Thierry Ettlin

Best practice for motor imagery: a systematic literature review on motor imagery training elements in five different disciplines

BackgroundThe literature suggests a beneficial effect of motor imagery (MI) if combined with physical practice, but detailed descriptions of MI training session (MITS) elements and temporal parameters are lacking. The aim of this review was to identify the characteristics of a successful MITS and compare these for different disciplines, MI session types, task focus, age, gender and MI modification during intervention.MethodsAn extended systematic literature search using 24 databases was performed for five disciplines: Education, Medicine, Music, Psychology and Sports. References that described an MI intervention that focused on motor skills, performance or strength improvement were included. Information describing 17 MITS elements was extracted based on the PETTLEP (physical, environment, timing, task, learning, emotion, perspective) approach. Seven elements describing the MITS temporal parameters were calculated: study duration, intervention duration, MITS duration, total MITS count, MITS per week, MI trials per MITS and total MI training time.ResultsBoth independent reviewers found 96% congruity, which was tested on a random sample of 20% of all references. After selection, 133 studies reporting 141 MI interventions were included. The locations of the MITS and position of the participants during MI were task-specific. Participants received acoustic detailed MI instructions, which were mostly standardised and live. During MI practice, participants kept their eyes closed. MI training was performed from an internal perspective with a kinaesthetic mode. Changes in MI content, duration and dosage were reported in 31 MI interventions. Familiarisation sessions before the start of the MI intervention were mentioned in 17 reports. MI interventions focused with decreasing relevance on motor-, cognitive- and strength-focused tasks. Average study intervention lasted 34 days, with participants practicing MI on average three times per week for 17 minutes, with 34 MI trials. Average total MI time was 178 minutes including 13 MITS. Reporting rate varied between 25.5% and 95.5%.ConclusionsMITS elements of successful interventions were individual, supervised and non-directed sessions, added after physical practice. Successful design characteristics were dominant in the Psychology literature, in interventions focusing on motor and strength-related tasks, in interventions with participants aged 20 to 29 years old, and in MI interventions including participants of both genders. Systematic searching of the MI literature was constrained by the lack of a defined MeSH term.

Blink Reflexes Elicited by Electrical, Acoustic and Visual Stimuli

Blink reflexes elicited by electrical stimulation of the supraorbital nerves, by monoaurally presented 1 kHz sine wave bursts of 20-ms duration, and by flashes of light presented monocularly were investigated in 32 healthy controls. Absolute latencies of the individual components and side differences were measured. An outline of possible anatomical pathways which might be involved in the transmission of these reflexes is given.

Phantom and Amputation Illusions in Paraplegic Patients

In paraplegic patients, amputation illusions and anosognosia with phantom position illusions are distinct phenomena which do not concur in any one patient. A permanent amputation illusion regularly follows a complete spinal injury with concomitant brain concussion, whereas all patients who are conscious during their spinal trauma remain aware of their paralyzed limbs in definite phantom positions which are clearly related to the position of the body at the moment of injury.

Objectively-assessed outcome measures: a translation and cross-cultural adaptation procedure applied to the Chedoke McMaster Arm and Hand Activity Inventory (CAHAI)

BackgroundStandardised translation and cross-cultural adaptation (TCCA) procedures are vital to describe language translation, cultural adaptation, and to evaluate quality factors of transformed outcome measures. No TCCA procedure for objectively-assessed outcome (OAO) measures exists. Furthermore, no official German version of the Canadian Chedoke Arm and Hand Activity Inventory (CAHAI) is available.MethodsAn eight-step for TCCA procedure for OAO was developed (TCCA-OAO) based on the existing TCCA procedure for patient-reported outcomes. The TCCA-OAO procedure was applied to develop a German version of the CAHAI (CAHAI-G). Inter-rater reliability of the CAHAI-G was determined through video rating of CAHAI-G. Validity evaluation of the CAHAI-G was assessed using the Chedoke-McMaster Stroke Assessment (CMSA). All ratings were performed by trained, independent raters. In a cross-sectional study, patients were tested within 31 hours after the initial CAHAI-G scoring, for their motor function level using the subscales for arm and hand of the CMSA. Inpatients and outpatients of the occupational therapy department who experienced a cerebrovascular accident or an intracerebral haemorrhage were included.ResultsPerformance of 23 patients (mean age 69.4, SD 12.9; six females; mean time since stroke onset: 1.5 years, SD 2.5 years) have been assessed. A high inter-rater reliability was calculated with ICCs for 4 CAHAI-G versions (13, 9, 8, 7 items) ranging between r = 0.96 and r = 0.99 (p < 0.001). Correlation between the CAHAI-G and CMSA subscales for hand and arm was r = 0.74 (p < 0.001) and r = 0.67 (p < 0.001) respectively. Internal consistency of the CAHAI-G for all four versions ranged between α = 0.974 and α = 0.979.ConclusionsThe TCCA-OAO procedure was validated regarding its feasibility and applicability for objectively-assessed outcome measures. The resulting German CAHAI can be used as a valid and reliable assessment for bilateral upper limb performance in ADL in patients after stroke.

