Clinical Practice & Epidemiology in Mental Health




ISSN: 1745-0179 ― Volume 15, 2019

Mental Practice Combined with Motor Rehabilitation to Treat Upper Limb Hemiparesis of Post-Stroke Patients: Clinical and Experimental Evidence



Sergio Machado1, 2, *, Eduardo Lattari1, 2, Flávia Paes1, Nuno B.F. Rocha3, Antonio E. Nardi1, Oscar Arias-Carrión4, Gioia Mura5, Ti-Fei Yuan6, Mauro G. Carta5, Carlos Campos1
1 Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, Brazil
2 Physical Activity Neuroscience Laboratory, Physical Activity Sciences Postgraduate Program, Salgado de Oliveira University, Niterói, Brazil
3 Polytechnic Institute of Porto, School of Allied Health Sciences, Portugal
4 Unidad de Trastornos de Movimiento y Sueño, Hospital General Dr. Manuel Gea Gonzalez, Secretaria de Salud México DF, México
5 Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Italy
6 School of Psychology, Nanjing Normal University Nanjing, China

Abstract

Stroke is one of the major causes of disability in the world. Due to the extended lifetime of the world's population, the number of people affected by stroke has increased substantially over the last years. Stroke may lead to sensorimotor deficits, usually causing hemiplegia or hemiparesia. In order to reduce motor deficits and accelerate functional recovery, MP combined with motor rehabilitation was introduced to the rehabilitation process of post-stroke patients. Evidence has shown that MP combining with motor rehabilitation based on activities of daily living was more effective than conventional motor rehabilitation used per se. This combination proved very useful and effective, with significant results in improvement of motor deficits in post-stroke patients. However, further studies must be conducted to determine specific parameters, such as type of imagery, frequency or duration.

Keywords: Hemiparesis, kinesthetic imagery, mental practice, stroke, visual imagery.


Article Information


Identifiers and Pagination:

Year: 2016
Volume: 12
First Page: 9
Last Page: 13
Publisher Id: CPEMH-12-9
DOI: 10.2174/1745017901612010009

Article History:

Received Date: 26/12/2014
Revision Received Date: 12/7/2015
Acceptance Date: 06/08/2015
Electronic publication date: 15/3/2016
Collection year: 2016

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open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International Public License (CC BY-NC 4.0) (https://creativecommons.org/licenses/by-nc/4.0/legalcode), which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the Institute of Psychiatry, Federal University of Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, Brazil; Tel: +5521991567006; Fax: +552135187880; E-mail: secm80@gmail.com




Stroke is one of the major causes of disability in the world [1Cicerone KD, Dahlberg C, Malec JF, et al. Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002. Arch Phys Med Rehabil 2005; 86(8): 1681-92.
[http://dx.doi.org/10.1016/j.apmr.2005.03.024] [PMID: 16084827]
]. Due to the extended lifetime of the world's population, the number of people affected by stroke has increased substantially over the last years [2Stewart DG. Stroke rehabilitation. 1. Epidemiologic aspects and acute management. Arch Phys Med Rehabil 1999; 80(5)(Suppl. 1): S4-7.
[http://dx.doi.org/10.1016/S0003-9993(99)90095-3] [PMID: 10326897]
]. Stroke may lead to sensorimotor deficits, usually causing hemiplegia or hemiparesia [2Stewart DG. Stroke rehabilitation. 1. Epidemiologic aspects and acute management. Arch Phys Med Rehabil 1999; 80(5)(Suppl. 1): S4-7.
[http://dx.doi.org/10.1016/S0003-9993(99)90095-3] [PMID: 10326897]
]. Various forms of treatment have been proven by the literature as promising alternatives to improve motor function and quality of life in these patients [3Lattari E, Pereira-Junior PP, Neto GA, et al. Effects of chronic exercise on severity, quality of life and functionality in an elderly Parkinson’s disease patient: case report. Clin Pract Epidemiol Ment Health 2014; 10: 126-8.
[http://dx.doi.org/10.2174/1745017901410010126] [PMID: 25419223]
-5Carta MG, Hardoy MC, Pilu A, et al. Improving physical quality of life with group physical activity in the adjunctive treatment of major depressive disorder. Clin Pract Epidemiol Ment Health 2008; 26: 4-1.
[http://dx.doi.org/10.1186/1745-0179-4-1]
]. Thus, in order to reduce motor deficits and accelerate functional recovery, some researchers began to investigate the effects of (MP) combined with motor rehabilitation for motor recovery of upper limbs in post-stroke patients [6Van Leeuwen R, Inglis JT. Mental practice and imagery: a potential role in stroke rehabilitation. Phys Ther Rev 1998; 3: 47-52.
[http://dx.doi.org/10.1179/ptr.1998.3.1.47]
-10Malouin F, Richards CL, Jackson PL, Dumas F, Doyon J. Brain activations during motor imagery of locomotor-related tasks: a PET study. Hum Brain Mapp 2003; 19(1): 47-62.
[http://dx.doi.org/10.1002/hbm.10103] [PMID: 12731103]
].

