Towards the integration of mental practice in rehabilitation programs. A critical review

You'll have to demand your doctor get these protocols. S/he has only had 7 years to get them so ask why they are so fucking incompetent.  And the earliest research referred to is back to 2000, so 20 years of incompetency, how fucking long will you allow that to continue? It is your responsibility to get competence in your stroke hospital, that leadership(board of directors) is completely failing.

• mental practice (7 posts to July 2015)

• motor imagery (48 posts to January 2013)

• motor learning (9 posts to June 2015)

Towards the integration of mental practice in rehabilitation programs. A critical review

Front. Hum. Neurosci., 19 September 2013 | https://doi.org/10.3389/fnhum.2013.00576

Francine Malouin^1,2*, Philip L. Jackson^2,3,4 and Carol L. Richards^1,2

• ¹Département de Réadaptation, Faculté de Médecine, Université Laval, Québec, QC, Canada
• ²Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale, Québec, QC, Canada
• ³École de Psychologie, Université Laval, Québec, QC, Canada
• ⁴Centre de Recherche de l'Institut Universitaire en Santé Mentale de Québec, Québec, QC, Canada

Many clinical studies have investigated the use of mental practice (MP) through motor imagery (MI) to enhance functional recovery of patients with diverse physical disabilities. Although beneficial effects have been generally reported for training motor functions in persons with chronic stroke (e.g., reaching, writing, walking), attempts to integrate MP within rehabilitation programs have been met with mitigated results. These findings have stirred further questioning about the value of MP in neurological rehabilitation. In fact, despite abundant systematic reviews, which customarily focused on the methodological merits of selected studies, several questions about factors underlying observed effects remain to be addressed. This review discusses these issues in an attempt to identify factors likely to hamper the integration of MP within rehabilitation programs. First, the rationale underlying the use of MP for training motor function is briefly reviewed. Second, three modes of MI delivery are proposed based on the analysis of the research protocols from 27 studies in persons with stroke and Parkinson's disease. Third, for each mode of MI delivery, a general description of MI training is provided. Fourth, the review discusses factors influencing MI training outcomes such as: the adherence to MI training, the amount of training and the interaction between physical and mental rehearsal; the use of relaxation, the selection of reliable, valid and sensitive outcome measures, the heterogeneity of the patient groups, the selection of patients and the mental rehearsal procedures. To conclude, the review proposes a framework for integrating MP in rehabilitation programs and suggests research targets for steering the implementation of MP in the early stages of the rehabilitation process. The challenge has now shifted towards the demonstration that MI training can enhance the effects of regular therapy in persons with subacute stroke during the period of spontaneous recovery.

Introduction

The ever-increasing number of publications attests to clinician expectations of mental practice (MP) through motor imagery (MI) as a means of promoting the recovery of motor function (for a review see Malouin and Richards, 2013). MP not only provides a unique opportunity to increase the number of repetitions in a safe and autonomous manner without undue physical fatigue, but it also allows the mental rehearsal of motor tasks when and where the patient wants to, or is able to, practice. Furthermore, MP enables the rehearsal of more demanding or complex motor tasks (e.g., walking, writing) when physical practice is impossible or too difficult. Yet, despite these obvious advantages, MP is a complex mental process that is not readily amenable to be integrated into clinical practice. To date, in most published studies, MP has been used within constrained research environments to meet the requirements associated with research methodology.

As highlighted by several review papers concerning the use of MP in rehabilitation, (van Leeuwen and Inglis, 1998; Jackson et al., 2001; Braun et al., 2006; Dickstein and Deutsch, 2007; Zimmermann-Schlatter et al., 2008; Dijkerman et al., 2010; Malouin and Richards, 2010, 2013) there are marked differences in designs, research protocols, training regimens and outcome measures among the growing number of studies. Despite this heterogeneity, positive effects of MP on motor function have been generally reported. However, Braun et al. (2006), in a systematic review of five selected randomized controlled trials (RCT), stated that although there was some evidence that MP as an adjunct therapeutic intervention had beneficial effects on arm function, they were not able to draw definite conclusions(Well then, write up a provisional protocol, waiting for perfection is stupid.) and stated that further research with a clear definition of the content of the MP and standardized outcome measures were needed. In a more recent review that included six studies, Barclay-Goddard et al. (2011) also concluded that the combination of MP with other treatments appeared to be more effective than other treatments alone to improve upper extremity function. Based on their assessment with the PEDro scale, the quality of the evidence was moderate. Likewise, in their systematic review of 15 studies, Nilsen et al. (2010) attested that when MP was added to physical practice (PP), it was an effective intervention. Nevertheless, they also mentioned that further research was needed to identify those patients most likely to benefit from training, the optimal dose, and the most effective protocols.

These reviews, however, did not include the findings originating from recent multicenter RCTs (Bovend'Eerdt et al., 2010; Ietswaart et al., 2011; Braun et al., 2012; Timmermans et al., 2013) in subacute patients that have attempted to integrate MI training in regular rehabilitation programs. Not only did the addition of MP to conventional training on all tasks fail to yield better functional outcomes than conventional training, but the low compliance of therapists (Bovend'Eerdt et al., 2010; Braun et al., 2010, 2012) and realities related to patients such as advanced age of those in nursing homes (Braun et al., 2012) point to some of the difficulties encountered when attempting to introduce MP into regular clinical practice. The findings of two recent RCTs, (Ietswaart et al., 2011; Timmermans et al., 2013) did not confirm the additional benefits of including MI training in the rehabilitation program aimed at improving upper limb function. Despite meticulously designed MI training that included a variety of approaches (action observation through mirror therapy, implicit imagery, and self-practice), patients with subacute stroke did not show additional gains in the performance of activities of daily living (ADL) (Ietswaart et al., 2011). Altogether, these latest findings reflect the complexity of integrating MP into regular rehabilitation programs. Thus, this review scrutinizes the current application of MP, and from this analysis proposes a framework for its integration into usual rehabilitation programs.

Rationale Underlying MI Training

With the turn of the twenty-first century, we have witnessed the emergence of clinical studies designed to investigate the effects of MP on the relearning of motor skills in persons with stroke. The rationale for using MI training to promote the relearning of motor function arises from research on the functional correlates that MI shares with the execution of physical movements. It is now widely recognized that the duration of mentally simulated actions usually correlates with the duration of real movements (temporal coupling), that the simulation of movements evokes similar autonomic responses and that the imagination of an action or its physical execution engage largely similar neural networks (Decety and Boisson, 1990; Decety et al., 1991; Decety and Jeannerod, 1995; Wuyam et al., 1995; Decety, 1996; Decety and Grèzes, 1999; Lafleur et al., 2002; Malouin et al., 2003; Fusi et al., 2005; Munzert and Zentgraf, 2009; Hétu et al., 2013). These similarities led to the notion of functional equivalence. Thus, real and covert movements during MI obey similar principles and share similar neural mechanisms, likely explaining the beneficial effects of MP on motor performance (Jeannerod, 1995).