CRITICALLY APPRAISED PAPER (CAP)

CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION Is the combination of occupational therapy (OT) and mental practice (MP), from either an internal or an external perspective, an effective intervention to reduce sensorimotor impairment, improve function, and enhance self-perception of clients after stroke while participating in functional tasks? Nilsen, D. M., Gillen, G., DiRusso, T., & Gordon, A. M. (2012). Effect of imagery perspective on occupational performance after stroke: A randomized controlled trial. American Journal of Occupational Therapy, 66, 320 329. http://dx.doi.org/10.5014/ajot.2012.003475 CLINICAL BOTTOM LINE: This study is a Level I, randomized controlled trial (RCT) with a pretest posttest control design. Throughout the study, the same trained occupational therapist (OT) was blinded to assignments and evaluated participants for the pretest and posttest measures. Immediately following sessions, the interventionist conducted a manipulation check to have the participants verbally explain his or her mental images and rated whether the individual engaged in internal or external imagery on a scale on four separate occasions. All the participants received treatment by the same neurorehabilition-experienced OT. The OT sessions were administered in either a clinic-based setting (n = 12) or participant s home environment (n = 5). OTs did not note any differences in the individual s characteristics related to the setting of the session. The researchers noted in the data analysis portion of the study that they set all the statistical test level of significance at p <.05. Limitations mentioned throughout the study included: Small sample size. Lack of blinding of the interventionist. Failure to question participants about MP use or activities engaged in at home. Researchers did not stratify randomization of participants by their involved side, age time after stroke, or impairment level. Lesion location was not documented (researchers found that other researchers claimed lesion location does not determine imagery ability). 1

OT practice: Because most stroke survivors have impairments of upper-extremity (UE) function that inhibit the individual s ability to engage in valued occupations, it is important for OTs to continue identifying and testing the effectiveness of interventions that target remediation of a stroke survivor s arm and hand function. Results from this study indicate that MP combined with purposeful activity allows an opportunity for individuals to improve UE recovery after stroke. The researchers that conducted this study and concluded the following: Incorporating MP of functional tasks into OT programs can improve arm and hand function during poststroke recovery. Clients may be able to self-select either (internal or external) imagery perspective to mentally practice functional tasks. RESEARCH OBJECTIVE(S) List study objectives. Determine whether: OT combined with MP from either perspective would reduce impairment, improve function, and enhance self-perception of performance above a control condition MP using internal perspective would be more effective in reducing impairment and improving function than MP using an external perspective MP using an external perspective would be more effective in enhancing self-perspective of occupational performance than MP using an internal perspective DESIGN TYPE AND LEVEL OF EVIDENCE: RCT Level I Pretest posttest control design Limitations (appropriateness of study design): Was the study design type appropriate for the knowledge level about this topic? Circle yes or no, and if no, explain. YES/NO MP poststroke literature shows a difference in instruction regarding the perspective trained to use whether it is internal, external, or a combination of both. It is important to research and monitor whether clients maintain the perspective they are instructed to use during treatment, which has been neglected in the MP post stroke literature. Previous research on imagery from internal perspective stated it is essential for neurological rehabilitation, because it closely resembles physical practice. Some researchers have suggested that external imagery may enhance motivation and self-perception greater than imagery from internal perspective. Studies investigating perspective use during MP in healthy people have revealed that both perspectives can improve motor performance. Studies have not been done on people after stroke. 2

This study is the first comparison of the benefits of the two perspectives demonstrated by pretest and posttest control design. SAMPLE SELECTION How were subjects selected to participate? Please describe. The researchers used convenience sampling. They recruited participants from New York City and surrounding areas by posting flyers, contacting stroke support s, and using a stroke registry. After initial telephone contact, the researchers screened 30 people between ages 18 and 90 years with clinical evidence of a single unilateral stroke (minimum of 9-week post onset). Inclusion Criteria Cognitively intact (greater than or equal to a 69 on the modified Mini-Mental State Exam) Actively flex the wrist and at least two metacarpophalangeal and interphalangeal joints of the digits on the affected side of the body a minimum of 10 from neutral. Exclusion Criteria Excessive pain ( 4 on the visual analog scale) Spasticity ( 3 on the Modified Ashworth Spasticity Scale) Unable to perform imagery(> 36 on the internal or external visual imagery subscales of the Vividness of Movement Imagery Questionnaire-2 [VMIQ 2]) Too-low functioning (surpassing a total time of 1080 seconds on Jebson Taylor Test of Hand Function [JTTHF]) Too-high functioning (greater than 40% discrepancy between the hands on the JTTHF) Undergoing therapy to improve arm or hand function (or both) SAMPLE CHARACTERISTICS N = 19 % Dropouts 15.7% Analyzed N = 16 #/ (%) Male 9/ (42.4%) #/ (%) Female 10/ (52.6%) Ethnicity NR Disease/disability diagnosis Single unilateral stroke Check appropriate : < 20/study 20 50/study 51 100/study 101 149/study 150 200/study 3

