Northeast Rehabilitation Hospital Network

Incorporating Mental Imagery into Brain Injury Rehabilitation

Lisa Theroux PT, DPT, CSRSKristen Carlson PT, DPT, CSRS, CBIS

Objectives

•Provide a comprehensive understanding of motor imagery

•Review current research supporting use of motor imagery in rehabilitation

•Describe the process of performing motor imagery as a treatment strategy

• Identify appropriate patients and guidelines to create and incorporate a motor imagery treatment plan

Identifying Imagery

•Mental practice Mental Imagery Motor Imagery

•Research is evolving as varied disciplines begin to identify best practices

•Medicine field = motor imagery

History

•Has been researched for decades Early motor imagery studies from the 1960’s Pub Med search

“Mental Practice” = 48,499 articles “Motor Imagery” = 2,816 articles

•Sports rehabilitation PETTLEP Imagery

Physical Environment Task Timing Learning Emotion Perspective

Photo courtesy of: http://idrottsforum.org/journal-of-imagery-research-in-sport-and-physical-activity-volume-9-issue-1/

What is Motor

Imagery?

“Internally reactivated

action” Sharma et al 2006

“Cognitive rehearsal of movement” Wang et al 2016

“An act of expressing movement internally”

Oh et al 2017

“Imagination of moving specific

body parts” Schuster et al 2011

“Goal directed mental

rehearsal” Hwang et al 2010

Types of Imagery

Internal Motor Imagery vs. External Motor Imagery

Implicit Motor Imagery vs. Explicit Motor Imagery

Graded Motor Imagery

Internal vs. External

• Internal Motor imagery Kinesthetic/ Explicit/ 1st person

Subjects imagine sensation of motion in own body

•External Motor Imagery Visual/ 3rd person/ (form of mirror therapy)

Subjects view self as an external observer

3rd personPhotos courtesy of: https://unsplash.com/search/photos/

Implicit vs. Explicit

• Implicit motor imagery represented motor tasks in imagery are performed

without awareness and are perceptually driven L/R discrimination Hand grasp

•Explicit motor imagery feeling of the movement was experienced consciously

Adds kinesthetic components

Photos courtesy of: https://www.pexels.com/

https://www.pexels.com/

Graded Motor Imagery

Photos courtesy of: http://www.gradedmotorimagery.com/left-right-discriminiation.htmlhttp://mrri.org/tag/mirror-therapy/ ; https://www.pexels.com

Implicit Motor Imagery

Explicit Motor Imagery Mirror Therapy

Graded activation of cortical networks

Progressively complex levels

Photo courtesy of: https://www.frontiersin.org/files/Articles/269507/frym-05-00042-HTML/image_m/figure-1.jpg

How and Why?

Neuroplasticity

•The life long capacity of the brain to change and rewire itself in response to the stimulation of learning and experiencing.

•Skill acquisition through practice•Practice variables

Repetition, repetition, repetition Task intensity/difficulty Task complexity Relevancy

Neuroplasticity

•Motor Imagery vs. Motor Practice Similar autonomic response Similar temporal organization

Equivalent timing or “temporal coupling” Activate overlapping neural networks

fMRI shows overlapping regions are activated during motor imagery (MI) and motor execution (ME)

Functionally equivalent to motor control planning and preparation stages

(a) Control_ME (b ) Control_MI

(c) Patient_ME (d) Patient_MI

123

L R L R

L R L R

12 12

12

33

3

Wang et al 2016

Figure 1: Brain activation in the control and patient groups under different conditions. (a) Control subjects during motor execution; (b) controls during motor imagery; (c) patients during motor execution; (d) patients during

motor imagery. All voxels were significant at p

Neuroplasticity

Motor imagery causes neural activity, which in turn could be utilized to “exercise” the brain without physical performance.

