Integrating Mental P r a c t i c e w i t h Tas k - s p e c i f i c Tra i n i n g a n d B e h a v i o r a l Su p p o r t s i n P o s t s t ro k e R e h a b i l i t a t i o n Evidence, Components, and Augmentative Opportunities Heather T. Peters,
MOT, OTR/L
a,
*, Stephen J. Page,
PhD, MS, OTR/L, FAHA, FACRM
b
KEYWORDS Mental practice Motor imagery Stroke The PRACTICE principles Rehabilitation KEY POINTS Mental practice involves mental rehearsal of physical movements without the use of physical practice. Mental practice has been shown to increase motor learning and performance in a variety of clinical and performance-related environments. Mental practice elicits the same neural and muscular events as physical practice. Therefore, if used repetitively, its use is thought to increase poststroke skill reacquisition. The PRACTICE (part-whole practice, repetitive and goal focused, activities that are salient, client driven, train practically, impairments addressed, challenge regularly, and emphasize accomplishments) principles can be used as a guide to structure the contents of mental and physical practice. Noninvasive brain stimulation can be used adjunctively with mental practice.
Disclosures: None. a B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Department of Occupational Therapy, The Ohio State University, 453 West 10th Avenue, Suite 443, Columbus, OH 43210, USA; b B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Department of Occupational Therapy, The Ohio State University, 453 West 10th Avenue, Suite 406, Columbus, OH 43210, USA * Corresponding author. E-mail address: [email protected] Phys Med Rehabil Clin N Am 26 (2015) 715–727 http://dx.doi.org/10.1016/j.pmr.2015.06.004 1047-9651/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
pmr.theclinics.com
716
Peters & Page
Stroke remains a leading cause of death and one of the most costly and burdensome diseases.1–3 For example, the 2010 Global Burden of Disease Study estimated that there were 16.9 million people who had experienced a first-ever stroke, 33 million stroke survivors, and 102 million disability-adjusted life-years lost in that year alone.4 Moreover, despite organized efforts to prevent and treat stroke more quickly and effectively, since 1990 there has been continued growth in the overall incidence and mortality of stroke.4 The global impact of stroke and the rapidly expanding number of stroke survivors with residual disabilities4 provide impetus for the development of rehabilitative approaches that increase poststroke function. In response, several rehabilitative regimens have been tested, with the most efficacious therapies5–7 encouraging survivors to practice functionally and repetitively (termed repetitive task-specific practice [RTP]). RTP seems to be a critical factor in poststroke plasticity and functional increases.8 For example, in stroke survivors with minimally impaired upper extremities (UEs), constraint-induced movement therapy increases UE use and function5,7 by integrating RTP with behavioral strategies that encourage paretic limb use. Similarly, among survivors with moderate UE impairments (people with no active movement in their paretic wrists and fingers) RTP augmented by electrical stimulation enables active participation in UE motor practice, and significantly increases paretic UE use and function.9–12 Informed by these promising findings, and based on decades of motor learning, neuroplasticity, and cognitive behavior training literature, we recently proposed the PRACTICE principles,13 which speak to the ways in which RTP should ideally be integrated into poststroke care. Specific components of the PRACTICE principles are as follows: (1) part-whole practice should be used, with an eye toward realistic task analysis, (2) repetitive and goal focused, (3) activities should be salient, (4) client driven, (5) train in a practical way, (6) impairments should be addressed, (7) challenge regularly and appropriately, and (8) emphasize accomplishments. One of the concepts elucidated by the PRACTICE principles is the ability of the client to easily access and meaningfully engage in RTP (ie, train in a practical fashion). This principle speaks to the match of a regimen’s practice parameters with the abilities and physical activity tolerance of the client (eg, are the parameters too intensive and/or too long in duration for the client to tolerate? Does the regimen use equipment that the client and/or the clinic cannot easily integrate into care?), as well as the physical proximity and accessibility of the resources needed to fully implement the regimen. Such practical considerations are important in ensuring full client participation and high fidelity with the regimen to facilitate neural and motor changes. However, they are not always embraced by contemporary approaches, such as those mentioned earlier, which often require intensive parameters and/or expensive equipment that is only available at specialized rehabilitation and academic medical centers. For instance, in the largest trial to date of constraint-induced movement therapy, subjects could only tolerate about two-thirds of the assigned 6 hours of RTP before fatigue set in.12 In response to these limitations, this laboratory was the first to apply mental practice (MP) to increase learning and outcomes in stroke,14 later showing that MP use increases paretic UE use and function.15,16 More recently, our work has shown that MP use causes the same cortical changes as physical practice in survivors of stroke.17 The regimen has also been extended to other poststroke impairments and neurologic conditions,18–20 and our pioneering findings have been replicated by others around the world.21–26 The critical advantage of MP compared with newer but less pragmatic rehabilitative approaches (and even some conventional rehabilitative therapies) is its use of cognitive rehearsal without the use of physical practice or voluntary physical movement attempts by the client. Instead, the client listens to an audio file that
