Task-oriented arm training for stroke patients based on remote handling technology concepts: A feasibility study.

BACKGROUND: Improving arm-hand skill performance is a major therapeutic target in stroke rehabilitation. Arm-hand rehabilitation may be enriched in content and variation by using technology-assisted training. Especially for people with a severely affected arm, technology-assisted training offers more challenging training possibilities. OBJECTIVE: The aim of this study was to explore the feasibility of ReHab-TOAT, a "Remote Handling Based Task-Oriented Arm Training" approach featuring enriched haptic feedback aimed at improving daily activities and participation. METHODS: Five subacute or chronic stroke patients suffering moderate to severe arm-hand impairments and five rehabilitation therapists participated. All participants received 2 ReHab-TOAT sessions. Outcome measure was a bespoke feasibility questionnaire on user experiences and satisfaction regarding 'motivation', 'individualization of training', 'potential training effects', and 'implementation in rehabilitation' of patients and therapists. RESULTS: Both patients and therapists experienced ReHab-TOAT as being feasible. They found ReHab-TOAT very motivating and challenging. All patients perceived an added value of ReHab-TOAT and would continue the training. Small improvements regarding exercise variability were suggested. CONCLUSION: ReHab-TOAT seems to be a feasible and very promising training approach for arm-hand rehabilitation of stroke patients with a moderately or severely affected arm. Further research is necessary to investigate potential training effects of ReHab-TOAT.

Effects of a remote-handling-concept-based task-oriented arm training (ReHab-TOAT) on arm-hand skill performance in chronic stroke: a study protocol for a two-armed randomized controlled trial.

BACKGROUND: Improving arm-hand skill performance is a major therapeutic target in stroke rehabilitation and needs intensive and varied training. However, guided treatment time is limited. Technology can assist in the training of patients, offering a higher intensity and more variety in content. A new task-oriented arm training approach was developed, using a 'Remote Handling concept based' device to provide haptic feedback during the performance of daily living activities (ReHab-TOAT). This study aims to investigate the effects of ReHab-TOAT on patients' arm-hand function and arm-hand skill performance, quality of life of both patients in the chronic phase after stroke and their caregivers and the patients' perception regarding the usability of the intervention. METHODS: A randomized clinical trial was designed. Adult chronic stroke patients suffering from hemiparesis and arm-hand problems, with an Utrechtse Arm-hand Test score of 1-3, will be invited to participate. Participants in the experimental group receive ReHab-TOAT additional to care as usual. ReHab-TOAT contains task-oriented arm training for stroke patients in combination with haptic feedback, generated by a remote handling device. They will train for 4 weeks, 3× per week, 1.5h per day. Participants in the control group will receive no additional therapy apart from care as usual. The Fugl-Meyer Assessment (FMA), measuring participants' motor performance of the affected arm, is used as the primary outcome measure. Secondary outcome measures are arm-hand capacity of the patient (ARAT), perceived arm-hand skill performance (MAL), actual arm-hand skill performance (accelerometry), patients' quality of life (EuoQol-5D) and caregivers' quality of life (CarerQoL). Participants' perception regarding the usability of the intervention, including both the developed approach and technology used, will be evaluated by the System Usability Scale and a questionnaire on the user experience of technology. Measurements will be performed at 1, 2, 3 and 4 weeks pre-intervention (baseline); immediately post-intervention; and 3, 6 and 9 months post-intervention. Statistical analysis includes linear mixed model analysis. DISCUSSION: This study is designed to investigate the evidence regarding the effects of ReHab-TOAT on patients' performance at different levels of the International Classification of Functioning, disability and health (ICF) model, i.e. a framework measuring functioning and disability in relation to a health condition, and to provide insights on a successful development and research process regarding technology-assisted training in co-creation. TRIAL REGISTRATION: Netherlands Trial Register NL9541. Registered on June 22, 2021.

Patients' experiences of an information brochure for knee arthroplasty. A brief qualitative study.

