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Comparisons between Modified Constraint-induced Movement Therapy (mCIMT) and
a Combined Therapy of Mental Practiceand mCIMT in Persons with Stroke
The Graduate School
Yonsei University
Department of Occupational Therapy
Hee Kim
Comparisons between Modified Constraint-induced Movement Therapy (mCIMT) and
a Combined Therapy of Mental Practiceand mCIMT in Persons with Stroke
Hee Kim
A DissertationSubmitted to the Department of Occupational Therapy
and the Graduate School of Yonsei Universityin partial fulfillment of the
requirements for the degree of Doctor of Philosophy
June 2014
This certifies that the dissertation ofHee Kim is approved.
Thesis Supervisor : Eun-Young Yoo
Min-Ye Jung
Jong-Bae Kim
Ji-Hyuk Park
Dae-Hyuk Kang
The Graduate SchoolYonsei University
June 2014
Acknowledgements
I would like to express my deepest appreciation to my thesis supervisor, Dr. Eun
Young Yoo, who has patiently guided me from the start of this study, encouraged me
whenever encountering obstacles and from whom I have learned the virtue of a
scholar. Also, I extend my gratitude to my thesis committee members, Dr. Min Ye
Jung for her warm support that I could make this journey through, Dr. Jong Bae Kim
for his striking advices, and Ji Hyuk Park for his scientific reasoning to improve the
quality of this study. Last but not least, a thank you to Dr. Dae Hyuk Kang who had to
flew and drive a long way to supervise me with his heart and soul.
As for the people who helped me with the process of research to make this study
possible, I am sincerely thankful to Dr. Kyung Joon Oh for his effort in arranging and
testing the MEP. To Jong Hoon Lee, Gyung Jun Lee, Sun Ho Kim, and Dr. Ik Soo
Kim, I thank them for helping me with recruiting participants of this study. To Ae
Eun Lee and Dr. Ki Wan Kim, I appreciate their generous support and cooperation
during my hardest time of collecting data. To Dr. Eun Hee Choi, I convey my
gratitude to her troublesome of giving me statistical supervision. I am thankful to
Hoon Jo, Sang Yoon Cho, Bo Mi Lee and other graduate students of Yonsei
University on their willingness to aid my urgent requests throughout this study.
I wish to send my respect to Dr. Karen Jacobs and Jessica Kramer who had
introduced me to the art of clinical reasoning in occupational therapy. Also, I would
like to express my appreciation to the inspiring Dr. Yu Jin Cha, my mentor, who
spares no effort to help me, especially in developing the script for mental practice.
Finally, I wish to dedicate this dissertation to my family and parents. I especially
thank my parents and in laws who supported me in every way and had to share my
burden as a mother of taking care of my son. I appreciate my sister, Dr. Yoon Kim for
her attempt to help me with correcting my English writings. Also, my son, John Kim
thank you for growing up to be a considerate boy with great understandings of the
importance of studying. Most importantly, Dr. Soo Han Kim, my life and scholarly
companion and the love of my life, thank you for always being there for me.
I will always remember my blessing and try to live up to the expectation of these
people. Thank you.
- i -
Table of Contents
List of Figures ······································································ v
List of Tables ······································································· vii
Abstract ············································································· viii
Introduction ··········································································· 1
Methods ··············································································· 7
1. Participants ······································································ 7
2. Instruments ···································································· 12
2.1 Instruments for participant selection ·································· 12
2.1.1 Mini Mental State Exam-Korean (MMSE-K) ················· 12
2.1.2 Vividness of Movement Imagery Questionnaire (VMIQ) ··· 12
2.1.3 Brunnstrom’s hand function recovery stage ··················· 13
2.2 Instruments for outcome measures ···································· 14
2.2.1 Motor-evoked potential (MEP)·································· 14
2.2.2 3-D motion analyzer ·············································· 18
2.2.3 Jebsen-Taylor Hand Function Test ····························· 21
2.2.4 Motor Activity Log (MAL) ······································ 21
3. Experimental Method ························································ 23
3.1 Independent variables ··················································· 23
3.1.1 modified Constraint-induced movement therapy (mCIMT) · 23
- ii -
3.1.2 Mental practice aided with action observation ················ 26
3.2 Dependent variables ····················································· 29
3.2.1 Corticospinal excitability ········································ 29
3.2.1.1 MEP Latency ·············································· 29
3.2.1.2 MEP Amplitude ··········································· 29
3.2.2 Quality of movement ············································· 29
3.2.2.1 Movement speed ·········································· 29
3.2.2.2 Movement time ··········································· 30
3.2.2.3 Movement smoothness ··································· 30
3.2.3 Upper extremity function ········································ 30
3.2.4 Activities of daily living (ADLs) ······························· 31
4. Procedure ······································································ 32
4.1 Subject Recruitment ····················································· 33
4.2 Screening and Randomization ·········································· 33
4.3 Pre-intervention test ····················································· 34
4.3.1 Motor evoked potential ··········································· 34
4.3.2 3-D motion analysis ·············································· 35
4.4 Intervention phase ······················································· 36
4.4.1 mCIMT ····························································· 36
4.4.2 MP ·································································· 37
4.5 Post-intervention test ···················································· 38
5. Data Analysis ································································· 39
- iii -
5.1 3-D motion analysis indicator ·········································· 39
5.1.1 Movement speed ················································· 40
5.1.2 Movement time ·················································· 40
5.1.3 Movement smoothness ·········································· 41
5.2 Statistical analysis ······················································· 42
Results ··············································································· 44
1. Corticospinal excitability ···················································· 44
1.1 MEP ······································································· 44
1.1.1 MEP Latency ······················································ 44
1.1.2 MEP Amplitude ··················································· 47
1.1.3 The neurological change by mental practice··················· 50
2. Quality of movement ························································ 53
2.1 3-D motion analysis ····················································· 53
