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2007; 87:942-953.PHYS THER. Ruth Dickstein and Judith E DeutschMotor Imagery in Physical Therapist Practice

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Motor Imagery inPhysical Therapist PracticeRuth Dickstein, Judith E Deutsch

Motor imagery is the mental representation of movement without any body move-ment. Abundant evidence on the positive effects of motor imagery practice on motorperformance and learning in athletes, people who are healthy, and people withneurological conditions (eg, stroke, spinal cord injury, Parkinson disease) has beenpublished. The purpose of this update is to synthesize the relevant literature aboutmotor imagery in order to facilitate its integration into physical therapist practice.This update also will discuss visual and kinesthetic motor imagery, factors that modifymotor imagery practice, the design of motor imagery protocols, and potential appli-cations of motor imagery.

R Dickstein, PT, DSc, is AssociateProfessor, Department of PhysicalTherapy, Faculty of Social Welfareand Health Sciences, University ofHaifa, Mount Carmel 31905,Haifa, Israel. Address all corre-spondence to Dr Dickstein at:[email protected].

JE Deutsch, PT, PhD, is Professorand Director of the Rivers Lab,Doctoral Programs in PhysicalTherapy Department of Develop-mental and Rehabilitative Sci-ences, University of Medicine andDentistry of New Jersey, Newark,NJ.

[Dickstein R, Deutsch JE. Motorimagery in physical therapistpractice. Phys Ther. 2007;87:942–953.]

© 2007 American Physical TherapyAssociation

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Imagery refers to the “creation (orre-creation) of any experience inthe mind—auditory, visual, tactile,

olfactory, gustatory, kinesthetic, or-ganic. It is a cognitive process em-ployed by most, if not all, humans.”1

Imagery bridges diverse domains ofknowledge from psychology to art.2

Specifically, motor imagery (MI) isthe mental representation of move-ment without any body move-ment.3,4 It is a complex cognitive op-eration5–8 that is self-generated usingsensory and perceptual processes,enabling the reactivation of specificmotor actions within working mem-ory. Therefore, sensory-perceptual,memory, and motor mechanisms areincluded in broader definitions ofthe term.

Mental practice is the voluntary re-hearsal of imagery scenes or tasks,whereas motor imagery practice re-fers specifically to the mental re-hearsal of MI contents with the goalof improving motor performance.9,10

The terms “motor imagery practice”and “mental practice” (or mental re-hearsal) often are used interchange-ably. Accordingly, in this update, wealso will treat these terms assynonyms.

Surprisingly, although mental prac-tice of a poem, a melody, or a role ina play is universally used by people,the mental practice of motor tasksuntil recently has been confinedmainly to sports activities. The appli-cation of knowledge and principlesof mental practice to rehabilitationbegan slowly in the late 1980s11,12

and early 1990s.13 The number ofdynamic brain imaging studies pub-lished recently has stimulated the re-examination of MI for rehabilitation,because these imaging techniqueshave reduced the subjectivity associ-ated with MI by elucidating the neu-ral substrates that subserve MI.14–17

Evidence for neural reorganization asa result of MI training is emerging aswell.18,19

Because MI is inexpensive and acces-sible and because of the increasingnumber of reports about the benefitsof MI in improving motor perfor-mance,9,20,22 it seems appropriate toinform physical therapists about itsuse. The purpose of this update,therefore, is to synthesize the rele-vant literature about MI in order tofacilitate its integration into physicaltherapist practice.

Evidence SupportingEffects of MI PracticeMotor imagery is practiced to im-prove motor performance and tolearn motor tasks. Abundant evi-dence on the positive effects of MIpractice on motor performance andlearning has been published.23–28 Forindividuals who are healthy or thosewho have health-related problems,the rehearsal or practice of imagerytasks has been proven to be eitherbeneficial by itself or in addition tophysical practice.3,9,21,29 In addition,enhanced self-efficacy accompaniesthe motor effects of imagery practicefor both individuals who are healthyand those who are not.30–33

Individuals Who Are Healthy andAthletesStudies of individuals who arehealthy have shown the enhance-ment of the performance of variousaspects of motor control because ofMI practice. These enhancements ofperformance include gains instrength (force production capacity)of selected muscle groups,34,35 im-proved speed in arm pointing capac-ity,36 increased range of motion ofthe hip joint when MI was added toproprioceptive neuromuscular facili-tation,37 and improved postural con-trol in elderly people.11,38

Recently, the use of MI practice tofacilitate the mastering of perceptuo-motor professional skills such asnursing and surgery has been dem-onstrated.39,40 Similar advantagesmight be produced by imagery prac-

tice of physical therapist manualtechniques. For imagery applied inthe sports context, positive effectshave been reported in speed,41,42

performance accuracy,41,43 musclestrength, movement dynamics,41,44

and motor skill performance (for arecent review, see Taktek45).

