Motor imagery in neurorehabilitation. - An introductory workshop - Imagery-Publications. Welcome. Workshop goals. Corina Schuster-Amft (PT, PhD)

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1 Welcome Motor imagery in neurorehabilitation - An introductory workshop - Corina Schuster-Amft (PT, PhD) Reha Rheinfelden, Bern University of Applied Sciences, University of Basel Workshop goals Main goal: Participants try to use motor imagery with their patients. Subgoals: Participants are able to describe what is motor imagery and how it works. Participants know outcome measures to evaluate motor imagery ability in their patients. Participants developed an understanding for motor imagery by practical experience. Corina Schuster 3 PubMed search: Imagery-Publications mental imagery 240 motor imagery

2 German treatment guideline: upper extremity German treatment guideline 5.13: mental training uex Mentales Training Ähnlich wie bei der Spiegeltherapie, bei der der Patient scheinbar die gelähmte Hand sich bewegen sieht (im Spiegel), gibt es auch die Möglichkeit, dass wir uns die Bewegung des gelähmten Armes vor unserem geistigen Auge vorstellen. Beispielsweise können Patienten sich vorstellen, wie sie den gelähmten Arm bei Alltagsverrichtungen benutzen. Auch das kann die motorische Erholung fördern (Page et al. 2005). Zusätzlich zur sonstigen motorischen Therapie sollte ein über mehrere Wochen durchgeführtes tägliches mentales Training (10 30 Minuten) mit vorgestelltem Gebrauch des betroffenen Armes im Alltag bei subakuten und chronischen Schlaganfall-Patienten mit vorhandener Restfunktion der Hand erwogen werden, wenn eine Verbesserung der Armfunktion angestrebt wird (Klassifikation S2k, Evidenz mittel (3 Studien), Einschätzung der Effekte: mittlere Qualität; Empfehlungsgrad B) Leitlinie Rehabilitation von sensomotorischen Corina Störungen; Schuster 5. überarbeitete Auflage 2012, S. 7, gültig bis Leitlinie der Deutschen Gesellschaft für Neurologische Rehabilitation: Motorische Therapien für die obere Extremität zur Behandlung des Schlaganfalls, Stand: , gültig Corina bis , Schuster aktuell überarbeitet 6 Overview Sensible input External stimulation TMS Electrodes Brain plasticity Context factors Active practice Mental simulation External focus Goals WHAT is motor imagery? Meaningful context Motor learning Repetitions. Person-specific factors Competence Autonomy Social integration Learning stage Corina Schuster 8 2

3 Definition Motor imagery What is motor imagery? Motor imagery (MI) may be defined as a dynamic state during which the representation of a given motor act is internally rehearsed within working memory without any overt motor output. Decety & Grèzes, 1999 Corina Schuster 9 Adjunct method Increase therapy amount / repetitions Safe and cheap therapy method Independent from therapist, location, time of the day, exercise/movement selection (complex, challenging) Influence on Motor function / activities Cognitive function (self-confidence, concentration, memory, motivation) Corina Schuster 10 Mechanism of action Bio-informational theory Reinforcement of representation of the movement in the memory (stimulus, answer, meaning) Access / retrieval of a movement answer, facilitation the meaning of the movement Neurophysiological arousal Similar for MI & PP (brain areas, cortico-spinal excitability) Neuro-muscular mechanism Subliminal arousal or too less inhibition Schack T.Essig K.Frank C.Koester D. Mental representation Corina and motor Schuster imagery training. Front Hum Neurosci 2014;8: Objective measurement Blood flow, metabolism (fmri / PET / SPECT / NIRS) Corina Schuster Baseline, whole body vs. upper extremity movements Cortical areas (bilateral lateral and medial premotor cortices, medial frontal gyrus including supplementary motor area (SMA) and pre SMA, precentral gyri of both hemispheres, primary motor cortex, left frontal operculum and insula) Parietal areas (only left hemisphere, superior and inferior parietal lobe) Subcortical areas (right basal ganglia including putamen, pallidum and caudate nucleus) (Szameitat et al. 2007) 3

4 Objective measurement M. gastrocnemius left Physiological Changes Muscle fibre activity M. rectus femoris - Electromyography left (EMG) M. gastrocnemius right M. rectus femoris right Metronom Objective measurement Eye movements - Electrooculography (EOG) MI: 89% participants Eyes open MI: 84% participants Eyes closed Task-related eye movements => Amount & extent of eye movements were almost similar Dickstein R.Gazit Grunwald M.Plax M.Dunsky A.Marcovitz E. EMG activity in selected target muscles during imagery rising on tiptoes in healthy adults and poststroke hemiparetic patients. J Mot Behav Corina 2005;37(6): Schuster 13 Corina Schuster 14 Objective measurement Electrical brain activity Electroencephalography (EEG) Objective measurement Autonomic nervous system (skin resistance, temperature, heart rate, breathing frequency) Corina Schuster 15 Corina Schuster 16 4

