Mental Practice Essay Sample

Mental practice refers to thinking rehearsal where people make mental images of themselves performing physical activities (Decety et al, 1989). It’s very effective when people are learning new skills or preparing for competitions as it helps people practice in their minds before performing an activity. Consensus on the importance of mental practice is hindered by the fact that its precise definition has not been achieved, and empirical results seem inconclusive. An article from Decety’s work in “Behavioral Brain Research” indicates that mental practice presents an encouraging and noteworthy effect on an individual’s performance, and its effectiveness depends on the type of the task being performed. The effectiveness, the article continues, is also dependant on the time interval between the mental practice and performance, as well as the amount of time that a mental practice takes (Decety et al, 1989).

“Occupational therapy in mental health” explains that thinking on how to perform a task prior the undertaking produces better results than just a physical execution. This is why athletes are taught how to practice mentally. Mental practice takes two forms: internal and external imaging (Craik, 1998). Internal imaging is when an individual approximates real life situations that he/she expects while undertaking a task. External imaging is when an individual views him/herself as the observer.  It states that a mind preparation strategy is very vital as it produces maximum performance. Craik emphasizes that rehearsing a competitive situation in anticipation of the event is so important in optimizing performance. “Occupational therapy in mental health” notes that there are two major explanations as to why rehearsing an activity mentally produces better results. Mental rehearsal brings about sensory information that may help in learning a skill. In his paper “Repeatable Battery for the Assessment”, Dr. Randolph explains that sensory effects are vital in facilitating strong recall, and he considers mind rehearsal as a way of response formulation that helps in a tuning process. He explains that, early during the learning process, people attempt to figures out what they want to do. This is when the understanding of how a skill needs to be executed begins to dawn on a person. This assists a person such that he/she consolidates strategies that need to be followed, also correct any perceived errors (Randolph).

During the early stages of mental practice persons are asked to visualize their movements so as to acquire skills. They are encouraged to carry out rehearsal strategies as well as put themselves in a problem solving state before the real activity. They are taught the techniques of how to imagine the correct movements that need to be performed. In the activity is to take place at a specific location, as with athletes, these people are given an opportunity to visit this location before the important activities. Individuals are encouraged to visualize themselves when in peak performance of the activity. These learners are then helped to perform imagined exercises when they are relaxed because it during this time that the subconscious mind most active.

In this paper, I decide to focus on how mental practice comes out as an effective treatment that improves after stroke recovery. Available statistics shows that when an individual applies a simple act of thinking and imagining that they are moving a leg or hand affected by a stroke may actuate the same regions in the brain that requires repetitive stimulation to enable him/her to regain control of the arm. This has proved most effective with recent stroke, although it also helps even when the stroke has affected the victim for years. Decety notes in his “Behavioral Brain Research” paper that mental practice asks for absolute relaxation and then concentrating on certain aspects regarding movement or an undertaking that a person is attempting to improve. He regards it as a rehearsal of the whole movement in an individual’s mind (Kosslyn et al, 2001). There is an audio program referred to as the Mental Movement Therapy that teaches people on how to use the method of mental practice on their own. The audio program guides individuals some of the best and most effective application of this technique. For mental practice to be effective, the brain locations that normally control verbal processing, attention, and motivation must not be damaged as this could make its effectiveness limited. Mental practice has no side effects. It is easily incorporated into a rehabilitation program.

Following a stroke, people are left with a motor impairment that restrains their ability to perform meaningful duties like work, leisure activities, and self-care. Sensor motor deficits such as decreased speed in movement (Trombly, 1992), weakness (Magill, 2001), impaired coordination (Trombly, 1992), and reduced angular excursion of the limb joints. When trunk coordination and hand function are impaired, the result is that the use of the affected to perform various activities is limited. Therefore, an occupational therapist who works with such patients use methods that optimize motor behavior aimed at restoring occupational performance. Treatment methods like constraint induced movement medical aid, material based occupation, or task specific training are widely used training methods when  restoring the performance of an  affected limb (Michaelsen, 2006). The methods help to stress a person’s dynamic participation while manipulating goal oriented tasks and the environmental characteristic that drives motor behavior. Patients are made to practice the task as a whole or the components involved in the task as the conditions are varied.