Photo courtesy of: http://www.cognopedia.com/images/thumb/7/7d/Motor_imagery.jpg/180px-Motor_imagery.jpg

Upper Extremity & ADL Outcomes

•Greater learning and carryover of new ADL tasks

• Improved upper extremity: strength gesture quality task performance speed

• Increased effectiveness of pinch grip Changes are greater than or equal

to Minimal Clinically Important Difference (MCID) :

Fugl – Meyer Assessment (FMA) Wolf Motor Function Test (WMFT) Action Research Arm Test (ARAT)

Photo courtesy of: https://www.neurorehabdirectory.com/stroke-recovery-using-constraint-induced-movement-therapy-cimt/http://www.reha-stim.de/cms/index.php?id=125

Trunk Control• Improved trunk muscle activity

in conjunction with physical practice

• Improved proprioception

Photo Courtesy of: https://media.lanecc.edu/users/howardc/PTA204L/204LNeuromuscReEd/204LNeuromuscReEd_print.html

Lower Extremity & Gait Outcomes

• Gait quality Stride length Hip flexion torque Speed Single limb support time Decreased double limb

support

• Leg Strength• Dynamic balance• Fear of falling/ confidence

•Changes are greater than or equal to Minimal Clinically Important Difference (MCID): Tinneti Functional Reach TUG 10M walk test Fugl-Myer

Photo courtesy of: http://boneandspine.com/normal-gait-cycle/

Patient Activity Level

Figure 1. Physical activity, people present, and location data from observations between 8 am and 5 pm averaged across all cases.

Copyright © American Heart Association, Inc. All rights reserved.

Patient and Provider Challenges

Time constraints

within treatment

Patient activity

tolerance

MotivationChoosing the best option

Photo courtesy of: https://www.mackenziecorp.com/are-there-time-constraints-associated-with-the-research-project-2/

Photo courtesy of: https://me.me/i/this-is-as-far-as-i-m-willing-to-go-3241279 Photo courtesy of: https://strategicdynamicsfirm.com/crafting-good-better-best-value-statements/

Photo courtesy of: https://www.mirror.co.uk/lifestyle/health/feeling-tired-heres-10-reasons-6579569

Consider the Pros…

Feasible

Clinically relevant

Low cost

Easy to perform

Can be done without supervision

May Reduce fear

Can be done early and often

Improves functional independence

No effect on physical fatigue

Enables practice of complex tasks

Gives patient control and autonomy over treatment tasks/ goals

Similar autonomic changes noted in some research

Who is appropriate?

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Criteria

Patient can attend to task for approx. 10 minutes

Able to follow 3 step command Can form a vivid image Able to recall meaningful task from before

brain injury Intact primary motor cortex Screen for cognitive function

Patient Selection

•The location of the lesion affects how vivid MI is: Cerebellum/basal ganglia Parietal cortex Prefrontal cortex

•Right sided lesions had a difficult time with both implicit and explicit images More impulsive response

•Acute lesions Spontaneous recovery

How to Screen for Cognitive Function

Screening

Tools

Working memory &

attention skills

Kinesthetic and Visual Imagery Questionnaire

(KVIQ)

Movement Imagery Questionnaire – 3

(MIQ-3)

Hand Laterality Judgment

Test (HLJT)

Example of MIQ-3 Questions

•Sample question – External Visual Imagery:

STARTING POSITION: Extend the arm of your non-dominant hand straight out to your side so that it is parallel to the ground, palm down. ACTION: Move your arm forward until it is directly in

front of your body (still parallel to the ground). Keep your arm extended during the movement, and make the movement slowly. MENTAL TASK: Assume the starting position. Attempt to

see yourself making the movement just observed from an external perspective. Now rate the ease/difficulty with which you were able to do this mental task and the angle the image was observed from (see additional sheet provided for full list of different angles)

Rating: __________Williams, S. E., Cumming, J., Ntoumanis, N., Nordin-Bates, S. M., Ramsey, R., & Hall, C. (2012). Further validation and development of the Movement Imagery Questionnaire. Journal of Sport & Exercise Psychology, 34, 621-646.http://works.bepress.com/jennifer_cumming/27/

MIQ-3

1 2 3 4 5 6 7

Very hard to see

Hard to see Somewhat hard to see

Neutral (not easy nor hard)

Somewhateasy to see

Easy to see Very easy to see

Visual Analog Scale

Kinesthetic Analog Scale

1 2 3 4 5 6 7

Very hard to feel

Hard to feel Somewhat hard to feel

Neutral (not easy nor hard)

Somewhateasy to feel

Easy to feel Very easy to feel

Williams, S. E., Cumming, J., Ntoumanis, N., Nordin-Bates, S. M., Ramsey, R., & Hall, C. (2012). Further validation and development of the Movement Imagery Questionnaire. Journal of Sport & Exercise Psychology, 34, 621-646.http://works.bepress.com/jennifer_cumming/27/

