From Disability to ‘THIS ABILITY’:

Current Implications of Mental Imagery

on Post-Stroke Balance and Motor
Activity

Hernan Cortez Labao, PTRP BSPT MSPT (Neuro) CPE

Lecturer, Department of Physiotherapy
Faculty of Health and Life Sciences
INTI International University, Nilai, Negeri Sembilan, Malaysia
MENTAL PRACTICE
 “Refers to the mental or cognitive rehearsal of a skill
without actual physical movement”

 Early stage of learning (cognitive phase): building up a

mental picture of the expected performance in their mind

 Advanced performers: MP is used to rehearse possible

alternative strategies or complex actions /sequences

 Helps with response preparation, reactions and

anticipation
- Letswaart, Butler, Jackson, & Edwards, 2015
 MENTAL IMAGERY
• The active process by which
humans relive sensations with or
without external stimuli
• Use different modalities such as
visual, auditory, tactile, kinesthetic,
olfactory, gustatory, or any
combination of these
MENTAL PRACTICE
• Consists of training methods by
which internal reproduction of a
given motor act is repeated
extensively with the intention of
improving performance

• Motor Imagery – the active

process during which the
representation of a specific action is
internally produced within working
memory without motor any output
- Letswaart, Butler, Jackson, & Edwards, 2015
 EXTERNAL IMAGERY
• Athletes visualize themselves
from a third person’s
perspectives

• Athletes watch the other

INTERNAL IMAGERY opponent in the match or
they use video clips to see
• Athletes visualize themselves
the tournament
as doing the task

• Athlete visualize the

tournaments in their mind

- Parnabas, V., Parnabas, J., & Parnabas, A.M., 2011

 USES OF MENTAL PRACTICE
MEDICINE

PSYCHOLOGY
SPORTS

MUSIC
EDUCATION
 USES OF MENTAL
Education
PRACTICE
• Patients with Stroke in nursing
homes and Patients with
Sports Medicine Parkinson’s Disease at different
MENTAL disease levels

PRACTICE • Effects of MP in terms of goal-

setting, self-efficacy, motivation
and mood, and working memory

Psycho-
Music
• Improvement of motor and
logy strength-focused tasks

- Schuster et al., 2011

Theories related with
 PSYCHO-
NEUROMUSCULAR
THEORY
“Postulates that feedback
generated during mental
imagery helps strengthen
the motor program
corresponding to a motor
task (Jacobson, 1932)”

- Slimani et al., 2011

PSYCHOBIOLOGICAL MODEL

“Any psychological and

physiological factor that
increases potential motivation
or increase maximal voluntary
activation will improve strength
performance and that any
psychological or physiological
factors that reduce the
potential motivation or MVA
will undermine strength
performance”
- Slimani et al., 2011
MENTAL IMAGERY-MUSCLE STRENGTH
RELATIONSHIP AND MOTIVATIONAL
INTENSITY THEORY

“An increase maximal voluntary

action (MVA) and potential
motivation are ultimate
determinants of enhanced
strength performance (Brehm &
Self, 1989)”

- Slimani et al., 2011

Effects of Mental Imagery on Motor
Activity
Improvement in;

• Muscle strength, movement

speed, accuracy, and variability
• Relies on imagery modality
(kinesthetic or visual), imagined
or actual execution, and
environment in which
intervention is performed
- Ruffino, Papaxanthis, Lebon, 2017
CORTICAL PLASTICITY DURING MOTOR
RECOVERY
• MI may integrate the feedbacks
induced by sensory cues to facilitate
the cortical reorganization

• Enhancement of the finger map area

and volume in both hemispheres in a
way that partly corrected the abnormal
asymmetry between affected and non-
affected hands

- Ruffino, Papaxanthis, Lebon, 2017

 CHAOTIC MOTOR
IMAGERY
 Defined ‘‘as an inability to perform
motor imagery accurately or, if
having preserved accuracy,
demonstration of temporal
uncoupling”

