Home-Based Motor Imagery Training for Gait Rehabilitation

Transcription

1 1580 ORIGINAL ARTICLE Home-Based Motor Imagery Training for Gait Rehabilitation of People With Chronic Poststroke Hemiparesis Ayelet Dunsky, PhD, Ruth Dickstein, DSc, Emanuel Marcovitz, MD, Sandra Levy, MA, Judith Deutsch, PT, PhD S ABSTRACT. Dunsky A, Dickstein R, Marcovitz E, Levy S, TROKE IS CONSIDERED TO BE the leading cause of Deutsch J. Home-based motor imagery training for gait rehabilitation of people with chronic poststroke hemiparesis. Arch adult disability. 1 With walking impairments being one of 2 the most devastating disabilities of poststroke hemiparesis, it Phys Med Rehabil 2008;89: is not surprising that stroke patients ranked the restoration of 3 Objective: To test the feasibility and efficacy of a home-based walking as one of the most important goals of rehabilitation. motor imagery gait training program to improve walking perfor-thmance of individuals with chronic poststroke hemiparesis. weeks after a stroke. However, recovery is often incomplete, recovery of walking ability is usually accomplished 12 4 Design: Nonrandomized controlled trial. leaving the patients with gait impairment characterized by an 2,5,6 Setting: Local facility. asymmetric pattern and slow speed. Participants: Participants (N 17) were community-dwelling volunteers with hemiparesis caused by a unilateral stroketreatment is available. 7,8 However, the integration of intensive Improvement in gait performance is possible when sufficient that occurred at least 3 months before the study. gait practice into home-based therapy is unlikely because resources provided in rehabilitation settings are not available in Intervention: Participants received 15 minutes of supervised imagery gait training in their homes 3 days a week for home 6 health programs. 9 As a result, stroke patients who live at weeks. The intervention addressed gait impairments of the home are often restricted to walking short distances, and their affected lower limb and task-specific gait training. Walking already impaired walking performance further deteriorates because of a lack of practice. ability was evaluated by kinematics and functional scales twice 10 before the intervention, 3 and 6 weeks after the intervention Motor imagery is a cognitive operation that increases brain began, and at the 3-week follow-up activity in neuronal cortical networks. Repetition and practice of motor scenes and routines by imagery facilitate the Main Outcome Measures: Spatiotemporal, kinematic, and functional walking measurements. 14 learning or relearning of motor tasks. Motor training per - Results: Walking speed increased significantly by 40% after formed by using imagery is a low-cost and low-risk motor training, and the gains were largely maintained at the 3-week rehabilitation intervention for poststroke individuals. The follow-up. The effect size of the intervention on walking speed was moderate (.64). There were significant increases in stride justification for using motor imagery as a rehabilitation tool is length, cadence, and single-support time of the affected lower supported by brain-imaging studies showing that comparable limb, whereas double-support time was decreased. Improvements brain areas are activated during actual performance and during were also noted on the gait scale of the Tinetti Performancemental rehearsal of the same tasks. It is further strength - Oriented Mobility Assessment as well as in functional gait. Sixtyfive percent of the participants advanced 1 walking category in the ened by studies of motor imagery pointing to the reorganization 23 of functional neuronal networks in healthy subjects and people poststroke. 24 The majority of studies documenting the Modified Functional Walking Categories Index. Conclusions: Although further study is recommended, the poststroke treatment effects of motor imagery training have findings support the feasibility and justify the incorporation of focused on the functions of the upper limbs with the application 17,25,26 home-based motor imagery exercises to improve walking skills of physical and imagery training. Only a few studies for poststroke hemiparesis. have considered the effect of motor imagery training on rehabilitation of the lower limbs or on walking ability. None 27,28 29 Key Words: Gait; Hemiparesis; Home care services; Rehabilitation; Stroke. of the previous research used imagery as part of a home-based 2008 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and approach. In previous publications, 30,31 we described case studies of Rehabilitation subjects with chronic poststroke hemiparesis who received a structured program of motor imagery training at home to improve their walking skills. The main objective of the current study was to confirm and extend the findings of home-based From The Zinman College of Physical Education and Sport Sciences, Wingatemotor imagery training on walking speed and related kinematic Institute, Netanya, Israel (Dunsky); Department of Physical Therapy, Faculty of gait variables among poststroke individuals in the chronic Social Welfare and Health Sciences, University of Haifa, Haifa, Israel (Dickstein); Flieman Rehabilitation Hospital, Haifa, Israel (Marcovitz); Neeman Association for Stroke Survivors, Haifa, Israel (Levy); and Graduate Programs in Physical Therapy, School of Health Related Professions, University of Medicine and Dentistry of New Jersey, Newark, NJ (Deutsch). Supported by Kort (grant no ). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Ayelet Dunsky, PhD, The Zinman College of Physical Education and Sport Sciences, Wingate Institute, Netanya, Israel 42902, ayelet@wincol.ac.il /08/ $34.00/0 doi: /j.apmr phase. ANOVA CNS FMA POMA ROM List of Abbreviations analysis of variance central nervous system Fugl-Meyer Assessment Performance-Oriented Mobility Assessment range of motion

