The Effect of Motor Imagery
on Gait in Patients PostChronic Stroke:
A Meta Analysis
By: Mysa Sangria DPTc
UCSF/SFSU
PT 209-910
Cerebral Vascular Accident (CVA)
http://www.medicinenet.com/stroke_pictures_slideshow/article.htm
Interruption of blood supply to the brain resulting in
damage or death to the affected brain tissue
(National Stroke Association, 2013)
CVA Impairments
Sensory
Fatigue
Neuromuscula
r
Cognition
Function
Activity
Participation
(Langhorn et al., 2011)
Significance
Prevalance
6.8 M
Incidence
795,000
Medical Costs
315.4 B
Second most
common cause
of disability
(Go et al., 2014)
Neuroplasticity
The brain’s ability of remapping by forming
new neuronal connections
Langhorne et.al. 2013
Clinical Problem
Multisystem
Impairments:
Neuromuscular
Sensation
Cognition
Psychosocial
Persistent adverse
compensatory
movement
Post-chronic
stroke
Plateau of
mechanics
neuroplasticity
patients
need additional
resulting :
results in a to
plateau
interventions
improve Decreased mobility
of functional
gait and
functional
independence
mobility
mobility
return to work
and activities
Paz et al., 2013
“Motor Imagery (mental
practice) is an active practice
in which the patient imagines
or visualizes the performance
of a function, a movement, or
a task without overt
movement.”
(Hwang et al., 2010)
http://www.eurolondon.com/blog/de/category/bilingual/
Motor Imagery (MI)
 Repetition and Rehearsal
of Images
 Visual Imagery –physical
movement from an
external perspective
 Kinaesthetic Imagery –
imagines internal
sensory information
during physical
movement
(Cho et al., 2010)
Cho et al. 2010)
(
http://stock-clip.com/video/5414411-first-personview-of-walking-down-a-hallwayfisheye
http://www.clker.com/clipart14727.html
Theoretical Construct
 Parietal Lobe
 Preservation &
generation of
kinaesthetics
 Frontal Lobe
 Motor planning
 Executive control
 Occipital Lobe
 Visuospatial processing
 3rd person perspective
http://www.brighthubeducation.com/lesson-plans-grades-3-5/62004-teachingthe-parts-of-the-brain/
Moran et al., 2012. Vries et al., 2007
Theoretical Construct
Type
Activity
Response
Autonomic
Walking
Bicycling
Increase heart &
respiration rate
Mental
Chronometry
Walking
Similar processing
time
Neuro-Imaging
Walking
Dancing
Cortical network
activation
Guillot & Collet, 2005. Jackson et al., 2003
Relevance to PT
 Motor Imagery
Benefits
Physiological
response
 Home exercise
program
Improve
Mobility and
Quality of
Life
Similar
cortical
networks
 No specialized
equipment
 Cost effective
 Safe Intervention
Foreground:
Does motor imagery
training improve gait
speed and functional
mobility in chronic
post CVA individuals?
Gap in Literature
Strong Evidence
for UE:
Lower Extremity
Mobility & Gait:
- Systematic reviews &
Meta Analysis
- Case Studies
- Several RCTs but no
meta- analysis done
(Veerbeek et al., 2014)
(Dunsky etal., 2006; Dickstein et al., 2004)
Hypotheses:
Within & Between Groups
 Null Hypothesis (A)
 No improvement in
gait speed with MI
training
 Alternative
Hypothesis (A)
 Improvement in gait
speed with MI training
 Null Hypothesis (B)
 No improvement in
functional mobility
with MI training
 Alternative
Hypothesis (B)
 Improvement in
functional mobility
with MI training
Research Question
 P = patients post-chronic stroke (6
months)
 I = motor imagery training (LE/gait)
 C= no motor imagery training for
LE/Gait
 O = gait speed and/or functional
mobility
Expected Findings
At least 3-5 randomized
controlled trials and cohort
studies
Search Procedures
Databases
Search Terms
 Motor imagery
 Mental practice
blog.unmc.edu
 Mental Rehearsal
 Mental imagery
www.pedro.org.au
 Gait
 Ambulation
 CVA
 Stroke
www4.stanbridge.edu
 Cerebral vascular accident
Search Procedures
Inclusion Criteria
 Chronic post CVA
Exclusion Criteria
 At least 6 months
 Not in English
 Ambulatory with or without and
AD – at least 10 feet
 Case Studies
 Motor imagery training
 LE movement
 Gait tasks
 Outcomes (At least one of the
following)
 Gait speed
 Validated mobility outcomes
Statistical Summary
 Individual Effect Sizes Calculated for
Selected Outcomes:
 Gait Speed: Gait speed, 10 Meter Walk Test (10MWT)
 Functional Mobility: Timed Up and Go (TUG), Dynamic Gait Index
(DGI)
 Heterogeneity Statistic (Q) with p-value:
 P > 0.05 fixed model for gait speed
 P < 0.05 random effects model (including weighting) for functional
mobility
 Grand effect size using 95% Confidence
Interval
PRISMA Diagram
Harm and Cost
 Unfamiliar with
treadmills:
 Falls
 Injury
 Increased Activity
 Fatigue
 Injury
 No reporting of
training
therapists/testers
 Treadmill ($200)
 Video recorder
($300)
 Television set
($800)
Results: Gait Speed
Significan
t
Within Groups
Clinically Significant:
0.13m/s within groups
0.078 m/s between
groups
Between Groups
10 MWT MCID: 0.06m/s
Grand effect size and 95% CI:
0.62 and (0.12,1.1)
Significan
t
Grand effect size and 95% CI: 0.34
and (0.00, 0.68)
Discussion: Reject the Null Hypothesis ?