Mental practice is a conditioning method where people cognitively rehearse a physical undertaking using motor imagination without physical motions in a manner that enhances the performance of a motor skill. “The Case for Mental Imagery” carefully documents the benefits of mental practice in skill performance even with healthy people. Simulation Theory, as elaborated by Kosslyn, Thompson, and Ganis, there exist an underground stage for every action. This underground stage help to establish the aim of the said action gather the information required to make it happen, and its possible outcomes. According to them, there are similarities seen in neural activity between the simulation state of an action and its execution state and that it’s this similarity that gives the benefits evident with mental practice. “The Case for Mental Imagery” gives evidence that supports the Simulation Theory which is that the executed and imagined actions proceeds with similar processes. For example, during the behavioral stage, multiple commonalities with the two states have been evident.

The contextual hindrance effect expresses that hindered practice helps in skill acquisition and unplanned practice assists in the retention.  In Fitts’ Law (as cited in Magill, 2001), Fitts noted in 1954 that movement durations increases when the distance to the target increases or the target width reduces. He referred this as the speed accuracy trade off. The contextual hindrance effect and the Fitts’ Law are two helpful findings used in the control literature and motor learning (Magill, 2001). The two findings have proved true with imagined (Decety et al, 1989). Another observation  is that a healthy person’s mental and physical undertakings share similar periods. Therefore, the Fitt’s Law and contextual hindrance effect have equivalent functions (Sirigu et al., 1996). For instance, reviewing the mental movement duration showed temporal equivalence for grasping; reaching; writing; and other cyclical activities, like running and walking (Guillot & Collet, 2005).

More evidence showing the similarity between the Fitt’s Law and the contextual hindrance effect shows that the physiological correlation for executed and imagined actions are comparable. They show that when individuals undertake mental practice, changes in muscle activity, muscle strength and vegetative functions actually occurs in a manner comparable to the one seen at the time of physical engagement (Roure et al., 1998). Perhaps the most convincing line of evidence comes from studies investigating the neural correlates of imagined and executed actions in healthy people. The studies undertaken through the use of anti-electron emission imaging (Lafleur et al., 2002), functional magnetized resonance envisioning (Page et al., 2001b), and trans-cranial magnetized stimulation has all disclosed similarities in the neurotic substrate regularizing executed and imagined actions (Kosslyn et al., 2001). As the covert and overt actions are interchangeable at the neural, physiological, and behavioral levels, and since mental practice has demonstrated enhancement in motor performance of healthy people, research workers have reflected on its usefulness in neuron-rehabilitation (Michaelsen, 2006).

Indeed, so many review articles analyzing the effect of mental practice are in publication. Two of these reviews (Magill, 2001) have examined the outcomes of stroke in a general manner that does not limit their examination to upper extremity focused outcomes. Both of these articles contain investigations that had been published by 2005. Two other reviews dedicated on the upper appendage outcomes are available in research work published by 2003 (Trombly, 1992). These reviews nevertheless do not attempt to grade the reviewed studies with regard to the degree of evidence that they provide. Therefore, in this research, I endeavor to determine if mental practice has an effective treatment potential capable of remediating mal-functionality in the limbs in a manner that improves the working of the upper limb after a stroke. To achieve this, I examine and rate the available evidence provided by statistical data collected during various works of research.

METHOD

Sources

I have conducted a literature review using certain studies and then summarized some of the study elements. I've also rated each of them according to the evidence it presents. The authors of the paper “Improvement in upper limb motor performance following stroke: The use of mental practice”, Murray B. J. and Bell A. R, conducted independent searches explorations of databases including the Cochrane and Medline databases during the period 1985 to 2009. Moreover, they went on to hand search reference listings of the articles they obtained. The terms they employed in their searches includes mental imagery, mental practice, cerebral-vascular accident, stroke, upper extremity, arm and limb. They limited their search on journals that were published in the English language.

The Study Selection

I have included studies that has been completed and published in this research paper as long as they involved people whose primary diagnosis had been established to be a stroke, they used mental practice as a component of the treatment plan whether in conjunction or in isolation with some other therapies. I also focused on studies where in order to improve or reduce the upper extremity impairment, mental practice was used. I considered all levels of manifestation in this research. These levels are from Level I  to Level V. Level I uses randomized but controlled trials while Level V  involves case reports.

