Mental practice is effective in upper limb recovery after stroke: a randomized single-blind cross-over study. Mental practice improves hand function after hemiparetic stroke. Modified constraint-induced therapy combined with mental practice: thinking through better motor outcomes. A randomized efficacy and feasibility study of imagery in acute stroke. Effects of mental practice on affected limb use and function in chronic stroke. Mental practice in chronic stroke: results of a randomized, placebo-controlled trial.
The aim of this study was to investigate the role of mental practice (MP) in functional recovery of upper limbs in stroke patients.
                Thirty-six hemiparetic stroke patients (15 females and 21 males) were enrolled in a randomized single blind cross-over study. Patients were randomly divided into two groups, (A and B) each comprising 18 patients. Patients in group A underwent the conventional neuro-rehabilitation protocol (therapeutic exercise and occupational therapy) for three weeks (3 hours a day, 5 days a week) and in the following 3 weeks, they received an additional 60 minutes of MP training. Patients in group B, instead, underwent, in the first 3 weeks, the rehabilitation program plus MP training and in the following 3 weeks, only the conventional neurorehabilitation program. All patients were evaluated at baseline (T0), at 3 weeks (T1) and at 6 weeks (T2) with the Motricity Index (MI) and the Arm Functional Test (AFT).
                At baseline (T0) there were no significant differences at MI and AFT between the two groups. At T1 the differences between the two groups became significant. At T2 the difference was once again minimal.
                These results suggest that MP could be used to complement to the conventional neurorehabilitative treatments usually prescribed for post-stroke neuromotor recovery. However, there is still much to be tested and discussed regarding the role that MP might play in the treatment of neurological patients. In a multiple baseline design, we tested the hypothesis that imagery of finger movements is a specific strategy to improve hand function.
                The effect of mental training of sequential finger movements (n=6) on hand function was compared to the repetitive execution of the same movements (n=6) and conventional physical therapy (n=5) in 17 patients after their first hemiparetic stroke. The behavioral outcome measures consisted of peak force of the pinch grip using a force transducer and manipulation functions of the upper extremity (Jebsen-test). In addition, activities of daily living (Barthel Index) were acquired to describe the population.
                Mental training resulted in an increase in the peak force of the pinch grip and generalized in a better functionality of the upper extremity (Jebsen-test). This effect was similar to the repetitive execution of the movements and superior to conventional physiotherapy.
                Our results suggest that the control of finger movements benefits from mental training of sequential finger movements and, thus, may be employed as a strategy in post-stroke rehabilitation. Modified constraint-induced therapy (mCIT) is an outpatient therapy encouraging repetitive, task-specific practice with the affected arm. mCIT has shown efficacy in all stages poststroke. Given its efficacy when combined with other therapy regimens, the current study examined the efficacy of mental practice when combined with mCIT versus mCIT only using randomized, controlled methods.
                Ten patients with chronic stroke (7 males; mean age, 61.4+/-3.02 years; age range, 48 to 79 years; mean time since stroke, 28.5 months; range, 13 to 42 months) exhibiting stable, affected arm motor deficits were administered mCIT, consisting of: (1) structured therapy emphasizing affected arm use in functional activities 3 days/week for 10 weeks; and (2) less affected arm restraint 5 days/week for 5 hours. Both of these components were administered during a 10-week period. Subjects randomly assigned to the mCIT+mental practice experimental condition also received 30-minute mental practice sessions provided directly after therapy sessions. These mental practice sessions required daily cognitive rehearsal of the activities of daily living practiced during mCIT clinical sessions.
                No pre-existing differences were found between groups on any demographic variable or movement scale. All subjects exhibited marked reductions in affected arm impairment and functional limitation. However, subjects in the mCIT+mental practice group exhibited significantly larger changes on both movement measures after intervention: Action Research Arm Test, +15.4-point change versus +8.4-point change for mCIT only subjects (P<0.001); Fugl-Meyer, +7.8-point change versus +4.1-point change for the mCIT only subjects (P=0.01). These changes were sustained 3 months after intervention.
                mCIT remains a promising motor intervention. However, its efficacy appears to be enhanced by use of mental practice provided directly after mCIT clinical sessions. To compare the feasibility and efficacy of a programme combining imagery and occupational therapy with a programme of therapy only.
                Randomized, controlled case series.
                Subacute outpatient clinic.
                Thirteen consecutively admitted patients between four weeks and one year post stroke exhibiting stable motor deficits in their affected upper limbs.
                All patients received an hour of therapy three times a week for six weeks administered by the same physical and occupational therapists. During the same period, eight patients participated in 10-minute guided imagery sessions after each therapy session, as well as practising imagery at home twice each week. Five patients participated in a control intervention consisting of exposure to stroke information.
                The Fugl-Meyer Assessment of Motor Recovery (Fugl-Meyer) and Action Research Arm Test (ARA).
                After intervention, Fugl-Meyer and ARA scores of patients in the therapy only group remained virtually the same; therapy plus imagery group scores improved by 13.8 and 16.4 points, respectively, on the Fugl-Meyer and ARA.
                Imagery is a clinically feasible, cost-effective complement to therapy that may improve outcomes more than participation in therapy only. To determine the efficacy of a mental practice (MP) protocol in increasing the function and use of the more affected limb in stroke patients.
                Randomized, controlled, multiple baseline, pre-post, case series.
                Outpatient rehabilitation hospital.
                Eleven patients who had a stroke more than 1 year before study entry (9 men; mean age, 62.3+/-5.1 y; range, 53-71 y; mean time since stroke, 23.8 mo; range, 15-48 mo; 10 strokes exhibiting upper-limb hemiparesis on the dominant side) and who exhibited affected arm hemiparesis and nonuse.
                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.
                The Motor Activity Log and Action Research Arm (ARA) test.
                Affected limb use as rated by MP patients and their caregivers increased (1.55, 1.66, respectively), as did patient and caregiver ratings of quality of movement (2.33, 2.15, respectively) and ARA scores (10.7). In contrast, the controls showed nominal increases in the amount they used their affected limb and in limb function. A Wilcoxon test on the ARA scores revealed significantly ( P =.004) greater changes in the MP group's scores.
                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. The mechanisms whereby MP increases affected arm use are unknown. Perhaps using the more affected limb becomes more salient through MP, or perhaps motor schema are altered during MP to integrate limb use. Mental practice (MP) of a particular motor skill has repeatedly been shown to activate the same musculature and neural areas as physical practice of the skill. Pilot study results suggest that a rehabilitation program incorporating MP of valued motor skills in chronic stroke patients provides sufficient repetitive practice to increase affected arm use and function. This Phase 2 study compared efficacy of a rehabilitation program incorporating MP of specific arm movements to a placebo condition using randomized controlled methods and an appropriate sample size. Method- 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.
                No pre-existing group differences were found on any demographic variable or movement scale. 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.