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Effect of graded motor imagery on upper limb motor functions and quality of life
in patients with stroke: a randomized clinical trial

Article  in  International Journal of Therapies and Rehabilitation Research · January 2015

DOI: 10.5455/ijtrr.00000047

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International Journal of
Therapies and Rehabilitation Research [E-ISSN: 2278-0343]
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IJTRR 2015, 4: 1 I doi: 10.5455/ijtrr.00000047

Original Article Open Access

Effect of graded motor imagery on upper limb motor functions and

quality of life in patients with stroke: a randomized clinical trial
Manisha Uttam*, Divya Midha, Narkeesh Arumugam
Manisha Uttam, Assistant Professor, Maharishi Markandeshwar Institute of Physiotherapy & Rehabilitation,
Maharishi Markandeshwar University (MMU) Mullana
Divya Midha, Assistant Professor, Maharishi Markandeshwar Institute of Physiotherapy & Rehabilitation,
Maharishi Markandeshwar University (MMU) Mullana
Narkeesh Arumugam, Head and Professor, Department of Physiotherapy, Punjabi University, Patiala.

ABSTRACT
OBJECTIVES: To find out the effect of GMI and conventional treatment on upper limb motor
impairment and in enhancing the quality of life of patients with stroke.
MATERIALS/METHODS: 26 subjects consisting of 15 males and 11 females were randomly allocated to the
GMI group (n=13) and to the Conventional group (n=13) by using sealed red and blue colored chits
containing the treatment allocation for each participant. Conventional group received conventional
treatment containing Task oriented upper extremity functional exercises. GMI group received GMI
consisted of two weeks each of left right discrimination training, explicit motor imagery and mirror
therapy. Primary outcome measure upper limb motor function was assessed by Fugl meyer assessment
scale (FMA) and Chedoke arm and hand activity inventory scale (CAHAI) and Secondary outcome measure
quality of life was assessed by Stroke specific quality of life (SS-QOL) were recorded at baseline and after 6
weeks.
RESULTS: Paired t test was used to determine the difference between the pre and post treatment score
within the group A and B and Unpaired t test was used to analyze the baseline scores and pre-post mean
difference between the group A and B. The results suggested that there was improvement in mean change
scores of FMA, CAHAI and SS-QOL after treatment in GMI group and Conventional group. But statistical
analysis reveals that there was more significant improvement in GMI group (p value ≤0.05). Between group
effect sizes were calculated by using Cohen’s d coefficient which was large for all three outcome measures
(d>1.6).
CONCLUSION: GMI group along with conventional treatment shows more significant improvement than
conventional group alone in improving upper limb motor functions and quality of life in patients with
Stroke.
KEYWORDS: Motor Imagery program, Stroke, Mirror therapy, Upper limb functions

______________________________________

*Corresponding Author: Manisha Uttam, Ph. No – 9872798212 , E mail – manisha_uttam1989@rediffmail.com

