Does Mental Practice Promote Cortical Reorganization and Improved Hand Function in Stroke?
Mental Practice , Stroke , Transcranial Magnetic Stimulation
The upper extremity is often left with permanent disability following stroke and therapeutic techniques used at present have had limited success. This prospective clinical trial evaluated the effectiveness of mental practice (MP) through motor imagery (MI) a therapy technique to enhance upper extremity motor recovery after stroke. MI ability, upper extremity hand function, finger strength, and motor cortical output were examined in 18 stroke subjects (mean 67.5 years). Subjects were randomly allocated to the MP treatment group or the control group which received cognitive therapy. Both groups received their respective treatment daily for 30 minutes for a 3 week period. Assessments were performed prior to treatment, post treatment and at 3 months post treatment. Imagery ability was measured using the Kinesthetic and Visual Imagery Questionnaire (KVIQ) and mental chronometric testing. Hand function was assessed with the box and block test (BBT) and finger strength with maximum voluntary contraction (MVC). To determine the effect of MI on neural excitability, focal transcranial magnetic stimulation was applied over the primary motor cortex while participants were at rest and while they imagined themselves performing abduction of the index finger. Motor evoked potentials were recorded from the contralateral first dorsal interosseous (FDI), abductor digiti minimi (ADM) and abductor pollicis brevis (APB) muscles. Data were analyzed using multifactor and repeated measures ANOVAs with the significance level set to p < 0.05. Results showed no significant difference between groups on any of the outcome measures (p > 0.05) although all subjects improved their hand function over the study period (p < 0.05). In addition, motor threshold was found to decrease over time (p < 0.001) in all subjects demonstrating improvement in cortical motor excitability and output. Motor evoked potentials (MEPs) elicited during MI were significantly larger compared to those evoked at rest (p < 0.022). MEP amplitudes from FDI, the muscle targeted with MP, showed a significant interaction effect between time and group (p = 0.021) which reflected an increase in MEPs in the MP group over time whereas a decline occurred in the cognitive group. These findings indicate that MI enhances motor cortical output in stroke and that MP using MI appears to increase corticospinal output to the target FDI muscle. No differential effects of MP and cognitive therapy interventions were evident in terms of hand function and finger muscle strength.