Importance of Coupling MI with Physical Practice (PP)

•Repetition: Coupling MI and PP creates a priming effect Fewer repetitions to learn a new task are required

•Task Intensity: Utilize MI when complex motor tasks can not be yet

physically performed

•Task Complexity: When MI is combined with PP – less PP is required to

achieve optimal task performance

•Relevancy Physical and mental tasks must be both pertinent and

meaningful

MI Delivery & Task Examples

Research Protocols Tasks

1. Separate sessions

1a: PP + MI audio recording

1b: PP + Caregiver guided MI

ADL

Gait, ADL

2. Combined/Embedded

Caregiver guided MI Rising up from a chair/sitting down, reach/grasp, gait

3. Alone

Caregiver guided MI Gait, ADL, sequence of finger movements

Malouin F, Jackson P, Richards C. Towards the Integration of Mental Practice in Rehabilitation Programs. A Critical Review. Frontiers in Human Neuroscience. 2013;7:576:3. doi:10.3389/fnhum.2013.00576.

ADL Task Training

vs.

Walking

Gain Gain

Gain Gain

MI PP MI PPPP MI

Gain

MI MI PP

PP

Malouin F, Jackson P, Richards C. Towards the Integration of Mental Practice in Rehabilitation Programs. A Critical Review. Frontiers in Human Neuroscience. 2013;7:576:10. doi:10.3389/fnhum.2013.00576.

Protocol

•No universally accepted protocol found Initial relaxation

Research is conflicting Interventions predominantly combine motor

imagery with physical practice Combined training sessions:

30-60 minutes o 10-20 minutes average spent on MI

2-5x/week 2-10 weeks

oAverage: 6 weeks

Introducing MI

•Goal: Introduce MI Familiarize patient with concept and process Apply MI to 1-2 tasks with scripts to learn

movement strategies and gain confidence Task is not demanding Add MI to treatment plan via recording or

audiovisual

•Bottom line: Performance preparation

Aligning Imagery to Practice

•Goal: Simple tasks increase in number and complexity Increase number of repetitions through MI Initially small number of MI that gradually

increase so it is greater than PP

•Bottom line: Skill learning - Mental rehearsal promotes the next physical execution of the task and the physical rehearsal provides sensory feedback to promote vividness of the task rehearsed mentally

Self Practice

•Goal: Increase the number of repetitions to improve

motor learning Establish a home exercise program Development of dynamic interactive application Continued open line of communication for

manipulation checks

•Bottom line: give patient a sense of empowerment

How do I use MI?

•Basic principles to remember:Make it a familiar task Can be done anywhere Can be done at anytime The degree the image will vary and change

as healing happens Tailor it to a goal, the more meaningful it is,

the more power it has!

Clinical Example

• Identify the patient 47 year old female admitted to NRH after right basal

ganglia stroke Upon initial evaluation:

Left sided weakness in both upper extremity and lower extremity

Required assistance for functional mobility and unable to walk

• Introduce MI to the patient and establish any barriers Initial videos on YouTube for ambulation was

suggested

•Choosing a task Walking into the kitchen

Clinical Example

•Gathering information for the script Sights:

Wooden floor that transitioned to linoleum Sounds:

Sound of music coming from her daughters room Smells:

Cookies baking in oven

•Developing the script 3rd person, gross motor task

Clinical Example

•Script Guided 1:1 Relaxation prior to MI

•Combined MI and PP MI was performed after PP (either treadmill training

or gait training) Progressed to videos of her walking on the treadmill

•Manipulation checks

Clinical Example

• Progress to self practice Recorded her MI script on her iPhone Increased mental repetitions

• Outcomes at discharge Utilized left ankle brace and was walking 200’ with a cane

and steadying assist Performing full flight of stairs with 1 hand rail and

supervision Length of stay: 20 days

• Follow – up after discharge No longer using ankle brace or cane, walking

independently

• Patient perspective Felt “empowered” Kept her “busy” during downtime

Future Research

•Gold standard protocol

•Additional rehabilitation diagnoses Parkinson’s Disease & Parkinsonism Multiple Sclerosis Spinal Cord Injury Amputation CRPS Chronic Pain

Tips for Guiding MI

•Create a quiet environment•Keep the patient comfortable•Be articulate •Speak at appropriate volume•Get to know your patient

Thank You!