2 MOTOR IMAGERY FOR HEMIPARETIC GAIT, Dunsky 1581 METHODS lateral aspect of the knee joint, and the greater trochanter of each lower extremity. 33 Participants Data were collected by using a 2-dimensional Ariel Performance Analysis System video film a at 60Hz. The 2 digital Participants (N 17) with hemiparesis were recruited from a community support group of people who suffered a stroke. video cameras b were positioned at 50 relative to the plane of They volunteered to take part in the study and met the following inclusion criteria: (1) had a unilateral stroke that occurred m filming area. At least 4 walking trials were con- progression at a distance of 2.5m from the calibrated at least 3 months before joining the study, (2) were able to walk ducted at a self-selected speed along a straight 6-m path. a total of 6m with or without a cane, (3) were able to maintain Offline analysis was performed on 4 strides that were recorded proper communication skills as determined by free conversation with each volunteer and by reports of relatives, and (4) did middle of the walking path. The reported accuracy of angular while the participant was traversing the calibrated area in the not suffer from dementia as determined by a minimal score of measurements and linear data obtained with the Ariel Performance Analysis System in adults without known pathology or points on the Folstein Mini-Mental State Examination. Participants gave their written informed consent before participation in the study. 4.6, and 3.1mm along the x, y, and z axes, respectively. 34 impairments is between , 34,35 and between 1.3, None of them received any kind of therapy during the study The second was the clinical and functional gait measure- which included the gait portion of the Tinetti POMA 36 period. Before initiation of the study, institutional review boardments, 37 approval was obtained. Participants major demographic and and the Modified Functional Walking Categories Index. Motor abilities of the paretic upper and lower limb were assessed clinical details are presented in table with the FMA for upper and lower extremities. The rationale Study Framework behind the employment of this test was to control for the As previously reported, 30 the study consisted of 5 laboratory Hawthorne effect, by which improvement can be achieved as a 39 assessments and 6 weeks of home-based motor imagery training. The preintervention baseline testing consisted of 2 assess- result of the attention directed to the participants. Accordingly, we hypothesized that improvement of this kind, if any, ments, the first at 2 weeks before starting imagery training and would be nonspecific and would be expressed not only in gait the second on the day before starting. The midterm assessment but also in motor performance of the extremities. All measurements were conducted by a senior neurologic physical therapist took place after 3 weeks of home imagery training, and the postintervention assessment was performed at the end of the 6 who did not participate in the motor imagery intervention. weeks of training. Retention of training gains was tested with a follow-up assessment 3 weeks after termination of training. Intervention All motor imagery trainings were provided by the same Measurements person in the patient s own home. They were provided 3 times Two types of measurements were applied in each assessmenta week for a total period of 6 weeks, with each session lasting session. The first was spatiotemporal and kinematic gait pa-1rameters, which included the calculation of stride length, stepschedule is provided in appendix 1. efly, B r i the first 4 weeks to 20 minutes. The outline of the intervention and testing length, single- and double-support times, and ankle and kneeof treatment focused on the enhancement of imagery train- of push-off performance by the paretic leg and on prolon- ROMs. Mean gait speed, cadence, and symmetry (calculated asing paretic single-support time/nonparetic single-support time) gation of the loading phase of that leg. During the last 2 weeks, were further established. Participants were tested wearing sportsubjects were directed to increase their imagined speed and shoes and bright clothes, with dark markers fixed at the fifth symmetry of walking. A description of the contents of the metatarsal bone, the lateral malleolus, the medial malleolus, themotor imagery training of the fourth week of the intervention Table 1: Participants Demographic and Clinical Data Subject Sex Age (y) Time Since Stroke (mo) Body Side Affected Etiology Lesion Site 1 M Right Ischemic Brainstem 2 M Left Ischemic Subcortical 3 M Right Hemorrhagic Subcortical 4 M Left Ischemic Cortical 5 M Left Ischemic Subcortical 6 M Left Ischemic Cortical 7 M Right Ischemic Cortical 8 M Left Ischemic Cortical 9 M Left Ischemic Cortical 10 F Left Ischemic Cortical 11 M 60 9 Left Hemorrhagic Subcortical 12 M Right Ischemic Cortical 13 F Left Ischemic Cortical 14 M Left Hemorrhagic Subcortical 15 M Left Ischemic Subcortical 16 M Right Ischemic Cortical 17 M Right Ischemic Brainstem Abbreviations: F, female; M, male.

