Integration of Motor Imagery and Physical Practice in Group Treatment Applied to Subjects With Parkinson’s Disease

Rehabilitation interventions in Parkinson disease

OBJECTIVE

This self-directed learning module provides an evidence-based update of exercise-based rehabilitation interventions to treat Parkinson disease (PD). It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This focused review emphasizes treatment of locomotion deficits, upper limb motor control deficits, and hypokinetic dysarthria. New dopaminergic agents and deep brain stimulation are facilitating longer periods of functional stability for patients with PD. Adjunctive exercise-based treatments can therefore be applied over longer periods of time to optimize function before inevitable decline from this neurodegenerative disease. As function deteriorates in patients with PD, the role of caregivers becomes more critical, thus training caregivers is of paramount importance to help maintain a safe environment and limit caregiver anxiety and depression. The overall goal of this article is to enhance the learner's existing practice techniques used to treat PD through exercise-based intervention methods.

Effectiveness of intensive inpatient rehabilitation treatment on disease progression in parkinsonian patients: a randomized controlled trial with 1-year follow-up

BACKGROUND

Rehabilitation treatments have acute beneficial effects in Parkinson's disease (PD) patients, but whether the effects persist over time is unclear.

OBJECTIVE

To assess whether an intensive rehabilitation treatment (IRT) is effective in improving motor performance compared with a control group in a 12-month follow-up, to investigate whether a second cycle administered after 1 year has the same efficacy as the first treatment, and to determine whether IRT reduces the need for increasing levodopa dosage.

METHODS

A total of 50 PD patients were randomly assigned to 2 groups; 25 participants had 4 weeks of inpatient physical therapy that included treadmill and stabilometric platform training. At discharge, these patients were invited to continue doing the learned exercises. After 12 months, the same treatment was repeated. The control group of 25 patients received only pharmacological treatment and was invited to practice generic physical exercise at home. The rating scales used for the clinical evaluation were the Unified Parkinson's Disease Rating Scale Sections II and III (UPDRS II and III) and total (UPDRS tot).

RESULTS

The authors found that the beneficial effects of IRT persisted over time. A second rehabilitation cycle administered after 1 year was as effective as the first treatment. At the end of the study, daily medication dosage was reduced in treated patients, whereas it was significantly increased in control patients.

CONCLUSION

These findings suggest that the natural worsening of symptoms associated with PD can be effectively counteracted by a properly designed IRT.

External cueing improves motor imagery quality in patients with Parkinson disease

BACKGROUND

Patients with Parkinson disease (PD) are often profoundly slow in their performance of physical tasks, as well as in motor imagery (MI). This may limit the implementation and potential benefits of MI practice during rehabilitation.

OBJECTIVE

The authors investigated whether the quality of MI could be improved by external cueing.

METHODS

Fourteen patients with PD and 14 healthy controls physically executed and visually imagined a goal-directed aiming task and a box-and-block task, both in the presence and absence of visual and auditory cues. Mental chronometry and eye movement recording allowed objective evaluation of the temporal and spatial characteristics of MI when compared with physical execution. Visual analogue scales were used to assess imagery vividness.

RESULTS

The presence of visual cues significantly reduced the patients' bradykinesia during MI and increased their imagery vividness.

CONCLUSIONS

Visual cueing optimizes MI quality for PD patients and is a potential tool to increase the efficacy of MI practice in PD rehabilitation.

Best practice for motor imagery: a systematic literature review on motor imagery training elements in five different disciplines

BACKGROUND

The literature suggests a beneficial effect of motor imagery (MI) if combined with physical practice, but detailed descriptions of MI training session (MITS) elements and temporal parameters are lacking. The aim of this review was to identify the characteristics of a successful MITS and compare these for different disciplines, MI session types, task focus, age, gender and MI modification during intervention.

METHODS

An extended systematic literature search using 24 databases was performed for five disciplines: Education, Medicine, Music, Psychology and Sports. References that described an MI intervention that focused on motor skills, performance or strength improvement were included. Information describing 17 MITS elements was extracted based on the PETTLEP (physical, environment, timing, task, learning, emotion, perspective) approach. Seven elements describing the MITS temporal parameters were calculated: study duration, intervention duration, MITS duration, total MITS count, MITS per week, MI trials per MITS and total MI training time.

