Added Value of Mental Practice Combined with a Small Amount of Physical Practice on the Relearning of Rising and Sitting Post-Stroke: A Pilot Study

Overview of Effects of Motor Learning Strategies in Neurologic and Geriatric Populations: A Systematic Mapping Review

Objective

To provide a broad overview of the current state of research regarding the effects of 7 commonly used motor learning strategies to improve functional tasks within older neurologic and geriatric populations.

Data Sources

PubMed, CINAHL, and Embase were searched.

Study Selection

A systematic mapping review of randomized controlled trials was conducted regarding the effectiveness of 7 motor learning strategies-errorless learning, analogy learning, observational learning, trial-and-error learning, dual-task learning, discovery learning, and movement imagery-within the geriatric and neurologic population.

Data Extraction

Two thousand and ninety-nine articles were identified. After screening, 87 articles were included for further analysis. Two reviewers extracted descriptive data regarding the population, type of motor learning strategy/intervention, frequency and total duration intervention, task trained, movement performance measures, assessment time points, and between-group effects of the included studies. The risk of bias 2 tool was used to assess bias; additionally, papers underwent screening for sample size justification.

Data Synthesis

Identified articles regarding the effects of the targeted motor learning strategies started around the year 2000 and mainly emerged in 2010. Eight populations were included, for example, Parkinson's and stroke. Included studies were not equally balanced: analogy learning (n=2), errorless learning and trial-and-error learning (n=5), mental practice (n=19), observational learning (n=11), discovery learning (n=0), and dual-tasking (n=50). Overall studies showed a moderate-to-high risk of bias. Four studies were deemed sufficiently reliable to interpret effects. Positive trends regarding the effects were observed for dual-tasking, observational learning, and movement imagery.

Conclusions

Findings show a skewed distribution of studies across motor learning interventions, especially toward dual-tasking. Methodological shortcomings make it difficult to draw firm conclusions regarding the effectiveness of motor learning strategies to improve functional studies. Future researchers are strongly advised to follow guidelines that aid in maintaining methodological quality. Moreover, alternative designs fitting the complex practice situation should be considered.

Effects of enriched task-specific training on sit-to-stand tasks in individuals with chronic stroke

BACKGROUND

Approximately 80% of stroke survivors experience motor impairment of the contralateral limb that severely affects their activities of daily living (ADL).

OBJECTIVE

To evaluate whether an enriched task-specific training (ETT) program affected the performance and kinetics of sit-to-stand (STS) tasks.

METHODS

The study was part of an exploratory study with a within-subject, repeated-measure-design, with assessments before and after a three-week-long baseline period, and six months after the intervention. Forty-one participants underwent assessments of strength and endurance measured by the 30-second-chair-stand test (30sCST). The STS-kinetics, including the vertical ground reaction force (GRF) during STS, were analysed in an in-depth-subgroup of three participants, using a single-subject-experimental-design (SSED). For kinetic data, statistical significance was determined with the two-standard deviation band method (TSDB).

RESULTS

After the baseline period, a small increase was seen in the 30sCST (from 5.6±4.5 to 6.1±4.9, p = 0.042). A noticeable significant change in the 30sCST was shown after the intervention (from 6.1±4.9 to 8.2±5.4, p < 0.001), maintained at six months. The in-depth kinetic analyses showed that one of three subjects had a significant increase in loading of the affected limb post-intervention.

CONCLUSION

ETT can produce long-term gains in STS performance. Weight-bearing strategies could be one of several factors that contribute to improvements in STS performance in the chronic phase after stroke.

Effectiveness of mental practice for limb dysfunction in patients who have experienced a stroke: a systematic review and meta-analysis

Stroke is the second largest cause of death in adults and the principal cause of long-term severe adult disability worldwide. Approximately 70% of patients present with upper limb weakness following stroke. One intervention for the treatment of upper limb impairment post-stroke is mental practice. This article critically appraises a systematic review which assesses the effectiveness of mental practice for limb dysfunction in patients who have experienced stroke.

Study Paradigms and Principles Investigated in Motor Learning Research After Stroke: A Scoping Review

OBJECTIVES

To (1) characterize study paradigms used to investigate motor learning (ML) poststroke and (2) summarize the effects of different ML principles in promoting skill acquisition and retention. Our secondary objective is to evaluate the clinical utility of ML principles on stroke rehabilitation.

DATA SOURCES

Medline, Excerpta Medica Database, Allied and Complementary Medicine, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched from inception on October 24, 2018 and repeated on June 23, 2020. Scopus was searched on January 24, 2019 and July 22, 2020 to identify additional studies.

STUDY SELECTION

Our search included keywords and concepts to represent stroke and "motor learning. An iterative process was used to generate study selection criteria. Three authors independently completed title, abstract, and full-text screening.

DATA EXTRACTION

Three reviewers independently completed data extraction.