3 1582 MOTOR IMAGERY FOR HEMIPARETIC GAIT, Dunsky is provided as an example in appendix 2. As suggested previously, 40,41 various walking tasks were used throughout the process by using visual imagery (in which participants view themselves from the perspective of an external observer) and kinesthetic imagery (in which participants imagine experiencing bodily sensations that might be expected in the actual situation) Chronometry of imagined walking 30 was used to gauge engagement in imagery training. Briefly, the cadence for imagery training was set through a metronome to coincide with the participant s natural cadence, as determined during assessments. After training imagery gait consistent with the tempo of the metronome beats, the metronome was turned off, and the participant was asked to continue walking at the same pace and to announce the completion of 6 additional imagery steps. Fig 2. The average stride and step length values (and SEs) along assessments. *Significantly different from baseline (P<.001). Data Analysis Differences in the 2 baseline assessments were tested by using a paired t test. ANOVA with repeated measures followed length improved by 15% (F 1, , P.001), and nonparetic by contrast analysis was used to establish the effect of imagery step length improved by 16% (F 1, , P.001) (fig 2). The training on temporal-distance gait parameters; the values established at midterm, post, and follow-up assessment con- baseline measurement ( steps/min). average cadence increased (F 1,16 9.5, P.01) by 8% over the trasted with the mean values of the corresponding variables Joint Kinematics during baseline. The functional-clinical parameters were analyzed by using a chi-square test. The effect size of motor Between the baseline measurement and the postintervention imagery treatment on gait parameters was evaluated by using assessment, the sagittal ROM of the paretic knee joint increased significantly by 18% ( ; F 1, , partial 2 c derived from the statistical analysis. P.01). No significant changes were found in the ROM of the RESULTS ankle joints (F 1, , P.12 for the paretic ankle; Because none of the participants dropped out from the study, F 1, , P.15 for the nonparetic ankle). the results are based on all 17 admitted patients. No significant Gait Symmetry differences were found between the 2 baseline assessments for any of the measured variables. Therefore, the mean of the There was a 10% improvement in gait symmetry in the 6 values from the first and second assessments was calculated for each variable to determine the baseline average. For overall ANOVA of the effect of time on the spatiotemporal parameter, see appendix 3. Spatiotemporal Parameters At 6 weeks postintervention, mean gait speed increased by 40% over the baseline measurement (.38.17m/s to.53.25m/s; F 1, , P.001). Gait speed at follow-up (.52.24m/s) was still significantly faster than the baseline average (F 1, , P.001) (fig 1) (for individual results of this parameter, see appendix 4). At postintervention, stride length improved by 18% (F 1, , P.001), paretic step weeks from the baseline measurement to the postintervention assessment (66.73% 74.51%; F 1, , P.05). This improvement was derived mainly from a 13% increase in the paretic limb support period (F 1, , P.01), with no significant change in the nonparetic limb support period (F 1, , P.19) (for percentage loading on each lower limb, see fig 3). Concomitantly, there was a significant 10% decrease in the double-support period (F 1, , P.01) (see fig 3). Symmetry gains were not fully maintained at follow-up (F 1, , P.05). Fig 1. The average gait speed values (and standard errors) along assessments. *Significantly different from baseline (P<.001). Fig 3. The average single- and double-support period values (and SEs) along assessments. *Significantly different from baseline (P<.001). **Significantly different from baseline (P<.005).

