Mental Practice in Stroke Rehabilitation


Status: Not yet recruiting
Keywords: stroke , rehabilitation , neuroplasticity , mental practice , motor skills
IRB Number: 00063739
Specialty: Occupational Therapy
Sub Specialties:

Brief Summary


Specific Aim 1: Determine efficacy of MP + RTP as compared to RTP and a home exercise program on affected arm functional limitation. Subjects with chronic stroke will be randomly assigned to receive: (a) MP combined with RTP (MP + RTP); [or] (b) RTP only (RTP). This study design will ascertain the additive effect of MP training to RTP, while also discerning the relative contribution of RTP only since motor learning-based, RTP approaches are frequently used by therapists in clinical environments.[1,2}


Affected arm functional limitation, the primary study outcome, will be measured by the Action Research Arm Test (ARAT), the primary outcome measure. The ARAT will be administered by a blinded rater twice before intervention (PRE-1, PRE-2), and directly after intervention (POST), with POST serving as the primary study endpoint. The primary study hypothesis is that subjects in the MP + RTP group will exhibit significantly larger ARAT score changes than RTP subjects at POST. It is also hypothesized that these changes will be sustained 3 months after treatment (POST-3).


Specific Aim 2: Determine the impact of MP + RTP on affected arm outcomes. The sites will administer the upper extremity portion of the Fugl-Meyer Impairment Test (FM), the Arm Motor Ability Test (AMAT), the Motor Activity Log (MAL), and the Stroke Impact Scale (SIS) to all subjects. When compared to their scores before intervention, it is hypothesized that MP + RTP subjects will exhibit significantly larger FM score changes, significantly larger AMAT score changes, significantly larger score changes on the Amount of Use Scale of the MAL, significantly larger score changes on the Quality of Movement scale of the MAL, and larger SIS score changes, all at POST. These differences will be sustained at POST-3. Exploratory analyses will also examine relationships among affected arm use and motor outcomes.


Specific Aim 3: Determine MP + RTP effects on cortical organization using functional magnetic resonance imaging (fMRI). Both sites will administer fMRI at PRE and POST. Based on preliminary data, it is predicted that activation patterns of subjects participating in the MP + RTP and RTP groups will show increased activation volume within the primary region of interest, the ipsilesional affected arm primary motor cortex area (M1), with larger increases in the MP + RTP group. MP + RTP subjects are also expected to exhibit increased ipsilesional activation patterns in the sensorimotor cortex (SMC) and premotor cortex (PMC). In addition, a voxelwise exploratory analysis will examine which brain areas in the PRE fMRI scan predict subsequent behavioral gains, including a covariate term for treatment group to assess whether predictive value of fMRI differs significantly across treatment groups. The researchers will also compare subject outcomes with how the fMRI task activates brains of healthy, age matched controls.

Principal Investigator: Lorie Richards
Co Investigator: Jeanette Koski
Co Investigator: Kasey Mitchell

Contact Information

Name:Lorie Richards
Phone: 801-585-1069

Inclusion Criteria

Inclusion criteria are based on preliminary work,1-7 and would be the following: (1) Minimum motor criteria: Patients will be included based on their active ranges of motion at their wrists and fingers AND on their initial scores on the motor and coordination portions of the Fugl-Meyer (FM) test. This is because use of the FM as an adjunct to finalizing motor criteria will yield a less ambiguous inclusion criterion if coupled with these active ranges of motion measures. Active range of motion determinations will be made with the subject sitting, the forearm supported in neutral. Based on successful pilot work criteria, to be included in the study, the participant must be able to at least actively flex the affected wrist a minimum of 10° and actively flex the MP joints of the thumb, and at least 2 additional MP joints in two additional fingers at least 10°. These movements must be repeated at least 3 times in one minute. The minimal FM score that corresponds to the above movement capabilities, and that has captured the majority of all participants in the PI’s previous studies, was 28. Thus, subjects in this study will have to exhibit the aforementioned active range of motion and a FM score of 28 to be eligible for study inclusion. (2) stroke experienced > 6 months prior to study enrollment; (3) a score > 25 on the Folstein Mini Mental Status Examination (MMSE), (4) age > 21 < 80; (5) have experienced one clinical stroke as verified by a physician; (6) discharged from all forms of physical rehabilitation; (7) if meeting fMRI criteria, willing to undergo fMRI.  

Exclusion Criteria


Exclusion criteria would be: (1) < 21 years old (the immature nervous system might respond differently to therapy than the mature nervous system; while studying juvenile hemiparesis would be of value, this effort should be undertaken in a separate project after confirmatory work is completed in this trial); (2) excessive pain in the affected hand, arm or shoulder, as measured by a score > 5 on a 10-point visual analog scale; (3) excessive spasticity in the affected biceps, triceps, wrist, or fingers, as defined as a score of greater than or equal to 2 on the Modified Ashworth Spasticity Scale;92 (4) currently participating in any experimental rehabilitation or drug studies; (5) mirror movements (i.e., involuntary movements by the unaffected hand during attempts at unilateral movement by the stroke-affected hand); (6) contraindication to a MRI procedure (i.e., metal implants, claustrophobia; pregnant). Females of childbearing age will be administered a pregnancy test; kits will be purchased by the grant supporting this study and administered in the restroom of the neuroimaging center prior to scanning; (7) history of a parietal stroke (because some data suggest that ability to estimate manual motor performance through mental imagery is disturbed after parietal lobe damage);93 (8) affected arm joint restriction that in the opinion of the investigators would hinder study participation