Motor Imagery / Mental Practice

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

The present module compiled results from 30 RCTs – 16 high quality RCTs, 12 fair quality RCTs and 2 low quality RCTs – and 1 non-randomized quasi experimental study. A Cochrane review by Barclay-Goddard et al. (2011) and systematic reviews by Harris & Hebert (2015), Nilsen, Gillen & Gordon (2010), and Braun et al. (2006) were also reviewed to ensure completeness of results.

Studies were excluded if: (1) they were not RCTs and outcomes within those studies could be found in RCTs; (2) both groups were receiving a form of mental imagery training; and/or (3) no between-group analyses were performed.

Studies included in this review used mental imagery across all stages of stroke recovery, although most studies included individuals in the chronic phase or mixed phases of recovery (acute/subacute/chronic). Overall, mental imagery was often provided in combination with other interventions (e.g. conventional rehabilitation, physical therapy, occupational therapy, electrical stimulation or modified-Constraint Induced Movement Therapy – mCIMT). While in many instances it was found to achieve similar results to other interventions, mental imagery was shown to be more effective than comparison interventions in improving outcomes such as:

  • Acute stroke – functional independence and instrumental activities of daily living;
  • Subacute stroke – gait speed;
  • Chronic stroke – balance, gait speed, lower extremity motor function, mobility and stroke outcomes.

Note: Mental imagery, motor imagery or mental rehearsal are used interchangeably in this module.

Please click here to see the Authors’ Results Table.

Acute phase

Functional independenceEffective1b

One high quality RCT (Liu et al., 2004) investigated the effect of mental imagery on functional independence in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Functional independence of trained and untrained tasks was measured by a 7-point Likert Scale at post-treatment (3 weeks) and at follow-up (1 month). Significant between-group differences in functional independence (trained and untrained tasks) were found at post-treatment, favoring mental imagery + ADL training vs. ADL training alone. Significant between-group differences in functional independence (trained tasks only) were found at follow-up, favoring mental imagery + ADL training vs. ADL training alone.
Note: In this study, mental imagery training was aimed at creating a strategy to correct ADLs in general, rather than to improve a particular movement.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is more effective than a comparison intervention (ADL training alone) in improving functional independence in patients with acute stroke.

Instrumental activities of daily living (IADLs)Effective2a

One fair quality RCT (Liu et al., 2009) investigated the effect of mental imagery on instrumental activities of daily living (IADLs) in patients with acute stroke. This fair quality RCT randomized patients to receive mental imagery training or conventional functional rehabilitation. IADLs (trained: sweeping, tidying, cooking, going outdoors, going to a shop; untrained: cooking, cleaning, visiting a resource center) were measured at post-treatment (3 weeks). There were significant between-group differences in performance of 3/5 trained tasks (tidying, cooking, going outdoors) and 2/3 untrained tasks (cleaning, visiting a resource center) at post-treatment, favoring mental imagery training vs. conventional functional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mental imagery training is more effective than a comparison intervention (conventional functional rehabilitation) in improving IADLs in patients with acute stroke.

Motor function (lower extremity)Not effective1b

One high quality RCT (Liu et al., 2004) investigated the effect of mental imagery on lower extremity motor function in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Lower extremity motor function was measured by the Fugl-Meyer Assessment – Lower Extremity at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training alone) in improving lower extremity motor function in patients with acute stroke.

Motor function (upper extremity)Not effective1b

One high quality RCT (Liu et al., 2004) investigated the effects of mental imagery on upper extremity motor function in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity at post-treatment (3 weeks). No significant between-group differences were found.  

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training alone) in improving upper extremity motor function in patients with acute stroke.

SensationNot effective1b

One high quality RCT (Liu et al., 2004) investigated the effect of mental imagery on sensation in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Sensation was measured by the Fugl-Meyer Assessment – Sensation subtest at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training) in improving sensation in patients with acute stroke.

Sustained visual attentionNot effective1b

One high quality RCT (Liu et al., 2004) investigated the effects of mental imagery on sustained visual attention in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Sustained attention was measured by the Color Trails Test at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training alone) in improving sustained attention in patients with acute stroke.

Subacute phase

DexterityNot effective1b

One high quality RCT (Ietswaart et al., 2011) investigated the effect of mental imagery on dexterity in patients with subacute stroke. This high quality RCT randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Dexterity was measured by a timed manual dexterity task at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving dexterity in patients with subacute stroke.

Functional independenceNot effective1b

One high quality RCT (Ietswaart et al., 2011) investigated the effect of mental imagery on functional independence in patients with subacute stroke. This high quality RCT randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Functional independence was measured by the Barthel Index and the Modified Functional Limitations Profile at post-treatment (4 weeks). No significant between-group differences were found on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving functional independence in patients with subacute stroke.

Gait speedEffective1b

One high quality RCT (Oostra et al., 2015) investigated the effect of mental imagery on gait speed in patients with subacute stroke. This high quality RCT randomized patients to receive lower extremity mental imagery practice or muscle relaxation. Gait speed was measured by the 10 Meter Walking Test at post-treatment (6 weeks). Significant between-group differences were found at post-treatment, favoring lower extremity mental imagery practice vs. muscle relaxation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mental imagery practice is more effective than a comparison intervention (muscle relaxation) in improving gait speed in patients with subacute stroke.

Grip strengthNot effective1b

One high quality RCT (Ietswaart et al., 2011) investigated the effect of mental imagery on grip strength in patients with subacute stroke. This high quality RCT randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Grip strength was measured with a dynamometer at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving grip strength in patients with subacute stroke.

Motor function (lower extremity)Not effective1b

One high quality RCT (Oostra et al., 2015) investigated the effect of mental imagery on lower extremity motor function in patients with subacute stroke. This high quality RCT randomized patients to receive lower extremity mental imagery practice or muscle relaxation. Lower extremity motor function was measured by the Fugl-Meyer Assessment – Lower Extremity (far transfer) at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mental imagery practice is not more effective than a comparison intervention (muscle relaxation) in improving lower extremity motor function in patients with subacute stroke.

Motor function (upper extremity)Not effective1b

One high quality RCT (Ietswaart et al., 2011) and one fair quality RCT (Riccio et al., 2010) investigated the effect of mental imagery on upper extremity motor function in patients with subacute stroke.

The high quality RCT (Ietswaart et al., 2011) randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Upper extremity motor function was measured by the Action Research Arm Test at post-treatment (4 weeks). No significant between-group differences were found.

