The Efficacy of Graded Motor Imagery in Post-Traumatic Stiffness of Elbow A Randomized Controlled Trial

J Shoulder Elbow Surg (2022) 31, 2147–2156
www.elsevier.com/locate/ymse
ELBOW
The efficacy of graded motor imagery in

post-traumatic stiffness of elbow: a randomized
controlled trial
€leyman Altun, MDd
Tansu Birinci, PT, PhDa,b,*, Ebru Kaya Mutlu, PT, PhDc, Su
a
Institute of Graduate Studies, Istanbul University-Cerrahpasa, Istanbul, Turkey
b
Division of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul Medeniyet University, Istanbul,
Turkey
c
Division of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Bandırma Onyedi Eylul University, Balıkesir,
Turkey
d
Department of Orthopedics and Traumatology, University of Health Sciences, Bakırk€oy Dr. Sadi Konuk Training and
Research Hospital, Istanbul, Turkey
Background: Physiotherapy improves the movement range after the onset of post-traumatic elbow stiffness and reduces the pain, which
is a factor limiting elbow range of motion. However, no results have been reported for motor-cognitive intervention programs in post-
traumatic elbow stiffness management. The objective was to investigate the efficacy of graded motor imagery (GMI) in post-traumatic
elbow stiffness.
Methods: Fifty patients with post-traumatic elbow stiffness (18 female; mean age, 41.9 10.9 years) were divided into 2 groups. The
GMI group (n ¼ 25) received a program consisting of left-right discrimination, motor imagery, and mirror therapy (twice a week for 6
weeks); the structured exercise (SE) group (n ¼ 25) received a program consisting of range-of-motion, stretching, and strengthening
exercises (twice a week for 6 weeks). Both groups received a 6-week home exercise program. The primary outcome was the Disabilities
of the Arm, Shoulder, and Hand (DASH) questionnaire. The secondary outcomes were the active range of motion (AROM), visual
analog scale (VAS), Tampa Scale for Kinesiophobia (TSK), muscle strength of elbow flexors and extensors, grip strength, left-right
discrimination, and Global Rating of Change. Patients were assessed at baseline, at the end of treatment (12 sessions), and a 6-week
follow-up.
Results: The results indicated that both GMI and SE interventions significantly improved outcomes (P < .05). After a 6-week inter-
vention, the DASH score was significantly improved with a medium effect size in the GMI group compared with the SE group, and
improvement continued at the 6-week follow-up (F1,45 ¼ 3.10, P ¼ .01). The results with a medium to large effect size were also sig-
nificant for elbow flexion AROM (P ¼ .02), elbow extension AROM (P ¼ .03), VAS-activity (P ¼ .001), TSK (P ¼ .01), and muscle
strength of elbow flexors and elbow extensors (P ¼ .03) in favor of the GMI group.
Conclusion: The GMI is an effective motor-cognitive intervention program that might be applied to the rehabilitation of post-traumatic
elbow stiffness to improve function, elbow AROM, pain, fear of movement-related pain, and muscle strength.
Ethical approval for this study was obtained from the Clinical Research *Reprint requests: Tansu Birinci, PT, PhD, Istanbul Medeniyet Uni-
Ethical Committee of Istanbul University-Cerrahpasa, Medical Faculty versity, Faculty of Health Sciences, Division of Physiotherapy and Reha-
(approval no. 2019/A-17). bilitation, 34700, Istanbul, Turkey.
E-mail address: tansubirinci@hotmail.com (T. Birinci).
1058-2746/$ - see front matter Ó 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
https://doi.org/10.1016/j.jse.2022.05.031
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2148 T. Birinci et al.
Level of evidence: Level I; Randomized Controlled Trial; Treatment Study

Ó 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Keywords: Arm bones; immobilization; mirror neurons; pain; rehabilitation
Joint stiffness is a common complication after articular- intensity, fear of movement-related pain muscle and grip
related trauma in the elbow, resulting in significant upper strength, left-right discrimination, and patient satisfaction.
