Frequently asked questions


Lefts and rights

Q. I can't decide if the body part is left or right because some of the photos are taken from the front or the back. Is it the same as watching TV or looking at a mirror? A. The body part relates to the person in the image, not to you. Ask yourself: Is that picture of a person's left or right hand? Or, in the case of the spine: Is this person moving to their left or right? So it relates to the person, not to you.
Q. Some of the postures of body parts and contexts (animals, textures, environments) on the Recognise App really disturb me. Is there a way I can choose to use (or not use) particular images? A. If you find some or many images too disturbing, you can always add up to 50 of your own images to the 'My Images' category. Update your personal images as you progress through the Recognise App and maybe you can gradually start to take tests using other images available with the program.
Q. Some of the photos are not showing the correct way up (ie are rotated randomly). I have tried in Firefox and Google chrome browsers with the same results. A. The rotation is intended. Whenever a picture isn't the right way up your brain has to work that little bit harder to figure out whether it is left or right. The Recognise App has a category for testing called 'basic' which means the images are not rotated from their origin. It is definitely easier to do the testing and can be useful to gradually ease into the tests. The rotated images in the 'Vanilla' category allow a progression for testing from 'Basic'
Q. Why is the initial step in right/left discrimination called vanilla hands? A. 'Vanilla' images have a plain, mono-coloured background, so there is no distraction and no emotional or contextual ties. 'Basic' images on Recognise are 'Vanilla' in style but are not rotated from their origin.

Explicit motor imagery

Q. I've started using the Recognise App in the clinic. What do I do in order to have patients use it on their own? Is there anything for motor imagery? A. Patients can enter their clients details and export results via email with a few taps.The Recognise App has left/right discrimination and explicit motor imagery exercises.

Different mirrors

Q. Is the NOI mirror box large enough to use with my leg? A. No. Although the mirror may be suitable for some users with smaller feet and legs, we recommend using the NOI mirror box for hands only. Alternate mirror solutions are offered in The Graded Motor Imagery Handbook and a 'box' can be constructed quite easily. We also recommend using Perspex mirrors to avoid injuries from broken glass.
Q. My wife has pain in her left shoulder that has been diagnosed as CRPS following months working on a diagnosis of "frozen shoulder". From research by Ramachandran and Moseley, we have been attempting "mirror therapy", but finding it difficult to translate the usual presentations of working with limbs to the shoulder. We work with a Physical Therapist who is helping with range of motion, but has not specifically done mirror therapy. What would be most helpful would be some guidance on positioning a mirror and potentially beneficial movements to assist in the "brain work". A. We have no data on whether frozen shoulder is associated with brain representational changes, but this is quite possible – especially with the more long standing and painful frozen shoulders. Before contemplating mirror therapy, you will need to make sure that the person has a reasonable sense of left/right discrimination and the ability to imagine movements and postures of the shoulder. You can quickly test this using the Recognise App.
Presuming that this is OK, mirror therapy may form a part of ideal management. See The Graded Motor Imagery Handbook for working with large mirrors and different body parts.

Normals and 'Protocol'