The fair quality RCT (Riccio et al., 2010) randomized patients to receive mental rehearsal training + conventional rehabilitation or conventional rehabilitation alone, in a cross-over design study. Upper extremity motor function was measured by the Motricity Index – Upper Extremity subscale (MI-UE) and the Arm Functional Test – Functional Ability Scale and Time score (AFT-FAS, AFT-T) score at post-treatment of Phase 1 (3 weeks) and post-treatment of Phase 2 (6 weeks). Significant between-group differences were found on all measures of upper extremity motor function at both time points, in favour of the group that had just undergone mental rehearsal training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving upper extremity motor function in patients with subacute stroke.
Note:
However, one cross-over fair quality RCT found that mental rehearsal training + conventional rehabilitation was more effective than conventional rehabilitation alone in improving upper extremity motor function in patients with subacute stroke.

Motor imagery abilityNot effective1b

One high quality RCT (Oostra et al., 2015) investigated the effect of mental imagery on motor imagery ability in patients with subacute stroke. This high quality RCT randomized patients to receive lower extremity mental imagery practice or muscle relaxation. Motor imagery ability was measured by the Movement Imagery Questionnaire Revised – Visual and Kinesthetic scales, and the Walking Trajectory Test (imagery/actual walking time) at post-treatment (6 weeks). There was a significant between-group difference on only one measure (Movement Imagery Questionnaire Revised – kinesthetic scale) at post-treatment, favoring lower extremity mental imagery practice vs. muscle relaxation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mental imagery practice is not more effective than a comparison intervention (muscle relaxation) in improving motor imagery ability in patients with subacute stroke.
Note:
However, there was a significant difference in kinaesthetic motor imagery, in favour of lower extremity mental imagery practice vs. muscle relaxation.

Chronic phase

BalanceEffective1a

Four high quality RCTs (Hwang et al., 2010; Cho et al., 2012; Hosseini et al., 2012; Kim & Lee, 2013) investigated the effect of mental imagery on balance in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Balance was measure by the Berg Balance Scale (BBS) at post-treatment (4 weeks). Significant between-group differences were found in balance, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Cho et al., 2012) randomized patients to receive mental imagery + gait training or gait training alone. Balance was measured by the Functional Reach Test (FRT) at post-treatment (6 weeks). Significant between-group differences were found in balance, favoring mental imagery + gait training vs. gait training alone.

The third high quality RCT (Hosseini et al., 2012) randomized patients to receive mental imagery + occupational therapy or occupational therapy alone. Balance was measured by the BBS at post-treatment (5 weeks) and at follow-up (7 weeks). Significant between-group differences were found in balance at post-treatment, favoring mental imagery + occupational therapy vs. occupational therapy alone. Differences did not remain significant at follow-up.

The forth high quality RCT (Kim & Lee, 2013) randomized patients to receive mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone. Balance was measured by the FRT at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that mental imagery training is more effective than comparison interventions (sham imagery training, gait training alone, occupational therapy alone) in improving balance in patients with chronic stroke. However, a fourth high quality RCT reported no significant between-group differences when comparing mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone in improving balance in patients with chronic stroke.

Balance confidenceConflicting4

Two high quality RCTs (Hwang et al., 2010Dickstein et al., 2013) investigated the effect of mental imagery on balance confidence in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Balance confidence was measure by the Activities Specific Balance Confidence Scale at post-treatment (4 weeks). Significant between-group differences were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Dickstein et al., 2013) randomized patients to receive mental imagery training or physical therapy. Balance confidence was measured by the Falls Efficacy Scale at post-treatment (4 weeks) and at follow-up (6 weeks). No significant between-group differences were found at either time point.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery on balance confidence in patients with chronic stroke. While one high quality RCT found that videotape-based locomotor imagery training was more effective than sham mental imagery training, one second high quality RCT found that mental imagery training was not more effective than physical therapy in improving balance confidence in patients with chronic stroke.
Note:
Studies used different measures of balance confidence.

Functional independenceNot effective1a

Two high quality RCTs (Bovend’Eerdt et al., 2010; Hong et al., 2012) investigated the effect of mental imagery on functional independence in patients with chronic stroke.

The first high quality RCT (Bovend’Eerdt et al., 2010) randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Functional independence was measured by the Barthel Index (BI) at post-treatment (6 weeks). No significant between-group differences were found.

The second high quality RCT (Hong et al., 2012) randomized patients to receive mental imagery with electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. Functional independence was measured by the modified BI at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, functional electric stimulation) in improving functional independence in patients with chronic stroke.

Gait parametersConflicting4

Two high quality RCTs (Hwang et al., 2010Kim & Lee, 2013) and one fair quality RCT (Lee et al., 2011) investigated the effect of mental imagery on gait parameters in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Gait parameters (cadence, joint motion, stride length) were measured by a 3D motion capture system at post-treatment (4 weeks). Significant between-group differences in some gait parameters (joint motion, stride length) were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Kim & Lee, 2013) randomized patients to receive mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone. Gait parameters (cadence, speed, single/double limb support, step/stride length) were measured by the GAITRite system at post-treatment (4 weeks). There were significant between-group differences in three gait parameters (cadence, speed, single limb support) at post-treatment, favoring action observation training + physical therapy vs. physical therapy alone.

The fair quality RCT (Lee et al., 2011) randomized patients to receive mental imagery + treadmill training or treadmill training alone. Gait parameters (cadence, speed, single/double limb support, step/stride length) were measured at post-treatment (2 weeks following a 6-week treatment block). No significant between-group differences were found.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery training on gait parameters in patients with chronic stroke. While one high quality RCT found that videotape-based locomotor imagery training is more effective than a comparison intervention (sham mental imagery training) in improving some gait parameters in patients with chronic stroke, another high quality RCT and one fair quality RCT found that mental imagery training is not more effective than comparison interventions (action observation training with physical therapy, physical therapy alone, treadmill training alone) in improving gait parameters in patients with chronic stroke.

Gait speedEffective1a

Three high quality RCTs (Hwang et al., 2010Cho et al., 2012Dickstein et al., 2013) investigated the effect of mental imagery on gait speed in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Gait speed was measured by the 10 Meter Walk Test (10MWT) at post-treatment (4 weeks). Significant between-group differences were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Cho et al., 2012) randomized patients to receive mental imagery + gait training or gait training alone. Gait speed was measured by the 10MWT at post-treatment (6 weeks). Significant between-group differences were found in gait speed at post-treatment, favoring mental imagery + gait training vs. gait training alone.

The third high quality RCT (Dickstein et al., 2013) randomized patients to receive mental imagery training or physical therapy. Gait speed was measured by the 10MWT at post-treatment (4 weeks) and at follow-up (6 weeks). Significant between-group differences were found at both time points, favoring mental imagery training vs. physical therapy.
Note: Further, all participants who received physical therapy crossed-over to receive mental imagery training for 4 weeks. A significant improvement in gait speed was reported among those participants at both time points.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that mental imagery training is more effective than comparison interventions (sham imagery training, gait training alone, physical therapy) in improving gait speed in patients with chronic stroke.