 Limb-specific, affecting distal but

not proximal movement in patients
with parietal damage

- Ruffino, Papaxanthis, Lebon, 2017

- Ruffino, Papaxanthis, Lebon, 2017
UPPER LIMB FUNCTION RECOVERY
• Motor imagery or mental practice combined with conventional
therapy – relearn tasks and transfer improvements

• Changes the quality and range of movement of the paretic arm

by increasing its functionality

• Improves both upper and lower limb for ADL

- Systematic Review by Carrasco & Cantalapiedra , 2016

UPPER LIMB ACTIVITY

• Improve motor activity of the upper

limb
- Cho, Kim, & Lee, 2012

• MP-guided NMES showed superior

result than conventional NMES
• MP is an effective complementary
therapy either given with or w/out
neurofeedback
• Has effect on Motor learning –
promotes awareness and active
involvement
- Park, Kim, & Yang, 2018
UPPER LIMB ACTIVITY

• Moderate evidence – MP + Physical

rehabilitation more effective than
physical rehabilitation alone
• Improvement in arm movements
and arm functions
- Barclay, Stevenson, Poluha, Semenko, & Schubert, 2020

• Activation of neural networks in

premotor cortex, parietal lobe, and
cerebellum - Lee et al., 2015
 TRUNK CONTROL
• Has carry-over
Improvement in Trunk effects on ADL and
Impairment Scale (TIS) functional balance
Score
• Recommendations:
• MI focused on
Improved lower trunk
lateral flexion and rotation lateral flexion
(dynamic sitting)
and rotation
(coordination)
Increases pelvic
stability

- Shah, Karthikbabu, Syed, & Ratnavalli, 2016

Enhances weight shifting
ability
EFFECTIVE COMBINATIONS
MI combined with Physical
Practice

• “promotes the cognitive

adaptation process during motor
learning, leading to more
elaborate representations than
physical practice only”

- Ruffino, Papaxanthis, Lebon, 2017

 EFFECTIVE
MI COMBINED WITH ACTION
COMBINATIONS OBSERVATION

Neurons are activated both during

actual execution and during
Facilitation of observation of the same task
corticospinal excitability
during the combined
condition was muscle-
specific
- Ruffino, Papaxanthis, Lebon, 2017
 EFFECTIVE COMBINATIONS

MI combined with Action Observation

Three (3) Effective combination

1. The observer imagines the action, while observing a third person performing
the same type of action
2. One could imagine an action in response to an observed movement, a
combination called coordinative MI and observation, also known as joint
action
3. Conflicting MI and action observation may be used to further understand the
biases effect of MI on observed actions, and inversely

- Ruffino, Papaxanthis, Lebon, 2017

 EFFECTIVE COMBINATIONS
MI combined with Cortical Stimulation
• Repetitive TMS and transcranial direct current stimulation
(TDCS) potentiate Motor area and facilitate neuroplasticity
during motor relearning

• Motor area and left dorsolateral pre-frontal cortex -

important for long-term potentiation-like processes
associated with motor learning

- Ruffino, Papaxanthis, Lebon, 2017

Effects of Mental Imagery on Balance
 EFFECTS ON BALANCE
• Not very risky, effective method of improving
balance ability – both static and dynamic
balance - Lee et al., 2015

• Increased dynamic balance – by stimulating

proprioception and reducing dependence on
visual function for maintaining balance
- Cho, Kim, & Lee, 2012

• Positive effect on improving and maintaining a

symmetrical stance posture
- Bae et al., 2015

- Systematic Review by Carrasco & Cantalapiedra , 2016

  Evidence of brain reorganization

 Improvement in gait and other tasks

GAIT PARAMETERS involving coordinated lower limb and
body movements in people with
- Malouin & Richards, 2010
Stroke and Parkinson’s Disease
EFFECTS ON GAIT
PARAMETERS
• Increased standing stability and gait velocity
• Increased weight bearing on the affected
extremity
• Increased position sense (proprioception) at
the ankles
- Lee et al., 2015