Uttam M et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 43-51
INTRODUCTION
Stroke is the third most common cause of death and most common cause of acquired adult disability in
developed countries.1 Without intervention, the number of global deaths was projected to rise to 6.5 million in
2
2015 and to 7.8 million in 2030 . The functional impairment of upper limb is a usual consequence of stroke that
affects about 85% of stroke survivors. Various rehabilitative treatments have been introduced such as Constraint
induced movement therapy, robotic therapy, neuromuscular electro- stimulation and bilateral arm training. Improving
upper limb function is a core element of rehabilitation after stroke, in order to maximize patient outcomes and
3,4
reduce disability .
Different Motor learning programs have been extensively utilized in the rehabilitation of stroke patients that has
lead to tremendous improvement in quality of life. These programs are common in that they involve different extents
of relearning of lost functions5. Recently some promising trials of Motor imagery and Mirror therapy have been published.
Both Motor imagery and Mirror therapy combine to form Graded Motor imagery (GMI).
Motor Imagery can be defined as covert cognitive process of imagining a movement of your own body without
6
actually moving your body . Graded motor imagery (GMI) is a rehabilitation process used to treat pain and
movement problems related to altered nervous system by exercising the brain in measured and monitored steps
7
which increase in difficulty as progress is made . The three different treatment techniques include left/right
discrimination training, explicit motor imagery exercises and mirror therapy8. These techniques require graded
sequencing which prevent adverse responses produced by the shock of seeing what appears to be the affected
limb in the mirror. Through this sequencing and avoidance of adverse responses, the reinforcement of non
9
productive neural pathways can be prevented and productive pathways reinforced and developed . The aim of the
present study was to determine the effect of GMI on upper limb motor functions and quality of life in patients with
stroke.
METHODOLOGY
This study is a prospective, randomized clinical trial. Study was conducted at Maharishi Markandeshwar Institute of
Physiotherapy and Rehabilitation (MMIPR), Mullana and Parmarth Mission Hospital, New Delhi for a total of one year where
intervention was given five days a week for six weeks. The proposal of the study was approved by the Institutional Research
Committee of M.M University, Mullana – Ambala. The clinical study is registered in a database Clinical trials.gov
NCT02232295. The procedure of the study was explained to the subjects and written consent was taken. The sample size
10
was estimated using the formula given by Zhong B through which 26 subjects were selected, out of which 15 were males
and 11 were females. Subjects were selected by means of purposive sampling based on inclusion and exclusion criteria.
Eligible subjects were randomly allocated in to two groups using sealed red and blue colored chits containing the treatment
allocation for each participant.
The inclusion criteria were: subjects between age 45 to 65 years, Individuals who experienced one episode of
stroke only, Both males and females were included in the study, Both ischemic & hemorrhagic stroke individuals were
included in the study, Duration of stroke between 1 to 6 months, Mini mental status examination (MMSE) (score > 23),
Patients with brunnstrom stage 1 & 2. Exclusion criteria were: Individuals having any musculoskeletal Disorders,
neurological disorder other than stroke, visual impairment, systemic disease, Non co-operative patients, Patients suffering
from psychological problems.
The subjects under group A had received GMI programme with conventional treatment and subjects under group B
received only conventional treatment. Both groups delivered treatment of 5 days a week, for 6 weeks. Conventional
treatment consists of Task oriented upper extremity functional exercises. Components of Task oriented training include
11
weight bearing, supportive reactions, and reaching, grasping, holding and release activities . GMI is a three stage process
comprises of:
Left Right discrimination training:
Online Recognize Programme software was used to perform the Left Right discrimination training. Initially, 20
photographs of vanilla hand images were displayed in a variety of postures on a computer screen for 20 seconds response
time. Response time was decreased and number of photographs was increased according to the progress of each patient.

Uttam M et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 43-51
Subjects were told to use their index finger to respond. Responses were made using the left arrow key on keyboard for left
sided response and right arrow for right sided response. When a response was made the next image would immediately
appear. If the subject did not respond, next image will automatically appear when time elapses. Accuracy and Speed of
response time was measured at the end of each session. Three sessions were performed per day.
Explicit Motor Imagery:
20 pictures of the affected hand in a variety of posture were randomly displayed from the computer screen.
Patients were advised to imagine moving their own affected hand to adopt the posture shown in the picture, but the
affected hand was resting comfortably, and then asks the patient to imagine returning the hand to its resting position.
Repeat the process twice for each picture. Stopwatch was used to record the time of each trial performed. Accuracy is
emphasized rather than speed in this trial.
Mirror Therapy:
Patients were made to perform the Mirror therapy training and mirror (30cmx30cm) was placed vertically on a
table. The affected hand was concealed (behind the mirror) and unaffected hand in front of the mirror. The practice consists
of unaffected side wrist and finger flexion and extension movements and then progress to forearm supination and
pronation. Patients were asked to try to do the same movements with the affected hand while they are moving the
unaffected hand. Increase the speed of the exercise as progress is made.
Outcome measures:
Subjects were evaluated at baseline and after 6 weeks of treatment. To measure improvement in upper limb motor
function, Fugl meyer assessment scale (FMA) and Chedoke arm and hand activity inventory (CAHAI) were used for
evaluation as a primary outcome measures, and for the quality of life Stroke specific – quality of life (SS-QOL) was used as a
secondary outcome measure.
The data were analyzed using Statistical Package for the social sciences (SPSS) 22 version software. Unpaired t test
was used to compare the mean age, MMSE Score, stroke duration between both groups. Chi square test was used to
compare the gender differences, stroke type and side affected between two groups. Paired t test was used to determine the
difference between the pre treatment and post treatment score within the group A and B and Unpaired t test was used to
analyze the baseline scores and pre-post mean difference between the group A and B of FMA, CAHAI and SS-QOL. Between
group effect sizes were calculated by using the Cohen’s d coefficient. The results were considered statistically significant if
the p value was ≤ 0.05.

