Efficacy of motor imagery additional to motor-based therapy in the recovery of motor function of the upper limb in post-stroke individuals: a systematic review

Segmentary exclusion syndrome in hand traumatology - definition, rehabilitation and orthosis

BACKGROUND

Segmentary exclusion syndrome is a motor behavioral disorder consisting in non-use or underuse of a limb or limb segment following local inflammation, most often of traumatic origin, primarily affecting the fingers and hand. It can be associated with somatosensory disorder, limitation of range of motion, and pain.

PURPOSE OF THE STUDY

The objective of this article is to further describe segmentary exclusion syndrome, and to present practical rehabilitation techniques and strategies focused on prevention, assessment and treatment.

Immersive VR for upper-extremity rehabilitation in patients with neurological disorders: a scoping review

BACKGROUND

Neurological disorders, such as stroke and chronic pain syndromes, profoundly impact independence and quality of life, especially when affecting upper extremity (UE) function. While conventional physical therapy has shown effectiveness in providing some neural recovery in affected individuals, there remains a need for improved interventions. Virtual reality (VR) has emerged as a promising technology-based approach for neurorehabilitation to make the patient's experience more enjoyable. Among VR-based rehabilitation paradigms, those based on fully immersive systems with headsets have gained significant attention due to their potential to enhance patient's engagement.

METHODS

This scoping review aims to investigate the current state of research on the use of immersive VR for UE rehabilitation in individuals with neurological diseases, highlighting benefits and limitations. We identified thirteen relevant studies through comprehensive searches in Scopus, PubMed, and IEEE Xplore databases. Eligible studies incorporated immersive VR for UE rehabilitation in patients with neurological disorders and evaluated participants' neurological and motor functions before and after the intervention using clinical assessments.

RESULTS

Most of the included studies reported improvements in the participants rehabilitation outcomes, suggesting that immersive VR represents a valuable tool for UE rehabilitation in individuals with neurological disorders. In addition, immersive VR-based interventions hold the potential for personalized and intensive training within a telerehabilitation framework. However, further studies with better design are needed for true comparison with traditional therapy. Also, the potential side effects associated with VR head-mounted displays, such as dizziness and nausea, warrant careful consideration in the development and implementation of VR-based rehabilitation programs.

CONCLUSION

This review provides valuable insights into the application of immersive VR in UE rehabilitation, offering the foundation for future research and clinical practice. By leveraging immersive VR's potential, researchers and rehabilitation specialists can design more tailored and patient-centric rehabilitation strategies, ultimately improving the functional outcome and enhancing the quality of life of individuals with neurological diseases.

A systematic review on functional electrical stimulation based rehabilitation systems for upper limb post-stroke recovery

Background

Stroke is one of the most common neurological conditions that often leads to upper limb motor impairments, significantly affecting individuals' quality of life. Rehabilitation strategies are crucial in facilitating post-stroke recovery and improving functional independence. Functional Electrical Stimulation (FES) systems have emerged as promising upper limb rehabilitation tools, offering innovative neuromuscular reeducation approaches.

Objective

The main objective of this paper is to provide a comprehensive systematic review of the start-of-the-art functional electrical stimulation (FES) systems for upper limb neurorehabilitation in post-stroke therapy. More specifically, this paper aims to review different types of FES systems, their feasibility testing, or randomized control trials (RCT) studies.

Methods

The FES systems classification is based on the involvement of patient feedback within the FES control, which mainly includes "Open-Loop FES Systems" (manually controlled) and "Closed-Loop FES Systems" (brain-computer interface-BCI and electromyography-EMG controlled). Thus, valuable insights are presented into the technological advantages and effectiveness of Manual FES, EEG-FES, and EMG-FES systems.

