Melanie Kleynen

Using mental practice in stroke rehabilitation: a framework

Introduction: Motor imagery and mental practice are getting increased attention in neurological rehabilitation. Several different mental practice intervention protocols have been used in studies on its effect on recovery in stroke rehabilitation. The content of the intervention protocols itself is rarely discussed or questioned. Objective: To give a practical framework of how mental practice could be integrated into therapy, drawing on available evidence and theory. The aim of the treatment programme described is to enhance both the patients physical performance and their empowerment and self-determination. The framework: Based on evidence from sports rehabilitation and our own experiences the framework will eventually be evaluated in a randomized controlled trial. Five steps are described to teach and upgrade the patients imagery technique: (1) assess mental capacity to learn imagery technique; (2) establish the nature of mental practice; (3) teach imagery technique; (4) embed and monitor imagery technique; (5) develop self-generated treatments. The description is not, however, a recipe that should be followed precisely. It leaves enough room to tailor the mental practice intervention to the specific individual possibilities, skills and needs of the patient in accordance with evidence-based practice. Discussion: Different aspects of the described protocol are discussed and compared with experiences from sports and evidence available in rehabilitation.

The effects of mental practice in neurological rehabilitation; a systematic review and meta-analysis.

Objective: To investigate the beneficial and adverse effects of a mental practice intervention on activities, cognition, and emotion in patients after stroke, patients with Parkinsons disease or multiple sclerosis. Methods: Electronic databases PubMed/Medline, PEDro, Science Direct, Cochrane Library, PsycINFO, Rehadat, Embase, and Picarta were searched until June 2012. Fourteen randomized controlled trials in stroke and two randomized controlled trials in Parkinsons disease were included, representing 491 patients (421 with stroke). No randomized controlled trials in multiple sclerosis were identified. The methodologic quality of the included trials was assessed with the Amsterdam-Maastricht-Consensus-List (AMCL). Information on study characteristics and outcomes was summarized and evidence for effects described. Data from individual studies in stroke with same outcome measures were pooled. Results: The included 16 randomized controlled trials were heterogeneous and methodologic quality varied. Ten trials reported significant effects in favor of mental practice in patients with stroke (n = 9) and Parkinsons disease (n = 1). In six studies mental practice had similar effects as therapy as usual (n = 5 in stroke and n = 1 in Parkinsons disease). Of six performed meta-analyses with identical measures in stroke studies only two showed significant effects of mental practice: short-term improvement of arm-hand-ability (ARAT: SMD 0.62; 95% CI: 0.05 to 1.19) and improvement of performance of activities (NRS: SMD 0.9; 95% CI: 0.04 to 1.77). Five studies found effects on cognition (e.g., effects on attention, plan actions in unfamiliar surroundings) and four reported observed side-effects, both positive (e.g., might increase motivation and arousal and reduce depression) and negative (e.g., diminished concentration, irritation). Conclusions: Mental practice might have positive effects on performance of activities in patients with neurological diseases, but this review reports less positive results than earlier published ones. Strengths and limitations of past studies are pointed out. Methodologic recommendations for future studies are given.

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

QUESTIONS Is mental practice embedded in standard physiotherapy compared with relaxation embedded in standard physiotherapy more effective at improving mobility tasks in people with Parkinsons disease in the community? Does disease severity influence the treatment effect? DESIGN A multicentre randomised controlled trial. PARTICIPANTS People with Parkinsons disease. INTERVENTION During a six-week intervention period, both groups received physiotherapy as usual with the addition of either mental practice (experimental group) or relaxation (control group). Imagery skills were taught using a four-step protocol. Movement imagery (in thought) and the performance of motor activities were combined. OUTCOME MEASURES Outcomes were assessed at six weeks and three months with: the patient- and therapist-perceived effect on walking performance (visual analogue scale), the Timed Up and Go test, and the 10 m Walk test. Primary analysis was performed using intention-totreat and was repeated as a per-protocol analysis, and as a sub-group analysis of participants with Hoehn and Yahr stage of less than 3. Generalised estimating equations were used to analyse effects. RESULTS 47 participants were assigned to the control (n = 22) and experimental (n = 25) groups. No effect in favour of the mental practice intervention on any outcome measure could be detected at any of the measurement points. In the sub-group analysis of participants with milder disease, the experimental group improved more than the control group but this was not statistically significant. CONCLUSION In this study, we did not find differences between embedded mental practice and relaxation with current standard of care. TRIAL REGISTRATION Nederlands Trial Register: NTR1735.