MP consists of a training method, whereby the internal reproduction of a given motor act (mental simulation) is repeated extensively with the intention of promoting learning or improvement of motor skills [11Decety J, Grèzes J. Neural mechanisms subserving the perception of human actions. Trends Cogn Sci (Regul Ed) 1999; 3(5): 172-8.
[http://dx.doi.org/10.1016/S1364-6613(99)01312-1] [PMID: 10322473]
]. This mental simulation (motor imagery) corresponds to a dynamic state during the performance of a specific action, internally reactivated by working memory in the absence of any movement [12Lotze M, Cohen LG. Volition and imagery in neurorehabilitation. Cogn Behav Neurol 2006; 19(3): 135-40.
[http://dx.doi.org/10.1097/01.wnn.0000209875.56060.06] [PMID: 16957491]
]. MP results of a conscious access to motor intention, which is usually performed unconsciously during motor preparation [11Decety J, Grèzes J. Neural mechanisms subserving the perception of human actions. Trends Cogn Sci (Regul Ed) 1999; 3(5): 172-8.
[http://dx.doi.org/10.1016/S1364-6613(99)01312-1] [PMID: 10322473]
, 12Lotze M, Cohen LG. Volition and imagery in neurorehabilitation. Cogn Behav Neurol 2006; 19(3): 135-40.
[http://dx.doi.org/10.1097/01.wnn.0000209875.56060.06] [PMID: 16957491]
], establishing a relationship between motor events and cognitive perceptions [7Jackson PL, Lafleur MF, Malouin F, Richards C, Doyon J. Potential role of mental practice using motor imagery in neurologic rehabilitation. Arch Phys Med Rehabil 2001; 82(8): 1133-41.
[http://dx.doi.org/10.1053/apmr.2001.24286] [PMID: 11494195]
].

