mental imagery and visualization in post- stroke rehabilitation frances copeland eddie revuelta...
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MENTAL IMAGERY AND VISUALIZATION IN POST-STROKE REHABILITATION
Frances Copeland
Eddie Revuelta
Jessica Salzman
Linda Heu
Claudiu Mich
Katherine Tsobanoudis
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Learning ObjectivesAt the completion of this topic students will be able
to: Define Motor imagery & Mental practice/Motor
imagery practice Describe the neurophysiological areas
associated with MI Describe the 5-step framework of MI Describe the best way to implement MI in post-
stroke rehab Discuss the effectiveness of MI for relearning
daily functional tasks
– In both the Upper & Lower Extremities
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Imagery Definitions:
Motor Imagery: “Imagining of an action without its physical execution; it is an active process during which the representation of an action is internally reproduced within working memory without any overt output.”
Mental Practice/Motor Imagery Practice: “repetition or rehearsing of imagined motor acts with the intention of improving their physical execution.”
(F Malouin et al., 2010)
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History of Mental Imagery
• The notion that thoughts rely on imagery was common among philosophers, as far back as Plato (~300 BCE)
• Introspectionists recorded peoples experiences of MI, following Wundt (~1850)
• From the ~1913-1960 study of imagery not considered scientific, interest revived after the cognitive revolution.
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History of Mental Imagery Guidelines from Sport Science
– Teaching and developing imagery can be abstracted from sports
– Combine overt movement with imagery techniques, enhances vividness• More vivid = more blood flow to visual
areas
– Sports literature clearly divides imagery techniques and uses applied models• Not always the case with Rehab, huge
range of actions
(S Braun et al., 2008)
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Neuroscience and MI
• Technology used to research the brain while an imagery task is performed
– fMRI = functional magnetic resonance imaging• Measures hemodynamic response to
neural activity
– TMS = transcranial magnetic stimulation• Noninvasive method to excite neuron
• Shows causality, by showing what regions are active during a task
(Caltech.edu, 2004)
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Neuroscience and MI (cont.)
• fMRI results = V1 (primary visual cortex) is activated during visualization
• TMS results = disrupting V1 with magnetic impulses causes problems with vision and visual imagery
• Shows V1 is important for both visual perception and mental imagery
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Neurophysiological Study
• Premotor cortex and rostral part of the posterior SMA were activated bilaterally, this supports the hypothesis that motor imagery involves virtually all stages of motor control. • Mental imagery
activation is 30% of the level
seen in actual performance motor cortex
(Roth et al., 1996)
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Developing a Framework
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5 Step Outline to Intervention
1. Suitable Candidate?
2. Nature of Rx
3. Teach
4. Implant, incorporate, monitor
5. PT reduces support gradually
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MI in UE Recovery of Function with Stroke Patients
• Page et al. (2007) conducted a Randomized Placebo-Controlled Trial
• 32 chronic stroke patients with moderate motor deficits.
• Placebo group did 30 minutes of relaxation instead of 30 minutes of mental practice
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MI in UE Recovery of Function with Stroke Patients (cont.)
• Results: MP group showed improvements in ARA and UE FM score. The differences between pre and post-treatment data were significant. Placebo group showed no significant differences between pre and post
• Conclusion: A traditional rehabilitation program that includes mental practice of tasks practiced during therapy increases outcomes significantly
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MI in UE Recovery of Function with Stroke Patients (cont.)• Liu (2009) investigated the benefits of an MI
intervention to enhance performance of tasks in a new environment for post-stroke patients.
• 34 patients with a first acute stoke were included
• All patients received 1 hour of physical therapy five times a week for three weeks
• Patients in MI group received 1 hour of MI
• Patients in FR group were given conventional therapy
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MI in UE Recovery of Function with Stroke Patients (cont.)
• Results: There were significant differences between the MI and FR groups in the training environment for the three tasks that involved UE
• There were significant differences between the MI and FR groups in a new environment, including the three tasks that involved the UE
• Conclusion: This study provides evidence of the positive effects of MI for improving patients’ generalization of task performance to new environments
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MI in UE Recovery of Function with Stroke Patients• In summary, the evidence of MI
rehabilitation is promising but still limited (Braun et al (2008)).
• What does this mean?
• MI can be applied to post stroke patients in efforts to recover UE function along with physical practice.