INTRODUCTION: Patient information holds an important role in knee arthroplasty surgery regarding patients' expectations and outcomes after surgery. The purpose of the present study was to explore the experiences and opinions of patients undergoing knee arthroplasty (KA) surgery on an information brochure provided preoperatively. METHODS: A qualitative case study of 8 patients using individual semi-structured interviews was conducted to explore patients' opinions on an information brochure in KA surgery. RESULTS: Patients rated the brochure as good and recommended its use. Unsatisfactory information regarding wound healing, pain expectations, postoperative exercises and use of walking aids was reported. Patients stated that the table of contents was insufficient and the size of the brochure (A4-format) too large. Patients reported to have no need for additional digital sources (e.g. applications, websites). CONCLUSION: These opinions support the use of an information brochure. The reported opinions were used to improve the brochure. Future research should focus on the improvement of information sources by involving patients (and other users) in the development process in which the information is tailored towards patient needs.

Implicit and Explicit Motor Learning Interventions Have Similar Effects on Walking Speed in People After Stroke: A Randomized Controlled Trial.

OBJECTIVE: Clinicians may use implicit or explicit motor learning approaches to facilitate motor learning of patients with stroke. Implicit motor learning approaches have shown promising results in healthy populations. The purpose of this study was to assess whether an implicit motor learning walking intervention is more effective compared with an explicit motor learning walking intervention delivered at home regarding walking speed in people after stroke in the chronic phase of recovery. METHODS: This randomized, controlled, single-blind trial was conducted in the home environment. The 79 participants, who were in the chronic phase after stroke (age = 66.4 [SD = 11.0] years; time poststroke = 70.1 [SD = 64.3] months; walking speed = 0.7 [SD = 0.3] m/s; Berg Balance Scale score = 44.5 [SD = 9.5]), were randomly assigned to an implicit (n = 38) or explicit (n = 41) group. Analogy learning was used as the implicit motor learning walking intervention, whereas the explicit motor learning walking intervention consisted of detailed verbal instructions. Both groups received 9 training sessions (30 minutes each), for a period of 3 weeks, targeted at improving quality of walking. The primary outcome was walking speed measured by the 10-Meter Walk Test at a comfortable walking pace. Outcomes were assessed at baseline, immediately after intervention, and 1 month postintervention. RESULTS: No statistically or clinically relevant differences between groups were obtained postintervention (between-group difference was estimated at 0.02 m/s [95% CI = -0.04 to 0.08] and at follow-up (between-group difference estimated at -0.02 m/s [95% CI = -0.09 to 0.05]). CONCLUSION: Implicit motor learning was not superior to explicit motor learning to improve walking speed in people after stroke in the chronic phase of recovery. IMPACT: To our knowledge, this is the first study to examine the effects of implicit compared with explicit motor learning on a functional task in people after stroke. Results indicate that physical therapists can use (tailored) implicit and explicit motor learning strategies to improve walking speed in people after stroke who are in the chronic phase of recovery.

Application of motor learning in neurorehabilitation: a framework for health-care professionals.

Learning motor skills is an essential part of most rehabilitation processes. Facilitating and supporting motor learning is particularly challenging in neurological rehabilitation: patients who suffer from neurological diseases experience both physical limitations and difficulties of cognition and communication that affect and/or complicate the motor learning process. Therapists (e.g. physiotherapists and occupational therapists) who work in neurorehabilitation are therefore continuously searching for the best way to facilitate patients during these intensive learning processes. To support therapists in the application of motor learning, a framework was developed, integrating knowledge from the literature and the opinions and experiences of international experts. This article presents the framework, illustrated by cases from daily practice. The framework may assist therapists working in neurorehabilitation in making choices, implementing motor learning in routine practice, and supporting communication of knowledge and experiences about motor learning with colleagues and students. The article discusses the framework and offers suggestions and conditions given for its use in daily practice.

The immediate influence of implicit motor learning strategies on spatiotemporal gait parameters in stroke patients: a randomized within-subjects design.

