Motor Imagery in Neuro rehabilitation

motor imagery in neuro rehsbilitation

1. Motor Imagery Presenter : Ashik Dhakal Moderator : Mr. Sydney Roshan Rebello

2. Content Introduction History Theories Types Neurophysiology Framework for practice Supporting evidence

3. Introduction MI also known as mental imagery Imagining of an action without its physical execution ; using all of the senses. It is an active process during which the representation of an action is internally reproduced within working memory without any overt (observable) output. Used To treat people who have health problems, including injury to the spinal cord, stroke, Parkinson's disease, or fibromyalgia. Walking, Relearning daily activities, Awareness of affected limb, etc.

4. Studies have shown that this " mental rehearsal /motor imagery practice” i.e, repetition or rehearsing of imagined motor acts with the intention of improving their physical execution actually stimulates the brain areas responsible for making the weaker arm or leg move. In a study Jeannerod, stated that conscious MI and unconscious motor preparation share common mechanics and are functionally equivalent. So the mental practice using MI training results in improvement in motor performance.

5. History Johann Friedrich Herbart in 1825, proposed that the imagery of perceptual effects can elicit the related movements. William James in 1890 , wrote “that every representation of a movement awakens in some degree the actual movement”. In rehabilitation, Fansler CL in 1980s stated that mental practice can improve the motor performance, in his study “Effects of mental practice on balance in elderly women.”

6. In sports, Studies have shown that specific training can increase the amount and the efficiency of kinaesthetic imagery. And also explained that by practicing imagery in the same way as we practice the skill itself, the desired neural pathways are strengthened . Motor imagery is a cognitive tool strategically used by athletes for learning and optimising their specific movement tasks. Boschker,  2001 stated, the main aim of motor imagery is to enhance specific motor actions. Dancers, for example, use motor imagery to exercise the memorisation of long sequences and to improve movement quality in terms of spatiotemporal adaptation and artistic expression.

7. Theories of mental imagery Abstract/Symbolic theories: Mental “images” aren’t images at all Mental imagery consists of the manipulation of abstract symbols in the brain (like computer code) Analog/Pictoral theories: Mental imagery is similar to perception. These are current dominating theories.

8. Other theories of mental imagery Psychoneuromuscular theories Imagery programs muscles for action Imagery facilitates the learning of motor skills because imagined events innervate the muscles as physical practice, they strengthen neural pathways . Symbolic theory : Breaking task into symbols, represent things by symbols.

9. Bioinformational theory : Basketball free hit actions actually helps in proper execution of action. Triple code model: Primary importance is placed in the psychophysiology of imagery Image : sensory experience Somatic : psychological response Meaning of the image (personal)

10. How does it work in sports

11. Types of motor imagery Kinaesthetic motor imagery (internal )(i.e. imagining the feeling associated with performing a movement) Visual motor imagery (external)(i.e. imagining the movement itself)

12. Neurophysiology of motor imagery Premotor cortex and rostral part of the posterior SMA were activated bilaterally. Mental imagery activation is 30% of the level seen in actual performance motor cortex.

13. Recent research works suggest that motor imagery of different body parts has significant relation with the specific areas (in homunculus) as shown in the fig below.

14. When we perform particular movement or imagine the movement, motor imagery could produce ERD (event related desynchronisation) in the corresponding hemisphere and ERS (event related synchronisation) in the opposite hemisphere.

15. Video

16. Neuroscience and MI Technology used to research the brain while an imagery task is performed. PET scan SPECT fMRI = measures hemodynamic response to neural activity. ;- because of their spatial and temporal resolution Because these technique have been applied to the study of mapping the neural basis of motor imagery.

17. Developing a framework The subjects may imagine the movement in: 3rd person perspective (or external imagery) 1st person perspective (or internal imagery) 3 pillars in developing imagery framework The patient - pt’s choose activities Evidence - mental practice may alter neural function Therapist - Utilise 5-step outline to keep intervention dynamic.

18. 5 steps outline to intervention 1. Suitable candidate 2. Nature of treatment 3. Teach 4. implant, incorporate, monitor 5. PT reduces support gradually

19. Four W’s of imagery in rehabilitation Where When Why What

20. Evidence supporting effect of motor imagining Motor imagery is practiced to improve motor performance and to learn motor tasks. Abundant evidence on the positive effects of MI practice on motor performance and learning has been published. For individuals who are healthy or those who have health-related problems, the rehearsal or practice of imagery tasks has been proven to be either beneficial by itself or in addition to physical practice.

21. For healthy individual and athletes Studies of healthy individuals have shown enhancement of the performance of various aspects of motor control because of MI practice. Including gains in strength of selected muscle groups, improved speed in arm pointing capacity, increased range of motion of the hip joint when MI was added to proprioceptive neuromuscular facilitation, and improved postural control in elderly people.

22. Recently, the use of MI practice to facilitate the mastering of professional skills such as nursing and surgery has been demonstrated. For imagery applied in the sports, positive effects have been reported in speed, performance accuracy, muscle strength, and motor skill performance.

