on the Effectiveness of Mental Practice with Motor Imagery in the Neurologic Rehabilitation of Stroke Patients

Background: Mental practice with motor imagery entails an individual to symbolically rehearse a physical activity within working memory in the absence of overt body movement. It has been proven to be useful in sports training and other skills training. However, much is yet to be determined if the same promising results may be gained when this training method is used with persons with brain lesions, like stroke patients. Objectives: The aim of the study is to investigate evidence for the effectiveness of mental practice with motor imagery in the neurological rehabilitation of stroke patients in improving their impairments and functional limitations, and to identify variations in mental practice protocols (duration, type of imagery employed, etc) and characteristics of participants, (age of subjects, duration of stroke prior to intervention) that may have affected the results gathered. Methods: Literature search was accomplished with electronic databases such as Science Direct, Pub Med, Proquest, MEDLINE, CINAHL, Cochrane Library for Systematic Reviews and OVID. Criteria used in selecting articles included (1) Clinical controlled trials or RCTs, (2) adult stroke patients, except with cerebellar or basal ganglia pathology, (3) intervention given was mental practice with motor imagery without external aids. Two peer reviewers individually rated the quality of each study using checklists used by JBI. Results:. A total of 7 articles were included for this systematic review after quality appraisal. This included 5 randomized controlled trials and 2 CCTs. All studies reported improvement of UE function after the intervention. Conclusion Although researches done with this intervention have yielded equivocal results, a relatively small body of evidence for mental practice with motor imagery in rehabilitation of UE of stroke patients still exists. Future studies employing quality research endeavors with research designs at the upper levels of the hierarchy of evidence are recommended to strengthen the present evidence. INTRODUCTION One of the major goals in rehabilitation for survivors of central nervous system (CNS) trauma is the return to independence in activities of daily living. The success of achieving plastic changes in the CNS after skill training appears to be dependent on the amount of practice from that particular skill. It has been proposed that positive changes in the cortical representations at the primary sensory-motor areas are “activity-dependent,” stressing therefore the importance of practice in acquisition of skill. Practice may be accomplished with overt movement, i.e. actual performance of the task, or with covert movement, i.e. mental imagery, which is used with mental practice. A systematic review on the effectiveness of mental practice with motor imagery in the neurologic rehabilitation of stroke patients 2 © The Internet Journal of Allied Health Sciences and Practice, 2009 Jackson et al. distinguishes the terms mental imagery and mental practice. Mental imagery is the umbrella term for the active process of reliving sensations with or without external stimuli.1 This is facilitated by the use of images brought about by combinations of the different modalities, i.e. visual, auditory, tactile, kinesthetic, olfactory, gustatory. When movement of an action of a person or object is imaged, this is referred to as movement imagery. Specifically when it is the human body that is imaged by the internal reactivation of the action within working memory without overt motor output, it is called motor imagery. Mental practice, on the other hand, is defined as a symbolic rehearsal of a physical activity in the absence of any gross muscular movement, serving as a training method in utilizing motor representations with the use of motor imagery to improve motor performance. Images generated could vary from a person seeing themselves or another do the action using a third person perspective, as if watching a movie, called visual imagery. Or, it could be facilitated through a first person perspective where the individual internalizes the sensations that accompany the imagined movement. This is referred to as kinesthetic imagery. The success of mental imagery has been well documented in the fields of sports psychology in enhancing athletic performance. This has encouraged the application of mental imagery for other skill development for normal individual’s i.e. surgical skills, playing instruments, or balance training for elderly women. The use of such techniques has only recently been explored in rehabilitation settings. Carr and Shepherd have emphasized the importance of engaging in motor or physical practice of tasks for as much time as possible during rehabilitation programs.2 However, practice sessions are usually confined to the few hours of therapy in the clinic per day, and the possibility of ensuing fatigue and staff availability further limits practice sessions. Thus, mental practice with motor imagery may serve as an avenue for patients to continue their skills training even when they are already physically exhausted, or when supervised therapy sessions have finished. With the growing number of studies on this intervention for the stroke population, there is the need to consolidate this evidence to determine the potential use of mental practice with motor imagery in neurological rehabilitation particularly for stroke patients.