2.1.1 Movement speed ·················································· 53
2.1.2 Movement time···················································· 53
2.1.3 Movement smoothness ··········································· 56
3. Upper extremity function ···················································· 58
3.1 Jebsen-Taylor Hand Function Test ···································· 58
4. ADLs ·········································································· 60
4.1 Motor Activity Log (MAL) ············································ 60
Discussion ··········································································· 64
Conclusion ·········································································· 70
- iv -
References ·········································································· 71
Abstract in Korean ································································ 81
Appendix 1 Instructions for mental practice ·································· 84
- v -
List of Figures
Figure 1. (A) Dantec
TM KeyPoint
®, (B) Circular coil C 100,
and (C) MagProR30 ····················································· 15
Figure 2. (A) MEP test position, (B) C3, and (C) C4 on
International 10-20 system ············································· 17
Figure 3. Attachment sites of the active and reference electrodes ············· 18
Figure 4. WinArm software ························································ 19
Figure 5. Three markers’ placement of 3-D motion analyzer ·················· 20
Figure 6. A Meshed mitt for constraining the hand ····························· 23
Figure 7. Use of shaping technique to make instant coffee ···················· 24
Figure 8. Action observation training of first-person perspective for right(A)
and left(B) hand ························································· 27
Figure 9. Experimental flow chart ················································ 32
Figure 10. Starting(A) and ending(B) positions of
the simulated feeding task ············································ 35
Figure 11. A participant watching the action observation video and listening
to the audio during the mental practice intervention ··············· 38
Figure 12. Designating a single movement segment ···························· 39
Figure 13. Designating the maximum angular velocity in T-VWD graph ··· 40
Figure 14. Movement time during a single movement segment ··············· 41
- vi -
Figure 15. Numbers of movement units corresponding to
the movement smoothness ············································ 42
Figure 16. Changes in MEP latency of affected side in experimental
and control groups ····················································· 46
Figure 17. Changes in MEP amplitude of affected side in experimental
and control groups ····················································· 49
Figure 18. Change of MEP amplitude from resting in pre-intervention
test to mental practice in post-intervention ························· 52
Figure 19. Changes in movement time in experimental
and control groups ····················································· 55
Figure 20. Changes in movement units in experimental
and control groups ····················································· 57
Figure 21. Changes in amount of use in experimental
and control groups ····················································· 62
Figure 22. Changes in movement quality in experimental
and control groups ····················································· 63
- vii -
List of Tables
Table 1. Demographic characteristics ············································ 10
Table 2. Comparison of the general characteristics of experimental
and control groups ························································ 11
Table 3. Examples of repetitive task in ADL and IADL areas ················ 25
Table 4. Changes in MEP latency in experimental and control group ········ 45
Table 5. Changes in MEP amplitude in experimental and control group ···· 48
Table 6. Comparison of MEP during rest and mental practice
in experimental group ···················································· 51
Table 7. Changes in quality of movement in experimental and
control group ····························································· 54
Table 8. Changes in upper extremity function in experimental and
control group ······························································ 59
Table 9. Changes in ADLs in experimental and control group ················ 61
- viii -
ABSTRACT
Comparisons between Modified Constraint-induced
Movement Therapy (mCIMT) and a Combined
Therapy of Mental Practice and mCIMT in Persons
with Stroke
Hee Kim
Dept. of Occupational Therapy
The Graduate School
Yonsei University
This study aimed to compare the effect of combined therapy of mental practice
(MP) and modified Constraint-induced Movement Therapy (mCIMT) with mCIMT
alone on hemiplegic stroke patients.
The subjects of this study were fourteen people who have had a stroke and they
were divided into two groups of experimental (n=7) and control group (n=7) using
stratified randomization. Motor evoked potential was used to measure the
- ix -
corticospinal excitability, 3D motion analysis to examine the quality of movement,
Jebsen-Taylor hand function test to evaluate the functional quality, and Motor Ativity
Log(MAL) to evaluate the changes in activities of daily living(ADL). All participants
participated in 2-week of mCIMT intervention and only the experimental group
partook in additional ten minutes of mental practice.
As a result, when applied the combined therapy of mental practice and mCIMT and
mCIMT alone, both group significantly improved in the movement quality of
reaching and performance level in daily lives (p <.05). However, in the experimental
group receiving the combined therapy of mental practice and mCIMT, functional
improvement of upper limb additionally took place (p <.05). Also, the improvement
of corticospinal excitability, upper extremity function, and performance in ADL was
significantly greater in the experimental group as compared to the control group (p
<.05). Further, when measured the corticospinal excitability in four conditions of rest
and mental practice at pre- and post-intervention test of the experimental group, the
gradual increase in corticospinal excitability was statistically significant (p <.05).
This study confirmed that the combined therapy of mental practice and mCIMT
makes more effective improvement than mCIMT alone in corticospinal excitability,
upper limb function, and ADL. Therefore, the combined therapy of mental practice
and mCIMT could be used as a clinically useful intervention.
Key Words: Corticospinal excitability, Motor imagery, Occupational performance,
Stratified randomization, Task oriented training, Stroke
- 1 -
Introduction
Stroke is one of the three major causes of death following cancer and heart
disease in South Korea (Statistics Korea, 2013). Even if people who have had a stroke
survive from it, 50% of the cases accompany hemiparesis of the upper limb, and 26%
loose independence in activities of daily livings (ADLs) making stroke a serious
neurologic disorder (Go et al., 2013). In the field of rehabilitation, including
occupational therapy, repetitive task oriented training is mainly adapted to enhance
upper limb function and independence in ADLs (Wolf, Blanton, Baer, Breshears, &
Butler, 2002).
