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 2

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) 3

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 ~ study of imagery not considered scientific, interest revived after the cognitive revolution.
- Wilhelm Wundt believed, “Every physical event has a mental counterpart, and every mental event has a physical counterpart.” 4

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)
The need to combine overt movement with imagery to enhance the vividness or the necessity to teach imagery before using it is once principle from sport transferred to rehab
There’s a huge range of actions that have been included under the rubric of “mental practice” in rehab. Therefore, difficult to categorize mental imagery with regard to rehab. 5

6. 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) 6

7. 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
So for example…
Vi is activated during visualization
When V1 was disrupted by magnetic impulses the subjects experienced problems with vision and visual imagery (recall localization theory) 7

8. 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)
Roth M, Decety J, Raybaudi M, Massarelli R, Delon-Martin C, Segebarth C, Morand S, Gemignani A, Décorps M, Jeannerod M.
Inserm U438, CHU de Grenoble, France.
The role of the primary motor cortex (M1) during mental simulation of movement is open to debate. In the present study, functional magnetic resonance imaging (fMRI) signals were measured in normal right-handed subjects during actual and mental execution of a finger-to-thumb opposition task with either the right or the left hand. There were no significant differences between the two hands with either execution or simulation. A significant involvement of contralateral M1 (30% of the activity found during execution) was detected in four of six subjects. Premotor cortex (PM) and the rostral part of the posterior Supplementary motor area (SMA) were activated bilaterally during motor imagery. These findings support the hypothesis that motor imagery involves virtually all stages of motor control. 8

9. 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)
With 3rd person perspective, the subject acts as spectator, when imagining another person walking, or using their arm, or engaging in various motor tasks
This perspective implies primarily a visual representation of the motor task
With 1st person perspective, the movement representation is made from the inside, as if the subject is the actor
In addition to visual representation, are kinesthetic sensations associated with the simulated movements
3 pillars involved in developing an imagery framework
Patient: pt is able to choose meaningful activities they want to improve.
Mental practice intervention adjustable to practiced motor action, as well as pt’s abilities
Important that imagery technique taught correctly and incorporated into daily activities  increased empowerment and autonomy
Evidence: results from brain imaging techniques have shown that mental practice may alter neural function  basic idea of using thought to improve motor function is founded on this idea
More practice is more effective
Motor tasks should be practiced in the pt’s context to be most effective
Therapist: therapist can use his/her experience and expertise to tailor the mental practice content to the abilities and preferences of the patient and the context in which it is practiced 9

10. 5 Step Outline to Intervention
Suitable Candidate?
Nature of Rx
Teach
Implant, incorporate, monitor
PT reduces support gradually
1.) Use clinical judgment to assess the mental capacity of the pt: Can the pt sustain 30 min of treatment? Can the pt follow 3-step command?
2.) Establish the nature of the Rx: important to establish if pt’s expectations are realistic and if they meet the therapist’s expectations. Also, find out relevant experiences to set mental practice in context that’s relevant to pt
3.) Teach imagery technique: what are the important and realist motor skills the pt wants to improve? Does the pt have a correct representation of the action? (Make sure sequencing and timing is correct  he/she should be imagining correctly)
4.) Embed mental practice in other active training and monitor progress: evaluating imagery skills should be done as often as possible; make sure cues are still appropriate. Pt should be encouraged to use mental practice outside of therapy
5.) Develop self-generated Rx: as soon as pt can practice an activity on their own, a new activity can be considered. Therefore, need to teach pt self-monitoring and problem-solving. The therapist can gradually reduce their support 10

11. 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
In a critical review done by McEwen et al on cognitive strategy use to enhance motor skill acquisition post-stroke, there were 3 upper extremity MI studies that had strong evidence.
Crosbie et al. wanted to investigate the effects of MP of a functional goal-directed upper limb task as an adjunct to standard physiotherapy in an acute stroke unit setting.
The Motricity Index can be used to assess the motor impairment in a patient who has had a stroke. 11 11

12. 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
AOU = amount of use (6 pt. scale)
QOM = quality of movement (6 pt. scale)
ARA = action research arm test (a 19 item test divided into 4 categories: grasp, grip, pinch, gross movement) – each item graded on a 4 pt. scale 12 12

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
Mental group had first person visuomotor imagery task. 13 13

14. 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 14

15. 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. 15

16. 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)
Autonomic studies: changes in HR and RR with increased walking speed (Fusi et al.)
Temporal organization: temporal coupling between duration of real and imagined walking conditions; time increased as task-difficulty increased (narrow path, uphill, through gates…) (Bakker et al.)
Overlapping neural networks: overlapping among neural substrates/activation of similar cortical networks during real and imagined movements also applies to complex body movements – fMRI (Szamcitat et al. 2007)