Results and discussion

The review analyzed 25 studies and found that the use of FES-based rehabilitation systems resulted in favorable outcomes for the stroke recovery of upper limb functional movements, as measured by the FMA (Fugl-Meyer Assessment) (Manually controlled FES: mean difference = 5.6, 95% CI (3.77, 7.5), P < 0.001; BCI-controlled FES: mean difference = 5.37, 95% CI (4.2, 6.6), P < 0.001; EMG-controlled FES: mean difference = 14.14, 95% CI (11.72, 16.6), P < 0.001) and ARAT (Action Research Arm Test) (EMG-controlled FES: mean difference = 11.9, 95% CI (8.8, 14.9), P < 0.001) scores. Furthermore, the shortcomings, clinical considerations, comparison to non-FES systems, design improvements, and possible future implications are also discussed for improving stroke rehabilitation systems and advancing post-stroke recovery. Thus, summarizing the existing literature, this review paper can help researchers identify areas for further investigation. This can lead to formulating research questions and developing new studies aimed at improving FES systems and their outcomes in upper limb rehabilitation.

Re-learning mental representation of walking after a brain lesion. Effects of a cognitive-motor training with a robotic orthosis

Introduction

Stroke-related deficits often include motor impairments and gait dysfunction, leading to a limitation of social activities and consequently affecting the quality of life of stroke survivors. Neurorehabilitation takes advantage of the contribution of different techniques in order to achieve more benefits for patients. Robotic devices help to improve the outcomes of physical rehabilitation. Moreover, motor imagery seems to play a role in neurological rehabilitation since it leads to the activation of the same brain areas as actual movements. This study investigates the use of a combined physical and cognitive protocol for gait rehabilitation in stroke patients.

Methods

Specifically, we tested the efficacy of a 5-week training program using a robotic orthosis (P.I.G.R.O.) in conjunction with motor imagery training. Twelve chronic stroke patients participated in the study. We evaluated balance and gait performance before and after the training. Six of them underwent fMRI examination before and after the training to assess the effects of the protocol on brain plasticity mechanisms in motor and imagery tasks.

Results

Our results show that the rehabilitation protocol can effectively improve gait performance and balance and reduce the risk of falls in stroke patients. Furthermore, the fMRI results suggest that rehabilitation is associated with cerebral plastic changes in motor networks.

Discussion

The present findings, if confirmed by future research, have the potential to advance the development of new, more effective rehabilitation approaches for stroke patients, improving their quality of life and reducing the burden of stroke-related disability.

Time to reconcile research findings and clinical practice on upper limb neurorehabilitation

The problem

In the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs.

Proposed solutions

The objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions.

Conclusions

It's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery.

The Association between Mental Motor Imagery and Real Movement in Stroke

Background: Stroke is the main cause of disability in adults; the most common and long-term sequela is upper-limb hemiparesis. Many studies support the idea that mental motor imagery, which is related to the visualization of movement patterns, activates the same areas of the cortex as if the movement occurred. Objectives: This study aims to examine the capacity to elaborate mental motor images, as well as its relationship to loss of movement in the upper limbs after a stroke. Method: An observational study, in a sample of 39 adults who suffered a stroke, was carried out. The upper limb movement and functionality, cognitive disorders, the ability to visualize mental images, and activities of daily living were examined. Results: The results depicted a statistically significant correlation between the ability to visualize upper limb mental motor images with movement, functionality, and strength. In addition, a correlation between visual–spatial skills and mental visualization of motor ability and upper limb movement was found. Conclusions: These results suggest that the rehabilitation approach focused on the improvement of mental motor imagery could be of interest for the upper limb rehabilitation of movement and functionality.

Emergence of flexible technology in developing advanced systems for post-stroke rehabilitation: a comprehensive review

OBJECTIVE

Stroke is one of the most common neural disorders, which causes physical disabilities and motor impairments among its survivors. Several technologies have been developed for providing stroke rehabilitation and to assist the survivors in performing their daily life activities. Currently, the use of flexible technology (FT) for stroke rehabilitation systems is on a rise that allows the development of more compact and lightweight wearable systems, which stroke survivors can easily use for long-term activities.

APPROACH

For stroke applications, FT mainly includes the "flexible/stretchable electronics", "e-textile (electronic textile)" and "soft robotics". Thus, a thorough literature review has been performed to report the practical implementation of FT for post-stroke application.