23. MI for rehabilitation In conditions like stroke, spinal cord injury (SCI), Parkinson disease (PD), and people with intractable pain.

24. 1. Stroke Sharma et al in her systemic review in 2006, characterized motor imagery as a “backdoor” to accessing the motor system and rehabilitation at all stages of stroke recovery because “it is not dependent on residual functions yet still incorporates voluntary drive” The literature suggests the encouraging effect of motor imagery training on motor recovery after stroke. Based on the available literature in healthy volunteers, robust (vigorous) activation of the nonprimary motor structures, but only weak and inconsistent activation of M1, occurs during motor imagery. Provided appropriate methodology, motor imagery may provide a valuable tool to access the motor network and improve outcome after stroke.

25. MI in UE recovery of function with stroke patients 2. Seong-Sik kim, PT, PhD and , Byoung-Hee Lee, PT, PhD conducted a RCT ,2015 Population : 24 patients, control group 12 and motor imagery group 12. Intervention : The MI group participated in 30 minutes of MI training on each of the 18 tasks (9 hours total) related to their daily living activities . After the 4-week intervention period, the FMA - Upper Extremity outcomes and Wolf Motor Function Test outcomes were compared.

26. Results : The post-test score of the motor imagery group on the outcomes was significantly higher than that of the control group. Conclusion : Motor imagery training has a positive influence on upper extremity performance by improving functional mobility during stroke rehabilitation. These results suggest that motor imagery training is feasible and beneficial for improving upper extremity function i n stroke patients.

27. MI for gait training 1. Ruth Dickstein, Ayelet Dunsky, Emanuel Marcovitz conducted a case report A 69 year old man with left hemiparesis received MI gait practice for 6 weeks . Intervention focused on task-oriented gait and on impairments of the affected lower limb. Outcomes: temporal-distance stride parameters and sagittal kinematics of the knee joint were taken. Preintervention, midterm, postintervention, and follow-up measurements were taken.

28. Intervention : 1st 4 weeks focused on the specific gait impairments and on improving speed and symmetry, last 2 weeks to the performance of functional task-oriented gait activities Results : At 6 weeks postintervention, the patient had a 23% increase in gait speed and a 13% reduction in double-support time. An increase in range of motion of the knees, No changes in gait symmetry were noted. Conclusion : MI may be useful for the enhancement of walking ability in patients following stroke.

29. 2. Gyuchang Lee, PT, PhD and collegues conducted a study to investigate the effects of motor imagery training on improvement of gait ability of patients with chronic stroke The motor imagery training was performed using imagination of normal gait movement. Participants were randomly allocated to two groups: a motor imagery training group 13 and a control group 11. Both groups received treadmill training for 30 minutes 3 sessions per week for 6 weeks . The motor imagery training group practiced additional motor imagery training for 15 minutes . Measures were evaluated by gait ability.

30. Results : The outcomes significantly improved by motor imagery training were— gait speed, step length paretic side, step length of non-paretic side, stride length of paretic side, stride length of non-paretic side, single limb support period of paretic side, and double limb support period of both sides. Conclusion: The motor imagery training improved gait ability . These results suggest that motor imagery training is feasible and suitable for individuals with stroke.

31. 3. Gait rehabilitation of chronic post-stroke hemiparesis 17 post stroke patients, MI training only Intervention : 15-20 min sessions, 3/week for 6 weeks Results : increased walking speed, stride length, and single-leg stance time (affected LE) Conclusion : Improved mobility and dynamic balance.

32. 2. Spinal cord injury 1. Study done by Steven C. Cramer and collegues “Effects of motor imagery training after chronic, complete spinal cord injury” Subjects : 10 subjects with SCI and complete paraplegia and 10 healthy controls underwent assessment before and after 7 days of motor imagery training to tongue and to foot. Results : Motor imagery training significantly improved the behavioral outcome measure, speed of movement, in non-paralyzed muscles.

33. Training was also associated with increased fMRI activation in left putamen, an area associated with motor learning, during attempted right foot movement in both groups , despite foot movements being present in controls and absent in subjects with SCI. The current study found that motor imagery training improves motor performance and alters brain function in subjects with complete SCI despite lack of voluntary motor control and peripheral feedback. Motor imagery might be of value as one component of a restorative intervention.

34. 2. Study conducted by Alkadhi H at el., “What disconnection tells about motor imagery: evidence from paraplegic patients” They investigated patients with complete SCI to find out how the complete disruption of motor efferents and sensory afferents influences brain activation during motor imagery of the disconnected feet. Subjects : 8 SCI patients underwent behavioural assessment and fMRI. Results : When compared to a healthy population, stronger activity was detected in primary and all non-primary motor cortical areas and subcortical regions. In paraplegic patients the primary motor cortex was consistently activated , even to the same degree as during movement execution in the controls.

35. In paraplegics the extent of activation in the primary motor cortex and in non-primary motor areas was significantly correlated with the vividness of movement imagery, as assessed by an interview. The present findings provide new insights on the neuroanatomy of motor imagery and the possible role of kinaesthetic feedback in the suppression of cortical motor output required during covert movements .