OBJECTIVES:: To investigate immediate changes in walking performance associated with three implicit motor learning strategies and to explore patient experiences of each strategy. DESIGN:: Participants were randomly allocated to one of three implicit motor learning strategies. Within-group comparisons of spatiotemporal parameters at baseline and post strategy were performed. SETTING:: Laboratory setting. SUBJECTS:: A total of 56 community-dwelling post-stroke individuals. INTERVENTIONS:: Implicit learning strategies were analogy instructions, environmental constraints and action observation. Different analogy instructions and environmental constraints were used to facilitate specific gait parameters. Within action observation, only videotaped gait was shown. MAIN MEASURES:: Spatiotemporal measures (speed, step length, step width, step height) were recorded using Vicon 3D motion analysis. Patient experiences were assessed by questionnaire. RESULTS:: At a group level, three of the four analogy instructions ( n = 19) led to small but significant changes in speed ( d = 0.088 m/s), step height (affected side d = 0.006 m) and step width ( d = -0.019 m), and one environmental constraint ( n = 17) led to significant changes in step width ( d = -0.040 m). At an individual level, results showed wide variation in the magnitude of changes. Within action observation ( n = 20), no significant changes were found. Overall, participants found it easy to use the different strategies and experienced some changes in their walking performance. CONCLUSION:: Analogy instructions and environmental constraints can lead to specific, immediate changes in the walking performance and were in general experienced as feasible by the participants. However, the response of an individual patient may vary quite considerably.

The Effects of Implicit and Explicit Motor Learning in Gait Rehabilitation of People After Stroke: Protocol for a Randomized Controlled Trial.

BACKGROUND: A significant part of neurological rehabilitation focuses on facilitating the learning of motor skills. Training can adopt either (more) explicit or (more) implicit forms of motor learning. Gait is one of the most practiced motor skills within rehabilitation in people after stroke because it is an important criterion for discharge and requirement for functioning at home. OBJECTIVE: The aim of this study was to describe the design of a randomized controlled study assessing the effects of implicit motor learning compared with the explicit motor learning in gait rehabilitation of people suffering from stroke. METHODS: The study adopts a randomized, controlled, single-blinded study design. People after stroke will be eligible for participation when they are in the chronic stage of recovery (>6 months after stroke), would like to improve walking performance, have a slow walking speed (<1 m/s), can communicate in Dutch, and complete a 3-stage command. People will be excluded if they cannot walk a minimum of 10 m or have other additional impairments that (severely) influence gait. Participants will receive 9 gait-training sessions over a 3-week period and will be randomly allocated to an implicit or explicit group. Therapists are aware of the intervention they provide, and the assessors are blind to the intervention participants receive. Outcome will be assessed at baseline (T0), directly after the intervention (T1), and after 1 month (T2). The primary outcome parameter is walking velocity. Walking performance will be assessed with the 10-meter walking test, Dynamic Gait Index, and while performing a secondary task (dual task). Self-reported measures are the Movement Specific Reinvestment Scale, verbal protocol, Stroke and Aphasia Quality of Life Scale, and the Global Perceived Effect scale. A process evaluation will take place to identify how the therapy was perceived and identify factors that may have influenced the effectiveness of the intervention. Repeated measures analyses will be conducted to determine significant and clinical relevant differences between groups and over time. RESULTS: Data collection is currently ongoing and results are expected in 2019. CONCLUSIONS: The relevance of the study as well as the advantages and disadvantages of several aspects of the chosen design are discussed, for example, the personalized approach and choice of measurements. TRIAL REGISTRATION: Netherlands Trial Register NTR6272; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6272 (Archived by WebCite http://www.webcitation.org/6ytA937m5). REGISTERED REPORT IDENTIFIER: RR1-10.2196/9595.

Physiotherapists use a great variety of motor learning options in neurological rehabilitation, from which they choose through an iterative process: a retrospective think-aloud study.

