Key points

Stroke remains a leading cause of death and one of the most costly and burdensome diseases. For example, the 2010 Global Burden of Disease Study estimated that there were 16.9 million people who had experienced a first-ever stroke, 33 million stroke survivors, and 102 million disability-adjusted life-years lost in that year alone. Moreover, despite organized efforts to prevent and treat stroke more quickly and effectively, since 1990 there has been continued growth in the overall incidence and mortality of stroke.

The global impact of stroke and the rapidly expanding number of stroke survivors with residual disabilities provide impetus for the development of rehabilitative approaches that increase poststroke function. In response, several rehabilitative regimens have been tested, with the most efficacious therapies encouraging survivors to practice functionally and repetitively (termed repetitive task-specific practice [RTP]). RTP seems to be a critical factor in poststroke plasticity and functional increases. For example, in stroke survivors with minimally impaired upper extremities (UEs), constraint-induced movement therapy increases UE use and function by integrating RTP with behavioral strategies that encourage paretic limb use. Similarly, among survivors with moderate UE impairments (people with no active movement in their paretic wrists and fingers) RTP augmented by electrical stimulation enables active participation in UE motor practice, and significantly increases paretic UE use and function.

Informed by these promising findings, and based on decades of motor learning, neuroplasticity, and cognitive behavior training literature, we recently proposed the PRACTICE principles, which speak to the ways in which RTP should ideally be integrated into poststroke care. Specific components of the PRACTICE principles are as follows: (1) part-whole practice should be used, with an eye toward realistic task analysis, (2) repetitive and goal focused, (3) activities should be salient, (4) client driven, (5) train in a practical way, (6) impairments should be addressed, (7) challenge regularly and appropriately, and (8) emphasize accomplishments. One of the concepts elucidated by the PRACTICE principles is the ability of the client to easily access and meaningfully engage in RTP (ie, train in a practical fashion). This principle speaks to the match of a regimen’s practice parameters with the abilities and physical activity tolerance of the client (eg, are the parameters too intensive and/or too long in duration for the client to tolerate? Does the regimen use equipment that the client and/or the clinic cannot easily integrate into care?), as well as the physical proximity and accessibility of the resources needed to fully implement the regimen. Such practical considerations are important in ensuring full client participation and high fidelity with the regimen to facilitate neural and motor changes. However, they are not always embraced by contemporary approaches, such as those mentioned earlier, which often require intensive parameters and/or expensive equipment that is only available at specialized rehabilitation and academic medical centers. For instance, in the largest trial to date of constraint-induced movement therapy, subjects could only tolerate about two-thirds of the assigned 6 hours of RTP before fatigue set in.

In response to these limitations, this laboratory was the first to apply mental practice (MP) to increase learning and outcomes in stroke, later showing that MP use increases paretic UE use and function. More recently, our work has shown that MP use causes the same cortical changes as physical practice in survivors of stroke. The regimen has also been extended to other poststroke impairments and neurologic conditions, and our pioneering findings have been replicated by others around the world. The critical advantage of MP compared with newer but less pragmatic rehabilitative approaches (and even some conventional rehabilitative therapies) is its use of cognitive rehearsal without the use of physical practice or voluntary physical movement attempts by the client. Instead, the client listens to an audio file that elucidates the goal-directed actions to be performed, and/or watches a video depicting these movements. Restated, during MP, the individual is cognitively rehearsing RTP. These straightforward requirements allow MP to be performed with minimal direct supervision, minimal expense, and in virtually any environment with no specialized equipment. Moreover, a variety of laboratories have confirmed that MP use activates the same neural areas and musculature as physical practice of the same tasks, providing a strong scientific rationale for cognitively rehearsing a skill to simulate conditions brought about by RTP. This finding is important because, in some clinical situations, mental rehearsal may be a safer and/or better justified clinical option than engaging in physical practice because of the client’s impairments (eg, when it is unsafe for a client to physically practice ambulation).

Given its implementation advantages compared with many physically based practice approaches and its strong scientific bases, the overall goal of this article is to review the considerations associated with the clinical implementation of MP. Specifically, this article begins by briefly discussing literature supporting MP use, including current MP work occurring at this laboratory. It then describes the basic components of clinical MP regimens with the goal of facilitating increased integration of MP into clinical practice. In addition, it concludes with a discussion of future directions and emerging applications designed to enhance MP outcomes. Most of discussion focuses on motor impairments, because this is the primary area of MP investigation in the stroke population, and because motor impairments are frequent and especially disabling.

