Dawn M. Nilsen

Motor imagery training in hemiplegic cerebral palsy: a potentially useful therapeutic tool for rehabilitation

Converging evidence indicates that motor deficits in cerebral palsy (CP) are related not only to problems with execution, but also to impaired motor planning. Current rehabilitation mainly focuses on alleviating compromised motor execution. Motor imagery is a promising method of training the more ‘cognitive’ aspects of motor behaviour, and may, therefore, be effective in facilitating motor planning in patients with CP. In this review first we present the specific motor planning problems in CP followed by a discussion of motor imagery and its use in clinical practice. Second, we present the steps to be taken before motor imagery can be used for rehabilitation of upper limb functioning in CP. Motor imagery training has been shown to be a useful addition to existing rehabilitation protocols for poststroke rehabilitation. No such study has been conducted in CP. The age at which children can reliably use motor imagery, as well as the specific way in which motor imagery training needs to be implemented, must be researched before motor imagery training can be employed in children with CP. Based on the positive results for poststroke rehabilitation, and in light of the motor problems in CP, motor imagery training may be a valuable additional tool for rehabilitation in CP.

Effect of Imagery Perspective on Occupational Performance After Stroke: A Randomized Controlled Trial

OBJECTIVE This preliminary study sought to determine whether the imagery perspective used during mental practice (MP) differentially influenced performance outcomes after stroke. METHOD Nineteen participants with unilateral subacute stroke (9 men and 10 women, ages 28-77) were randomly allocated to one of three groups. All groups received 30-min occupational therapy sessions 2×/wk for 6 wk. Experimental groups received MP training in functional tasks using either an internal or an external perspective; the control group received relaxation imagery training. Participants were pre- and posttested using the Fugl-Meyer Motor Assessment (FMA), the Jebsen-Taylor Test of Hand Function (JTTHF), and the Canadian Occupational Performance Measure (COPM). RESULTS At posttest, the internal and external experimental groups showed statistically similar improvements on the FMA and JTTHF (p < .05). All groups improved on the COPM (p < .05). CONCLUSION MP combined with occupational therapy improves upper-extremity recovery after stroke. MP does not appear to enhance self-perception of performance. This preliminary study suggests that imagery perspective may not be an important variable in MP interventions.

Chronic stroke outcome measures for motor function intervention trials: Expert panel recommendations

Background—About half of survivors with stroke experience severe and significant long-term disability. The purpose of this article is to review the state of the science and to make recommendations for measuring patient-centric outcomes in interventions for motor improvement in the chronic stroke phase. Methods and Results—A 9-member expert panel reviewed evidence to identify measures of upper and lower extremity function used to date as outcomes in trials with patients who experienced a stroke ≥6 months before assessment. Outcome measures were screened using StrokEDGE consensus panel recommendations, and evaluated for availability of a published minimal clinically important difference. Measures meeting these criteria were further evaluated with regard to their level of measurement, psychometric properties, and ability of minimal clinically important difference to capture gains associated with improved function and clinical relevance to patients, to arrive at recommendations. A systematic literature review yielded 115 clinical trials of upper and lower extremity function in chronic stroke that used a total of 34 outcome measures. Seven of these had published minimal clinically important differences and were recommended or highly recommended by StrokEDGE. Those are the Fugl-Meyer Upper Extremity and Lower Extremity scales, Wolf Motor Function Test, Action Research Arm Test, Ten-Meter and Six-Minute Walk Tests, and the Stroke Impact Scale. All had evidence for their psychometric performance, although the strength of evidence for validity varied, especially in populations with chronic stroke Fugl-Meyer Upper and Lower Extremity scales showing the strongest evidence for validity. Conclusions—The panel recommends that the Fugl-Meyer Upper and Lower Extremity scales be used as primary outcomes in intervention trials targeting motor function in populations with chronic stroke. The other 6 measures are recommended as secondary outcomes.

Using mirror therapy in the home environment: a case report.

OBJECTIVE Mirror therapy (MT) is a potential intervention to improve function after stroke. How to apply this intervention in practice is not clear. This case report illustrates the feasibility and effectiveness of a self-administered home-based MT program. METHOD A home-based MT program was practiced over 5 wk. The participant was encouraged to use MT for 30 min 5×/wk. Therapist contact occurred 1×/wk to monitor performance. An independent evaluator administered three outcome measures pre- and postintervention: Upper Extremity Sensory and Pain sections of the Fugl-Meyer Assessment; Jebsen-Taylor Test of Hand Function, and the Manual Ability Measure-20. RESULTS The participant engaged in a mean of 39.23 (±7.44) min of MT per day and used a variety of the recommended activities. Change scores indicated improvement on all of the included outcome measures. CONCLUSION This case report suggests that a predominantly self-administered home-based MT program is feasible and effective at improving function after stroke.

The feasibility and effectiveness of using prism adaptation to treat motor and spatial dysfunction in stroke survivors with multiple incidents of stroke

ABSTRACT Background Strokes resulting in cognitive and motor problems can be debilitating and prolong recovery. Risk of a second stroke occurs for 40% of all first-time stroke survivors within five years. Prism adaptation treatment (PAT) may simultaneously improve functions of both spatial and motor systems. This has not been studied with a cohort comprised of multiple strokes nor measured change using specific motor outcomes. Objectives To determine the feasibility and effectiveness of using PAT to improve spatial and motor functions in stroke survivors with multiple strokes. Method A prospective intervention with retrospective comparison. Thirteen participants from an inpatient rehabilitation facility (IRF) comprised the treatment group; 13 others who only received standard care comprised the comparison group. Treatment group tested on: 4 motor and 3 spatial outcome measures before and after the 10 PAT sessions. The comparison group tested on: 1 motor and 3 spatial measures before and after standard care. Results Thirteen participants successfully completed the PAT. Both groups improved on measures of spatial neglect over time (p < .001), but the treatment group showed greater improvement on two subtests of spatial function (Behavior inattention test) (p = .001 & p = .002). Similarly, both groups improved in motor function (Functional independence measure) (p < .001), although the treatment group’s improvement was not statistically significant against the comparison group (p = .853). Conclusion PAT is a feasible treatment for stroke survivors with multiple strokes. PAT did improve spatial neglect function more than standard care, only at one level of analysis of standard paper and pencil measures. Further research is necessary.

Occupational Therapy Interventions for Adults With Stroke.

Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Associations (AOTAs) Evidence-Based Practice project. The clinical condition discussed in this inaugural Evidence Connection article is adults with stroke. Findings from the systematic reviews on this topic were published in the January/February 2015 issue of the American Journal of Occupational Therapy and in AOTAs Occupational Therapy Practice Guidelines for Adults With Stroke (Wolf & Nilsen, 2015). Each article in this series will summarize the evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. Evidence Connection articles illustrate how the research evidence from the reviews can be used to inform and guide clinical decision making.