What were the results of this trial and did your hospital do one damn thing in the ensuing 15 years?
Effects of mental practice embedded in daily therapy compared to therapy as usual in adult stroke patients in Dutch nursing homes: design of a randomised controlled trial
BMC Neurology volume 7, Article number: 34 (2007)
Abstract
Background
Mental practice as an additional cognitive therapy is getting increased attention in stroke rehabilitation. A systematic review shows some evidence that several techniques in which movements are rehearsed mentally might be effective but not enough to be certain. This trial investigates whether mental practice can contribute to a quicker and/or better recovery of stroke in two Dutch nursing homes. The objective is to investigate the therapeutic potential of mental practice embedded in daily therapy to improve individually chosen daily activities of adult stroke patients compared to therapy as usual. In addition, we will investigate prognostic variables and feasibility (process evaluation).
Methods
A randomised, controlled, observer masked prospective trial will be conducted with adult stroke patients in the (sub)acute phase of stroke recovery. Over a six weeks intervention period the control group will receive multi professional therapy as usual. Patients in the experimental group will be instructed how to perform mental practice, and will receive care as usual in which mental practice is embedded in physical, occupation and speech therapy sessions. Outcome will be assessed at six weeks and six months. The primary outcome measure is the patient-perceived effect on performance of daily activities as assessed by an 11-point Likert Scale. Secondary outcomes are: Motricity Index, Nine Hole Peg Test, Barthel Index, Timed up and Go, 10 metres walking test, Rivermead Mobility Index. A sample size of the patients group and all therapists will be interviewed on their opinion of the experimental program to assess feasibility. All patients are asked to keep a log to determine unguided training intensity.
Discussion
Advantages and disadvantages of several aspects of the chosen design are discussed.
Trial registration
ISRCTN27582267
Background
Stroke is a major health problem, which is likely to increase due to aging [1–3]. Patients are often confronted with disabilities on a physical, cognitive, social and/or communicative level. Rehabilitation of stroke patients is a time consuming process in which patients and caregivers have to learn new skills. In the Netherlands about 5,3 billion Euro are spend on rehabilitation of patients with cardiovascular diseases of which 1,5 billion is spend in nursing homes each year [4].
While it is reasonably established that the overall process of rehabilitation is effective, there is little evidence to support many specific rehabilitation therapeutic techniques [3, 5]. Currently it seems that task orientated practice (i.e. practising an activity of relevance) is probably the most effective single therapeutic technique [6]. This is not dissimilar to the situation in sport where practice is the bedrock of improving skills. Indeed improving any skilled motor activity seems to depend upon continuing practice. It is perhaps this similarity that has lead to using mental practice, a technique from sports, in neurological rehabilitation.
The use of mental practice or motor imagery is well established in sports [7–12]. The principle is simple: a person imagines himself undertaking a skilled movement without actually doing the movement. It is a cognitive ability which is often used (un)consciously by all of us. Many therapists report that they use imagery in their therapy sessions already, but not systematically. They just ask the patient to imagine moving in a different way. Recently the use of mental practice has been subject to systematic research in neurological rehabilitation [13]. Although many aspects of mental practice still remain unclear, it does seem to be a promising addition to the therapy, based on best evidence. Further research into mental practice is needed, particularly where it is embedded into normal rehabilitation services.
In the Netherlands, nursing homes provide a substantial amount of stroke care although most research is restricted to academic hospitals and rehabilitation centres [14]. Consequently, more stroke research should take place in nursing homes.
The overall aim of the proposed research project is to investigate systematically the therapeutic potential of mental practice embedded in daily rehabilitation therapy on the improvement of daily activities of adult stroke patients compared to therapy as usual.
The first additional research question is which prognostic variables or patient characteristics are associated with a positive outcome in the experimental subgroup.
The second additional research question investigates the feasibility of the mental practice-based therapy as judged by the patients and therapists.
This paper reports on preliminary work, and explains the choices made in the final study design, which has been approved by the medical ethical committee of the Atrium Medical Centre & Maasland Hospital in Heerlen, The Netherlands.
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