Studies have shown that there are similarities in psychophysical and physiological functions between executed and imagined movements, suggesting that they are based on the same processes [13Michelon P, Vettel JM, Zacks JM. Lateral somatotopic organization during imagined and prepared movements. J Neurophysiol 2006; 95(2): 811-22.
[http://dx.doi.org/10.1152/jn.00488.2005] [PMID: 16207787]
, 14Jeannerod M. Neural simulation of action: a unifying mechanism for motor cognition. Neuroimage 2001; 14(1 Pt 2): S103-9.
[http://dx.doi.org/10.1006/nimg.2001.0832] [PMID: 11373140]
]. Experiments using functional magnetic resonance imaging (fMRI) showed that not only the supplementary and premotor motor areas and cerebellum were activated during imagined movements of the hand and fingers, but also the contralateral primary motor cortex (cM1) [8Nair DG, Purcott KL, Fuchs A, Steinberg F, Kelso JA. Cortical and cerebellar activity of the human brain during imagined and executed unimanual and bimanual action sequences: a functional MRI study. Brain Res Cogn Brain Res 2003; 15(3): 250-60.
[http://dx.doi.org/10.1016/S0926-6410(02)00197-0] [PMID: 12527099]
, 15Lotze M, Montoya P, Erb M, et al. Activation of cortical and cerebellar motor areas during executed and imagined hand movements: an fMRI study. J Cogn Neurosci 1999; 11(5): 491-501.
[http://dx.doi.org/10.1162/089892999563553] [PMID: 10511638]
, 16Gerardin E, Sirigu A, Lehéricy S, et al. Partially overlapping neural networks for real and imagined hand movements. Cereb Cortex 2000; 10(11): 1093-104.
[http://dx.doi.org/10.1093/cercor/10.11.1093] [PMID: 11053230]
]. fMRI and transcranial magnetic stimulation (TMS) studies indicated that the contralateral side of the primary motor area is activated during the imagination of complex movements, confirming previous findings that showed a more prominent involvement of the primary motor area in the performance of complex motor sequences [17Kuhtz-Buschbeck JP, Mahnkopf C, Holzknecht C, Siebner H, Ulmer S, Jansen O. Effector-independent representations of simple and complex imagined finger movements: a combined fMRI and TMS study. Eur J Neurosci 2003; 18(12): 3375-87.
[http://dx.doi.org/10.1111/j.1460-9568.2003.03066.x] [PMID: 14686911]
, 18Gerloff C, Corwell B, Chen R, Hallett M, Cohen LG. The role of the human motor cortex in the control of complex and simple finger movement sequences. Brain 1998; 121(Pt 9): 1695-709.
[http://dx.doi.org/10.1093/brain/121.9.1695] [PMID: 9762958]
].

Regarding the similarity of cortical areas activated and engaged in the execution and imagination of a movement, it was found that such resemblances in brain activity occurred during finger movements [19Li S, Kamper DG, Stevens JA, Rymer WZ. The effect of motor imagery on spinal segmental excitability. J Neurosci 2004; 24(43): 9674-80.
[http://dx.doi.org/10.1523/JNEUROSCI.2781-04.2004] [PMID: 15509755]
]. Within this context, several investigations attempt to apply these findings in the motor rehabilitation process, especially in cases that concern the recovery of areas involved in motor function, after lesion in the central nervous system [6Van Leeuwen R, Inglis JT. Mental practice and imagery: a potential role in stroke rehabilitation. Phys Ther Rev 1998; 3: 47-52.
[http://dx.doi.org/10.1179/ptr.1998.3.1.47]
, 9Jackson PL, Lafleur MF, Malouin F, Richards CL, Doyon J. Functional cerebral reorganization following motor sequence learning through mental practice with motor imagery. Neuroimage 2003; 20(2): 1171-80.
[http://dx.doi.org/10.1016/S1053-8119(03)00369-0] [PMID: 14568486]
]. MP applied alone achieves less interesting results than motor rehabilitation alone in patients with neurological disorders. Nevertheless, the combination of both techniques (MP and motor rehabilitation) proved to be more effective than the two techniques applied alone [20Pascual-Leone A, Nguyet D, Cohen LG, Brasil-Neto JP, Cammarota A, Hallett M. Modulation of muscle responses evoked by transcranial magnetic stimulation during the acquisition of new fine motor skills. J Neurophysiol 1995; 74(3): 1037-45.
[PMID: 7500130]
-23Weiss T, Hansen E, Rost R, et al. Mental practice of motor skills used in poststroke rehabilitation has own effects on central nervous activation. Int J Neurosci 1994; 78(3-4): 157-66.
[http://dx.doi.org/10.3109/00207459408986054] [PMID: 7883452]
].