RESULTS
The p values of demographic (continuous and categorical variables) and baseline characteristics, shown no
significant difference between group A and B which had suggested that homogeneity between the groups were maintained
(Table 1). Table 2 shows scores of FMA within as well as between the group A and B. Table 3 shows scores of CAHAI within
as well as between the group A and B. Table 4 shows scores of SS-QOL within as well as between the group A and B. Among
all the three outcome measures, the analysis reveals that there was statistically significant improvement in Pre and Post
treatment measures among the groups.

Uttam M et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 43-51
 Table 1. Demographic and Baseline Characteristics of Participants

Variable Group A Group B p value

Age (years) 54.77±6.392 57.85±4.375 0.165*

Stroke duration (days) 74.384±32.523 92.384±30.226 0.157*

Stroke Ischemic 9 (69.2) 8 (61.5)

type 0.68*

Hemorrhagic 4 (30.8) 5(38.5)

Male 8 (61.5) 7 (53.8)

Gender 0.69*
no(%)
Female 5 (38.5) 6 (46.2)

Right 7 (53.8) 5 (38.5)

Side 0.69*
affected
no(%) Left 6 (46.2) 8 (61.5)

a
MMSE Score (mean±SD) 27.692±1.437 26.692±1.653 0.112*

a
FMA (mean±SD) 29.46±4.034 27.61±2.364 0.167*

a
CAHAI (mean±SD) 23.6±5.455 23±8.165 0.226*

SS-QOLa (mean±SD) 112.46±9.024 108.46±10.844 0.316*

a
*p≤0.05 considered as significant, calculated by Unpaired t test.

Uttam M et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 43-51
MMSE: Mini Mental Status Examination, FMA: Fugl Meyer assessment scale, CAHAI: Chedoke arm and hand activity
inventory scale, SS-QOL – Stroke specific quality of life scale

Table 2. Within and Between Group Comparison of FMA Score among the Groups

WITHIN AND BETWEEN GROUP COMPARISON OF CHANGE SCORE OF FMA

Within group Between group

Treatment CH1 CH2
Groups Data Mean± S.D Mean ± S.E.M t value Mean± S.E.M t value
Collection (95% C.I) (p value) (p value)
Pre
treatment 29.46±4.034 FC (fa-fb) = 18.373
Group A (fa) (27.024-31.899) 21.230± (0.0001)
Post 4.166
treatment 50.69±2.213 FC-F’C’= 3.497
(fb) (49.355-52.030) 4.23± (0.001)*
Pre 2.875
treatment 27.61±2.364 F’C’ (f’a’-f’b’) = 47.478
Group B (f’a’) (26.187-29.044) 17 ± (0.0001)
Post 1.291
treatment 44.6±2.364
(f’b’) (43.187-46.044)

*p≤0.05 considered as significant

FMA: Fugl meyer assessment scale, CI: Confidence interval, SD: Standard deviation, S.E.M: Standard error of mean, CH1 =
Change score within group, CH2 = Change score between group

Uttam M et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 43-51
 Table 3. Within and Between Group Comparison of CAHAI Score among the Groups

WITHIN AND BETWEEN GROUP COMPARISON OF CHANGE SCORE OF CAHAI

Within group Between group

Treatment Data Mean± S.D CH1 t value CH2 t value

Groups Collection (95% C.I) Mean± S.E.M (p value) Mean± S.E.M (p value)

Pre 23.61 ± 5.455

Group A treatment (20.319-26.912)
(ca) FC (ca-fb) = 22.439
43.153± (0.0001)
Post 66.69 ± 4.990 7.010
treatment (63.677-69.708) 3.344
(cb) CC-C’C’= (0.002)*
11.307±
Pre 23 ± 8.165 2.964
treatment (18.066-27.934) F’C’ (c’a’-f’b’)
Group B (c’a’) = 31.846± 11.513
9.974 (0.0001)
Post 54.84 ± 4.451
treatment (52.156-57.536)
(c’b’)

*p≤0.05 considered as significant, CAHAI: Chedoke arm and hand activity inventory scale.