The Frontal Lobe Score: part II: evaluation of its clinical validity

Objective: To evaluate the ability of the Frontal Lobe Score (FLS) to differentiate patients with frontal lobe lesions from those with nonfrontal lesions and normal controls. Design: In a prospective, blind setup, the sensitivity and specificity of the Frontal Lobe Score was compared with the Wisconsin Card Sorting Test (WCST) and the Stroop Test. Patients: A sample of 108 subjects (26 patients with cerebral lesions confined to the frontal lobes, 28 patients with cerebral lesions without involvement of the frontal lobes, 31 patients with mixed frontal/nonfrontal lesions, 23 controls without cerebral lesions) was examined. Measures: Frontal Lobe Score, Wisconsin Card Sorting Test, Stroop Test. Results: The Frontal Lobe Score detected pure frontal lesions with a sensitivity of 92.3%. It discriminated patients with frontal lesions from normal controls with a specificity of 100%; differentiation from patients with nonfrontal lesions was obtained with a specificity of 75.0%. For the WCST, sensitivity for detection of pure frontal lesions was 65.4%, while specificity was 60.9% compared with normal controls and 53.6% compared with nonfrontal lesions. The Stroop Test showed a sensitivity of 30.8%, a specificity compared with normal controls of 95.7% and compared with nonfrontal lesions of 92.9%. Conclusion: The Frontal Lobe Score has clinical usefulness for screening of effects of frontal lobe damage superior to that of the WCST and the Stroop Test.

Two assessments to evaluate imagery ability: translation, test-retest reliability and concurrent validity of the German KVIQ and Imaprax

BackgroundA combination of physical practice and motor imagery (MI) can improve motor function. It is essential to assess MI vividness in patients with sensorimotor impairments before implementing MI interventions. The studys aims were to translate the Canadian Kinaesthetic and Visual Imagery Questionnaire (KVIQ) and the French Imaprax, and to examine reliability and validity of the German versions.MethodsQuestionnaires were translated according to guidelines. With examiner’s help patients (diagnosis: stroke: subacute/chronic, brain tumour, Multiple Sclerosis, Parkinson’s disease) were tested twice within seven days (T0, T1). KVIQ-G: Patients were shown a movement by the examiner, before executing and imagining the movement. They rated vividness of the image and intensity of the sensations on a five-point Likert-scale. Imaprax required a 3-step procedure: imagination of one of six gestures; evaluation of gesture understanding, vividness, and imagery perspective. Questionnaire data were analysed overall and for each group. Reliability parameters were calculated: intraclass correlation coefficient (ICC), Cronbachs alpha, standard error of measurement, minimal detectable change. Validity parameters included Spearmans rank correlation coefficient and factor analysis of the KVIQ-G-20.ResultsPatients (N = 73, 28 females, age: 63 ± 13) showed the following at T0: KVIQ-G-20vis 41.7 ± 9, KVIQ-G-10vis 21.1 ± 5. ICC for KVIQ-G-20vis and KVIQ-G-10vis was 0.77; KVIQ-G-20kin 36.4 ± 12, KVIQ-G-10kin 18.3 ± 6. ICCs for KVIQ-G-20kin and KVIQ-G-10kin were 0.83/0.85; Imapraxvis 32.7 ± 4 and ICC 0.51. Internal consistency was estimated for KVIQ-G-20 αvis = 0.94/αkin = 0.92, KVIQ-G-10 αvis = 0.88/αkin = 0.96, Imaprax-G αvis = 0.70. Validity testing was performed with 19 of 73 patients, who chose an internal perspective: rs = 0.36 (p = 0.13). Factor analysis revealed two factors correlating with r = 0.36. Both explain 69.7% of total variance.ConclusionsKVIQ-G and Imaprax-G are reliable instruments to assess MI in patients with sensorimotor impairments confirmed by a KVIQ-G-factor analysis. KVIQ-G visual values were higher than kinaesthetic values. Patients with Multiple Sclerosis showed the lowest, subacute stroke patients the highest values. Hemiparetic patients scored lower in both KVIQ-G subscales on affected side compared to non-affected side. It is suggested to administer the Imaprax-G before the KVIQ-G to test patient’s ability to distinguish between external and internal MI perspective. Duration of both questionnaires lead to an educational effect. Imaprax validity testing should be repeated.