DATA SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension guidelines for scoping reviews were used to guide our synthesis. Thirty-nine studies were included. Study designs were heterogeneous, including variability in tasks practiced, acquisition parameters, and retention intervals. ML principles investigated included practice complexity, feedback, motor imagery, mental practice, action observation, implicit and explicit information, aerobic exercise, and neurostimulation. An additional 2 patient-related factors that influence ML were included: stroke characteristics and sleep. Practice complexity, feedback, and mental practice/action observation most consistently promoted ML, while provision of explicit information and more severe strokes were detrimental to ML. Other factors (ie, sleep, practice structure, aerobic exercise, neurostimulation) had a less clear influence on learning.

CONCLUSIONS

Improved consistency of reporting in ML studies is needed to improve study comparability and facilitate meta-analyses to better understand the influence of ML principles on learning poststroke. Knowledge of ML principles and patient-related factors that influence ML, with clinical judgment can guide neurologic rehabilitation delivery to improve patient motor outcomes.

Effects of motor imagery training on lower limb motor function of patients with chronic stroke: A pilot single-blind randomized controlled trial

AIMS

This pilot study aimed to evaluate the effects of motor imagery training on lower limb motor function of stroke patients.

BACKGROUND

Motor imagery training has played an important role in rehabilitation outcomes of stroke patients.

METHODS

In this pilot randomized controlled trial 32 stroke patients were randomly divided into experimental and control groups from January to June 2017. Patients in both groups received conventional neuro-rehabilitation five times a week in 3-h segments for 6 weeks. Patients in the experimental group underwent an additional 20 min of motor imagery training. Measures were evaluated by motor function of the lower extremity, activities of daily living and balance ability.

RESULTS

The outcomes significantly improved by motor imagery training were the Fugl-Meyer Assessment of the lower extremity, the Functional Independence Measure dealing with transfers and locomotion, and the Berg Balance Scale.

CONCLUSION

Motor imagery training could be used as a complement to physical rehabilitation of stroke patients. Our findings may be helpful to develop nursing strategies aimed at improving functional ability of stroke patients and thus enhancing their quality of life.

SUMMARY STATEMENT

What is already known about this topic? Lower extremity dyskinesia is among the most common complications that significantly limit the patient's activities of daily living. Motor imagery training, a safe and cost-efficient technique, may be used as a complement to physical rehabilitation of stroke patients. Evidence suggests that motor imagery training is effective in upper limb recovery after stroke. There is limited evidence of the effectiveness of motor imagery training on lower limb motor functions of patients with chronic stroke. What this paper adds? Motor imagery training can be incorporated into conventional therapy among individuals by rehabilitation specialist nurses with sufficient experience of motor imagery training, but substantial resources are needed. Six-week motor imagery training resulted in a significant improvement in the motor performance of lower limbs in patients with stroke. Further study is needed to modify and optimize the present programme and should be focused on enabling more stroke patients to benefit from motor imagery training. The implications of this paper: The addition of motor imagery training to the conventional neuro-rehabilitation can significantly promote the recovery of motor performance of lower limbs in stroke patients, thus reducing long-term disability and associated socio-economic burden. The findings of this pilot study may be helpful to develop nursing strategies aimed at improving functional ability and consequently the quality of life of stroke patients. Nurses can learn the motor imagery training as a technique for practising psychomotor nursing skills.

Adapting Motor Imagery Training Protocols to Surgical Education: A Systematic Review and Meta-Analysis

Objective. Motor imagery (MI) is widely used to improve technical skills in sports and has been proven to be effective in neurorehabilitation and surgical education. This review aims to identify the key characteristics of MI protocols for implementation into surgical curricula. Design. This study is a systematic review and meta-analysis. PubMed, MEDLINE, Embase and PsycINFO databases were systematically searched. The primary outcome was the impact of MI training on measured outcomes, and secondary outcomes were study population, MI intervention characteristics, study primary outcome measure and subject rating of MI ability (systematic review registration: PROSPERO CRD42019121895). Results. 456 records were screened, 60 full texts randomising 2251 participants were reviewed and 39 studies were included in meta-analysis. MI was associated with improved outcome in 35/60 studies, and pooled analysis also showed improved outcome on all studies with a standardised mean difference of .39 (95% CI: .12, .67, P = .005). In studies where MI groups showed improved outcomes, the median duration of training was 24 days (mode 42 days), and the median duration of each individual MI session was 30 minutes (range <1 minute-120 minutes). Conclusions. MI training protocols for use in surgical education could have the following characteristics: MI training delivered in parallel to existing surgical training, in a flexible format; inclusion of a brief period of relaxation, followed by several sets of repetitions of MI and a refocusing period. This is a step towards the development of a surgical MI training programme, as a low-cost, low-risk tool to enhance practical skills.

Motor imagery for gait rehabilitation after stroke

BACKGROUND

Motor imagery (MI) is defined as a mentally rehearsed task in which movement is imagined but is not performed. The approach includes repetitive imagined body movements or rehearsing imagined acts to improve motor performance.

