Effectiveness of Mental Practice Combined with Physical Practice in the Treatment of Post Stroke Patients

Purpose: To determine the effectiveness of mental practice combine with Physical practice in post stroke patients.

Methodology: This was an experimental study of 30 stroke patients having first ever unilateral stroke. All the subjects were enrolled in identical subgroup and divided into two equal group one experimental and another control group. Experimental group did 30 to control group and displayed efficient improvement in motor function of the upper extremity after 6 weeks.

Conclusions: Mental practice with physical practice is more effective than physical practice alone, thereby providing evidence that it is a better strategy to include mental practice in combination with physical practice in stroke minutes mental practice followed by 30 minutes physical practice and control group performed 30 minutes physical practice. After completing 6 weeks of intervention in both the groups, posttest measurement done with Fugl-Meyer Assessment (FMA) scale.

Results: The result obtained from the study demonstrated that experimental group showed significant results as compared rehabilitation.

Stroke; Mental practice; Physical practice; Upper extremity

Stroke or Brain attack is the sudden loss of neurological function caused by an interruption of the blood flow to the brain. The term Cerebrovascular accident is used interchangeably with stroke to refer to the vascular conditions of the brain [1]. According to World Health Organization ��?stroke is defined as rapidly developed clinical sign of a focal disturbance of cerebral function of presumed vascular origin and of more than 24 hours duration��?. Included within this definition are most cases of cerebral infarction, cerebral haemorrhage and subarachnoid haemorrhage but deliberately excluded are those cases in which recovery occurs within 24 hours [2].

Stroke is third leading cause of death and the most common cause of disability among adults worldwide [3]. The prevalence of stroke in India varies in different regions of the country and ranges from 40 to 270 per 100,000 population [4], approximately 12% of all strokes occur in the population <40 years of age [5]. The National Commission on Macroeconomics and Health has projected that cases of stroke would increase from 1,081,480 in 2000 to 1,667,372 in 2015 [6].

Ischemic stroke is the most common type, affecting about 80% of individuals with stroke, and results when a clot blocks or impairs blood flow, depriving the brain of essential oxygen and nutrients [7]. Haemorrhagic stroke occurs when blood vessels rupture, causing leakage of blood in or around the brain [8].

Involvement of upper limb in stroke

Mental practice

Thirty subjects, both male and female selected by means of simple random sampling from MMIMSR hospital based on inclusion and exclusion criteria. Patients randomly allocated into two groups.

Inclusion criteria

1. First Stroke

2. 40-70 years of age

3. Willing to participate in 6 weeks intervention

4. Unilateral upper limb paresis

5. Minimal or no sensory deficit

6. Must have CT or MRI with them

Exclusion criteria

1. Stroke occurred less than 4 weeks or more than one year

2. Aphasia

3. Inability to sit

4. Cognitive impairment (MMSE<23)

5. Excessive spasticity or pain at elbow, wrist or hand (MAS>2)

6. Any cardiovascular, orthopaedic or neurologic impairment other than stroke

7. Upper extremity impairment level (FMA<11)

Total 38 patients were selected and out of which 5 were excluded because they refused to participate in the study and 3 were having cognitive impairment, so 30 subjects were randomly allocated according to criteria. Demographic details of subjects that include age, gender, affected side etc were collected. Patients were assigned randomly into group A and group B. All patients were evaluated by Fugl-Meyer Scale (FMA) which is a valid and reliable tool for measuring recovery following a stroke [16,17], Modified Ashworth Scale (MAS) which is remain the primary clinical measures of tone [18,19] and the most widely used Mini-Mental State Examination (MMSE) scale screening tests to provide brief, objective measures of cognitive functioning [20,21].

The procedure of the study was explained to the subjects and written consent was taken. Group A subjects were instructed about the procedure by making them aware of the fact that there is an audio recording which they have to listen and they are not supposed to perform the activity, they just have to imagine the task.

