Mental Practice

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Mental Practice (aka MP, Motor Imagery Practice and Visualisation) is based on imagining your body moving or performing an activity while you are at rest. For example, an athlete might visualise how he or she will run a race. There is a good deal of evidence to support the positive benefits of mental practice. It is commonly used to enhance sporting performance, as well as helping people with a range of neurological conditions, including spinal cord injury and Parkinson’s disease. ‘Motor imagery and mental practice are getting increased attention in neurological rehabilitation.’1

Mental practice

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It may be difficult to believe that simply imagining an exercise can produce changes in your body, but it can. Visualising yourself performing an activity can cause electrical changes in your skin, as well as changes to skin temperature, blood flow and heart rate.2In one study, the participants imagined they were cycling. As they thought about riding their bikes faster, their heart rates increased at the same rate.3

There is also evidence to show that mental practice can causes changes to your mental map.4 This is based on the idea that our brains are ‘plastic’; in other words, we can change the structure of our brains with the right mental exercises. This type of research gives hope to people with all kinds of brain damage.

During mental practice treatment, you are often asked to sit or lie down with your eyes closed. The therapist might introduce some relaxation techniques, as being physically and mentally relaxed can make it easier to imagine each scenario. Treatments for people with neurological conditions typically last between 12 and 30 minutes. Mental practice is most effective for people who are able to visualise events clearly, e.g. if you can imagine your hand opening and closing, even if it is paralysed. Some studies have also shown that it is better to focus on familiar activities, rather than attempting to imagine new tasks.5

 

  • Possible benefits of Mental Practice for stroke

    There is a good deal of research to suggest that mental practice can have a positive effect on stroke recovery. Some studies show improvements in a number of arm and leg movements, the ability to move from sitting to standing, and a wide range of household tasks.6 For example, a study in 2006 asked whether people could improve their walking simply by using visualisation exercises. Four people suffering from chronic hemiparesis were asked to do imaginary walking practice. They did so three days a week for six weeks. Researchers found:

    ‘At 6 weeks from the beginning of treatment, the participants increased walking speed, stride length, cadence and single-support time on the affected lower limb, while decreasing double-support time.’7

    Other studies show that it is possible to make significant improvements more than one year after a stroke:

    ‘The ability of individuals with chronic hemiplegia to achieve functional gains through imagery practice has further been supported by reports of significant, long-standing improvement in wrist movements and object manipulation in 2 patients as well as in the improvement in line tracing in 3 patients with right poststroke hemiparesis. In patients with chronic stroke, daily home practice of moving tokens with the affected hand for a total period of 4 weeks was associated with significant improvement in task performance compared with the progress made by control group subjects.8

    In 2009, another study demonstrated how mental practice can help stroke survivors to improve their arm mobility. The authors also noted that this treatment is low cost and easy for a therapist to deliver:

    ‘Conclusions. MP is an easy to use, cost-effective strategy that was again shown to improve affected arm outcomes after stroke.9

    A recent pilot study with 12 participants tested the effects of combining MP with a small amount of physical practice to relearn rising up from and sitting down on a chair. The individuals were divided into three groups at random. One group was asked to do MP with physical practice, one group did physical practice and cognitive training, and the third group only did physical practice. Training was provided three times a week for four weeks. The study found that participants who combined series of mental repetitions (about 1100) with a small amount of physical repetition (about 110) did significantly better than the other two groups and were also able to retain those gains. The researchers concluded that the results were very promising but the study was very small and large-scale tests would be required to validate the findings.10

  • Arguments against using Mental Practice for stroke

    Mental practice may not work for all stroke survivors. The technique works best when your memory is functioning properly and you have good powers of visualisation. The benefits of MP might also be affected by the specific areas of the brain that have been damaged.

  • Case histories
    1. In 2005, a study was conducted on 11 stroke survivors who had ‘upper-limb hemiparesis on the dominant side’:

      ‘All patients received 30-minute therapy sessions 2 days a week for 6 weeks. The sessions emphasized activities of daily living (ADLs): 6 subjects randomly assigned to the MP [Mental Practice] condition concurrently received sessions requiring daily MP of the ADLs; 5 subjects (control group) received an intervention consisting of relaxation techniques.