OBJECTIVES

To assess the treatment effects of MI for enhancing ability to walk among people following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group registry, CENTRAL, MEDLINE, Embase and seven other databases. We also searched trial registries and reference lists. The last searches were conducted on 24 February 2020.

SELECTION CRITERIA

Randomized controlled trials (RCTs) using MI alone or associated with action observation or physical practice to improve gait in individuals after stroke. The critical outcome was the ability to walk, assessed using either a continuous variable (walking speed) or a dichotomous variable (dependence on personal assistance). Important outcomes included walking endurance, motor function, functional mobility, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials according to pre-defined inclusion criteria, extracted the data, assessed the risk of bias, and applied the GRADE approach to evaluate the certainty of the evidence. The review authors contacted the study authors for clarification and missing data.

MAIN RESULTS

We included 21 studies, involving a total of 762 participants. Participants were in the acute, subacute, or chronic stages of stroke, and had a mean age ranging from 50 to 78 years. All participants presented at least some gait deficit. All studies compared MI training versus other therapies. Most of the included studies used MI associated with physical practice in the experimental groups. The treatment time for the experimental groups ranged from two to eight weeks. There was a high risk of bias for at least one assessed domain in 20 of the 21 included studies. Regarding our critical outcome, there was very low-certainty evidence that MI was more beneficial for improving gait (walking speed) compared to other therapies at the end of the treatment (pooled standardized mean difference (SMD) 0.44; 95% confidence interval (CI) 0.06 to 0.81; P = 0.02; six studies; 191 participants; I² = 38%). We did not include the outcome of dependence on personal assistance in the meta-analysis, because only one study provided information regarding the number of participants that became dependent or independent after interventions. For our important outcomes, there was very low-certainty evidence that MI was no more beneficial than other interventions for improving motor function (pooled mean difference (MD) 2.24, 95% CI -1.20 to 5.69; P = 0.20; three studies; 130 participants; I² = 87%) and functional mobility at the end of the treatment (pooled SMD 0.55, 95% CI -0.45 to 1.56; P = 0.09; four studies; 116 participants; I² = 64.2%). No adverse events were observed in those studies that reported this outcome (seven studies). We were unable to pool data regarding walking endurance and all other outcomes at follow-up.

AUTHORS' CONCLUSIONS

We found very low-certainty evidence regarding the short-term benefits of MI on walking speed in individuals who have had a stroke, compared to other therapies. Evidence was insufficient to estimate the effect of MI on the dependence on personal assistance and walking endurance. Compared with other therapies, the evidence indicates that MI does not improve motor function and functional mobility after stroke (very low-certainty evidence). Evidence was also insufficient to estimate the effect of MI on gait, motor function, and functional mobility after stroke compared to placebo or no intervention. Motor Imagery and other therapies used for gait rehabilitation after stroke do not appear to cause significant adverse events.

Effects of mental and physical orofacial training on pressure pain sensitivity and tongue strength: A single-blind randomized controlled trial

OBJECTIVES

The main objective of this study was to analyze differences on pain pressure thresholds, tongue strength and perceived effort between various orofacial motor exercise training dosages of mental representation training through motor imagery (MI) and action observation (AO), first in isolation and then in combination with real exercise performance.

METHODS

A single-blind randomized controlled trial was designed. 48 asymptomatic individuals were randomized into two groups: Intensive training group (IG) and Moderate training group (MG). Both groups performed a first session of MI and AO of orofacial exercises training and a second session of actual orofacial exercises combined with mental representation training, but with different dosage in terms of series and repetitions. Pain pressure thresholds (PPTs) in the masseter and temporal muscles and tongue muscle strength were the main variables.

RESULTS

Regarding the PPT, ANOVA revealed significant between-group differences, where MG showed a significantly higher PPT than IG at post-day2, with a medium effect size. Both groups showed with-in group differences between pre and post intervention measures in the first session, but only the IG showed differences in the second. Regarding tongue muscle strength, ANOVA revealed significant within-group differences only in MG between the pre-day and post-day first intervention.

CONCLUSION

The results of the present study suggest that movement representation training performed in isolation may have a positive effect on PPTs and tongue muscle strength. In addition, the combination with the actual execution of the exercises could be considered effective, but it is necessary to take into account the training dosage to avoid fatigue responses.

Thumbs up: Imagined hand movements counteract the adverse effects of post-surgical hand immobilization. Clinical, behavioral, and fMRI longitudinal observations

Motor imagery (M.I.) training has been widely used to enhance motor behavior. To characterize the neural foundations of its rehabilitative effects in a pathological population we studied twenty-two patients with rhizarthrosis, a chronic degenerative articular disease in which thumb-to-fingers opposition becomes difficult due to increasing pain while the brain is typically intact. Before and after surgery, patients underwent behavioral tests to measure pain and motor performance and fMRI measurements of brain motor activity.