Goal attainmentNot effective1b

One high quality RCT (Bovend’Eerdt et al., 2010) investigated the effect of mental imagery training on goal attainment in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Goal attainment was measured by the Goal Attainment Scale at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (conventional rehabilitation alone) in improving goal attainment in patients with chronic stroke.

Instrumental activities of daily living (IADLs)Not effective1b

One high quality RCT (Bovend’Eerdt et al., 2010) investigated the effect of mental imagery training on instrumental activities of daily living (IADLs) in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. IADLs were measured by the Nottingham Extended Activities of Daily Living at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (conventional rehabilitation alone) in improving IADLs in patients with chronic stroke.

MobilityConflicting4

Seven high quality RCTs (Malouin et al., 2009Bovend’Eerdt et al., 2010Hwang et al., 2010; Cho et al., 2012Hosseini et al., 2012Dickstein et al., 2013Kim & Lee, 2013) investigated the effect of mental imagery training on mobility in patients with chronic stroke.

The first high quality RCT (Malouin et al., 2009) randomized patients to receive mental imagery + physical practice, cognitive training + physical practice, or no training. Mobility was measured by the change scores in leg loading of the affected leg as a percent of body weight during the rising-to-sitting action at baseline, post-treatment (4 weeks) and follow-up (7 weeks). Significant between-group differences in change scores from baseline to post-treatment were found, favoring mental imagery training + physical practice vs. cognitive training + physical practice; and favoring mental imagery training + physical practice vs. no training. Significant between-group differences were not maintained at follow-up.

The second high quality RCT (Bovend’Eerdt et al., 2010) randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Mobility was measured by the Timed Up and Go Test (TUGT) and the Rivermead Mobility Index at post-treatment (6 weeks). No significant between-group differences were found on any of the measures.

The third high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Mobility was measured by the Dynamic Gait Index and the Modified Emory Functional Ambulation Profile at post-treatment (4 weeks). Significant between-group differences in both measures of mobility were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The forth high quality RCT (Cho et al., 2012) randomized patients to receive mental imagery + gait training or gait training alone. Mobility was measured by the TUGT at post-treatment (6 weeks). Significant between-group differences were found, favoring mental imagery + gait training vs. gait training alone.

The fifth high quality RCT (Hosseini et al., 2012) randomized patients to receive mental imagery + occupational therapy or occupational therapy alone. Mobility was measured by the TUGT at post-treatment (5 weeks) and at follow-up (7 weeks). Significant between-group differences were found at post-treatment, favoring mental imagery + occupational therapy vs. occupational therapy alone. Significant between-group differences were not maintained at follow-up.

The sixth high quality RCT (Dickstein et al., 2013) randomized patients to receive mental imagery training or physical therapy. Mobility was measured by step activity monitor (community ambulation) and number of steps/minute at post-treatment (4 weeks) and at follow-up (6 weeks). There were no significant between-group differences in both measures of mobility at either time point.

The seventh high quality RCT (Kim & Lee, 2013) randomized patients to receive mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone. Mobility was measured by the TUGT, Walking Ability Questionnaire, and Functional Ambulation Category at post-treatment (4 weeks). A significant between-group difference in one measure of mobility (TUGT) was found at post-treatment, favoring action observation training + physical therapy vs. physical therapy alone.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery on mobility in patients with chronic stroke. While four high quality RCTs found that mental imagery training is more effective than comparison interventions (cognitive training + physical practice, no training, sham imagery training, gait training alone, occupational therapy alone) in improving mobility in patients with chronic stroke; three other high quality RCTs found that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, physical therapy, action observation training + physical therapy) in improving mobility in patients with chronic stroke.

Motor activity (upper extremity)Not effective1b

One high quality RCT (Hong et al., 2012) and one fair quality RCT (Page et al., 2005) investigated the effect of mental imagery on upper extremity motor activity among patients with chronic stroke.

The high quality RCT (Hong et al., 2012) randomized patients to receive mental imagery + electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. Upper extremity motor activity was measured by the Motor Activity Log – Amount of Use and Quality of Movement (MAL-AOU, MAL-QOM) at post-treatment (4 weeks). No significant between-group differences were found.

The fair quality RCT (Page et al., 2005) randomized patients to receive mental imagery training or relaxation training. Upper extremity motor activity was measured by the MAL at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that mental imagery training is not more effective than comparison interventions (functional electrical stimulation to the affected forearm, relaxation training) in improving upper extremity motor activity in patients with chronic stroke.

Motor function (lower extremity)Effective1b

One high quality RCT (Cho et al., 2012) investigated the effect of mental imagery on lower extremity motor function in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + gait training or gait training alone. Lower extremity motor function was measured by the Fugl-Meyer Assessment – Lower Extremity at post-treatment (6 weeks). Significant between-group differences were found, favoring mental imagery + gait training vs. gait training alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + gait training is more effective than a comparison intervention (gait training alone) in improving lower extremity motor function in patients with chronic stroke.

Motor function (upper extremity)Conflicting4

Four high quality RCTs (Bovend’Eerdt et al., 2010Page et al., 2011;Hong et al., 2012Nilsen et al., 2012) and five fair quality RCTs (Page, 2000Page et al., 2005Ertelt et al., 2007Page et al., 2007Page et al., 2009) investigated the effect of mental imagery on upper extremity motor function in patients with chronic stroke.

The first high quality RCT (Bovend’Eerdt et al., 2010) randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Upper extremity motor function was measured by the Action Research Arm Test (ARAT) at post-treatment (6 weeks). No significant between-group differences were found.

The second high quality RCT (Page et al., 2011) randomized patients to receive mental imagery or sham audio therapy. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE) and the ARAT at post-treatment (10 weeks). No significant between-group differences were found on any of the measures.

The third high quality RCT (Hong et al., 2012) randomized patients to receive mental imagery + electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. Upper extremity motor function was measured by the FMA-UE at post-treatment (4 weeks). Significant between-group differences in upper extremity motor function were found at post-treatment, favoring mental imagery + electromyogram-triggered electric stimulation vs. functional electric stimulation to the affected forearm.

The forth high quality RCT (Nilsen et al., 2012) randomized patients to receive mental imagery training using an internal perspective (internal group), mental imagery training using an external perspective (external group), or relaxation imagery; all groups received occupational therapy. Upper extremity motor function was measured by the FMA-UE and the Jebsen-Taylor Test of Hand Function at post-treatment (6 weeks). Significant between-group differences were found on both measures, favoring both styles of mental imagery training (internal group, external group) vs. relaxation imagery.