limb disability.39 In elbow fractures that are fixed surgi-
cally, there can be primary bone healing with little or no
visible callus formation; therefore, the joint should be
Methods
immobilized for a few weeks.12 Although immobilization is
necessary for bone healing, it adversely affects the joint
Study design
structure and function, leading to participation restrictions
A single-blind randomized clinical trial with a parallel design was
in daily living activities.9 The effects of immobilization are
conducted in Istanbul University-Cerrahpasa, Department of
not only confined to surrounding soft tissues and articular Physiotherapy and Rehabilitation, from October 2019 to June
surfaces of the joint but may also affect the sensorimotor 2021. Verbal and written explanations were provided to patients
and cortical representations of the upper limb.9,27,36 Recent about the study, and each provided written informed consent. This
studies revealed that even short-term immobilization, which study was registered on ClinicalTrials.gov (registration number:
reduces muscle use up to 48 hours, affects use-dependent NCT03969277).
cortical plasticity, cortical excitability, and motor
performance.27,36 Participants
Patients with post-traumatic stiffness of the elbow rarely
complain about pain at rest or throughout the available Consecutive patients who had undergone surgery for an elbow
range. However, pain at the end ranges of motion, which is fracture and had post-traumatic elbow stiffness were recruited
a factor limiting elbow movements, is a quite common between 4 and 8 weeks postoperatively at the Department of
complaint among patients with post-traumatic elbow Orthopedics and Traumatology, University of Health Sciences,
stiffness.7 The pain intensity is related to anxiety in post- Bakırk€ oy Dr. Sadi Konuk Training and Research Hospital. The
traumatic stiffness of the elbow; in turn, pain-related anx- eligibility criteria were as follows: (1) aged between 20 and 55
years; (2) having elbow limitation in flexion or extension; (3)
iety can further increase perceived pain intensity and lead
ability to read and write in Turkish; (4) having a Standardized
to pain-related fear of movement.21 In addition, fear of Mini-Mental State Examination score higher than 24 points; and
movement-related pain often results in a reluctance to (5) no pathology in visual ability and hearing. The exclusion
perform the required motor task, which may lead to criteria were as follows: (1) a history of malunion or nonunion; (2)
behavioral avoidance of movements and activities and, in presence of nonhealing wound or infection; (3) occurrence of
the long run, disuse.28 Following the fear to safety complex regional pain syndrome, peripheral nerve injury, het-
perspective, it is crucial that the initial phase of rehabili- erotopic ossification, myositis ossification, or post-traumatic
tation focus on pain control.5,39 ankylosing; (4) having any cardiovascular disease, neurologic
The graded motor imagery (GMI) is an intervention that disorder, rheumatic disease, or psychiatric disorder; (5) shoulder,
aims to promote functional level without associated pain elbow, or wrist movement limitation in contralateral upper ex-
experience, using a graded sequence of motor-cognitive tremity or absence of limbs in the contralateral upper extremity;
and (6) having previously received physiotherapy for elbow
strategies, including left-right discrimination (implicit
limitation.
motor imagery), imagined movements (explicit motor im-
agery), and mirror therapy.25 These 3 components, which
are effective in terms of outcomes, are often used separately Sample size
in rehabilitation programs.4,30,35 However, a limited num-
ber of studies have evaluated the effect of all stages of GMI The sample size and power calculation were performed using the
training in upper limb injuries.2,8,17,34 The GMI might help G*Power 3.1 power analysis program. The calculations were
based on a standard deviation of 17.2 points, a between-group
patients return to the prefracture functional level by mini-
difference of 17.1 points (the minimal clinically important dif-
mizing or eliminating the detrimental consequences of ference for the Disabilities of the Arm, Shoulder, and Hand
immobilization and pain-related fear of movement. There- [DASH] questionnaire, which was the suggested value for the
fore, the primary purpose of this study is to investigate the distal part of the upper extremity),32 an alpha level of 0.05, a b
efficacy of GMI on function in patients with the post- level of 20%, and the desired power of 90%. These parameters
traumatic stiffness of the elbow. The secondary purpose is generate a necessary sample size of at least 23 patients in each
to determine the effect of GMI on the range of motion, pain group. A total of 50 volunteer patients were included in the study.
GMI in post-traumatic stiffness of elbow 2149
Randomization and blinding ranges from 17 to 68, where the higher scores indicate an
increasing degree of fear of movement-related pain and
The orthopedist (S.A.) performed clinical follow-up at 4, 6, 8, and reinjury.24,38
12 weeks postoperatively. Confirmation that the bone fracture had The isometric muscle strength of the elbow flexors and ex-
healed was given based on physical examination and diagnostic tensors was measured as described by Douma et al10 in the supine
imaging before the enrolment. The block randomization method position with a handheld dynamometer (model 01160; The
was applied to randomize the patients into one of 2 parallel groups Lafayette Instrument Company, Lafayette, IN). Each participant
to receive either GMI or a structured exercise (SE) program (ratio was informed verbally about the technique of the test before
1:1). A researcher without clinical involvement in the study pre- starting. Each limb was assessed 3 times, with a 30-second in-
pared a computer-generated list using an online randomization web terval between tests, and the mean value was calculated for
service (https://www.random.org/) and administered the list. The analysis.