After surgery, the affected hand was immobilized, and patients were enrolled in a M.I. training. The sample was split in those who had a high compliance with the program of scheduled exercises (T+, average compliance: 84%) and those with low compliance (T−, average compliance: 20%; cut-off point: 55%). We found that more intense M.I. training counteracts the adverse effects of immobilization reducing pain and expediting motor recovery. fMRI data from the post-surgery session showed that T+ patients had decreased brain activation in the premotor cortex and the supplementary motor area (SMA); meanwhile, for the same movements, the T− patients exhibited a reversed pattern. Furthermore, in the post-surgery fMRI session, pain intensity was correlated with activity in the ipsilateral precentral gyrus and, notably, in the insular cortex, a node of the pain matrix.

These findings indicate that the motor simulations of M.I. have a facilitative effect on recovery by cortical plasticity mechanisms and optimization of motor control, thereby establishing the rationale for incorporating the systematic use of M.I. into standard rehabilitation for the management of post-immobilization syndromes characteristic of hand surgery.

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Motor imagery training counteracts the effects of post-surgical hand immobilization.

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It also reduces pain and expedites motor recovery after immobilization.

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These effects were accompanied by significant fMRI signs of brain plasticity.

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The clinical-fMRI evidence advocates for the use of motor imagery in rehabilitation.

Benefits of Motor Imagery for Human Space Flight: A Brief Review of Current Knowledge and Future Applications

Motor imagery (MI) is arguably one of the most remarkable capacities of the human mind. There is now strong experimental evidence that MI contributes to substantial improvements in motor learning and performance. The therapeutic benefits of MI in promoting motor recovery among patients with motor impairments have also been reported. Despite promising theoretical and experimental findings, the utility of MI in adapting to unusual conditions, such as weightlessness during space flight, has received far less attention. In this review, we consider how, why, where, and when MI might be used by astronauts, and further evaluate the optimum MI content. Practically, we suggest that MI might be performed before, during, and after exposure to microgravity, respectively, to prepare for the rapid changes in gravitational forces after launch and to reduce the adverse effects of weightlessness exposition. Moreover, MI has potential role in facilitating re-adaptation when returning to Earth after long exposure to microgravity. Suggestions for further research include a focus on the multi-sensory aspects of MI, the requirement to use temporal characteristics as a measurement tool, and to account for the knowledge-base or metacognitive processes underlying optimal MI implementation.

The effects of mental practice based on motor imagery for mobility recovery after subacute stroke: Protocol for a randomized controlled trial

BACKGROUND AND PURPOSE

Mental practice of motor imagery has shown beneficial effects in stroke recovery. However, there are few clinical trials investigating it on the subacute phase. This study will investigate the effects of mental practice in the mobility of patients with subacute stroke.

MATERIALS AND METHODS

Randomized controlled trial including persons with subacute stroke (<3 months). All participants will receive physical exercises and will be randomly allocated into an experimental group (Mental Practice) or into a control group (cognitive training) for 4 weeks(12 sessions).

RESULTS

Primary outcomes will be assessed at baseline and after intervention and will be related to mobility, using Timed Up and Go test and 5 m walking speed test. Whereas secondary outcomes will be muscular strength, biomechanical strategies, mental health and quality of life.

CONCLUSION

The beneficial effects that may be found in this trial can be greatly relevant in clinical practice, justifying this scientific question.

A Brazilian-Portuguese version of the Kinesthetic and Visual Motor Imagery Questionnaire

Motor imagery has emerged as a potential rehabilitation tool in stroke. The goals of this study were: 1) to develop a translated and culturally-adapted Brazilian-Portugese version of the Kinesthetic and Visual Motor Imagery Questionnaire (KVIQ20-P); 2) to evaluate the psychometric characteristics of the scale in a group of patients with stroke and in an age-matched control group; 3) to compare the KVIQ20 performance between the two groups. Test-retest, inter-rater reliabilities, and internal consistencies were evaluated in 40 patients with stroke and 31 healthy participants. In the stroke group, ICC confidence intervals showed excellent test-retest and inter-rater reliabilities. Cronbach's alpha also indicated excellent internal consistency. Results for controls were comparable to those obtained in persons with stroke. The excellent psychometric properties of the KVIQ20-P should be considered during the design of studies of motor imagery interventions for stroke rehabilitation.

Implementing Cognitive Training Into a Surgical Skill Course: A Pilot Study on Laparoscopic Suturing and Knot Tying

Mini-invasive surgery-for example, laparoscopy-has challenged surgeons' skills by extending their usual haptic space and displaying indirect visual feedback through a screen. This may require new mental abilities, including spatial orientation and mental representation. This study aimed to test the effect of cognitive training based on motor imagery (MI) and action observation (AO) on surgical skills. A total of 28 postgraduate residents in surgery took part in our study and were randomly distributed into 1 of the 3 following groups: (1) the basic surgical skill, which is a short 2-day laparoscopic course + MI + AO group; (2) the basic surgical skill group; and (3) the control group. The MI + AO group underwent additional cognitive training, whereas the basic surgical skill group performed neutral activity during the same time. The laparoscopic suturing and knot tying performance as well as spatial ability and mental workload were assessed before and after the training period. We did not observe an effect of cognitive training on the laparoscopic performance. However, the basic surgical skill group significantly improved spatial orientation performance and rated lower mental workload, whereas the 2 others exhibited lower performance in a mental rotation test. Thus, actual and cognitive training pooled together during a short training period elicited too high a strain, thus limiting potential improvements. Because MI and AO already showed positive outcomes on surgical skills, this issue may, thus, be mitigated according to our specific learning conditions. Distributed learning may possibly better divide and share the strain associated with new surgical skills learning.