The first fair quality RCT (Page, 2000) randomized patients to receive mental imagery training + occupational therapy or occupational therapy alone. Upper extremity motor function was measured by the FMA-UE at post-treatment (4 weeks). Significant between-group differences were found at post-treatment, favoring mental imagery training + occupational therapy vs. occupational therapy alone.

The second fair quality RCT (Page et al., 2005) randomized patients to receive mental imagery training or relaxation training. Upper extremity motor function was measured by the ARAT at post-treatment (6 weeks). Significant between-group differences were found, favoring mental imagery training vs. relaxation training.

The third fair quality RCT (Ertelt et al., 2007) randomized patients to receive action observation therapy or conventional rehabilitation. Upper extremity motor function was measured by the Frenchay Arm Test and the Wolf Motor Function Test at post-treatment (18 days); participants in the action observation group were reassessed 8 weeks later (follow-up). Significant between-group differences were found on both measures of upper extremity motor function at post-treatment, favoring action observation therapy vs. conventional rehabilitation. Significant within-group gains were maintained at follow-up.

The forth fair quality RCT (Page et al., 2007) randomized patients to receive mental imagery training or relaxation training. Upper extremity motor function was measured by the ARAT and the FMA-UE at post-treatment (1 week following a 6-week treatment). Significant between-group differences were found on both measures of upper extremity motor function at post-treatment, favoring mental imagery training vs. relaxation training.

The fifth fair quality RCT (Page et al., 2009) randomized patients to receive mental imagery + modified-constraint induced therapy (mCIMT) or mCIMT alone. Upper extremity motor function was measured by the ARAT and the FMA-UE at post-treatment (10 weeks) and follow-up (3 months). Significant between-group differences were found on both measures of upper extremity motor function at post-treatment and at follow-up, favoring mental imagery training + mCIMT vs. mCIMT alone.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery on upper extremity motor function. While two high quality RCTs found that mental imagery was not more effective than comparison interventions (conventional rehabilitation alone, sham audio therapy) in improving upper extremity motor function in patients with chronic stroke; two other high quality RCTs found that mental imagery was more effective than comparison interventions (functional electric stimulation to the affected forearm, relaxation imagery) in improving upper extremity motor function in patients with chronic stroke.
Note:
Five fair quality RCTs found that mental imagery training is more effective than comparison interventions (occupational therapy alone, relaxation training, conventional rehabilitation, mCIMT alone) in improving upper extremity motor function in patients with chronic stroke.

Occupational performanceNot effective1b

One high quality RCT (Nilsen et al., 2012) investigated the effect of mental imagery on occupational performance in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery training using an internal perspective (internal group), mental imagery training using an external perspective (external group), or relaxation imagery; all groups received occupational therapy. Occupational performance was measure by the Canadian Occupational Performance Measure at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery training using an internal or external perspective is not more effective than a comparison intervention (relaxation imagery) in improving occupational performance in patients with chronic stroke.

PainNot effective2b

One poor quality RCT (Cacchio et al., 2009) investigated the effect of mental imagery on pain in patients with chronic stroke. This poor quality RCT randomized patients with Complex Regional Pain Syndrome (CRPS) to receive mental imagery, mirror therapy or covered mirror practice. Pain was measured by Visual Analogue Scale at post-treatment (4 weeks). Significant between-group differences were found, favoring mirror therapy vs. mental imagery and favouring mirror therapy vs. covered mirror practice.
Note: Following 4 weeks, some participants crossed-over to the mirror therapy group. A significant reduction in pain was reported among participants who crossed-over from the mental imagery and covered mirror practice groups to the mirror therapy group.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that mental imagery is not more effective than comparison interventions (mirror therapy, covered mirror practice) in improving pain in patients with chronic stroke and CRPS. In fact, mirror therapy was more effective than mental imagery in reducing pain.

SpasticityNot effective1b

One high quality RCT (Hong et al., 2012) investigated the effect of mental imagery training on spasticity in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. Spasticity was measured by the Modified Ashworth Scale at post-treatment (4 weeks). No significant between-group differences were found.  

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + electromyogram-triggered electric stimulation is not more effective than a comparison intervention (functional electric stimulation to the affected forearm) in improving spasticity in patients with chronic stroke.

Stroke outcomesEffective2a

One fair quality RCT (Ertelt et al., 2007) investigated the effect of mental imagery on stroke outcomes in patients with chronic stroke. This high quality RCT randomized patients to receive action observation therapy or conventional rehabilitation. Stroke outcomes were measured by the Stroke Impact Scale at post-treatment (18 days); participants in the action observation group were reassessed 8 weeks later (follow-up). Significant between-group differences were found at post-treatment, favoring action observation therapy vs. conventional rehabilitation. Significant within-group gains were maintained at follow-up.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that action observation training is more effective than a comparison intervention (conventional rehabilitation) in improving stroke outcomes in patients with chronic stroke.

Phase not specific to one period

BalanceNot effective1a

Two high quality RCTs (Braun et al., 2012; Schuster et al., 2012) investigated the effect of mental imagery on balance in patients with stroke.

The first high quality RCT (Braun et al., 2012) randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Balance was measured by the Berg Balance Scale (BBS) at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point. 

The second high quality RCT (Schuster et al., 2012) randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training or time-matched stroke education tapes; all groups received physical therapy. Balance was measured by the BBS at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, time-matched stroke education tapes) in improving balance in patients with stroke.

Balance confidenceNot effective1b

One high quality RCT (Schuster et al., 2012) investigated the effect of mental imagery training on balance confidence in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive embedded mental imagery training or added mental imagery training or time-matched stroke education tapes; all groups received physical therapy. Balance confidence was measured by the Activities-Specific Balance Confidence Scale at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that embedded or added mental imagery is not more effective than a comparison intervention (time-matched stroke education tapes) in improving balance confidence in patients with subacute/chronic stroke.

DexterityNot effective1b

One high quality RCT (Braun et al., 2012) investigated the effect of mental imagery on dexterity in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Dexterity was measured by the Nine Hole Peg Test at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point. 

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (conventional rehabilitation alone) in improving dexterity in patients with acute/subacute stroke.

Functional independenceNot effective1a

Three high quality RCTs (Braun et al., 2012Schuster et al., 2012Timmermans et al., 2013), one fair quality RCT (Ferreira et al., 2011) and one poor quality RCT (Park et al., 2015) investigated the effect of mental imagery on functional independence in patients with stroke.

The first high quality RCT (Braun et al., 2012) randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Functional independence was measured by the Barthel Index (BI); patients’ and therapists’ perception of performance of daily activities (e.g. drinking, walking) was measured by a 10-point numeric rating scale at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found on either measure at either time point.