Uttam M et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 43-51
 Table 4. Within and Between Group Comparison of SS-QOL Score among the Groups

WITHIN AND BETWEEN GROUP COMPARISON OF CHANGE SCORE OF SS-QOL

Within group Between group

Treatment Data Mean± S.D Mean± S.E.M t value Mean ±S.E.M t value
Groups Collection (95% C.I) (p value) (p value)

Pre 112.46 ± 9.024

Group A treatment (107.01-117.19)
(sa) SC (sa-fb) = 18.371
66.384± (0.0001)
Post 178.85 ± 12.668 13.029
treatment (171.92-186.50)
(sb) SC-S’C’= 4.705
22.461± (0.0001)
Pre 107.85 ± 10.84 1.778 *
Group B treatment (101.91-115.02) S’C’ (s’a’-f’b’)
(s’a’) = 43.923± 14.076
11.251 (0.0001)
Post 152.38 ± 10.27 -
treatment (146.18-158.59)
(s’b’)

*p≤0.05 considered as significant, SS-QOL: Stroke specific quality of life,

DISCUSSION
The results suggested that there was improvement in mean change scores of Fugl – Meyer assessment scale (FMA),
Chedoke arm and hand activity inventory scale (CAHAI) and Stroke specific – quality of life (SS-QOL) after treatment in
Experimental group and Conventional group. (Table 2, 3, 4) But statistical analysis reveals that there is more significant
improvement in Experimental group (Table 2, 3, 4).
In the present study, the average within group change scores of FMA for subjects in group A and group B was
21.230 and 17 respectively. The average mean change scores in both groups exceeded value of minimal clinically important
12
difference (MCID) which was 10 (Table 2), but it was more in experimental group. For CAHAI, the mean within group
change score for subjects in group A and group B was 43.153 and 31.846 respectively and between group change score was
13
11.307 which was also exceeded value of minimal detectable change score (MDC) of 6.3 points (Table 3), suggesting a
clinically significant impact of adding GMI to conventional treatment. Between group effect sizes were large for all three
14
outcome measures (d>1.6) .
15
Results of present study are in support with a study conducted by Moseley who reported that Graded motor
imagery program is effective in chronic CRPS1 and conclude that GMI reduce pain by 20 points on Numerical pain rating
16
scale in the chronic CRPS1 population. Moseley conclude that Patients in GMI group did better than patients in either
of the other groups and the treatment components were only effective when they followed the sequential component.

Uttam M et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (1): 43-51
GMI imparts improvement in pain and disability and functional gains with patients of CRPS1, Phantom limb pain and chronic
pain and, it had been extended clinically to chronic back pain where a component of GMI has been used. Moseley made
.
major contribution towards the development of GMI intervention strategy There are many studies that look at the
17
provision of one component of GMI process, but limited research is there looking at the whole process .

Recovery after stroke also depends on cortical motor networks for functional recovery. CRPS1, Phantom limb pain
and stroke originate from distinct mechanism (peripheral trauma, deafferentation and cortical damage) respectively, but
each can be investigated with the same clinical, electrophysiological and imaging technique to determine their clinical
presentation and cortical response to treatment. Therefore, although they are different conditions but they show identical
aspects of symptomatic presentation and pattern of cortical reorganisation. Thus, based on these common findings the
established principles of complex region pain syndrome type 1 and phantom limb pain rehabilitation can also be applicable
18
to the rehabilitation of Stroke .
The novelty of the current study is that results of Graded motor imagery proven to be effective tool for the
enhancement of stroke rehabilitation when combined with conventional treatment programme of task oriented upper
extremity functional exercises. The more significant results in GMI training group may be because the GMI works on the
principle of perception, perceptual reorganization and imagined movement which will lead to the activation of cortical
motor networks even without the execution of movement of the affected limb, additionally it not only focus on affected
limb but also on non affected limb, which in turn, will further enhance the stroke rehabilitation when combined with
conventional task oriented programme than conventional treatment programme alone.

CLINICAL IMPLICATION
Approximately 70% to 80% patients who sustained stroke have upper extremity motor impairment which can lead
to difficulties in their daily living activities. This programme can be used clinically as an adjunct to other therapeutic
approaches for rehabilitation of upper limb motor impairment in stroke patients. This programme will further help the
stroke individuals to promote the functional recovery of upper extremity which will in turn improve their quality of life.
LIMITATIONS OF THE STUDY
No follow up was taken to see the long term effects of training due to non availability of patients and it is uncertain
whether the observed differences might remain beyond that time. Control group was not included in the study as GMI is
effective only in adjunct with conventional treatment to enhance the improvement in upper limb motor functions and
quality of life.

FUTURE SUGGESTIONS
1. More experimental trials need to be explored on the effect of GMI in the rehabilitation of stroke to make it more
evidence supported as there is very limited evidence.
2. Follow up study can be done to see the long term effects of the GMI training program in stroke individuals.

CONCLUSION
GMI group along with conventional treatment shows more significant improvement than conventional group alone in
improving upper limb motor functions and quality of life in patients with Stroke.

Conflict of Interest: None

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