Since its first applications in the context of neurological recovery, only eleven experiments were conducted combining these techniques in order to investigate whether this combination is really effective [24Page SJ. Imagery improves motor function in chronic stroke patients with hemiplegia: a pilot study. Occup Ther J Res 2000; 20: 200-15.-34Hemmen B, Seelen HA. Effects of movement imagery and electromyography-triggered feedback on arm hand function in stroke patients in the subacute phase. Clin Rehabil 2007; 21(7): 587-94.
[http://dx.doi.org/10.1177/0269215507075502] [PMID: 17702700]
] or not. Thus, it was not possible to standardize the use of MP as a rehabilitation practice in neurological recovery in post-stroke patients. In this sense, there is no consensus on the frequency (how many days per week and how many weeks), duration (minutes per session), type (visual or kinesthetic) and the appropriate time of application of MP (recovery phase of the pathology). However, such investigations have shown evidence that combining MP with motor rehabilitation based on activities of daily living was more effective than conventional motor rehabilitation used per se [24Page SJ. Imagery improves motor function in chronic stroke patients with hemiplegia: a pilot study. Occup Ther J Res 2000; 20: 200-15.-34Hemmen B, Seelen HA. Effects of movement imagery and electromyography-triggered feedback on arm hand function in stroke patients in the subacute phase. Clin Rehabil 2007; 21(7): 587-94.
[http://dx.doi.org/10.1177/0269215507075502] [PMID: 17702700]
].

MP demands a conscious engagement of certain brain regions often activated unconsciously during motor preparation. However, movement imagination is not reliant on motor execution skills, but it is quite dependent on central mechanisms processing [12Lotze M, Cohen LG. Volition and imagery in neurorehabilitation. Cogn Behav Neurol 2006; 19(3): 135-40.
[http://dx.doi.org/10.1097/01.wnn.0000209875.56060.06] [PMID: 16957491]
, 14Jeannerod M. Neural simulation of action: a unifying mechanism for motor cognition. Neuroimage 2001; 14(1 Pt 2): S103-9.
[http://dx.doi.org/10.1006/nimg.2001.0832] [PMID: 11373140]
]. With this in mind, it may be possible that the frequent use of MP facilitates the organization of central motor commands. Based on the “neural networks” theory, which underlines that they are previously established for certain motor acts, studies have reported that those neural networks involved in motor gesture execution are rehearsed during MP [9Jackson PL, Lafleur MF, Malouin F, Richards CL, Doyon J. Functional cerebral reorganization following motor sequence learning through mental practice with motor imagery. Neuroimage 2003; 20(2): 1171-80.
[http://dx.doi.org/10.1016/S1053-8119(03)00369-0] [PMID: 14568486]
]. Thus, the improved performance on the executed motor gesture occurs by the coordination of motor patterns responsible for that specific movement. It is based on the theory that “neural networks“ remain intact despite the physical damages, which suggests that post stroke patients could benefit of MP to activate the partially damaged “neural networks”. Those findings are in accordance with previous studies of MP despite the lack of neuroimaging data to reinforce this idea [24Page SJ. Imagery improves motor function in chronic stroke patients with hemiplegia: a pilot study. Occup Ther J Res 2000; 20: 200-15.-29Nilsen DM, Gillen G, DiRusso T, Gordon AM. Effect of imagery perspective on occupational performance after stroke: a randomized controlled trial. Am J Occup Ther 2012; 66(3): 320-9.
[http://dx.doi.org/10.5014/ajot.2012.003475] [PMID: 22549597]
]. Moreover, those findings are also in accordance with studies that relate changes in motor functions to cortical functions after several specific motor training protocols were used [35Stevenson T, Thalman L, Christie H, Poluha W. Constraint-induced movement therapy compared to dose-matched interventions for upper-limb dysfunction in adult survivors of stroke: a systematic review with meta-analysis. Physiother Can 2012; 64(4): 397-413.
[http://dx.doi.org/10.3138/ptc.2011-24] [PMID: 23997396]
], including MP [30Page SJ, Szaflarski JP, Eliassen JC, Pan H, Cramer SC. Cortical plasticity following motor skill learning during mental practice in stroke. Neurorehabil Neural Repair 2009; 23(4): 382-8.
[http://dx.doi.org/10.1177/1545968308326427] [PMID: 19155350]
]. Such theory is attributed to the mechanism of cerebral reorganization, where new areas are recruited to assist the movements of the affected arm [35Stevenson T, Thalman L, Christie H, Poluha W. Constraint-induced movement therapy compared to dose-matched interventions for upper-limb dysfunction in adult survivors of stroke: a systematic review with meta-analysis. Physiother Can 2012; 64(4): 397-413.
[http://dx.doi.org/10.3138/ptc.2011-24] [PMID: 23997396]
]. Another theory currently emerging on the improvement in motor act is based on self-consciousness of movements (reflective and pre-reflective), where skilled atheletes seem to be able to increase its motor proficiency, although they are already experts [36Toner J, Moran A. In praise of conscious awareness: a new framework for the investigation of “continuous improvement” in expert athletes. Front Psychol 2014; 5(5): 769.
[PMID: 25076931]
]. There is an increased attentional focus on the "proprioceptive sense" of their movement while performing the skill. This suggests a greater capacity to switch attention between different modes of body perception during the performance [36Toner J, Moran A. In praise of conscious awareness: a new framework for the investigation of “continuous improvement” in expert athletes. Front Psychol 2014; 5(5): 769.
[PMID: 25076931]
]. Perhaps this greater cognitive effort required by the MP technique can contribute to the motor rehabilitation process.