4 MOTOR IMAGERY FOR HEMIPARETIC GAIT, Dunsky 1583 Table 2: Treatment Effect Size on Dependent Variables Variable Partial 2 Stride length.759 Nonparetic step length.661 Paretic step length.645 Gait speed.641 Nonparetic knee ROM.610 Paretic single-support period.585 Double-support period.488 Cadence.487 Paretic knee ROM.481 Symmetry index.279 Functional and Motor Abilities The examination of walking ability showed an improvement of 1 to 4 points (/12) on the gait scale of POMA 36 in 14 of the 17 participants ( , P.001). Walking independence, as measured by the Modified Functional Walking Categories Index, 37 was upgraded by 1 category (of six) in 11 of the 17 participants ( , P.001). The motor abilities of the lower and the upper extremities were not affected by the imagery training of gait as shown by the scores of the FMA 38 (upper extremity, points at baseline, points at postintervention; lower extremity, points at baseline, points at postintervention), which showed no significant changes related to the intervention ( , P.739). Treatment Effect Size The effect size of motor imagery intervention on walking speed was moderate (.64), as it was for most of the variables. Stride length was the most highly affected variable, whereas symmetry was the least affected variable. The effect size of the intervention on variables whose values changed significantly at postintervention is presented in table 2. DISCUSSION The main purpose of this study was to determine the feasibility and efficacy of using home-based motor imagery training to improve the walking performance of people with chronic poststroke hemiparesis. All participants completed training with excellent adherence to the program. Thus, there were no dropouts, and, for the entire program, only 2 sessions were cancelled and rescheduled. The kinematic and clinical test findings provide preliminary support for the efficacy of this treatment mode for rehabilitation of walking ability after a stroke. It was found that walking speed increased and, importantly, the improvement was largely maintained at follow-up. Functionally, 11 of 17 participants upgraded their functional walking category. The performance of lower- and upper-extremity movements, as measured with the FMA, 38 remained almost unchanged throughout the study period. This finding supports the notion that improvement in gait was not because of a nonspecific effect; rather, imagery training seems to have had an unequivocal effect on the tasks that were practiced. The rehabilitation of gait ability among people who have suffered a stroke takes place primarily during the active rehabilitation period. 2,3,46,47 Thus, for many people, returning to the community means the end of the rehabilitation process. 10,48 The results of the current study point to the potential of a motor imagery training program to augment and extend the rehabilitation process. Gait speed was chosen here as the major variable to assess changes in walking ability because slow gait is considered as the major functional limitation for people who have suffered a stroke. 2,37,49,50 The use of motor imagery led to a 40% improvement in walking speed, about.15m/s on average. In other studies, the gait speed of people with acute hemiparesis was found to improve by.20 to.25m/s because of treadmill training, whereas in chronic hemiparesis, the most effective treadmill training protocol was associated with an improvement of.15m/s 54 (similar to the gains of our intervention). A muscle-strengthening program applying a comparable dose of therapy was also associated with a mean improvement of.16m/s in gait speed. 55 The current study used a total dose of 4.5 hours of therapy, which is dramatically lower than that of many other studies. Importantly, the enhancement of gait speed was also translated into an upgrade in walking category, suggesting increased participation. To improve gait speed among participants in the current study, motor imagery training was used to increase both stride length and cadence. Training modules were gradually added over the 6-week intervention period to encourage a symmetrical gait by emphasizing the enhancement of push-off (to increase forward speed) 49,56,57 and by lengthening the loading period on the affected lower limb (to improve balance and subsequently speed). 40,41 The findings indicate that the increase in gait speed in this study occurred mainly as the result of an increase in stride length. Yet, stride length was somewhat shortened at the follow-up assessment in comparison with the postintervention assessment (see fig 2), whereas the increase in cadence was almost completely maintained at follow-up. The sustained improvement in cadence could be caused by the use of the metronome in the second and fourth weeks of the intervention, as suggested by others who have studied the effect of motor imagery treatments 58 as well as by those who have studied the effect of rhythmic stimulus on gait symmetry and gait speed in people with hemiparesis after a stroke. 2,59 Improvements in stride length, cadence, and speed were obvious after the first part of the intervention and continued during the second part of the program (see figs 1, 2). In addition, shortening of the double-support period (see fig 3), which is a marker of increasing gait speed, 60 and an increase in knee flexion during swing (allowing better foot clearance) were noted. Altogether, the spatiotemporal and kinematic progress can explain the concomitant improvement in functional walking ability. Improvement in symmetry took place mainly during the first part of the intervention, with a lesser trend through its second half. Negligible improvement in gait symmetry was also noted in other comparable studies using physical rehabilitation. 2,60-62 Perhaps the last 2 weeks of concentration on the walking itself rather than on performance variables of the affected lower limb deterred subjects attention from trying to maintain a symmetrical gait pattern. The treatment effect size related to gait speed was moderate (.64). A recent meta-analysis 63 and a systematic review 41 revealed a significant medium effect ( 0.14 to 1.94) of gaitoriented training intervention on gait speed, a nonsignificant medium effect (.35.47) of cardiorespiratory fitness programs, and no significant effect (.74 to.64) of lower-limb strengthening programs. A high effect size (.81) for walking-speed enhancement was reported for a hospital rehabilitation program 64 ; however, the effect size associated with gait speed in chronic poststroke patients was found to be low (.12.16). 63 Thus, the effect of the motor imagery program that was pre-