Patient PopulationsStudies of MI in rehabilitation havebeen conducted mainly on peoplewith neuromuscular conditions. Thisupdate will discuss evidence fromstudies of people who have had astroke, people with a spinal cord in-jury (SCI), people with Parkinsondisease (PD), and people with intrac-table pain.

Stroke. The majority of studies onMI practice have been conducted inthe field of neurological rehabilita-tion, especially in stroke rehabilita-tion. Several review articles offersummaries of these studies.9,29,46

Sharma et al characterized motor im-agery as a “backdoor” to accessingthe motor system and rehabilitationat all stages of stroke recovery be-cause “it is not dependent on resid-ual functions yet still incorporatesvoluntary drive.”29(p1942)

In numerous clinical studies, the ef-fects of physical therapy or occupa-tional therapy interventions in isola-tion were compared with the effectsof an approach that combined phys-ical and MI practice. These studiesconsistently found that the greatestimprovements in motor perfor-mance occurred with interventionsthat combined physical and mentalpractice, followed by physical prac-tice alone, and then by MI practicealone, which was superior to nopractice at all.47,48

For individuals with hemiparesis,promising findings were reported forenhancing reaching as well as forisolated movements of the hand andfingers.49,50 Practice-related improve-

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ment in ankle movements as well asin sit-to-stand performance and activ-ities of daily living (ADL) also werereported.48,51,52 The adverse effectsof unilateral neglect likewise wereameliorated after imagery practice,allowing patients to find routes andwalk53 as well as to improve onneuropsychological tests.54

The ability to apply MI as well as thecontribution of MI practice to reha-bilitation has been established for in-dividuals with acute, chronic, mild,and severe hemiparesis.29,55–57 Pageand colleagues26,47,52 demonstratedthe advantage of motor imagerypractice in 1 case report and 2 smallrandomized controlled trials (RCTs).In the most recent RCT, the 11 indi-viduals in the chronic phase afterstroke who mentally rehearsed ADLsignificantly improved comparedwith those who only had physicalpractice.52

Similarly, in an RCT, Liu and associ-ates51 investigated the relearning offunctional tasks, such as householdwork, cooking, and shopping, usingMI. After 15 practice sessions, signif-icant gains were achieved in house-hold and community tasks, gains thatinterestingly transferred to 5 unprac-ticed activities.51 These gains wereclinically meaningful with a 2-pointincrease, on average, in FunctionalIndependence Measure scores, indi-cating an improvement in the pa-tient’s functional status from “mod-erate assistance” to “supervision.”51

The ability of individuals withchronic hemiplegia to achieve func-tional gains through imagery prac-tice has further been supported byreports of significant, long-standingimprovement in wrist movementsand object manipulation in 2 pa-tients50 as well as in the improve-ment in line tracing in 3 patientswith right poststroke hemiparesis.58

In patients with chronic stroke, dailyhome practice of moving tokens

with the affected hand for a totalperiod of 4 weeks was associatedwith significant improvement in taskperformance compared with theprogress made by control groupsubjects.49

Although the evidence supportingpreservation of imagery for peopleafter a stroke is compelling, it cannotbe universally applied to all patientswith stroke.59 For example, impair-ments in MI ability due to contralat-eral parietal and premotor lesions,especially with regard to upper-extremity pointing and rotation ac-tivities, have been identified.60,61 Fur-thermore, despite evidence ofpreservation of MI after stroke, it ap-pears that both accuracy and tempo-ral coupling can be disrupted.Sharma et al29 labeled this phenom-enon “chaotic motor imagery.” Yet,given the multitude of factors affect-ing imagery ability and rehearsal, aperson with impaired ability can stillpractice MI.29