Among various repetitive task oriented training methods, Constraint-induced
Movement Therapy (CIMT) is one of the popular treatment methods that had proved
its effectiveness. In order to gain successful results from the CIMT, the following
three major conditions should be met (Hakkennes & Keating, 2005). Firstly, subjects
participating in a CIMT intervention should be able to perform ADL using their
affected upper extremity alone which means they should have ability to actively
extend more than 20 ° and 10 ° of their affected wrist and fingers, respectively.
Secondly, participants are encouraged to use their affected arm by physically limiting
the use of their unaffected upper limb for 90% of their waking hours. Lastly,
participants should partake in a repetitive and focused functional task training of the
affected upper limb for about 6 hours a day.
- 2 -
Many studies reported that intensive CIMT treatment enhances upper limb
function of the affected side and improves the ability to use affected side in everyday
life in short term (Dahl et al, 2008; Wolf et al, 2006). However, some studies pointed
out a great drawback of CIMT not being clinically widespread because more than
65% of the patients claimed great burdens of having to limit their upper limb which
they mainly used during a majority of time (Page, Levine, Sisto, Bond, & Johnston,
2002). In addition, some patients pointed out shortcomings in risk of fall or feeling
psychological frustrations (de Groot, Phillips, & Eskes, 2003).
Recently, modified CIMT(mCIMT) amended some CIMT methods in an effort
to decrease discomfort and drop outs of its participants due to the high intensity of
CIMT. mCIMT method is diverse, but in most cases, the limiting time of the
unaffected upper extremity is reduced to within 6 hours and the training time of
reptetitive task performance is reduced variously from 30 minutes to 6 hours a day
(Page, Levine, & Hill, 2007a;. Peurala et al, 2012). Despite the significantly reduced
intervention time to perform the forced non-use, mCIMT has still confirmed its
effectiveness in improving function of the affected side (Peurala et al., 2012).
Attempts of combining mental practice (MP) with CIMT is another way to
complement the shortcomings of such psychological burdens due to CIMT. Mental
practice is a method of rehearsing movements repeatedly in one’s mind without
moving the body parts (Braun et al, 2008). Therefore, it can be applied to people with
poor physical functions only if they are possible to consistently focus on verbal
instructions and have cognitive level to imagine (Page et al., 2007a). In addition,
- 3 -
mental practice has advantages of less physical burden such as fatigue and safe from
the risk of body damage caused by excessive use (Cha, 2013). In the field of sports,
mental practice has already been utilized in combination with the physical practice as
a way to enhance the practice effect of athletes without physical burden for a long
time (Feltz & Landers, 1983).
According to a study examined the neurological effects of mental practice, when
confirmed the activated parts of the brain using functional Magnetic Resonance
Imaging (fMRI) while practicing actual movement and mentally practicing, the
striatum area which serves as an inhibitor during motor performance was activated in
both condition (Lacourse, Orr, Cramer, & Cohen, 2005). In addition, the amplitude of
motor-evoked potential (MEP) from the motor cortex of the brain increased while the
subjects were mentally practicing movements (Williams, Pearce, Loporto, Morris, &
Holmes, 2012). As well as the neurological changes caused by mental practice,
functional changes also occur. According to a study integrated and analyzed several
experiments that examined the effects of mental practice for stroke patients, mental
practice has meaningful effects on promoting functional recovery and performance of
upper extremity after stroke (Cha, Yoo, Jung, Park, & Park, 2012). Therefore, through
mental practice, it is possible to obtain the similar effect of neuroplasticity as
performing actual movement while taking a break physically.
Even though the benefits and effects of each mental practice and mCIMT on
functional improvement of patients with stroke were confirmed in many studies,
research on to what extent the combined therapy of the two treatments is more
- 4 -
effective is almost totally lacking. The study of Page, Levine, and Khoury (2009), the
only previous study, compared the effect of the combined therapy of mental practice
and mCIMT with the mCIMT alone and showed the possibility of combining the two
intervention method. However, limitations of this study were small number of
participants and lack of evidence to support the combined therapy of both
interventions because they did not assess other dependent variables like qualitative or
neurological difference other then upper extremity functions. Therefore, it is
necessary to examine that the combined therapy of mental practice and mCIMT
causes neurological or movement qualitative improvements and further differences in
real life of people with stroke, not to mention their improvement of upper limb
function.
Another problem is that, a considerable number of mental practice studies
applied questionable research methods in whether they are appropriate to stroke
patients. Most studies adapted more than thirty minutes of a mental practice session
which is very long for patients with stroke (Ietswaart et al, 2011; Liu, Chan, Lee, &
Hui- Chan, 2004), and a great amount of studies on mental practice processed without
visually helpful examples of movement (Page, Levine, & Leonard, 2007b). Even if
people who have had a stroke were classified as having normal cognitive functions,
they have short attention span (Tatemichi, Desmond, Stern, Paik, Sano, & Bagiella,
1994) and limited ability to imagine due to damage of the brain (Mulder, 2007).
Therefore, in order to complement the intervention methods to allow stroke patients
to specifically imagine, action observation that shows normal movement in first-
- 5 -
person perspective is necessary prior to mental practice (Cha, 2013). In addition,
many previous studies only attempted to assess whether their participants have the
level of cognitive functions to engage in mental practice through structured interview
format evaluations, not whether they are actually giving their full concentrations to
the mental practice intervention (Ietswaart et al., 2011; Page et al., 2007b). Since
mental practice is a process of repetitively practicing movements in the mind, it is
hard for others to figure out the participant is actually focusing on the mental practice
at the moment. Prior to prove the effect of the mental practice, it is necessary to
confirm that the participants are fully concentrating on the mental practice
intervention by measuring the neurological changes while they are mentally
rehearsing activities.