Experimental group

Mental practice: Relax yourself, Sit comfortably by easily supported yourself, slowly and slowly close your eyes completely. Now take deep breath and then gently exhale out breadth, Inhale and exhale deeply. Repeat this 2-3 times. Imagine that you are in a peaceful and safe place, See green plants and feel great weather, try to visualize a clear picture. Look at to your eyes, they look relaxed, your whole body looks calm. Now time for contracting the muscles. Imagine that you are sitting on a chair and there is a table lying in front of you having a mug place over it. Contract your hand muscles then forearm then upper arm and finally shoulder. Now feel that your hand try to reach for that mug by lifting your arm, extending your elbow and fingers. Try to imagine the movement in a slow motion and stay relaxed like that till the end of the session. Good going. Pay attention and grasp that mug, Sense the feeling of holding and grasping that mug. Now take that mug close to your mouth. Relax and make yourself comfortable and Place that mug to the same location. Again repeat the whole procedure of grasping and holding the mug. Now we are coming back to the surrounding of this room, listen to the noises surrounding you. Follow my count from 5 to 1, when I say 1 open your eyes. 5,...4,...3,...2,...1.

Mental practice continues in increasing speed and complexity of tasks with the Corresponding weeks.

During physical practice session emphasis was on performing task oriented activities:

Writing

Self-feeding

Reaching for a thing placing over shelf forward

Folding and hanging towel

Turning pages

Opening and closing lock

Cutting fruit Combing Buttoning

Tie shoe laces

These Task oriented training using functional meaningful activities to improve functional performance. The use of real, functional objects also showed evidence as an effective method to enhance efficient, smooth, and coordinated post-stroke upper extremity movement. This helps in preventing contractures and development of abnormal postures. These exercises start with simple movements and subsequently complex movements and actions are tried [22,23].

Control group

Comparison was performed between both the group��?s first at baseline level then analyzed from baseline to the end of 6^th week for each group, and finally at the end of 6 weeks. Data analysis was done using SPSS version 16, software package. Mean and standard deviation were used as descriptive statistics. Data was tested Non parametrically to determine the Effect of Mental Practice combined with Physical Practice in the treatment of post stroke patients for upper extremity functional recovery. Wilcoxon signed rank sum test was used to compare within group values. Mann

Whitney U test was used for between group comparisons. The level of significance was set at p<0.05.

Fifteen subjects were taken in each group with mean age of 59.00 ± 9.27 and 58.33 ± 9.29 in Group A and Group B respectively. There is no statistically significant difference between both the groups that is they are matched for baseline characteristics (Table 1).

A total of 22 males and 8 females participated in the study. Group A consisted of 3 left sided and 12 right sided affected patients. Group B consisted of 4 left sided and 11 right sided affected patients.

In Group A, 80% patients were right side affected and remaining 20% patients were left side affected whereas in Group B, 73% patients were right side affected and remaining 27% patients were left side affected.

In Group A, 67% were male and 33% were females whereas in Group B, 80% were males and 20% were females. No statistically significant difference was found between the groups showing that subjects are matched for baseline characteristics (Table 2).

Mann-Whitney U test has been used to compare the median of Pre FMA score between Group A and Group B. Group A pre FMA value is 22.00 ± 4.00. Group B pre FMA value is 23.00 ± 4.50. The results revealed non-significant difference between pre FMA measurements in both the groups at p<0.05 (Table 3 and Figure 1).

Mann Whitney U test has been used to compare post FMA score between Group A and Group B. Group A and B post FMA value are 30.00 ± 3.00 and 27.00 ± 4.00. The results revealed significant difference in both groups because test value is less in both the groups than the table value at 0.05 (Table 4 and Figure 2).

Wilcoxon signed rank sum test has been used to compare Pre-Post FMA score within Group A and Group B. Pre and post FMA value are 22.00 ± 4.00 and 30.00 ± 3.00 within Group A. Pre and Post FMA value are 23.00 ± 4.50 and 27.00 ± 4.00 within Group B. The results are significant within the groups (Table 5 and Figure 3).

The present study deals with the effect of Mental Practice (MP) along with Physical Practice (PP) and physical practice alone in post stroke patients.

When analysis was done for demographic information of participants, no statistically significant difference was found showing that subjects are matched for baseline characteristics. There is no significant difference between pre FMA score in both the groups at baseline level. There is statistically significant difference within pre and post FMA score in both the groups, which shows that mental practice combine with physical practice and physical practice alone both are effective in post stroke patients.

When comparison was done between post FMA score in both the groups it was found that after 6 weeks of intervention experimental group has better prognosis than control group.

