Stroke & Mental

Imagery: Effect on Upper

Extremity Motor Function
Jenna Yoneda, MOT, OTS
Chatham University

PICO Question
Is mental imagery
combined with
occupational therapy
effective in promoting
upper extremity motor
function with clients
post stroke?

Clinical Relevance
Stroke is a leading cause of serious long-term
disability that impacts an individuals quality of life.
According to the CDC (2015), stroke costs the U.S.
an estimated $34 billion each year for the cost of
health care services, medications, & missed days of
work.
Upper extremity hemiparesis is one of the most
prevalent impairments caused by stroke as it
negatively impacts occupational performance in
valued activities.
(Page, Levine, Sisto, & Johnston, 2001)

Personal Topic of Interest

Desire to work with clients post stroke & gain further

understanding of effective evidence-based holistic
interventions.
Fieldwork experience at an inpatient stroke
rehabilitation unit.

Search Strategy
Electronic Databases
CINAHL, OT Search & AJOT
Key Words Searched
Occupational Therapy, Upper
Extremity/Limb Recovery and:
Mental Imagery
Mental Practice
Guided Imagery
Motor Imagery
Inclusion Criteria
Stroke
Peer Reviewed
Exclusion Criteria
Chronic pain management,
breast cancer, COPD, or any
other diagnosis/condition.
Non-peer reviewed

Summary of Evidence
Level of Evidence

Study Design/Methodology
of Selected Articles

Number of Articles
Found

High Quality RCT, Systematic

Reviews of RCT, Meta-analysis

II

Small-scale RCT
Non-randomized studies (with a
control group)

III

Non-randomized studies (without

control group)
Quasi-experimental studies

IV

Descriptive Studies (case studies,

single subject designs, etc.)
Non-experimental designs

Expert Opinion, Literature Review,

Laboratory research

Qualitative Study

Total:

Best Evidence
Article

Level of Evidence

Kho, A. Y., Liu, K. Y., & Chung, R. K. (2014). Meta-analysis on the

effect of mental imagery on motor recovery of the
hemiplegic upper extremity function. Australian Occupational
Therapy Journal, 61(2), 38-48 11p. doi:10.1111/1440-1630.12084

Kim, S., & Lee, B. (2015). Motor imagery training improves upper
extremity performance in stroke patients. Journal of Physical
Therapy Science, 27(7), 2289-2291 3p.

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, 320329. http://dx.doi. Org/
10.5014/ajot.2012.003475
Page, S. J., Levine, P., Sisto, S., & Johnston, M. V. (2001). A
randomized efficacy and feasibility study of imagery in acute
stroke. Clinical Rehabilitation, 15(3), 233-240. doi:
10.1191/026921501672063235

II

II

What is Mental Imagery?

Also known as mental practice, mental rehearsal,
&visualization
Mind-body relationship
Focused mental technique where individuals cognitively
rehearse physical skills (Page et al., 2001)
Stimulates activation in brain areas & muscles similar to
those involved in actual task performance (Nilsen, Gillen, &
Gordon, 2010)

5 types of mental imagery incorporating multiple senses

(Kho, Liu, & Chung, 2014)

Visual, auditory, olfactory, somatosensory, & motor imagery

(kinesthetic imagery & visual movement imagery)

Article #1
Meta-analysis on the Effect of Mental Imagery
on Motor Recovery of the Hemiplegic Upper
Extremity Function

(Kho, Liu, & Chung, 2014)

Article #1: Objectives

(Kho et al., 2014)

The goal of this meta-analysis was to

determine the effects of mental
imagery on motor recovery of the
hemiplegic upper extremity post
stroke.

Article #1: Methods

(Kho et al., 2014)

Literature search using electronic databases:

PubMed, EBSCOhost (Academic Search
Premiere, CINAHL & Educational Resource
Information Center), PsycINFO, Medline & ISI Web
of Knowledge (Science Citation Index & Social
Sciences Citation Index)

Search Terms: imagery, mental practice,

mental rehearsal, motor, stroke, upper limb, &
upper extremity

Article #1: Methods

(Kho et al., 2014)

Methodological Quality Assessment

PEDro Scale (11 item quality assessment) based
on Delphi list
Blinding, randomization, procedures, appropriate
data reported, data analysis, & adequacy of
follow up

Inclusion: only RCTs & CCTs comparing mental

imagery with other interventions
Total of 6 studies reviewed

Article #1: Outcomes

(Kho et al., 2014)

Trend in literature supporting use of

mental imagery for upper extremity
motor rehabilitation post stroke
Safe, cost effective, & multiple
practice opportunities

Article #2
Motor Imagery Training Improves Upper
Extremity Performance in Stroke Patients
(Kim & Lee, 2015)

Article #2: Objective

(Kim & Lee, 2015)

To determine if motor imagery training

positively influences upper extremity
performance in patients post stroke.