Spinal cord injury. For individualswith SCI, MI practice has not beenreported to directly affect motor per-formance. Cramer and colleagues62

trained 10 subjects with completetetraplegia or paraplegia and 10 con-trol subjects who were healthy toimagine movements of the tongueand foot. For people with SCI, themain outcome pointed to improve-ment in the function of nonpara-lyzed muscles. Cramer and col-leagues62 also found activation ofcortical networks in congruencewith imagery of specific movements,which suggested to them that brainmotor system function can be mod-ulated independently of voluntarymotor control and peripheral feed-back. They concluded that motor im-agery training might have value as anadjunct to restorative interventionstargeting post-SCI deficits.62

Activation of movement-related ar-eas of the brain during engagement

in MI in patients with chronic SCIalso has been demonstrated in sev-eral other studies.63–65 Finally, brainactivity related to MI has recentlybeen harnessed using an electro-encephalogram-based brain-computerinterface to produce hand or neuro-prosthetic movements in patients withtetraplegia.66,67 Obviously, furtherdevelopments can be expected.

Parkinson disease. For individu-als with PD, the ability to apply MI iscontroversial.68–71 Only a few stud-ies have looked at the effects of men-tal practice in this patient group.Data from one such study showedthat patients with PD failed to learn agraphomotor task using imagerypractice, whereas individuals withHuntington disease did show im-provement. The authors interpretedthese findings as disordered imageryability resulting from deficits in do-pamine inputs to the basal ganglia inpatients with PD.72 On the otherhand, in a recent controlled groupstudy, daily functions that deterio-rated because of bradykinesia im-proved more in patients receivingcombined physical and mental prac-tice than in patients receiving onlyphysical practice.73 In patients withPD treated with dopaminergic stim-ulation, imagery-related enhance-ment in several sites of the brain wasnoted during the “on” phase but notthe “off” phase.

Intractable pain. According toMoseley,74–76 MI practice has beenused to alleviate long-standing com-plex regional pain syndrome of thehand. The treatment approach,termed “graded motor imagery,” iscomposed of 3 sequential phases.During the first phase, subjects learnto recognize the left or right image oftheir hands or feet, which are shownto them in various postures; in thesecond phase, they practice thesepostures via imagery of smooth andpain-free movements; in the lastphase, they perform movements of




both limbs using a mirror box thathides the affected limb. This methodwas developed over 3 successivestudies and is based on the idea thattreatment of these chronic pain syn-dromes should focus on “training thebrain.”76,77 The results pointed to asignificant and substantial reductionin pain related to the interventionand an increase in function of theinvolved limb, which was main-tained at a 6-month follow-up. Futureresearch in the direction of these pi-lot findings is highly warranted.

In summary, the majority of studiesdealing with MI practice in peoplewho are healthy and in patient pop-ulations show progress in the perfor-mance of the target practiced move-ments or motor tasks. Evidence ofretention of practice gains51,78 aswell transfer to nonpracticedtasks28,36,51 also is accumulating.Practice protocols, as expected, varydepending on the study population,the target movements or motortasks, environmental conditions, andthe priorities of the person conduct-ing the study.

Types of ImageryImagery has been categorized as ex-ternal (visual) and internal (kines-thetic).79 External imagery can be ofthe person or of the environment, orboth. The perspective the personuses to imagine can be either firstperson (kinesthetic or visual) orthird person (visual).80 The first-person perspective is related eitherto the person’s view (sight) of theimagery contents or to its kinestheticsensation. The third-person perspec-tive is the visual imagery of scenesoutside the person.

Definitions of external and internalimagery have evolved. Mahoney andAvener distinguished between exter-nal (visual) and internal (kinesthetic)imagery as follows: “In external im-agery, a person views himself fromthe perspective of an external ob-

server; internal imagery, on the otherhand, requires an approximation ofthe real life phenomenology suchthat the person actually imagines be-ing inside his/her body and experi-encing those sensations that mightbe expected in the actual situa-tion.”79 This relatively old definitionhas raised some debate, especially inthe sports literature (for example,see Callow and Hardy80). In currentpsychological and clinical studies,the definition of visual imagery in-volves self-visualization of action,whereas kinesthetic imagery impliessomesthetic sensations elicited byaction.3,4

A somewhat different distinction be-tween kinesthetic and visual imageryrelates MI to kinesthetic imagery ofone’s own movements, whereas vi-sual imagery is associated with spa-tial coordinates of a movement in theenvironment. Thus, visual imageryapplies mainly to imagery of movingobjects or to movement of anotherperson in the imagined environ-ment, although imaging one’s ownmovement is also possible.81

Some authors80 have divided visualimagery into internal and externalimagery, which refer to imagery ofone’s own movement and of anotherperson’s movement, respectively.Yet, in the literature cited in thisupdate, this distinction is not ex-plicitly made; therefore, in the cur-rent context, the term “visual imag-ery” pertains to self-performance in aspecific imagined environment.