5 MI-quality and external simulus Eye movements Patient > healthy individuals (MI, PP) External stimulus MI-qualityé (MI-duration ê) Spatial MI-accuracy é Visual > auditive Objective measurement MI ability Folding paper Cut cubes mental rotation Rotate objects Heremans et al. Cued motor imagery in patients with multiple Corina sclerosis. Schuster Neuroscience. 2012;206: Corina Schuster 18 Mental chronometry Temporal congruency of mental and physical execution of a movement Ratio = time needed to imagine Ratio 1 time needed to perform Malouin F, Richards CL, Desrosiers J, Doyon J. Bilateral slowing of mentally simulated actions after stroke. NeuroReport, 2004;15(8): Corina Schuster 19 Subjective measurement Imagery vividness or clarity Galton (1880) Breakfast Table Inquiry (Questionnaire) Bett (1909) Bett s Questionnaire upon Mental Imagery (QMI) Singer (1966) Imaginal Processes Inventory (IPI) Sheehan (1967) A shortened form of Bett s questionnaire upon MI Marks (1973) Vividness of Visual Imagery Questionnaire (VVIQ) Switras (1978) "An alternate-form instrument to assess vividness and controllability of mental imagery in seven modalities" Hall (1985) Movement Imagery Questionnaire (MIQ) Isaac (1986) The vividness of movement imagery questionnaire (VMIQ) Hall (1997) rev. Movement Imagery Questionnaire (MIQ-R) Kwekkeboom (2000) The imaging ability questionnaire Blajenkova (2006) "Object-spatial imagery questionnaire (OSIQ) Malouin (2007) Kinesthetic and visual imagery questionnaire (KVIQ) Roberts (2008) rev. The vividness of movement imagery questionnaire (VMIQ) 5

6 KVIQ-G Group work 1: Mental rotation Movements KVIQ-G-20 Bend/extent neck Shrug shoulders Arm elevation* Elbow flexion* Move thumb to finger tips* Bend trunk forward Extent knee* Move leg sideward Tap foot* Move foot outward* Visual imagery scale Kinaesthetic imagery scale With partner identify 10 foot and hand cards (right / left) View every card max. 5 seconds Record errors Time: 3min per person Corina Schuster 21 Corina Schuster 22 Group work 2: Mental chronometry Perform 2 movements with partner: 1x active, 1x mental Sit-to-stand movement Extent / bend lower leg Record time needed for all movements (stopp watch) Partner indicates start and stopp of a mental movement with a hand / finger movement If possible, calculate the ratio between time needed to imagine and time needed to physically perform Time: 3min per person Group work 3: KVIQ-G With partner perform tasks/movements 3, 4, and 5 based on the standardised description First, evaluate all tasks/movments on the visual scale Second, evaluate all tasks/movments on the kinaesthetic scale Record scores on the questionnaire Time: 3min per person Corina Schuster 23 Corina Schuster 24 6