17. 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)
Sacco/colleagues: tango step lessons to focus subjects’ conscious attn on movements involved in walking – basic tango steps require specific ways of walking
mental (15min/day x 5 days) + physical practice (45 min/day x 5 days)
Results via fMRI:
expansion of bilateral motor areas
Reduction of visuospatial activation in post. cortex  focusing attn on foot movements  increased role of motor-kinesthetic vs. visual imagery processes
TMS (transcranial magnetic stim.) study (Bakker et al.):
similar TA activity in DF and gait
corticospinal effects of a simple task can predict those of a more complex motor imagery task involving the same muscle

18. PET and fMRI Studies with Mental 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
16 subjects
Viewed video clips observing walking, imagined themselves walking, and actually physically walked
Similar cadence during actual walking and imaginary walking  shared gait planning mechanism
motor planning centers of gait (supp motor area, medial primary sensorimotor cortex, and dorsal premotor cortex) activated during imagination and observation of gait  similar to physically walking
(Iseki et al 2008)

19. 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
Study elaborated on single case study in 2004 of 69 y/o man with hemiparesis following stroke
Main objectives:
Focus on specific problems (forefoot initial contact, push-off) to improve walking posture
Promote functional walking in pt’s own environment
Complexity of task during MI progressively increased (closed  open environment)
Gait rehabilitation program:
15-20 min sessions, 3x/week for 6 weeks
↑ gait speed 10-80% (avg. 15cm/sec)
↑ stride length 18%
↑ single-leg stance time 13% (involved LE)
↑ mobility and dynamic balance
(Dunsky et al 2008)

20. 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
Gradually increase mental reps b/c mental rehearsals at outset of training demand much attention and concentration
Including 1 physical execution b/t bouts of mental reps helpful in maintaining kinesthetic sensations of task
Number of sessions/reps req to observe motor improvement may depend on type and complexity of task
(Malouin et al. 2010)

21. 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)
best results when MI used in conjucntion with physical performance
Mental practice to be used as adjunct to habitual therapy/conventional gait training and stroke rehab
Does NOT replace physical performance of same task
Still need to define optimal practice program for the use of mental imagery in gait training
Further clinical studies w/ strong designs and larger groups to confirm/generalize positive findings already reported

22. 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 22

23. References (2010)
Fusi S, Cutuli D, Valente MR, et al. Cardioventilatory responses during real or imagined walking at low speed. Arch Ital Biol ; 143:
Bakker M, Verstappen CCP, Bloem B R, Toni I. Recent advances in functional neuroimaging of gait. J Neural Transm. 2007; 114:
Szamcitat AJ, Shen S, Sterr A. Motor imagery of complex everyday movements: an fMRI study. Neuroimage. 2007; 34:
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:
Bakker M, Overeem S, Snijders AH, et al. Motor imagery of foot dorsiflexion and gait: effects on corticospinal excitability. Clin Neurophysiol. 2008; 119:
Iseki K, Hanakawa T, Shinuzaki J, et al. Neural mechanisms involved in mental imagery and observation of gait. Neuroimage ; 41:
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:
Malouin F, Richards CL. Mental practice for relearning locomotor skills. Phys Ther. 2010; 90:
Liu, P. Use of mental imagery to improve task generalization after a stroke. Hong Kong Medical Journal. 2009; 15:
 Page, SJ, Levine, P, Leonard, A. Mental practice in chronic stroke: results of a randomized, placebo-controlled trial. Stroke ; 38:
Braun, S, Kleynen, M, Schack, T. Using mental practice in stroke rehabilitation: a framework. Clinical Rehabilitation. 2007; 22:
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:

24. References (2009)
Braun, S, Kleynen, M, Schack, T. Using mental practice in stroke rehabilitation: a framework. Clinical Rehabilitation. 2007; 22:
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:
DeStephano, D. (2002). Visual Knowledge [pdf document]. Received from
Dickstein, R, Dunsky, A, Marcovitz, E. Motor Imagery for Gait Rehabilitation in Post-Stroke Hemiparesis. Physical Therapy. 2004; 84:
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:
Iseki, K., Hanakawa, T., Shinozaki, J., et al. Neural mechanisms involved in mental imagery and observation of gait. NeuroImage. 2008; 41:
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:
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:
Mental Imagery (October 10, 2008). Stanford Encyclopedia of Philosophy. Received from
Muller, K, Butefisch, C, Seitz, R, et al. Mental practice improves hand function after hemiparetic stroke. Restorative Neurology and Neuroscience. 2007; 25:
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:
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: 24