Therefore, the main purpose of this study was to compare the effect of combined
therapy of mental practice which utilized action observation to compromise the
limitations of previous studies and mCIMT with mCIMT alone on (1) the variation of
one’s corticospinal excitability, (2) enhancing the quality of the movement of the
affected upper extremity, (3) improving upper motor functions, and (4) promoting
the performance of the affected arm in daily life. Further, we attempted to verify the
changes of corticospinal excitability during mental practice.
Hypothesis to prove the effectiveness of combined therapy of mental practice
and mCIMT is as follows. (1) The combined therapy of mental practice and mCIMT
causes more effective changes on corticospinal excitability, movement quality, upper
- 6 -
motor functions, and ADL than using mCIMT alone. (2) While concentrating on
mental practice on an activity, the subject's neurological changes occur.
- 7 -
Methods
1. Participants
Sixteen individuals with hemiparetic stroke were recruited from a medical center,
university hospital, rehabilitation hospital and welfare center in Won-Ju, Republic of
Korea. The study was conducted for five months from October 2, 2013 to March 2,
2014.
Inclusion criteria were: (1) adults who have received a diagnosis of hemiplegic
stroke and the onset has passed three months or more, (2) adults without hearing
impairments, (3) adults received 24 points or more in Mini Mental State Examination-
Korean (MMSE-K), (4) adults received 2.26 points or less in Vividness of Movement
Imagery Questionnaire (VMIQ), (5) adults in stage 3 or higher in Bruunstrom's hand
function recovery stage, and (6) adults who can actively extend more than 10 ° in the
metacarpophalangeal (MP) joint and 20 ° in wrist of the affected side.
Also, since the participants had to be evaluated with the motor evoked potentials
(MEP), individuals corresponding to the following exclusion criteria of MEP measure
were excluded from this study: (1) adults with heart pacemaker, (2) adults who had
epilepsy, (3) adults who have the possibility of pregnancy, (4) adults with metallic
parts in the head, and (5) adults who have serious uncontrolled medical conditions.
8
A total of sixteen people diagnosed with stroke of four female and twelve male
participated in this study. They were randomly assigned into experimental and control
groups of six male and two female in each group. Among them, a male from the
experimental group dropped out 3 days after the start of the intervention phase for the
reason that he had not enough time to participate in the study and a male from the
control group dropped out right after we finished his pre-intervention test because of
his health issues. Thus, a total of fourteen participants completed this study with
seven in each experimental and control group. This study was approved by the Yonsei
University Wonju Campus Institutional Review Board and all participants provided a
written consent after being informed about the purpose and procedure of this study
(IRB management number: 1041849-201310-BM-017-02).
Clinical and demographic characteristics of the subjects who fully participated in
the study and completed the post-evaluation are shown in Table 1. Median age of the
participants was 52 (49-74) years of age in the experimental group and 66 (49-72)
years in the control group. Both groups were comprised of four outpatients and three
inpatients. In the experimental group, five participants were right hemiplegia and the
other two were left and in the control group, four participants were right hemiplegia
and the other three were left. Four patients had cerebral infarction and the other three
had cerebral hemorrhage in each experimental group and control group. Median years
of education were 12 (6-15) years in the experimental group and 11 (8-17) years in
the control group. Median periods after the onset of the stroke were 41 (8-120)
months in the experimental group and 65 (3-192) months in the control group.
9
Median and mode level of Brunnstrom stage of hand recovery were step 6 in both
groups. Median MMSE-K score was 30 (28-30) points in the experimental group and
29 (28-30) points in the control group. Median and mode VMIQ score were 1.00 in
both groups.
As a result of using the chi-square test and Mann-Whitney U test to test the pre
homogeneity between the basic information of the experimental and control groups,
all variables of age, outpatient or inpatient status, gender, education level, time past
from the onset, cognitive level (MMSE), mental practice level (VMIQ), upper limb
recovery level (Bruunstrom stage), hemiplegic side, and type of cerebrovascular
accident (CVA) had no statistically significant difference between two groups (p>.
05) (Table 2).
- 10 -
Table 1. Demographic characteristics (N=14) Participant Gender
/ Age
Inpatient or
outpatient
Affected
extremity
Cerebral Infarction
or hemorrhage
Years of
Education
Months
Post-stroke
Brunnstrom
stage
MMSE
-K
VMIQ
Experimental Group
1 M/49 Inpatient Lt. hemorrhage 15 20 6 30 1.19
2 M/51 Outpatient Lt. Infarction 12 93 4 30 1.67
3 M/61 Inpatient Rt. Infarction 9 43 3 30 1
4 F/52 Outpatient Rt. Infarction 9 120 6 30 1
5 M/51 Outpatient Rt. hemorrhage 12 41 6 30 1
6 F/74 Outpatient Rt. Infarction 6 8 6 28 1
7 M/53 Inpatient Rt. hemorrhage 14 20 6 28 1 Control Group
1 M/49 Inpatient Rt. hemorrhage 11 34 6 30 1.33
2 M/52 Outpatient Lt. Infarction 9 120 6 29 1.31
3 M/67 Inpatient Rt. Infarction 16 25 6 30 1
4 M/52 Inpatient Lt. Hemorrhage 12 96 3 29 1
5 F/66 Outpatient Rt. Hemorrhage 8 192 6 29 1
6 M/72 Outpatient Rt. Infarction 9 3 4 29 1
7 F/68 Outpatient Lt. Infarction 17 65 6 28 1 MMSE-K: Mini-Mental State Examination-Korean; VMIQ: Vividness of Movement Imagery Questionnaire
- 10
-
Tabl
e 1.
