Mental Practice in Stroke Rehabilitation

Rationale: Mental practice as an embedded or additional therapy is getting increased attention in stroke rehabilitation around the world. A systematic review of the studies undertaken so far in stroke shows that although there may be some evidence that the technique might be effective, at present it is not certain whether it is effective. Little is known about the short- and long-term effect (>6 months) of mental practice interventions. This trial investigates whether mental practice can contribute to a quicker and/or a better recovery of stroke patients in every day practice. The trial will be conducted in the Klevarie Nursing Home of the Vivre Foundation (Maastricht) and Nursing Home St. Camillus, Land van Gelre and Gulick (Roermond), The Netherlands, over a period of 2 years (mid 2007- mid 2009).
Objective: The overall aim of the proposed research project is to investigate systematically the therapeutic potential of mental practice embedded in daily therapy on the improvement of daily activities of adult stroke patients compared to therapy as usual alone. The first additional research question is which prognostic variables or patient characteristics are associated with a positive outcome in the experimental subgroup. The second additional research question investigates the feasibility of the mental practice-based therapy as judged by the patients and therapists.
Study design: The study design is a multi-centre randomised controlled trial.
Study population: Adult stroke patients in the (sub)acute and chronic phase of stroke recovery will be recruited from the stroke ward of the Klevarie nursing home in Maastricht and Nursing Home St. Camillus in Roermond, The Netherlands. After giving informed consent, 70 patients will be assigned randomly to one of two rehabilitation programs (35/35).
Intervention: Patients will be followed over a 6 weeks intervention period (T0 and T1). The control group will receive multi professional approach therapy as usual. The experimental group will receive multi professional approach therapy in which mental practice is embedded in every physical, occupation and speech therapy session. Patients will be instructed how to perform MP training for improving 'drinking from a cup' and ‘walking’. The instruction for use, training and evaluation of MP takes place in 4 phases during 6 weeks. A follow up measure will take place after 6 months (T2).
Main study parameters/endpoints: The primary outcome measure is patient-perceived effect on performance of ‘drinking from a cup and walking’ as assessed by an 11-point Likert Scale. Secondary outcomes are on functional status: Motricity Index, Nine Hole Peg Test, Barthel Index, Timed up and Go, 10 metres walking test, Rivermead Mobility Index. A quantitative electro-encephalogram (QEEG) is performed at T0 to investigate its prognostic value. Because of the additional load in assessment time, re-measurements with the QEEG at T1 and T2 are optional. A sample size (n=10 in each group for both sites) of the patients and all therapists involved in the study will be interviewed on their opinion of the MP rehabilitation program to assess the feasibility of the program and patients are asked to keep a log in order to determine unguided training intensity.

It is hypothesized, that mental practice embedded in daily multi approach therapy in Nursing Homes will improve daily activities of adult stroke patients more and/or faster compared to therapy as usual alone.

All patients included in the study will receive 6 weeks of multi professional approach interventions. The control group will receive therapy as usual. The experimental group will receive therapy as usual in which MP-techniques and ¡Vprinciples are embedded in every paramedical therapy session. Six paramedical therapists working at the Klevarie Nursing Home and six paramedical therapists working at Nursing Home St. Camillus will be instructed on how to treat the patients in the experimental group (two occupational, two physical and two speech therapists). Patients allocated to the control group can be treated by any of the therapists. To prevent/limit contamination in therapy of the instructed therapists, an expert (also the trainer of MP for the participating therapists) will monitor the contrast between the experimental and control therapy.
Experimental intervention
The experimental group will receive therapy in which mental practice is embedded in every occupational, speech or physical therapy. We choose embedded MP for several reasons. There is some evidence that mental rehearsal should be combined regularly with the overt movement to increase imagery vividness. Second, improving skills seems to depend on continuous practice. In addition, we believe that a higher training intensity will not only increase skills but also consolidate the MP technique, making the patient more confident that he/she is practicing correctly and thereby increasing compliance and motivating patients to practice unguided. The experimental intervention period is divided into four phases.
Patients will first be familiarised with MP-based therapy and educated by an expert as to basic imagery principles and the importance of imagery training on a regular basis (phase 1). The expert will therefore instruct all the patients in the experimental group in phase 1. There is some evidence that patients educated on and familiarised with the technique are more likely to practice in general and to practice correctly.
In phase 2 they will be taught by their 'own' treating therapist how to use the MP technique to improve 'drinking from a cup' and 'walking'. We choose these two activities for several reasons. The main reason is that patients in both sites report these activities the most frequently as being activities they want to improve. Second, we wanted two common activities all patients practiced. We can standardize the learning process by using the same activities and we will be able to compare results at the end of the study. Third, 'drinking from a cup' and 'walking' are different kind of tasks involving different amounts of cortical information. We would like to assess if arm-hand-functions are more suitable to practice for they need more cortical involvement (attention) for a successful performance than walking. The vividness of imagery will be enhanced using videos of the tasks, results from the Structural Dimensional Analysis ¡V of Motor Memory (SDA-M) program and external cues.
The SDA-M is used to determine the basic architecture of specific goal-directed movements. It is for example used to identify weak spots in the sequence of events that should lead to a certain motor performance in sports. In a preliminary study, we investigated the reproducibility and feasibility of the SDA-M in the Klevarie stroke population for the motor action 'drinking out of a cup'. The measuring protocol was successfully adjusted to the ability of the stroke population to process information. The measure instrument seems useful in rehabilitation. The SDA-M outcome will be used to tailor the MP intervention of individual patients in the experimental group.

During the four week training period (phase 3) patients will receive guided MP-based therapy and will be motivated to practice unguided as much as they want. Three refreshment sessions will be held in which the task is shown. Only if the patient benefits from the information, the SDA-M is repeated and results used to adjust the content of the mental practice intervention. Apart from optimizing the mental practice of ¡¥drinking from a cup¡¦ and ¡¥walking¡¦ the aim of the refreshment session is to add additional tasks in case the patient is fully able to perform the ¡¥drinking¡¦ and the ¡¥walking¡¦ task.

In the fourth phase, a general evaluation will take place to see whether any adaptations, advice or alterations are necessary in order for the patient to continue MP at home.

Control intervention
The control group will receive therapy as usual in accordance with the Dutch Guidelines for Stroke Rehabilitation.
The patients in the control group will be assessed with the same testing battery at baseline and follow up (T1 and T2). To compensate for the unguided imagery training, patients in the control group will be motivated to do homework as well (physical training). As the experimental group will receive more attention due to keeping a log and being interviewed, patients in the control group will be instructed to use logs as well and will be interviewed on their opinion on therapy as usual.
Just as in the experimental group, the rehabilitation program (therapy as usual) will be evaluated and patients motivated to practice at home (phase 4).