PURPOSE: The goal of this study was to examine which motor learning options are applied by experienced physiotherapists in neurological rehabilitation, and how they choose between the different options. METHODS: A descriptive qualitative approach was used. A purposive sample of five expert physiotherapists from the neurological ward of a rehabilitation center participated. Data were collected using nine videotaped therapy situations. During retrospective think-aloud interviews, the physiotherapists were instructed to constantly "think aloud" while they were watching their own videos. RESULTS: Five "operators" were identified: "act", "know", "observe", "assess" and "argue". The "act" operator consisted of 34 motor learning options, which were clustered into "instruction", "feedback" and "organization". The "know", "observe", "assess" and "argue" operators explained how therapists chose one of these options. The four operators seem to be interrelated and together lead to a decision to apply a particular motor learning option. CONCLUSIONS: Results show that the participating physiotherapists used a great variety of motor learning options in their treatment sessions. Further, the decision-making process with regard to these motor learning options was identified. Results may support future intervention studies that match the content and process of therapy in daily practice. The study should be repeated with other physiotherapists. Implications for Rehabilitation The study provided insight into the way experienced therapist handle the great variety of possible motor learning options, including concrete ideas on how to operationalize these options in specific situations. Despite differences in patients' abilities, it seems that therapists use the same underlying clinical reasoning process when choosing a particular motor learning option. Participating physiotherapists used more than the in guidelines suggested motor learning options and considered more than the suggested factors, hence adding practice based options of motor learning to the recommended ones in the guidelines. A think-aloud approach can be considered for peer-to-peer and student coaching to enhance discussion on the motor learning options applied and the underlying choices and to encourage research by practicing clinicians.

Multidisciplinary Views on Applying Explicit and Implicit Motor Learning in Practice: An International Survey.

BACKGROUND: A variety of options and techniques for causing implicit and explicit motor learning have been described in the literature. The aim of the current paper was to provide clearer guidance for practitioners on how to apply motor learning in practice by exploring experts' opinions and experiences, using the distinction between implicit and explicit motor learning as a conceptual departure point. METHODS: A survey was designed to collect and aggregate informed opinions and experiences from 40 international respondents who had demonstrable expertise related to motor learning in practice and/or research. The survey was administered through an online survey tool and addressed potential options and learning strategies for applying implicit and explicit motor learning. Responses were analysed in terms of consensus (≥ 70%) and trends (≥ 50%). A summary figure was developed to illustrate a taxonomy of the different learning strategies and options indicated by the experts in the survey. RESULTS: Answers of experts were widely distributed. No consensus was found regarding the application of implicit and explicit motor learning. Some trends were identified: Explicit motor learning can be promoted by using instructions and various types of feedback, but when promoting implicit motor learning, instructions and feedback should be restricted. Further, for implicit motor learning, an external focus of attention should be considered, as well as practicing the entire skill. Experts agreed on three factors that influence motor learning choices: the learner's abilities, the type of task, and the stage of motor learning (94.5%; n = 34/36). Most experts agreed with the summary figure (64.7%; n = 22/34). CONCLUSION: The results provide an overview of possible ways to cause implicit or explicit motor learning, signposting examples from practice and factors that influence day-to-day motor learning decisions.

The development of the MIBBO: A measure of resident preferences for physical activity in long term care settings.

Offering physical activities matching with the preferences of residents in long-term care facilities could increase compliance and contribute to client-centered care. A measure to investigate meaningful activities by using a photo-interview has been developed ("MIBBO"). In two pilot studies including 133 residents living on different wards in long-term care facilities, feasibility, most chosen activities, and consistency of preferences were investigated. It was possible to conduct the MIBBO on average in 30 min with the majority (86.4%) of residents. The most frequently chosen activities were: gymnastics and orchestra (each 28%), preparing a meal (31%), walking (outside, 33%), watering plants (38%), and feeding pets (40%). In a retest one week after the initial interview 69.4% agreement of chosen activities was seen. The MIBBO seems a promising measure to help health care professionals in identifying residents' preferred activities. Future research should focus on the implementation of the tailored activity plan, incorporating it into the daily routine.

"Interactive surfaces" technology as a potential tool to stimulate physical activity in psychogeriatric nursing home residents.