Use of visual or kinesthetic motorimagery appears to be influenced bytype of task and stage of learning. Forlearning a new motor task, Fery82

demonstrated that visual imagerywas more suitable for tasks that em-phasized form, whereas kinestheticimagery was better for those tasksthat emphasized timing or coordina-tion of the two hands. Visual imagerywas more effective than kinesthetic

imagery in the enhancement ofstance postural stability, alluding tothe dependence of stance stabilityon environmental factors.83

Hall et al84 claimed that the instruc-tions for using kinesthetic imagerywere more effective for learningclosed motor skills, whereas visual-based imagery were more appropri-ate for learning open motor skills.Regarding retention of practicegains, visual imagery was reported tobe effective when environmentalspace, or patterned movement in agraphic task, were learned.85,86 Onthe other hand, for a task involvinghand accuracy performance, kines-thetic imagery led to better retentionthan visual imagery.87

Several factors influence the deci-sion about which imagery category(visual or kinesthetic) to use in ther-apy. The first factor is that imagery ofhuman movement is a cognitive op-eration that depends on the dynamicrelationship among the individual,the movement, and the environ-ment.81 In addition, imagery per-spectives should be determined bythe nature of the task, the environ-ment, and individual characteristics.Considering that the separation intovisual and kinesthetic imagery ishighly artificial,80 perhaps even aca-demic, the application of both visualand kinesthetic imagery appears fea-sible and appropriate for mostindividuals.

Factors Modifying MIPracticeImagery AbilityIn order to optimize the benefitsfrom MI practice, the individual’sability to use imagery is a relevantconsideration. Various recommenda-tions and reservations regarding thescreening of individual candidatesfor MI practice have been pointedout in the literature. Although noneof these should be regarded as im-




perative, a short summary with rele-vance to physical therapy follows.

Imagery is a multifaceted capacitythat differs between individuals.88,89

Motor imagery ability usually is as-sessed by individual responses to or-dinal rating scales. Three of theseinstruments are commented on indetail.

The Movement Imagery Question-naire (MIQ)90 and its short, revisedversion (MIQ-R)91 are based on sub-jects’ ratings of the ease of imagingpredefined upper- or lower-extremity movements on a 7-pointLikert scale. Before scoring eachmovement, subjects are asked to per-form the movement. Movement im-agery is rated twice, once for visualimagery of movement performance(subjects are asked to “see” them-selves in their mind performing thetask) and once for kinesthetic imag-ery (subjects are asked to feel theirown body executing the movementtask). Test-retest reliability of theMIQ and its internal consistency val-ues (Cronbach alpha) were reportedto be .87 and .89, respectively.92–94

Corresponding reported values forthe MIQ-R are .88 and .82, respec-tively.94 Evidence of a direct relation-ship between MIQ scores and motorskill acquisition rate exists.94

The Vividness of Motor ImageryQuestionnaire (VMIQ)95 focuses onrating the vividness of imagery tasks.The questionnaire is a 48-item,5-point scale. Like the MIQ, re-sponses to half of the questions arebased on visual imagery and re-sponses to the other half are basedon kinesthetic imagery. The re-ported test-retest reliability of theVMIQ is .76; the reported correlationbetween the visual and kinestheticsubscores of the VMIQ and the cor-responding subscores of the MIQwere .65 and .49, respectively.94,96

Whereas the MIQ and the VMIQwere formulated for subjects whoare healthy, a newer index—the Kin-esthetic and Visual Imagery Ques-tionnaire (KVIQ)—has been de-signed to evaluate imagery abilityand has been validated on subjectswho are healthy and people with dis-abilities. The KVIQ94 uses a 5-pointordinal scale to assess the clarity ofthe image (visual: V subscale) andthe intensity of the sensations (kin-esthetic: K subscale) that the sub-jects are able to imagine from thefirst-person perspective. Items con-sist of simple movements, such asfoot tapping and shoulder flexion,that can be performed more easilythan the items in the MIQ and VMIQ.