7 Application of MI CRPS Anterior After surgical after Joint cruciate Shoulder flexor tendon Amputation wrist Osteo- Burn replace- ligament impingement Stroke MS PD SCI TBI repair fracture arthritis injury ment surgery ADL-function x x x x motor function x x ROM x x x x movements x x Finger x x Arm movements x x Foot movements x x x Spastizität / Dehnung x x Gewichtsübernahme x Sit to stand x Proprioception Sensibility Walking / walking speed x x x Pain x x x x x x Speech x Neglect x x Muscle activation x Strength x x Perception UE function x Postural balance x Tremor x HOW to imagine / visualise movements? Corina Schuster 26 How to do MI? What should patients imagine? How should patients perform MI? How should MI and PP be combined? How long should patients imagine a movement? How frequently should patients imagine a movement? Corina Schuster 27 Literature reviews 1. Machado et al. (2015). Is mental practice an effective adjunct therapeutic strategy for upper limb motor restoration after stroke? A systematic review and meta- analysis. CNS Neurol Disord Drug Targets, 14(5), Harris & Hebert. (2015). Utilization of motor imagery in upper limb rehabilitation: A systematic scoping review. Clin Rehabil, Malouin et al. (2013) Towards the integration of mental practice in rehabilitation programs. A critical review. Front Hum Neurosci, 7: Braun et al. (2013) The effect of mental practice in neurlogical rehabilitation: a systematic review and metaanalysis. Front Hum Neurosci, Carrasco et al. (2013) Effectiveness of motor imagery or mental practice in functional recovery after stroke: a systematic review. Neurologia. 6. Schuster et al. (2011) Best practice for motor imagery: A systematic literature review on motor imagery training elements in five different disciplines. BMC Med, 9: Wang et al. (2011) Efficacy of mental practice on rehabilitation of hand function in patients with post-stroke: A systematic review. Chin J Evid-Based Med, 11: Nilsen et al. (2010) Use of mental practice to improve upper-limb recovery after stroke: A systematic review. Am J Occup Ther, 64: Calayan & Dizon (2009) A Systematic Review on the Effectiveness of Mental Practice with Motor Imagery in the Neurologic Rehabilitation of Stroke Patients. Internet J Allied Health Sci Pract, Zimmermann-Schlatter, Schuster et al. (2008) Efficacy of motor imagery in post-stroke rehabilitation: a systematic review. J Neuroeng Rehabil, Ziemainz et al. (2008) The Application of Mental Training in the Rehabilitation of Stroke Patients Review and Calculating Effect Sizes. Phys Med Rehab Kuror, 18: Kossert & Munroe-Chandler (2007) Exercise Imagery: A Systematic Review of the Empirical Literature. J Imagery Res Sport Phys Activity, Braun et al. (2006) The effects of mental practice in stroke rehabilitation: a systematic review. Arch Phys Med Rehabil 2006, 87: Taktek (2004) The effects of mental imagery on the acquisition of motor skills and performance: A literature review with theoretical implications. J Ment Imagery, 28:

8 Literature reviews Literature reviews Barclay-Goddard RE, Stevenson TJ, Poluha W, Thalman L. Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke. Cochrane Database Syst Rev 2011;5:CD Braun S, Kleynen M, van Heel T, Kruithof N, Wade D, Beurskens A: The effect of mental practice in neurlogical rehabilitation: a systematic 24. review August and 2018 meta-analysis. Front Hum Neurosci 2013, Corina 7. Schuster 30 PETTLEP-Principle MI perspective Abk. Engl. Begriff Dt. Begriff P Physical Körperlicher Zustand E Environment Umgebung T Task Bewegungsaufgabe T Timing Dauer L Learning Lernen und Anpassen E Emotion Gefühl und Zustand P Perspective Perspektive und Modus Holmes & Collins: The PETTLEP approach to motor imagery: A functional equivalence model for sport psychologists. J Appl Sport Psychol 2001, 13: Pat.: 25 STR, 25 MS, 5 PD: Patients selected both perspectives spontaneously: internal & external during visual and kinaesthetic motor imagery External perspective used for axial & proximal movements Patients aged 64+ selected external perspective more frequently Chronic patients more consistent in perspective selection ÞExact MI ability evaluation is important for effective MI training in clinical routine Koppel, Gerber, Schuster-Amft. Which perspective is selected? The evaluation of motor imagery perspectives in patients with sensorimotor impairments. Submitted. Corina Schuster 32 8

9 Recommendations for MI practice Group work: Practical experience - See working sheet - 1. What knowledge has the patient regarding MI? 2. How well can he/she imagine movements (MI ability)? 3. How well is the patients compliance? 4. Does he/she know the movement to be imagined? 5. What is the temporal ratio of MI and PP of the movement? 6. Create MI for one movement (1-4 repetitions, do not predefine perspective, mode) 7. Test MI content (questions) 8. Modify / extent MI Corina Schuster 33 Corina Schuster 34 Summary I MI for re-learning / improvement of movements MI always in combination with PP Before MI start evaluate your patient MI ability (1+ Assessments) to generate and modulate mental images Know the movement to be imagined (complete and detailed imagination of the movement) (Working-) memory, attention Corina Schuster 35 Summary II Almost no recommendations for practical implementation of MI Duration of MI and PP should be similar Evaluate patients compliance Start with less repetitions Do not predefine mode and perspective Unclear: what patients, what dosage, what technique External stimuli might help to improve MI quality (vis>auditive) Corina Schuster 36 9

10 Summary III Workshop goals Main goal: Participants try to use motor imagery with their patients. Subgoals: Participants are able to describe what is motor imagery and how it works. Participants know outcome measures to evaluate motor imagery ability in their patients. Participants developed an understanding for motor imagery by practical experience. Corina Schuster 37 Corina Schuster 38 Take home message Thank you very much for your attention! Corina Schuster-Amft 1) Motor Imagery in theory and practice 21. Mar & 20. Sep 2019 at the Reha Rheinfelden Corina Schuster 39 2) Focused symposium: Motor imagery in neurorehabilitation May 2019 at the WCPT World Congress in Geneva 10

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