The second high quality RCT (Schuster et al., 2012) randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training, or time-matched stroke education tapes; all groups received physical therapy. Functional independence was measured by the BI at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

The third high quality RCT (Timmermans et al., 2013) randomized patients with acute/subacute stroke to receive mental imagery or neurodevelopmental therapy; both groups received conventional rehabilitation. Functional independence was measured by the BI at post-treatment (6 weeks) and at follow-up (6 and 12 months). No significant between-group differences were found at any time point.

The fair quality RCT (Ferreira et al., 2011) randomized patients with subacute/chronic stroke to receive mental imagery + conventional rehabilitation, visual scanning training + conventional rehabilitation, or conventional rehabilitation alone. Functional independence was measured by the Functional Independence Measure (FIM) at post-treatment (5 weeks) and at follow-up (3 months). There were no significant differences between mental imagery + conventional rehabilitation and other treatment groups at either time point.
Note: Significant between-group differences in functional independence (FIM – self-care items only) were found at post-treatment, favoring visual scanning + conventional rehabilitation vs. conventional rehabilitation alone. Differences did not remain significant at follow-up.

The poor quality RCT (Park et al., 2015) randomized patients with subacute/chronic stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Functional independence was measured by the modified BI at post-treatment (2 weeks). Significant between-group differences were found, favoring mental imagery + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs and one fair quality RCT that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, time-matched stroke education tapes, neurodevelopmental therapy, visual scanning training + conventional rehabilitation) in improving functional independence in patients with stroke.
Note
: One poor quality RCT found that mental imagery training + conventional rehabilitation is more effective than a comparison intervention (conventional rehabilitation alone) in improving functional independence in patients with subacute/chronic stroke.

Gait speedNot effective1b

One high quality RCT (Braun et al., 2012) investigated the effect of mental imagery on gait speed in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Gait speed was measured by the 10 Meter Walk Test at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point. 

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + conventional rehabilitation is not more effective than a comparison intervention (conventional rehabilitation alone) in improving gait speed in patients with acute/subacute stroke.

Grip strengthEffective2a

One fair quality RCT (Muller et al., 2007) investigated the effect of mental imagery on grip strength in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive mental imagery training, motor practice training or conventional physical therapy. Grip strength was measured by a force transducer at post-treatment (4 weeks). Significant between-group differences were found, favoring mental imagery vs. physical therapy l rehabilitation and favoring motor practice vs. physical therapy rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mental imagery training is more effective than a comparison intervention (conventional physical therapy) in improving grip strength in patients with acute/subacute stroke.

Instrumental activities of daily living (IADLs)Not effective1b

One high quality RCT (Timmermans et al., 2013) investigated the effect of mental imagery on instrumental activities of daily living (IADLs) in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery or neurodevelopmental therapy; both groups received conventional rehabilitation. IADLs were measured by the Frenchay Activity Index at post-treatment (6 weeks) and at follow-up (6 and 12 months). No significant between-group differences were found at any time point. 

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (neurodevelopmental therapy) in improving IADLs in patients with acute/subacute stroke.

MobilityNot effective1b

One high quality RCT (Braun et al., 2012) investigated the effect of mental imagery on mobility in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Mobility was measured by the Rivermead Mobility Index at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point. 

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + conventional rehabilitation is not more effective than a comparison intervention (conventional rehabilitation alone) in improving mobility in patients with acute/subacute stroke.

Motor activityNot effective1b

One high quality RCT (Schuster et al., 2012) investigated the effect of mental imagery on motor activity in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training, or time-matched stroke education tapes; all groups received physical therapy. Motor activity was measured by (i) time taken to complete a motor task; (ii) the Chedoke McMaster Stroke Assessment (activity scale); and (iii) stage of motor task as per Adams & Tyson classification, at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found on any measure at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that embedded or added mental imagery training is not more effective than a comparison (time-matched stroke education tapes) in improving motor activity in patients with subacute/chronic stroke.

Motor activity (upper extremity)Not effective1b

One high quality RCT (Timmermans et al., 2013) and one quasi-experimental design study (Rajesh, 2015) investigated the effect of motor imagery on upper extremity motor activity among patients with stroke.

The high quality RCT (Timmermans et al., 2013) randomized patients with acute/subacute stroke to receive mental imagery or neurodevelopmental therapy; both groups received conventional rehabilitation. Upper extremity motor activity was measured by accelerometry (total activity, activity/hour, activity ratio of affected/unaffected arm) at post-treatment (6 weeks) and at follow-up (6 and 12 months). No significant between-group differences were found at either time point.

The quasi-experimental design study (Rajesh, 2015) assigned patients with stroke (stage of recovery not specified) to receive mental imagery + occupational therapy or occupational therapy alone. Upper extremity motor activity was measured by the Motor Activity Log at post-treatment (3 weeks). Significant between-group differences were found, favoring mental imagery + conventional occupational therapy vs. conventional occupational therapy alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (neurodevelopmental therapy) in improving upper extremity motor activity in patients with acute/subacute stroke.
Note:
However, one quasi-experimental study found that mental imagery was more effective than a comparison intervention (conventional occupational therapy alone) in improving upper extremity motor activity in patients with stroke. Discrepancies could result from differences in employed measurement scales and treatment duration (6 vs. 3 weeks).

Motor function (upper extremity)Not effective1a

Two high quality RCTs (Welfringer et al., 2011Timmermans et al., 2013), two fair quality RCTs (Page et al., 2001Muller et al., 2007), and one poor quality RCT (Park et al., 2015) investigated the effect of mental imagery on upper extremity motor function in patients with stroke.

The first high quality RCT (Welfringer et al., 2011) randomized patients with acute/subacute stroke to receive visuomotor imagery + conventional rehabilitation or conventional rehabilitation alone. Upper extremity motor function was measured by the Action Research Arm Test (ARAT) at post-treatment (3 weeks). No significant between-group differences were found.

The second high quality RCT (Timmermans et al., 2013) randomized patients with acute/subacute stroke to receive mental imagery or neurodevelopmental therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured by the Wolf Motor Function Test, Frenchay Arm Test and Fugl-Meyer Assessment – Upper Extremity (FMA-UE) at post-treatment (6 weeks) and at follow-up (6 and 12 months). No significant between-group differences were found on any measure at any time point. 

The first fair quality RCT (Page et al., 2001) randomized patients with acute/subacute/chronic stroke to receive mental imagery training or stroke education; both groups received time-matched occupational therapy. Upper extremity motor function was measured by the FMA-UE and the ARAT at post-treatment (6 weeks). Differences in both measures of upper extremity motor function were found at post-treatment, favoring mental imagery training vs. stroke education.