Dem
ogra
phic
cha
ract
eris
tics
(N
=14)
Pa
rtici
pant
G
ende
r
/ Age
Inpa
tient
or
outp
atie
nt
Aff
ecte
d
extre
mity
Cer
ebra
l Inf
arct
ion
or h
emor
rhag
e
Yea
rs o
f
Educ
atio
n
Mon
ths
Post
-stro
ke
Bru
nnst
rom
stag
e
MM
SE
-K
VM
IQ
Expe
rim
enta
l Gro
up
1 M
/49
Inpa
tient
Lt
. he
mor
rhag
e 15
20
6
30
1.19
2 M
/51
Out
patie
nt
Lt.
Infa
rctio
n 12
93
4
30
1.67
3 M
/61
Inpa
tient
R
t. In
farc
tion
9 43
3
30
1
4 F/
52
Out
patie
nt
Rt.
Infa
rctio
n 9
120
6 30
1
5 M
/51
Out
patie
nt
Rt.
hem
orrh
age
12
41
6 30
1
6 F/
74
Out
patie
nt
Rt.
Infa
rctio
n 6
8 6
28
1
7 M
/53
Inpa
tient
R
t. he
mor
rhag
e 14
20
6
28
1 C
ontr
ol G
roup
1
M/4
9 In
patie
nt
Rt.
hem
orrh
age
11
34
6 30
1.
33
2 M
/52
Out
patie
nt
Lt.
Infa
rctio
n 9
120
6 29
1.
31
3 M
/67
Inpa
tient
R
t. In
farc
tion
16
25
6 30
1
4 M
/52
Inpa
tient
Lt
. H
emor
rhag
e 12
96
3
29
1
5 F/
66
Out
patie
nt
Rt.
Hem
orrh
age
8 19
2 6
29
1
6 M
/72
Out
patie
nt
Rt.
Infa
rctio
n 9
3 4
29
1
7 F/
68
Out
patie
nt
Lt.
Infa
rctio
n 17
65
6
28
1 M
MSE
-K: M
ini-M
enta
l Sta
te E
xam
inat
ion-
Kor
ean;
VM
IQ: V
ivid
ness
of M
ovem
ent I
mag
ery
Que
stio
nnai
re
- 10 -
Table 1. Demographic characteristics (N=14) Participant Gender
/ Age
Inpatient or
outpatient
Affected
extremity
Cerebral Infarction
or hemorrhage
Years of
Education
Months
Post-stroke
Brunnstrom
stage
MMSE
-K
VMIQ
Experimental Group
1 M/49 Inpatient Lt. hemorrhage 15 20 6 30 1.19
2 M/51 Outpatient Lt. Infarction 12 93 4 30 1.67
3 M/61 Inpatient Rt. Infarction 9 43 3 30 1
4 F/52 Outpatient Rt. Infarction 9 120 6 30 1
5 M/51 Outpatient Rt. hemorrhage 12 41 6 30 1
6 F/74 Outpatient Rt. Infarction 6 8 6 28 1
7 M/53 Inpatient Rt. hemorrhage 14 20 6 28 1 Control Group
1 M/49 Inpatient Rt. hemorrhage 11 34 6 30 1.33
2 M/52 Outpatient Lt. Infarction 9 120 6 29 1.31
3 M/67 Inpatient Rt. Infarction 16 25 6 30 1
4 M/52 Inpatient Lt. Hemorrhage 12 96 3 29 1
5 F/66 Outpatient Rt. Hemorrhage 8 192 6 29 1
6 M/72 Outpatient Rt. Infarction 9 3 4 29 1
7 F/68 Outpatient Lt. Infarction 17 65 6 28 1 MMSE-K: Mini-Mental State Examination-Korean; VMIQ: Vividness of Movement Imagery Questionnaire
- 10
-
Tabl
e 1.
Dem
ogra
phic
cha
ract
eris
tics
(N
=14)
Pa
rtici
pant
G
ende
r
/ Age
Inpa
tient
or
outp
atie
nt
Aff
ecte
d
extre
mity
Cer
ebra
l Inf
arct
ion
or h
emor
rhag
e
Yea
rs o
f
Educ
atio
n
Mon
ths
Post
-stro
ke
Bru
nnst
rom
stag
e
MM
SE
-K
VM
IQ
Expe
rim
enta
l Gro
up
1 M
/49
Inpa
tient
Lt
. he
mor
rhag
e 15
20
6
30
1.19
2 M
/51
Out
patie
nt
Lt.
Infa
rctio
n 12
93
4
30
1.67
3 M
/61
Inpa
tient
R
t. In
farc
tion
9 43
3
30
1
4 F/
52
Out
patie
nt
Rt.
Infa
rctio
n 9
120
6 30
1
5 M
/51
Out
patie
nt
Rt.
hem
orrh
age
12
41
6 30
1
6 F/
74
Out
patie
nt
Rt.
Infa
rctio
n 6
8 6
28
1
7 M
/53
Inpa
tient
R
t. he
mor
rhag
e 14
20
6
28
1 C
ontr
ol G
roup
1
M/4
9 In
patie
nt
Rt.
hem
orrh
age
11
34
6 30
1.
33
2 M
/52
Out
patie
nt
Lt.
Infa
rctio
n 9
120
6 29
1.
31
3 M
/67
Inpa
tient
R
t. In
farc
tion
16
25
6 30
1
4 M
/52
Inpa
tient
Lt
. H
emor
rhag
e 12
96
3
29
1
5 F/
66
Out
patie
nt
Rt.
