MOTOR IMAGERY

Cerebrovascular accidents are now considered one of the leading causes causes of mortality
among adults in European regions. There are approximately a million incidents of stroke among
Europeans. the most frequently occurring is hemiparesis, which presents by mobility
impairments on one side of the body, this severely limits functionality, independence and
quality of life. Various treatment approaches have been developed to aid recovery of
hemiplegic patients including, constrained induced movement therapy, mirror symmetric
bimanual movement priming, virtual reality and motor imagery training.(García et al, 2016) The
latter is the technique addressed in this research.

It is worth mentioning that functional recovery occurring is due to the reorganization process
occurring in the damaged brain area. Self-reorganization is possible when partial damage was
done to the functional system, but if system was completely damaged recovery is attributed to
process of substitution, that is when another area of the brain is recruited to perform functions
of area damaged by stroke. (de Vries, 2007)
Imagery can be categorized into external/visual and internal/kinesthetic. External imagery is
when the person views himself as an observer, while internal imagery is the approximation of
real life phenomena’s that the person imagines being In his body and experiencing the
phenomenon along with the sensations he might feel (Dickstein, 2007). Mental imaging is the
ability to imagine events, objects that are not really there. As we are able to imagine how an
object would look from the opposite side without actually changing our position or move, we
can describe how an object would feel without actually touching it. We can define Motor
imagery as the cognitive process of imagining movement of own body (/ body part) without
actually moving it(de Vries, 2007). Mental practice refers to the voluntary rehearsal of a scene
or task, while motor imagery practice refers to motor imagery with the aim of improving motor
performance (Dickstein, 2007). recent papers suggest that information provided by imagination
of movements might form an additional source of information that could be useful for motor
rehabilitation after stroke. The rationale behind this is that brain areas that are normally
involved in movement planning and execution are also active during the imagination of a
movement. It is known that the imagination of a movement activates more or less the same
brain areas as the actual execution of a movement. Several studies using brain mapping
techniques have found that, during motor imagery brain areas related to motor execution were
activated.(de Vries, 2007)
Neuroimaging has shown significant similarities between imagined movement and real
movement, this lead to a theory named “the stimulation hypothesis”. Stimulation hypothesis
states that covert movement (motor imagery) and overt movement are essentially based of the
same process. Imagining, executing and observing a movement are driven by the same
mechanism. This supported by similarities in behavioral domain, the time taken to complete an
imagined movement is the same time taken to physically execute it, this is known as mental
isochrony (de Vries & Mulder, 2007), (Sharma et al., 2006) also mentioned the existence of
temporal coupling between executed movements and motor imagery which is the time needed
to mentally perform a task is very similar to that needed in actually executing it. The second
evidence that supports hypothesis is that the neural system, used for action control is the same
one used during imagination of movement. This has been proven by brain imaging studies that
showed similarity at a neural level, where the parts most often involved in motor imagery are
the areas related to planning and control of movement like the pre-motor cortex, cerebellum
and the basal ganglia. However there still is a discussion about the involvement of more
executive areas of central nervous system such as the primary motor cortex.(de Vries , 2007)
Theoretically if motor imagery training results in changes of motor performance, then cortical
reorganization must have taken place, similar to what happens in physical training. Some
studies have reported image related cortical reorganization. according to Pascual-Leone et al,
physical practice and motor imager of finger movement had the same reorganizational
changes. (Pascual-Leone A, 1995)
In stroke patients we should consider the ability to accurately perform motor imagery and
temporal coupling, as they may be affected depending on site of stroke. Since the parietal lobe
is involved in generation and preservation of kinaesthetic model. Therefore, injury to parietal
lobe reduces the accuracy of motor imagery, making the use of this practice rather challenging
if not impossible. (Sharma et al., 2006)

Temporal uncoupling might occur after parietal lobe or frontal lobe damage but it doesn’t have
to be affected by a stroke. Motor imagery could be preserved after stroke, but both temporal
coupling and accuracy could be disrupted. This has been referred to as chaotic motor imagery.

Due to motor imagery concealed nature, a subject can use alternative cognitive strategies and
we wouldn’t know unless screened for, causing conflicting results. These alternative strategies
can be boiled down into the following.