Test-retest reliability was establishedfor subjects who are healthy (intra-class correlation coefficient [ICC]�.72–.81) and for people who havehad a stroke (ICC�.81–.90). Theconstructs of visual and kinestheticability were validated on a sample ofindividuals who had a stroke; whohad lower-limb amputations, lower-limb immobilization, or blindness;and control subjects who werehealthy. Application of the tool hasyet to be determined; however, theshort form with test questions can beadministered quickly.

Information on the application of theMIQ, VMIQ as well as of the SportImagery Questionnaire97 and its re-vised version98 can be found in sev-eral references.99–102 Only a fewstudies, all from the sports psychol-ogy literature, reported a positive re-lationship between scores on imag-ery scales and gains achieved byimagery practice103; many othershave not found such an unequivocalconnection.44,104 Because the abilityto access MI is, by itself, a faculty thatcan improved by practice in individ-uals who are healthy as measured bythe VMIQ,38 it appears that the initialscores on the scales described above

should not be used to exclude pa-tients from MI intervention.

Task FamiliaritySome authors have claimed that fa-miliarity is a prerequisite for success-ful use of MI practice. Mulder andassociates105 found that after mentalpractice, motor performance of anew motor task (big toe abduction)improved substantially in a group ofpeople who had previously masteredthe task compared with the groupwith no previous practice. Mutsaartset al106 showed that individuals withhemiparetic cerebral palsy whoseimagery ability was impaired wereunable to plan novel tasks. Based onthese findings, the authors advisedavoiding imagery practice of com-pletely new motor tasks.

In tangential work, Aleman et al107

explored the ability of people withtotal congenital blindness to performtasks that are mediated by visualmental imagery in people who arenot blind. In contrast to previouslycited reports on familiarity with im-agery, Aleman and colleagues107

found that people who are congeni-tally blind were able to perform tasksthat are mediated by visual mentalimagery in people who are not blind.Although the people who were blindmade more errors than participantswho were not blind, they were ableto perform both a pictorial and aspatial imagery task. The authorsmaintained that their observationsstrongly suggest that vision and hap-tics share common representationsand, therefore, haptic sensation canbe substituted for the lack of visualinformation.107 Imbiriba and col-leagues108 made similar conclusionsfor subjects who were blind.

We contend that the conflicting in-formation on the role of familiarity insuccessfully using MI is masked bythe multitude of operational defini-tions for terms such as “motor tasks”and “novelty” (contrast, for example,




toe abduction with pointing tomeaningful objects). Generalizationsmade from one study to other pop-ulations or conditions, therefore,should be made with caution. Nev-ertheless, the notion that effective-ness of mental practice is related tofamiliarity with the motor task, withfamiliar tasks being associated withbetter outcomes than practice of un-familiar tasks,109,110 should be con-sidered when selecting patients andplanning an intervention.

Working MemoryWorking memory is a complex pro-cess that includes storage and manip-ulation of information; it can be cat-egorized as visual, verbal, orkinesthetic.10 The mutual relation-ship between working memory andimagery ability,5,111 which underliesthe inclusion of working memory inthe broad definition of MI, is an im-portant consideration.29

Malouin et al10 observed that im-provement in the performance of“sit to stand” after a combined phys-ical and imagery intervention was en-hanced in a group with intact work-ing memory compared with a groupwith deficits in working memory.The strongest relationship was man-ifested in the visual-spatial domain(r�.83), followed by the verbal(r�.62) and kinesthetic (r�.59) do-mains. Malouin and colleagues, de-scribing motor imagery as a “dy-namic state during which therepresentation of a specific action isinternally reactivated,”10(p177) furthermaintained that mental rehearsal re-quires that subjects maintain and ma-nipulate visual and kinesthetic infor-mation in their working memory. Animpairment in working memory,therefore, may hinder the ability toengage successfully in MI, and thuscurtail the outcomes of mental prac-tice.10 Despite these reservations, itis worth noting that MI practice com-bined with physical practice wasshown to enhance the performance

of an anticipatory motor task morethan physical practice alone in indi-viduals with a high probability ofdeficits in working memory (eg,adolescents with mild mentalretardation).112

MotivationFindings on motivation and anxietyas modifiers to effective mental prac-tice are equivocal. On the one hand,it is well substantiated that peoplewho are highly motivated who useMI improve more than people whoare not as highly motivated.89,98,113

Similarly, people with low cognitiveanxiety scores practiced better men-tally than people with high anxietyscores.31 On the other hand, engage-ment in mental practice may in-crease arousal and self-efficacy, thushaving positive effect on motivationand self confidence.30,82,101 There-fore, individuals with low motivationor anxiety should not be excluded,but rather should be encouraged totake part in MI practice.

