[ARTICLE] A randomized controlled trial of motor imagery combined with structured progressive circuit class therapy on gait in stroke survivors – Full Text

Abstract

Structured Progressive Circuit Class Therapy (SPCCT) was developed based on task-oriented therapy, providing benefits to patients’ motivation and motor function. Training with Motor Imagery (MI) alone can improve gait performance in stroke survivors, but a greater effect may be observed when combined with SPCCT. Health education (HE) is a basic component of stroke rehabilitation and can reduce depression and emotional distress. Thus, this study aimed to investigate the effect of MI with SPCCT against HE with SPCCT on gait in stroke survivors. Two hundred and ninety stroke survivors from 3 hospitals in Yangon, Myanmar enrolled in the study. Of these, 40 stroke survivors who passed the selection criteria were randomized into an experimental (n = 20) or control (n = 20) group. The experimental group received MI training whereas the control group received HE for 25 minutes prior to having the same 65 minutes SPCCT program, with both groups receiving training 3 times a week over 4 weeks. Temporo-spatial gait variables and lower limb muscle strength of the affected side were assessed at baseline, 2 weeks, and 4 weeks after intervention. After 4 weeks of training, the experimental group showed greater improvement than the control group in all temporospatial gait variables, except for the unaffected step length and step time symmetry which showed no difference. In addition, greater improvements of the affected hip flexor and knee extensor muscle strength were found in the experimental group. In conclusion, a combination of MI with SPCCT provided a greater therapeutic effect on gait and lower limb muscle strengths in stroke survivors.

Introduction

Stroke is one of the top causes of long-term disability and mortality in many countries throughout the world^1,2, with a high potential of this population increasing further due to the ageing population³. According to the disability-adjusted life years, stroke disease stands in fourth place among the disease burden. In 2005, there were 5.7 million deaths globally and 87% of them came from developing countries⁴.

Gait is one of the most important functions after stroke⁵. Stroke survivors usually exhibit gait alterations with longer stride time and lower gait speed and cadence when compared to aged matched healthy individuals⁶. Gait asymmetry is shown as one of the common characteristics in stroke survivors. It has been reported that 33.3% and 55.5% of ambulating stroke survivors had significant asymmetries in the temporal and spatial variables of gait⁷. Asymmetry of gait is clinically important and has been related to increases in energy expenditure, reduced balance control, and risk of unaffected limb injury⁸. The most important factor attributing to gait asymmetry is the reduction in muscle strength in the affected side. Previous studies exploring the relationship between lower limb muscle strength and walking ability, found significant associations in all muscle groups, especially in the hip flexors and ankle plantar flexors which showed the largest contribution to gait speed⁹. A review article reported that muscle weakness was one of the causation factors of falls, it is therefore considered to be the primary objective of promoting mobility ability in stroke survivors¹⁰.

Task-oriented training is one of several training techniques that has been used to improve motor function in stroke survivors^11–14. This technique has been reported to improve functional tasks, allowing the patients to participate actively, and allows easy progression in the training levels and task adaptability¹⁵. The Structure Progressive Circuit Class Training (SPCCT) was developed based on the task-oriented training concept. The key components of this method are to provide group therapy with a minimum of 2 participants under 1 therapist supervisor and encouraging repeated practice exercises with continual progression¹⁶. This has advantages over other techniques and has been shown to increase therapy dosage and reduce treatment costs. This treatment technique may be suitable for a large number of patients, however, a limited number of therapists implement these techniques within the clinical setting.

Motor imagery (MI) is a cognitive function paradigm that involves the mental imitation of the movement without actual execution. MI has been used as part of training programs for a number of clinical conditions to improve motor ability, and has been shown to produce similar brain activity to real movement actions^17,18. Imagination and motor planning are key parts of the brain’s capability to perform movement effectively. The purpose of MI training is to improve learning ability by repetitive practice of particular tasks¹⁹. Although studies support the practice with MI alone to improve lower limb function^20,21, better results have been reported when MI was combined with physical training^22–24. However, the previous studies have been conducted on upper limb function and only a few studies have reported its use in the lower limb^14,25.

For a conservative treatment, health education (HE) is one of the crucial elements in stroke management. Stroke awareness is administered in the context of the national stroke policies in countries worldwide^26,27. This provides knowledge about the disease and other necessary information for the patients and caregivers, and helps to inform patients how to take care of themselves as well as to prevent recurrence. This present study aimed to investigate the effect of the combined techniques of MI and SPCCT on gait and lower limb muscle strength on the affected side in stroke survivors. We hypothesized that the intervention of MI with SPCCT would show greater improvements when compared to HE with SPCCT.[…]

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