The impact of goal-oriented task design on neurofeedback learning for brain-computer interface control

Neurofeedback training teaches individuals to modulate brain activity by providing real-time feedback and can be used for brain-computer interface control. The present study aimed to optimize training by maximizing engagement through goal-oriented task design. Participants were shown either a visual display or a robot, where each was manipulated using motor imagery (MI)-related electroencephalography signals. Those with the robot were instructed to quickly navigate grid spaces, as the potential for goal-oriented design to strengthen learning was central to our investigation. Both groups were hypothesized to show increased magnitude of these signals across 10 sessions, with the greatest gains being seen in those navigating the robot due to increased engagement. Participants demonstrated the predicted increase in magnitude, with no differentiation between hemispheres. Participants navigating the robot showed stronger left-hand MI increases than those with the computer display. This is likely due to success being reliant on maintaining strong MI-related signals. While older participants showed stronger signals in early sessions, this trend later reversed, suggesting greater natural proficiency but reduced flexibility. These results demonstrate capacity for modulating neurofeedback using MI over a series of training sessions, using tasks of varied design. Importantly, the more goal-oriented robot control task resulted in greater improvements.

Structure and feasibility of extra practice during stroke rehabilitation: A systematic scoping review

BACKGROUND/AIM

Improved motor performance is related to the amount of practice completed after a stroke. Australian guidelines recommend that at least one hour of active practice should be completed per day. Yet active practice levels remain low. The aims of this scoping review were to describe how extra practice at the activity level is structured for stroke survivors, and explore the feasibility of participants completing extra practice.

METHODS

A systematic search was conducted of five electronic databases up to August 2015. Trials were included when the intended dose of the control intervention was less than the experimental intervention. The structure of extra practice was classified by the level of supervision, type of personnel, and whether equipment was used. Feasibility of practice was explored by comparing the intended and actual dose of practice completed.

RESULTS

Thirty-five trials, comprising 40 comparisons were included. Multiple configurations of personnel, supervision and equipment were used to structure extra practice. The structure most often used was full supervision by staff without equipment (30 comparisons), typically involving a therapist (17 comparisons), with equipment being used occasionally (12 comparisons). Sixteen comparisons reported both the intended and the actual dose of extra practice completed. The mean percentage of actual extra practice completed was 80% (SD 18) of the intended dose.

CONCLUSIONS

Extra practice during rehabilitation after stroke is most often structured using full supervision by a therapist, and appears feasible for stroke survivors to complete. Less often, extra practice is structured using equipment, non-therapists and/or group classes.

Modulation of motor cortex inhibition during motor imagery

Motor imagery (MI) is similar to overt movement, engaging common neural substrates and facilitating the corticomotor pathway; however, it does not result in excitatory descending motor output. Transcranial magnetic stimulation (TMS) can be used to assess inhibitory networks in the primary motor cortex via measures of 1-ms short-interval intracortical inhibition (SICI), long-interval intracortical inhibition (LICI), and late cortical disinhibition (LCD). These measures are thought to reflect extrasynaptic GABA_A tonic inhibition, postsynaptic GABA_B inhibition, and presynaptic GABA_B disinhibition, respectively. The behavior of 1-ms SICI, LICI, and LCD during MI has not yet been explored. This study aimed to investigate how 1-ms SICI, LICI, and LCD are modulated during MI and voluntary relaxation (VR) of a target muscle. Twenty-five healthy young adults participated. TMS was used to assess nonconditioned motor evoked potential (MEP) amplitude, 1-ms SICI, 100- (LICI₁₀₀) and 150-ms LICI, and LCD in the right abductor pollicis brevis (APB) and right abductor digiti minimi during rest, MI, and VR of the hand. Compared with rest, MEP amplitudes were facilitated in APB during MI. SICI was not affected by task or muscle. LICI₁₀₀ decreased in both muscles during VR but not MI, whereas LCD was recruited in both muscles during both tasks. This indicates that VR modulates postsynaptic GABA_B inhibition, whereas both tasks modulate presynaptic GABA_B inhibition in a non-muscle-specific way. This study highlights further neurophysiological parallels between actual and imagined movement, which may extend to voluntary relaxation.NEW & NOTEWORTHY This is the first study to investigate how 1-ms short-interval intracortical inhibition, long-interval intracortical inhibition, and late cortical disinhibition are modulated during motor imagery and voluntary muscle relaxation. We present novel findings of decreased 100-ms long-interval intracortical inhibition during voluntary muscle relaxation and increased late cortical disinhibition during both motor imagery and voluntary muscle relaxation.