      Results: Affected limb use as rated by MP patients and their caregivers increased (1.55, 1.66, respectively), as did patient and caregiver ratings of quality of movement (2.33, 2.15, respectively) and ARA scores (10.7). In contrast, the controls showed nominal increases in the amount they used their affected limb and in limb function. A Wilcoxon test on the ARA scores revealed significantly (P = .004) greater changes in the MP group’s scores.’11

    2. In 2005, a clinical trial was set up to study how successfully mental practice could help stroke survivors to relearn everyday tasks. They looked at 46 patients in a stroke rehabilitation unit in Hong Kong. They were all 60 years of age or older and had suffered a cerebral infarction:
      ‘Interventions: Patients were randomized to receive 15 sessions (1h/d for 3wk) of either the mental imagery program or the conventional functional training intervention on the relearning of daily living tasks.Main Outcome Measures: Performance of 15 trained and 5 untrained tasks, including household, cooking, and shopping tasks; and the Fugl-Meyer Assessment and Color Trails Test (CTT).Results: Patients engaged in mental imagery-based intervention showed better relearning of both trained and untrained tasks compared with the control group (trained tasks: P_.005; untrained tasks:P_.001). They also demonstrated a greater ability to retain the trained tasks after 1 month and transfer the skills relearned to other untrained tasks (P_.001). However, among the various ability measures, the mental imagery group showed a significant increase in the CTT scores only after the intervention (P_.005).Conclusions: Mental imagery can be used as a training strategy to promote the relearning of daily tasks for people after an acute stroke. The imagery process is likely to improve the planning and execution of both the trained and the untrained (novel) tasks. The effect of its relearning appears to help patients to retain and generalize the skills and tasks learned in the rehabilitation program.’12
  • Notes and references
    1. ‘Using Mental Practice in Stroke Rehabilitation: A Framework’ by Susy Braun, Melanie Kleynen et al. InClinical Rehabilitation, Vol. 22, No. 7, 579-591 (2008)
    2. ‘Contribution from neurophysiological and psychological methods to the study of motor imagery.’ By Guillot A, Collet C. In Brain Research Reviews. 2005;50:387–397
    3. ‘Vegetative response during imagined movement is proportional to mental effort’ by Decety J, Jeannerod M, Germain M, Pastene J. In Behavioural Brain Research. 1991;42:1–5
    4. ‘Cortical Plasticity Following Motor Skill Learning During Mental Practice in Stroke’ by S.J. Page, J. P. Szaflarski, J. C. Eliassen, H. Pan, and S.C. Cramer. In Neurorehabil Neural Repair, May 1, 2009; 23(4): 382 – 388.
    5. ‘The role of motor imagery in learning a totally novel movement’ by Mulder T, Zijlstra S, Zijlstra W, Hochstenbach. In Journal Experimental Brain Research. 2004;154:211–217.
    6. ‘Motor Imagery in Physical Therapist Practice’ by Ruth Dickstein and Judith E Deutsch. In Physical Therapy, Vol. 87, No. 7, July 2007, pp. 942-953
    7. ‘Motor imagery practice in gait rehabilitation of chronic post-stroke hemiparesis: four case studies’ by A. Dunsky, R. Dickstein et al. In International Journal of Rehabilitation Research. Volume: 29, Issue: 4, Pages: 351-356, Published: DEC. 2006.
    8. ‘Motor Imagery in Physical Therapist Practice’ by Ruth Dickstein and Judith E Deutsch. In Physical Therapy, Vol. 87, No. 7, July 2007, pp. 942-953
    9. ‘Cortical Plasticity Following Motor Skill Learning During Mental Practice’ by Stephen J. Page, Jerzy P. Szaflarski, James C. Eliassen, Hai Pan, Steven C. Cramer. In Stroke Neurorehabilitation and Neural Repair, Vol. 23, No. 4, 382-388 (2009)
    10. Malouin F, Richards CL, et al. ‘Added value of mental practice combined with a small amount of physical practice on the relearning of rising and sitting post-stroke: a pilot study’. In Journal of Neurological Physical Therapy 2009, 33(4), pp. 195-202
    11. ‘Effects of mental practice on affected limb use and function in chronic stroke’ by Page SJ, Levine P, Leonard AC. In Archives of Physical Medicine and Rehabilitation. Volume: 86, Issue: 3, Pages: 399-402, Published: MAR. 2005
    12. ‘Mental imagery for promoting relearning for people after stroke: a randomized controlled trial’ by Liu KP, Chan CC, Lee TM, Hui-Chan CW. In Archive of Physical Medicine and Rehabilitation. 2004;85:1403–1408

Aviva Cohen is the author and CEO of Neuro Hero