Objective To investigate the effects of adjuvant mental practice (MP) on affected upper limb function following a stroke using three-dimensional (3D) motion analysis.
Methods In this AB/BA crossover study, we studied 10 hemiplegic patients who had a stroke within the past 6 months. The patients were randomly allocated to two groups: one group received MP combined with conventional rehabilitation therapy for the first 3 weeks followed by conventional rehabilitation therapy alone for the final 3 weeks; the other group received the same therapy but in reverse order. The MP tasks included drinking from a cup and opening a door. MP was individually administered for 20 minutes, 3 days a week for 3 weeks. To assess the tasks, we used 3D motion analysis and three additional tests: the Fugl-Meyer Assessment of the upper extremity (FMA-UE) and the motor activity logs for amount of use (MAL-AOU) and quality of movement (MAL-QOM). Assessments were performed immediately before treatment (T0), 3 weeks into treatment (T1), and 6 weeks into treatment (T2).
Results Based on the results of the 3D motion analysis and the FMA-UE index (p=0.106), the MAL-AOU scale (p=0.092), and MAL-QOM scale (p=0.273), adjuvant MP did not result in significant improvements.
Conclusion Adjuvant MP had no significant effect on upper limb function following a stroke, according to 3D motion analysis and three clinical assessment tools (the FMA-UE index and the two MAL scales). The importance of this study is its use of objective 3D motion analysis to evaluate the effects of MP. Further studies will be needed to validate these findings.
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INTRODUCTION
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Stroke patients with dysfunction of the upper extremities can face significant problems in their activities of daily living (ADLs) as well as in the recovery of other general functions [1].
Although many different therapeutic approaches are available for improving upper extremity function after a stroke [1], it is important to select the most appropriate intervention for rehabilitation in accordance with the severity of impairment.
Mental imagery is an active process that combines all six senses: visual, auditory, tactile, kinesthetic, olfactory, and gustatory [2]. Motor imagery, a component of mental imagery, is associated with a specific movement produced by the internal reproduction of motor action without motor output [2, 3]. Mental practice (MP) involves motor imagery and includes repetitive imagination of a physical activity with the intention of performing that activity or improving performance [2, 4]. MP allows an individual to perform tasks repeatedly without physical exhaustion or any risk to safety [5]. In addition, it enables patients to practice complex physical tasks that the stroke had rendered difficult.
MP was first used in sports to improve techniques, and it is believed that neural loops and movement patterns may be activated during MP [1]. The application of MP in stroke patients was reported to activate the cerebral and cerebellar sensorimotor structures repeatedly [6], and similar results were obtained when the actual tasks were practiced, according to a study involving positron emission tomography [7]. Another study [8] showed that MP increased activity in the premotor area, the primary motor cortex, and the superior parietal cortex. In patients receiving hemiplegic stroke rehabilitation, the application of MP along with other neurological practices was shown to help recovery of unilateral upper limb function at a low cost and without risks or complications [8, 9, 10].
Based on a review of the Cochrane database in 2011 (6 trials, n=119), the use of rehabilitation treatments combined with MP was found to be more effective for improving upper extremity function after stroke than were rehabilitation treatments without MP [4]. Previous studies assessed MP for accomplishing ADLs (such as ironing or buttoning a shirt, turning a page in a book, lifting a cup, or opening a door). However, results of several studies using the Fugl-Meyer Assessment of the upper extremity (FMA-UE), the action research arm test (ARAT), and the motor activity log (MAL) to evaluate muscle power and hand function indicated a mismatch between the intervention and evaluation methods [10, 11, 12].
Conventional studies [10, 11, 13, 14] have shown that upper extremity function can be improved with adjunctive MP; however, in these studies, the tasks performed during MP and the tools used for evaluating upper extremity function differed, making it difficult to measure the actual changes. Furthermore, the authors of a previous study [12] claimed that patients with motor recovery after a stroke episode that occurred within the previous 6 months (subacute) did not benefit from MP. These patients had performed tasks such as opening, grasping, and lifting household objects; however, upper extremity function was measured by means of the ARAT, which led to differences between the tasks and the evaluation method. In order to evaluate the actual changes in a patient’s motions, we used objective three-dimensional (3D) motion analysis to investigate the identical motions that correspond to MP (in this case, drinking from a cup and opening a door).
The patients assessed in previous MP studies usually had chronic stroke, and few such studies have been performed in patients with subacute stroke. Because our hospital treats mainly those with subacute stroke, we focused on the effects of MP in this group.
In order to participate in therapy and follow instructions, patients undergoing traditional studies of MP and upper limb function [1, 8, 10, 11, 12, 13, 15, 16] are required to have good cognitive scores on the Mini-Mental State Examination (MMSE) or stable mental status, as well as the ability to understand verbal instructions. However, adequate MMSE scores and compliance with instructions alone are not sufficient to validate the effectiveness of MP. Therefore, our investigation cites studies on motor imagery [17,18], evaluating patients using a standard score of 2.26 on the Vividness of Movement Imagery Questionnaire (VMIQ).
In the present study, additional MP was provided to stroke patients who practiced conventional occupational therapy and performed identical tasks along with MP. Moreover, 3D motion analysis was carried out to understand the effects of MP on upper extremity function in real life after a stroke. We also compared the outcomes of 3D motion analysis and of clinical assessments (FMA-UE and MAL) to detect evidence of any congruity between these methods of evaluation.
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TBI Rehabilitation 