INTERVENTION(S) AND CONTROL GROUPS Group 1: Internal Group (OT and MP from internal perspective) Brief Description OT (sessions focused on three trained tasks) 1st and 2nd week drinking from cup (involved hand) 3rd and 4th week donning button down shirt (both hands) 5th and 6th week folding towel (both hands) Engaged in a variety of unimanual and bimanual purposive activities designed to improve arm and hand function and encourage participants to continue with their normal daily routines at home Immediately following OT, participants engaged in internal MP training sessions by listening to an audiotape that facilitated the imagery modalities to the three trained tasks taught in OT sessions. Scripts were designed to last same duration (about 20 minutes) and divided as follows: introduction (about 2 minutes), relaxation (about 5 minutes), focused imagery (about 8 minutes), and refocusing (about 3 minutes). Setting Who Delivered? Frequency? Duration? Clinic-based setting or participant s home environment All participants received treatment from the same OT with neurorehabilitation experience 30-minute sessions, twice a week 6 weeks Group 2: External Group (OT and MP from the external perspective) Brief Description OT (sessions focused on three trained tasks) 1st and 2nd week drinking from cup (involved hand) 3rd and 4th week donning button down shirt (both hands) 5th and 6th week folding towel (both hands) Engaged in a variety of unimanual and bimanual purposive activities designed to improve arm and hand function and encourage participants to continue with their normal daily routines at home Immediately following OT, participants engaged in external MP training sessions by listening to an audiotape that facilitated the imagery modalities to the three trained tasks taught in OT sessions. Scripts were designed to last same duration (about 20 minutes) and divided as follows: introduction (about 2 minutes), relaxation (about 5 minutes), focused imagery (about 8 minutes), and refocusing (about 3 minutes). Setting Who Delivered? Frequency? Duration? Clinic-based setting or participant s home environment All participants received treatment from the same OT with neurorehabilitation. 30-minute sessions, twice a week 6 weeks 4

Group 3: Control Group (OT & relaxation imagery) Brief Description OT (sessions focused on three trained tasks) Setting Who Delivered? Frequency? Duration? 1st and 2nd week drinking from cup (involved hand) 3rd and 4th week donning button down shirt (both hands) 5th and 6th week folding towel (both hands) Engaged in a variety of unimanual and bimanual purposive activities designed to improve arm and hand function and encourage participants to continue with their normal daily routines at home Immediately following OT, participants engaged in a relaxation imagery training session by listening to an audiotape focused on relaxation imagery for the same duration. This was provided no instruction regarding imagery perspective use. Clinic-based setting or participant s home environment All participants received treatment from the same OT with neurorehabilitation experience 30-minute sessions, twice a week 6 weeks Intervention Biases: Circle yes or no and explain, if needed. Contamination YES/NO On four occasions (sessions 3, 6, 9, and 12) immediately after imagery sessions, the interventionist conducted a manipulation check on perspective use. Participants verbally engaged in a perspective rating scale to determine which perspective they had used. They verbally described the mental images they experienced and the interventionist transcribed the information. Participants made a mark on a 10-centimeter line, with one side stating 100% internal and 100% external to rate whether they engaged in internal or external visual imagery. Co-intervention Timing YES/NO This was part of the exclusion criteria. YES/NO Twice a week for 6 weeks allows the OT to relate this intervention to treatment practiced in the field because of the session restrictions given by a client s insurance. Site YES/NO The OTs did not note a difference regarding the participants characteristics on whether the participants received sessions within the clinic vs. home environment. 5

