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

Francine Malouin, Philip L Jackson, Carol L Richards, Francine Malouin, Philip L Jackson, Carol L Richards

Abstract

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

Keywords: Parkinson's disease; mental practice; motor imagery; motor imagery training; motor skill learning; neurological rehabilitation; stroke; stroke rehabilitation.

Figures

Figure 1
Figure 1
Schematic representation of the time dedicated to Motor Imagery training (MI) and Physical Practice (PP) for each mode of MI delivery. The vertical lines indicate the proportion of time for relaxation (prior to MI) and refocusing (after MI). More time is allotted to PP than MI training in the separate mode of MI delivery, whereas in the other two modes more time is devoted to MI training.
Figure 2
Figure 2
Bar graphs illustrating the mean changes in Arm Research Action Test (ARAT) and Fugl-Meyer Assessment (FMA). The dotted line represents the Minimal Clinically Important Difference (MCID) for each outcome measure.
Figure 3
Figure 3
Bar graph illustrating the mean changes (cm/s) in gait speed (upper graph) and the mean changes (in seconds) for the Timed Up and Go (TUG) test in patients with chronic stroke. The dotted line (upper graph) indicates the Minimal Clinically Important Difference.
Figure 4
Figure 4
Schema illustrating the patterns of responses when manipulating the amount of MI training and physical practice (PP) in the studies investigating the effects of MI interventions on ADL tasks of the upper limb and on walking. The addition of MI to PP promotes motor performance in ADL for the upper limb (Gain) and this performance is further enhanced with more PP, but not with longer MI sessions; for walking, however, MI alone promotes walking speed as much as MI plus treadmill walking.
Figure 5
Figure 5
Schematic representation of a framework for integrating MI training in current clinical practice.

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