Designing ImageryProtocolsIt is widely accepted that MI practiceis similar to physical practice exceptfor the absence of neuromuscu-lar output during imagery prac-tice.36,42,114 Thus, both physical andmental practices are self-generated,with the intent of improving perfor-mance and promoting motorlearning.

Developing an intervention toachieve motor or task competence islargely comparable for real and imag-ined exercises; therefore, the same“rules” and concepts that underlinethe formulation of exercise therapyfor solving a clinical problem applyto imagery practice.114,115 This im-plies that, for both modes of exer-cises, interventions should plannedand devised to respond to specificindividual goals and movement prob-lems at the appropriate level of im-pairment or function. In different

sports, there are multiple models ofmental practice that address differ-ent goals.21

In order to facilitate imagery prac-tice, however, some establishedfacts should be considered. First,challenging or unfamiliar actions aremore difficult to imagine than simpleor familiar ones.116,117 Second,closed loop skills are easier to prac-tice than open loop skills.110 Third,gains from mental practice may behigher when imagery is used at theinitial or cognitive phase of motorskill acquisition.45,109 Positive effectsof imagery practice during a laterphase, which is thought to be theconsolidation phase of motor learn-ing, also have been suggested.118

Motor imagery practice is routinelyapplied under professional supervi-sion during individual or group ses-sions. Mental practice also can beapplied unsupervised for short peri-ods of time. For example, precompe-tition rehearsal of specific activitiesfor the enhancement of motor per-formance and self-efficacy is com-mon in different sports.100,119 Simi-larly, athletes who are injuredfrequently mentally rehearse a move-ment just before its actual perfor-mance.120 Obviously, patients withdifficulties in performing a motortask should be encouraged to useimagery routines before actual per-formance of a challenging motortask.

The following comments pertain toMI practice during supervised phys-ical therapy intervention. Relaxationhas been reported to promote favor-able conditions for concentration bypermitting the formation of vivid im-ages.119 Thus, MI practice is gener-ally applied with subjects seating re-clined or lying down with the eyesclosed. Relaxation “exercises” topromote a relaxed state of body andmind precede actual imagery prac-tice.45,121,122 During practice, it has




been recommended that the instruc-tions of imagery exercises should bedetailed and oriented towards eitherthe visual or kinesthetic aspects ofthe task.45

Duration of MI practice is shorterthan that of physical practice. Basedon a meta-analysis of controlled stud-ies of mental practice, the recom-mendation for treatment for peoplewho are healthy is limited to 20 min-utes.123 In fact, there is a negativerelationship between effect and in-creased practice duration.123 For in-dividuals with neurologic condi-tions, training duration might beeven shorter, with protocols report-ing training times of 12 to 15 min-utes for individuals after a stroke.122

It is relevant to add that part of theimagery training time may involverelaxation to prepare the person toimagine more effectively.52,122

Descriptions of MI clinical treatmentprotocols that could serve as guide-lines for physical therapists arescarce and vary highly both in con-tent and approach. Existing studiesshould be regarded as suggestionsfor protocols; one should bear inmind that these protocols were com-piled by individual clinicians andresearchers for a specific group ofsubjects under particular study con-ditions. Their partial or completeadoption by other therapists shouldbe determined using sound judg-ment. For those seeking specificguidelines for implementation of mo-tor imagery practice, the majority ofthe answers can be found in the lit-erature related to motor learning andmotor rehabilitation (eg, Magill,124

O’Sullivan and Schmitz,125 andStrangman et al126). The guidelinesdescribed by Suinn27 for sport per-formance enhancement also arerelevant.

For the sake of brevity, only few MIpractice protocols are reviewed insome detail below. Other protocols

can be found in the sports literature(for reviews, see Taktek45 andGrouios110).