MAIN RESULTS

In this review, the highlights of the advancement of FT in stroke rehabilitation systems are dealt with. Such systems mainly involve the "biosignal acquisition unit", "rehabilitation devices" and "assistive systems". In terms of biosignals acquisition, electroencephalography (EEG) and electromyography (EMG) are comprehensively described. For rehabilitation/assistive systems, the application of functional electrical stimulation (FES) and robotics units (exoskeleton, orthosis, etc.) have been explained.

SIGNIFICANCE

This is the first review article that compiles the different studies regarding flexible technology based post-stroke systems. Furthermore, the technological advantages, limitations, and possible future implications are also discussed to help improve and advance the flexible systems for the betterment of the stroke community.

Does Real-Time Feedback Affect Sensorimotor EEG Patterns in Routine Motor Imagery Practice?

Background. Motor imagery engages much of the same neural circuits as an overt movement. Therefore, the mental rehearsal of movements is often used to supplement physical training and might aid motor neurorehabilitation after stroke. One attempt to capture the brain’s involvement in imagery involves the use, as a marker, of the depression or event-related desynchronization (ERD) of thalamocortical sensorimotor rhythms found in a human electroencephalogram (EEG). Using fast real-time processing, it is possible to make the subject aware of their own brain reactions or—even better—to turn them into actions through a technology called the brain–computer interface (BCI). However, it remains unclear whether BCI-enabled imagery facilitates a stronger or qualitatively different brain response compared to the open-loop training. Methods. Seven healthy volunteers who were experienced in both closed and open-loop motor imagery took part in six experimental sessions over a period of 4.5 months, in which they performed kinesthetic imagery of a previously known set of finger and arm movements with simultaneous 30-channel EEG acquisition. The first and the last session mostly consisted of feedback trials in which the subjects were presented with the classification results of the EEG patterns in real time; during the other sessions, no feedback was provided. Spatiotemporal and amplitude features of the ERD patterns concomitant with imagery were compared across experimental days and between feedback conditions using linear mixed-effects modeling. Results. The main spatial sources of ERD appeared to be highly stable across the six experimental days, remaining nearly identical in five of seven subjects (Pearson’s ρ > 0.94). Only in one subject did the spatial pattern of activation statistically significantly differ (p = 0.009) between the feedback and no-feedback conditions. Real-time visual feedback delivered through the BCI did not significantly increase the ERD strength. Conclusion. The results imply that the potential benefits of MI could be yielded by well-habituated subjects with a simplified open-loop setup, e.g., through at-home self-practice.

Influence of the visuo-proprioceptive illusion of movement and motor imagery of the wrist on EEG cortical excitability among healthy participants

INTRODUCTION

Motor Imagery (MI) is a powerful tool to stimulate sensorimotor brain areas and is currently used in motor rehabilitation after a stroke. The aim of our study was to evaluate whether an illusion of movement induced by visuo-proprioceptive immersion (VPI) including tendon vibration (TV) and Virtual moving hand (VR) combined with MI tasks could be more efficient than VPI alone or MI alone on cortical excitability assessed using Electroencephalography (EEG).

METHODS

We recorded EEG signals in 20 healthy participants in 3 different conditions: MI tasks involving their non-dominant wrist (MI condition); VPI condition; and VPI with MI tasks (combined condition). Each condition lasted 3 minutes, and was repeated 3 times in randomized order. Our main judgment criterion was the Event-Related De-synchronization (ERD) threshold in sensori-motor areas in each condition in the brain motor area.

RESULTS

The combined condition induced a greater change in the ERD percentage than the MI condition alone, but no significant difference was found between the combined and the VPI condition (p = 0.07) and between the VPI and MI condition (p = 0.20).

CONCLUSION

This study demonstrated the interest of using a visuo-proprioceptive immersion with MI rather than MI alone in order to increase excitability in motor areas of the brain. Further studies could test this hypothesis among patients with stroke to provide new perspectives for motor rehabilitation in this population.

