Graded Motor Imagery

The Graded Motor Imagery (GMI) programme is an evidence based therapeutic approach that falls under the brain training umbrella. This is because the treatment targets changes that have occurred in the brain. We know about these changes from a number of brain scanning studies in recent years. The actual programme has been developed largely through the brilliant work of Lorimer Moseley, so for this we are truly grateful.

The programme runs through three sequential stages, laterality (recognising left and right), imagined movements and mirror therapy. In essence this is graded progression, working the brain to desensitise, habituate and develop function. These areas of the brain are part of the pain matrix which means that they have a role in pain production as well as other functions that are non-nociceptive (nothing to do with danger).

We know that pain is a brain experience influenced by physical, psychological and social factors, hence the biopsychosocial model. Targeting the brain with clinical treatments is offering a very modern approach to pain and chronic pain in particular.

Mirror therapy using a mirror box or standing mirror was initially used for stroke rehabilitation and for phantom limb pain but in fact it can be used for a range of nasty pains and functional problems. The brain ‘sees’ a normally functioning hand, foot or other body part as the affected area is hidden and the unaffected side is moved. Observing the reelection of the unaffected side, the brain thinks that the affected side is working well and looking normal. As the brain uses visual information over and above information from the tissues, it will prioritise what it sees compared to what it feels.

At Specialist Pain Physio we use this programme in its entirety but also the different components. We also integrate the techniques with others to optimise the learning process and changes in the nervous system that lead to pain relief and improved ability.

Rehabilitation is learning and the underlying process is similar to learning a language or a musical instrument. It takes time, practice, motivation and perseverance. Give the brain and the nervous system the opportunity and it can change for the better.

We commonly use GMI for complex regional pain syndrome (CRPS), arthritis, tendon pain and injury, sports injuries and repetitive strain injury (RSI). The principles can be applied in a range of other conditions to provide a more complete bodywide rehabilitation programme.


Is sitting a problem?

The following piece from Scientific American looks at the problem with sitting despite the fact that you may exercise regularly. A huge study in 2009 (17,000 participants) found that the time spent sitting was associated with increased risk of all-cause and cardiovascular disease mortality. It seems that the best way to manage this time, often at work, is to regularly break up the sitting periods. This is a strategy that we recommend to many clients, often to manage pain that gradually builds when you are in one position. However, it is clear that there are many other healthy benefits of taking on this approach. Read on for the article by Travis Saunders

We all know that physical activity is important for good health—regardless of your age, gender or body weight, living an active lifestyle can improve your quality of life and dramatically reduce your risk of death and disease. But even if you are meeting current physical activity guidelines by exercising for one hour per day (something few Americans manage on a consistent basis), that leaves 15 to 16 hours per day when you are not being active. Does it matter how you spend those hours, which account for more than 90% of your day? For example, does it matter whether you spend those 16 hours sitting on your butt, versus standing or walking at a leisurely pace? Fortunately or unfortunately, new evidence suggests that it does matter, and in a big way.

What is sedentary behavior?

Before we go any further, it’s important that we define the term “sedentary behavior”. Sedentary behavior is typically defined as any behavior with an exceedingly low energy expenditure (defined as <1.5 metabolic equivalents). In general, this means that almost any time you are sitting (e.g. working on a computer, watching TV, driving) or lying down, you are engaging in sedentary behavior. There are a few notable exceptions when you can be sitting or lying down but still expend high energy expenditure (e.g. riding a stationary bike), but in general if you are sitting down, you are being sedentary.