MI Used to Improve ADL andUpper-Extremity Use forIndividuals After StrokeLiu and colleagues51 compared therelearning and transfer of ADL tasksand the retention of interventiongains in 2 groups of individuals whosustained a stroke, with one groupreceiving imagery and the second(control group) receiving conven-tional training of the same tasks. Theintervention protocol included 3practice sets, each composed of 5ADL tasks, given for 1 hour, 5 days aweek, for a period of 3 weeks. Men-tal practice of the easiest task set(put clothes on hanger and fold thelaundry) was practiced in the firstweek, whereas the most difficult (goto a park and outdoors shopping)was practiced in the last week.

Before MI, explicit information (ver-bal, pictorial, video/film) on taskcharacteristics and steps for its mas-tery was provided. A computer pro-gram guided patients in relearningthe steps required to perform eachof the 15 tasks. In addition, feedbackon physical performance of the priortasks practiced with MI was pro-vided throughout the practice pe-riod. Compared with the controlgroup, the MI group reached a sig-nificantly higher performance levelon the trained tasks as well as on 5untrained tasks tested at the end ofthe training program. There also washigher retention of performancelevel in the MI group at a 1-monthfollow-up compared with the con-trol group.51

In another study, Page and col-leagues52 supplemented real exer-cise practice for individuals withchronic poststroke hemiparesis with30 minutes of imagery practice (eg,reaching towards a cup) twice aweek that was the same as the phys-

ical practice. The mental practicesessions were provided by audio-tapes. They consisted of 5 minutes ofrelaxation followed by imagery prac-tice of ADL tasks performed with theaffected upper extremity. The final 3to 5 minutes allowed patients to re-focus into the room. Improvement inthe function of the affected upperextremity related to the imagerytraining was reported at the comple-tion of the 6-week program.52

MI Used to Improve Walking forIndividuals After a StrokeIn case studies by Dickstein and col-leagues,78,122 gait was trained using ahome-based MI practice program.Participants who had a stroketrained for 15 minutes, 3 times aweek for 6 weeks, using both visualand kinesthetic imagery. While earlypractice sessions focused on amelio-rating specific gait impairments,practice modules were graduallyadded over the 6-week period to in-tegrate the performance of push-offand loading the affected lower ex-tremity with the demands to in-crease gait speed and symmetry. Thelast 2 weeks were geared towardwalking practice, which was custom-ized to the individuals’ needs. Partic-ipants were encouraged to practicethe same protocol during their freetime.78,122 The enhancement in gaitspeed and single support time in theparetic limb and of the angularchanges at the knees support spe-cific aspects of the intervention.

Confirming PatientEngagementOne of the challenges in applying MIto practice is the persistent questionof how a clinician knows if the indi-vidual is engaged in MI. There areseveral sources of validation for em-ployment of MI. Dynamic brain im-aging studies have confirmed theneural substrates associated with im-agery as well as the reorganizationresulting from MI training. The richliterature on this topic is beyond the




scope of this update. Monitoring ofautonomic nervous system functionshas provided physiological corre-lates to the practice of MI. Mentalchronometry serves as a clinicalprobe confirming engagement in MI.We briefly discuss autonomic moni-toring and mental chronometry be-cause they are relevant to practice.

Autonomic MonitoringA comprehensive review of studiesconfirming autonomic alterationsduring MI was recently been pro-vided by Guillot and Collet.3 Accord-ingly, for each of 3 following physi-ological categories, 2 measures havepointed to mental practice relatedautonomic changes:

• for electrodermal responses: skinresistance and skin potential mea-surements were elicited;

• for thermovascular responses: skinblood flow and skin temperaturerecordings pointed to relaxation;and

• for cardiorespiratory changes:heart and respiratory rate increasedin close association with increase inmental effort.

A detailed review of studies describ-ing autonomic changes during imag-ery practice falls beyond the scopeof this update. It is noteworthy, how-ever, that, in the clinical setting, sim-ple measurements such as heart ratecan provide an estimate of patients’engagement in imagery practice. Forexample, Decety et al127 demon-strated that as the intensity of animagined bicycling exercise in-creased, so did the correspondingmeasurements of heart rate. Simi-larly, Fusi and colleagues128 foundthat cardiorespiratory responseswere comparable when individualswalked and imagined walking atslow speed.