Data Extraction

I used a review method similar to the one that Murray B. J. and Bell A. R used in their work, “Improvement in upper limb motor performance following stroke: The use of mental practice”. I reviewed several articles include discussions on mental imagery, mental practice, cerebral-vascular accident, stroke, and upper extremity and I extracted data on level of design and evidence, study objectives, description of the participants (including age and time since stroke occurred), the intervention description, the measures of outcome and the dimension of outcome based on International Classification in Functioning, Health and Disability (WHO, 2001). In this work, I used various levels of evidence.  Level II includes case control trial and nonrandom controlled trials. Level III is about pre and post-test designs and cross sectional designing. Level IV is a single subject design that involves case series. My source “Improvement in upper limb motor performance following stroke: The use of mental practice” used the Pedro scale which was partitioned in 2003 and rates the statistical reporting and internal validity of a study using the 2-point and 8-point scale respectively. The higher the score shown meant that the quality was higher.

Results

Researchers Murray and Bell show 15 articles while using the key words: mental imagery, mental practice, cerebral-vascular accident, stroke, upper extremity, arm and limb and study choice criteria. All these articles addresses treatment of the upper limb functionality directly also successfully completes the studies. These articles were seriously reviewed and classified as par the criteria previously described. When the results of this work were summarized, it was evident that mental practice improves the upper limb recovery subsequent to a stroke.

The summary indicated that the research designing differed considerably with various studies. Decisive assessment of this study designing lead to four of the works being arranged as Level One evidence (Page, 2000), two as Level Two(Siligu et al, 1996), one as Level Three (Trombly, 1992), six as level Four (Trombly, 1992) and 2 as Level Five (Page, 2000). The assessments of Levels one and two studies have been further summarized  and their Internal Validity Quality Assessment of the Random Clinical Trials put on the partitioned Scale. With regard to the validity, the ultimate score ranges from 2 to 5. Four in the six studies have been rated positive in the random allocation (Page, 2000). The assessors note that three of the six studies scores positively (Page et al, 2001b), while only two of studies have the therapists blinding (Page et al, 2001b). On all the studies, key outcomes were positively obtained with at least 85% of all participants who were initially allocated to various groups. All studies showed negative scores with concealment of the allocation, intention to treat analysis, and blinding of the participants. Regarding statistical reporting, overall score ranges from one to two; with all but one study scoring positively in the two items (Page et al., 2001b).

There existed in the study design and methodological quality which together with intervention protocols, outcome measures, and patient characteristic made the studies to differ. With regard to patient characteristics, every study has included individuals sustaining a unilateral left or right cerebral vascular accident. However, the beginning of a stroke shows a considerable variation across and within studies ranging from the acute phase, which is the phase within a small time after stroke to the lasting phase which is several years since the stroke occurred (Page et al, 2001). Moreover, the exclusion and inclusion criteria vary from vividly stated exclusion-inclusion criteria (Page et al, 2001) to none that has been expressed at all. However, most of the studies did not access a participant’s ability in engaging in imagination. This means that even though stroke patients may retain their ability to represent limb movements mentally, it appears like certain brain sections cause inability for the patient to perform the motor imagery (Sirigu et al., 1996). Data obtained from healthy participants have shown that imagination ability potentially affects performance gains (Page, 2000).

With regard to intervention applied, majority of the studies did combine physical and mental practice although the intervention protocols used had substantial differences among the studies. For instance, the imagination technique used, facilitation of the mental practice (for example written instructions, pictures, or audio tapes), the practiced tasks and intensity and duration of the sessions of practice were valid amongst the studies. Regarding to the way mental practice got underway, studies employed audio-taped instructions, written instructions, video-taped instructions and visually displaying the limb affected through mirror boxes or computer generated images. In some of the studies, participants use internal view (i.e. the first person view), and others use the external view (i.e. the third person view) (Page, 2000). Some perspectives used were not very clear, although various tasks on mental practice sessions were used. Among these tasks were simple forearm and wrist movements (Michaelsen, 2006), functional reaching (Page, 2000) and line tracing (Michaelsen, 2006).