Empirical support for mental practice

Although there is a growing body of evidence for the impact of MP on lower extremity function, most efforts to date have targeted UE motor recovery. Results and methods from selected cited trials are included in Table 1 . Specifically, research gathered from these trials suggests that MP combined with RTP is the most efficacious approach, resulting in greater increases in UE motor function than RTP alone. In addition to these significant gains in UE function, Liu and colleagues showed that MP combined with RTP may also facilitate increased translation of learned motor skills to new environments. Based on promising results from controlled trials, several sites have also implemented MP alongside rehabilitative therapies in clinical settings (eg, inpatient rehabilitation ) with patients in the acute/subacute phase of recovery, finding significant gains in performance of activities of daily living (ADLs) and UE function for those receiving MP alongside conventional therapy compared with conventional therapy alone. In addition to significant improvements on aforementioned motor-based and activity-based outcome measures, evidence also suggests that MP combined with RTP results in improved UE kinematics, increased cortical representation of the affected hemisphere, efficacy when combined with other therapies (eg, modified constraint-induced therapy ), and more frequent paretic UE use. Building on this work, our laboratory is now leading a multicenter, randomized controlled trial examining the effect of MP and RTP in chronic, hemiparetic stroke. This is the first multicenter trial to investigate the effect of an MP regimen not only on affected UE outcomes and impairment but also on cortical reorganization in the ipsilesional motor cortex.

Empirical support for mental practice

Although there is a growing body of evidence for the impact of MP on lower extremity function, most efforts to date have targeted UE motor recovery. Results and methods from selected cited trials are included in Table 1 . Specifically, research gathered from these trials suggests that MP combined with RTP is the most efficacious approach, resulting in greater increases in UE motor function than RTP alone. In addition to these significant gains in UE function, Liu and colleagues showed that MP combined with RTP may also facilitate increased translation of learned motor skills to new environments. Based on promising results from controlled trials, several sites have also implemented MP alongside rehabilitative therapies in clinical settings (eg, inpatient rehabilitation ) with patients in the acute/subacute phase of recovery, finding significant gains in performance of activities of daily living (ADLs) and UE function for those receiving MP alongside conventional therapy compared with conventional therapy alone. In addition to significant improvements on aforementioned motor-based and activity-based outcome measures, evidence also suggests that MP combined with RTP results in improved UE kinematics, increased cortical representation of the affected hemisphere, efficacy when combined with other therapies (eg, modified constraint-induced therapy ), and more frequent paretic UE use. Building on this work, our laboratory is now leading a multicenter, randomized controlled trial examining the effect of MP and RTP in chronic, hemiparetic stroke. This is the first multicenter trial to investigate the effect of an MP regimen not only on affected UE outcomes and impairment but also on cortical reorganization in the ipsilesional motor cortex.