5 1584 MOTOR IMAGERY FOR HEMIPARETIC GAIT, Dunsky sented here does not fall short of nonimagery gait rehabilitation courses. To our knowledge, this is the first study to present data supporting the use of home-based motor imagery training for people poststroke. The findings show that this training program, administered without the use of any equipment, produced improvements in walking that were comparable to gains achieved with other intervention modes. The parallel improvements in quantitative and clinical measures point to a positive effect of motor imagery training on gait performance of those with chronic stroke hemiparesis. The observed improvement in gait can be described as a learning effect that was induced by the cognitive practice approach and took place at high levels of the CNS. The efficacy of motor imagery practice for activating cerebral and cerebellar sensorimotor networks (eg, Lacourse et al 23 ) and its potential to produce functional reorganization in the contralesional brain side of subjects with chronic poststroke hemiplegia 24 have already been shown. The potential role of mental practice in enhancing plastic CNS changes that accelerate functional recovery in patients with CNS lesions has frequently been acknowledged (eg, Miyai 65 and de Vries and Mulder 11 for recent reviews), with future study directions pointed out. Thus, our encouraging findings are in line with emerging evidence on central mechanisms that are activated by imagery practice. Study Limitations The major drawback of this work is the lack of a control group receiving an alternate intervention. The FMA that was applied by us was used only to control for a Hawthorne effect; thus, full randomized controlled trials to test the effects of the described intervention are highly warranted. CONCLUSIONS In future controlled studies, the effects of imagery training should be contrasted with no intervention as well as with the effects of other interventions; one intriguing question that should be resolved through a controlled study is the effect of verbal descriptions or performance instructions on the subsequent execution of a motor task in comparison to the effect of motor imagery on performance of that same task. The possibility that some of the improvements are because of participants attempting to walk more frequently, drawing on their memory of the instructions provided during the imagery sessions, should further be considered. In addition, in view of the inherent variability in the population of subjects who had suffered a stroke, many questions await to be resolved; these pertain to the relationship between the ability to be engaged in motor imagery, communication deficits, side and site of the lesion, motivation, individual life style, and other personal factors. Modification and optimization of the presented training program is needed. For example, because the employment of a personal trainer could constitute a financial burden, the benefits of imagery training with basic guidance, self-practice, and minimal supervision, as recently suggested, 48 should be tested. Acknowledgments: We thank Claudet Ariav, PT, and the Neeman Association for Stroke Survivors. APPENDIX 1: INTERVENTION AND TESTING SCHEDULE OUTLINE Intervention (wk) Assessment Outline Baseline 1 Two weeks before the intervention Baseline 2 One day before the intervention 1 Familiarization with motor imagery practice: imagery gait practice in an isolated place, on a flat road, with no disturbances 2 Focus of attention during training placed on the timed application of propulsive force during push-off 3 Training emphasis placed also on loading of the affected side during stance and on increasing gait speed Midterm End of the 3rd intervention week 4 Integrating prior practice components into the gait cycle; imagery walking practice with increasing cadence, while stressing gait symmetry 5 6 Imagery practice of walking toward meaningful targets within as well as outside the participant s home; walking on different terrains, such as carpets, roads, and grass Postintervention One day postintervention Follow-up Three weeks postintervention APPENDIX 2: MOTOR IMAGERY TRAINING SESSION Week 4 focus: push-off paretic step length metronome 2 3 minutes of relaxation: Close your eyes... inhale deeply and exhale slowly. Contract your arm muscles: hands, forearms, upper arms, and shoulders (3s). Now relax your body. Contract your leg muscles: feet, lower legs, and thighs (3s). Now relax your body. Contract your abdomen and hips (3s). Now relax. Try to stay relaxed like that till the end of the session. Visual (external motor imagery training) for 5 minutes: See yourself in a very peaceful and safe place. See green plants, feel great weather and a nice breeze. Watch a straight ahead walking path with no obstacles. Try to visualize a clear picture or image of yourself standing at the beginning of the lane. Your posture is erect, your face looking forward. Look at your eyes, they look relaxed.