Effect of Motor Imagery on the F-Wave Parameters in Hemiparetic Stroke Survivors

Objective

To assess the effect of motor imagery, as a rehabilitation method in stroke, on F-wave parameters that undergo changes during upper motor neuron involvement.

Methods

Twenty-one fully conscious hemiparetic stroke survivors with a completely plegic hand (power 0/5) and a minimum interval of 72 hours since stroke were recruited into this study. The mean F-wave latency, amplitude, and persistence in the median and ulnar nerves were measured in both the affected and non-affected sides at rest and in the paretic hand during a mental task. Comparison was made between data from the affected hand and the non-affected hand as well as between data from the affected hand at baseline and during motor imagery.

Results

Patients had significantly different F-wave persistence between the affected and non-affected sides (paired t-test, p<0.001). Motor imagery could improve F-wave persistence in both the investigated nerves (paired t-test, p=0.01 for ulnar nerve and p<0.001 for median nerve) and F-response amplitude in the median nerve (paired t-test, p=0.01) of the affected limb.

Conclusion

The amplitude and persistence of F-wave were improved during motor imagery, representing F-wave facilitation. This result suggests that motor imagery can restore motor neuron excitability, which is depressed after stroke.

Interventions for improving sit-to-stand ability following stroke

BACKGROUND

Standing up from a seated position is one of the most frequently performed functional tasks, is an essential pre-requisite to walking and is important for independent living and preventing falls. Following stroke, patients can experience a number of problems relating to the ability to sit-to-stand independently.

OBJECTIVES

To review the evidence of effectiveness of interventions aimed at improving sit-to-stand ability after stroke. The primary objectives were to determine (1) the effect of interventions that alter the starting posture (including chair height, foot position, hand rests) on ability to sit-to-stand independently; and (2) the effect of rehabilitation interventions (such as repetitive practice and exercise programmes) on ability to sit-to-stand independently. The secondary objectives were to determine the effects of interventions aimed at improving ability to sit-to-stand on: (1) time taken to sit-to-stand; (2) symmetry of weight distribution during sit-to-stand; (3) peak vertical ground reaction forces during sit-to-stand; (4) lateral movement of centre of pressure during sit-to-stand; and (5) incidence of falls.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (June 2013), CENTRAL (2013, Issue 5), MEDLINE (1950 to June 2013), EMBASE (1980 to June 2013), CINAHL (1982 to June 2013), AMED (1985 to June 2013) and six additional databases. We also searched reference lists and trials registers and contacted experts.

SELECTION CRITERIA

Randomised trials in adults after stroke where: the intervention aimed to affect the ability to sit-to-stand by altering the posture of the patient, or the design of the chair; stated that the aim of the intervention was to improve the ability to sit-to-stand; or the intervention involved exercises that included repeated practice of the movement of sit-to-stand (task-specific practice of rising to stand).The primary outcome of interest was the ability to sit-to-stand independently. Secondary outcomes included time taken to sit-to-stand, measures of lateral symmetry during sit-to-stand, incidence of falls and general functional ability scores.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts, extracted data and appraised trials. We undertook an assessment of methodological quality for random sequence generation, allocation concealment, blinding of outcome assessors and method of dealing with missing data.

MAIN RESULTS

Thirteen studies (603 participants) met the inclusion criteria for this review, and data from 11 of these studies were included within meta-analyses. Twelve of the 13 included studies investigated rehabilitation interventions; one (nine participants) investigated the effect of altered starting posture for sit-to-stand. We judged only four studies to be at low risk of bias for all methodological parameters assessed. The majority of randomised controlled trials included participants who were already able to sit-to-stand or walk independently.Only one study (48 participants), which we judged to be at high risk of bias, reported our primary outcome of interest, ability to sit-to-stand independently, and found that training increased the odds of achieving independent sit-to-stand compared with control (odds ratio (OR) 4.86, 95% confidence interval (CI) 1.43 to 16.50, very low quality evidence).Interventions or training for sit-to-stand improved the time taken to sit-to-stand and the lateral symmetry (weight distribution between the legs) during sit-to-stand (standardised mean difference (SMD) -0.34; 95% CI -0.62 to -0.06, seven studies, 335 participants; and SMD 0.85; 95% CI 0.38 to 1.33, five studies, 105 participants respectively, both moderate quality evidence). These improvements are maintained at long-term follow-up.Few trials assessing the effect of sit-to-stand training on peak vertical ground reaction force (one study, 54 participants) and functional ability (two studies, 196 participants) were identified, providing very low and low quality evidence respectively.The effect of sit-to-stand training on number of falls was imprecise, demonstrating no benefit or harm (OR 0.75, 95% CI 0.46 to 1.22, five studies, 319 participants, low quality evidence). We judged the majority of studies that assessed falls to be at high risk of bias.