The above definition may seem rather intuitive, but this is not the way that the term sedentary has been used by exercise science researchers for the past 50 years. Up until very recently, referring to someone as sedentary meant simply that they were not meeting current guidelines for physical activity. In simple terms, if you were exercising for 60+ minutes/day, you were considered physically active. If you were exercising 10 minutes/day, you were sedentary. Case closed. But as we will discuss below, sedentary time is closely associated with health risk regardless of how much physical activity you perform on a daily basis. Further, it is entirely possible to meet current physical activity guidelines while still being incredibly sedentary. Thus, to quote researcher Marc Hamilton, sitting too much is not the same as exercising too little. (if you take only one thing from this post, let it be that quote from Dr Hamilton). Which is why it is so important that when we use the term “sedentary”, we are all on the same page about what that means.

Now that we know what sedentary behavior is, let’s look at its relationship with health risk.

Epidemiological Evidence

In 2009 Dr Peter Katzmarzyk and colleagues at the Pennington Biomedical Research Center published an influential longitudinal paper examining the links between time spent sitting and mortality in a sample of more than 17,000 Canadians. Not surprisingly, they report that time spent sitting was associated with increased risk of all-cause and cardiovascular disease mortality (there was no association between sitting and deaths due to cancer). But what is fascinating is that the relationship between sitting time and mortality was independent of physical activity levels. In fact, individuals who sat the most were roughly 50% more likely to die during the follow-up period than individuals who sat the least, even after controlling for age, smoking, and physical activity levels. Further analyses suggested that the relationship between sitting time and mortality was also independent of body weight. This suggests that all things being equal (body weight, physical activity levels, smoking, alcohol intake, age, and sex) the person who sits more is at a higher risk of death than the person who sits less.

The above findings linking excessive sitting with poor health are far from isolated. For example, a similar longitudinal study from Australia reports that each hour of daily television viewing (a proxy of sedentary time) is associated with an 11% increase in the risk of all-cause mortality regardless of age, sex, waist circumference, and physical activity level. And as my colleagues and I summarize in a recent review paper (PDF), numerous epidemiological studies have linked sedentary behavior with obesity, cardiometabolic risk, and even some cancers.

New evidence also suggests that in addition to the quantity of sedentary time, the quality of sedentary time may also have an important health impact. For example, Genevieve Healy and colleagues examined this issue in participants of the Australian Diabetes, Obesity and Lifestyle (AusDiab) Study. A total of 168 men and women aged 30-87 years wore an accelerometer (an objective measure of bodily movement) during all waking hours for 7 consecutive days, which allowed the researchers to quantify the amount of time that participants spent being sedentary, as well as how frequently they interrupted these sedentary activities (e.g. standing, walking to the washroom, etc).

What did they find?

The greater the number of breaks taken from sedentary behavior, the lower the waist circumference, body mass index, as well as blood lipids and glucose tolerance. This was true even if the total amount of sedentary time and physical activity time were equal between individuals—the one who took breaks more frequently during their time at the office or while watching television was less obese and had better metabolic health. Importantly, the breaks taken by the individuals in this study were of a brief duration (<5 min) and a low intensity (such as walking to the washroom, or simply standing).

Taken together, the epidemiological evidence strongly suggests that prolonged sitting is an important health risk factor. But what explains these relationships? Let’s now look at the multiple mechanisms linking sedentary time with increased health risk.


Reduced Energy Expenditure

Quite obviously (and by definition), when you are sedentary, you are not being physically active. And so one common assumption is that people who sit more are at increased health risk simply because they are getting less physical activity. However, somewhat surprisingly, sitting time and physical activity do not appear to be related for most people. For example a paper from the European Youth Heart Study published in PLoS Medicine reports no association between physical activity and TV watching in a sample of nearly 2000 children and teenagers, and other reports suggest that there is little evidence that sedentary behavior displaces moderate or vigorous physical activity. So while it makes intuitive sense that being sedentary reduces energy expenditure, it is likely through the reduction of very light intensity physical activity (e.g. standing, walking at a slow pace), rather than by reducing the volume of what we typically think of as exercise. This may also help explain why the relationship between sedentary behavior and health risk are often independent of moderate or vigorous physical activity.