• Improves spatio-temporal gait parameters,

reduces fear of falling and promotes earlier
retraining of gait
- Systematic Review by Carrasco & Cantalapiedra , 2016
 EFFECTS ON GAIT
PARAMETERS
OVERALL
IMPROVEMENT of
Improvement in pelvic stability Functional balance
when walking

Improvement in stepping ability Enhances weight-

shifting ability

- Shah, Karthikbabu, Syed, & Ratnavalli, 2016

 EFFECTS ON GAIT
PARAMETERS
• Increased in gait speed
• Benefits:
1. Strengthens motivation – self confidence
2. MI plus kinematic and visual imagery effectively improves
motor function

• Conclusion: Adding motor imagery training to gait training

produced more significant enhancements in balance and gait
abilities than gait training alone - Cho, Kim, & Lee, 2012
HEALTHY ADULT POPULATION

 Motor Imagery improved maximal voluntary strength – MI + PP

 Dose:
 Training Period: 4 weeks
 Frequency: 3 times per week
 Sets: 2-3 sets per session
 Repetitions: 25 per set
 Duration: single session of 15 minutes

- Based on a Systematic Review with Meta-Analysis by Paravlic et al., 2018

EFFECTS ON MUSCLE STRENGTH

 Improvement in skilled movement –

adaptation in motor cortex neurons

 Stronger cortical signals to muscles

generated by repetitive mental attempts
at maximal muscle activation

 Improvement not only on motor

execution but also muscle strength

 Improvement of strength-based tasks

- Based on a Systematic Review of Slimani et al., 2016
EFFECTS ON MUSCLE STRENGTH

 Internal imagery is more effective than

external imagery in enhancing muscle force

 Increase lower limb muscular force (leg

press)

 Short and long term memories on motor

relearning and performance

- Based on a Systematic Review of Slimani et al., 2016

VARIABLES OF MENTAL IMAGERY
for Improving Strength
1. Characteristics of Imagery Interventions

 Most important factor

 High mental effort yielded more strength than low mental effort and
more than those not having mental imagery training (Raganathan et
al., 2002)
 Internal imagery better than external imagery (Raganathan et al.,
2002)
 Effective for enhancing performance when combined with other
cognitive techniques such as relaxation, goal-setting, hypnosis, and
self-talk (Hatzigeorgiadis et al., 2011)
- Based on a Systematic Review of Slimani et al., 2016
VARIABLES OF MENTAL IMAGERY
for Improving Strength
2. Training Duration

 Shorter mental imagery (3-6 weeks) induced greater effects on

strength performance in student athletes than longer mental imagery
(7-12 weeks)
 Short term (3 weeks) motor imagery strength training can increased
motor-evoked potentials
 3 sessions per week are more effective than once or twice a week
(Wakefield & Smith, 2011)

- Based on a Systematic Review of Slimani et al., 2016

VARIABLES OF MENTAL IMAGERY
for Improving Strength
3. Types of Skills

 External imagery supports performance of only one task, Internal

imagery serves multi-task performance
 Closed Skills – internal imagery, Open Skills – external imagery
 Internal imagery for rehearsal program in sports, external imagery
good for new and different experience

- Based on a Systematic Review of Slimani et al., 2016

VARIABLES OF MENTAL IMAGERY
for Improving Strength
4. Athlete Skills Level

 More experienced or elite athletes – use more internal imagery

 Most of literature indicate a greater effect of internal imagery on
muscular strength than external mental imagery