Use of different therapists to provide intervention YES/NO All participants received treatment by the same OT. MEASURES AND OUTCOMES Complete for each relevant measure when answering the evidence-based question: Name of measure, what outcome was measured, whether the measure is reliable and valid (as reported in article yes/no/nr [not reported]), and how frequently the measure was used. VMIQ 2 Evaluates imagery ability from both internal and external visual imagery perspective using the kinesthetic imagery modality In each subsection, people imagine themselves performing 12 movements (e.g., walking, throwing a stone) and rate the clarity and vividness of the image using a 5-point scale (scores for each subsection range from 12 to 60, and lower scores indicate more vivid images) Concurrent and construct validity; reliability was not reported A trained OT blinded to assignment evaluated the participants 3 days before starting the intervention; the same evaluator tested participants within 3 days of completing the intervention. Primary measure 1: UE section of the Fugl-Meyer Assessment of Motor Recovery (FMA) Evaluates impairment using a 3-point ordinal scale (maximum score = 66 points; higher scores indicate less impairment) High test retest reliability (r =.99), interrater reliability (rs =.96.97), and construct validity A trained OT blinded to assignment evaluated the participants 3 days before starting the intervention; the same evaluator tested participants within 3 days of completing the intervention. Primary measure 2: JTTHF Evaluates hand function; faster times indicate greater hand function Durations of 6 of the 7 subtests (the writing was removed) were summed to generate a total time score) Strong test retest reliability (r =.67.99) and validity in predicting functional hand use in activities of daily living (ADLs) A trained OT blinded to assignment evaluated the participants 3 days before starting the intervention; the same evaluator tested participants within 3 days of completing the intervention. Secondary measure: The Canadian Occupational Performance Measure (COPM) Evaluates a person s perception of occupational performance and satisfaction of occupational performance using 2 10-point ordinal scales 6

Strong test retest reliability (intraclass correlation [ICC] =.63 for performance, ICC =.84 for satisfaction, content validity, and concurrent validity) Modified from original form in a manner consistent with previous research Participants were asked to rate five preselected tasks: drinking from a cup, donning a button-down shirt, folding a towel, brushing teeth, and unpacking groceries A trained OT blinded to assignment evaluated the participants 3 days before starting the intervention; the same evaluator tested participants within 3 days of completing the intervention. Measurement Biases Were the evaluators blind to treatment status? Circle yes or no, and if no, explain. YES/NO The evaluator was a trained OT and blinded to assignments. The same OT evaluated all participants using the outcome measures during the pretest and posttest. The evaluator reported that blinding was maintained throughout the study period. Another OT experienced in neurorehabilitation administered all treatment sessions for each participant. Recall or memory bias. Circle yes or no, and if yes, explain. YES/NO The interventionist conducted a manipulation check on perspective use immediately following four sessions. The participants were asked to recall and discuss their mental images verbally with interventionist and rate on a scale whether they engaged in internal or external visual imagery. The intervention was not biased. Out of the 17 participants, only one in the external had difficulty maintaining the external perspective and was excluded from analysis. RESULTS List results of outcomes relevant to answering the focused question Include statistical significance where appropriate (p < 0.05) Include effect size if reported FMA scores increased from pretest to posttest across all three s, but only the internal and external s increased significantly (very large effect sizes were seen for both perspectives; p =.042). JTTHF significantly decreased from the pretest to posttest for the internal and external s, whereas it did not for the control (very large effect sizes were seen for both perspectives; p =.022). Although s did not differ significantly at the baseline on the primary outcomes measures, the internal was a higher functioning, which caused the researchers to run an analysis of covariance on posttest scores using the pretest scores (p =.047). 7

Comparisons of pretests and posttests scores revealed that the experimental s were significantly different from the control, while not being significantly different from each other. The mean COPM self-perception of performance and satisfaction scores increased significantly across all the s regardless of whether the task was trained or untrained (p <.001). Was this study adequately powered (large enough to show a difference)? Circle yes or no, and if no, explain. YES/NO Having a small sample size was a limitation of this study. Were appropriate analytic methods used? Circle yes or no, and if no, explain. YES/NO One rater scored the individual retrospective verbalization transcripts for each participant to determine perspective use to calculate the mean. They also calculated the mean of the four scores on the rating scale and used a correlation to evaluate the relationship. Changes in impairment and activity limitation were determined from the results of the FMA and JTTHF. Changes in perception of satisfaction of the occupational performance were determined by adding the ratings of each of the five tasks on the performance and satisfaction scale of the COPM to obtain a total performance and satisfaction score. Change scores (posttest pretest) were calculated for each participant for each measure; using those scores, a within- mean change and standard error of mean was calculated for each measure. A three () two (test) ANOVA was used for all measures to assess change from pretest to posttest. Level of significance was p <.05 for all tests. Were statistics appropriately reported (in written or table format)? Circle yes or no, and if no, explain. YES/NO Scatter plot and double bar graphs Charts Table CONCLUSIONS State the authors conclusions that are applicable to answering the evidence-based question. When combined with OT, MP is an effective intervention to improve arm and hand therapy. However, the researchers concluded that the instruction for imagery perspective does not appear to be an important variable for success of MP interventions because both perspectives produced similar results at various levels of analysis. MP does not have an effect on clients perception of occupational performance. 8

This work is based on the evidence-based literature review completed by Kayla Huesgen, OTS, and Rebecca von der Heyde, PhD, OTR/L, CHT, Faculty Advisor, Maryville University. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 9