PURPOSE: The aims of this study were to determine whether and how psychogeriatric nursing home residents would respond to the interactive surfaces on the floor without receiving instructions and to determine how long residents would be physically active. METHODS: The "interactive surfaces" technology includes different graphic shapes that are projected through a beamer on a floor. The surfaces are "activated" by a person's movements in the area of the projection field, which is detected by an infrared camera. Every day for 1 h during an 11-day period one of seven different projections was shown. Spontaneous observed physical responses were counted, clustered and visualized in a tree diagram. Duration of physically responses was measured per session and during the total observation period of 11 h. RESULTS: During 343 of 490 observations residents (n = 58) noticed the interactive surface and in 148 observations they engaged physically. In total, 4067 s (1 h, 7 min and 47 s) of physical activity were measured. Individual times that residents were active ranged from 3 to 415 s. CONCLUSIONS: Interactive surfaces technology may be a promising tool in psychogeriatric nursing home residents to stimulate physical activity. Further research is needed to assess its full potential. Implications for Rehabilitation Innovative technology used to adapt the environment might stimulate nursing home residents to become more physically active. The use of innovative technologies may increase physical activity without necessarily increasing the workload of care professionals.

Using a Delphi technique to seek consensus regarding definitions, descriptions and classification of terms related to implicit and explicit forms of motor learning.

BACKGROUND: Motor learning is central to domains such as sports and rehabilitation; however, often terminologies are insufficiently uniform to allow effective sharing of experience or translation of knowledge. A study using a Delphi technique was conducted to ascertain level of agreement between experts from different motor learning domains (i.e., therapists, coaches, researchers) with respect to definitions and descriptions of a fundamental conceptual distinction within motor learning, namely implicit and explicit motor learning. METHODS: A Delphi technique was embedded in multiple rounds of a survey designed to collect and aggregate informed opinions of 49 international respondents with expertise related to motor learning. The survey was administered via an online survey program and accompanied by feedback after each round. Consensus was considered to be reached if ≥70% of the experts agreed on a topic. RESULTS: Consensus was reached with respect to definitions of implicit and explicit motor learning, and seven common primary intervention strategies were identified in the context of implicit and explicit motor learning. Consensus was not reached with respect to whether the strategies promote implicit or explicit forms of learning. DISCUSSION: The definitions and descriptions agreed upon may aid translation and transfer of knowledge between domains in the field of motor learning. Empirical and clinical research is required to confirm the accuracy of the definitions and to explore the feasibility of the strategies that were identified in research, everyday practice and education.

Exploring the utility of analogies in motor learning after stroke: a feasibility study.

Individuals who have experienced a stroke need to (re)learn motor skills. Analogy learning has been shown to facilitate motor learning in sports and may also be an attractive alternative to traditional approaches in therapy. The aim of this study was to assess the feasibility and utility of analogies to improve the walking performance in long-term stroke survivors. Three men aged 76, 87 and 70 years who were 6, 1 and 3 years poststroke, respectively, presented with different walking deficits. An analogy, targeted at improving the walking performance was designed with the help of each participant. During a 3-week intervention period, the analogy was practiced once weekly under supervision and daily at home. To assess feasibility, a structured interview was conducted at the end of the intervention period. To assess utility, walking performance was assessed using the 10-Metre Walking Test. All three participants were supportive of the feasibility and benefits of analogy learning. Two of the participants had a meaningful improvement on the 10-Metre Walking Test (0.1 and 0.3 m/s). The third participant did not improve most likely because of medication issues during the week of the retest. Developing analogies in therapy is a creative and challenging process, as analogies must not only guide the correct movement pattern, but also be meaningful to the individual. However, as participants were supportive of the use of analogies, and positive trends were seen in walking speed it seems worthwhile to pursue the use of analogies in future research.

The effects of mental practice in neurological rehabilitation; a systematic review and meta-analysis.