Hem
orrh
age
8 19
2 6
29
1
6 M
/72
Out
patie
nt
Rt.
Infa
rctio
n 9
3 4
29
1
7 F/
68
Out
patie
nt
Lt.
Infa
rctio
n 17
65
6
28
1 M
MSE
-K: M
ini-M
enta
l Sta
te E
xam
inat
ion-
Kor
ean;
VM
IQ: V
ivid
ness
of M
ovem
ent I
mag
ery
Que
stio
nnai
re
- 10 -
Table 1. Demographic characteristics (N=14) Participant Gender
/ Age
Inpatient or
outpatient
Affected
extremity
Cerebral Infarction
or hemorrhage
Years of
Education
Months
Post-stroke
Brunnstrom
stage
MMSE
-K
VMIQ
Experimental Group
1 M/49 Inpatient Lt. hemorrhage 15 20 6 30 1.19
2 M/51 Outpatient Lt. Infarction 12 93 4 30 1.67
3 M/61 Inpatient Rt. Infarction 9 43 3 30 1
4 F/52 Outpatient Rt. Infarction 9 120 6 30 1
5 M/51 Outpatient Rt. hemorrhage 12 41 6 30 1
6 F/74 Outpatient Rt. Infarction 6 8 6 28 1
7 M/53 Inpatient Rt. hemorrhage 14 20 6 28 1 Control Group
1 M/49 Inpatient Rt. hemorrhage 11 34 6 30 1.33
2 M/52 Outpatient Lt. Infarction 9 120 6 29 1.31
3 M/67 Inpatient Rt. Infarction 16 25 6 30 1
4 M/52 Inpatient Lt. Hemorrhage 12 96 3 29 1
5 F/66 Outpatient Rt. Hemorrhage 8 192 6 29 1
6 M/72 Outpatient Rt. Infarction 9 3 4 29 1
7 F/68 Outpatient Lt. Infarction 17 65 6 28 1 MMSE-K: Mini-Mental State Examination-Korean; VMIQ: Vividness of Movement Imagery Questionnaire
- 10
-
Tabl
e 1.
Dem
ogra
phic
cha
ract
eris
tics
(N
=14)
Pa
rtici
pant
G
ende
r
/ Age
Inpa
tient
or
outp
atie
nt
Aff
ecte
d
extre
mity
Cer
ebra
l Inf
arct
ion
or h
emor
rhag
e
Yea
rs o
f
Educ
atio
n
Mon
ths
Post
-stro
ke
Bru
nnst
rom
stag
e
MM
SE
-K
VM
IQ
Expe
rim
enta
l Gro
up
1 M
/49
Inpa
tient
Lt
. he
mor
rhag
e 15
20
6
30
1.19
2 M
/51
Out
patie
nt
Lt.
Infa
rctio
n 12
93
4
30
1.67
3 M
/61
Inpa
tient
R
t. In
farc
tion
9 43
3
30
1
4 F/
52
Out
patie
nt
Rt.
Infa
rctio
n 9
120
6 30
1
5 M
/51
Out
patie
nt
Rt.
hem
orrh
age
12
41
6 30
1
6 F/
74
Out
patie
nt
Rt.
Infa
rctio
n 6
8 6
28
1
7 M
/53
Inpa
tient
R
t. he
mor
rhag
e 14
20
6
28
1 C
ontr
ol G
roup
1
M/4
9 In
patie
nt
Rt.
hem
orrh
age
11
34
6 30
1.
33
2 M
/52
Out
patie
nt
Lt.
Infa
rctio
n 9
120
6 29
1.
31
3 M
/67
Inpa
tient
R
t. In
farc
tion
16
25
6 30
1
4 M
/52
Inpa
tient
Lt
. H
emor
rhag
e 12
96
3
29
1
5 F/
66
Out
patie
nt
Rt.
Hem
orrh
age
8 19
2 6
29
1
6 M
/72
Out
patie
nt
Rt.
Infa
rctio
n 9
3 4
29
1
7 F/
68
Out
patie
nt
Lt.
Infa
rctio
n 17
65
6
28
1 M
MSE
-K: M
ini-M
enta
l Sta
te E
xam
inat
ion-
Kor
ean;
VM
IQ: V
ivid
ness
of M
ovem
ent I
mag
ery
Que
stio
nnai
re
- 10 -
Table 1. Demographic characteristics (N=14) Participant Gender
/ Age
Inpatient or
outpatient
Affected
extremity
Cerebral Infarction
or hemorrhage
Years of
Education
Months
Post-stroke
Brunnstrom
stage
MMSE
-K
VMIQ
Experimental Group
1 M/49 Inpatient Lt. hemorrhage 15 20 6 30 1.19
2 M/51 Outpatient Lt. Infarction 12 93 4 30 1.67
3 M/61 Inpatient Rt. Infarction 9 43 3 30 1
4 F/52 Outpatient Rt. Infarction 9 120 6 30 1
5 M/51 Outpatient Rt. hemorrhage 12 41 6 30 1
6 F/74 Outpatient Rt. Infarction 6 8 6 28 1
7 M/53 Inpatient Rt. hemorrhage 14 20 6 28 1 Control Group
1 M/49 Inpatient Rt. hemorrhage 11 34 6 30 1.33
2 M/52 Outpatient Lt. Infarction 9 120 6 29 1.31
3 M/67 Inpatient Rt. Infarction 16 25 6 30 1
4 M/52 Inpatient Lt. Hemorrhage 12 96 3 29 1
5 F/66 Outpatient Rt. Hemorrhage 8 192 6 29 1
6 M/72 Outpatient Rt. Infarction 9 3 4 29 1
7 F/68 Outpatient Lt. Infarction 17 65 6 28 1 MMSE-K: Mini-Mental State Examination-Korean; VMIQ: Vividness of Movement Imagery Questionnaire
- 10
-
Tabl
e 1.