Q. I assessed a patient with chronic low back pain using Recognise images of the back. He tested within normal response times and 100% accuracy on vanilla & context images. So I'm thinking he doesn't have any L/R discrimination impairment, right? And spending time on Recognise won't likely affect his pain? I advised him there is no need to use Recognise with his normal values and am just wondering about your thoughts. A. Correct - focus on return to normal movement and activity. Simply, many people including some patients have no disturbance of left/right discrimination.
Q. Within the Recognise App, are there any normals on left/right discrimination accuracy and response times for the various tests? A. See the posters or The Graded Motor Imagery Handbook for a more thorough explanation of 'normal' but as a guide the ideal results for tests have no bias to the left or right for both time and accuracy, an accuracy of 80% and above, around 2 seconds response time (give or take 0.5 seconds). Backs and necks are about 0.5 seconds faster. Results should be consistent within these parameters – i.e. the scores should remain stable for at least a week or through a stress state. 
Handedness doesn't appear to make a difference.
I can't seem to find information on how to best utilize the Recognise App. I seem to remember reading that short, frequent sessions are better, but what does that mean exactly... once a day, twice a day, every hour... for how long, how many tests? My daughter has CRPS that affects her right leg and arm. We bought this last year, but did not fully utilize it... just bought it for another year and want to get the best use of it... but she does need to work with both hands and feet. Thanks for your help! A. In Lorimer Moseley's research for CRPS-1 they used left/right discrimination exercises for two hours per day for two weeks before moving on to explicit motor imagery and mirror therapy for similar times. That sounds a lot and many users may not require this time or can break it up into serviceable bits. Of course, the online program is not the only way to exercise left/right discrimination. There are flash cards, apps, you can use magazines, photo albums, facebook etc., etc.
Q. My patient with CRPS of her right hand is so sensitive that using Recognise even for a few images will often make her more sensitive. Where do I start? A. There are two suggestions. First, you could do left/right discrimination exercises of the feet or the neck. This probably exercises similar areas in the brain to the hand without bringing on hand pain. The other suggestion is to go to watching activities related to the limb. Just watching people knitting or a piano movie would be an example of this.

GMI in context

Q. What do you think of the idea of flooding the senses, I have a patient will hypersensitivity with shifting paraesthesia and changing pain quality, I thought that I might try to distract his brain pattern by introducing music and maybe even ice away from the affected limb, what do you think? A. It's a good idea to alter the context of an activity and even an "activity" such as left/right discrimination exercises can be carried out in various contexts such as time, environment, knowledge and emotions. "Flooding" may be too much for many people with chronic pain and stress states. The broad suggestion here is that contexts should be altered gradually with consideration of things like familiar to less familiar, and threatening to less threatening. See Tim's chapter in The Graded Motor Imagery Handbook for more here.

Strange responses

Q. I recently started using the Recognize App with some patients and noticed something odd with one of them. This lady has some generalized chronic pain (focussed on right knee and left flank) and dizziness. She has been investigated for both and appeared to be a good candidate to try GMI. In the start, she was fluctuating anywhere from 30% to 70% accuracy for both limbs but in the past week she has suddenly jumped on her right to 80-100% and dropped on her left to 10-30%. She is generally feeling less pain in her knee, more confident, and less dizzy. She has associated most of her pain to the right side in the past so part of this correlates, but what the heck is happening on the left? A. These are odd responses but we have heard similar stories and want to look at this more closely from a research perspective. The broad questions we would have include:
  • Is there a side dominance and an area dominance of her pain?
  • How long have there been symptoms?
  • Are there any coexisting issues such as dyslexia, coordination issues?
The accuracy shifts are really odd. Of course under 50% is less than chance and it sort of means that she thinks the left is the right. Frustration/stress will blow the results out but not usually like this. It is worth continuing to see if you can get back to what it was before. Some suggestions would include:
  • Just do L/R discrim on the least sensitive parts of the body
  • Drop back and just watch left sides of the limb (this can be set up easily by taking 'imagery' tests on Recognise)