Motor Imagery Experiences and Use: Asking Patients after Stroke Where, When, What, Why, and How They Use Imagery: A Qualitative Investigation

Background. A framework on where, when, what, why, and how to use imagery from sports psychology was explored whether it can be applied in patients after stroke in their chronic stage. Methods. Eleven patients (ages 31–85, 3 females, 1.3–6.4 years after stroke) were interviewed. Semistructured interviews were conducted before and after a two-week MI intervention period with six MI sessions. Information was obtained regarding experiences and knowledge of MI, and the evaluation of an MI practical example. The coding scheme was based on the framework and a hierarchical categorisation. Results. Information regarding domains where, when, what, why, and how to use imagery was addressed. Patients imagined themselves as healthy individuals, did not focus on surroundings during MI practice,and reported to use positive imagery only. After MI training, patients became more flexible regarding their location and position during MI practice. Conclusions. MI became an automatic process, and patients did not need specific concentration and quietness as mentioned in the first interview. Patients recommended daily MI training and began to transfer MI to practice movements that were affected by the stroke. In contrast to sports, patients did not talk about how MI was triggered rather than how MI was designed.

Blink Reflexes Elicited by Electrical, Acoustic and Visual Stimuli. II. Their Relation to Visual-Evoked Potentials and Auditory Brain Stem Evoked Potentials in the Diagnosis of Multiple Sclerosis

Blink reflexes, elicited by flashes of light, tone bursts and electrical stimuli, as well as checkerboard reversal visual-evoked potentials and brain stem auditory evoked potentials were investigated in 55 patients with different degrees of diagnostic probability of multiple sclerosis. It is demonstrated that electrically and acoustically elicited blink reflexes are simple but rather sensitive methods of indicating brain stem lesions. They should be used complementarily with brain stem auditory potentials. Flash-elicited blink reflexes, although sensitive, are thought to be of minor importance, since they give only restricted localizing information.

Alien Hand Syndrome of the Dominant Hand and Ideomotor Apraxia of the Nondominant Hand

Following an extended infarction in the territory of the left anterior cerebral artery including the anterior corpus callosum, a 66-year-old right-handed man exhibited an alien hand syndrome on the right side and an ideomotor apraxia of the left hand. In addition to other typical symptoms of frontal lobe lesions, he presented with an interesting difference in the manifestation of perseveration in either hand. In the right hand, the perseveration was part of the alien hand syndrome, whereas in the left hand perseveration showed in the inability to switch promptly from one movement to another on instruction during praxis testing.

German version of the whiplash disability questionnaire: reproducibility and responsiveness.

