First, we have provided references and summaries of the research that led to our development of Mental Movement Therapy. If you know of any more recent publishings on the topic or a similar topic that might lead to the enhancement of our program, please feel free to share them with us through email.
Secondly, at the bottom of this page, we have included some research on the ability of stroke survivors to participate in mental imagery and a brief discussion of kinesthetic vs visual imagery.
1. Butler, A.J. and Page, S.J.. (2006, December). Mental practice with motor imagery: evidence for motor recovery and cortical reorganization after stroke. Arch Phys Med & Rehab, 87(12), suppl: 2-11.
Three men and 1 woman with moderate upper-limb hemiparesis after stroke were randomized. Two patients received mental practice and CIMT, 1 patient received only mental practice, and 1 received only CIMT. The case series indicated that for these patients with chronic, moderate upper-extremity impairment after stroke, a 2-week regimen of CIMT or CIMT plus mental practice only (in 1 case) resulted in modest changes occurring as a decrease in impairment, with functional improvement.
2. Colotla, Victor A. and Bach-y-Rita, Paul. (2002). Shepherd Ivory Franz: His contributions to neuropsychology and rehabilitation. Cognitive, Affective, & Behavioral Neuroscience, 2(2), 141-148.
3. Dickstein, R. and Deutsch, J.E. (2007, July). Motor imagery in physical therapist practice. Phys Ther, 87(7), 942-953.
Abundant evidence on the positive effects of motor imagery practice on motor performance and learning in athletes, people who are healthy, and people with neurological conditions (e.g., stroke, spinal cord injury, Parkinson disease) has been published. The purpose of this update is to synthesize the relevant literature about motor imagery in order to facilitate its integration into physical therapist practice. This update will also discuss visual and kinesthetic motor imagery, factors that modify motor imagery practice, the design of motor imagery protocols and potential applications of motor imagery.
4. Dickstein, R., Dunsky, A. and Marcovitz, E. (2004, December). Motor imagery for gait rehabilitation in post-stroke hemiparesis. Phys Ther, 84(12), 1167-1177.
A 69-year-old man with left hemiparesis received mental imagery gait practice for 6 weeks. Intervention focused on task-oriented gait and on impairments of the affected lower limb. Preintervention, midterm, postintervention and follow-up measurements of temporal-distance stride parameters and sagittal kinematics of the knee joint were taken. Main Outcomes- at 6 weeks post-intervention, the patient had a 23% increase in gait speed and a 13% reduction in double-support time. An increase in range of motion of the knees was also observed. No changes in gait symmetry were noted. Discussion. The outcomes suggest that MI may be useful for the enhancement of walking ability in patients following stroke. Because improvement was mainly in temporal-distance gait variables and knee movement, imagery practice probably should focus on its specific impairments during gait in order to affect the performance of the paretic lower extremity.
5. Dunsky, A., Dickstein, R., Marcovitz, E., Levy, S. and Deutsch, J.E. (2008, November). Home-based motor imagery training for gait rehabilitation of people with chronic poststroke hemiparesis. Arch Phys Med Rehabil, 80(11), 2223.
Participants received 15 minutes of supervised imagery gait training in their homes 3 days a week for 6 weeks. The intervention addressed gait impairments of the affected lower limb and task-specific gait training. Walking ability was evaluated by kinematics and functional scales twice before the intervention, 3 and 6 weeks after the intervention began, and at the 3-week follow-up. Walking speed increased significantly by 40% after training, and the gains were largely maintained at the 3-week follow-up. The effect size of the intervention on walking speed was moderate (.64). There were significant increases in stride length, cadence, and single-support time of the affected lower limb, whereas double-support time was decreased. Improvements were also noted on the gait scale of the Tinetti Performance-Oriented Mobility Assessment as well as in functional gait. Sixty-five percent of the participants advanced 1 walking category in the Modified Functional Walking Categories Index. Although further study is recommended, the findings support the feasibility and justify the incorporation of home-based motor imagery exercises to improve walking skills for poststroke hemiparesis.