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Questions

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References

• Tong Y, Pendy JT, Li WA, et al. Motor Imagery-Based Rehabilitation: Potential Neural Correlates and Clinical Application for Functional Recovery of Motor Deficits after Stroke. Aging and Disease. 2017;8(3):364-371. doi:10.14336/AD.2016.1012.

• Hwang, S et al."Locomotor Imagery Training Improves Gait Performance in People with Chronic Hemiparetic Stroke- a Controlled Clinical Trial." Clinical Rehabilitation. 24.6 (2010) 514-522.

• Oh D-S, Choi J-D. The effect of motor imagery training for trunk movements on trunk muscle control and proprioception in stroke patients. Journal of Physical Therapy Science. 2017;29(7):1224-1228. doi:10.1589/jpts.29.1224.

• Garcia Carrasco D. and Aboitiz Cantalapiedra J. Effectiveness of motor imagery or mental practice in functional recovery after stroke: a systematic review. Neurologia. 2016;31:43-52

• Polli A, Moseley GL, Gioia E, Beames T, Baba A, Agostini M, et al. Graded motor imagery for patients with stroke: a non-randomized controlled trial of a new approach. Eur J Phys Rehabil Med 2017;53:14-23. DOI: 10.23736/S1973-9087.16.04215-5

• Wang L, Zhang J, Zhang Y, Yan R, Liu H, Qiu M. Conditional Granger Causality Analysis of Effective Connectivity during Motor Imagery and Motor Execution in Stroke Patients. BioMed Research International. 2016;2016:3870863. doi:10.1155/2016/3870863.

• Takashi Hanakawa.Organizing motor imageries. Neuroscience Research. 2016;104:56-63. ISSN 0168-0102 https://doi.org/10.1016/j.neures.2015.11.003.

• Nikhil Sharma, Valerie M. Pomeroy and Jean-Claude Baron. Stroke. 2006;37:1941-1952, originally published June 26, 2006 https://doi.org/10.1161/01.STR.0000226902.43357.fc

• Smith, Dave. Enhancing Sports Performance using PETTLEP Imagery. Podium Sports Journal. 2010 http://www.podiumsportsjournal.com/2010/12/20/using-pettlep-imagery-to-enhance-sports-performance/

• Moseley, G. L., Butler, D. S., Beames, T. B., Giles, T. J. (2012). The graded motor imagery handbook. Noigroup publications.

References Continued

• Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008 Feb;51(1):S225-39. doi: 10.1044/1092-4388(2008/018).

• Hwang, S et al."Locomotor Imagery Training Improves Gait Performance in People with Chronic Hemiparetic Stroke- a Controlled Clinical Trial." Clinical Rehabilitation. 24.6 (2010) 514-522.

• De Vries S, Tepper M, Feenstra W, Oosterveld H, Boonstra AM, Otten B. Motor imagery ability in stroke patients: the relationship between implicit and explicit motor imagery measures. Frontiers in Human Neuroscience. 2013;7:790. doi:10.3389/fnhum.2013.00790.

• Kho AY1, Liu KP, Chung RC. Meta-analysis on the effect of mental imagery on motor recovery of the hemiplegic upper extremity function. Aust Occup Ther J. 2014 Apr;61(2):38-48. doi: 10.1111/1440-1630.12084. Epub 2013 Oct 20.

• Hwi-young Cho, June-sun Kim, Gyu-Chang Lee. Effects of motor imagery training on balance and gait abilities in post-stroke patients: a randomized controlled trial. Clinical Rehabilitation. 2012 Nov.;27(8):675 – 680

• Schuster C, Hilfiker R, Amft O, et al. Best practice for motor imagery: a systematic literature review on motor imagery training elements in five different disciplines. BMC Medicine. 2011;9:75. doi:10.1186/1741-7015-9-75.

• Hwang, S et al."Locomotor Imagery Training Improves Gait Performance in People with Chronic Hemiparetic Stroke- a Controlled Clinical Trial." Clinical Rehabilitation. 24.6 (2010) 514-522.

• Braun SM, Beurskens AJ, Borm PJ, et al. The effects of mental practice in stroke rehabilitation: a systematic review. Arch Phys Med Rehabil. 2006;87:842– 852.