6 MOTOR IMAGERY FOR HEMIPARETIC GAIT, Dunsky 1585 APPENDIX 2: MOTOR IMAGERY TRAINING SESSION (Cont d) Week 4 focus: push-off paretic step length metronome Your whole body looks very calm. You start walking at a relaxed pace. Look closer at your legs, and slowly focus on your feet. Pay attention to each foot, 1 at a time. Focus on your left foot (nonparetic limb). Watch the way you place the heel on the ground, the way your forefoot pushes backward, the way it goes up and far-far forward before the heel touches the ground once again. Now look at your right foot. Try to imagine its movement in slow motion. Imagine that it performs the same movement in the exact way your left foot just did. Watch how your right heel touches the ground, how the forefoot pushes into the ground while the heel goes up, the foot is lifted and advances forward, and the heel touches the ground again. Try to look in a way that you can see both feet. Follow them as they touch the ground one by one: first left heel touches the ground, forefoot pushes into the ground, the heel starts to rise while the right heel touches the ground, the forefoot pushes into the ground, the heel rises and is sent far forward. Now the left heel touches the ground, the foot pushes down and backward. The heel starts to rise and is sent forward, again the right foot touches the ground. Continue in this manner for a few more steps forward. I shall now play the metronome tempo.... Try to see yourself walking to the pace of the tempo (5s). I shall now switch it off. Try to see yourself walking 6 steps at the same pace. After the sixth step, raise your left hand. Now expand your view in order to be able to see your whole body. Watch your movements; you are very relaxed and confident. You now increase your speed slightly. In order to do this, you push harder into the ground. Take a good look at your feet. I shall now play a faster tempo on the metronome. Try to match the speed of your walking to the new tempo. Try to see yourself walking calmly at a faster pace, the same pace with both feet (5s). Try to see clearly how confident you are as you walk. You look forward with no worries and continue walking. I shall now switch off the metronome. Gradually slow your pace until you reach the pace of the straight path. You now stop to rest a little. Look around you, there are trees and greenery and a pleasant breeze. Look at yourself. You are part of the surroundings. You are erect and sure of yourself, just as you were before your injury. We will now focus on your inner body feelings during the walk. Kinesthetic (internal) imagery for 5 minutes: Try to get inside the standing body. Try to feel the various parts of the body while you are standing. Try to sense the feeling you have in your back, standing erect, facing forward. Your body weight is distributed evenly between both feet. Turn around and look at the beginning of the lane. In your imagination, start walking. Try entering your body, feeling each movement your feet make. Feel each step forward individually. Feel yourself walking at a relaxed pace; sense the contact of each foot on the ground. Pay attention to sense the same feeling with both legs. Concentrate on the feelings in your left foot; feel how it touches the ground, how it pushes the ground, how the heel lifts, and then the whole foot lifts and is sent far ahead. Now you are concentrating on your right foot, on its touching the ground, pushing the ground hard, the heel lifts, and then the whole foot lifts and is sent far ahead. Now concentrate on the feeling of both feet. First the right foot the heel touches the ground, the foot pushes down and back, and the foot is sent far forward. Now the left heel touches the ground, the foot pushes down and back, and is sent far ahead. Again your right foot touches the ground. Continue in this manner a few more steps (5s). I shall now play the first tempo on the metronome; try and pace yourself to the beat. I shall now switch off the instrument. Try and walk 6 steps at the same pace. After the sixth step, raise your hand. Now try walking at a faster pace. I shall play a faster tempo. Feel yourself walking with confidence, looking straight ahead. You have no worries. Feel the same strength you have in both your legs. Feel how your back is erect, the feeling of confidence equally in both your legs. I shall switch off the metronome. Gradually slow down your walking. Concentrate on how your whole body feels, straight back, head looking straight forward, relaxed feeling with confidence in yourself as before the injury. At the end of the walk, in your imagination, you have reached a chair or a bench and you are sitting and resting. 