researcher allocated the patients to one of the 2 groups based on The grip strength was measured in a sitting position with the
each participant’s selected sealed opaque envelope. The in- shoulder adducted, neutrally rotated, and the elbow flexed at 90
terventions were applied by the same physical therapist (T.B.), and with the wrist in neutral using a dynamometer (Baseline Evalua-
the assessments were made by another physical therapist (E.K.M.). tion Instrument; Fabrication Enterprises, Inc.).13 Each participant
The outcome assessor and patients were kept blind to allocation. was informed verbally about the technique of the test before
starting. Each limb was assessed 3 times, with a 30-second in-
terval between tests, and the mean value was calculated for
Outcome measures analysis.
The left-right discrimination was assessed with Recognise
The primary outcome measure for the present study was the (NOI, Adelaide, Australia), an application designed to measure
functional level of the upper extremity, which was assessed by the the speed and accuracy of making left-right hand discrimination
DASH score. The secondary outcome measures were the active judgments.37 Recognise Hand and Recognise Shoulder applica-
range of motion in the elbow joint, pain intensity, fear of tions were used for assessment. ‘‘Vanilla’’ block was selected with
movement-related pain, muscle strength of elbow flexors and the default setting of 20 images, with 5 seconds to view each
extensors, grip strength, left-right discrimination, and patient image. Patients were instructed to respond as quickly as possible
satisfaction. Assessment of primary and secondary outcome without guessing whether the image displayed was of a right or
measures (functional level, active range of motion in the elbow left hand or shoulder. The test was repeated 2 times, with a 1-
joint, pain intensity, fear of movement-related pain, and left-right minute interval between tests, and data from the second trial
discrimination) was performed at baseline, at the end of treatment were analyzed. Left-right discrimination accuracy of about 80%, a
(12 sessions), and a 6-week follow-up. The other secondary response time of 2.0 0.5 seconds for hands, and around 2 sec-
outcome measures (muscle strength of elbow flexors and exten- onds are normal for shoulders.25
sors, grip strength, and patient satisfaction) were performed at the Patient satisfaction regarding improvement in elbow function
end of treatment (12 sessions) and a 6-week follow-up. The was assessed with the Global Rating of Change scale.18 Partici-
vividness of motor imagery was not an outcome measure, but it pants were asked to rate their condition at the end of the treatment
was assessed at baseline to ensure the homogeneity of the motor compared to baseline by indicating whether they had improved
imagery level in both groups. significantly, improved slightly, were unchanged, had deteriorated
The subjective rating of the functional level of the upper ex- slightly, or deteriorated significantly.
tremity was assessed by the DASH score, including a 30–core The vividness of motor imagery was assessed by the Vividness
item questionnaire and optional additional 8 questions, and its of Movement Imagery Questionnaire–2 (VMIQ-2), a 36-item
questions are scored on a 5-point Likert-type scale (no difficulty to questionnaire. Its questions are scored on a 5-point Likert scale
unable). The cumulative DASH score is ranged from 0 to 100, (perfectly clear and as vivid to no image at all). The total score
where higher scores indicate an increasing degree of ranges from 12 to 60 for each subscale (external visual imagery,
disability.11,15 internal visual imagery, and kinesthetic imagery), with lower
Active range of motion (AROM) of elbow flexion-extension average scores representing greater vivid imaging.29
and forearm supination-pronation was measured as described by
Norkin and White26 in the supine position using a digital goni- Interventions
ometer (Baseline Evaluation Instrument; Fabrication Enterprises,
Inc., White Plains, NY, USA). Each participant was informed
Patients in both groups received individual treatment sessions
verbally about the technique of the test before starting. The
(twice a week for 6 weeks). After the 6-week intervention period,
affected side was assessed 3 times, with a 30-second interval
all patients received instructions for home exercises and were
between tests, and the best value was calculated for analysis.
encouraged to practice exercises at least twice a week for 6 weeks
Pain intensity was measured using the visual analog scale. The
after treatment.