Dem
ogra
phic
cha
ract
eris
tics
(N
=14)
Pa
rtici
pant
G
ende
r
/ Age
Inpa
tient
or
outp
atie
nt
Aff
ecte
d
extre
mity
Cer
ebra
l Inf
arct
ion
or h
emor
rhag
e
Yea
rs o
f
Educ
atio
n
Mon
ths
Post
-stro
ke
Bru
nnst
rom
stag
e
MM
SE
-K
VM
IQ
Expe
rim
enta
l Gro
up
1 M
/49
Inpa
tient
Lt
. he
mor
rhag
e 15
20
6
30
1.19
2 M
/51
Out
patie
nt
Lt.
Infa
rctio
n 12
93
4
30
1.67
3 M
/61
Inpa
tient
R
t. In
farc
tion
9 43
3
30
1
4 F/
52
Out
patie
nt
Rt.
Infa
rctio
n 9
120
6 30
1
5 M
/51
Out
patie
nt
Rt.
hem
orrh
age
12
41
6 30
1
6 F/
74
Out
patie
nt
Rt.
Infa
rctio
n 6
8 6
28
1
7 M
/53
Inpa
tient
R
t. he
mor
rhag
e 14
20
6
28
1 C
ontr
ol G
roup
1
M/4
9 In
patie
nt
Rt.
hem
orrh
age
11
34
6 30
1.
33
2 M
/52
Out
patie
nt
Lt.
Infa
rctio
n 9
120
6 29
1.
31
3 M
/67
Inpa
tient
R
t. In
farc
tion
16
25
6 30
1
4 M
/52
Inpa
tient
Lt
. H
emor
rhag
e 12
96
3
29
1
5 F/
66
Out
patie
nt
Rt.
Hem
orrh
age
8 19
2 6
29
1
6 M
/72
Out
patie
nt
Rt.
Infa
rctio
n 9
3 4
29
1
7 F/
68
Out
patie
nt
Lt.
Infa
rctio
n 17
65
6
28
1 M
MSE
-K: M
ini-M
enta
l Sta
te E
xam
inat
ion-
Kor
ean;
VM
IQ: V
ivid
ness
of M
ovem
ent I
mag
ery
Que
stio
nnai
re
- 10 -
Table 1. Demographic characteristics (N=14) Participant Gender
/ Age
Inpatient or
outpatient
Affected
extremity
Cerebral Infarction
or hemorrhage
Years of
Education
Months
Post-stroke
Brunnstrom
stage
MMSE
-K
VMIQ
Experimental Group
1 M/49 Inpatient Lt. hemorrhage 15 20 6 30 1.19
2 M/51 Outpatient Lt. Infarction 12 93 4 30 1.67
3 M/61 Inpatient Rt. Infarction 9 43 3 30 1
4 F/52 Outpatient Rt. Infarction 9 120 6 30 1
5 M/51 Outpatient Rt. hemorrhage 12 41 6 30 1
6 F/74 Outpatient Rt. Infarction 6 8 6 28 1
7 M/53 Inpatient Rt. hemorrhage 14 20 6 28 1 Control Group
1 M/49 Inpatient Rt. hemorrhage 11 34 6 30 1.33
2 M/52 Outpatient Lt. Infarction 9 120 6 29 1.31
3 M/67 Inpatient Rt. Infarction 16 25 6 30 1
4 M/52 Inpatient Lt. Hemorrhage 12 96 3 29 1
5 F/66 Outpatient Rt. Hemorrhage 8 192 6 29 1
6 M/72 Outpatient Rt. Infarction 9 3 4 29 1
7 F/68 Outpatient Lt. Infarction 17 65 6 28 1 MMSE-K: Mini-Mental State Examination-Korean; VMIQ: Vividness of Movement Imagery Questionnaire
- 10
-
Tabl
e 1.
Dem
ogra
phic
cha
ract
eris
tics
(N
=14)
Pa
rtici
pant
G
ende
r
/ Age
Inpa
tient
or
outp
atie
nt
Aff
ecte
d
extre
mity
Cer
ebra
l Inf
arct
ion
or h
emor
rhag
e
Yea
rs o
f
Educ
atio
n
Mon
ths
Post
-stro
ke
Bru
nnst
rom
stag
e
MM
SE
-K
VM
IQ
Expe
rim
enta
l Gro
up
1 M
/49
Inpa
tient
Lt
. he
mor
rhag
e 15
20
6
30
1.19
2 M
/51
Out
patie
nt
Lt.
Infa
rctio
n 12
93
4
30
1.67
3 M
/61
Inpa
tient
R
t. In
farc
tion
9 43
3
30
1
4 F/
52
Out
patie
nt
Rt.
Infa
rctio
n 9
120
6 30
1
5 M
/51
Out
patie
nt
Rt.
hem
orrh
age
12
41
6 30
1
6 F/
74
Out
patie
nt
Rt.
Infa
rctio
n 6
8 6
28
1
7 M
/53
Inpa
tient
R
t. he
mor
rhag
e 14
20
6
28
1 C
ontr
ol G
roup
1
M/4
9 In
patie
nt
Rt.
hem
orrh
age
11
34
6 30
1.
33
2 M
/52
Out
patie
nt
Lt.
Infa
rctio
n 9
120
6 29
1.
31
3 M
/67
Inpa
tient
R
t. In
farc
tion
16
25
6 30
1
4 M
/52
Inpa
tient
Lt
. H
emor
rhag
e 12
96
3
29
1
5 F/
66
Out
patie
nt
Rt.