Mental Practice in Stroke
elucidates the goal-directed actions to be performed, and/or watches a video depicting these movements. Restated, during MP, the individual is cognitively rehearsing RTP. These straightforward requirements allow MP to be performed with minimal direct supervision, minimal expense, and in virtually any environment with no specialized equipment. Moreover, a variety of laboratories have confirmed that MP use activates the same neural areas and musculature as physical practice of the same tasks,27–30 providing a strong scientific rationale for cognitively rehearsing a skill to simulate conditions brought about by RTP. This finding is important because, in some clinical situations, mental rehearsal may be a safer and/or better justified clinical option than engaging in physical practice because of the client’s impairments (eg, when it is unsafe for a client to physically practice ambulation). Given its implementation advantages compared with many physically based practice approaches and its strong scientific bases, the overall goal of this article is to review the considerations associated with the clinical implementation of MP. Specifically, this article begins by briefly discussing literature supporting MP use, including current MP work occurring at this laboratory. It then describes the basic components of clinical MP regimens with the goal of facilitating increased integration of MP into clinical practice. In addition, it concludes with a discussion of future directions and emerging applications designed to enhance MP outcomes. Most of discussion focuses on motor impairments, because this is the primary area of MP investigation in the stroke population, and because motor impairments are frequent and especially disabling. EMPIRICAL SUPPORT FOR MENTAL PRACTICE
Although there is a growing body of evidence for the impact of MP on lower extremity function,31–34 most efforts to date have targeted UE motor recovery.6,14,17,21–24,34–40 Results and methods from selected cited trials are included in Table 1. Specifically, research gathered from these trials suggests that MP combined with RTP is the most efficacious approach, resulting in greater increases in UE motor function than RTP alone.6,14,21,23,24,34,35,37 In addition to these significant gains in UE function, Liu and colleagues21 showed that MP combined with RTP may also facilitate increased translation of learned motor skills to new environments. Based on promising results from controlled trials, several sites have also implemented MP alongside rehabilitative therapies in clinical settings (eg, inpatient rehabilitation21,23,37) with patients in the acute/subacute phase of recovery, finding significant gains in performance of activities of daily living (ADLs)21,23 and UE function21,23,37 for those receiving MP alongside conventional therapy compared with conventional therapy alone. In addition to significant improvements on aforementioned motor-based and activity-based outcome measures, evidence also suggests that MP combined with RTP results in improved UE kinematics,15 increased cortical representation of the affected hemisphere,17 efficacy when combined with other therapies (eg, modified constraint-induced therapy40), and more frequent paretic UE use.16 Building on this work, our laboratory is now leading a multicenter, randomized controlled trial examining the effect of MP and RTP in chronic, hemiparetic stroke. This is the first multicenter trial to investigate the effect of an MP regimen not only on affected UE outcomes and impairment but also on cortical reorganization in the ipsilesional motor cortex. CONSIDERATIONS FOR INTEGRATING MENTAL PRACTICE INTO CLINICAL ENVIRONMENTS
Stroke rehabilitation is ultimately focused on regaining the ability to perform valued ADLs to facilitate maximal independence in the community. As such, rehabilitation
717
718
Primary Outcome Measures
Author, Year
Study Objective
Study Design, Participants
Intervention
Liu et al,37 2004
Determine efficacy of MP in promoting UE motor relearning
Design: prospective, randomized controlled trial Participants: 46 acute inpatients, >60 y old
15 sessions (1 h/d for 3 wk) of either MP and therapy or conventional therapy only
Trained and untrained tasks, FM and CTT
MP group improved significantly on trained (P
MOT, OTR/L
a,
*, Stephen J. Page,
PhD, MS, OTR/L, FAHA, FACRM
b
KEYWORDS Mental practice Motor imagery Stroke The PRACTICE principles Rehabilitation KEY POINTS Mental practice involves mental rehearsal of physical movements without the use of physical practice. Mental practice has been shown to increase motor learning and performance in a variety of clinical and performance-related environments. Mental practice elicits the same neural and muscular events as physical practice. Therefore, if used repetitively, its use is thought to increase poststroke skill reacquisition. The PRACTICE (part-whole practice, repetitive and goal focused, activities that are salient, client driven, train practically, impairments addressed, challenge regularly, and emphasize accomplishments) principles can be used as a guide to structure the contents of mental and physical practice. Noninvasive brain stimulation can be used adjunctively with mental practice.