2 minutes refocusing on the external environment: Now return to the feeling of your arms on the armrest, wriggle your fingers slightly, your wrists. Move your hands slightly. Feel your legs on the chair. Move your big toes, the ankles, the knees, and the thighs. Feel your back against the backrest. Move your back slightly away from the backrest, and lean back again. Listen to the noises surrounding you. Now, gradually return to the surroundings of your room. Follow my count from 5 to 1, when I say 1 open your eyes. 5,...4,...3,...2,...1. APPENDIX 3: OVERALL ANOVA OF THE SPATIOTEMPORAL PARAMETERS Variable Baseline Midterm Postintervention Follow-Up Speed (m/s) Mean SD F 1, * 21.29* 24.95* Stride length (cm) Mean SD

7 1586 MOTOR IMAGERY FOR HEMIPARETIC GAIT, Dunsky *P.001. P.005. APPENDIX 3: OVERALL ANOVA OF THE SPATIOTEMPORAL PARAMETERS (Cont d) Variable Baseline Midterm Postintervention Follow-Up F 1, * 44.78* 45.67* Paretic step length (cm) Mean SD F 1, * 26.98* 20.83* Nonparetic step length (cm) Mean SD F 1, * 30.85* 25.76* Cadence (steps/min) Mean SD F 1, * 11.50* ROM paretic knee joint (deg) Mean SD F 1, * 9.49* 11.95* ROM paretic ankle joint (deg) Mean SD F 1, * Gait symmetry (%) Mean SD F 1, Paretic limb support period (%) Mean SD F 1, * Nonparetic limb support period (%) Mean SD F 1, Double-support period (%) Mean SD F 1, * 14.35* Speed (m/s) APPENDIX 4: INDIVIDUAL RESULTS OF GAIT SPEED Base1 Base 2 Midterm Post Follow-up Assessment The individual results are presented here to enable better interpretation of the data about improvement of gait speed. References 1. Whitall J. Stroke rehabilitation research: time to answer more specific questions? Neurorehabil Neural Repair 2004;18:3-8; author reply Hesse S. Rehabilitation of gait after stroke: evaluation, principles of therapy, novel treatment approaches, and assistive devices. Top Geriatr Rehabil 2003;19: Bohannon RW, Horton MG, Wikholm JB. Importance of four variables of walking to patients with stroke. Int J Rehabil Res 1991;14: Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Recovery of walking function in stroke patients: the Copenhagen stroke study. Arch Phys Med Rehabil 1995;76: Richards CL, Olney SJ. Hemiparetic gait following stroke. Part III: recovery and physical therapy. Gait Posture 1996;4: Kim CM, Eng JJ. The relationship of lower-extremity muscle torque to locomotor performance in people with stroke. Phys Ther 2003;83: Wade DT, Collen FM, Robb GF, Warlow CP. Physiotherapy intervention late after stroke and mobility. BMJ 1992;304: Green J, Forster A, Bogle S, Young J. Physiotherapy for patients with mobility problems more than 1 year after stroke: a randomised controlled trial. Lancet 2002;359: Weinrich M, Good DC, Reding M, et al. Timing, intensity, and duration of rehabilitation for hip fracture and stroke: report of a workshop at the National Center for Medical Rehabilitation Research. Neurorehabil Neural Repair 2004;18: Lord SE, Rochester L. Measurement of community ambulation after stroke: current status and future developments. Stroke 2005; 36: de Vries S, Mulder T. Motor imagery and stroke rehabilitation: a critical discussion. J Rehabil Med 2007;39: Cicinelli P, Marconi B, Zaccagnini M, Pasqualetti P, Filippi MM, Rossini PM. Imagery-induced cortical excitability changes in stroke: a transcranial magnetic stimulation study. Cereb Cortex 2006;16: Kosslyn SM, Ganis G, Thompson WL. Neural foundations of imagery. Nat Rev Neurosci 2001;2:

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