RESULTS

Both independent reviewers found 96% congruity, which was tested on a random sample of 20% of all references. After selection, 133 studies reporting 141 MI interventions were included. The locations of the MITS and position of the participants during MI were task-specific. Participants received acoustic detailed MI instructions, which were mostly standardised and live. During MI practice, participants kept their eyes closed. MI training was performed from an internal perspective with a kinaesthetic mode. Changes in MI content, duration and dosage were reported in 31 MI interventions. Familiarisation sessions before the start of the MI intervention were mentioned in 17 reports. MI interventions focused with decreasing relevance on motor-, cognitive- and strength-focused tasks. Average study intervention lasted 34 days, with participants practicing MI on average three times per week for 17 minutes, with 34 MI trials. Average total MI time was 178 minutes including 13 MITS. Reporting rate varied between 25.5% and 95.5%.

CONCLUSIONS

MITS elements of successful interventions were individual, supervised and non-directed sessions, added after physical practice. Successful design characteristics were dominant in the Psychology literature, in interventions focusing on motor and strength-related tasks, in interventions with participants aged 20 to 29 years old, and in MI interventions including participants of both genders. Systematic searching of the MI literature was constrained by the lack of a defined MeSH term.

Rehabilitation with mental practice has similar effects on mobility as rehabilitation with relaxation in people with Parkinson's disease: a multicentre randomised trial

QUESTIONS

Is mental practice embedded in standard physiotherapy compared with relaxation embedded in standard physiotherapy more effective at improving mobility tasks in people with Parkinson's disease in the community? Does disease severity influence the treatment effect?

DESIGN

A multicentre randomised controlled trial.

PARTICIPANTS

People with Parkinson's disease.

INTERVENTION

During a six-week intervention period, both groups received physiotherapy as usual with the addition of either mental practice (experimental group) or relaxation (control group). Imagery skills were taught using a four-step protocol. Movement imagery (in thought) and the performance of motor activities were combined.

OUTCOME MEASURES

Outcomes were assessed at six weeks and three months with: the patient- and therapist-perceived effect on walking performance (visual analogue scale), the Timed Up and Go test, and the 10 m Walk test. Primary analysis was performed using intention-totreat and was repeated as a per-protocol analysis, and as a sub-group analysis of participants with Hoehn and Yahr stage of less than 3. Generalised estimating equations were used to analyse effects.

RESULTS

47 participants were assigned to the control (n = 22) and experimental (n = 25) groups. No effect in favour of the mental practice intervention on any outcome measure could be detected at any of the measurement points. In the sub-group analysis of participants with milder disease, the experimental group improved more than the control group but this was not statistically significant.

CONCLUSION

In this study, we did not find differences between embedded mental practice and relaxation with current standard of care.

TRIAL REGISTRATION

Nederlands Trial Register: NTR1735.

The Kinesthetic and Visual Imagery Questionnaire is a reliable tool for individuals with Parkinson disease

BACKGROUND AND PURPOSE

It is not known whether individuals with Parkinson disease (PD) can practice movements mentally. Before this question can be addressed, a reliable imagery assessment tool must be established. The recently developed Kinesthetic and Visual Imagery Questionnaire (KVIQ) is valid for non-disabled individuals and individuals with stroke. We have extended this work by examining the test-retest reliability and concurrent validity of the KVIQ in individuals with PD.

METHODS

Eleven individuals with mild to moderate PD were assessed, while on medication, by the same examiner at 2 sessions (5-12 days apart). Test-retest reliability was measured using intraclass correlation coefficients (ICCs). To examine concurrent validity, KVIQ scores from the second session were compared with a gold standard, the revised Movement Imagery Questionnaire, using Spearman rank order correlation coefficients.

RESULTS

There was no significant difference between total KVIQ scores for the test-retest sessions (P > 0.05). Overall, test-retest reliability of the KVIQ was good (ICC = 0.87), and reliability of the subscale of the KVIQ for indexing visual imagery and kinesthetic imagery was also good (ICC = 0.82 and 0.95, respectively). However, the subscale indexing axial visual imagery showed less reliability (ICC = 0.74), suggesting that individuals with PD were not as reliable when imagining axial visual movements as they were for imagining limb movements. Concurrent validity between the second session KVIQ score and the revised Movement Imagery Questionnaire score (gold standard) was excellent (rho = 0.93).