patients were asked to indicate their perceived pain at rest, during
activity, and at night on the 10-cm line between no pain and
terrible pain. The score was determined by measuring the distance Graded motor imagery
on a 10-cm line using a ruler.6
The subjective rating of fear of movement-related pain was The patients assigned to the GMI group received a comprehensive
assessed by the Tampa Scale for Kinesiophobia, a 17-item ques- program consisting of GMI training (left-right discrimination
tionnaire. Its questions are scored on a 4-point Likert scale [laterality], motor imagery, and mirror therapy) that is appropri-
(strongly disagree to strongly agree). The total score of the scale ately included in the rehabilitation program for post-traumatic
elbow stiffness (Supplementary Appendix S1). The first stage was Statistical analysis
laterality, which is the ability to identify left or right images of the
affected upper limb. Laterality training started with 20 simple SPSS, version 21.0 (IBM, Armonk, NY, USA), for Windows
laterality images (with 5 seconds to view each image) and pro- software was used for all statistical analyses. Before the statistical
gressed to 20 complex laterality images (with 5 seconds to view analysis, the Kolmogorov-Smirnov test was used to assess data
each image). Because the elbow joint is intermediate, the distribution. Demographic data and clinical baseline variables
Recogniseä Hand and Recogniseä Shoulder apps were used for were compared among the 2 groups by independent samples t test
training. Patients worked progressively through 4 stages of each for continuous variables and a c2 test for categorical variables.
application, from ‘‘Basic, Vanilla, through to Context and Ab- Changes in variable scores within the groups were measured by
stract’’ sections. A total of 160 images from various angles and means (95% confidence interval) of the paired sample t test.
positions were used and patients worked through each section Repeated measures analysis of variance was conducted with time
once. The second stage of GMI was motor imagery, which is the (at baseline, at the end of treatment, and a 6-week follow-up) as a
ability to imagine a motor movement by rehearsing in working within-subject variable and group (GMI group or SE group) as a
memory without overt motor output. Patients were asked to between-subjects variable to analyze the effect of the interventions
imagine doing functional activities with the affected limb, such as on the primary and secondary outcomes (AROM in the elbow,
combing hair, putting on and taking off a shirt-coat, opening the visual analog scale, left-right discrimination, and Tampa Scale for
door, turning a key, drinking water, washing the face, brushing the Kinesiophobia). Second, repeated measures analysis of variance
teeth, reaching out from the top shelf, and taking a glass. The was also conducted, with time (at the end of treatment and a 6-
mental practice was carried out in a quiet environment where week follow-up) as a within-subject variable and group (GMI
environmental stimuli were minimized and in a position where the group or SE group) as a between-subjects variable to analyze the
patients felt most comfortable. The third stage of GMI was mirror effect of the interventions on the muscle strength of elbow flexors
therapy, in which a mirror was placed between the upper limbs. and extensors, grip strength, and Global Rating of Change. Partial
Patients were instructed to observe the reflection of the unaffected h2 was used as an effect size indicator, elucidated as small, 0.01;
elbow, which created the illusion that the affected elbow is moving medium, 0.06; and large, 0.14. The significance level was set at
unrestricted by stiffness and without pain.19,30 The shoulder, P < .05.
elbow, forearm, and wrist AROM exercises were performed with
simultaneous movement of the affected and unaffected limb, while
observing the unaffected limb in the mirror. The grip strength and Results
finger exercise with Theraputty continued with the mirror box.
Achieva SMART-Mirror (North Coast Medical, Inc., Morgan Hill,
CA, USA) and a standard-size posture mirror were used for the Fifty-seven patients with post-traumatic elbow stiffness
hand and the shoulder-elbow complex, respectively. Patients were screened for possible inclusion. Seven patients were
removed the accessories such as rings, bracelets, and watches excluded for various reasons; as described in the CON-
before the session. The mirror’s position was adjusted by con- SORT flow chart, 25 patients were randomized to the GMI
trolling the image reflected in the mirror to avoid visual stimulus group, and 25 patients were randomized to the SE group
confusion. (Fig. 1). The time between randomization and initiation of
the intervention was 3-5 days for each patient. None of the
Structured exercise program patients reported any adverse effects or complications
during the intervention. Regarding adherence, all patients
The patients assigned to the SE group received a SE program had attended all sessions (12 sessions) of their treatment.
consisting of the range of motion, stretching, and strengthening The demographic and baseline characteristics of the
exercises (Supplementary Appendix S1). The SE program was patients are presented in Table I. There were no significant
prepared considering the soft tissue and bone healing process after differences between groups regarding sociodemographic
elbow joint fracture. Our previous study showed that the SE characteristics and baseline clinical variables (P > .05). In
program positively affects function, elbow flexion AROM, and addition, 2 groups had similar external visual imagery, in-
pain intensity during activity and at rest.3 ternal visual imagery, and kinesthetic imagery perspective
at the baseline (P > .05).