6. Hafsteinsdottir, T.B., Algra, A., Kappelle, L.J. and Grypdonck, M.H. (2005, June). Neurodevelopmental treatment after stroke: a comparative study. Journal of Neurology, Neurosurgery & Psychiatry, 76(6), 788-792.
7. Jackson, P.L., Doyon J., Richards, C.L. and Malouin, F. (2004, June). The efficacy of combined physical and mental practice in the learning of a foot-sequence task after stroke: a case report. Neurorehabil Neural Repair, 18(2), 106-111.
A single-case study. Setting. Research laboratory of a university-affiliated rehabilitation center. Patient. A right-handed 38-year-old man who had suffered a left hemorrhagic subcortical stroke 4 months prior. Intervention. The patient practiced a serial response time task with the lower limb in 3 distinct training phases over a period of 5 weeks: 2 weeks of physical practice, 1 week of combined physical and mental practice, and then 2 weeks of mental practice alone. Main Outcome Measures. Performance on the task measured through errors and response times. Imagery abilities measured through questionnaires. Results. The patient’s average response time improved significantly during the 1st 5 days of physical practice (26%) but then failed to show further improvement during the following week of physical practice. The combination of mental and physical practice during the 3rd week yielded additional improvement (10.3%), whereas the following 2 weeks of mental practice resulted in a marginal increase in performance (2.2%). Conclusion. The findings show that mental practice, when combined with physical practice, can improve the performance of a sequential motor skill in people who had a stroke, and suggest that mental practice could play a role in the retention of newly acquired abilities.
8. Liepert, J., Bauder, H., Wolfgang, M.H.R., Taub, E. and Weiller, C. (2000). Treatment-induced cortical reorganization after stroke in humans. Stroke, 31, 1210-1216.
9. Liu, K., Chan, C., Lee, T.M. and Hui-Chan, C.W. (2004). Mental imagery for promoting relearning for people after stroke: a randomized controlled trial. Arch Phys Med Rehabil, 85, 1403-1408.
46 inpatients, 60 yrs of age or older, after a cerebral infarction. Patients were randomized to receive 15 sessions (1h/d for 3 wk) of either the mental imagery program or the conventional functional training intervention on the relearning of daily living tasks. Patients engaged in mental imagery-based intervention showed better relearning of both trained and untrained tasks compared with the control group. They also demonstrated a greater ability to retain the trained tasks after 1 month and transfer the skills relearned to other untrained tasks. Mental imagery can be used as a training strategy to promote the relearning of daily tasks for people after an acute stroke.
10. Malouin, F. and Richards, Carol. (2010, February). Mental practice for relearning locomotor skills. Phys Ther, 90(2), 240-251.
Although much of the clinical work with mental practice has focused on the retraining of upper-extremity tasks, this article reviews the evidence supporting the potential of motor imagery for retraining gait and tasks involving coordinated lower-limb and body movements. First, motor imagery and mental practice are defined, and evidence from physiological and behavioral studies in healthy individuals supporting the capacity to imagine walking activities through motor imagery is examined. Then the effects of stroke, spinal cord injury, lower-limb amputation, and immobilization on motor imagery ability are discussed. Evidence of brain reorganization in healthy individuals following motor imagery training of dancing and of a foot movement sequence is reviewed, and the effects of mental practice on gait and other tasks involving coordinated lower-limb and body movements in people with stroke and in people with Parkinson disease are examined. Lastly, questions pertaining to clinical assessment of motor imagery ability and training strategies are discussed.
11. Paci, M. (2003, January). Physiotherapy based on the Bobath concept for adults with post-stroke hemiplegia: a review of effectiveness studies. Journal of Rehabilitation Medicine, 35(1), 2-7.
12. Page, S.J., Levine, P. and Leonard, A.C. (2005, March). Effects of mental practice on affected limb use and function in chronic stroke. Arch of Phys Med Rehabil, 86(3), 399-402.