Increased Food Intake

In addition to reducing our energy expenditure, sedentary behaviors may also promote excess food intake. For example, a recently published study in the American Journal of Public Health suggests that the amount of commercial television (e.g. television with advertisements) that children watch before the age of 6 is associated with increased body weight 5 years down the road, even after adjustment for other important variables including physical activity, socio-economic status and mother’s BMI. In contrast, watching non-commercial television (DVD’s or TV programs without commercials) showed no association with body weight. Similarly, it has also been reported that each hour of daily television watching in children is associated with an increased consumption of 167 calories per day (PDF), mainly through increased consumption of high calorie, low nutrient foods (e.g. the foods most commonly advertised on television). Much of this is likely just a learned behavior—watching TV exposes us to food ads promoting unhealthy fare, which is likely to have a disproportionate influence on younger viewers. Just as importantly, people may just really enjoy munching on food while relaxing on the couch. Either way, excess sitting (and TV watching in particular) seems to put us in situations where we choose to eat more than we would otherwise.

Physiological Adaptations

I don’t think the mechanisms described above—that sitting too much may lead to reduced energy expenditure and increased food intake—will come as much of a surprise. But what I find truly fascinating is that sedentary behavior also results in rapid and dramatic changes in skeletal muscle. For example, in rat models, it has been shown that just 1 day of complete rest results in dramatic reductions in muscle triglyceride uptake, as well as reductions in HDL cholesterol (the good cholesterol). And in healthy human subjects, just 5 days of bed rest has been shown to result in increased plasma triglycerides and LDL cholesterol, as well as increased insulin resistance—all very bad things. And these weren’t small changes—triglyceride levels increased by 35%, and insulin resistance by 50%!

These negative changes are likely related to reductions in the activity of lipoprotein lipase, an enzyme which allows muscle to uptake fat, thereby reducing the amount of fat circulating in the blood (it also strongly influences cholesterol levels—the details can be found here). Animal research has shown that lipoprotein lipase activity is reduced dramatically after just six hours of sedentary behavior—not unlike a typical day at work or school for many individuals. Sedentary behavior may also reduce glucose transporter protein content in the muscle, making it more difficult for glucose to be taken into the muscle and resulting in higher blood sugar levels. What is most interesting to me personally is that these physiological changes in skeletal muscle have little or nothing to do with the accumulation of body fat, and occur under extremely rapid time-frames. This means that both lean and obese individuals, and even those with otherwise active lifestyles, are at increased health risk when they spend excessive amounts of time sitting down.

Should we be concerned about the health impact of sedentary behavior?


Western society is built around sitting. We sit at work, we sit at school, we sit at home, and we sit in our cars as we commute back and forth. In fact, a recent survey reports that the average American accumulates more than 8 hours of sedentary behavior every day—roughly half of their waking hours. The situation in children is, unfortunately, no different. There is evidence that children in both Canada and the USA accumulate more than 6 hours of screen-time (time spent in front of the TV, computer, or other screen-based device) on a daily basis. Keep in mind that screen-time is almost exclusively sedentary (active video games excluded), and that all these hours of sedentary behavior are in addition to the hours and hours (and hours) that kids spend sitting at school. In fact, a recent study reports that roughly 70% of class time, including physical education class, is completely sedentary (while slightly better than class time, children were also sedentary for the majority of lunch and recess).

In short, given the consistent links between sedentary behavior and both death and disease, and the ubiquity of sedentary behavior in our society, we should be very concerned about the health impact of sedentary behavior.

What is the take-home message?

There is a rapidly accumulating body of evidence which suggests that prolonged sitting is very bad for our health, even for lean and otherwise physically active individuals. The good news? Animal research suggests that simply walking at a leisurely pace may be enough to rapidly undo the metabolic damage associated with prolonged sitting, a finding which is supported by epidemiological work in humans. So, while there are a lot of questions that remain unanswered (e.g. Is there a “safe” amount of daily sedentary time?), the evidence seems clear that we should strive to limit the amount of time we spend sitting. And when we do have to sit for extended periods of time (which, let’s face it, is pretty much every single day for many of us) we should take short breaks whenever possible.