- Based on a Systematic Review of Slimani et al., 2016

AREAS FOR FURTHER RESEARCH
 Aspects of MP dose
 Adherence to MP program
 Comparison between responders
and non-responders
 Distractions during MP
 Underlying mechanisms of MP
- Letswaart, Butler, Jackson, & Edwards, 2015
 Impact of MP on perspectives of
neurophysiological and hormonal
adaptations
 Comparison on different mental
imagery intervention and to
examine the effects of these
interventions for athletes on
competitive situations
- Based on a Systematic Review of
Slimani et al., 2016
References
• Bae, Y.-H., Ko, Y., Ha, H., Ahn, S. Y., Lee, W., & Lee, S. M. (2015). An efficacy study on improving balance and gait
in subacute stroke patients by balance training with additional motor imagery: a pilot study. Journal of
Physical Therapy Science, 27(10), 3245–3248. https://doi.org/10.1589/jpts.27.3245
• Barclay, R. E., Stevenson, T. J., Poluha, W., Semenko, B., & Schubert, J. (2020). Mental practice for treating
upper extremity deficits in individuals with hemiparesis after stroke. Cochrane Database of Systematic
Reviews. https://doi.org/10.1002/14651858.CD005950.pub5
• Cho, H., Kim, J., & Lee, G.-C. (2013). Effects of motor imagery training on balance and gait abilities in post-
stroke patients: a randomized controlled trial. Clinical Rehabilitation, 27(8), 675–680.
https://doi.org/10.1177/0269215512464702
• García Carrasco, D., & Aboitiz Cantalapiedra, J. (2016). Efectividad de la imaginería o práctica mental en la
recuperación funcional tras el ictus: Revisión sistemática. Neurologia.
https://doi.org/10.1016/j.nrl.2013.02.003
• Letswaart, M., Butler, A. J., Jackson, P. L., & Edwards, M. G. (2015). Editorial: Mental practice: Clinical and
experimental research in imagery and action observation. Frontiers in Human Neuroscience.
https://doi.org/10.3389/fnhum.2015.00573
References
• Lee, H., Kim, H., Ahn, M., & You, Y. (2015). Effects of proprioception training with exercise imagery on balance
ability of stroke patients. Journal of Physical Therapy Science. https://doi.org/10.1589/jpts.27.1
• Malouin, F., & Richards, C. L. (2010). Mental practice for relearning locomotor skills. Physical Therapy, 90(2),
240–251. https://doi.org/10.2522/ptj.20090029
• Paravlic, A. H., Slimani, M., Tod, D., Marusic, U., Milanovic, Z., & Pisot, R. (2018). Effects and Dose–Response
Relationships of Motor Imagery Practice on Strength Development in Healthy Adult Populations: a Systematic
Review and Meta-analysis. Sports Medicine. https://doi.org/10.1007/s40279-018-0874-8
• Park, S. W., Kim, J. H., & Yang, Y. J. (2018). Mental practice for upper limb rehabilitation after stroke: A
systematic review and meta-analysis. International Journal of Rehabilitation Research.
https://doi.org/10.1097/MRR.0000000000000298
• Parnabas, V., Parnabas, J., & Parnabas, A. M. (2015). Internal and External Imagery on Sports Performance
among Swimmers Background of the Study. European Academic Research.
References
• Ruffino, C., Papaxanthis, C., & Lebon, F. (2017). Neural plasticity during motor learning with motor imagery
practice: Review and perspectives. Neuroscience. https://doi.org/10.1016/j.neuroscience.2016.11.023
• Schuster, C., Hilfiker, R., Amft, O., Scheidhauer, A., Andrews, B., Butler, J., … Ettlin, T. (2011). Best practice for
motor imagery: A systematic literature review on motor imagery training elements in five different
disciplines. BMC Medicine. https://doi.org/10.1186/1741-7015-9-75
• Slimani, M., Tod, D., Chaabene, H., Miarka, B., & Chamari, K. (2016). Effects of mental imagery on muscular
strength in healthy and patient participants: A systematic review. Journal of Sports Science and Medicine.
• Pictures from Public Domains
ACKNOWLEDGMENT:
Prof. Dr. R. Jaya Bharathi
Principal, Sree Abirami College of Physiotherapy
Coimbatore, Tamilnadu, India

Dr. Nandakumar Ramasamy

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