Article #2: Methods

(Kim & Lee, 2015)

24 participants who experienced first stroke

Inclusion Criteria

Exclusion Criteria

6-12 months post stroke

Mini-Mental State Examination
score >24 points
Sits independently for > 30 minutes

Severe cognitive disability (such

as unilateral neglect, dementia,
depression, or seizure)
Musculoskeletal Disorders
Muscle Contracture
Limitation of Joint Motion

Participants signed informed consent forms

Study was approved by Ethics Committee (KyungHee
University Medical Center Institutional Review Board)

Article #2: Methods

(Kim & Lee, 2015)

Evaluation of upper extremity (UE) function using

Fugl-Meyer Assessment (FMA-UE) & Wolf Motor
Function Test (WMFT)
24 participants randomly assigned to:
Control Group
Experimental (Motor Imagery) Group
Over 4 week span, 12 participants in the experimental group
participated in 30 minutes of motor imagery training where
they listened to speakers & imagined performing 18 tasks (9
hours total) related to daily living.

Article #2: Outcomes

(Kim & Lee, 2015)

After 4 week intervention period, FMA-UE

post-test score of experimental (motor imagery)
group were significantly higher than that of the
control group
Shoulder, wrist, & hand scores were notably increased
Experimental Group

Control Group

FMA-UE Score: Pre: 27.92

Post: 36.08
*Increase of 8.17 (p<0.05)

FMA-UE Score- Pre: 28.58

Post: 31
*Increase of 2.42 (p<0.05)

Article #2: Outcomes

(Kim & Lee, 2015)

Physical practice along with motor imagery

training improves recovery
Motor imagery positively influences UE
performance by improving functional mobility
in patients post stroke
Motor imagery training is feasible & beneficial
for improving UE function post stroke

Article #3
Effect of Imagery Perspective on
Occupational Performance After Stroke: A
Randomized Controlled Trial
(Nilsen, Gillen, Dirusso, & Gordon, 2012)

Article #3: Objectives

(Nilsen et al., 2012)

To determine whether occupational therapy combined

with mental practice from either internal or external
perspective would reduce impairment, improve
function, & enhance self perception of performance
above the control group.
To determine whether mental practice using an internal
perspective would be more effective in reducing
impairment & improving function than mental practice
using external perspective, & vice versa (external more
effective than internal).

Article #3: Methods

(Nilsen et al., 2012)

Single-blinded, Randomized Controlled Trial over 18 month

period
19 participants randomly assigned to 3 groups
Occupational therapy + mental practice (internal perspective)
Occupational therapy + mental practice (external perspective)
Occupational therapy + relaxation imagery (control group)

All groups received 30 minute occupational therapy sessions

2x/week for 6 weeks.
Pre & post test using Fugl Meyer (FMA), Jebsen-Taylor Test of
Hand Function (JTTHF), & Canadian Occupational
Performance Measure (COPM)

Article #3: Outcomes

(Nilsen et al., 2012)

Significant increases in FMA scores for internal &

external imagery groups
COPM scores increased significantly across all
groups
Mental practice reduces impairments & improves
function when combined with occupational
therapy
Mental practice is an effective intervention to
improve arm & hand recovery post stroke

Article #4
A Randomized Efficacy and Feasibility
Study of Imagery in Acute Stroke
(Page, Levine, Sisto, & Johnston, 2001)

Article #4: Objectives

(Page et al., 2001)

To examine feasibility of an imagery

protocol with subacute stroke patients.
To compare the effectiveness of a
program combining imagery &
occupational therapy with a program
of therapy only.

Article #4: Methods

(Page et al., 2001)

Recruitment of participants through advertisements

posted in outpatient therapy departments.
Exclusion criteria: CVA < 4 weeks or > 1 year, serious
cognitive deficits (< 20 Mini Mental Status),
hemorrhagic lesions or lesions affecting both
hemispheres, excessive spasticity (> 2 Modified
Ashworth Scale) at elbow, wrist, or hand, receptive
aphasia, unable to use imagination (Movement
Imagery Questionnaire).