Finally, if you take only one thing from this post, let it be this—sitting too much is not the same as exercising too little.


Treatment for pain relief and relaxation

Our treatment programmes target the pain source(s) by working out the type of pain that you have. This is the most modern way of reliving pain and is known as a ‘pain mechanism’ approach. It has been described in the scientific press for medication (pharmacology) and because we love science at Specialist Pain Physio, we adopted the principles. Basically it means that through your description and the examination we can work out the main drivers such as inflammation, the immune system and stress, and the devise personal strategies and treatment techniques to deal with the problems.

Our aims are:

  • To relieve pain
  • To ease suffering
  • Restore activity levels
  • Help return to work, sports and other activities
  • To relieve stress and anxiety related to the pain & injury
  • Reduce the risk of recurring injury & pain
  • Promote health & wellbeing
  • Maximise your potential physically & psychologically

Appointments 07518 445493


Tips for effective rehabilitation

Tips for effective rehabilitation


Rehabilitation is absolutely essential in restoring normal activity after an injury or painful event, as part of chronic pain management, improving one’s ability to be active and following an operation or other medical procedure. The programme should be individualised, progressive and be appropriate for the goals of the individual, i.e. functional for work, sport and other activities. The following tips are ways of really enhancing the process of rehabilitation, drawing upon some of the most recent understanding in neuroscience and cognitive science.


In no particular order:

1. Ensure that you have set goals related to your objectives. Follow the SMART procedure.

2. Keep a rehabilitation or training diary so that you can tick off your exercises and feel good about it as well as mark off goals when they have been achieved.

3. The programme should start at a baseline determined with the help of your health professional. This is the start point from where you move forwards.

4. The programme should be progressive, fitting with your goals, looking to challenge and move forwards but without causing unnecessary flare-ups.

5. Flare-up management should involve understanding what it is, how it can be managed effectively and used as a learning experience.

6. Rehabilitation should include components of education, motor control, proprioception, functional exercise, strength, endurance and posture. Other aspects can be power, speed, agility, work and sports specific tasks.

7. Understand realistic time lines that includes the healing process so that you know what to expect and where you are along the line of recovery. You should ask your health professional to keep you updated on this point.

8. Vary the tasks when you can. By the nature of rehabilitation you have to repeat the exercises, in some cases very often. This is because in essence there is a learning process going on and it takes time, just like learning a language or musical instrument. Changing the context can help to keep the interest.

9. Gaining feedback is really important. This can come from an observer or a mirror. Mirrors are brilliant rehabilitation tools as the brain uses visual feedback over sensory feedback and therefore can help to correct movement patterns. Mirror therapy is a different approach that can be used in certain conditions with good effect when used appropriately by a trained practitioner, for example in stroke victims, phantom limb pain, complex regional pain syndrome and other painful conditions.

10. Using cognitive and motivational techniques has a huge effect and can make a really significant difference to the outcomes. Again this requires an appropriately trained and knowledgeable practitioner who can integrate these methods into the programme. Targeting the brain is a very powerful way of maximising potential. Techniques include awareness, assessing beliefs, education, goal setting and mindfulness.

11. Set up the environment to promote concentration, focus and awareness

These factors and others are fundamental to a successful rehabilitation programme. Enhanced programmes make a difference as they draw upon not just the physical parameters such as altered movement, pain, the healing process and altered neurodynamics, but also the integration of senses, past experience, cognition, immune function, stress, anxieties and other psychological states, personality, culture, understanding and a host of other human characteristics. Looking at rehabilitation in a wider sense is complicated, takes time and understanding, however by drawing upon the knowledge of brain and nervous system function, immune activity, tissue healing and other bodily systems, we can create bespoke, challenging, progressive and fun programmes that maximise potential.