CONCLUSION

Our data support the conclusion that the KVIQ is a reliable and valid test for indexing mental imagery ability in individuals with PD. The KVIQ is easy to administer, and the movements (both real and imagined) required are appropriate for individuals with neuropathology. Our data suggest that the KVIQ is a good choice for clinicians who may wish to index motor imagery ability before implementing imagery as a rehabilitation intervention.

Time-of-day effects on the internal simulation of motor actions: psychophysical evidence from pointing movements with the dominant and non-dominant arm

It is well known that circadian rhythms modulate human physiology and behavior at various levels. However, chronobiological data concerning mental and sensorimotor states of motor actions are still lacking in the literature. In the present study, we examined the effects of time-of-day on two important aspects of the human motor behavior: prediction and laterality. Motor prediction was experimentally investigated by means of imagined movements and laterality by comparing the difference in temporal performance between right and left arm movements. Ten healthy participants had to actually perform or to imagine performing arm-pointing movements between two targets at different hours of the day (i.e., 08:00, 11:00, 14:00, 17:00, 20:00, and 23:00 h). Executed and imagined movements were accomplished with both the right and left arm. We found that both imagined and executed arm pointing movements significantly fluctuated through the day. Furthermore, the accuracy of motor prediction, investigated by the temporal discrepancy between executed and imagined movements, was significantly better in the afternoon (i.e., 14:00, 17:00, and 20:00 h) than morning (08:00 and 11:00 h) and evening (23:00 h). Our results also revealed that laterality was not stable throughout the day. Indeed, the smallest temporal differences between the two arms appeared at 08:00 and 23:00 h, whereas the largest ones occurred at the end of the morning (11:00 h). The daily variation of motor imagery may suggest that internal predictive models are flexible entities that are continuously updated throughout the day. Likewise, the variations in temporal performance between the right and the left arm during the day may indicate a relative independence of the two body sides in terms of circadian rhythms. In general, our findings suggest that cognitive (i.e., mental imagery) and motor (i.e., laterality) states of human behavior are modulated by circadian rhythms.

Mental practice for relearning locomotor skills

Over the past 2 decades, much work has been carried out on the use of mental practice through motor imagery for optimizing the retraining of motor function in people with physical disabilities. Although much of the clinical work with mental practice has focused on the retraining of upper-extremity tasks, this article reviews the evidence supporting the potential of motor imagery for retraining gait and tasks involving coordinated lower-limb and body movements. First, motor imagery and mental practice are defined, and evidence from physiological and behavioral studies in healthy individuals supporting the capacity to imagine walking activities through motor imagery is examined. Then the effects of stroke, spinal cord injury, lower-limb amputation, and immobilization on motor imagery ability are discussed. Evidence of brain reorganization in healthy individuals following motor imagery training of dancing and of a foot movement sequence is reviewed, and the effects of mental practice on gait and other tasks involving coordinated lower-limb and body movements in people with stroke and in people with Parkinson disease are examined. Lastly, questions pertaining to clinical assessment of motor imagery ability and training strategies are discussed.

Effects of dance on gait and balance in Parkinson's disease: a comparison of partnered and nonpartnered dance movement

Partnered tango dance can improve balance and gait in individuals with Parkinson's disease (PD). Partnered dance may allow these individuals to challenge balance more than nonpartnered dance. Alternatively, partnered practice could reduce balance gains because the participant may rely on the partner as a balance aid when challenged. The authors compared the effects of partnered and nonpartnered dance on balance and mobility in 39 people (11 women) with mild-moderate PD (Hoehn and Yahr stages I-III). Participants were randomly assigned to partnered or nonpartnered tango and attended 1-hour classes twice per week, completing 20 lessons within 10 weeks. Balance and gait were evaluated in the weeks immediately before, immediately after, and 1 month after the intervention. Both groups significantly improved on the Berg Balance Scale, comfortable and fast-as-possible walking velocity, and cadence. Improvements were maintained at the 1-month follow-up. The nonpartnered class improved as much as the partnered class; however, partnered participants expressed more enjoyment and interest in continuing.