AUTHORS' CONCLUSIONS

This review has found insufficient evidence relating to our primary outcome of ability to sit-to-stand independently to reach any generalisable conclusions. This review has found moderate quality evidence that interventions to improve sit-to-stand may have a beneficial effect on time taken to sit-to-stand and lateral symmetry during sit-to-stand, in the population of people with stroke who were already able to sit-to-stand independently. There was insufficient evidence to reach conclusions relating to the effect of interventions to improve sit-to-stand on peak vertical ground reaction force, functional ability and falls. This review adds to a growing body of evidence that repetitive task-specific training is beneficial for outcomes in people receiving rehabilitation following stroke.

What is the evidence for physical therapy poststroke? A systematic review and meta-analysis

BACKGROUND

Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

METHODS AND FINDINGS

Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.

CONCLUSIONS

There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.

Mobile EEG and its potential to promote the theory and application of imagery-based motor rehabilitation

Studying the brain in its natural state remains a major challenge for neuroscience. Solving this challenge would not only enable the refinement of cognitive theory, but also provide a better understanding of cognitive function in the type of complex and unpredictable situations that constitute daily life, and which are often disturbed in clinical populations. With mobile EEG, researchers now have access to a tool that can help address these issues. In this paper we present an overview of technical advancements in mobile EEG systems and associated analysis tools, and explore the benefits of this new technology. Using the example of motor imagery (MI) we will examine the translational potential of MI-based neurofeedback training for neurological rehabilitation and applied research.

Towards the integration of mental practice in rehabilitation programs. A critical review

Many clinical studies have investigated the use of mental practice (MP) through motor imagery (MI) to enhance functional recovery of patients with diverse physical disabilities. Although beneficial effects have been generally reported for training motor functions in persons with chronic stroke (e.g., reaching, writing, walking), attempts to integrate MP within rehabilitation programs have been met with mitigated results. These findings have stirred further questioning about the value of MP in neurological rehabilitation. In fact, despite abundant systematic reviews, which customarily focused on the methodological merits of selected studies, several questions about factors underlying observed effects remain to be addressed. This review discusses these issues in an attempt to identify factors likely to hamper the integration of MP within rehabilitation programs. First, the rationale underlying the use of MP for training motor function is briefly reviewed. Second, three modes of MI delivery are proposed based on the analysis of the research protocols from 27 studies in persons with stroke and Parkinson's disease. Third, for each mode of MI delivery, a general description of MI training is provided. Fourth, the review discusses factors influencing MI training outcomes such as: the adherence to MI training, the amount of training and the interaction between physical and mental rehearsal; the use of relaxation, the selection of reliable, valid and sensitive outcome measures, the heterogeneity of the patient groups, the selection of patients and the mental rehearsal procedures. To conclude, the review proposes a framework for integrating MP in rehabilitation programs and suggests research targets for steering the implementation of MP in the early stages of the rehabilitation process. The challenge has now shifted towards the demonstration that MI training can enhance the effects of regular therapy in persons with subacute stroke during the period of spontaneous recovery.

A standardized motor imagery introduction program (MIIP) for neuro-rehabilitation: development and evaluation

Background: For patients with central nervous system (CNS) lesions and sensorimotor impairments a solid motor imagery (MI) introduction is crucial to understand and use MI to improve motor performance. The study's aim was to develop and evaluate a standardized MI group introduction program (MIIP) for patients after stroke, multiple sclerosis (MS), Parkinson's disease (PD), and traumatic brain injury (TBI).

Methods: Phase 1: Based on literature a MIIP was developed comprising MI theory (definition, type, mode, perspective, planning) and MI practice (performance, control). Phase 2: Development of a 27-item self-administered MIIP evaluation questionnaire, assessing MI knowledge self-evaluation of the ability to perform MI and patient satisfaction with the MIIP. Phase 3: Evaluation of MIIP and MI questionnaire by 2 independent MI experts based on predefined criteria and 2 patients using semi-structured interviews. Phase 4: Case series with a pre-post design to evaluate MIIP (3 × 30 min) using the MI questionnaire, Imaprax, Kinaesthetic and Visual Imagery Questionnaire, and Mental Chronometry. The paired t-test and the Wilcoxon signed-rank test were used to determine significant changes.

Results: Data of eleven patients were analysed (5 females; age 62.3 ± 14.1 years). Declarative MI knowledge improved significantly from 5.4 ± 2.2 to 8.8 ± 2.9 (p = 0.010). Patients demonstrated good satisfaction with MIIP (mean satisfaction score: 83.2 ± 11.4%). MI ability remained on a high level but showed no significant change, except a significant decrease in the Kinaesthetic and Visual Imagery Questionnaire score.

Conclusion: The presented MIIP seems to be valid and feasible for patients with CNS lesions and sensorimotor impairments resulting in improved MI knowledge. MIIP sessions can be held in groups of four or less. MI ability and Mental Chronometry remained unchanged after 3 training sessions.

The effect of altering a single component of a rehabilitation programme on the functional recovery of stroke patients: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of altering a single component of a rehabilitation programme (e.g. adding bilateral practice alone) on functional recovery after stroke, defined using a measure of activity.