Using a Delphi Technique to Seek Consensus Regarding Definitions, Descriptions and Classification of Terms Related to Implicit and Explicit Forms of Motor Learning

Background Motor learning is central to domains such as sports and rehabilitation; however, often terminologies are insufficiently uniform to allow effective sharing of experience or translation of knowledge. A study using a Delphi technique was conducted to ascertain level of agreement between experts from different motor learning domains (i.e., therapists, coaches, researchers) with respect to definitions and descriptions of a fundamental conceptual distinction within motor learning, namely implicit and explicit motor learning. Methods A Delphi technique was embedded in multiple rounds of a survey designed to collect and aggregate informed opinions of 49 international respondents with expertise related to motor learning. The survey was administered via an online survey program and accompanied by feedback after each round. Consensus was considered to be reached if ≥70% of the experts agreed on a topic. Results Consensus was reached with respect to definitions of implicit and explicit motor learning, and seven common primary intervention strategies were identified in the context of implicit and explicit motor learning. Consensus was not reached with respect to whether the strategies promote implicit or explicit forms of learning. Discussion The definitions and descriptions agreed upon may aid translation and transfer of knowledge between domains in the field of motor learning. Empirical and clinical research is required to confirm the accuracy of the definitions and to explore the feasibility of the strategies that were identified in research, everyday practice and education.

A Multicenter Randomized Controlled Trial to Compare Subacute ‘Treatment as Usual’ With and Without Mental Practice Among Persons With Stroke in Dutch Nursing Homes

OBJECTIVE Systematic reviews suggest that mental practice as an additional therapy for people with stroke might be effective and suggest that more trials with better defined interventions are needed. This study investigated whether imagining the skilled movement systematically can contribute to a quicker and/or better recovery of stroke patients in long term care. DESIGN A multicenter randomized controlled trial. SETTING Dutch nursing homes. PARTICIPANTS Stroke patients in the subacute phase of recovery. INTERVENTIONS Study participants were randomly assigned to the control or experimental group. Over a 6-week intervention period, both groups received multi professional therapy as usual. Additionally, patients in the experimental group had instruction on mental practice with a 4-step framework embedded in regular therapy time. MAIN OUTCOME Outcomes were assessed at 6 weeks and 6 months with the patient-perceived effect on performance of daily activities (10-point Numeric Rating Scale). Six secondary outcomes on impairment and activity level were also assessed. Primary analyses were performed according to the intention-to-treat principle. Generalized estimating equations (GEE) were used to analyze effects. RESULTS Thirty-six adult stroke patients (average age 77.8, ± 7.2 years) participated in the trial. No effect in favor of the mental practice intervention on any outcome measure could be detected at either measuring points. CONCLUSIONS This study could not show differences between embedded mental practice and current standard of care. However, stroke pathways in Dutch nursing homes select specific and frail patients, which might have reduced the effects of training.

Investigating the Dutch Movement-Specific Reinvestment Scale in people with stroke

Objective: Reinvestment is a phenomenon in which conscious control of movements that are best controlled automatically disrupts performance. The propensity for reinvestment may therefore play an important role in the movement rehabilitation process. The Movement-Specific Reinvestment Scale measures an individual’s propensity for reinvestment. The aim of this study was to translate the scale for use with Dutch participants with stroke and to assess its reliability. Design: A test–retest design. Setting: In community after discharge from rehabilitation centre. Subjects: Forty-five people with stroke. Measures: Reliability of the translated scale was assessed using intraclass correlation coefficients (ICC) and Bland–Altman plot. Results: The ICC was 0.85 (95% confidence interval (CI) 0.74–0.91). Limits of agreement ranged from −2.38 to 3.10. Conclusion: The Dutch Movement-Specific Reinvestment Scale appears to be a reliable tool with which to assess the propensity for movement-specific reinvestment by people with stroke.

Multidisciplinary Views on Applying Explicit and Implicit Motor Learning in Practice: An International Survey.

Background A variety of options and techniques for causing implicit and explicit motor learning have been described in the literature. The aim of the current paper was to provide clearer guidance for practitioners on how to apply motor learning in practice by exploring experts’ opinions and experiences, using the distinction between implicit and explicit motor learning as a conceptual departure point. Methods A survey was designed to collect and aggregate informed opinions and experiences from 40 international respondents who had demonstrable expertise related to motor learning in practice and/or research. The survey was administered through an online survey tool and addressed potential options and learning strategies for applying implicit and explicit motor learning. Responses were analysed in terms of consensus (≥ 70%) and trends (≥ 50%). A summary figure was developed to illustrate a taxonomy of the different learning strategies and options indicated by the experts in the survey. Results Answers of experts were widely distributed. No consensus was found regarding the application of implicit and explicit motor learning. Some trends were identified: Explicit motor learning can be promoted by using instructions and various types of feedback, but when promoting implicit motor learning, instructions and feedback should be restricted. Further, for implicit motor learning, an external focus of attention should be considered, as well as practicing the entire skill. Experts agreed on three factors that influence motor learning choices: the learner’s abilities, the type of task, and the stage of motor learning (94.5%; n = 34/36). Most experts agreed with the summary figure (64.7%; n = 22/34). Conclusion The results provide an overview of possible ways to cause implicit or explicit motor learning, signposting examples from practice and factors that influence day-to-day motor learning decisions.