Mental ChronometryAnother tactic to monitor engage-ment in imagery practice is mental

chronometry. This strategy is basedon the observation that duration ofmentally simulated and executedmotor tasks are comparable. Thissimilarity was confirmed in severalstudies using different paradigms insubjects who were healthy,36,129–131

and in several groups of patients. Si-rigu and colleagues,132 for example,showed in a patient with unilateralmotor cortex damage a parallel slow-ing of the contralateral upper ex-tremity during both real and imag-ined movements. In contrast, thistemporal congruence was notpresent for individuals with parietallobe damage.60 In addition, imaginedmovements follow Fitt’s law, point-ing to preservation of the speed-accuracy trade-off during imaginedmovements by subjects who werehealthy116,133–135 as well as by se-lected patients with Huntingtondisease.136

Thus, knowing the time length of thephysical act, the therapist can askthe patient to signal the beginningand termination of the imagery per-formance. A comparable time periodof the imagery and physical perfor-mance of the task is considered to beevidence of engagement in motorimagery practice of the requiredtask.

There are some important limitationsto mental chronometry. It does notgive information on MI vividness butonly on the characteristics of timepreservation.132 In addition, the no-tion that the timing of mentally sim-ulated actions closely mimic actualmovement times is far from beingabsolute. In a recent review, Guillotand Collet137 described that, insports activities, the similarity be-tween the durations of the same ac-tual and imagined movements ap-plied only for automatic movementssuch as cycling or walking. The au-thors claimed that when athletessimulate only dynamic phases ofmovement or perform MI just before

competition, environmental andtime constraints lead to an underes-timation of actual duration. Con-versely, complex attention demand-ing movements take longer to image.They further showed that the simi-larity between actual and imaginedmovement is greater in expert thanin novice athletes.137,138

Potential ApplicationsMotor imagery interventions can alsobe combined with modeling and ob-servation. These combinations ap-pear to be natural complementsbased on work of mirror neurons inanimal models (for a review, see Buc-cino et al139). Mirror neurons havebeen identified for hand, mouth, andfoot actions in humans and appear tocontribute to imitation, observation,and imagination of movement. These3 processes share similar neural sub-strates with executed movements,making them useful additions tophysical practice.139

An interesting and exciting possibil-ity that takes advantage of individu-als’ abilities to imagine movement isthe use of motor imagery to drivecomputer interfaces to navigate vir-tual worlds.140 Morganti et al140 usedstylized representations of move-ments to drive motor behavior byhaving individuals imagine the com-pletion of the image. Scherer andcolleagues141,142 have harnessed theelectroencephalogram signals gener-ated during the imagination of move-ment in person with cerebral palsyto distinguish between rest andimagination. More recently, thisgroup has shown that imaging themovement of one’s hand can bemapped to moving in a virtual envi-ronment,142 as well as having imagi-nation of walking transfer to walkingin a virtual environment.143 Theseapplications of MI are in the feasibil-ity testing phase, but the use of im-agery for rehabilitation has promise.




SummaryEvidence that mental practice of MIimproves motor and task perfor-mance exists for individuals who arehealthy and is emerging for individ-uals with neurologic conditions.Brain studies have served to validateMI as a dynamic process with strongcorrelates to executed movement.Behavioral studies also have con-firmed a correspondence betweenimagined and executed movementsby preserved timing and similarspeed-accuracy trade-offs. Guidanceon how to select individuals who canimagine can be done using invento-ries, although there are no well-established exclusion criteria. Thedesign of MI interventions can useprinciples from executed movementinterventions. In addition, we knowthat some form of relaxation andcombined use of kinesthetic and vi-sual imagery strategies can be ap-plied. Variables to consider in pa-tient selection and MI practiceapplication are familiarity with andtype of task, motivation, and work-ing memory. In general, exercisedosing appears to be smaller thanthat used for executed exercise, sug-gesting a potential efficiency of men-tal practice relative to physical prac-tice. Several strategies are availableto monitor MI engagement such asmental chronometry and cardiovas-cular and respiratory responses toexercise. Use of mental practice as acomplement to physical practiceseems warranted.

Both authors provided concept/idea/research design and writing.

This article was submitted October 28, 2006,and was accepted March 5, 2007.

DOI: 10.2522/ptj.20060331

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doi: 10.2522/ptj.20060331Originally published online May 1, 2007

2007; 87:942-953.PHYS THER. Ruth Dickstein and Judith E DeutschMotor Imagery in Physical Therapist Practice

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