introduced to GMI as an alternative strategy.

Initial assessment revealed central sensitization, pain-related fear, and body perception disturbances. Outcomes included the Oswestry Disability Index (ODI), Pain Catastrophizing Scale (PCS), and the Fremantle Back Awareness Questionnaire (FreBAQ). The results showed high disability and distorted body perception.

GMI was introduced in three graded stages over several weeks:

1. Left/Right Discrimination: The patient identified images of backs as left or right to stimulate sensorimotor processing.
2. Explicit Motor Imagery: She visualized moving her back without actually moving.
3. Mirror Therapy: Movements were performed with a mirror to stimulate normal movement and reduce fear and pain.

The intervention was tailored to her tolerance, emphasizing progression without exacerbating symptoms.

Results

After the GMI program, the patient reported:

• Reduced pain and disability (improved ODI scores)
• Improved body awareness (better FreBAQ scores)
• Lower fear and catastrophizing thought (reduced PCS)

She was able to return to activities she had previously avoided due to pain.

Discussion

The report highlights GMI’s potential to target central nervous system changes underlying chronic pain. It emphasizes the importance of treating not just tissue damage but also the brain’s perception of the body. The results support the integration of GMI into pain rehabilitation, particularly for patients with evidence of central sensitization and distorted body image.

Conclusion

GMI was an effective, low-cost, and non-invasive that helped reduce pain and disability in a patient with longstanding chronic LBP. The case supports its use as part of a multidisciplinary pain management approach.

References

Iglar, D., Dritsas, J., and Cortese, F. (2021). Monkey see, monkey do: Using graded motor imagery in the management of chronic low back pain- A case report. Journal of Orthopaedic & Sports Physical Therapy, 51(1), 41-41.. https://doi.org/10.2519/jospt.2021.9966

Introduction/Background

Methods

Results

Discussion

References

 Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction

Commonly, ataxias are caused by cerebellar disorders of peripheral nerves. People with ataxias are likely to have most difficulty with gait, balance, speech, swallowing, and vision leading to a reduced quality of life. To date, there is no cure for the progressive disease, but some interventions may be helpful in managing the symptoms. This review aims to compile available data on rehabilitation interventions for managing cerebellar ataxia.

Methods

A total of 58 studies collected were published in Portuguese or English between 1990-2020. The review also included articles on the topics of new and emerging interventions.

Results by Category

Physical Therapy

Physical therapy is recommended for all stages of the disease. Coordination training improves motor performance and reduces ataxia symptoms. There is weak evidence for using virtual reality, biofeedback, and bodyweight support treadmill exercises for postural training, however high-intensity motor coordination training proved beneficial for those with degenerative ataxia for stability and motor coordination. Many studies at various levels of evidence conclude that rehab improves mobility, function, ataxia, and balance in adults and children, however, studies lack long-term follow-up and specific training strategies.

Outcome Measures and Clinical Scales

Scale for the Assessment and Rating of Ataxia is commonly used to quantify severity of ataxia with good construct validity. The Neurological Examination Score for Spinocerebellar Ataxias is also commonly used for measuring ataxia severity with good interrater reliability and consistency. The Berg Balance Scale and Timed Up and Go were determined to be the best outcome measures for the population.

Exergames and New Technologies

Incorporating virtual reality into therapy (exergames) can add a motivational aspect to rehab and target coordination, balance, and weight transfer. Some studies found that games such as the Wii can not only improve daily training, but also if used regularly can improve postural sway, balance, gait, and fall frequency.

Speech, Voice, Swallowing Therapy

Early detection and intervention for swallowing and speech impairments for degenerative ataxias is important due to the ultimate progression of the disease. Early intervention can improve swallowing and speech can enhance quality of life.

Occupational Therapy

OT can improve balance, and coordination of patients with degenerative ataxias, however, when combined OT and PT is more effective for long-term benefit. Though it is known that OT should be tailored to patients’ specific needs, specific aspects of treatment and interventions should continue to be studied.

Conclusion

Although there is no cure for cerebellar ataxias, various studies have proven that physical therapy, occupational therapy, speech therapy is essential for patient care and can aid with management of the disease. Some studies suggest they are best used in combination and when implemented early.

Reference

Chien, H.F., Zonta, M.B., Chen, J., Diaferia, G., Viana, C.F., Teive, H.A.G., Pedroso, J.L., &Barsottini, O.G.P. (2022). Rehabilitation in Patients with Cerebellar Ataxias. SciELO Brazil, 80(3), 306-315. https://doi.org/10.1590/0004-282X-ANP-2021-0065