Terminology, Taxonomy, and Facilitation of Motor Learning in Clinical Practice: Protocol of a Delphi Study

Background Facilitating motor learning in patients during clinical practice is complex, especially in people with cognitive impairments. General principles of motor learning are available for therapists to use in their practice. However, the translation of evidence from the different fields of motor learning for use in clinical practice is problematic due to lack of uniformity in definition and taxonomy of terms related to motor learning. Objective The objective of this paper was to describe the design of a Delphi technique to reach consensus on definitions, descriptions, and taxonomy used within motor learning and to explore experts’ opinions and experiences on the application of motor learning in practice. Methods A heterogeneous sample of at least 30 international experts on motor learning will be recruited. Their opinions regarding several central topics on motor learning using a Delphi technique will be collected in 3 sequential rounds. The questionnaires in the 3 rounds will be developed based on the literature and answers of experts from earlier rounds. Consensus will be reached when at least 70% of the experts agree on a certain topic. Free text comments and answers from open questions on opinions and experiences will be described and clustered into themes. Results This study is currently ongoing. It is financially supported by Stichting Alliantie Innovatie (Innovation Alliance Foundation), RAAK-international (Registration number: 2011-3-33int). Conclusions The results of this study will enable us to summarize and categorize expert knowledge and experiences in a format that should be more accessible for therapists to use in support of their clinical practice. Unresolved aspects will direct future research.

Exploring the utility of analogies in motor learning after stroke: a feasibility study

Individuals who have experienced a stroke need to (re)learn motor skills. Analogy learning has been shown to facilitate motor learning in sports and may also be an attractive alternative to traditional approaches in therapy. The aim of this study was to assess the feasibility and utility of analogies to improve the walking performance in long-term stroke survivors. Three men aged 76, 87 and 70 years who were 6, 1 and 3 years poststroke, respectively, presented with different walking deficits. An analogy, targeted at improving the walking performance was designed with the help of each participant. During a 3-week intervention period, the analogy was practiced once weekly under supervision and daily at home. To assess feasibility, a structured interview was conducted at the end of the intervention period. To assess utility, walking performance was assessed using the 10-Metre Walking Test. All three participants were supportive of the feasibility and benefits of analogy learning. Two of the participants had a meaningful improvement on the 10-Metre Walking Test (0.1 and 0.3 m/s). The third participant did not improve most likely because of medication issues during the week of the retest. Developing analogies in therapy is a creative and challenging process, as analogies must not only guide the correct movement pattern, but also be meaningful to the individual. However, as participants were supportive of the use of analogies, and positive trends were seen in walking speed it seems worthwhile to pursue the use of analogies in future research.

“Interactive surfaces” technology as a potential tool to stimulate physical activity in psychogeriatric nursing home residents

Abstract Purpose: The aims of this study were to determine whether and how psychogeriatric nursing home residents would respond to the interactive surfaces on the floor without receiving instructions and to determine how long residents would be physically active. Methods: The “interactive surfaces” technology includes different graphic shapes that are projected through a beamer on a floor. The surfaces are “activated” by a person’s movements in the area of the projection field, which is detected by an infrared camera. Every day for 1 h during an 11-day period one of seven different projections was shown. Spontaneous observed physical responses were counted, clustered and visualized in a tree diagram. Duration of physically responses was measured per session and during the total observation period of 11 h. Results: During 343 of 490 observations residents (n = 58) noticed the interactive surface and in 148 observations they engaged physically. In total, 4067 s (1 h, 7 min and 47 s) of physical activity were measured. Individual times that residents were active ranged from 3 to 415 s. Conclusions: Interactive surfaces technology may be a promising tool in psychogeriatric nursing home residents to stimulate physical activity. Further research is needed to assess its full potential. Implications for Rehabilitation Innovative technology used to adapt the environment might stimulate nursing home residents to become more physically active. The use of innovative technologies may increase physical activity without necessarily increasing the workload of care professionals.