Comparison of embedded and added motor imagery training in patients after stroke: study protocol of a randomised controlled pilot trial using a mixed methods approach

BACKGROUND

Two different approaches have been adopted when applying motor imagery (MI) to stroke patients. MI can be conducted either added to conventional physiotherapy or integrated within therapy sessions. The proposed study aims to compare the efficacy of embedded MI to an added MI intervention. Evidence from pilot studies reported in the literature suggests that both approaches can improve performance of a complex motor skill involving whole body movements, however, it remains to be demonstrated, which is the more effective one.

METHODS/DESIGN

A single blinded, randomised controlled trial (RCT) with a pre-post intervention design will be carried out. The study design includes two experimental groups and a control group (CG). Both experimental groups (EG1, EG2) will receive physical practice of a clinical relevant motor task ('Going down, laying on the floor, and getting up again') over a two week intervention period: EG1 with embedded MI training, EG2 with MI training added after physiotherapy. The CG will receive standard physiotherapy intervention and an additional control intervention not related to MI. The primary study outcome is the time difference to perform the task from pre to post-intervention. Secondary outcomes include level of help needed, stages of motor task completion, degree of motor impairment, balance ability, fear of falling measure, motivation score, and motor imagery ability score. Four data collection points are proposed: twice during baseline phase, once following the intervention period, and once after a two week follow up. A nested qualitative part should add an important insight into patients' experience and attitudes towards MI. Semi-structured interviews of six to ten patients, who participate in the RCT, will be conducted to investigate patients' previous experience with MI and their expectations towards the MI intervention in the study. Patients will be interviewed prior and after the intervention period.

DISCUSSION

Results will determine whether embedded MI is superior to added MI. Findings of the semi-structured interviews will help to integrate patient's expectations of MI interventions in the design of research studies to improve practical applicability using MI as an adjunct therapy technique.

Potential influences of complementary therapy on motor and non-motor complications in Parkinson's disease

Nearly two-thirds of patients with Parkinson's disease (PD) use vitamins or nutritional supplements, and many more may use other complementary therapies, yet <50% of patients have discussed the use of these complementary therapies with a healthcare professional. Physicians should be aware of the complementary therapies their patients with PD are using, and the possible effects of these therapies on motor and non-motor symptoms. Complementary therapies, such as altered diet, dietary supplements, vitamin therapy, herbal supplements, caffeine, nicotine, exercise, physical therapy, massage therapy, melatonin, bright-light therapy and acupuncture, may all influence the symptoms of PD and/or the effectiveness of dopaminergic therapy. Preliminary evidence suggests complementary therapy also may influence non-motor symptoms of PD, such as respiratory disorders, gastrointestinal disorders, mood disorders, sleep and orthostatic hypotension. Whenever possible, clinicians should ensure that complementary therapy is used appropriately in PD patients without reducing the benefits of dopaminergic therapy.

The effects of exercise on balance in persons with Parkinson's disease: a systematic review across the disability spectrum

BACKGROUND AND PURPOSE

Parkinson's disease is a progressive neurodegenerative disorder that affects neurophysiologic function, movement abilities, and quality of life (QOL). Research examining the effects of exercise has suggested benefits related to a variety of outcomes; however, no reviews have synthesized research findings across the spectrum of disability. This project sought to systematically review studies that examined the impact of exercise interventions on balance outcomes for people with Parkinson's disease, within the categories defined by the World Health Organization in the International Classification of Functioning, Disability, and Health (ICF) model.

METHODS

A systematic review of medical literature databases was performed using keywords Parkinson's disease and exercise. Studies were eligible if the intervention included exercise and examined variables within one of the three ICF categories. Following the ICF model, outcomes regarding Body Structure and Function, Activity, and Participation were measured, respectively, in terms of postural instability, balance task performance, and QOL and fall events.

RESULTS

Within the Body Structure and Function category, there was moderate evidence that exercise resulted in improvements in postural instability. Within the Activity category, there was moderate evidence that exercise was effective for improving balance task performance. In contrast, within the Participation category, there was limited evidence that exercise resulted in improvements in QOL measures or fall events.

DISCUSSION AND CONCLUSIONS

Regardless of the strength of the evidence, the studies reviewed all report that exercise resulted in improvements in postural stability and balance task performance. Despite these improvements, the number and quality of the studies and the outcomes used were limited. There is a need for longer term follow-up to establish trajectory of change and to determine if any gains are retained long term. The optimal delivery and content of exercise interventions (dosing, component exercises) at different stages of the disease are not clear.

Circadian Modulation of Mentally Simulated Motor Actions: Implications for the Potential Use of Motor Imagery in Rehabilitation

Background. Mental practice through motor imagery improves subsequent motor performance and thus mental training is considered to be a potential tool in neuromotor rehabilitation. Objective. The authors investigated whether a circadian fluctuation of the motor imagery process occurs, which could be relevant in scheduling mental training in rehabilitation programs. Methods. The executed and imagined durations of walking and writing movements were recorded every 3 hours from 8 AM to 11 PM in healthy participants. The authors made a cosinor analysis on the temporal features of these movements to detect circadian rhythms. Temporal differences between executed and imagined movements as well as their variability during the day were also quantified. Results. Circadian rhythms were detected for both the executed and the imagined movements. Furthermore, these rhythms covaried between them and with body temperature. The participants' ability to internally simulate their movements also fluctuated significantly during the day. The isochrony between the executed and the imagined movements was exclusively observed between 2 PM and 8 PM. In the morning (8 AM and 11 AM) and the evening (11 PM), the durations of the imagined movements were significantly longer than the durations of executed movements. Conclusions . Predictive internal models fluctuate in a circadian basis, as do many other physiological parameters. It could be important to take into consideration the time of day in the planning of rehabilitation programs using physical or mental training.

Gait disorders and balance disturbances in Parkinson's disease: clinical update and pathophysiology

PURPOSE OF REVIEW

Gait disorders and balance impairments are one of the most incapacitating symptoms of Parkinson's disease. Here, we discuss the latest findings regarding epidemiology, assessment, pathophysiology and treatment of gait and balance impairments in Parkinson's disease.

RECENT FINDINGS

Recent studies have confirmed the high rate and high risk of falls of patients with Parkinson's disease. Therefore, it is crucial to detect patients who are at risk of falling and how to prevent falls. Several studies have shown that multiple balance tests improve the prediction of falls in Parkinson's disease. Difficulty turning may be caused by axial rigidity, affected interlimb coordination and asymmetries. Turning difficulties are easily assessed by timed performance and the number of steps during a turn. Impaired sensorimotor integration, inability of switching between sensory modalities and lack of compensatory stepping may all contribute to the high incidence of falls in patients with Parkinson's disease. Similarly, various studies highlighted that pharmacotherapy, neurosurgery and physiotherapy may adversely affect balance and gait in Parkinson's disease.

SUMMARY

Insights into the pathophysiology of Parkinson's disease continue to grow. At the same time, it is becoming clear that some patients may in fact deteriorate with treatment. Future research should focus on the development and evaluation of multifactorial fall prevention strategies.

Using mental practice in stroke rehabilitation: a framework

Introduction: Motor imagery and mental practice are getting increased attention in neurological rehabilitation. Several different mental practice intervention protocols have been used in studies on its effect on recovery in stroke rehabilitation. The content of the intervention protocols itself is rarely discussed or questioned.

Objective: To give a practical framework of how mental practice could be integrated into therapy, drawing on available evidence and theory. The aim of the treatment programme described is to enhance both the patient's physical performance and their empowerment and self-determination.

The framework: Based on evidence from sports rehabilitation and our own experiences the framework will eventually be evaluated in a randomized controlled trial. Five steps are described to teach and upgrade the patient's imagery technique: (1) assess mental capacity to learn imagery technique; (2) establish the nature of mental practice; (3) teach imagery technique; (4) embed and monitor imagery technique; (5) develop self-generated treatments. The description is not, however, a recipe that should be followed precisely. It leaves enough room to tailor the mental practice intervention to the specific individual possibilities, skills and needs of the patient in accordance with evidence-based practice.

Discussion: Different aspects of the described protocol are discussed and compared with experiences from sports and evidence available in rehabilitation.

Motor imagery in physical therapist practice

Motor imagery is the mental representation of movement without any body movement. Abundant evidence on the positive effects of motor imagery practice on motor performance and learning in athletes, people who are healthy, and people with neurological conditions (eg, stroke, spinal cord injury, Parkinson disease) has been published. The purpose of this update is to synthesize the relevant literature about motor imagery in order to facilitate its integration into physical therapist practice. This update also will discuss visual and kinesthetic motor imagery, factors that modify motor imagery practice, the design of motor imagery protocols, and potential applications of motor imagery.