BackgroundThe Whiplash Disability Questionnaire (WDQ) poses a validated tool for the assessment of patients who experience whiplash-associated disorders. A German translation and cross-cultural adaptation was recently produced and presented high validity and internal consistency. As a follow-up, the presented study tests the translated Whiplash Disability Questionnaire’s (WDQ-G) retest reliability and responsiveness to change.MethodsThe WDQ-G was assessed on three different measurement events: first upon entry (ME1), second four days after entry (ME2), and third at discharge (ME3). Test-retest reliability data from ME1 and ME2 was analysed in a group of stable patients to obtain the intraclass correlation coefficient (ICC) and the standard error of measurement (SEM). To test the instrument’s responsiveness, WDQ-G change data were compared to concurrent instruments. The probability of each instrument, to correctly distinguish patients of the stable phase (ME1 to ME2) from patients who deemed to have improved between from ME1 to ME3, was analysed.ResultsIn total, 53 patients (35 females, age = 45 ± 12.2) were recruited. WDQ-G scores changed from ME1 to ME2 by 5.41 ± 11.6 points in a stable group. This corresponds to a test-retest reliability of ICC = 0.91 (95% CI = 0.80–0.95) with a SEM of 6.14 points. Minimal Detectable Change, at 95% confidence, was calculated to be 17 points change in scores. Area under Receiver Operator Characteristics of the WDQ-G’s responsiveness revealed a probability of 84.6% (95% CI = 76.2%–93%) to correctly distinguish between improved and stable patients. Optimal sensitivity (73.2%) and specificity (76.2%) was established at 11-point change.ConclusionsHigh retest reliability and good responsiveness of the WDQ-G support clinical implementation of the translated version. The data suggest, that change in total score greater than eleven points can be interpreted as clinical relevant from a patient’s perspective. Minimal Important Change is suggested at 15 points where there is still high specificity and a 90% confidence MDC.German abstractHintergrundDer Whiplash Disability Questionnaire (WDQ) stellt einen validierten Fragebogen zur Erfassung der Alltagseinschränkungen bei Patienten nach kraniozervikalem Beschleunigungstrauma (KZBT) dar. Eine deutsche Übersetzung und kulturelle Anpassung mit hoher Validität und interner Konsistenz wurde bereits erstellt und getestet. In dieser Anschlussstudie soll die übersetzte Version auf Testwiederholung und Veränderungssensitivität überprüft werden.MethodenDie deutsche Version des WDQ (WDQ-G) wurde an drei verschiedenen Messzeitpunkten getestet: zuerst nach Eintritt (MZP1), vier Tage nach Eintritt (MZP2) und beim Austritt (MZP3). Für die Testwiederholung (Test-Retest) wurde die Veränderung der Punktzahl von MZP1 bis MZP2 in einer Gruppe stabiler Patienten untersucht und der Intraklassenkorrelationskoeffizient (ICC) sowie der Standardfehler der Messungen (SEM) berechnet. Für die Veränderungssensitivität wurde die Veränderung der Punktzahl des WDQ-G mit dem von konkurrierenden Fragebogen verglichen. Dabei wurde die Fähigkeit der Fragebogen untersucht, die stabilen Patienten aus der ICC-Analyse von den Patienten zu unterscheiden, die gemäss eigenen Angaben sich nach der Behandlung besser fühlten.ResultateInsgesamt wurden 53 Patienten (35 weiblich, Alter = 45 ± 12.2) rekrutiert. Die WDQ-G Punktezahl veränderte sich von MZP1 bis MZP2 um 5.41 ± 11.6 in der stabilen Gruppe. Dies entspricht einem ICC von 0.91 (95% CI = 0.80–0.95) mit einem SEM von 6.14 Punkten. Für eine statistisch relevante Veränderung (MDC) waren 17 Punkte nötig (95% Konfidenz). Die Wahrscheinlichkeit des WDQ-G, die Patienten korrekt zu unterscheiden, lag bei 84.6% (95% CI = 76.2%–93.0%). Optimale Sensitivität (73.2%) und Spezifizität (76.2%) sind bei einer Veränderung von 11 Punkten zu erreichen.SchlussfolgerungHohe Reliabilität und gute Veränderungssensitivität unterstützen die Empfehlung, den WDQ-G für die Einschätzung von KZBT Patienten zu nutzen. Die Resultate suggerieren eine Veränderung von 11 Punkten als relevant aus Patientenperspektive. Um systematische Fehler des Fragebogens zu berücksichtigen, sollte eine Veränderung unter 15 Punkten (90% Konfidenz) nicht als relevant interpretiert werden.