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

Relevance of this review

Stroke is one of the most common causes of acquired disability worldwide, leading to difficulty managing and participating in home and/or community activities. It may lead to changes in perception, cognition, mood, and speech, along with functional problems of walking and arm use. In stroke population, upper extremity impairments range between 33% and 95% due to affected motor, somatosensory, and perceptual abilities that require rehabilitative intervention. Conventional rehabilitation programs often fail in these patients due to their poor compliance and the inadequate frequency and intensity of practice. In this scenario, a training of mental practice (MP) might improve performance of the upper extremity abilities using cognitive rehearsal.
Cognitive rehearsal means to create in the individual's imagination a movement specific to an activity, such as picking up a cup. Then the patient is trained to mentally repeat that movement as MP for a defined number of repetitions and time duration, without any actual visual cueing, with the aim of improving performance of that activity.
It may lead to neuroplasticity, since the neuroimaging studies have shown that similar brain areas are activated in mental imagery and physical movement. Therefore, this review searched for evidence as to whether these mental practices are effective for upper extremity impairment in patients after stroke. Review is important for Patients with stroke and their family/caregivers, health professionals and researchers dealing with stroke rehabilitation, general practitioners, and policymakers.

Key outcomes of the review

Mental practice (MP) has been proposed as a potential adjunct to physical practice, and the objective of this review was to determine whether MP improves outcomes of upper extremity rehabilitation for individuals after stroke. It included 25 parallel-/cross- group randomized controlled trials (RCTs) from nine countries with 676 adult participants. Results provided moderate-certainty evidence of improved arm function and movement outcomes for MP in addition to other physical rehabilitation treatment compared to other treatment; moreover, MP alone may make no difference in improving upper extremity impairment compared to conventional treatment with a low-certainty evidence. No adverse effects or harms were reported in any of the studies.
Authors’ conclusions

Moderate-certainty evidence was demonstrated on benefits in improving upper extremity activity of MP plus other treatment versus other treatment alone. Low-certainty evidence suggested that activities of daily living may not be improved with MP plus other treatment versus other treatment. Further study is required to evaluate the volume of MP required, eventually effects post stroke and duration on long term.

Future aspects from this review 

High-quality studies using CONSORT guidelines are required, including patient characteristics (duration post-stroke, gender, ability to imagine the necessary movement), MP optimal dosage, economic costs, outcomes (like activities of daily-living, health-related quality of life), and adverse events.

Commented by Sunita Gudwani