Eleven patients who had a stroke more than 1 year before study entry (9 men; mean age, 62.3±5.1y; range, 53–71y; mean time since stroke, 23.8mo; range, 15–48mo; 10 strokes exhibiting upper-limb hemiparesis on the dominant side) and who exhibited affected arm hemiparesis and non-use. All patients received 30-minute therapy sessions 2 days a week for 6 weeks. The sessions emphasized activities of daily living (ADLs): 6 subjects randomly assigned to the MP condition concurrently received sessions requiring daily MP of the ADLs; 5 subjects (control group) received an intervention consisting of relaxation techniques. Participation in an MP protocol may increase a stroke patient’s use of his/her more affected limb. Data further support that the protocol resulted in correlative, MP-induced, motor function improvements.
13. Page, S.J., Levine, P. and Leonard, A.C. (2007). Mental practice in chronic stroke. Stroke, 38, 1293-1297.
Thirty-two chronic stroke patients (mean = 3.6 years) with moderate motor deficits received 30-minute therapy sessions occurring 2 days/week for 6 weeks, and emphasizing activities of daily living. Subjects randomly assigned to the experimental condition also received 30-minute MP sessions provided directly after therapy requiring daily MP of the activities of daily living; subjects assigned to the control group received the same amount of therapist interaction as the experimental group, and a sham intervention directly after therapy, consisting of relaxation. Outcomes were evaluated by a blinded rater using the Action Research Arm test and the upper extremity section of the Fugl-Meyer Assessment. Subjects receiving MP showed significant reductions in affected arm impairment and significant increases in daily arm function (both at the P < 0.0001 level). Only patients in the group receiving MP exhibited new ability to perform valued activities. The results support the efficacy of programs incorporating mental practice for rehabilitating affected arm motor function in patients with chronic stroke. These changes are clinically significant.
14. Page, S.J., Levine, P., Sisto, S.A. and Johnston, M.V. (2001, August). Mental practice combined with physical practice for upper-limb motor deficit in subacute stroke. Phys Ther, 81(8), 1455-1462.
Case Description. The patient was a 56-year-old man with stable motor deficits, including ULH, on his dominant side resulting from a right parietal infarct that occurred 5 months previously. He received physical therapy for an hour 3 times a week for 6 weeks. In addition, 2 times a week the patient listened to an audiotape instructing him to imagine himself functionally using the affected limb. The patient also listened to the audiotape at home 2 times a week. Pretreatment and posttreatment measures were the upper-extremity scale of the Fugl-Meyer Assessment of Sensorimotor Impairment (Fugl-Meyer Scale), the Action Research Arm Test (ARA), and the Stroke Rehabilitation Assessment of Movement (STREAM). Outcomes. The patient exhibited reduction in impairment (Fugl-Meyer Scale) and improvement in arm function, as measured by the ARA and STREAM. Discussion. Mental practice may complement physical therapy to improve motor function after stroke.
15. Page, S.J., Szflarski, J.P., Eliassen, J.C., et al. (2009, January). Cortical Plasticity Following Motor Skill Learning During Mental Practice in Stroke. Neurorehabil Neural Repair, 20.
16. Pascual-Leone, A., Nguyet, D., Cohen, L.G., Brasil-Neto, J.P., Cammarota, A. and Hallett, M. (1995, September). Modulation of muscle responses evoked by transcranial magnetic stimulation during the acquisition of new fine motor skills. J Neurophysiol, 74(3), 1037-1045.
17. Sharma, N. and Pomery, V.M. (2006). Motor imagery. Stroke, 37, 1941.
The review highlights the difficulty in addressing cognitive screening and compliance in motor imagery studies, particularly with regards and learn How to Use With Patients. Despite this, the literature suggests the encouraging effect of motor imagery training on motor recovery after stroke. Based on the available literature in healthy volunteers, robust activation of the nonprimary motor structures, but only weak and inconsistent activation of M1, occurs during motor imagery. In patients with stroke, the cortical activation patterns are essentially unexplored as is the underlying mechanism of motor imagery training. Provided appropriate methodology is implemented, motor imagery may provide a valuable tool to access the motor network and improve outcome after stroke.