OBJECTIVE: To investigate the beneficial and adverse effects of a mental practice intervention on activities, cognition, and emotion in patients after stroke, patients with Parkinson's disease or multiple sclerosis. METHODS: Electronic databases PubMed/Medline, PEDro, Science Direct, Cochrane Library, PsycINFO, Rehadat, Embase, and Picarta were searched until June 2012. Fourteen randomized controlled trials in stroke and two randomized controlled trials in Parkinson's disease were included, representing 491 patients (421 with stroke). No randomized controlled trials in multiple sclerosis were identified. The methodologic quality of the included trials was assessed with the Amsterdam-Maastricht-Consensus-List (AMCL). Information on study characteristics and outcomes was summarized and evidence for effects described. Data from individual studies in stroke with same outcome measures were pooled. RESULTS: The included 16 randomized controlled trials were heterogeneous and methodologic quality varied. Ten trials reported significant effects in favor of mental practice in patients with stroke (n = 9) and Parkinson's disease (n = 1). In six studies mental practice had similar effects as therapy as usual (n = 5 in stroke and n = 1 in Parkinson's disease). Of six performed meta-analyses with identical measures in stroke studies only two showed significant effects of mental practice: short-term improvement of arm-hand-ability (ARAT: SMD 0.62; 95% CI: 0.05 to 1.19) and improvement of performance of activities (NRS: SMD 0.9; 95% CI: 0.04 to 1.77). Five studies found effects on cognition (e.g., effects on attention, plan actions in unfamiliar surroundings) and four reported observed side-effects, both positive (e.g., might increase motivation and arousal and reduce depression) and negative (e.g., diminished concentration, irritation). CONCLUSIONS: Mental practice might have positive effects on performance of activities in patients with neurological diseases, but this review reports less positive results than earlier published ones. Strengths and limitations of past studies are pointed out. Methodologic recommendations for future studies are given.

Terminology, taxonomy, and facilitation of motor learning in clinical practice: protocol of a delphi study.

BACKGROUND: Facilitating motor learning in patients during clinical practice is complex, especially in people with cognitive impairments. General principles of motor learning are available for therapists to use in their practice. However, the translation of evidence from the different fields of motor learning for use in clinical practice is problematic due to lack of uniformity in definition and taxonomy of terms related to motor learning. OBJECTIVE: The objective of this paper was to describe the design of a Delphi technique to reach consensus on definitions, descriptions, and taxonomy used within motor learning and to explore experts' opinions and experiences on the application of motor learning in practice. METHODS: A heterogeneous sample of at least 30 international experts on motor learning will be recruited. Their opinions regarding several central topics on motor learning using a Delphi technique will be collected in 3 sequential rounds. The questionnaires in the 3 rounds will be developed based on the literature and answers of experts from earlier rounds. Consensus will be reached when at least 70% of the experts agree on a certain topic. Free text comments and answers from open questions on opinions and experiences will be described and clustered into themes. RESULTS: This study is currently ongoing. It is financially supported by Stichting Alliantie Innovatie (Innovation Alliance Foundation), RAAK-international (Registration number: 2011-3-33int). CONCLUSIONS: The results of this study will enable us to summarize and categorize expert knowledge and experiences in a format that should be more accessible for therapists to use in support of their clinical practice. Unresolved aspects will direct future research.

Investigating the Dutch Movement-Specific Reinvestment Scale in people with stroke.

OBJECTIVE: Reinvestment is a phenomenon in which conscious control of movements that are best controlled automatically disrupts performance. The propensity for reinvestment may therefore play an important role in the movement rehabilitation process. The Movement-Specific Reinvestment Scale measures an individual's propensity for reinvestment. The aim of this study was to translate the scale for use with Dutch participants with stroke and to assess its reliability. DESIGN: A test-retest design. SETTING: In community after discharge from rehabilitation centre. SUBJECTS: Forty-five people with stroke. MEASURES: Reliability of the translated scale was assessed using intraclass correlation coefficients (ICC) and Bland-Altman plot. RESULTS: The ICC was 0.85 (95% confidence interval (CI) 0.74-0.91). Limits of agreement ranged from -2.38 to 3.10. CONCLUSION: The Dutch Movement-Specific Reinvestment Scale appears to be a reliable tool with which to assess the propensity for movement-specific reinvestment by people with stroke.

A multicenter randomized controlled trial to compare subacute 'treatment as usual' with and without mental practice among persons with stroke in Dutch nursing homes.