Home exercise program A comparison of primary and secondary outcome mea-
sures between groups and within-group score changes is
Patients in both groups received the home exercise program shown in Tables II and III. Within-group score changes
consisting of (1) strengthening exercises with an elastic band were significant in terms of primary and secondary
(Thera-Band; The Hygenic Corp, Akron, OH, USA) for scapular
outcome measures, except for recognition accuracy of the
retraction, elbow flexion-extension, and wrist flexion-extension;
shoulder on the affected side, the response time of the
(2) proprioception exercises for elbow joint (rolling the ball on the
wall or surface, transferring exercise ball hand to hand around the shoulder on the affected side, and grip strength in both
trunk, weightbearing exercise on even and uneven ground, and groups (P < .05). There is a significant difference between
throwing and catching the ball). Patients were asked to complete groups for DASH score as the primary outcome
the training diary for the home exercise program during the (F1,45 ¼ 3.10, P ¼ .01) in favor of the GMI group. Similar
follow-up period. to the DASH score, the overall group-by-time interaction
Enrolment
Allocation
Follow-up
Analysis
Figure 1 Design of the study (CONSORT flow diagram).
for repeated measures analysis of variance was significant (P ¼ .34). The GMI group performed an average of
for elbow flexion-extension AROM, visual analog 9.2 2.1 sessions, and the SE group performed an average
scale–activity, Tampa Scale for Kinesiophobia, recognition of 9.3 1.8 sessions out of 12 sessions during the
accuracy and response time of hand in the affected side, follow-up.
and muscle strength of elbow flexors and elbow extensors
(P < .05).
Eighty percent of patients (n ¼ 20/25) in the GMI group Discussion
and 72% patients (n ¼ 18/25) in the SE group reported that
they had improved significantly after the 6-week interven- The principal findings of the current study are that a 6-week
tion (P ¼ .21). There was no significant difference between GMI intervention resulted in an improvement in function,
groups regarding adherence to the home exercise program an increase in active elbow flexion-extension range of
Table I Baseline characteristics of patients with post-traumatic elbow stiffness in both groups
Characteristics Graded motor imagery group (n ¼ 25) Structured exercise group (n ¼ 25) P value*
Age, yr, mean (SD) 42.1 11.2 41.7 10.5 .19
Sex, n (%) .22y
Female 8 (32) 10 (40)
Male 17 (68) 15 (60)
Body mass index, mean (SD) 26.3 3.8 26.5 4.2 .83
Education, yr, mean (SD) 10.9 4.3 9.6 3.0 .24
Fracture side, n (%) .67y
Distal humerus 6 (24) 4 (16)
Radial head 13 (52) 16 (64)
Proximal ulna 6 (24) 5 (20)
Affected side, n (%) .57y
Right 10 (40) 13 (52)
Left 15 (60) 12 (48)
Immobilization, d, mean (SD) 21.4 13.4 22.6 12.1 .10
Postoperative time, weeks, mean (SD) 5.6 2.7 5.8 2.1 .22
SMMSE score, mean (SD) 27.5 1.2 26.8 0.9 .21
VMIQ-2 score, mean (SD)
External visual imagery 26.9 7.7 27.1 7.4 .30
Internal visual imagery 23.0 7.1 24.7 7.8 .42
Kinesthetic imagery 25.4 10.7 25.0 9.2 .88
DASH score, mean (SD) 47.7 17.3 46.5 17.2 .54
Range of motion, degrees, mean (SD)
Elbow flexion 93 12.9 95 11.7 .21
Elbow extension –32 11.7 –32 10.9 .99
Supination 59 23.6 59 28.6 .95
Pronation 57 18.5 58 19.6 .35
Pain intensity, cm, mean (SD)
VAS-rest 4.2 1.0 4.3 1.1 .24
VAS-activity 7.6 1.8 7.3 1.7 .18
VAS-night 3.6 2.3 3.7 2.8 .51
TSK score, mean (SD) 41.8 5.5 42.0 6.0 .55
Muscle strength, kg/N, mean (SD)
Elbow flexors 9.8 2.0 7.0 1.7 .19
Elbow extensors 10.5 1.9 8.8 1.8 .49
Grip strength, kg, mean (SD) 22.2 7.0 22.5 5.8 .26
Left-right discrimination, mean (SD)
Shoulder (affected side)
Recognition accuracy, % 86.5 8.0 85.7 10.4 .30
Response time, s 2.6 0.4 2.9 0.4 .45
Hand (affected side)
Recognition accuracy, % 69.4 10.7 68.1 9.3 .29
Response time, s 2.8 0.4 2.1 0.3 .59
SD, standard deviation; SMMSE, Standardized Mini-Mental State Examination; VMIQ-2, Vividness of Movement Imagery Questionnaire–2; DASH, Dis-
abilities of the Arm, Shoulder and Hand; VAS, visual analog scale; TSK, Tampa Scale for Kinesiophobia.