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Evidence That Locomotor Activities Can Be Imagined Through MI
• Mentally-simulated and physically-executed locomotor activities:
– Similar autonomic responses
– Similar temporal organization
– Activate neural networks that greatly overlap
(Fusi et al. 2005)
(Szamcitat et al. 2007)
(Bakker et al. 2007)
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Evidence of Induced Brain Reorganization
• Mental and physical practice leads to expansion of bilateral motor areas
• Initial performance improvement due to greater motor preparation and planning
(Sacco et al. 2006)
• Similar TA activation during motor imagery of simple dorsiflexion and gait
(Bakker et al. 2008)
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PET and fMRI Studies withMental Imagery and LE Function
• MRI scan of subject’s brain while:
a) Observing video of walking
b) Imagining self walking
c) Actually walking
• Results: brain activity similar in imaginary/observational walking as in actual walking
(Iseki et al 2008)
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Gait Rehabilitation of Chronic Post–Stroke Hemiparesis
• 17 post-stroke patients, MI training only
• Intervention:
– 15-20 min sessions, 3x/week for 6 weeks
• Results:
• Increased walking speed, stride length, and single-leg stance time (affected LE)
• Improved mobility and dynamic balance
(Dunsky et al 2008)
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MI Combined with Physical Practice in Gait Training
• Best adherence and learning effects when training strategies combined
• Proportions of practice time range from– 1 physical + 5 mental rehearsals– 1 physical + 10 mental rehearsals
• Best to gradually increase number of mental repetitions
(Malouin et al. 2010)
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Effectiveness of MI in Gait Training Post-Stroke
• Best results: MI + physical practice
• MI = adjunct to conventional gait training
• Does NOT replace physical practice
(Malouin et al. 2010)
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Review Learning Objectives
Students should be able to: Define Motor imagery & Mental practice/Motor
imagery practice Describe the neurophysiological areas
associated with MI Describe the 5-step framework of MI Describe the best way to implement MI in post-
stroke rehab Discuss the effectiveness of MI for relearning
daily functional tasks
– In both the Upper & Lower Extremities
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References (2010)Fusi S, Cutuli D, Valente MR, et al. Cardioventilatory responses during real or imagined walking at low speed. Arch Ital Biol.
2005; 143: 223-228.
Bakker M, Verstappen CCP, Bloem B R, Toni I. Recent advances in functional neuroimaging of gait. J Neural Transm. 2007; 114: 1232-1331.
Szamcitat AJ, Shen S, Sterr A. Motor imagery of complex everyday movements: an fMRI study. Neuroimage. 2007; 34: 702-713.
Sacco K, Cauda F, Cerliani L, et al. Motor imagery of walking following training in locomotor attention: the effect of “the tango lesson.” Neuroimage. 2006; 32: 1441-1449.
Bakker M, Overeem S, Snijders AH, et al. Motor imagery of foot dorsiflexion and gait: effects on corticospinal excitability. Clin Neurophysiol. 2008; 119: 2519-2527.
Iseki K, Hanakawa T, Shinuzaki J, et al. Neural mechanisms involved in mental imagery and observation of gait. Neuroimage. 2008; 41: 1021-1031.
Dunsky A, Dickstein R, Marcovitz E, et al. Home-based motor imagery training for gait rehabilitation of people with chronic poststroke hemiparesis. Arch Phys Med Rehabil. 2008; 89: 1580-1588.
Malouin F, Richards CL. Mental practice for relearning locomotor skills. Phys Ther. 2010; 90: 240-251.
Liu, P. Use of mental imagery to improve task generalization after a stroke. Hong Kong Medical Journal. 2009; 15: 37-41.
Page, SJ, Levine, P, Leonard, A. Mental practice in chronic stroke: results of a randomized, placebo-controlled trial. Stroke. 2007; 38: 1293-1297.
Braun, S, Kleynen, M, Schack, T. Using mental practice in stroke rehabilitation: a framework. Clinical Rehabilitation. 2007; 22: 579-591.
Roth, M, Decety, J, Raybaudi, M, et al. Possible involvement of primary motor cortex in mentally simulated movement: a functional resonance imaging study. Neuroreport. 1996; 17: 1280-4.
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References (2009)Braun, S, Kleynen, M, Schack, T. Using mental practice in stroke rehabilitation: a framework. Clinical Rehabilitation. 2007;
22: 579-591.
Crosbie, J, McDonough, S, Gilmore, D, et al. The adjunctive role of mental practice in the rehabilitation of the upper limb after hemiplegic stroke: a pilot study. Clinical Rehabilitation, 2004; 18: 60-68.
DeStephano, D. (2002). Visual Knowledge [pdf document]. Received from http://chat.carleton.ca/~ddestefa/270Slides/chap11.PDF
Dickstein, R, Dunsky, A, Marcovitz, E. Motor Imagery for Gait Rehabilitation in Post-Stroke Hemiparesis. Physical Therapy. 2004; 84: 1167-1177.
Dunsky, A, Dickstein, R, Ariav, C et. al. Motor imagery practice in gait rehabilitation of chronic post-stroke hemiparesis: four case studies. International Journal of Rehabilitation Research. 2006; 29: 351-356.
Iseki, K., Hanakawa, T., Shinozaki, J., et al. Neural mechanisms involved in mental imagery and observation of gait. NeuroImage. 2008; 41: 1021-1031.
Jackson, P, Doyon, J, Richards, C L, et. al. The efficacy of combined physical and mental practice in the learning of a foot-sequence task after stroke: a case report. Neurorehabilitation and Neural Repair. 2004; 18: 106-111.
McEwen, S, Huijbregts, M, Ryan, J, et al. Cognitive strategy use to enhance motor skill acquisition post-stroke: a critical review. Brain Injury. 2009; 23: 263-277.
Mental Imagery (October 10, 2008). Stanford Encyclopedia of Philosophy. Received from http://plato.stanford.edu/entries/mental-imagery/
Muller, K, Butefisch, C, Seitz, R, et al. Mental practice improves hand function after hemiparetic stroke. Restorative Neurology and Neuroscience. 2007; 25: 501-511.
Page, S, Levine, P, & Leonard, A. Effects of mental practice on affected limb use and function in chronic stroke. Archives of Physical Medicine and Rehabilitation. 2005; 86: 399-402.
Roth, M, Decety, J, Raybaudi, M, et al. Possible involvement of primary motor cortex in mentally simulated movement: a functional resonance imaging study. Neuroreport. 1996; 17: 1280-4.