Imagery ability, to optimize the benefits from this practice, we should take into consideration
the individual’s ability to use imagery. Therefore screening and assessment of this ability should
be done prior to use of motor imagery practice using the following scales The Movement
Imagery Questionnaire (MIQ), its short revised version (MIQ-R), Vividness of Motor Imagery
Questionnaire (VMIQ) these where formulated for healthy subjects, the Kinesthetic and Visual
Imagery Questionnaire (KVIQ) this has been formulated for both healthy subjects and subjects
with disability.(Sharma et al., 2006)

Failure to comply, executed movements compliance can be checked by observation but this
can’t be applied to motor imagery. In a previously conducted where they used visually
presented numbers to help “guide” subjects through a finger-tapping sequence that was pre-
taught. Then, subjects are instructed to begin with a specific finger then presented a number;
the subject then moves the corresponding steps through the sequence, and at end of block is
asked to confirm the position. Even though this method provides evidence of compliance, it
does encourage use of alternative techniques, counting. a variant of this method can be used, a
motor imagery task is paced and stopped unexpectedly then the subject has to confirm reached
position. Another method which could be used is mental chronometry, which could also be a
useful motor imagery training. Nonetheless, all of these tasks can be solved by the use of
alternative strategies such as visual imagery, counting, or 3rd person imagery.

Concealed use of alternative strategy subjects should perform the imagery task from the 1st
person perspective, and not in visual imagery or 3rd person perspective, also without
counting. This applies to assessment not imagery practice. Chaotic motor imagery at the time
of the study there wasn’t a specific assessment published. using motor imagery practice on a
subject with chaotic motor imagery wouldn’t have much positive effects.(Sharma et al., 2006)

Task familiarity, some authors claim that for successful us of motor imagery the practiced
should be familiar. It’s been proved that after motor imagery practice, motor performance of a
motor task significantly in a group who had previously mastered task in question, in comparison
with the group that had no previous practice. Another study showed that people with
hemiparetic cerebral palsy that had impaired imagery ability where unable to plan novel tasks.
Therefore, it was advised to avoid new motor tasks in imagery practice and taken into
consideration during planning of intervention. (Dickstein, 2007).

Working memory is a complex process, including the manipulation and storage of information;
it can classify as verbal, visual, or kinesthetic. The mutual relationship between working
memory and imagery ability, which underlies the inclusion of working memory in the broad
definition of Motor imagery, is an important consideration. Malouin and colleagues, describing
motor imagery as a “dynamic state during which the representation of a specific action is
internally reactivated,” further maintained that mental rehearsal requires that subjects
manipulate and maintain kinesthetic and visual information in their working memory. An
impairment in working memory, may hinder the ability to successfully engage in Motor imagery
practice, and thus altering mental practice outcomes.

Motivation, highly motivated people who use Motor imagery improve more than those who
are not. Similarly, people with low anxiety scores practiced mentally better than those having
high anxiety scores. On the other hand, participating in mental practice may increase self-
efficacy and arousal, resulting in a positive effect on self-confidence and motivation. Therefore,
individuals with anxiety or low motivation should be encouraged to take part in MI practice
rather than excluded.(Dickstein, 2007)
According to a systematic review conducted between 2011 and 2012 on the efficacy of motor
imagery on functional stroke recovery concluded that motor imagery combined with
conventional therapy can help relearn tasks and apply these improvements to new
environments. They also mentioned that motor imagery is applicable when used as an adjuvant
to conventional therapy in patients having preserved imagery skills. Session length should be
gradually increased.(García Carrasco, 2016)
An example of using motor imagery in intervention, intervention consists of three, one hour
sessions lasting a month. Using 2 types of motor imagery, the first includes computer facilitated
imagery focused on wrist extension, pronation, supination providing visual cues showing
movement of the arm from 3 different angles and at 4 different speeds. The second task used a
mirror box facilitated imagery, the patient was instructed to imagine the reflected limb as his
actual limb moving freely, the first week focused on learning to identify the reflected limb as
affected limb moving freely. The following weeks focused on simple movement while the final
weeks focuses on complex movements like drawing geometric shapes.(Stevens, 2003)
Another approach is using recorded tapes after conventional intervention, after therapy
patients listened to a tape recorded imagery intervention lasting 10 minutes in a quiet room
away from physical therapy department, the first 3 minutes focused on relaxation and asking
them to imagine themselves in a warm relaxing place then asking them to contract and relax
their muscles then the tape starts to suggest external visual images related to using the
affected arm in functional tasks like reaching for a cup. Patients were also given tapes to listen
to at home. Different tapes were available with new scenarios to avoid boredom.(Page et al.,
2001)

BIBLIOGRAPHY
de Vries, S., & Mulder, T. (2007). Motor imagery and stroke rehabilitation: A critical discussion. Journal

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Dickstein, R., & Deutsch, J. E. (2007). Motor Imagery in Physical Therapist Practice. Physical Therapy,

87(7), 942–953. https://doi.org/10.2522/ptj.20060331

García Carrasco, D., & Aboitiz Cantalapiedra, J. (2016). Effectiveness of motor imagery or mental practice

in functional recovery after stroke: A systematic review. Neurología (English Edition), 31(1), 43–

52. https://doi.org/10.1016/j.nrleng.2013.02.008

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.

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