* Independent samples t test; significance was accepted as P < .05.
y
c2 test, significance was accepted as P < .05.
motion, a decrease in pain intensity during activity, a Left-right discrimination involves implicit motor imag-
reduction in fear of movement-related pain, and an increase ery, which consists in viewing images of a body part and
in muscle strength in patients with post-traumatic elbow determining whether they belong to the left or right side.25
stiffness. More specifically, our study found that both GMI Longer than normal response time and poor recognition
and SE programs had a beneficial effect on outcome mea- accuracy reflect delayed neural processing or disrupted
sures in post-traumatic elbow stiffness, but the patients in cortical proprioceptive representation of the body part.4
the GMI group have improved to a greater extent than in The present study showed that left-right hand discrimina-
the SE program. tion in the affected side was disturbed in patients with post-
Table II Comparison of function, active range of motion, pain intensity, kinesiophobia, and left-right discrimination between groups
Variables Group Baseline End of the Within-group P* 6-week rANOVA
treatment score change follow-up
F Py Effect size
(95% CI)
(partial h2)
Level of function
DASH GMI 47.7 17.3 8.6 2.3 39.1 (20.5, 57.6) .001 4.6 2.1 3.10 .01 0.11
SE 46.5 17.2 18.2 5.2 28.3 (18.5, 38.0) .001 15.3 4.9
Range of motion, degrees
Elbow flexion GMI 93 12.9 135 8.6 42.4 (32.4, 52.4) .001 141 7.3 2.18 .02 0.13
SE 95 11.7 130 7.2 34.3 (28.2, 40.4) .001 135 9.4
Elbow extension GMI –32 11.7 –7 5.7 24.9 (22.3, 27.6) .001 –2 2.2 1.25 .03 0.10
SE –32 10.9 –12 8.7 19.5 (15.1, 24.0) .001 –7 4.0
Supination GMI 59 23.6 88 4.2 28.4 (20.3, 36.5) .001 88 0.5 0.15 .44 0.006
SE 59 28.6 86 5.1 26.5 (20.4, 31.6) .003 88 0.1
Pronation GMI 57 18.5 78 3.1 21.1 (14.2, 28.9) .009 85 0.7 0.72 .23 0.001
SE 58 19.6 78 7.2 19.9 (12.2, 26.6) .005 84 0.3
Pain intensity, cm
VAS-rest GMI 4.2 1.0 1.1 0.2 3.1 (2.6, 3.6) .002 0 0 1.87 .07 0.06
SE 4.3 1.1 1.8 0.4 2.4 (1.9, 2.9) .001 1.7 0.2
VAS-activity GMI 7.6 1.8 2.0 0.9 5.6 (3.8, 7.4) .003 0.0 0. 5.36 .001 0.15
SE 7.3 1.7 4.6 1.3 2.7 (2.0, 3.4) .001 1.9 0.5
VAS-night GMI 3.6 2.3 0.7 0.1 2.8 (2.1, 3.6) .01 0 0 0.44 .52 0.009
SE 3.7 2.8 1.2 0.3 2.4 (2.4, 2.5) .03 0 0
Kinesiophobia
TSK GMI 41.8 5.5 25.0 3.4 16.7 (10.0, 23.4) .001 23.1 1.4 1.00 .01 0.11
SE 42.0 6.0 32.9 4.1 9.1 (8.0, 10.3) .001 32.2 3.2
Left-right discrimination
Shoulder (affected side)
Recognition GMI 86.5 8.0 88.1 9.9 1.5 (0.1, 3.0) .23 96.3 7.3 0.93 .37 0.004
accuracy, %
SE 85.7 10.4 87.1 8.8 1.3 (0.5, 2.2) .33 86.7 9.6
Response time, s GMI 2.6 0.4 2.2 0.4 0.3 (0.2, 0.5) .10 1.0 0.4 0.55 .79 0.003
SE 2.9 0.4 2.5 0.4 0.4 (0.1, 0.6) .56 1.9 0.3
Hand (affected side)
Recognition GMI 69.4 10.7 89.0 10.1 19.5 (15.2, 23.9) .01 91.0 7.9 2.33 .001 0.11
accuracy, %
SE 68.1 9.3 75.0 10.0 6.9 (5.2, 8.6) .42 79.2 8.1
Response time, s GMI 2.8 0.4 1.5 0.3 1.3 (0.9, 1.7) .02 1.2 0.3 1.87 .03 0.10
SE 2.1 0.3 2.1 0.1 0.0 (0.0, 0.0) .36 2.9 0.4
DASH, Disabilities of the Arm, Shoulder, and Hand; VAS, visual analog scale; TSK, Tampa Scale for Kinesiophobia; GMI, graded motor imagery; SE,
structured exercise; CI, confidence interval; rANOVA, repeated measures analysis of variance.