• Page SJ, Levine P, Sisto S, Johnston MV. A randomized efficacy and feasibility study of imagery in acute stroke. Clin Rehabil. 2001;15:233–240.

• Taktek K. The effects of mental imagery on the acquisition of motor skills and performance: a literature review with theoretical implications. Journal of Mental Imagery. 2004;29:79 –114.

• De Vries S, Tepper M, Otten B, Mulder T. Recovery of Motor Imagery Ability in Stroke Patients. Rehabilitation Research and Practice. 2011;2011:283840. doi:10.1155/2011/283840.

References Continued

• Bovend'eerdt, TJ, H Dawes, C Sackley, and DT Wade. "Practical Research-Based Guidance for Motor Imagery Practice in Neurorehabilitation." Disability and Rehabilitation. 34.25 (2012): 2192-200. Print.• Braun, S, M Kleynen, J Schols, T Schack, A Beurskens, and D Wade. "Using Mental Practice in Stroke Rehabilitation: a Framework." Clinical Rehabilitation. 22.7 (2008): 579-91. Print.• Malouin F, Jackson PL, Richards CL. Towards the integration of mental practice in rehabilitation programs. A critical review. Frontiers in Human Neuroscience. 2013;7:576. doi:10.3389/fnhum.2013.00576.• Malouin F. and Richards, C. Mental Practice for relearning locomotor skills. Physical Therapy February 2010 vol. 90 no. 2 240-251• Stroke Engine: Motor Imagery/ Mental Practice. Expert Reviewer Stephen Page PhD. Evidence reviewed as of 2011. http://www.strokengine.ca/intervention/motor-imagery-mental-practice/• Oostra, Kristine M. et al.cMotor Imagery Ability in Patients With Traumatic Brain Injury. Arch Phys Med Rehabil. 2012 May;93(5):828-33. doi: 10.1016/j.apmr.2011.11.018. Epub 2012 Feb 24.• Lebon F1, Collet C, Guillot A. Benefits of motor imagery training on muscle strength. J Strength Cond Res. 2010 Jun;24(6):1680-7. doi: 10.1519/JSC.0b013e3181d8e936.• Dunsky A., Dickstein R., Marcovitz E., Levy S., Deutsch J. Home-based motor imagery training for gait rehabilitation of people with chronic poststroke hemiparesis. Archives of Physical Medicine and Rehabilitation 2008; 89 (8):1580-1588.• Monteiro da Silva, Douglas & Coriolano, Maria das Graças & Gabriel Figuêredo de Macêdo, João & Pereira da Silva, Liliane & Lins, Otávio Practice of mental protocols used in rehabilitation of patients with Parkinson's disease: a systematic review. Acta Fisiátrica. 2016;23(3):155-160 10.5935/0104-7795.20160030. • Braun S, Kleynen M, van Heel T, Kruithof N, Wade D, Beurskens A. The effects of mental practice in neurological rehabilitation; a systematic review and meta-analysis. Frontiers in Human Neuroscience. 2013;7:390. doi:10.3389/fnhum.2013.00390.

• Blefari ML, Sulzer J, Hepp-Reymond M-C, Kollias S, Gassert R. Improvement in precision grip force control with self-modulation of primary motor cortex during motor imagery. Frontiers in Behavioral Neuroscience. 2015;9:18. doi:10.3389/fnbeh.2015.00018.

Incorporating Mental Imagery into Brain Injury RehabilitationObjectivesIdentifying ImageryHistorySlide Number 5Types of ImageryInternal vs. ExternalImplicit vs. ExplicitGraded Motor ImagerySlide Number 10How and Why?NeuroplasticityNeuroplasticitySlide Number 14NeuroplasticityUpper Extremity & �ADL OutcomesTrunk ControlLower Extremity & Gait OutcomesPatient Activity LevelPatient and Provider ChallengesConsider the Pros…Who is appropriate?CriteriaPatient SelectionHow to Screen for Cognitive FunctionExample of MIQ-3 QuestionsMIQ-3Importance of Coupling MI with Physical Practice (PP)MI Delivery & Task ExamplesADL Task Training ���vs.���WalkingProtocolIntroducing MIAligning Imagery to Practice Self PracticeHow do I use MI?Clinical ExampleClinical ExampleClinical ExampleClinical ExampleFuture ResearchTips for Guiding MIThank You!QuestionsReferencesReferences ContinuedReferences Continued