18. Smania, N., Bazoli, F., Piva, D. and Guidetti, G. (1997). Visuomotor imagery and rehabilitation of neglect. Arch Phys Med Rehabil, 78, 430-436.
Two patients with acquired brain injury who were suffering from sever and long-lasting unilateral neglect consequent to large lesions of the cortical and subcortical right-brain. The visuomotor imagery training ameliorated the deficit in performance related to neglect in both patients. All the outcome measures were positively influenced by the treatment, and the improvement was stable over a 6-month period.
19. Stein, J., et al. (2009). Stroke Recovery and Rehabilitation. Demos Medical Publishing.
20. Yue, G. and Cole, K.J. (1992). Strength Increases from the motor program: comparison of training with maximal voluntary and imagined muscle contractions. Journal of Neurophysiology, 67(5), 1114-1123.
Are stroke survivors capable of mental imagery?
CAN people who have suffered a stroke effectively participate in a program of mental movement practice? In other words, when they have lost motor ability, do they retain the mental ability to imagine that lost motor ability? Francine Malouin and Carol Richards provide an excellent review of the current literature on this question. Their article is entitled “Mental Practice for ReLearning Locomotor Skills,” and was published in Physical Therapy Feb 2010 (full citation in list above).
Motor imagery ability has been studied extensively in people with cerebral lesions. The findings indicate that the representation of movement remains possible after stroke, even in people with chronic or severe motor impairments, suggesting that the mental representation of movement is not dependent on motor activity following CNS injury. To date, only a few patients with focalized lesions in the superior region of the parietal cortex or the frontal cortex have shown motor imagery impairment. Recently, findings in patients with stroke and age-matched healthy subjects who were assessed with the Kinesthetic and Visual Imagery Questionnaire (KVIQ) revealed that the level of motor imagery vividness following stroke was similar to that of healthy subjects, with good and bad imagers in both groups. Likewise, using a left- or right-hand judgment task that implicitly requires motor imagery (mental rotation), Johnson and colleagues found that people with stroke and healthy subjects had a range of accuracy scores that was similar in both groups, with very accurate subjects (above 90%) and less accurate subjects (above 65%) in each group. This wide range of scores in accuracy and vividness of motor imagery indicates that motor imagery ability is not an all-or-none phenomenon; rather, there is a continuum in the level of performance, and in some cases the difficulty in forming internal representations of movement can be a premorbid trait unrelated to cerebral damage.
If you are particularly curious about an individual’s ability to use mental imagery and practice, there are several objective measurement tools available. We will refer back to Malouin and Richards for a brief description of two specific to people who have had a stroke.
The combination of the Time Dependent Motor Imagery (TDMI) screening test and the Kinesthetic and Visual Imagery Questionnaire (KVIQ), 2 measures that are simple and easy to use in a clinical setting, has been proposed as a clinical assessment procedure. The TDMI is a chronometric screening test wherein the examiner records the number of movements imagined (eg, stepping movement) over 3 time periods (15, 25, and 45 seconds); it assumes that individuals who report an increase in the number of movements imagined with increasing time are able to simulate movements and likely engage in motor imagery….
The KVIQ is a motor imagery questionnaire developed for people with physical disabilities that assesses the vividness of motor imagery from a first-person perspective and uses a 5-point scale to rate the clarity of the image (visual subscale) and the intensity of the sensations (kinesthetic subscale). It consists of 20 items (10 movements in each subscale) representing gestures with different body parts (head, shoulders, trunk, upper and lower limbs), and all movements are performed from a sitting position.
Perspective of Mental Imagery: Internal (kinesthetic) vs External (visual)
In internal or kinesthetic imagery, the participant imagines the feel of the activity or movement, as well as the visual sensations, from an internal perspective. In external or visual, imagery, the participant imagines seeing the activity or movement occur from a third person’s perspective.
Research shows that internal imagery is more effective than external imagery at activating the same or similar areas of the brain as that of physical performance (3,4,10). For this reason, we have designed our program using primarily the internal or kinesthetic perspective.