Data are expressed as mean standard deviation. Boldface indicates significance.
* Paired samples t test; significance was accepted as P < .05.
y
rANOVA; significance was accepted as P < .05.
traumatic elbow stiffness, whereas left-right shoulder schema and implicit motor imagery might have promising
discrimination in the affected side was quite normal. The effects on outcomes in post-traumatic elbow stiffness.
mean recognition accuracy of the hand on the affected side As pain after a musculoskeletal injury is a major risk
was about 69%, and the mean response time of the hand on factor inhibiting recovery, which results in poor functional
the affected was 2.5 seconds in our sample. This finding outcomes, the initial phase of post-traumatic elbow stiff-
may indicate that delayed neural processing or disrupted ness rehabilitation should focus on pain control.5,39 The
cortical representation of the affected limb may have GMI is a comprehensive intervention that directly targets
contributed to post-traumatic elbow stiffness. It, therefore, the reduction of the cortical disruptions after injury and
follows that interventions aimed at improving the body provides pain relief that changes the activation of the
Table III Comparison of muscle strength and grip strength between groups
Variables Group End of the 6-week follow-up Within-group score P* rANOVA
treatment change (95% CI)
F Py Effect size
(partial h2)
Muscle strength, kg/N
Elbow flexion GMI 9.8 2.0 15.2 3.7 5.3 (4.2, 6.4) .02 1.21 .03 0.08
SE 7.0 1.7 10.0 3.2 2.9 (1.9, 3.9) .04
Elbow extension GMI 10.5 1.9 14.1 1.5 3.5 (2.2, 4.8) .002 1.08 .03 0.09
SE 8.8 1.8 10.2 1.2 1.4 (1.1, 1.7) .04
Grip strength, kg GMI 22.2 7.0 29.4 6.5 7.1 (3.2, 11.0) .68 0.47 .55 0.004
SE 22.5 5.8 29.2 7.0 6.7 (3.3, 10.1) .64
GMI, graded motor imagery; SE, structured exercise; CI, confidence interval; rANOVA, repeated measures analysis of variance.
Data are expressed as mean standard deviation. Boldface indicates significance.
* Paired samples t test; significance was accepted as P < .05.
y
rANOVA; significance was accepted as P < .05.