Null Hypothesis (A) :
No improvement
in gait speed with
MI
Outcome
Significant
Within
Groups
Significant
Between
Groups
Gait Speed
Yes
Yes
Alternative Hypothesis (A) : There is an
improvement in gait speed with MI training
Results: Functional
Clinically Significant: Mobility
Significant
Within
6.2 seconds within groups
8.9 seconds between groups
Groups
Significan
Between Groups
t
TUG MCID: 2.9 seconds
Grand effect size and 95% CI:
2.72(0.87,4.56)
Grand effect size and 95% CI:
0.67(0.05,1.29)
Discussion: Functional Mobility
Null Hypothesis:
There is no
improvement in
functional mobility
with MI training
Outcome
Significant
Within
Groups
Significant
Between
Groups
Functional
Mobility
Yes
Yes
Alternative Hypothesis: There is an
improvement in functional mobility with MI
training
Hwang 2010
 Within-groups,
functional mobility:
 Volume and frequency
 MI + physical task
training = 30 min/day,
5days/week vs. 30
min/day, 3 days/week
 Patient specific task
training with a physical
therapist
Discussion: MI + Gait/Functional
Training
MI + Gait /
Functional
Training
Large (0.8) to greater than large
effect size for within and
between groups
Lee 2011, Cho 2013, Hwang 2010, Kim 2013, Hosseini
2012
MI Stand
Alone
Small (0.2) effect sizes for
within and between groups
Dunsky 2008, Dickstein 2013,2014
Gait /
Functional
Training:
20-30 minutes
3-4x / week
5-6 weeks
Increase in function :
Neuromuscular and
musculoskeletal
adaptations
Langhorne et al. 2013
Discussion: Patient
Demographics
MI is more effective in younger
populations and with a lower stroke
chronicity
 Hwang 2010, Hosseini 2012, Cho 2013 :
 50 years old, stroke chronicity of 1.5 years vs.
64 years old, stroke chronicity of 2-3 years
Discussion: Patient
Demographics
Aging cortex
experiences
neural decline
Cortical
changes:
decreased
thickness,
white matter
integrity,
cortical
engagement
Decreased
cortical
plasticity with
increased
time poststroke
Goh et al. 2009
Decreased
ability:
Functional
map expansion
Axonal
sprouting and
synaptogenesis
Discussion: MI Treatment
Parameters
Lee 2011, Cho 2013, Hosseini 2012: MI for
20-30 minutes, 3-5 times/week, and
visual and kinaesthetic imagery
Visual (3rd person) Imagery: Primarily
targets the cognitive stage of motor learning
through visual observation resulting in more task
interpretation and problem solving Hwang etal., 2010
Kinaesthetic (1st person) Imagery: Strongly
associated with stimulation of proprioception
pathway: joint position and movement and
internal sensory information Cho et al., 2013
PT Application
 20 – 30 minutes, 3-5x / week
 Visual and kinaesthetic imagery
 Adjunctive with gait or functional
mobility training
Limitations and Future Work
 Limited search
procedures
 No long term follow up
 Heterogeneous sample
population
 Various MI protocols
 MI + physical task
training
 Future Studies:
 Homogeneous
sample population
 Kinaesthetic
imagery vs. visual
imagery
 MI performed
independently
 MI protocol
Conclusion
 Motor imagery elicits the same cortical and
physiological effects as physical execution
of a task
 Motor imagery is effective in increasing gait
speed and functional mobility in postchronic stroke individuals
 Motor imagery can be implemented into
physical therapy practice as an adjunctive
intervention
THANK YOU
Maurine Coco, PT,DPT
Ck Andrade, PhD, PT
Andrew Lui, PT, DPT
Jeannette Lee, PhD, PT
Aaron Ortiz, DPTc
Patrice Jang, DPTc
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
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