The second fair quality RCT (Muller et al., 2007) randomized patients with acute/subacute stroke to receive mental imagery training, motor practice or conventional physical therapy. Upper extremity motor function was measured by the Jebsen Hand Function Test (JHFT – writing, turning over card, picking up small objects, simulated feeding, stacking checkers, picking up large light cans, picking up large heavy cans) at post-treatment (4 weeks). Significant between-group differences were found in some aspect of upper extremity motor function (JHFT – writing, simulated feeding), favoring mental imagery training vs. conventional physical therapy and favoring motor practice vs. conventional physical therapy.

The poor quality RCT (Park et al., 2015) randomized patients with subacute/chronic stroke to receive mental imagery training + conventional rehabilitation or conventional rehabilitation alone. Upper extremity motor function was measured by the ARAT and the FMA-UE at post-treatment (2 weeks). Significant between-group differences were found on both measures of upper extremity motor function at post-treatment, favoring mental imagery training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, neurodevelopmental therapy) in improving upper extremity motor function in patients with stroke.
Note: 
However, two fair quality RCTs and one poor quality RCT found that mental imagery is more effective than comparison interventions (stroke education, conventional physical therapy, conventional rehabilitation alone) in improving upper extremity motor function in patients with stroke.

Motor imagery abilityNot effective1b

One high quality RCT (Schuster et al., 2012) investigated the effect of mental imagery on motor imagery ability in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training, or time-matched stroke education tapes; all groups received physical therapy. Motor imagery ability was measured by the Imaprax Questionnaire and the Kinesthetic and Visual Imagery Questionnaire at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found on either measure at either time point.

Conclusion: There is moderate evidence (Level 1a) from one high quality RCT that embedded or added mental imagery is not more effective than a comparison intervention (time-matched stroke education tapes) in improving motor imagery ability in patients with stroke.

Unilateral spatial neglectNot effective1b

One high quality RCT (Welfringer et al., 2011) and one fair quality RCT (Ferreira et al., 2011) investigated the effect of mental imagery on unilateral spatial neglect (USN) in patients with stroke.

The high quality RCT (Welfringer et al., 2011) randomized patients with acute/subacute stroke to receive visuomotor imagery + conventional rehabilitation or conventional rehabilitation alone. USN was measured by the Bells Cancellation Test, Reading Test, Flower Copying Test, Clock Drawing Test and Representation Test (body touching, visual arm imagery, kinesthetic arm imagery) at post-treatment (3 weeks). No significant between-group differences were found on any measure.

The fair quality RCT (Ferreira et al., 2011) randomized patients with subacute/chronic stroke to receive mental imagery + conventional rehabilitation, visual scanning training + conventional rehabilitation, or conventional rehabilitation alone. USN was measured by the Behavioral Inattention Test at post-treatment (5 weeks) and at follow-up (3 months). There were no significant differences between mental imagery + conventional rehabilitation and other groups at either time point.
Note: Significant between-group differences favoring visual scanning + conventional rehabilitation vs. conventional rehabilitation alone were found at post-treatment and at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that mental imagery + conventional rehabilitation is not more effective than comparison interventions (conventional rehabilitation alone, visual scanning training + conventional rehabilitation) in improving USN in patients with stroke.

Quality of lifeNot effective1b

One high quality RCT (Schuster et al., 2012) and one quasi-experimental design study (Rajesh, 2015) investigated the effect of mental imagery on quality of life in patients with stroke.

The high quality RCT (Schuster et al., 2012) randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training, or time-matched stroke education tapes; all groups received physical therapy. Quality of life was measured by Visual Analogue Scale at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

The quasi-experimental design study (Rajesh, 2015) assigned patients with stroke (stage of recovery not specified) to receive mental imagery + conventional occupational therapy or conventional occupational therapy alone. Quality of life was measured by the Stroke-Specific Quality of Life scale at post-treatment (3 weeks). Significant between-group differences were found, favoring mental imagery practice + conventional occupational therapy vs. conventional occupational therapy alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that embedded or added mental imagery training is not more effective than a comparison intervention (time-matched stroke education tapes) in improving quality of life in patients with subacute/chronic stroke.
Note
: One quasi-experimental study found that mental imagery training + conventional occupational therapy is more effective than a comparison intervention (conventional occupational therapy alone) in improving quality of life in patients with stroke. Discrepancies could result from differences in employed measurement scales and treatment duration (2 vs. 3 weeks).

SensationNot effective1b

One high quality RCT (Welfringer et al., 2011) investigated the effect of visual imagery on sensation in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive visuomotor imagery with conventional rehabilitation or conventional rehabilitation alone. Upper extremity sensation was measured by the Arm Function Test – Sensation score at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that visual imagery + conventional rehabilitation is not more effective than a comparison intervention (conventional rehabilitation alone) for improving sensation in patients with acute/subacute stroke.

StrengthNot effective1b

One high quality RCT (Braun et al., 2012) investigated the effect of mental imagery training on strength in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Strength was measured by the Motricity Index at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point. 

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery training + conventional rehabilitation is not more effective than a comparison intervention (conventional rehabilitation alone) in improving strength in patients with acute/subacute stroke.


Reference list:

Bovend’Eerdt, T.J., Dawes, H., Sackley, C., Hooshang, I., & Wade, D.T. (2010). An Integrated Motor Imagery Program to Improve Functional Task Performance in Neurorehabilitation: A Single-Blind Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 91, 939-946.
https://www.ncbi.nlm.nih.gov/pubmed/20510987

Braun, S.M., Beurskens, A.J., Kleynen, M., Oudelaar, B., Schols, J.M., & Wade, D.T. (2012). A multicenter randomized controlled trial to compare subacute “treatment as usual” with and without mental practice among persons with stroke in Dutch Nursing Homes. JAMDA, 13, 1-7.
https://www.ncbi.nlm.nih.gov/pubmed/21450196

Cacchio, A., De Blasis, E., Necozione, S., di Orio, F., & Santilli, V. (2009). Mirror therapy for Chronic Complex Regional Pain Syndrome type 1 and stroke. New England Journal of Medicine, 361(6), 634-636.
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Cho, H. Y., Kim, J. S., & Lee, G. C. (2012). Effects of motor imagery training on balance and gait abilities in post-stroke patients: a randomized controlled trial. Clinical rehabilitation27(8), 675-680.
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Dickstein, R., Deutsch, J.E., Yoeli, Y., Kafri, M., Falash, F., Dunsky, A., Eshet, A., & Alexander, N. (2013). Effects of integrated motor imagery practice on gait of individuals with chronic stroke: a half-crossover randomized study. Archives of Physical Medicine and Rehabilitation, 94, 2119-25.
https://www.ncbi.nlm.nih.gov/pubmed/23872048