Using the duration and intensity as a reference, RCT studies were considerably effective with regards to the minutes that were engaged in the practice. Participants received approximately four to five hours of mental practice during a period of four or six weeks. A kinematic evaluation of purposeful reaching engagements was used in this study. Some other related studies use the outcome measures which are aimed at a compound task function (Page, 2000). Seven of these studies demonstrated significant variations. The studies emphasized on the importance of mental practice in treating stroke. Again, as the examination reveals, a combination of physical with mental practice appears to yield better outcomes than when physical practice is used on its own (Page 2000).

Lastly, four of the studies had consequences that evaluated the perception of the participants to recovery (Page et al., 2001b). Although not clearly stated, the implication is that the studies only employed secondary measures. One of the studies showed no effect on the sensed recovery while some other three indicated that the participants imagined they were moving their limb more and in a better quality of arm control in the movement (Page et al., 2001b). It was interesting that only 2 of the studies that seemed to include retention measure (Michaelsen, 2006). This leads to the doubts that the improvements seen during the mental practice are retainable overtime.

Conclusion

Most studies have indicated that mental imagery diminishes impairments while improving recovery of limbs. Mental imagery is an appropriate intervention method when used in post stroke rehabilitation. However, there needs to be more investigations so as to establish which category of people most probably benefits when mental imagery is used as an intervention, and whether its benefits are sustainable. We need also to establish the effects with regard to improving the assumed occupational functioning. Furthermore, it’s still unclear what is the optimal dosing with regard to application of mental imagery, or the ratio of physical to mental practice that is required so as for the imaging to have a positive effect.

It's necessary to know if a single type of instruction statement would have more beneficial impact in facilitating imagery in a manner that another can’t, and to what level should the participants be trained before the engagement in a mental practice for optimal performance (Page, 2000). It’s vital to note that every one of the studies probably applied a combination of kinesthetic and visual imagery, but this could have been done from a different imagery perspective. It is unfortunate however, that imagery perspective and modality are quite often regarded as similar, and this makes conclusions involving their benefits very hard to differentiate. For instance, neural-rehabilitation texts on mental practice propose that the 1st-person kinesthetic imagery and perspective are substitutable, but the 3rd-person view correspond to visual imaging (Sirigu et al., 1996).). In agreement with Page (2000), I believe motor representation comprises of both the biomechanical and kinesthetic constraints that associates with the action also the spatial organization of the action. Therefore, the modality of visual imagery is likely to be used in representing the special coordinates (i.e., the location and distance), and the imagery modality of kinesthetic that involves feeling your limb move could be applicable in the representation of the involved biomechanical constraints (Page, 2000).

Therefore, using both kinesthetic and visual imagery in mental practice could be valuable. However, a person can engage the two imagery modalities while starting from either of the perspective. For instance, a person may be in a position to feel and see his limb move from either of the two viewpoints. There is an erroneous assumption that spreads the belief that it’s the internal perspective that is suitable in kinesthetic imagery generation (Page et al., 2001b). Moreover, with healthy people, behavioral evidence suggests that imagery perspective and modality chosen during mental imaging can affect performance of the ftasks differently. Therefore, even though I agree with the work of de (Trombly, 1992) with regard to the importance of determining the advantages of external versus internal motor imagining, I think the perspective (which is, external versus internal), modality (which is kinesthetic versus visual), and the interrelation between both of them are separate fields that need more investigation in sufferers populations.

In summary, although the advantages of mental imaging in post stroke rehabilitation seem assuring, universal conclusions are hard to arrive at presently. Further investigations on the effects of imagining during mental imagery, mode of introduction, and appropriate dosing are warranted. Moreover, it has still not been determined whether the gains of mental imaging are retainable over time, and how imagining affects the occupational performance. There are no studies that investigate if mental imaging enhances the return to occupation performance as assumed by the individuals involved in the medical intervention. Limitation of this ordered review, as well as being limited to journal publish in English pose threats to the validity of the findings as there is a possibility that some studies will be missed. Finally, the evidence levels used in this review has not differentiated between small and large RCTs, which assigns Level 1 evidence to all of the RCTs.