OBJECTIVE: Systematic reviews suggest that mental practice as an additional therapy for people with stroke might be effective and suggest that more trials with better defined interventions are needed. This study investigated whether imagining the skilled movement systematically can contribute to a quicker and/or better recovery of stroke patients in long term care. DESIGN: A multicenter randomized controlled trial. SETTING: Dutch nursing homes. PARTICIPANTS: Stroke patients in the subacute phase of recovery. INTERVENTIONS: Study participants were randomly assigned to the control or experimental group. Over a 6-week intervention period, both groups received multi professional therapy as usual. Additionally, patients in the experimental group had instruction on mental practice with a 4-step framework embedded in regular therapy time. MAIN OUTCOME: Outcomes were assessed at 6 weeks and 6 months with the patient-perceived effect on performance of daily activities (10-point Numeric Rating Scale). Six secondary outcomes on impairment and activity level were also assessed. Primary analyses were performed according to the intention-to-treat principle. Generalized estimating equations (GEE) were used to analyze effects. RESULTS: Thirty-six adult stroke patients (average age 77.8, ± 7.2 years) participated in the trial. No effect in favor of the mental practice intervention on any outcome measure could be detected at either measuring points. CONCLUSIONS: This study could not show differences between embedded mental practice and current standard of care. However, stroke pathways in Dutch nursing homes select specific and frail patients, which might have reduced the effects of training.

Rehabilitation with mental practice has similar effects on mobility as rehabilitation with relaxation in people with Parkinson's disease: a multicentre randomised trial.

QUESTIONS: Is mental practice embedded in standard physiotherapy compared with relaxation embedded in standard physiotherapy more effective at improving mobility tasks in people with Parkinson's disease in the community? Does disease severity influence the treatment effect? DESIGN: A multicentre randomised controlled trial. PARTICIPANTS: People with Parkinson's disease. INTERVENTION: During a six-week intervention period, both groups received physiotherapy as usual with the addition of either mental practice (experimental group) or relaxation (control group). Imagery skills were taught using a four-step protocol. Movement imagery (in thought) and the performance of motor activities were combined. OUTCOME MEASURES: Outcomes were assessed at six weeks and three months with: the patient- and therapist-perceived effect on walking performance (visual analogue scale), the Timed Up and Go test, and the 10 m Walk test. Primary analysis was performed using intention-totreat and was repeated as a per-protocol analysis, and as a sub-group analysis of participants with Hoehn and Yahr stage of less than 3. Generalised estimating equations were used to analyse effects. RESULTS: 47 participants were assigned to the control (n = 22) and experimental (n = 25) groups. No effect in favour of the mental practice intervention on any outcome measure could be detected at any of the measurement points. In the sub-group analysis of participants with milder disease, the experimental group improved more than the control group but this was not statistically significant. CONCLUSION: In this study, we did not find differences between embedded mental practice and relaxation with current standard of care. TRIAL REGISTRATION: Nederlands Trial Register: NTR1735.

Using mental practice in stroke rehabilitation: a framework.

INTRODUCTION: Motor imagery and mental practice are getting increased attention in neurological rehabilitation. Several different mental practice intervention protocols have been used in studies on its effect on recovery in stroke rehabilitation. The content of the intervention protocols itself is rarely discussed or questioned. OBJECTIVE: To give a practical framework of how mental practice could be integrated into therapy, drawing on available evidence and theory. The aim of the treatment programme described is to enhance both the patient's physical performance and their empowerment and self-determination. THE FRAMEWORK: Based on evidence from sports rehabilitation and our own experiences the framework will eventually be evaluated in a randomized controlled trial. Five steps are described to teach and upgrade the patient's imagery technique: (1) assess mental capacity to learn imagery technique; (2) establish the nature of mental practice; (3) teach imagery technique; (4) embed and monitor imagery technique; (5) develop self-generated treatments. The description is not, however, a recipe that should be followed precisely. It leaves enough room to tailor the mental practice intervention to the specific individual possibilities, skills and needs of the patient in accordance with evidence-based practice. DISCUSSION: Different aspects of the described protocol are discussed and compared with experiences from sports and evidence available in rehabilitation.