36. 3. Parkinson disease For individuals with PD, the ability to apply MI is controversial The authors interpreted these findings as disordered imagery ability resulting from deficits in dopamine inputs to the basal ganglia in patients with PD In patients with PD treated with dopaminergic stimulation, imagery-related enhancement in several sites of the brain was noted during the “on” phase but not the “off” phase.

37. 1. Study done by Ruth Tamir, Ruth Dickstein, Moshe Huberman in 2007, “Integration of Motor Imagery and Physical Practice in Group Treatment Applied to Subjects With Parkinson’s Disease” Compared group treatment using a combination of physical and motor imagery practice with group treatment using only physical practice in subjects with PD. Subjects : 23 patients with idiopathic PD, 12 received combined therapy, whereas 11 received physical therapy alone. 1-h sessions held twice a week for 12 weeks . Comparable motor tasks provided to both groups included functional tasks, and relaxation exercises.

38. Outcome measures: the time required to complete sequences of movements, the performance of balance tasks, impairment and functional scores on the Unified Parkinson’s Disease Rating Scale ( UPDRS ), and specific cognitive abilities (Stroop and clock drawing tests). Results: the experimental group (EG) exhibited significantly faster performance of movement sequences than the control group. Subjects of EG demonstrated higher gains in the mental and motor subsets of the UPDRS and in the cognitive tests. Both groups improved on the ADL scale. Conclusions. The combination of motor imagery and real practice may be effective in the treatment of PD, especially for reducing bradykinesia .

39. Damage to Fronto-Parietal Networks Impairs Motor Imagery Ability after Stroke Aim: To identify brain regions that are mandatory for preserved motor imagery ability after stroke. Subjects : 37 patients with hemiplegia after a first time stroke participated. Outcomes : Motor Imagery questionnaire and temporal congruence test. A voxelwise lesion symptom mapping approach was used to identify neural correlates of motor imagery in this cohort within the first year post-stroke.

40. Results: Poor motor imagery vividness — lesions in the left putamen, left ventral premotor cortex and long association fibers linking parieto-occipital regions with the dorsolateral premotor and prefrontal areas. Poor temporal congruence — rostrally located white matter of the superior corona radiata. Conclusion: This study confirms the association between white matter tract lesions and impaired motor imagery ability, thus emphasising the importance of an intact fronto-parietal network for motor imagery also the crucial role of the basal ganglia and premotor cortex when performing motor imagery tasks.

41. Outcomes

42. 1. Movement imagery questionary

43. 2. Kinesthetic and visual imagery questionnaire (KVIQ)

44. 3. Vividness of motor imagery questionnaire (VMIQ)

45. References Dickstein R, Deutsch JE. Motor imagery in physical therapist practice. Physical therapy. 2007 Jul 1;87(7):942-53. Malouin F, Richards CL. Mental practice for relearning locomotor skills. Physical therapy. 2010 Feb 1;90(2):240-51. Iseki K, Hanakawa T, Shinozaki J, Nankaku M, Fukuyama H. Neural mechanisms involved in mental imagery and observation of gait. Neuroimage. 2008 Jul 1;41(3):1021-31. Oostra KM, Van Bladel A, Vanhoonacker AC, Vingerhoets G. Damage to fronto-parietal networks impairs motor imagery ability after stroke: a voxel-based lesion symptom mapping study. Frontiers in behavioral neuroscience. 2016 Feb 1;10:5.

46. Isaac A, Marks DF, Russell DG. An instrument for assessing imagery of movement: the vividness of movement imagery questionnaire (VMIQ). Journal of Mental Imagery . 1986;10:23–30 Braun S, Kleynen M, Schols J, Schack T, Beurskens A, Wade D. Using mental practice in stroke rehabilitation: a framework. Clinical rehabilitation. 2008 Jul;22(7):579-91. Cramer SC, Orr EL, Cohen MJ, Lacourse MG. Effects of motor imagery training after chronic, complete spinal cord injury. Exp Brain Res . 2006;177:233–242. Sharma N, Pomeroy VM, Baron JC. Motor imagery: a backdoor to the motor system after stroke? Stroke . 2006;37:1941–1952.

47. Stevens J, Stoykov ME. Using motor imagery in the rehabilitation of hemiparesis. Arch Phys Med Rehabil . 2003;84:1090–1092. Malouin F, Richards CL, Doyon J, et al.  . Training mobility tasks after stroke with combined mental and physical practice: a feasibility study. Neurorehabil Neural Repair . 2004;18:66–75 lewis, D.E., O’Reilly, M. J., Khuu, S. K., & Pearson, J. (2013). conditioning the mind’s eye associative learning with volunatry mental imagery. clinical psychological science, 2167702613484716 parkinson Tamir R, Dickstein R, Huberman M. Integration of motor imagery and physical practice in group treatment applied to subjects with Parkinson's disease. Neurorehabil Neural Repair . 2007;21:68–75. Hall CR, Pongrac J. Movement Imagery Questionnaire . London, Ontario, Canada: Department of Physical Education, University of Western Ontario; 1983.

48. Thank you