Jeannerod [12Lotze M, Cohen LG. Volition and imagery in neurorehabilitation. Cogn Behav Neurol 2006; 19(3): 135-40.
[http://dx.doi.org/10.1097/01.wnn.0000209875.56060.06] [PMID: 16957491]
] pointed out the importance of MP prior to motor execution. It would represent an additional or complementary technique to motor execution, but does not replace it [14Jeannerod M. Neural simulation of action: a unifying mechanism for motor cognition. Neuroimage 2001; 14(1 Pt 2): S103-9.
[http://dx.doi.org/10.1006/nimg.2001.0832] [PMID: 11373140]
]. Since the patients' ability to perform MP is evaluated, the focus can then be directed on the severity of the injury and the moment when MP should be introduced to the treatment. When the neurological condition does not allow patients to perform movements, MP is needed in order to keep the neural networks active [24Page SJ. Imagery improves motor function in chronic stroke patients with hemiplegia: a pilot study. Occup Ther J Res 2000; 20: 200-15.-29Nilsen DM, Gillen G, DiRusso T, Gordon AM. Effect of imagery perspective on occupational performance after stroke: a randomized controlled trial. Am J Occup Ther 2012; 66(3): 320-9.
[http://dx.doi.org/10.5014/ajot.2012.003475] [PMID: 22549597]
] and also to promote cortical reorganization [30Page SJ, Szaflarski JP, Eliassen JC, Pan H, Cramer SC. Cortical plasticity following motor skill learning during mental practice in stroke. Neurorehabil Neural Repair 2009; 23(4): 382-8.
[http://dx.doi.org/10.1177/1545968308326427] [PMID: 19155350]
], so that the motor preparation can facilitate future executions of specific movements during the rehabilitation program.

MP represents an intriguing “backdoor” approach to access motor rehabilitation at all stages of stroke recovery. Unlike active and passive motor therapies, MP, in principle, does not rely on residual function but still incorporates voluntary drive. In stroke patients, MP may then provide a substitute for executed movement as a way to activate the motor network. Thus, MP is most effective when the skills being mentally rehearsed are also physically practiced. This is due to motor rehabilitation component, which is believed to create a motor program or “motor schema” that MP reinforces.

When combined with motor rehabilitation, MP has proven to be useful with significant results in improvement of motor deficits in post-stroke patients. However, a recent published meta-analysis demonstrated that the use of mental practice had no significant results in motor rehabilitation of upper limbs [37Machado S, Lattari E, de Sá AS, et al. Is mental practice an effective adjunct therapeutic strategy for upper limb motor restoration after stroke? A systematic review and meta- analysis. CNS Neurol Disord Drug Targets 2015; 14(5): 567-75.
[http://dx.doi.org/10.2174/1871527314666150429112702] [PMID: 25921745]
]. Thus, further studies should be conducted to determine specific parameters such as number and weekly frequency, duration (minutes per session), type (visual or kinesthetic) and the appropriate moment to apply mental practice (recovery phases of pathology), in order to create specific protocols for each treatment phase. In addition, further studies are also needed using neuroimaging techniques in order to obtain more information about the patterns of brain activation and reorganization.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

References

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