Although upper limb function improvements were seen in both the treatment group (physical practice alone or combined together with mental practice) in post stroke patients but it was seen in this study that when physical practice combined with mental practice (or mental imagery) in the treatment protocol, a greater amount of improvement in upper limb function was noted after 6 weeks of intervention. Therefore the null hypothesis is rejected and thus the alternate hypothesis is accepted.

The changes were found in this study clinically significant. Indeed after intervention, patients reported performing Activities of daily living (ADL��?s) with their affected hands.

Finding of this study is supported by previous case report done by Stephen J Page et al. who suggested that that mental practice is a potentially useful method of practicing motor skills [24].

Similar finding where functional improvements were also consistent with the speculations of Page, who suggested that functional outcome could be enhanced by mental practice and they were consistent with functional improvements observed in other mental practice studies [25-27].

Magill [28] suggested that mental practice is effective because it augments existing motor schema, subjects participating in a regimen combining mental practice and Physical practice showed large reductions in affected arm impairment as measured by the FMAS, and large increases in movement as measured by the ARAT [25].

The reason behind better improvement in mental practice group is thought to provide its impact by atleast 2 independent but interrelated mechanisms. First, stroke patients have been shown for decades to not use their more affected arms, even when capable of doing, a phenomenon traditionally termed â�?�?hemiakinesiaâ�?, However, MP use was recently shown to increase affected arm use, thus overcoming this movement suppression phenomenon [29].

The second hypothesized mental practice mechanism is use-dependent brain reorganization, in which new cortical areas are recruited to assist in movement of the affected arm. Results of Previous study show that this phenomenon occurs with a variety of task specific protocols, even of a brief duration, including mental practice, and that motor changes co-relate with cortical changes [30,31].

Frequent practice of a skill causes improved motor performance. Mental practice, when combined with physical practice, has been shown to be even more effective in improving motor performance than physical practice alone. One viable hypothesis for this effect is that, during mental practice, concurrent activity occurs in the musculature and in the appropriate neuromotor pathways [32-36].

This correlative neuromotor activity occurs with repetitive physical practice and is responsible for the motor performance improvements that individuals exhibit after mental practice. It was also believe that the patient's improvements between the pretests and the posttest occurred because the patient, through mental practice, was provided with additional practice of functional tasks using the affected arm.

On a physiological level, we believe that this practice caused priming of the motor cortex and appropriate activation of the neuromotor pathways, which resulted in the patient's improvements.

Another reason behind better recovery in experimental group may be due to additional feedback such as auditory which was provided, improves motor learning. Feedback can inform individuals about the accuracy and progress of their performance. In addition, feedback can motivate them by affecting their perceptions of competence and accomplishment [37].

Jeannerod et al. implemented verbal information because current motor cognition theories, which suggest that language resonates with motor representations and activation of motor areas, can therefore be achieved through verbal route [38].

Mental Practice itself functions as feedback and exerts a direct effect on the central nervous system. Because imagery and movement have been shown to be functionally equivalent, mental images like those used in MP could help in the process of engram formation. This image would then create a perception of motor performance that would activate the "automatic monitoring centre" and facilitate the consolidation of engram programming [39].

In our opinion MP could be used to augment the frequency of repetition of movement at a cerebral level, with no increase in the physical demand for the patient. It could also be useful in maintaining the results achieved.

In this study we have not used more effective quantitative measurements such as ARAT for evaluation. Sample size was small, so the result cannot be generalized. Intensity and level of auditory imagery must be matched with patient��?s mental status and Comprehension.

We have used MMSE for screening function only there is need to use an instrument to find out how much improvement occurred in cognitive domain, this could be another limitation of this study.

Future clinical trial study can be carried out on a larger sample size with long term follow up. A similar study can be conducted including acute, sub-acute and chronic (in 3 different groups) stroke patients.

In this study, selected task oriented activities has been given to patients, further study has to be done with types of task oriented training.

The results of this study have important clinical implication for developing effective intervention for patients with stroke by incorporating mental practice for upper extremity muscles that can improve the motor functions for activities of daily living.

As auditory imagery practices do not require sophisticated equipments so they can be easily incorporated in any rehabilitation technique.

This study concludes that mental practice with physical practice is more effective than physical practice alone, thereby providing evidence that it is a better strategy to include mental practice in combination with physical practice in stroke rehabilitation.

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