Pain, No Gain: Acute Pain Interrupts Motor Imagery Processes and Affects Mental Training-Induced Plasticity

Pain influences both motor behavior and neuroplastic adaptations induced by physical training. Motor imagery (MI) is a promising method to recover motor functions, for instance in clinical populations with limited endurance or concomitant pain. However, the influence of pain on the MI processes is not well established. This study investigated whether acute experimental pain could modulate corticospinal excitability assessed at rest and during MI (Exp. 1) and limit the use-dependent plasticity induced by MI practice (Exp. 2). Participants imagined thumb movements without pain or with painful electrical stimulations applied either on digit V or over the knee. We used transcranial magnetic stimulation to measure corticospinal excitability at rest and during MI (Exp. 1) and to evoke involuntary thumb movements before and after MI practice (Exp. 2). Regardless of its location, pain prevented the increase of corticospinal excitability that is classically observed during MI. In addition, pain blocked use-dependent plasticity following MI practice, as testified by a lack of significant posttraining deviations. These findings suggest that pain interferes with MI processes, preventing the corticospinal excitability facilitation needed to induce use-dependent plasticity. Pain should be carefully considered for rehabilitation programs using MI to restore motor function.

Feasibility of motor imagery and effects of activating and relaxing practice on autonomic functions in healthy young adults: A randomised, controlled, assessor-blinded, pilot trial

Introduction

Motor imagery (MI) is the mental rehearsal of a motor task. Between real and imagined movements, a functional equivalence has been described regarding timing and brain activation. The primary study aim was to investigate the feasibility of MI training focusing on the autonomic function in healthy young people. Further aims were to evaluate participants’ MI abilities and compare preliminary effects of activating and relaxing MI on autonomic function and against controls.

Methods

A single-blinded randomised controlled pilot trial was performed. Participants were randomised to the activating MI (1), relaxing MI (2), or control (3) group. Following a MI familiarisation, they practiced home-based kinaesthetic MI for 17 minutes, 5 times/week for 2 weeks. Participants were called once for support. The primary outcome was the feasibility of a full-scale randomised controlled trial using predefined criteria. Secondary outcomes were participants’ MI ability using the Movement Imagery Questionnaire-Revised, mental chronometry tests, hand laterality judgement and semi-structured interviews, autonomic function.

Results

A total of 35 participants completed the study. The feasibility of a larger study was confirmed, despite 35% attrition related to the COVID-19 pandemic. Excellent MI capabilities were seen in participants, and significant correlations between MI ability measures. Interview results showed that participants accepted or liked both interventions. Seven major themes and insider recommendations for MI interventions emerged. No significant differences and negligible to medium effects were observed in MI ability or autonomic function between baseline and post-intervention measures or between groups.

Conclusions

Results showed that neither activating nor relaxing MI seems to change autonomic function in healthy individuals. Further adequately powered studies are required to answer open questions remaining from this study. Future studies should investigate effects of different MI types over a longer period, to rule out habituation and assess autonomic function at several time points and simultaneously with MI.

Dynamic Modeling of Common Brain Neural Activity in Motor Imagery Tasks

Evaluation of brain dynamics elicited by motor imagery (MI) tasks can contribute to clinical and learning applications. The multi-subject analysis is to make inferences on the group/population level about the properties of MI brain activity. However, intrinsic neurophysiological variability of neural dynamics poses a challenge for devising efficient MI systems. Here, we develop a time-frequency model for estimating the spatial relevance of common neural activity across subjects employing an introduced statistical thresholding rule. In deriving multi-subject spatial maps, we present a comparative analysis of three feature extraction methods: Common Spatial Patterns, Functional Connectivity, and Event-Related De/Synchronization. In terms of interpretability, we evaluate the effectiveness in gathering MI data from collective populations by introducing two assumptions: (i) Non-linear assessment of the similarity between multi-subject data originating the subject-level dynamics; (ii) Assessment of time-varying brain network responses according to the ranking of individual accuracy performed in distinguishing distinct motor imagery tasks (left-hand vs. right-hand). The obtained validation results indicate that the estimated collective dynamics differently reflect the flow of sensorimotor cortex activation, providing new insights into the evolution of MI responses.