Table 1

Selected, randomized controlled trials of MP in UE rehabilitation

Author, Year	Study Objective	Study Design, Participants	Intervention	Primary Outcome Measures	Results
Liu et al, 2004	Determine efficacy of MP in promoting UE motor relearning	Design: prospective, randomized controlled trial Participants: 46 acute inpatients, >60 y old	15 sessions (1 h/d for 3 wk) of either MP and therapy or conventional therapy only	Trained and untrained tasks, FM and CTT	MP group improved significantly on trained ( P <.005) and untrained ( P <.001). MP group improved significantly on CTT ( P <.005) but not on FM
Page et al, 2007	Determine efficacy of MP in increasing function and use of affected UE in chronic stroke	Design: randomized, placebo-controlled trial Participants: 32 patients with chronic stroke, average time poststroke = 3.6 y	30 min of traditional therapy 2 d/wk for 6 wk and either 30-min MP or relaxation session	UE section of the FM and ARAT	MP group increased significantly on the FM (+6.7 vs +1.0, P <.0001) and ARAT (+7.8 vs +0.44, P <.0001) compared with sham
Muller et al, 2007	Determine efficacy of MP in increasing hand function	Design: multiple baseline, randomized controlled trial Participants: 17 patients (6 women; mean age, 62 y) with severe hemiparesis	4 wk of mental rehearsal of a nonsequential finger opposition task, motor execution of a nonsequential finger opposition task, or conventional therapy	Pinch/grip strength, Jebsen Hand Function Test, Barthel Index, and European Stroke Scale	MP and motor groups showed statistically significant gains on Jebsen Hand Function Test and pinch/grip strength compared with the control group
Page et al, 2009	Determine efficacy of MP and mCIT on UE function	Design: randomized controlled trial Participants: 10 patients with chronic stroke (7 men). Mean age = 61.4 ± 3.02 y. Age range = 48–79 y Average time after stroke = 28.5 mo	MP (30 min/d) and mCIT or mCIT alone; both interventions 3×/wk for 10 wk	ARAT and FM	mCIT + MP group showed significantly greater increases on the FM (+7.8 vs +4.1, P = .01) and ARAT (+15.4 vs 8.4, P <.001) immediately following and 3-months after intervention
Liu et al, 2009	Determine effect of MP on generalization of learned task skills to trained and untrained tasks in new environments	Design: randomized controlled trial Participants: 35 patients with acute stroke	MP and traditional rehabilitation or traditional rehabilitation alone; both provided 1 h/d for 3 wk	Gains in task performance	MP participants improved performance significantly on 4 out of 5 trained tasks ( P = .001–.026) vs improvement on 1 trained task ( P = .021) in control group. MP participants improved performance on 3 out of 5 trained ( P = .025) and 2 out of 3 untrained tasks ( P = .042) in new environment
Bovend’Eert et al, 2010	Investigate feasibility of the integration of MP into occupational and physical therapy rehabilitation	Design: single-blind, randomized controlled trial Participants: 50 patients with stroke, brain injury, or multiple sclerosis in inpatient or outpatient rehabilitation (>18 y old)	6 wk of traditional rehabilitation and MP traditional rehabilitation only	Goal Attainment Scaling, Barthel Index, Rivermead Mobility Index, Nottingham Extended ADL, ARAT and Timed up and Go	Gains measured in both groups on all outcome measures, but no significant differences in outcome measures between groups
Riccio et al, 2010	Investigate effect of MP on functional UE recovery after stroke	Design: randomized, single-blind crossover study Participants: 36 patients with stroke with UE hemiparesis	Convention rehabilitation (3 h a day, 5 d a week) followed by 3 wk of conventional therapy with additional 60 min of MP. A separate group received the same intervention in reverse order	Motricity Index (UE section), Arm Function Test–Functional Ability Scale and time	The conventional + MP group at the 3-wk crossover point showed statistically significant improvement compared with the control group at the 3-wk crossover point on all outcome measures. There were no significant differences between groups at the end of treatment period
Letswaart et al, 2011	Examine the effect of MP on UE function in stroke	Design: multicenter, randomized controlled trial Participants: 121 patients with stroke. Average time post stroke≤3 months	Traditional rehabilitation 3 d/wk for 45 min. Participants additionally received MP, nonmotor mental rehearsal, or usual care with no mental rehearsal	ARAT, grip strength (dynamometry), timed manual dexterity performance	No significant changes between groups were seen on any outcome measures
Page et al, 2011	Compare efficacy of 20-min, 40-min, and 60-min sessions of MP on UE function after stroke	Design: single-blind, multiple baseline, randomized controlled trial Participants: 29 patients with chronic stroke	20-min, 40-min, or 60-min MP + RTP sessions or RTP + audiotaped sham intervention	FM and ARAT	Duration of MP predicted changes in FM scores, with the 60-min duration group showing the largest increases (+5.4). The 20-min duration showed the greatest gains in ARAT scores (changes were nonsignificant). Subjects who received MP, regardless of dose, showed larger increases than those in the control group, but differences were not statistically significant

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Predictors of Functional Outcome Following Stroke Upper Limb Motor Impairment After Stroke Hemiplegic Shoulder Pain Hemiparetic Gait Stroke Rehabilitation Using Virtual Environments Poststroke Communication Disorders and Dysphagia

Stay updated, free articles. Join our Telegram channel

Join