Article #4: Methods

(Page et al., 2001)

Testing Procedures
13 patients signed informed consent forms
2 separate pretesting sessions (1 week apart) with Fugl-Meyer &
Action Research Arm Test (ARA)
No intervention or research team contact between session
After second pretesting session, participants were randomly
assigned to either the therapy + imagery group or the therapy
only group
Computer generated random numbers table
Participants received therapy 1 hour, 3x/week for 6 weeks

Article #4: Methods

(Page et al., 2001)

Intervention Procedures
1 hour therapy sessions
30 minutes: upper extremity
30 minutes: lower extremity & gross arm
movements
All activities (transfers, balance/ambulation, ADL
training) performed bimanually
If necessary, performed with unaffected arm
supporting affected arm

Article #4: Methods

(Page et al., 2001)

Intervention Procedures
After therapy, patients assigned to experimental group
listened to 10 minute tape recorded imagery intervention read
by experienced male psychologist with expertise in imagery
2-3 minutes: Relaxation
Imagine self in warm, relaxing place (i.e. beach)
Progressive relaxation

5-7 minutes: External, cognitive visual images using affected

arm in functional tasks
For example, imagine yourself reaching for a cup on the table; feel
your arms and fingers extending as you reach for the cup.

- 2 minutes: Refocusing

Article #4: Methods

(Page et al., 2001)

Intervention Procedures
To maintain interest, 3 imagery scripts provided
for 6 weeks
Scripts focused on different functional
movements including: shoulder internal/external
rotation, pronation/supination, shoulder flexion,
and movement that facilitated grasp
Home Imagery Tapes: same as tape used in
therapy for that given week, 2 alternating
weekdays per week

Article #4: Methods

(Page et al., 2001)

Intervention Procedures
To ensure contact time was consistent,
patients in control group listened to 10 minute
tape containing information about stroke in
addition to listening to tape at home twice
per week
Instruments (Fugl Meyer & ACA) were
administered by blinded rater 1 week after
discharge

Article #4: Outcomes

(Page et al., 2001)

Home telephone calls & informal interviews with

patients, spouses/caregivers revealed adherence
& satisfaction with imagery protocol.
Participants from experimental group (therapy +
imagery) displayed substantial increases in their
Fugl-Meyer & AMA score whereas control group
(therapy only) remained stable.
Improvements in use of affected hand & wrist
Improvements of gross arm movements outside of
synergy

Clinical Implications of Findings

All reviewed studies determined that mental imagery in
combination with therapy is an effective intervention to
promote UE motor function.
Imagery activates appropriate muscles & neural
networks, providing extra practice of the desired task
(Page et al., 2001).

Safe, cost-effective, & provides numerous practice

opportunities (Kho et al., 2014).
Mental imagery in combination with therapy significantly
increased scores on standardized assessments such as
the FMA (Kim & Lee, 2015 & Page et al., 2001).

References
Kho, A. Y., Liu, K. Y., & Chung, R. K. (2014). Meta-analysis on the effect of mental imagery on motor recovery of the
hemiplegic upper extremity function. Australian Occupational Therapy Journal, 61(2), 38-48 11p. Doi:
10.1111/1440-1630.12084

Kim, S., & Lee, B. (2015). Motor imagery training improves upper extremity performance in stroke patients. Journal
of Physical Therapy Science, 27(7), 2289-2291 3p.
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,
320329. http://dx.doi. Org/10.5014/ajot.2012.003475

Nilsen, D. M., Gillen, G., & Gordon, A. M. (2010). Use of mental practice to improve upper-limb recovery after
stroke: A systematic review. American Journal Of Occupational Therapy, 64(5), 695-708 14p. doi:10.5014/ajot.
2010.09034

Page, S. J., Levine, P., Sisto, S., & Johnston, M. V. (2001). A randomized efficacy and feasibility study of imagery in
acute stroke. Clinical Rehabilitation, 15(3), 233-240. doi:10.1191/026921501672063235

Stroke Facts. (2015, March 24). Retrieved October 25, 2015, from
http://www.cdc.gov/stroke/facts.htm

Additional Resources
Nilsen, D. M., Gillen, G., Geller, D., Hreha, K., Osei, E., & Saleem, G. T. (2015). Effectiveness of interventions to
improve occupational performance of people with motor impairments after stroke: An evidence-based
review. American Journal of Occupational Therapy, 69, 6901180030
http://dx.doi.org/10.5014/ajot.2015.011965
Page, S. J., Levine, P., & Hill, V. (2015). Mental practicetriggered electrical stimulation in chronic, moderate,
upper- extremity hemiparesis after stroke. American Journal of Occupational Therapy, 69, 6901290050.
http://dx.doi.org/ 10.5014/ajot.2015.014902
Wu, A. J., Radel, J., & Hanna-Pladdy, B. (2011). Improved function after combined physical and mental
practice after stroke: A case of hemiparesis and apraxia. American Journal Of Occupational Therapy,
65(2), 161-168 8p. doi:10.5014/ajot.2011.000786