Entropy-Based Estimation of Event-Related De/Synchronization in Motor Imagery Using Vector-Quantized Patterns

Assessment of brain dynamics elicited by motor imagery (MI) tasks contributes to clinical and learning applications. In this regard, Event-Related Desynchronization/Synchronization (ERD/S) is computed from Electroencephalographic signals, which show considerable variations in complexity. We present an Entropy-based method, termed VQEnt, for estimation of ERD/S using quantized stochastic patterns as a symbolic space, aiming to improve their discriminability and physiological interpretability. The proposed method builds the probabilistic priors by assessing the Gaussian similarity between the input measured data and their reduced vector-quantized representation. The validating results of a bi-class imagine task database (left and right hand) prove that VQEnt holds symbols that encode several neighboring samples, providing similar or even better accuracy than the other baseline sample-based algorithms of Entropy estimation. Besides, the performed ERD/S time-series are close enough to the trajectories extracted by the variational percentage of EEG signal power and fulfill the physiological MI paradigm. In BCI literate individuals, the VQEnt estimator presents the most accurate outcomes at a lower amount of electrodes placed in the sensorimotor cortex so that reduced channel set directly involved with the MI paradigm is enough to discriminate between tasks, providing an accuracy similar to the performed by the whole electrode set.

Review on motor imagery based BCI systems for upper limb post-stroke neurorehabilitation: From designing to application

Strokes are a growing cause of mortality and many stroke survivors suffer from motor impairment as well as other types of disabilities in their daily life activities. To treat these sequelae, motor imagery (MI) based brain-computer interface (BCI) systems have shown potential to serve as an effective neurorehabilitation tool for post-stroke rehabilitation therapy. In this review, different MI-BCI based strategies, including "Functional Electric Stimulation, Robotics Assistance and Hybrid Virtual Reality based Models," have been comprehensively reported for upper-limb neurorehabilitation. Each of these approaches have been presented to illustrate the in-depth advantages and challenges of the respective BCI systems. Additionally, the current state-of-the-art and main concerns regarding BCI based post-stroke neurorehabilitation devices have also been discussed. Finally, recommendations for future developments have been proposed while discussing the BCI neurorehabilitation systems.

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.

What are the determinants of explicit and implicit motor imagery ability in stroke patients?: a controlled study

Purpose: The purposes of the study were to (a) investigate both explicit and implicit motor imagery ability (MIA) impairment after stroke, (b) examine predictive effects of clinical characteristics for MIA after stroke.Materials and Methods: Forty one patients with stroke (PwS) (mean age 59.41 ± 10.19 years; %41 female) and 36 healthy participants (mean age 62.47 ± 9.29 years; %47 female) completed Chaotic Motor Imagery Assessment-Hand Rotation for implicit MIA and Movement Imagery Questionnaire-3 (MIQ-3) and Box and Block Test (BBT) for explicit MIA. The severity of motor and sensory impairments were determined by the Fugl-Meyer Assessment-Upper Extremity (FMAUE) scores. The Turkish version of Motor Activity Log-28 was used to assess amount of use (AUS) and quality of movement in daily life.Results: Our results indicated that both implicit and explicit MIA (except kinaesthetic imagery of MIQ-3) in PwS were statistically impaired compared to controls (p < 0.05). The sensorimotor impairment level, amount of use and movement quality of the affected upper limb were found to be correlated with MIA in various degrees. Total motor scores in FMAUE and AUS were significant predictors of explicit MIA (p < 0.01). Additionally, explicit MIA scores of stroke subgroups were statistically different between severely and mildly impaired patients, in favour of mildly impaired group (p < 0.05).Conclusion: In conclusion, both motor impairment level and amount of daily use of upper extremity were found to be predictive factors for explicit MIA. Further investigation with brain imaging techniques is needed to explore the validity of these findings in establishing MIA.