related neuromotor network.17,25 The motor imagery and demonstrated a clinically meaningful (greater than 17
action observation could increase cortical excitability, points) functional improvement as measured by the DASH
associated with a decrease in pain perception.19 A sys- score, the between-group comparison indicated greater
tematic review reported that movement representation functional improvement in the GMI group.32 Consistent
techniques combined with usual care could decrease pain with our findings, previous studies have also emphasized
intensity compared with conventional treatment in post- that motor imagery and mirror therapy led to acquiring new
surgical and chronic pain.35 Similar to that result, this study motor gestures, improving performance, and enhancing
reported that the magnitude of improvement in pain in- range of motion.1,22,33 Functional improvement might be
tensity was clinically important in both groups after a 6- explained by the motor simulation theory, which suggests
week intervention.20 However, the improvement in pain that action, either self-intended or observed, activates the
intensity during activity and fear of movement-related pain motor system as part of a simulation network.16 On the
was greater in the GMI group. Rehabilitation programs may other hand, neuroplastic alterations previously reported for
benefit from the addition of pain management strategies both action observation and motor imagery interventions
based on the cortical model of pathologic pain, such as might elicit changes on a cortical level in both the sensory
GMI, to normalize the cortical proprioceptive representa- and motor maps of the somatosensory cortex within healthy
tion and reduce pain after a musculoskeletal injury. and clinical populations.1,22,23,30,33,35
In the present study, patients in both groups reached the Our results regarding muscle strength revealed that a
functional range motion of the elbow defined as 30 -130 combination of action observation and physical execution
of flexion-extension and 50 each of supination-prona- of the progressive resistance exercise is more effective than
tion.31 However, the GMI group showed significantly only the physical execution of the progressive resistance
greater improvement than the SE group in the active elbow exercise. The evidence reveals that the observation and
flexion and extension range of motion. One of the limited execution of motor acts activate mirror neurons.14,30 Using
studies investigating the effectiveness of GMI pointed out a mirror during the training could increase the amount of
that GMI provided beneficial effects in controlling pain, associated activity by engaging the mirror neurons and thus
improving grip strength and increasing upper extremity result in a more extensive training effect.14 However, the
functions in patients with dorsal radius fractures.8 In evidence about the effectiveness of the combined therapy of
addition, a recent study concluded that 6-week GMI im- mirror therapy and progressive resistance exercise simul-
proves the affective components of pain and active shoulder taneously for improving the upper limb motor function
flexion range of motion in patients with chronic shoulder after elbow fracture is lacking. Long-term studies are
pain syndrome.2 Putative mechanisms underlying GMI, warranted to investigate the effectiveness of GMI on mus-
related to the gradual activation of the cortical networks cle strength.
during movement without eliciting pain, might lead to This study has some limitations that should be high-
improved kinematic parameters and clinical symptoms.25 lighted. Adding more objective tools, such as functional
Not surprisingly, improvement in both pain during ac- magnetic resonance imaging, might provide more objective
tivity and the active elbow flexion and extension range of data and contribute to interpreting the changes after GMI
motion were associated with an improvement in function in intervention. Second, adherence to the home exercise pro-
the present study. Although both the GMI and SE groups gram was questioned with a self-reported adherence rating
scale with limited validity and reliability. Third, it might be 2. Araya-Quintanilla F, Gutierrez-Espinoza H, Jesus Mu~noz-Yanez M,
helpful to monitor long-term results, such as 1-year follow- Rubio-Oyarzun D, Cavero-Redondo I, Martınez-Vizcaino V, et al. The
short-term effect of graded motor imagery on the affective components
up after the 6-week intervention period. of pain in subjects with chronic shoulder pain syndrome: open-label
single-arm prospective study. Pain Med 2020;21:2496-501. https://
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stretching or static stretching in posttraumatic stiffness of the elbow: a
The present study provides evidence that the addition of randomized controlled trial. Clin Rehab 2019;33:241-52. https://doi.
GMI to a postoperative elbow rehabilitation program org/10.1177/0269215518802886
may contribute to a significant reduction in pain 4. Breckenridge JD, Ginn KA, Wallwork SB, McAuley JH. Do people
intensity and pain-related fear of movement and im- with chronic musculoskeletal pain have impaired motor imagery? A
meta-analytical systematic review of the left/right judgment task. J
provements in functional level in patients with post-
Pain 2019;20:119-32. https://doi.org/10.1016/j.jpain.2018.07.004
traumatic elbow stiffness. GMI, a motor-cognitive 5. Caneiro JP, Smith A, Bunzli S, Linton S, Moseley GL, O’Sullivan P.
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Funding: This study was supported by the Scientific Reference values for isometric muscle force among workers for the
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Research Projects Coordination Unit of Istanbul Uni-
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versity-Cerrahpasa (Project no: TDK-2019-33997). € uz Ç, Y€or€ukan S, Bilg€utay B, Ayhan Ç. Reli-
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The Efficacy of Graded Motor Imagery in Post-Traumatic Stiffness of Elbow A Randomized Controlled Trial

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The Efficacy of Graded Motor Imagery in Post-Traumatic Stiffness of Elbow A Randomized Controlled Trial

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J Shoulder Elbow Surg (2022) 31, 2147–2156

The efficacy of graded motor imagery in

Level of evidence: Level I; Randomized Controlled Trial; Treatment Study

Figure 1 Design of the study (CONSORT flow diagram).

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