Disclosures: None. a B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Department of Occupational Therapy, The Ohio State University, 453 West 10th Avenue, Suite 443, Columbus, OH 43210, USA; b B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Department of Occupational Therapy, The Ohio State University, 453 West 10th Avenue, Suite 406, Columbus, OH 43210, USA * Corresponding author. E-mail address: [email protected] Phys Med Rehabil Clin N Am 26 (2015) 715–727 http://dx.doi.org/10.1016/j.pmr.2015.06.004 1047-9651/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
pmr.theclinics.com
716
Peters & Page
Stroke remains a leading cause of death and one of the most costly and burdensome diseases.1–3 For example, the 2010 Global Burden of Disease Study estimated that there were 16.9 million people who had experienced a first-ever stroke, 33 million stroke survivors, and 102 million disability-adjusted life-years lost in that year alone.4 Moreover, despite organized efforts to prevent and treat stroke more quickly and effectively, since 1990 there has been continued growth in the overall incidence and mortality of stroke.4 The global impact of stroke and the rapidly expanding number of stroke survivors with residual disabilities4 provide impetus for the development of rehabilitative approaches that increase poststroke function. In response, several rehabilitative regimens have been tested, with the most efficacious therapies5–7 encouraging survivors to practice functionally and repetitively (termed repetitive task-specific practice [RTP]). RTP seems to be a critical factor in poststroke plasticity and functional increases.8 For example, in stroke survivors with minimally impaired upper extremities (UEs), constraint-induced movement therapy increases UE use and function5,7 by integrating RTP with behavioral strategies that encourage paretic limb use. Similarly, among survivors with moderate UE impairments (people with no active movement in their paretic wrists and fingers) RTP augmented by electrical stimulation enables active participation in UE motor practice, and significantly increases paretic UE use and function.9–12 Informed by these promising findings, and based on decades of motor learning, neuroplasticity, and cognitive behavior training literature, we recently proposed the PRACTICE principles,13 which speak to the ways in which RTP should ideally be integrated into poststroke care. Specific components of the PRACTICE principles are as follows: (1) part-whole practice should be used, with an eye toward realistic task analysis, (2) repetitive and goal focused, (3) activities should be salient, (4) client driven, (5) train in a practical way, (6) impairments should be addressed, (7) challenge regularly and appropriately, and (8) emphasize accomplishments. One of the concepts elucidated by the PRACTICE principles is the ability of the client to easily access and meaningfully engage in RTP (ie, train in a practical fashion). This principle speaks to the match of a regimen’s practice parameters with the abilities and physical activity tolerance of the client (eg, are the parameters too intensive and/or too long in duration for the client to tolerate? Does the regimen use equipment that the client and/or the clinic cannot easily integrate into care?), as well as the physical proximity and accessibility of the resources needed to fully implement the regimen. Such practical considerations are important in ensuring full client participation and high fidelity with the regimen to facilitate neural and motor changes. However, they are not always embraced by contemporary approaches, such as those mentioned earlier, which often require intensive parameters and/or expensive equipment that is only available at specialized rehabilitation and academic medical centers. For instance, in the largest trial to date of constraint-induced movement therapy, subjects could only tolerate about two-thirds of the assigned 6 hours of RTP before fatigue set in.12 In response to these limitations, this laboratory was the first to apply mental practice (MP) to increase learning and outcomes in stroke,14 later showing that MP use increases paretic UE use and function.15,16 More recently, our work has shown that MP use causes the same cortical changes as physical practice in survivors of stroke.17 The regimen has also been extended to other poststroke impairments and neurologic conditions,18–20 and our pioneering findings have been replicated by others around the world.21–26 The critical advantage of MP compared with newer but less pragmatic rehabilitative approaches (and even some conventional rehabilitative therapies) is its use of cognitive rehearsal without the use of physical practice or voluntary physical movement attempts by the client. Instead, the client listens to an audio file that