Ertelt, D., Small, S., Solodkin, A., Dettmers, C., McNamara, A., Binkofsk,i F.,&  Buccino G. (2007). Action observation has a positive impact on rehabilitation of motor deficits after stroke. Neuroimage, 36,164-173.
https://www.ncbi.nlm.nih.gov/pubmed/17499164

Ferreira, H.P., Lopes, M.A.L., Luiz, R.R., Cardoso, L., & Andre, S. (2011). Is visual scanning better than mental practice in hemispatial neglect? Results from a pilot study. Topics in Stroke Rehabilitation, 18(2), 155-61.
https://www.ncbi.nlm.nih.gov/pubmed/21447465

Hong, I.K., Choi, J.B., & Lee, J.H. (2012). Cortical changes after mental imagery training combined with electromyography-triggered electrical stimulation in patients with chronic stroke. Stroke, 43, 2506-09.
https://www.ncbi.nlm.nih.gov/pubmed/22798329

Hosseini, S.A., Fallahpour, M., Sayadi, M., Gharib, M., & Haghgoo, H. (2012). The impact of mental practice on stroke patients’ postural balance. Journal of Neurological Sciences, 322 (1-2), 263-7.
https://www.ncbi.nlm.nih.gov/pubmed/22857987

Hwang, S, Jeon, H, Yi, C, Kwon, O, et al. (2010). Locomotor imagery training improves gait performance in people with chronic hemiparetic stroke: a controlled clinical trial. Clinical Rehabilitation, 24, 514-522.
https://www.ncbi.nlm.nih.gov/pubmed/20392784

Ietswaart, M., Johnston, M., Kijkerman, C., Joice, S., Scott, C. L., MacWalter, R. S., & Hamilton, S. J. C. (2011). Mental practice with motor imagery in stroke recovery: Randomized controlled trial of efficacy. Brain, 134, 1373-1386.
https://www.ncbi.nlm.nih.gov/pubmed/21515905

Kim, J. H., & Lee, B. H. (2013). Action observation training for functional activities after stroke: a pilot randomized controlled trial. NeuroRehabilitation33(4), 565-574.
http://content.iospress.com/articles/neurorehabilitation/nre991

Lee, G.C., Song, C.H., Lee, Y.W., Cho, H.Y., & Lee, S.W. (2011). Effects of motor imagery training on gait ability of patients with chronic stroke. Journal of Physical Therapy Science, 23, 197-200.
https://www.jstage.jst.go.jp/article/jpts/23/2/23_2_197/_pdf

Liu, K.P., Chan, C.C., Lee, T.M., Hui-Chan, C.W. et al. (2004). Mental imagery for promoting relearning for people after stroke: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 85(9), 1403-1408.
https://www.ncbi.nlm.nih.gov/pubmed/15375808

Liu, K.P., Chan, C.C., Wong, R.S., Kwan, I.W., Yau, C.S., Li, L.S., Lee, T.M. (2009). A randomized controlled trial of mental imagery augment generalization of learning in acute poststroke patients. Stroke, 40(6), 2222-5.
https://www.ncbi.nlm.nih.gov/pubmed/19390069

Malouin, F., Richards, C. L., Durand, A., & Doyon, J. (2009). Added value of mental practice combined with a small amount of physical practice on the relearning of rising and sitting post-stroke: A pilot study. Journal of Neurologic Physical Therapy, 33, 195-202.
https://www.ncbi.nlm.nih.gov/pubmed/20208464

Müller, K., Bütefisch, C. M., Seitz, R., J. & Hömberg, V. (2007). Mental practice improves hand function after hemiparetic stroke. Restorative Neurology and Neuroscience, 25, 501-11.
https://www.ncbi.nlm.nih.gov/pubmed/18334768

Nilsen, D.M., Gillen, G., DiRusso, T., & Gordon, A.M. (2012). Effect of imagery perspective on occupational performance after stroke: a randomized controlled trial. The American Journal of Occupational Therapy, 66(3), 320-9.
https://www.ncbi.nlm.nih.gov/pubmed/22549597

Oostra, K.M., Oomen, A., Vanderstraeten, G., & Vingerhoets, G. (2015). Influence of motor imagery training on gait rehabilitation in sub-acute stroke: a randomized controlled trial. Journal of Rehabilitation Medicine, 47, 204-9.
https://www.ncbi.nlm.nih.gov/pubmed/25403275

Page, S.J. (2000). Imagery improves upper extremity motor function in chronic stroke patients: A pilot study. The Occupational Therapy Journal of Research, 20(3), 200-213.
http://psycnet.apa.org/psycinfo/2000-00370-003

Page, J.S., Levine, P., Sisto, S., & Johnston, M.V. (2001). A randomized efficacy and feasibility study of imagery in acute stroke. Clinical Rehabilitation, 15, 233-240.
https://www.ncbi.nlm.nih.gov/pubmed/11386392

Page, S. J., Levine, D., & Leonard, A.C. (2005). Effects of mental practice on affected limb use and function in chronic stroke. Archives of Physical Medicine & Rehabilitation, 86(3), 399-402.
https://www.ncbi.nlm.nih.gov/pubmed/15759218

Page, J.S., Laine, D., & Leonard, A.C. (2007). Mental practice in chronic stroke: results of a randomized, placebo-controlled trial. Stroke, 38(4), 1293-7.
https://www.ncbi.nlm.nih.gov/pubmed/17332444

Page, S., Levine, P., & Khoury, J. (2009). Modified Constraint-Induced Therapy Combined With Mental Practice: Thinking Through Better Motor Outcomes. Stroke, 40(2), 551-554.
https://www.ncbi.nlm.nih.gov/pubmed/19109542

Page, S.J., Dunning, K., Hermann, V., Leonard, A., & Levine, P. (2011). Longer versus shorter mental practice sessions for affected upper extremity movement after stroke: a randomized controlled trial. Clinical Rehabilitation, 25(7), 627-637.
https://www.ncbi.nlm.nih.gov/pubmed/21427151

Park, J., Lee, N., Cho, M., Kim, D., & Yang, Y. (2015). Effects of mental practice on stroke patients’ upper extremity function and daily activity performance. Journal of physical therapy science27(4), 1075-1077.
https://www.jstage.jst.go.jp/article/jpts/27/4/27_jpts-2014-664/_article

Rajesh, T. (2015). Effects of Motor Imagery on Upper Extremity Functional Task Performance and Quality of Life among Stroke Survivors. Disability, CBR & Inclusive Development26(1), 109-124.
http://dcidj.org/article/view/225

Riccio, I., Iolascon, G., Barillari, M.R., Gimigliano, R., Gimigliano, F. (2010) Mental Practice is effective in upper limb recovery after stroke: a randomized single-blind cross-over study. European Journal of Physical Rehabilitation Medicine,46 (1): 19-25.
https://www.ncbi.nlm.nih.gov/pubmed/20332722