Different pain states

Q. A patient of our pain centre in Dresden is suffering from phantom pain after losing his lower leg. Mirror therapy was tried in the hospital after the operation without effect. Would you recommend graded motor imagery for him? Does the Recognise App include feet and legs? A. The answer here is "Yes and Yes". The online Recognise App offers implicit (left/right) and explicit (imagined) motor imagery exercises for feet and knees for the lower limbs.
Q. When I had CRPS (in remission now) and I was in a lot of pain my scores were very poor, around 20%. When I was more comfortable scores were 70-80%. If I had a migraine scores were lowest. In the end I discovered it was the processing time that changed. Not that I couldn't recognise the hands but that the more pain I was in the slower I became and hence couldn't do it in the time I set myself per image. I practised looking at my hands in different positions and practised the test (practise should make perfect you know). However it didn't make a difference except that I developed sudden extreme pain in the observed hand one time when I was practising looking at my hands. I let it go for a while, tried again and found the same. Haven't used it since. I believe the brain remembers pain and dredged up old memories of hand pain. My original injury was a colles fracture. A. Thank you for sharing these reflections. We think you are probably right about the "dredged up old memories". We have occasionally heard similar stories from other users. It is very unlikely that the components of GMI can hurt anyone, after all it's mainly brain exercise! Perhaps marvel at the brain's power and get back and see if you can get the scores back to your 70-80%.
Q. I have a 69 year old male patient with Neuropathic Pain secondary to a stroke that was 18 years ago. Do you think he is a candidate for GMI? A. Brains are changeable and you can certainly teach "old dogs new tricks". Assess left/right discrimination abilities and give it a go. With 18 years of altered processing don't expect overnight results!
Q. My wife has pain in her left shoulder that has been diagnosed as CRPS following months working on a diagnosis of "frozen shoulder". From research by Ramachandran and Moseley, we have been attempting "mirror therapy", but finding it difficult to translate the usual presentations of working with limbs to the shoulder. We work with a Physical Therapist who is helping with range of motion, but has not specifically done mirror therapy. What would be most helpful would be some guidance on positioning a mirror and potentially beneficial movements to assist in the "brain work". A. We have no data on whether frozen shoulder is associated with brain representational changes, but this is quite possible – especially with the more long standing and painful frozen shoulders. Before contemplating mirror therapy, you will need to make sure that the person has a reasonable sense of left/right discrimination and the ability to imagine movements and postures of the shoulder. You can quickly test this using free Recognise trial. Presuming that this is OK, mirror therapy may form a part of ideal management. See The Graded Motor Imagery Handbook for working with large mirrors and different body parts.
Q. I was wondering if you have any specific advice for other problems with a central/cortical aspect to ongoing pain such as chronic low back pain or IBS, as I know they have been discussed as having very similar underlying mechanisms. A. There is no data on irritable bowel syndrome though we think it may well be worth exploring and we are currently involved in a pelvic pain pilot project. The data in on chronic low back pain show some left/right discrimination discrepancies do exist. Practically though, remember that for any test involving the spine the question asks, "Is this person turning to the left or right?" – rather than, "Is this the left or right side?" Mirrors are obviously difficult for the low back but sensory retraining is worth a try!

Looking for motivation

Q. I recently attended a course on GMI and was very inspired and have started implementing it with a number of CRPS hand patients. Do you have any additional tips on how to encourage regular practice at home? With only seeing the patients maybe once a week on average, I am getting the feeling they are not practicing as much as I am recommending and whilst I appreciate this will always be the case with any exercises/activities I suggest (from my own physio exercise experiences!!) do you have any tips on trying to encourage regular self-directed practice? A. The Recognise App has left/right discrimination and explicit motor imagery exercises. Patients can enter their clients details and export results via email with a few taps.

Tools

Q. How do I access the Recognise App? A. The Recognise App is available for download from the App Store for iPhones and iPads and Google Play for Android devices. Search 'recognise hands' or 'recognise feet' etc to find the App you want. Similar to flash cards, Recognise Apps are dedicated to a particular body part.
Q. Are the flash cards available as mixed sets? I would like hands and shoulders mixed together. A. No. A box of flash cards contains 24 left and 24 right images of a particular body part.
Q. Is the NOI mirror box large enough to use with my leg? A. No. Although the mirror may be suitable for some users with smaller feet and legs, we recommend using the NOI mirror box for hands only. Alternate mirror solutions are offered in The Graded Motor Imagery Handbook and a 'box' can be constructed quite easily. We also recommend using Perspex mirrors to avoid injuries from broken glass
Q. Where do I find a two point discriminator? A. You can usually get one in your top drawer, aka the 'paper clip'. But hardware stores usually stock them – cheap digital ones are widely available and extremely accurate.