Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke

Mental practice is a process through which an individual repeatedly mentally rehearses an action or task without actually physically performing the action or task. The goal of the mental practice is to improve performance of those actions or tasks. Mental practice has been proposed as a potential adjunct to the physical practice procedures that are commonly performed by survivors of stroke undergoing rehabilitation.  Our review of six studies involving 119 participants provided limited evidence that mental practice, when added to traditional physical rehabilitation treatment, produced improved outcomes compared with the use of traditional rehabilitation treatment alone. The evidence to date shows the improvements are limited to measures of performance of real-life tasks appropriate to the upper limb (e.g. drinking from a cup, manipulating a door knob). It is not clear if mental practice added to physical practice produces improvements in the motor capacity of the upper limb (i.e. the ability to perform selected movements of the upper limb with strength, speed and/or co-ordination). Finally, there is no evidence available detailing either the components of the mental practice (e.g. How long should the mental practice sessions be? How many mental practice sessions are necessary?, etc) or the qualities of the survivor of a stroke (How long since onset of stroke? How much recovery is required?, etc) that are required to obtain a positive outcome. However, there is reason for optimism that some of the questions will be answered as there are several large trials currently ongoing.

Authors' conclusions: 

There is limited evidence to suggest that MP in combination with other rehabilitation treatment appears to be beneficial in improving upper extremity function after stroke, as compared with other rehabilitation treatment without MP. Evidence regarding improvement in motor recovery and quality of movement is less clear. There is no clear pattern regarding the ideal dosage of MP required to improve outcomes. Further studies are required to evaluate the effect of MP on time post stroke, volume of MP that is required to affect the outcomes and whether improvement is maintained long-term. Numerous large ongoing studies will soon improve the evidence base.

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Background: 

Activity limitations of the upper extremity are a common finding for individuals living with stroke. Mental practice (MP) is a training method that uses cognitive rehearsal of activities to improve performance of those activities.

Objectives: 

To determine if MP improves the outcome of upper extremity rehabilitation for individuals living with the effects of stroke.

Search strategy: 

We searched the Cochrane Stroke Group Trials Register (November 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, November 2009), PubMed (1965 to November 2009), EMBASE (1980 to November 2009), CINAHL (1982 to November 2009), PsycINFO (1872 to November 2009), Scopus (1996 to November 2009), Web of Science (1955 to November 2009), the Physiotherapy Evidence Database (PEDro), CIRRIE, REHABDATA, ongoing trials registers, and also handsearched relevant journals and searched reference lists.

Selection criteria: 

Randomised controlled trials involving adults with stroke who had deficits in upper extremity function.

Data collection and analysis: 

Two review authors independently selected trials for inclusion. We considered the primary outcome to be the ability of the arm to be used for appropriate tasks (i.e. arm function).

Main results: 

We included six studies involving 119 participants. We combined studies that evaluated MP in addition to another treatment versus the other treatment alone. Mental practice in combination with other treatment appears more effective in improving upper extremity function than the other treatment alone (Z = 3.48, P = 0.0005; standardised mean difference (SMD) 1.37; 95% confidence interval (CI) 0.60 to 2.15). We attempted subgroup analyses, based on time since stroke and dosage of MP; however, numbers in each group were small. We evaluated the quality of the evidence with the PEDro scale, ranging from 6 to 9 out of 10; we determined the GRADE score to be moderate.

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