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Meta-Analysis
. 2020 May 25;5(5):CD005950.
doi: 10.1002/14651858.CD005950.pub5.

Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke

Ruth E Barclay  1 , Ted J Stevenson  2 , William Poluha  3 , Brenda Semenko  4 , Julie Schubert  5
Affiliations
Meta-Analysis

Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke

Ruth E Barclay et al. Cochrane Database Syst Rev. .

Abstract

Background: Stroke is caused by the interruption of blood flow to the brain (ischemic stroke) or the rupture of blood vessels within the brain (hemorrhagic stroke) and may lead to changes in perception, cognition, mood, speech, health-related quality of life, and function, such as difficulty walking and using the arm. Activity limitations (decreased function) of the upper extremity are a common finding for individuals living with stroke. Mental practice (MP) is a training method that uses cognitive rehearsal of activities to improve performance of those activities.

Objectives: To determine whether MP improves outcomes of upper extremity rehabilitation for individuals living with the effects of stroke. In particular, we sought to (1) determine the effects of MP on upper extremity activity, upper extremity impairment, activities of daily living, health-related quality of life, economic costs, and adverse effects; and (2) explore whether effects differed according to (a) the time post stroke at which MP was delivered, (b) the dose of MP provided, or (c) the type of comparison performed.

Search methods: We last searched the Cochrane Stroke Group Trials Register on September 17, 2019. On September 3, 2019, we searched the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Web of Science, the Physiotherapy Evidence Database (PEDro), and REHABDATA. On October 2, 2019, we searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We reviewed the reference lists of included studies.

Selection criteria: We included randomized controlled trials (RCTs) of adult participants with stroke who had deficits in upper extremity function (called upper extremity activity).

Data collection and analysis: Two review authors screened titles and abstracts of the citations produced by the literature search and excluded obviously irrelevant studies. We obtained the full text of all remaining studies, and both review authors then independently selected trials for inclusion. We combined studies when the review produced a minimum of two trials employing a particular intervention strategy and a common outcome. We considered the primary outcome to be the ability of the arm to be used for appropriate tasks, called upper extremity activity. Secondary outcomes included upper extremity impairment (such as quality of movement, range of motion, tone, presence of synergistic movement), activities of daily living (ADLs), health-related quality of life (HRQL), economic costs, and adverse events. We assessed risk of bias in the included studies and applied GRADE to assess the certainty of the evidence. We completed subgroup analyses for time since stroke, dosage of MP, type of comparison, and type of arm activity outcome measure.

Main results: We included 25 studies involving 676 participants from nine countries. For the comparison of MP in addition to other treatment versus the other treatment, MP in combination with other treatment appears more effective in improving upper extremity activity than the other treatment without MP (standardized mean difference [SMD] 0.66, 95% confidence interval [CI] 0.39 to 0.94; I² = 39%; 15 studies; 397 participants); the GRADE certainty of evidence score was moderate based on risk of bias for the upper extremity activity outcome. For upper extremity impairment, results were as follows: SMD 0.59, 95% CI 0.30 to 0.87; I² = 43%; 15 studies; 397 participants, with a GRADE score of moderate, based on risk of bias. For ADLs, results were as follows: SMD 0.08, 95% CI -0.24 to 0.39; I² = 0%; 4 studies; 157 participants; the GRADE score was low due to risk of bias and small sample size. For the comparison of MP versus conventional treatment, the only outcome with available data to combine (3 studies; 50 participants) was upper extremity impairment (SMD 0.34, 95% CI -0.33 to 1.00; I² = 21%); GRADE for the impairment outcome in this comparison was low due to risk of bias and small sample size. Subgroup analyses of time post stroke, dosage of MP, or comparison type for the MP in combination with other rehabilitation treatment versus the other treatment comparison showed no differences. The secondary outcome of health-related quality of life was reported in only one study, and no study noted the outcomes of economic costs and adverse events.

Authors' conclusions: Moderate-certainty evidence shows that MP in addition to other treatment versus the other treatment appears to be beneficial in improving upper extremity activity. Moderate-certainty evidence also shows that MP in addition to other treatment versus the other treatment appears to be beneficial in improving upper extremity impairment after stroke. Low-certainty evidence suggests that ADLs may not be improved with MP in addition to other treatment versus the other treatment. Low-certainty evidence also suggests that MP versus conventional treatment may not improve upper extremity impairment. Further study is required to evaluate effects of MP on time post stroke, the volume of MP required to affect outcomes, and whether improvement is maintained over the long term.

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Conflict of interest statement

Ruth E Barclay: none known. Ted J Stevenson: none known. William Poluha: none known. Brenda Semenko: none known. Julie Schubert: "I declare that I have employment with the University of Manitoba under the same principal investigator, Ruth Barclay; however the employment was in no relation to the current review. I declare no other conflicts of interest."

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Funnel plot of comparison: 1 mental practice in addition to other treatment versus other treatment (± placebo), outcome: 1.1 Upper extremity activity (arm function).
5
5
Funnel plot of comparison: 1 mental practice in addition to other treatment versus other treatment (± placebo), outcome: 1.2 Upper extremity impairment (motor control): FM, Motricity Index, grip strength.
6
6
Funnel plot of comparison: 1 mental practice in addition to other treatment versus other treatment (± placebo), outcome: 1.3 Activities of daily living: Barthel, modified Barthel.
1.1
1.1. Analysis
Comparison 1: Mental practice in addition to other treatment vs other treatment (± placebo), Outcome 1: Upper extremity activity
1.2
1.2. Analysis
Comparison 1: Mental practice in addition to other treatment vs other treatment (± placebo), Outcome 2: Upper extremity impairment
1.3
1.3. Analysis
Comparison 1: Mental practice in addition to other treatment vs other treatment (± placebo), Outcome 3: Activities of daily living
2.1
2.1. Analysis
Comparison 2: Time post stroke subgroup: mental practice in addition to other treatment vs other treatment (± placebo), Outcome 1: Upper extremity activity
2.2
2.2. Analysis
Comparison 2: Time post stroke subgroup: mental practice in addition to other treatment vs other treatment (± placebo), Outcome 2: Upper extremity impairment
3.1
3.1. Analysis
Comparison 3: Dosage of MP subgroup: mental practice in addition to other treatment vs other treatment (± placebo), Outcome 1: Upper extremity activity
3.2
3.2. Analysis
Comparison 3: Dosage of MP subgroup: mental practice in addition to other treatment vs other treatment (± placebo), Outcome 2: Upper extremity impairment
4.1
4.1. Analysis
Comparison 4: Comparison type subgroup: mental practice in addition to other treatment vs other treatment (± placebo), Outcome 1: Upper extremity activity
4.2
4.2. Analysis
Comparison 4: Comparison type subgroup: mental practice in addition to other treatment vs other treatment (± placebo), Outcome 2: Upper extremity impairment
5.1
5.1. Analysis
Comparison 5: Mental practice vs conventional, Outcome 1: Upper extremity impairment
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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References to studies awaiting assessment

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References to ongoing studies

ChiCTR‐IOR‐16008137 {published data only}
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CTRI/2019/01/016966 {published data only}
    1. CTRI/2019/01/016966. Effectiveness of Graded Motor Imagery (GMI) on upper limb motor function, visuospatial neglect, depression,body image and quality of life of patients with subacute stroke residing in selected community health setting of Calicut District, Kerala. http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=29578 (first received 8 January 2019).
KCT0002574 {published data only}
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NCT01651533 {published data only}
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NCT03251209 {published data only}
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SLCTR/2017/031 {published data only}
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