Rehabilitation programmes at Specialist Pain Physio Clinics are thought out based on your experience, presentation and the requirements that you identify. We constantly strive to update our methods by keeping abreast of research and science. Follow the blog and our Twitter page to learn more.


Mindfulness, stress reduction & healing

A talk by Jon Kabat-Zinn on mindfulness, stress reduction & healing.

Jon Kabat-Zinn started the programme of stress reduction in 1979 in the USA. This programme and its integration into mainstream healthcare has evolved and grown hugely ever since. At Specialist Pain Physio we have taken on this approach as part of the treatment and rehabilitation programmes for very good reason. Pain and stress are very much linked and integrated, affecting each other. We must deal with the stressor to manage and ease the pain from a physiological and psychological stand point. Pain itself is a stressor and places huge demand upon the body’s resources. Using the MBSR approach alongside other cognitive techniques is highly effective in easing suffering, symptoms, controlling and reducing stress and optimising treatment outcomes.

Mindfulness based stress reduction with Jon Kabat-Zinn


Repetitive strain injury (RSI)

Repetitive strain injury (RSI) is a common complaint that we see at Specialist Pain Physio Clinics as it is often reported as persisting or recurring. There is a spectrum from those suffering mild symptoms to those who have had to stop working due to pain and other signs and symptoms of RSI. The term describes what has happened in essence but we know more about how and why this problem occurs and continues therefore allowing for more effective treatment and management. The overall aim is to reduce symptoms and restore function, usually including a return to work.

Symptoms include

  • Pain: e.g./ sharp, dull, achy, spontaneous, shooting, throbbing
  • Altered sensation: pins & needles, numbness, crawling
  • Swelling
  • Altered perception of the limb, including size
  • Temperature change
  • Discolouration
  • Altered movement including being unable to grip, type, write, hold or perform fine motor skills (buttons, picking up small objects)
  • Altered joint position sense (unaware of where a body part is in space and where it is going, hence a loss of accuracy)
  • Fatigue

For normal tissue health the brain relies upon a regular flow of information about current status. There is a huge network of nerves performing this task. This information includes ‘online’ data about movement. However, with smaller movements such as typing, the brain does not register the movement as accurately. Essentially a mismatch can develop between what is expected and the information coming in. We know that this kind of sensorimotor mismatch can lead to the development of sensitivity. Subsequent to this sensitivity build up, the same nerve network can release chemicals into the tissues and provoke a host of symptoms. This is called neurogenic inflammation.

It is feasible that ‘overuse’ can lead to a breakdown of tissue via an imbalance that develops when the natural breakdown-rebuild process tips in the favour of the former. If an inflammatory process starts, the chemicals released cause sensitivity to develop. This can evolve into a greater problem over time if the tissues do not have the opportunity to heal adequately.

An inflammatory process that develops in the neck can cause a nerve to become sensitised with subsequent pain being felt in the tissues that the nerve supplies, in the hand for example. This is referred pain and can cause altered use of the limb that in itself leads to further problems of disuse and pain.

There are a range of conditions that can come under the repetitive strain banner:

  • Bursitis
  • Cubital tunnel syndrome
  • Carpal tunnel syndrome
  • DeQuervain’s syndrome
  • Diffuse RSI
  • Dupuytren’s contracture
  • Dystonia (writers cramp)
  • Epicondylitis
  • Gamekeeper’s thumb
  • Ganglion
  • Raynauds disease
  • Tendinitis
  • Tenosynovitis
  • Thoracic outlet syndrome

At Specialist Pain Physio we will ascertain the cause through the assessment along with the type(s) of pain so that we can provide the right treatment programme and advice. We work with you to restore function and relieve the symptoms.

Return to work

We provide return to work strategies that includes visiting your workplace and talking to your employer or occupational health department.

Useful resources: