Effects of mental practice on affected limb use and function in chronic stroke

Effectiveness of synchronous action observation and mental practice on upper extremity motor recovery after stroke

The purpose of this quasi-experimental pretest-posttest control group study was to examine the effect of group synchronous action observation/mental practice intervention compared to usual rehabilitation care on upper extremity motor recovery after stroke. The intervention group (n = 25) received usual care, consisting of a minimum of 3 hours of rehabilitation services per day, 5 days a week, plus group synchronous action observation/mental practice sessions 3 times per week and the control group (n = 26) received usual care. Outcome measures included the Kinesthetic and Visual Imagery Questionnaire Short Version (KVIQ-10), the Fugl-Meyer Assessment (FMA-UE) of affected upper extremity motor function only and The Box and Block Test (BBT). Although there were no statistically significant differences in upper extremity motor function between the two groups, a subgroup analysis of the intervention group identified statistically significant (FMA-UE: p < .001; BBT: p = .04) and Minimally Important Clinical Differences on upper extremity motor recovery between patients with behaviors demonstrating more versus less commitment to the intervention. Group synchronous action observation/mental practice is a promising intervention for patients demonstrating commitment to actively participating in the intervention to improve outcomes on upper extremity motor recovery after stroke.

The Impact of Mental Practice on Motor Function in Patients With Stroke: A Systematic Review and Meta-analysis

Mental practice (MP), the cognitive rehearsal of physical activities without overt movements, has recently emerged as a promising rehabilitation method for patients with stroke. This paper presents a systematic review and meta-analysis critically evaluating the existing evidence to offer a comprehensive estimate of the overall effect of MP on motor function in stroke patients. A systematic search of 3 international databases (PubMed, Embase, and the Cochrane Library) was conducted for randomized controlled trials. We finally selected 31 randomized clinical trials and conducted meta-analysis to determine the effectiveness of MP on motor recovery of upper extremity, upper extremity function, activities of daily living, and gait velocity in stroke patients. The results of the systematic reviews showed that MP combined with conventional therapy has a positive impact on improving upper extremity motor function, with a moderate quality of evidence. However, the beneficial effect of MP on gait velocity was not demonstrated. It is recommended to treat with MP in addition to conventional rehabilitation therapy to improve the motor outcome of stroke depending on the patient's condition (Recommendation level: Conditional Recommend Evidence certainty: Moderate).

Advances in Stroke Neurorehabilitation

Stroke is one of the leading causes of disability worldwide despite recent advances in hyperacute interventions to lessen the initial impact of stroke. Stroke recovery therapies are crucial in reducing the long-term disability burden after stroke. Stroke recovery treatment options have rapidly expanded within the last decade, and we are in the dawn of an exciting era of multimodal therapeutic approaches to improve post-stroke recovery. In this narrative review, we highlighted various promising advances in treatment and technologies targeting stroke rehabilitation, including activity-based therapies, non-invasive and minimally invasive brain stimulation techniques, robotics-assisted therapies, brain-computer interfaces, pharmacological treatments, and cognitive therapies. These new therapies are targeted to enhance neural plasticity as well as provide an adequate dose of rehabilitation and improve adherence and participation. Novel activity-based therapies and telerehabilitation are promising tools to improve accessibility and provide adequate dosing. Multidisciplinary treatment models are crucial for post-stroke neurorehabilitation, and further adjuvant treatments with brain stimulation techniques and pharmacological agents should be considered to maximize the recovery. Among many challenges in the field, the heterogeneity of patients included in the study and the mixed methodologies and results across small-scale studies are the cardinal ones. Biomarker-driven individualized approaches will move the field forward, and so will large-scale clinical trials with a well-targeted patient population.

Body Schema as Assessed by Upper Limb Left/Right Judgment Tasks Is Altered in Stroke: Implications for Motor Imagery Training

BACKGROUND AND PURPOSE

Individuals with stroke often experience significant impairment of the upper limb. Rehabilitation interventions targeting the upper limb are typically associated with only small to moderate gains. The knowledge that body schema can be altered in other upper limb conditions has contributed to the development of tailored rehabilitation approaches. This study investigated whether individuals with stroke experienced alterations in body schema of the upper limb. If so, this knowledge may have implications for rehabilitation approaches such as motor imagery.

METHODS

An observational study performed online consisting of left/right judgment tasks assessed by response time and accuracy of: (i) left/right direction recognition; (ii) left/right shoulder laterality recognition; (iii) left/right hand laterality recognition; (iv) mental rotation of nonembodied objects. Comparisons were made between individuals with and without stroke. Secondary comparisons were made in the stroke population according to side of stroke and side of pain if experienced.

RESULTS

A total of 895 individuals (445 with stroke) participated. Individuals with stroke took longer for all tasks compared to those without stroke, and were less accurate in correctly identifying the laterality of shoulder (P < 0.001) and hand (P < 0.001) images, and the orientation of nonembodied objects (P < 0.001). Moreover, the differences observed in the hand and shoulder tasks were greater than what was observed for the control tasks of directional recognition and nonembodied mental rotation. No significant differences were found between left/right judgments of individuals with stroke according to stroke-affected side or side of pain.

DISCUSSION AND CONCLUSIONS

Left/right judgments of upper limb are frequently impaired after stroke, providing evidence of alterations in body schema. The knowledge that body schemas are altered in individuals with longstanding stroke may assist in the development of optimal, well-accepted motor imagery programs for the upper limb.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A394).

Can mental practice adjunct in the recovery of motor function in the upper limbs after stroke? A systematic review and meta-analysis

BACKGROUND:

Studies indicate that mental practice can be an adjuvant rehabilitation, improving motor functions.

AIM:

To synthesize the evidence on the intervention with the mental practice for the rehabilitation of the upper limb after stroke in the context of a dependent task.

METHODS:

The review was registered on the PROSPERO with protocol number: CRD42020166624. We searched the PubMed, Medline, Embase, Central, PEDro, and Web of Science from randomized clinical trials from 1975 to 2022. A literature review was conducted with 13 studies that synthesized findings on mental practice such as adjuvant rehabilitation in the recovery of the upper limb after stroke based on Fugl-Meyer Assessment (FMA) Motor and action research arm test (ARAT) scores.

RESULTS:

The sample size was 232 were part of the intervention group and 180 of the control group. The findings no showed results in favor of mental practice after stroke accordingly to ARAT and FMA Motor scores (P > 0.05).

CONCLUSION:

Current evidence does not support the use of the mental practice to increase the recovery of the upper limb after stroke, although the evidence is conflicting for some aspects of the technique.

Motor Imagery-Based Brain-Computer Interface Combined with Multimodal Feedback to Promote Upper Limb Motor Function after Stroke: A Preliminary Study

Background

Recently, the brain-computer interface (BCI) has seen rapid development, which may promote the recovery of motor function in chronic stroke patients.

Methods

Twelve stroke patients with severe upper limb and hand motor impairment were enrolled and randomly assigned into two groups: motor imagery (MI)-based BCI training with multimodal feedback (BCI group, n = 7) and classical motor imagery training (control group, n = 5). Motor function and electrophysiology were evaluated before and after the intervention. The Fugl-Meyer assessment-upper extremity (FMA-UE) is the primary outcome measure. Secondary outcome measures include an increase in wrist active extension or surface electromyography (the amplitude and cocontraction of extensor carpi radialis during movement), the action research arm test (ARAT), the motor status scale (MSS), and Barthel index (BI). Time-frequency analysis and power spectral analysis were used to reflect the electroencephalogram (EEG) change before and after the intervention.

Results

Compared with the baseline, the FMA-UE score increased significantly in the BCI group (p = 0.006). MSS scores improved significantly in both groups, while ARAT did not improve significantly. In addition, before the intervention, all patients could not actively extend their wrists or just had muscle contractions. After the intervention, four patients regained the ability to extend their paretic wrists (two in each group). The amplitude and area under the curve of extensor carpi radialis improved to some extent, but there was no statistical significance between the groups.

Conclusion

MI-based BCI combined with sensory and visual feedback might improve severe upper limb and hand impairment in chronic stroke patients, showing the potential for application in rehabilitation medicine.

Effects of task complexity or rate of motor imagery on motor learning in healthy young adults

BACKGROUND

A growing body of evidence suggests the benefit of motor imagery in motor learning. While some studies tried to look at the effect of isolated mental practice, others evaluated the combined effect of motor imagery and physical practice in clinical rehabilitation. This study aimed to investigate the effects of task complexity or rates of motor imagery on motor learning in health young adults.

METHODS

Eighty-eight healthy individuals participated in this study. Participants were randomly allocated to either Group A (50% complex, N = 22), Group B (75% complex, N = 22), Group C (50% simple, N = 22), or Group D (75% simple, N = 22). Participants in the complex groups performed their task with nondominant hand and those in simple groups with a dominant hand. All participants performed a task that involved reach, grasp, and release tasks. The performance of the four groups was examined in the acquisition and retention phase. The main outcome measure was the movement time.

RESULTS

There were significant differences between immediate (i.e., acquisition) and late (i.e., retention) movement times at all three stages of task (i.e., MT1 [reaching time], MT2 [target transport time], and TMT [reaching time plus object transport time]) when individuals performed complex task with 75% imagery rate (p < .05). Similarly, there were significant differences between immediate and late movement times at all stages of task except the MT2 when individuals performed simple task with 75% imagery rate (p < .05). There were significant effects of task complexity (simple vs. complex tasks) on immediate movement time at the first stage of task (i.e., MT1 ) and late movement times of all three stages of task (p < .05). There were significant effects of the rate of imagery (50% vs. 75%) on late movement times at all three stages of tasks (p > .05). Additionally, there were no interaction effects of either task complexity or rate of imagery on both immediate and late movement times at all three stages of tasks (p > .05).

CONCLUSION

This study supports the use of higher rates (75%) of motor imagery to improve motor learning. Additionally, the practice of a complex task demonstrated better motor learning in healthy young adults. Future longitudinal studies should validate these results in different patient's population such as stroke, spinal cord injury, and Parkinson's disease.

A different point of view: the evaluation of motor imagery perspectives in patients with sensorimotor impairments in a longitudinal study

Background

Motor imagery (MI) has been successfully applied in neurological rehabilitation. Little is known about the spontaneous selection of the MI perspectives in patients with sensorimotor impairments. What perspective is selected: internal (first-person view), or external (third-person view)? The aim was to evaluate the MI perspective preference in patients with sensorimotor impairments.

Methods

In a longitudinal study including four measurement sessions, 55 patients (25 stroke, 25 multiple sclerosis, 5 Parkinson’s disease; 25 females; mean age 58 ± 14 years) were included. MI ability and perspective preference in both visual and kinaesthetic imagery modalities were assessed using the Kinaesthetic and Visual Imagery Questionnaire-20 (KVIQ-20), the body rotation task (BRT), and mental chronometry (MC). Additionally, patients’ activity level was assessed. Descriptive analyses were performed regarding different age- (< 45, 45–64, > 64), activity levels (inactive, partially active, active), and KVIQ-20 movement classifications (axial, proximal, distal, upper and lower limb). A mixed-effects model was used to investiage the relationship between the primary outcome (MI perspective: internal, external) with the explanatory variables age, MI modality (visual, kinaesthetic), movement type (axial, proximal, distal), activity levels and the different assessments (KVIQ-20, BRT, MC).

Results

Imagery modality was not a significant predictor of perspective preference. Over the four measurement sessions, patients tended to become more consistent in their perspective selection, however, time point was not a significant predictor. Movement type was a significant predictor: imagination of distal vs. axial and proximal vs. axial movements were both associated with preference for external perspective. Patients with increased physical activity level tend to use internal imagery, however, this effect was borderline not statistically significant. Age was neither a significant precictor. Regarding the MI assessments, the KVIQ- 20 score was a significant predictor. The patients with higher test scores tend to use the external perspective.

Conclusion

It is recommended to evaluate the spontaneous MI perspective selection to design patient-specific MI training interventions. Distal movements (foot, finger) may be an indicator when evaluating the consistency of the MI perspective in patients with sensorimotor impairments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02266-w.

Development of a Low-Cost EEG-Controlled Hand Exoskeleton 3D Printed on Textiles

Stroke survivors can be affected by motor deficits in the hand. Robotic equipment associated with brain–machine interfaces (BMI) may aid the motor rehabilitation of these patients. BMIs involving orthotic control by motor imagery practices have been successful in restoring stroke patients' movements. However, there is still little acceptance of the robotic devices available, either by patients and clinicians, mainly because of the high costs involved. Motivated by this context, this work aims to design and construct the Hand Exoskeleton for Rehabilitation Objectives (HERO) to recover extension and flexion movements of the fingers. A three-dimensional (3D) printing technique in association with textiles was used to produce a lightweight and wearable device. 3D-printed actuators have also been designed to reduce equipment costs. The actuator transforms the torque of DC motors into linear force transmitted by Bowden cables to move the fingers passively. The exoskeleton was controlled by neuroelectric signal—electroencephalography (EEG). Concept tests were performed to evaluate control performance. A healthy volunteer was submitted to a training session with the exoskeleton, according to the Graz-BCI protocol. Ergonomy was evaluated with a two-dimensional (2D) tracking software and correlation analysis. HERO can be compared to ordinary clothing. The weight over the hand was around 102 g. The participant was able to control the exoskeleton with a classification accuracy of 91.5%. HERO project resulted in a lightweight, simple, portable, ergonomic, and low-cost device. Its use is not restricted to a clinical setting. Thus, users will be able to execute motor training with the HERO at hospitals, rehabilitation clinics, and at home, increasing the rehabilitation intervention time. This may support motor rehabilitation and improve stroke survivors life quality.

Effects of motor imagery training on lower limb motor function of patients with chronic stroke: A pilot single-blind randomized controlled trial

AIMS

This pilot study aimed to evaluate the effects of motor imagery training on lower limb motor function of stroke patients.

BACKGROUND

Motor imagery training has played an important role in rehabilitation outcomes of stroke patients.

METHODS

In this pilot randomized controlled trial 32 stroke patients were randomly divided into experimental and control groups from January to June 2017. Patients in both groups received conventional neuro-rehabilitation five times a week in 3-h segments for 6 weeks. Patients in the experimental group underwent an additional 20 min of motor imagery training. Measures were evaluated by motor function of the lower extremity, activities of daily living and balance ability.

RESULTS

The outcomes significantly improved by motor imagery training were the Fugl-Meyer Assessment of the lower extremity, the Functional Independence Measure dealing with transfers and locomotion, and the Berg Balance Scale.

CONCLUSION

Motor imagery training could be used as a complement to physical rehabilitation of stroke patients. Our findings may be helpful to develop nursing strategies aimed at improving functional ability of stroke patients and thus enhancing their quality of life.

SUMMARY STATEMENT

What is already known about this topic? Lower extremity dyskinesia is among the most common complications that significantly limit the patient's activities of daily living. Motor imagery training, a safe and cost-efficient technique, may be used as a complement to physical rehabilitation of stroke patients. Evidence suggests that motor imagery training is effective in upper limb recovery after stroke. There is limited evidence of the effectiveness of motor imagery training on lower limb motor functions of patients with chronic stroke. What this paper adds? Motor imagery training can be incorporated into conventional therapy among individuals by rehabilitation specialist nurses with sufficient experience of motor imagery training, but substantial resources are needed. Six-week motor imagery training resulted in a significant improvement in the motor performance of lower limbs in patients with stroke. Further study is needed to modify and optimize the present programme and should be focused on enabling more stroke patients to benefit from motor imagery training. The implications of this paper: The addition of motor imagery training to the conventional neuro-rehabilitation can significantly promote the recovery of motor performance of lower limbs in stroke patients, thus reducing long-term disability and associated socio-economic burden. The findings of this pilot study may be helpful to develop nursing strategies aimed at improving functional ability and consequently the quality of life of stroke patients. Nurses can learn the motor imagery training as a technique for practising psychomotor nursing skills.

Investigating the Viability of Motor Imagery as a Physical Rehabilitation Treatment for Patients With Stroke-Induced Motor Cortical Damage

Although around 83% of individuals survive a stroke, they usually experience a significant loss in their motor execution (ME) capabilities due to their acquired cortical infarction. The loss of significant ME capabilities due to stroke damage was previously thought to be irreversible. Active movement therapies show considerable promise but depend on motor performance, excluding many otherwise eligible patients. Motor imagery (MI), a process that involves the use of mirror neurons to imagine motor activity, has emerged as a possible avenue to re-acquire some physical abilities lost to stroke damage. This paper examines previous studies to compare the strength of brain activation and connectivity in individuals who have brain lesions and those who do not as they all attempt ME and MI tasks. This paper reviews case studies investigating the direct effect of motor imagery in conjunction with physical therapy and the limitations of motor imagery based on the location of cortical damage and other variables, such as age. The findings analyzed in this review indicate that MI would serve as a beneficial addition to physical therapy and a viable option to stimulate motor evoked potentials (MEPs) in individuals not capable of pursuing physical therapy due to severe motor impairment. Regardless of the presence of brain lesions, motor imagery has consistently had a positive impact on motor rehabilitation either in boosting treatment or stimulating neuromuscular pathways. Therefore, we have concluded that MI is a viable supplemental treatment plan for motor recovery in most patients with motor cortical atrophy.

Adapting Motor Imagery Training Protocols to Surgical Education: A Systematic Review and Meta-Analysis

Objective. Motor imagery (MI) is widely used to improve technical skills in sports and has been proven to be effective in neurorehabilitation and surgical education. This review aims to identify the key characteristics of MI protocols for implementation into surgical curricula. Design. This study is a systematic review and meta-analysis. PubMed, MEDLINE, Embase and PsycINFO databases were systematically searched. The primary outcome was the impact of MI training on measured outcomes, and secondary outcomes were study population, MI intervention characteristics, study primary outcome measure and subject rating of MI ability (systematic review registration: PROSPERO CRD42019121895). Results. 456 records were screened, 60 full texts randomising 2251 participants were reviewed and 39 studies were included in meta-analysis. MI was associated with improved outcome in 35/60 studies, and pooled analysis also showed improved outcome on all studies with a standardised mean difference of .39 (95% CI: .12, .67, P = .005). In studies where MI groups showed improved outcomes, the median duration of training was 24 days (mode 42 days), and the median duration of each individual MI session was 30 minutes (range <1 minute-120 minutes). Conclusions. MI training protocols for use in surgical education could have the following characteristics: MI training delivered in parallel to existing surgical training, in a flexible format; inclusion of a brief period of relaxation, followed by several sets of repetitions of MI and a refocusing period. This is a step towards the development of a surgical MI training programme, as a low-cost, low-risk tool to enhance practical skills.

The Effectiveness and Recommendation of Motor Imagery Techniques for Rehabilitation after Anterior Cruciate Ligament Reconstruction: A Systematic Review

Motor imagery (MI) reported positive effects in some musculoskeletal rehabilitation processes. The main objective of this study was to analyze the effectiveness of MI interventions after anterior cruciate ligament (ACL) reconstruction. A systematic review was conducted from November 2018 to December 2019 in PubMed, Scopus, Web of Science, The Cochrane Library, and Physiotherapy Evidence Database (PEDro). The methodological quality, degree of recommendation, and levels of evidence were analyzed. A total of six studies were included. Selected studies showed unequal results (positive and negative) regarding pain, anxiety, fear of re-injury, function, and activities of daily living. Regarding the range of motion, anthropometric measurements, and quality of life, the results were not conclusive. Muscle activation, strength, knee laxity, time to remove external support, and neurobiological factors showed some favorable results. Nevertheless, the results were based on a limited number of studies, small sample sizes, and a moderate-weak degree of recommendation. In conclusion, our review showed a broader view of the current evidence, including a qualitative assessment to implement MI after ACL surgery. There was no clear evidence that MI added to physiotherapy was an effective intervention after ACL surgery, although some studies showed positive results in clinical outcomes. More adequately-powered long-term randomized controlled trials are necessary.

Systematic Review and Meta-Analysis of the Effectiveness of Mental Practice for the Upper Limb After Stroke: Imagined or Real Benefit?

OBJECTIVES

This systematic review sought to determine the effectiveness of mental practice (MP) on the activity limitations of the upper limb in individuals after stroke, as well as when, in whom, and how MP should be delivered.

DATA SOURCES

Ten electronic databases were searched from November 2009 to May 2020. Search terms included: Arm, Practice, Stroke rehabilitation, Imagination, Paresis, Recovery of function, and Stroke. Studies from a Cochrane review of MP (up to November 2009) were automatically included. The review was registered with the PROSPERO database of systematic reviews (reference no.: CRD42019126044).

STUDY SELECTION

Randomized controlled trials of adults after stroke using MP for the upper limb were included if they compared MP to usual care, conventional therapy, or no treatment and reported activity limitations of the upper limb as outcomes. Independent screening was conducted by 2 reviewers.

DATA EXTRACTION

One reviewer extracted data using a tool based on the Template for Intervention Description and Replication. Data extraction was independently verified by a second reviewer. Quality was assessed using the PEDro tool.

DATA SYNTHESIS

Fifteen studies (n=486) were included and 12 (n=328) underwent meta-analysis. MP demonstrated significant benefit on upper limb activities compared with usual treatment (standardized mean difference [SMD], 0.6; 95% confidence interval [CI], 0.32-0.88). Subgroup analyses demonstrated that MP was most effective in the first 3 months after stroke (SMD, 1.01; 95% CI, 0.53-1.50) and in individuals with the most severe upper limb deficits (weighted mean difference, 7.33; 95% CI, 0.94-13.72).

CONCLUSIONS

This review demonstrates that MP is effective in reducing activity limitations of the upper limb after stroke, particularly in the first 3 months after stroke and in individuals with the most severe upper limb dysfunction. There was no clear pattern of the ideal dosage of MP.

Motor imagery for gait rehabilitation after stroke

BACKGROUND

Motor imagery (MI) is defined as a mentally rehearsed task in which movement is imagined but is not performed. The approach includes repetitive imagined body movements or rehearsing imagined acts to improve motor performance.

OBJECTIVES

To assess the treatment effects of MI for enhancing ability to walk among people following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group registry, CENTRAL, MEDLINE, Embase and seven other databases. We also searched trial registries and reference lists. The last searches were conducted on 24 February 2020.

SELECTION CRITERIA

Randomized controlled trials (RCTs) using MI alone or associated with action observation or physical practice to improve gait in individuals after stroke. The critical outcome was the ability to walk, assessed using either a continuous variable (walking speed) or a dichotomous variable (dependence on personal assistance). Important outcomes included walking endurance, motor function, functional mobility, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials according to pre-defined inclusion criteria, extracted the data, assessed the risk of bias, and applied the GRADE approach to evaluate the certainty of the evidence. The review authors contacted the study authors for clarification and missing data.

MAIN RESULTS

We included 21 studies, involving a total of 762 participants. Participants were in the acute, subacute, or chronic stages of stroke, and had a mean age ranging from 50 to 78 years. All participants presented at least some gait deficit. All studies compared MI training versus other therapies. Most of the included studies used MI associated with physical practice in the experimental groups. The treatment time for the experimental groups ranged from two to eight weeks. There was a high risk of bias for at least one assessed domain in 20 of the 21 included studies. Regarding our critical outcome, there was very low-certainty evidence that MI was more beneficial for improving gait (walking speed) compared to other therapies at the end of the treatment (pooled standardized mean difference (SMD) 0.44; 95% confidence interval (CI) 0.06 to 0.81; P = 0.02; six studies; 191 participants; I² = 38%). We did not include the outcome of dependence on personal assistance in the meta-analysis, because only one study provided information regarding the number of participants that became dependent or independent after interventions. For our important outcomes, there was very low-certainty evidence that MI was no more beneficial than other interventions for improving motor function (pooled mean difference (MD) 2.24, 95% CI -1.20 to 5.69; P = 0.20; three studies; 130 participants; I² = 87%) and functional mobility at the end of the treatment (pooled SMD 0.55, 95% CI -0.45 to 1.56; P = 0.09; four studies; 116 participants; I² = 64.2%). No adverse events were observed in those studies that reported this outcome (seven studies). We were unable to pool data regarding walking endurance and all other outcomes at follow-up.

AUTHORS' CONCLUSIONS

We found very low-certainty evidence regarding the short-term benefits of MI on walking speed in individuals who have had a stroke, compared to other therapies. Evidence was insufficient to estimate the effect of MI on the dependence on personal assistance and walking endurance. Compared with other therapies, the evidence indicates that MI does not improve motor function and functional mobility after stroke (very low-certainty evidence). Evidence was also insufficient to estimate the effect of MI on gait, motor function, and functional mobility after stroke compared to placebo or no intervention. Motor Imagery and other therapies used for gait rehabilitation after stroke do not appear to cause significant adverse events.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke

BACKGROUND

Stroke is caused by the interruption of blood flow to the brain (ischemic stroke) or the rupture of blood vessels within the brain (hemorrhagic stroke) and may lead to changes in perception, cognition, mood, speech, health-related quality of life, and function, such as difficulty walking and using the arm. Activity limitations (decreased function) of the upper extremity are a common finding for individuals living with stroke. Mental practice (MP) is a training method that uses cognitive rehearsal of activities to improve performance of those activities.

OBJECTIVES

To determine whether MP improves outcomes of upper extremity rehabilitation for individuals living with the effects of stroke. In particular, we sought to (1) determine the effects of MP on upper extremity activity, upper extremity impairment, activities of daily living, health-related quality of life, economic costs, and adverse effects; and (2) explore whether effects differed according to (a) the time post stroke at which MP was delivered, (b) the dose of MP provided, or (c) the type of comparison performed.

SEARCH METHODS

We last searched the Cochrane Stroke Group Trials Register on September 17, 2019. On September 3, 2019, we searched the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Web of Science, the Physiotherapy Evidence Database (PEDro), and REHABDATA. On October 2, 2019, we searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We reviewed the reference lists of included studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of adult participants with stroke who had deficits in upper extremity function (called upper extremity activity).

DATA COLLECTION AND ANALYSIS

Two review authors screened titles and abstracts of the citations produced by the literature search and excluded obviously irrelevant studies. We obtained the full text of all remaining studies, and both review authors then independently selected trials for inclusion. We combined studies when the review produced a minimum of two trials employing a particular intervention strategy and a common outcome. We considered the primary outcome to be the ability of the arm to be used for appropriate tasks, called upper extremity activity. Secondary outcomes included upper extremity impairment (such as quality of movement, range of motion, tone, presence of synergistic movement), activities of daily living (ADLs), health-related quality of life (HRQL), economic costs, and adverse events. We assessed risk of bias in the included studies and applied GRADE to assess the certainty of the evidence. We completed subgroup analyses for time since stroke, dosage of MP, type of comparison, and type of arm activity outcome measure.

MAIN RESULTS

We included 25 studies involving 676 participants from nine countries. For the comparison of MP in addition to other treatment versus the other treatment, MP in combination with other treatment appears more effective in improving upper extremity activity than the other treatment without MP (standardized mean difference [SMD] 0.66, 95% confidence interval [CI] 0.39 to 0.94; I² = 39%; 15 studies; 397 participants); the GRADE certainty of evidence score was moderate based on risk of bias for the upper extremity activity outcome. For upper extremity impairment, results were as follows: SMD 0.59, 95% CI 0.30 to 0.87; I² = 43%; 15 studies; 397 participants, with a GRADE score of moderate, based on risk of bias. For ADLs, results were as follows: SMD 0.08, 95% CI -0.24 to 0.39; I² = 0%; 4 studies; 157 participants; the GRADE score was low due to risk of bias and small sample size. For the comparison of MP versus conventional treatment, the only outcome with available data to combine (3 studies; 50 participants) was upper extremity impairment (SMD 0.34, 95% CI -0.33 to 1.00; I² = 21%); GRADE for the impairment outcome in this comparison was low due to risk of bias and small sample size. Subgroup analyses of time post stroke, dosage of MP, or comparison type for the MP in combination with other rehabilitation treatment versus the other treatment comparison showed no differences. The secondary outcome of health-related quality of life was reported in only one study, and no study noted the outcomes of economic costs and adverse events.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that MP in addition to other treatment versus the other treatment appears to be beneficial in improving upper extremity activity. Moderate-certainty evidence also shows that MP in addition to other treatment versus the other treatment appears to be beneficial in improving upper extremity impairment after stroke. Low-certainty evidence suggests that ADLs may not be improved with MP in addition to other treatment versus the other treatment. Low-certainty evidence also suggests that MP versus conventional treatment may not improve upper extremity impairment. Further study is required to evaluate effects of MP on time post stroke, the volume of MP required to affect outcomes, and whether improvement is maintained over the long term.

Induction of plasticity in the human motor system by motor imagery and transcranial magnetic stimulation

KEY POINTS

Delivering transcranial magnetic brain stimulation over the motor cortex during motor imagination leads to enhanced motor output, which is selective for the muscles primarily involved in the imagined movement. This novel protocol may be useful to enhance function after damage to the motor system, such as after stroke.

ABSTRACT

Several paired stimulation paradigms are known to induce plasticity in the motor cortex, reflected by changes in the motor evoked potential (MEP) following the paired stimulation. Motor imagery (MI) is capable of activating the motor system and affecting cortical excitability. We hypothesized that it might be possible to use MI in conjunction with transcranial magnetic stimulation (TMS) to induce plasticity in the human motor system. TMS was delivered to the motor cortex of healthy human subjects, and baseline MEPs recorded from forearm flexor, forearm extensor and intrinsic hand muscles. Subjects were then asked to imagine either wrist flexion or extension movements during TMS delivery (n = 90 trials). Immediately after this intervention, MEP measurement was repeated. Control protocols tested the impact of imagination or TMS alone. Flexion imagination with TMS increased MEPs in flexors and an intrinsic hand muscle. Extensor imagination with TMS increased MEPs in extensor muscles only. The control paradigms did not produce significant changes. We conclude that delivering TMS during MI is capable of inducing plastic changes in the motor system. This new protocol may find utility to enhance functional rehabilitation after brain injury.

Efficacy of Verbally Describing One's Own Body Movement in Motor Skill Acquisition

The present study examined whether (a) verbally describing one’s own body movement can be potentially effective for acquiring motor skills, and (b) if the effects are related to motor imagery. The participants in this study were 36 healthy young adults (21.2 ± 0.7 years), randomly assigned into two groups (describing and control). They performed a ball rotation activity, with the describing group being asked by the examiner to verbally describe their own ball rotation, while the control group was asked to read a magazine aloud. The participants’ ball rotation performances were measured before the intervention, then again immediately after, five minutes after, and one day after. In addition, participants’ motor imagery ability (mental chronometry) of their upper extremities was measured. The results showed that the number of successful ball rotations (motor smoothness) and the number of ball drops (motor error) significantly improved in the describing group. Moreover, improvement in motor skills had a significant correlation with motor imagery ability. This suggests that verbally describing an intervention is an effective tool for learning motor skills, and that motor imagery is a potential mechanism for such verbal descriptions.

Content of inpatient rehabilitation for patients with traumatic brain injury: A comparison of Canadian and American facilities

Objective: To compare components of inpatient rehabilitation (IR) for patients with traumatic brain injury (TBI) between Canada and the US facilities. Design: Secondary analysis of the TBI-practice-based evidence dataset. Participants: Patients with TBI who had a higher Functional Independence Measure (FIM^TM) cognitive function score (≥21) that were admitted to 1 IR facility in Canada (n = 103) and 9 IR facilities in the US (n = 401). Main measures: demographic and clinical characteristics, type and intensity of activities by discipline, discharge location, FIM-Rasch score, social participation and quality of life. Results: Time from injury to rehabilitation admission was significantly longer in the Canadian cohort and they experienced a longer rehabilitation length of stay (p < .001, Cohen's d > .8). Patients in Canada received a greater total time of individual therapy and lower intensity of interventions per week from all disciplines. They also showed a higher score at discharge in FIM components, while US patients had better cognitive recovery and community participation long-term post-discharge. Conclusions: This study informs stakeholders of the large variation in service provision for patients who were treated in these two countries. These findings suggest the need for robust analyzes to investigate predictors of short and long-term outcomes considering the variation in health-care delivery. List of abbreviations: TBI: traumatic brain injury, CSI: comprehensive severity index, LoS: length of stay, OT: occupational therapy, PT: physical therapy, SLP: speech language pathology, IR: inpatient rehabilitation.

Comparison of brain activity between motor imagery and mental rotation of the hand tasks: a functional magnetic resonance imaging study

Motor imagery (MI) has been considered effective in learning and practicing movements in many fields. However, when evaluating the effectiveness of this technique, the examiner has no way of assessing the participant’s motor imagery process. As an alternative, we have been exploring a mental body-part rotation task, in which the examiner can estimate the participant’s motivation and ability to sustain attention through the scored results. In this study, we aimed to investigate the possible application of a mental rotation (MRot) task and used fMRI to compare the brain activity during the MRot task with that during an MI task in healthy volunteers. Increased blood oxygenation level-dependent signals were observed bilaterally in the premotor areas and supplementary motor area during performance of both MI and MRot tasks. Our findings suggest that MRot could be an alternative to MI.

The effects of mental practice based on motor imagery for mobility recovery after subacute stroke: Protocol for a randomized controlled trial

BACKGROUND AND PURPOSE

Mental practice of motor imagery has shown beneficial effects in stroke recovery. However, there are few clinical trials investigating it on the subacute phase. This study will investigate the effects of mental practice in the mobility of patients with subacute stroke.

MATERIALS AND METHODS

Randomized controlled trial including persons with subacute stroke (<3 months). All participants will receive physical exercises and will be randomly allocated into an experimental group (Mental Practice) or into a control group (cognitive training) for 4 weeks(12 sessions).

RESULTS

Primary outcomes will be assessed at baseline and after intervention and will be related to mobility, using Timed Up and Go test and 5 m walking speed test. Whereas secondary outcomes will be muscular strength, biomechanical strategies, mental health and quality of life.

CONCLUSION

The beneficial effects that may be found in this trial can be greatly relevant in clinical practice, justifying this scientific question.

Mental practice for upper limb rehabilitation after stroke: a systematic review and meta-analysis

Mental practice (MP) is usually provided in combination with other therapies, and new developments for neurofeedback to support MP have been made recently. The objectives of this study were to evaluate the effectiveness of MP and to investigate the intervention characteristics including neurofeedback that may affect treatment outcome. The Cochrane Central Register of Controlled Trials, PubMed, Embase, KoreaMed, Scopus, Web of Science, PEDro, and CIRRIE were searched from inception to March 2017 for randomized controlled trials to assess the effect of MP for upper limb rehabilitation after stroke. Fugl-Meyer Assessment (FMA) was used as the outcome measure for meta-analysis. Twenty-five trials met the inclusion criteria, and 15 trials were eligible for meta-analysis. Among the trials selected for meta-analysis, MP was added to conventional therapy in eight trials or to modified constraint-induced movement therapy in one trial. The other trials provided neurofeedback to support MP: MP-guided neuromuscular electrical stimulation (NMES) in four trials and MP-guided robot-assisted therapy (RAT) in two trials. MP added to conventional therapy resulted in significantly higher FMA gain than conventional therapy alone. MP-guided NMES showed superior result than conventional NMES as well. However, the FMA gain of MP-guided RAT was not significantly higher than RAT alone. We suggest that MP is an effective complementary therapy either given with neurofeedback or not. Neurofeedback applied to MP showed different results depending on the therapy provided. This study has limitations because of heterogeneity and inadequate quality of trials. Further research is requested.

Effect of the combination of motor imagery and electrical stimulation on upper extremity motor function in patients with chronic stroke: preliminary results

Background

The combination of motor imagery (MI) and afferent input with electrical stimulation (ES) enhances the excitability of the corticospinal tract compared with motor imagery alone or electrical stimulation alone. However, its therapeutic effect is unknown in patients with hemiparetic stroke. We performed a preliminary examination of the therapeutic effects of MI + ES on upper extremity (UE) motor function in patients with chronic stroke.

Methods

A total of 10 patients with chronic stroke demonstrating severe hemiparesis participated. The imagined task was extension of the affected finger. Peripheral nerve electrical stimulation was applied to the radial nerve at the spiral groove. MI + ES intervention was conducted for 10 days. UE motor function as assessed with the Fugl-Meyer assessment UE motor score (FMA-UE), the amount of the affected UE use in daily life as assessed with a Motor Activity Log (MAL-AOU), and the degree of hypertonia in flexor muscles as assessed with the Modified Ashworth Scale (MAS) were evaluated before and after intervention. To assess the change in spinal neural circuits, reciprocal inhibition between forearm extensor and flexor muscles with the H reflex conditioning-test paradigm at interstimulus intervals (ISIs) of 0, 20, and 100 ms were measured before and after intervention.

Results

UE motor function, the amount of the affected UE use, and muscle hypertonia in flexor muscles were significantly improved after MI + ES intervention (FMA-UE: p < 0.01, MAL-AOU: p < 0.01, MAS: p = 0.02). Neurophysiologically, the intervention induced restoration of reciprocal inhibition from the forearm extensor to the flexor muscles (ISI at 0 ms: p = 0.03, ISI at 20 ms: p = 0.03, ISI at 100 ms: p = 0.01).

Conclusion

MI + ES intervention was effective for improving UE motor function in patients with severe paralysis.

Effects of motor imagery and action observation on hand grip strength, electromyographic activity and intramuscular oxygenation in the hand gripping gesture: A randomized controlled trial

The aim of this study was to evaluate the effects of motor imagery and action observation combined with a hand grip strength program on the forearm muscles. Sixty subjects were selected and randomized into three groups: motor imagery (n = 20), action observation (n = 20), or a control group (n = 20). Outcome measures included hand grip strength, electromyographical activity and intramuscular oxygenation. The hand grip strength significantly increased in the motor imagery (p < .001) and action observation (p < .001) groups compared with the control group, although there were no differences between the both groups (p = .30). In the electromyographical activity, intra-group significant differences were found in motor imagery (p = .002) and action observation (p = .003) groups, although there were no differences between the both groups (p = 1.00) Intramuscular oxygenation results did not show any statistically significant differences between any of the study groups (p > .05). Our results suggest that both motor imagery and action observation training, combined with a hand grip strength program, present a significant strength gain and significant change in the strength and electromyographical activity of the forearm muscles, however no change was found in intramuscular oxygenation.

Yoga for stroke rehabilitation

BACKGROUND

Stroke is a major health issue and cause of long-term disability and has a major emotional and socioeconomic impact. There is a need to explore options for long-term sustainable interventions that support stroke survivors to engage in meaningful activities to address life challenges after stroke. Rehabilitation focuses on recovery of function and cognition to the maximum level achievable, and may include a wide range of complementary strategies including yoga.Yoga is a mind-body practice that originated in India, and which has become increasingly widespread in the Western world. Recent evidence highlights the positive effects of yoga for people with a range of physical and psychological health conditions. A recent non-Cochrane systematic review concluded that yoga can be used as self-administered practice in stroke rehabilitation.

OBJECTIVES

To assess the effectiveness of yoga, as a stroke rehabilitation intervention, on recovery of function and quality of life (QoL).

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched July 2017), Cochrane Central Register of Controlled Trials (CENTRAL) (last searched July 2017), MEDLINE (to July 2017), Embase (to July 2017), CINAHL (to July 2017), AMED (to July 2017), PsycINFO (to July 2017), LILACS (to July 2017), SciELO (to July 2017), IndMED (to July 2017), OTseeker (to July 2017) and PEDro (to July 2017). We also searched four trials registers, and one conference abstracts database. We screened reference lists of relevant publications and contacted authors for additional information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared yoga with a waiting-list control or no intervention control in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies. We performed all analyses using Review Manager (RevMan). One review author entered the data into RevMan; another checked the entries. We discussed disagreements with a third review author until consensus was reached. We used the Cochrane 'Risk of bias' tool. Where we considered studies to be sufficiently similar, we conducted a meta-analysis by pooling the appropriate data. For outcomes for which it was inappropriate or impossible to pool quantitatively, we conducted a descriptive analysis and provided a narrative summary.

MAIN RESULTS

We included two RCTs involving 72 participants. Sixty-nine participants were included in one meta-analysis (balance). Both trials assessed QoL, along with secondary outcomes measures relating to movement and psychological outcomes; one also measured disability.In one study the Stroke Impact Scale was used to measure QoL across six domains, at baseline and post-intervention. The effect of yoga on five domains (physical, emotion, communication, social participation, stroke recovery) was not significant; however, the effect of yoga on the memory domain was significant (mean difference (MD) 15.30, 95% confidence interval (CI) 1.29 to 29.31, P = 0.03), the evidence for this finding was very low grade. In the second study, QoL was assessed using the Stroke-Specifc QoL Scale; no significant effect was found.Secondary outcomes included movement, strength and endurance, and psychological variables, pain, and disability.Balance was measured in both studies using the Berg Balance Scale; the effect of intervention was not significant (MD 2.38, 95% CI -1.41 to 6.17, P = 0.22). Sensititivy analysis did not alter the direction of effect. One study measured balance self-efficacy, using the Activities-specific Balance Confidence Scale (MD 10.60, 95% CI -7.08,= to 28.28, P = 0.24); the effect of intervention was not significant; the evidence for this finding was very low grade.One study measured gait using the Comfortable Speed Gait Test (MD 1.32, 95% CI -1.35 to 3.99, P = 0.33), and motor function using the Motor Assessment Scale (MD -4.00, 95% CI -12.42 to 4.42, P = 0.35); no significant effect was found based on very low-grade evidence.One study measured disability using the modified Rankin Scale (mRS) but reported only whether participants were independent or dependent. No significant effect was found: (odds ratio (OR) 2.08, 95% CI 0.50 to 8.60, P = 0.31); the evidence for this finding was very low grade.Anxiety and depression were measured in one study. Three measures were used: the Geriatric Depression Scale-Short Form (GCDS15), and two forms of State Trait Anxiety Inventory (STAI, Form Y) to measure state anxiety (i.e. anxiety experienced in response to stressful situations) and trait anxiety (i.e. anxiety associated with chronic psychological disorders). No significant effect was found for depression (GDS15, MD -2.10, 95% CI -4.70 to 0.50, P = 0.11) or for trait anxiety (STAI-Y2, MD -6.70, 95% CI -15.35 to 1.95, P = 0.13), based on very low-grade evidence. However, a significant effect was found for state anxiety: STAI-Y1 (MD -8.40, 95% CI -16.74 to -0.06, P = 0.05); the evidence for this finding was very low grade.No adverse events were reported.Quality of the evidenceWe assessed the quality of the evidence using GRADE. Overall, the quality of the evidence was very low, due to the small number of trials included in the review both of which were judged to be at high risk of bias, particularly in relation to incompleteness of data and selective reporting, and especially regarding the representative nature of the sample in one study.

AUTHORS' CONCLUSIONS

Yoga has the potential for being included as part of patient-centred stroke rehabilitation. However, this review has identified insufficient information to confirm or refute the effectiveness or safety of yoga as a stroke rehabilitation treatment. Further large-scale methodologically robust trials are required to establish the effectiveness of yoga as a stroke rehabilitation treatment.

High-Intensity Chronic Stroke Motor Imagery Neurofeedback Training at Home: Three Case Reports

Motor imagery (MI) with neurofeedback has been suggested as promising for motor recovery after stroke. Evidence suggests that regular training facilitates compensatory plasticity, but frequent training is difficult to integrate into everyday life. Using a wireless electroencephalogram (EEG) system, we implemented a frequent and efficient neurofeedback training at the patients' home. Aiming to overcome maladaptive changes in cortical lateralization patterns we presented a visual feedback, representing the degree of contralateral sensorimotor cortical activity and the degree of sensorimotor cortex lateralization. Three stroke patients practiced every other day, over a period of 4 weeks. Training-related changes were evaluated on behavioral, functional, and structural levels. All 3 patients indicated that they enjoyed the training and were highly motivated throughout the entire training regime. EEG activity induced by MI of the affected hand became more lateralized over the course of training in all three patients. The patient with a significant functional change also showed increased white matter integrity as revealed by diffusion tensor imaging, and a substantial clinical improvement of upper limb motor functions. Our study provides evidence that regular, home-based practice of MI neurofeedback has the potential to facilitate cortical reorganization and may also increase associated improvements of upper limb motor function in chronic stroke patients.

Motor Imagery-Based Rehabilitation: Potential Neural Correlates and Clinical Application for Functional Recovery of Motor Deficits after Stroke

Motor imagery (MI), defined as the mental implementation of an action in the absence of movement or muscle activation, is a rehabilitation technique that offers a means to replace or restore lost motor function in stroke patients when used in conjunction with conventional physiotherapy procedures. This article briefly reviews the concepts and neural correlates of MI in order to promote improved understanding, as well as to enhance the clinical utility of MI-based rehabilitation regimens. We specifically highlight the role of the cerebellum and basal ganglia, premotor, supplementary motor, and prefrontal areas, primary motor cortex, and parietal cortex. Additionally, we examine the recent literature related to MI and its potential as a therapeutic technique in both upper and lower limb stroke rehabilitation.

Functional Brain Stimulation in a Chronic Stroke Survivor With Moderate Impairment

OBJECTIVE

To determine the impact of transcranial direct current stimulation (tDCS) combined with repetitive, task-specific training (RTP) on upper-extremity (UE) impairment in a chronic stroke survivor with moderate impairment.

METHOD

The participant was a 54-yr-old woman with chronic, moderate UE hemiparesis after a single stroke that had occurred 10 yr before study enrollment. She participated in 45-min RTP sessions 3 days/wk for 8 wk. tDCS was administered concurrent to the first 20 min of each RTP session.

RESULTS

Immediately after intervention, the participant demonstrated marked score increases on the UE section of the Fugl-Meyer Scale and the Motor Activity Log (on both the Amount of Use and the Quality of Movement subscales).

CONCLUSION

These data support the use of tDCS combined with RTP to decrease impairment and increase UE use in chronic stroke patients with moderate impairment. This finding is crucial, given the paucity of efficacious treatment approaches in this impairment level.

Modulation of motor cortex inhibition during motor imagery

Motor imagery (MI) is similar to overt movement, engaging common neural substrates and facilitating the corticomotor pathway; however, it does not result in excitatory descending motor output. Transcranial magnetic stimulation (TMS) can be used to assess inhibitory networks in the primary motor cortex via measures of 1-ms short-interval intracortical inhibition (SICI), long-interval intracortical inhibition (LICI), and late cortical disinhibition (LCD). These measures are thought to reflect extrasynaptic GABA_A tonic inhibition, postsynaptic GABA_B inhibition, and presynaptic GABA_B disinhibition, respectively. The behavior of 1-ms SICI, LICI, and LCD during MI has not yet been explored. This study aimed to investigate how 1-ms SICI, LICI, and LCD are modulated during MI and voluntary relaxation (VR) of a target muscle. Twenty-five healthy young adults participated. TMS was used to assess nonconditioned motor evoked potential (MEP) amplitude, 1-ms SICI, 100- (LICI₁₀₀) and 150-ms LICI, and LCD in the right abductor pollicis brevis (APB) and right abductor digiti minimi during rest, MI, and VR of the hand. Compared with rest, MEP amplitudes were facilitated in APB during MI. SICI was not affected by task or muscle. LICI₁₀₀ decreased in both muscles during VR but not MI, whereas LCD was recruited in both muscles during both tasks. This indicates that VR modulates postsynaptic GABA_B inhibition, whereas both tasks modulate presynaptic GABA_B inhibition in a non-muscle-specific way. This study highlights further neurophysiological parallels between actual and imagined movement, which may extend to voluntary relaxation.NEW & NOTEWORTHY This is the first study to investigate how 1-ms short-interval intracortical inhibition, long-interval intracortical inhibition, and late cortical disinhibition are modulated during motor imagery and voluntary muscle relaxation. We present novel findings of decreased 100-ms long-interval intracortical inhibition during voluntary muscle relaxation and increased late cortical disinhibition during both motor imagery and voluntary muscle relaxation.

The hybrid BCI system for movement control by combining motor imagery and moving onset visual evoked potential

OBJECTIVE

Movement control is an important application for EEG-BCI (EEG-based brain-computer interface) systems. A single-modality BCI cannot provide an efficient and natural control strategy, but a hybrid BCI system that combines two or more different tasks can effectively overcome the drawbacks encountered in single-modality BCI control.

APPROACH

In the current paper, we developed a new hybrid BCI system by combining MI (motor imagery) and mVEP (motion-onset visual evoked potential), aiming to realize the more efficient 2D movement control of a cursor.

MAIN RESULT

The offline analysis demonstrates that the hybrid BCI system proposed in this paper could evoke the desired MI and mVEP signal features simultaneously, and both are very close to those evoked in the single-modality BCI task. Furthermore, the online 2D movement control experiment reveals that the proposed hybrid BCI system could provide more efficient and natural control commands.

SIGNIFICANCE

The proposed hybrid BCI system is compensative to realize efficient 2D movement control for a practical online system, especially for those situations in which P300 stimuli are not suitable to be applied.

Motor Imagery during Action Observation: A Brief Review of Evidence, Theory and Future Research Opportunities

Motor imagery (MI) and action observation (AO) have traditionally been viewed as two separate techniques, which can both be used alongside physical practice to enhance motor learning and rehabilitation. Their independent use has largely been shown to be effective, and there is clear evidence that the two processes can elicit similar activity in the motor system. Building on these well-established findings, research has now turned to investigate the effects of their combined use. In this article, we first review the available neurophysiological and behavioral evidence for the effects of combined action observation and motor imagery (AO+MI) on motor processes. We next describe a conceptual framework for their combined use, and then discuss several areas for future research into AO+MI processes. In this review, we advocate a more integrated approach to AO+MI techniques than has previously been adopted by movement scientists and practitioners alike. We hope that this early review of an emergent body of research, along with a related set of research questions, can inspire new work in this area. We are optimistic that future research will further confirm if, how, and when this combined approach to AO+MI can be more effective in motor learning and rehabilitation settings, relative to the more traditional application of MI or AO independently.

Effects of Adjuvant Mental Practice on Affected Upper Limb Function Following a Stroke: Results of Three-Dimensional Motion Analysis, Fugl-Meyer Assessment of the Upper Extremity and Motor Activity Logs

Objective

To investigate the effects of adjuvant mental practice (MP) on affected upper limb function following a stroke using three-dimensional (3D) motion analysis.

Methods

In this AB/BA crossover study, we studied 10 hemiplegic patients who had a stroke within the past 6 months. The patients were randomly allocated to two groups: one group received MP combined with conventional rehabilitation therapy for the first 3 weeks followed by conventional rehabilitation therapy alone for the final 3 weeks; the other group received the same therapy but in reverse order. The MP tasks included drinking from a cup and opening a door. MP was individually administered for 20 minutes, 3 days a week for 3 weeks. To assess the tasks, we used 3D motion analysis and three additional tests: the Fugl-Meyer Assessment of the upper extremity (FMA-UE) and the motor activity logs for amount of use (MAL-AOU) and quality of movement (MAL-QOM). Assessments were performed immediately before treatment (T0), 3 weeks into treatment (T1), and 6 weeks into treatment (T2).

Results

Based on the results of the 3D motion analysis and the FMA-UE index (p=0.106), the MAL-AOU scale (p=0.092), and MAL-QOM scale (p=0.273), adjuvant MP did not result in significant improvements.

Conclusion

Adjuvant MP had no significant effect on upper limb function following a stroke, according to 3D motion analysis and three clinical assessment tools (the FMA-UE index and the two MAL scales). The importance of this study is its use of objective 3D motion analysis to evaluate the effects of MP. Further studies will be needed to validate these findings.

Retention of the spacing effect with mental practice in hemiparetic stroke

Mental practice (MP) is a promising adjuvant to physical practice that involves many of the same mechanisms and takes on many of the same properties as physical practice. This study compared efficacy of a "massed" MP regimen versus a "distributed" MP regimen on upper extremity (UE) motor impairment and functional limitation. Twenty-seven chronic stroke survivors were administered the UE section of the Fugl-Meyer (FM) and Action Research Arm Test (ARAT), followed by standardized physical practice and MP regimens. One group was administered "massed" MP (60 min of MP during a single daily session) and a second group administered distributed MP (20 min of MP occurring three times/day). After intervention, changes in FM and ARAT scores of subjects in the distributed condition were significantly higher than those of subjects in the massed condition (FM 3.65, 95 % CI 0.82-6.49, p value = 0.01; ARAT 3.95, 95 % CI 1.24-6.67, p value = 0.006). Likewise, at POST 3, subjects in the distributed group showed significantly higher change in ARAT scores (ARAT 4.90, 95 % CI 0.57-9.22, p value = 0.03); the change in FM scores at POST 3 was 3.18 points higher among subjects in the distributed condition, but only approached significance (95 % CI -1.27 to 7.63, p value = 0.15). Results suggest that a distributed MP schedule is more efficacious in bringing about paretic UE changes than a massed practice schedule, especially in terms of reducing UE functional limitation.

The effects of game-based virtual reality movement therapy plus mental practice on upper extremity function in chronic stroke patients with hemiparesis: a randomized controlled trial

[Purpose] The purpose of this study was to investigate the effects of game-based virtual reality movement therapy plus mental practice on upper extremity function in chronic stroke patients with hemiparesis. [Subjects] The subjects were chronic stroke patients with hemiparesis. [Methods] Thirty subjects were randomly assigned to either the control group or experimental group. All subjects received 20 sessions (5 days in a week) of virtual reality movement therapy using the Nintendo Wii. In addition to Wii-based virtual reality movement therapy, experimental group subjects performed mental practice consisting of 5 minutes of relaxation, Wii games imagination, and normalization phases before the beginning of Wii games. To compare the two groups, the upper extremity subtest of the Fugl-Meyer Assessment, Box and Block Test, and quality of movement subscale of the Motor Activity Log were performed. [Results] Both groups showed statistically significant improvement in the Fugl-Meyer Assessment, Box and Block Test, and quality of the movement subscale of Motor Activity Log after the interventions. Also, there were significant differences in the Fugl-Meyer Assessment, Box and Block Test, and quality of movement subscale of the Motor Activity Log between the two groups. [Conclusion] Game-based virtual reality movement therapy alone may be helpful to improve functional recovery of the upper extremity, but the addition of MP produces a lager improvement.

Mental Practice Combined with Motor Rehabilitation to Treat Upper Limb Hemiparesis of Post-Stroke Patients: Clinical and Experimental Evidence

Stroke is one of the major causes of disability in the world. Due to the extended lifetime of the world's population, the number of people affected by stroke has increased substantially over the last years. Stroke may lead to sensorimotor deficits, usually causing hemiplegia or hemiparesia. In order to reduce motor deficits and accelerate functional recovery, MP combined with motor rehabilitation was introduced to the rehabilitation process of post-stroke patients. Evidence has shown that MP combining with motor rehabilitation based on activities of daily living was more effective than conventional motor rehabilitation used per se. This combination proved very useful and effective, with significant results in improvement of motor deficits in post-stroke patients. However, further studies must be conducted to determine specific parameters, such as type of imagery, frequency or duration.

Relationship between functional connectivity and motor function assessment in stroke patients with hemiplegia: a resting-state functional MRI study

INTRODUCTION

Resting-state functional magnetic resonance imaging (fMRI) has been used to examine the brain mechanisms of stroke patients with hemiplegia, but the relationship between functional connectivity (FC) and treatment-induced motor function recovery has not yet been fully investigated. This study aimed to identify the brain FC changes in stroke patients and study the relationship between FC and motor function assessment using the resting-state fMRI.

METHODS

Seventeen stroke patients with hemiplegia and fifteen healthy control subjects (HCSs) were recruited in this study. We compared the FC between the ipsilesional primary motor cortex (M1) and the whole brain of the patients with the FC of the HCSs and studied the FC changes in the patients before and after conventional rehabilitation and motor imagery therapy. Additionally, correlations between the FC change and motor function of the patients were studied.

RESULTS

Compared to the HCSs, the FC in the patient group was significantly increased between the ipsilesional M1 and the ipsilesional inferior parietal cortex, frontal gyrus, supplementary motor area (SMA), and contralesional angular and decreased between the ipsilesional M1 and bilateral M1. After the treatment, the FC between the ipsilesional M1 and contralesional M1 increased while the FC between the ipsilesional M1 and ipsilesional SMA and paracentral lobule decreased. A statistically significant correlation was found between the FC change in the bilateral M1 and the Fugl-Meyer assessment (FMA) score change.

CONCLUSION

Our results revealed an abnormal motor network after stroke and suggested that the FC could serve as a biomarker of motor function recovery in stroke patients with hemiplegia.