Schuster, C., Butler, J., Andrews, B., Kischka, U., & Ettlin, T. (2012). Comparison of embedded and added motor imagery training in patients after stroke: results of a randomised controlled pilot trial. Trials13(1), 11.
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Timmermans, A.A.A., Verbunt, J.A., van Woerden, R., Moennekens, M., Pernot, D.H., & Seelen, H.A.M. (2013). Effect of mental practice on the improvement of function and daily activity performance of the upper extremity in patients with subacute stroke: a randomized clinical trial. JAMDA, 14, 204-12.
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Welfringer, A., Leifert-Fiebach, G., Babinsky, R., & Brant, T. (2011). Visuomotor imagery as a new tool in the rehabilitation of neglect: a randomized controlled study of feasibility and efficacy. Disability and Rehabilitation, 33 (21-22), 2033-43.
https://www.ncbi.nlm.nih.gov/pubmed/21348577


Excluded Studies:

Excluded references and reasons for exclusion:

Arulmozhe, A. & Sivakumar, V.P.R. (2016). Comparison of embedded versus added motor imagery training for improving balance and gait in individuals with stroke. International Journal of Pharmaceutical and Clinical Research, 8(9), 1331-8.
Reason for exclusion: both groups received a type of motor imagery training (added vs. embedded).

Barclay-Goddard, R. E., Stevenson, T. J., Poluha, W. & Thalman, L. (2011). Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke. Cochrane Database of Systematic Reviews 2011, Issue 5. Art. No.: CD005950. DOI: 10.1002/14651858.CD005950.pub4.
Reason for exclusion: systematic review

Braun, S. M., Beurskens, A. J., Borm, P. J., Schack, T., & Wade, D. T. (2006). The effects of mental practice in stroke rehabilitation: A systematic review. Archives of Physical Medicine and Rehabilitation, 87, 842-852.
Reason for exclusion: systematic review

Butler A.J., & Page S.J. (2006). Mental practice with motor imagery: evidence for motor recovery and cortical reorganization after stroke. Archives of Physical Medicine & Rehabilitation, 87(12 Suppl 2), S2-11.
Reason for exclusion: not RCT

Chan, K.Y. & Cameron, L.D. (2012). Promoting physical activity with goal-oriented mental imagery: a randomized controlled trial. Journal of Behavioral Medicine, 35, 347-63.
Reason for exclusion: no stroke population studied

Dickstein, R., Dunsky, A., & Marcovitz, E. (2005). Motor imagery for gait rehabilitation in post-stroke hemiparesis. Physical Therapy, 84(12), 1167-1175.
Reason for exclusion: not RCT

Dijkerman H.C. (2004). Does motor imagery training improve hand function in chronic stroke patients? A pilot study. Clinical Rehabilitation, 18(5), 538-49.
Reason for exclusion: not RCT

Dunsky, A., Dickstein, R., Ariav, C., Deutsch, J., & Marcovitz E. (2006) Motor imagery practice in gait rehabilitation of chronic post-stroke hemiparesis: four case studies. International Journal of Rehabilitation Studies, 29, 351-356.
Reason for exclusion: not RCT

Grabherr, L., Jola, C., Berra, G., Theiler, R., & Mast, F.W. (2015). Motor imagery training improves precision of an upper limb movement in patients with hemiparesis. Neurorehabilitation, 36, 157-66.
Reason for exclusion: not RCT; outcomes available in RCTs.

Guttman, A., Burstin, A., Brown, R., Bril, S., & Dickstein, R. (2012). Motor imagery practice for improving sit to stand and reaching to grasp in individuals with poststroke hemiparesis. Topics in Stroke Rehabilitation, 19(4), 306-19.
Reason for exclusion: not RCT

Harris, J.E. & Hebert, A. (2015). Utilization of motor imagery in upper limb rehabilitation: a systematic scoping review. Clinical Rehabilitation, 29(11), 1092-1107.
Reason for exclusion: systematic review

Hewett, T.E., Ford, K.R., Levine, P., & Page, S.J. (2007). Reaching kinematics to measure motor changes after mental practice in stroke. Topics in Stroke Rehabilitation, 14(4), 23-9.
Reason for exclusion: not RCT

Jackson, P.L., Doyon, J., Richards, C.L., & Malouin F. (2004). The efficacy of combined physical and mental practice in the learning of a foot-sequence task after stroke: A case report. NeuroRehabilitation and Neural Repair, 18(2), 106-111.
Reason for exclusion: not RCT

Kim, J.S., Oh, D.W., Kim, S.Y. & Choi, J.D. (2011). Visual and kinesthetic locomotor imagery training integrated with auditory step rhythm for walking performance of patients with chronic stroke. Clinical Rehabilitation, 25(2): 134-45.
Reason for exclusion: mental imagery provided to all groups with varying intensities.

Leifert-Fierbach, G., Welfringer., Babinsky, R., & Brandt, T. (2013). Motor imagery training in patietns with chronic neglect: a pilot study. NeuroRehabilitation, 32, 43-58.
Reason for exclusion: not RCT

Liu, K.P., Chan, C.C., Lee, T.M., & Hui-Chan, C.W. (2004b). Mental imagery for relearning of people after brain injury. Brain Injury, 18(11), 1163-72.
Reason for exclusion: not RCT

Liu, H., Song, L., & Zhang, T. (2014). Mental practice combined with physical practice to enhance hand recovery in stroke patients. Behavioral Neurology, 1-9.
Reason for exclusion: not RCT

Malouin, F., Belleville, S., Richards, C.L., Desrosiers, J., & Doyon J. (2004). Working memory and mental practice outcomes after stroke. Archives of Physical Medicine and Rehabilitation, 5, 177-83.
Reason for exclusion: not RCT

Page, J.S., Levine, P., Sisto, S., & Johnston, M.V. (2001b). Mental practice combined with physical practice for upper-limb motor deficit in sub-acute stroke. Physical Therapy, 81(8), 1455-1462.
Reason for exclusion: not RCT

Page, S.J., Levine, P., & Hill, V. (2007b). Mental practice as a gateway to modified Constraint-Induced Movement Therapy: A promising combination to improve function. American Journal of Occupational Therapy, 61, 321-327.
Reason for exclusion: not RCT

Stevens, J.A. & Stoykov, P.M.E. (2003). Using motor imagery in the rehabilitation of hemiparesis.Archives of Physical Medicine and Rehabilitation, 84(7), 1090-2.
Reason for exclusion: not RCT

Yoo, E., Park E., & Chung B. (2001). Mental practice effect on line-tracing accuracy in persons with hemiparetic stroke: A preliminary study. Archives of Physical Medicine and Rehabilitation, 82, 1213-8.
Reason for exclusion: not RCT