DATA SOURCES

A search was conducted of Medline/Pubmed, CINAHL and Web of Science.

REVIEW METHODS

Two reviewers independently assessed eligibility. Randomized controlled trials were included if all participants received the same base intervention, and the experimental group experienced alteration of a single component of the training programme. This could be manipulation of an intrinsic component of training (e.g. intensity) or the addition of a discretionary component (e.g. augmented feedback). One reviewer extracted the data and another independently checked a subsample (20%). Quality was appraised according to the PEDro scale.

RESULTS

Thirty-six studies (n = 1724 participants) were included. These evaluated nine training components: mechanical degrees of freedom, intensity of practice, load, practice schedule, augmented feedback, bilateral movements, constraint of the unimpaired limb, mental practice and mirrored-visual feedback. Manipulation of the mechanical degrees of freedom of the trunk during reaching and the addition of mental practice during upper limb training were the only single components found to independently enhance recovery of function after stroke.

CONCLUSION

This review provides limited evidence to support the supposition that altering a single component of a rehabilitation programme realises greater functional recovery for stroke survivors. Further investigations are required to determine the most effective single components of rehabilitation programmes, and the combinations that may enhance functional recovery.

Effectiveness of motor imagery or mental practice in functional recovery after stroke: a systematic review

INTRODUCTION

In recent decades, many stroke rehabilitation methods have been developed. Mental practice (MP) is a dynamic state in which the subject evokes an imaginary representation of a motor action or skill in order to learn or perfect that action. Although functional imaging has shown that MP produces similar cortical activation patterns to those of movement, the clinical effectiveness of such methods in rehabilitation and functional recovery has yet to be demonstrated.

DEVELOPMENT

Systematic search of all clinical studies published in the main scientific databases between December 2011 and October 2012 concerning mental practice in stroke rehabilitation. We selected 23 clinical trials testing different MP protocols in patients with hemiparesis.

CONCLUSIONS

MP is effective when used in conjunction with conventional physical therapy for functional rehabilitation of both upper and lower limbs, as well as for the recovery of daily activities and skills. Owing to the heterogeneity of the studies with regard to the intervention protocol, specific imagery technique, time spent practicing, patient characteristics, etc., more studies are needed in order to determine the optimal treatment protocol and patient profile.

Could motor imagery be effective in upper limb rehabilitation of individuals with spinal cord injury? A case study

STUDY DESIGN

A case study.

OBJECTIVE

The aim was to investigate whether motor imagery (MI) could be successfully incorporated into conventional therapy among individuals with spinal cord injury (SCI) to improve upper limb (UL) function.

SETTING

The Physical Medicine and Rehabilitation Unit at the Henry Gabrielle Hospital in Lyon, France.

METHODS

The participant was an individual with a complete C6 SCI. MI content was focused on functional UL movements, to improve hand transport to reach out and grasp with tenodesis. The participant was tested before and after 15 MI training sessions (45 min each, three times a week during 5 consecutive weeks). MI ability and program compliance were used as indicators of feasibility. The Minnesota and Box and Blocks tests, as well as movement time and hand trajectory during targeted movements were the dependent variables, evaluating motor performance before and after MI training.

RESULTS

The participant's ability to generate MI was checked and compliance with the rehabilitation program was confirmed. The time needed to complete the Minnesota test decreased by 1 min 25 s. The Box and Blocks score was improved by three units after MI program. Decreased movement time and enhanced hand trajectory smoothness were still observed 3 months later, despite a slight decrease in performance.

CONCLUSIONS

This study supports the feasibility for introducing MI in conventional therapy. Further studies should confirm the potential role of MI in motor recovery with a larger sample.

The Movement Imagery Questionnaire-Revised, Second Edition (MIQ-RS) Is a Reliable and Valid Tool for Evaluating Motor Imagery in Stroke Populations

Mental imagery can improve motor performance in stroke populations when combined with physical therapy. Valid and reliable instruments to evaluate the imagery ability of stroke survivors are needed to maximize the benefits of mental imagery therapy. The purposes of this study were to: examine and compare the test-retest intra-rate reliability of the Movement Imagery Questionnaire-Revised, Second Edition (MIQ-RS) in stroke survivors and able-bodied controls, examine internal consistency of the visual and kinesthetic items of the MIQ-RS, determine if the MIQ-RS includes both the visual and kinesthetic dimensions of mental imagery, correlate impairment and motor imagery scores, and investigate the criterion validity of the MIQ-RS in stroke survivors by comparing the results to the KVIQ-10. Test-retest analysis indicated good levels of reliability (ICC range: .83-.99) and internal consistency (Cronbach α: .95-.98) of the visual and kinesthetic subscales in both groups. The two-factor structure of the MIQ-RS was supported by factor analysis, with the visual and kinesthetic components accounting for 88.6% and 83.4% of the total variance in the able-bodied and stroke groups, respectively. The MIQ-RS is a valid and reliable instrument in the stroke population examined and able-bodied populations and therefore useful as an outcome measure for motor imagery ability.