Mental Practice in Stroke
elucidates the goal-directed actions to be performed, and/or watches a video depicting these movements. Restated, during MP, the individual is cognitively rehearsing RTP. These straightforward requirements allow MP to be performed with minimal direct supervision, minimal expense, and in virtually any environment with no specialized equipment. Moreover, a variety of laboratories have confirmed that MP use activates the same neural areas and musculature as physical practice of the same tasks,27–30 providing a strong scientific rationale for cognitively rehearsing a skill to simulate conditions brought about by RTP. This finding is important because, in some clinical situations, mental rehearsal may be a safer and/or better justified clinical option than engaging in physical practice because of the client’s impairments (eg, when it is unsafe for a client to physically practice ambulation). Given its implementation advantages compared with many physically based practice approaches and its strong scientific bases, the overall goal of this article is to review the considerations associated with the clinical implementation of MP. Specifically, this article begins by briefly discussing literature supporting MP use, including current MP work occurring at this laboratory. It then describes the basic components of clinical MP regimens with the goal of facilitating increased integration of MP into clinical practice. In addition, it concludes with a discussion of future directions and emerging applications designed to enhance MP outcomes. Most of discussion focuses on motor impairments, because this is the primary area of MP investigation in the stroke population, and because motor impairments are frequent and especially disabling. EMPIRICAL SUPPORT FOR MENTAL PRACTICE
Although there is a growing body of evidence for the impact of MP on lower extremity function,31–34 most efforts to date have targeted UE motor recovery.6,14,17,21–24,34–40 Results and methods from selected cited trials are included in Table 1. Specifically, research gathered from these trials suggests that MP combined with RTP is the most efficacious approach, resulting in greater increases in UE motor function than RTP alone.6,14,21,23,24,34,35,37 In addition to these significant gains in UE function, Liu and colleagues21 showed that MP combined with RTP may also facilitate increased translation of learned motor skills to new environments. Based on promising results from controlled trials, several sites have also implemented MP alongside rehabilitative therapies in clinical settings (eg, inpatient rehabilitation21,23,37) with patients in the acute/subacute phase of recovery, finding significant gains in performance of activities of daily living (ADLs)21,23 and UE function21,23,37 for those receiving MP alongside conventional therapy compared with conventional therapy alone. In addition to significant improvements on aforementioned motor-based and activity-based outcome measures, evidence also suggests that MP combined with RTP results in improved UE kinematics,15 increased cortical representation of the affected hemisphere,17 efficacy when combined with other therapies (eg, modified constraint-induced therapy40), and more frequent paretic UE use.16 Building on this work, our laboratory is now leading a multicenter, randomized controlled trial examining the effect of MP and RTP in chronic, hemiparetic stroke. This is the first multicenter trial to investigate the effect of an MP regimen not only on affected UE outcomes and impairment but also on cortical reorganization in the ipsilesional motor cortex. CONSIDERATIONS FOR INTEGRATING MENTAL PRACTICE INTO CLINICAL ENVIRONMENTS
Stroke rehabilitation is ultimately focused on regaining the ability to perform valued ADLs to facilitate maximal independence in the community. As such, rehabilitation
717
718
Primary Outcome Measures
Author, Year
Study Objective
Study Design, Participants
Intervention
Liu et al,37 2004
Determine efficacy of MP in promoting UE motor relearning
Design: prospective, randomized controlled trial Participants: 46 acute inpatients, >60 y old
15 sessions (1 h/d for 3 wk) of either MP and therapy or conventional therapy only
Trained and untrained tasks, FM and CTT
MP group improved significantly on trained (P
