MENTAL IMAGERY AND VISUALIZATION IN POST-STROKE REHABILITATION

1
MENTAL IMAGERY AND VISUALIZATION IN POST-STROKE
REHABILITATION

• Frances Copeland
• Eddie Revuelta
• Jessica Salzman
• Linda Heu
• Claudiu Mich
• Katherine Tsobanoudis

2
Learning Objectives

• At 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

3
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)

4
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.

5
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

• The subject may imagine the movement in
• 3rd Person perspective (or external imagery)
• 1st Person perspective (or internal imagery)
• (F Malouin et al., 2010)
• 3 Pillars in developing imagery framework
• The Patient Pt's choose activities
• The Evidence Mental practice may alter neural
  function
• The Therapist Utilize 5-step outline to keep
  intervention dynamic
• (S
  Braun et al., 2008)

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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

13
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)

18
PET and fMRI Studies withMental Imagery and LE
Function

• MRI scan of subjects 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 PostStroke
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

23
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
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• 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
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• Malouin F, Richards CL. Mental practice for
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• Liu, P. Use of mental imagery to improve task
  generalization after a stroke. Hong Kong Medical
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•  Page, SJ, Levine, P, Leonard, A. Mental practice
  in chronic stroke results of a randomized,
  placebo-controlled trial. Stroke. 2007 38
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• Braun, S, Kleynen, M, Schack, T. Using mental
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• Roth, M, Decety, J, Raybaudi, M, et al. Possible
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  simulated movement a functional resonance
  imaging study. Neuroreport. 1996 17 1280-4.

24
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
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• DeStephano, D. (2002). Visual Knowledge pdf
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• Iseki, K., Hanakawa, T., Shinozaki, J., et al.
  Neural mechanisms involved in mental imagery and
  observation of gait. NeuroImage. 2008 41
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• Jackson, P, Doyon, J, Richards, C L, et. al. The
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  in the learning of a foot-sequence task after
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• McEwen, S, Huijbregts, M, Ryan, J, et al.
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• Mental Imagery (October 10, 2008). Stanford
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• Muller, K, Butefisch, C, Seitz, R, et al. Mental
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  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
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• 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.