Hem
orrh
age
8 19
2 6
29
1
6 M
/72
Out
patie
nt
Rt.
Infa
rctio
n 9
3 4
29
1
7 F/
68
Out
patie
nt
Lt.
Infa
rctio
n 17
65
6
28
1 M
MSE
-K: M
ini-M
enta
l Sta
te E
xam
inat
ion-
Kor
ean;
VM
IQ: V
ivid
ness
of M
ovem
ent I
mag
ery
Que
stio
nnai
re
- 10 -
Table 1. Demographic characteristics (N=14) Participant Gender
/ Age
Inpatient or
outpatient
Affected
extremity
Cerebral Infarction
or hemorrhage
Years of
Education
Months
Post-stroke
Brunnstrom
stage
MMSE
-K
VMIQ
Experimental Group
1 M/49 Inpatient Lt. hemorrhage 15 20 6 30 1.19
2 M/51 Outpatient Lt. Infarction 12 93 4 30 1.67
3 M/61 Inpatient Rt. Infarction 9 43 3 30 1
4 F/52 Outpatient Rt. Infarction 9 120 6 30 1
5 M/51 Outpatient Rt. hemorrhage 12 41 6 30 1
6 F/74 Outpatient Rt. Infarction 6 8 6 28 1
7 M/53 Inpatient Rt. hemorrhage 14 20 6 28 1 Control Group
1 M/49 Inpatient Rt. hemorrhage 11 34 6 30 1.33
2 M/52 Outpatient Lt. Infarction 9 120 6 29 1.31
3 M/67 Inpatient Rt. Infarction 16 25 6 30 1
4 M/52 Inpatient Lt. Hemorrhage 12 96 3 29 1
5 F/66 Outpatient Rt. Hemorrhage 8 192 6 29 1
6 M/72 Outpatient Rt. Infarction 9 3 4 29 1
7 F/68 Outpatient Lt. Infarction 17 65 6 28 1 MMSE-K: Mini-Mental State Examination-Korean; VMIQ: Vividness of Movement Imagery Questionnaire
- 10
-
Tabl
e 1.
Dem
ogra
phic
cha
ract
eris
tics
(N
=14)
Pa
rtici
pant
G
ende
r
/ Age
Inpa
tient
or
outp
atie
nt
Aff
ecte
d
extre
mity
Cer
ebra
l Inf
arct
ion
or h
emor
rhag
e
Yea
rs o
f
Educ
atio
n
Mon
ths
Post
-stro
ke
Bru
nnst
rom
stag
e
MM
SE
-K
VM
IQ
Expe
rim
enta
l Gro
up
1 M
/49
Inpa
tient
Lt
. he
mor
rhag
e 15
20
6
30
1.19
2 M
/51
Out
patie
nt
Lt.
Infa
rctio
n 12
93
4
30
1.67
3 M
/61
Inpa
tient
R
t. In
farc
tion
9 43
3
30
1
4 F/
52
Out
patie
nt
Rt.
Infa
rctio
n 9
120
6 30
1
5 M
/51
Out
patie
nt
Rt.
hem
orrh
age
12
41
6 30
1
6 F/
74
Out
patie
nt
Rt.
Infa
rctio
n 6
8 6
28
1
7 M
/53
Inpa
tient
R
t. he
mor
rhag
e 14
20
6
28
1 C
ontr
ol G
roup
1
M/4
9 In
patie
nt
Rt.
hem
orrh
age
11
34
6 30
1.
33
2 M
/52
Out
patie
nt
Lt.
Infa
rctio
n 9
120
6 29
1.
31
3 M
/67
Inpa
tient
R
t. In
farc
tion
16
25
6 30
1
4 M
/52
Inpa
tient
Lt
. H
emor
rhag
e 12
96
3
29
1
5 F/
66
Out
patie
nt
Rt.
Hem
orrh
age
8 19
2 6
29
1
6 M
/72
Out
patie
nt
Rt.
Infa
rctio
n 9
3 4
29
1
7 F/
68
Out
patie
nt
Lt.
Infa
rctio
n 17
65
6
28
1 M
MSE
-K: M
ini-M
enta
l Sta
te E
xam
inat
ion-
Kor
ean;
VM
IQ: V
ivid
ness
of M
ovem
ent I
mag
ery
Que
stio
nnai
re
- 11 -
Table 2. Comparison of the general characteristics of experimental and control groups (N=14)
Characteristics Experimental
(n=7)
Control
(n=7)
U or
χ²
p
Age (yr), median (range) 52 (49-74) 66 (49-72) 17.50 .368
Gender, n(%) Male 5 (71.4) 5 (71.4) .000 1.000
Female 2 (28.6) 2 (28.6)
Inpatient or
outpatient, n(%)
Inpatient 3 (42.9) 3 (42.9) .000 1.000
Outpatient 4 (57.1) 4 (57.1)
Affected extremity,
n(%)
Right 5 (71.4) 4 (57.1) .311 .577
Left 2 (28.6) 3 (42.9)
Cerebral infarction or
hemorrhage, n(%)
Infarction 4 (57.1) 4 (57.1) .000 1.000
Hemorrhage 3 (42.9) 3 (42.9)
Years of education (yr),
median (range)
12 (6-15) 11 (8-17) 23.00 .846
Months post-stroke (m),
median (range)
41 (8-120) 65 (3-192) 18.50 .442
Bruunstrom stage,
median (range)
6 (3-6) 6 (3-6) 24.50 1.000
MMSE,
median (range)
30 (28-30) 29 (28-30) 18.00 .367
VMIQ,
median (range)
1.00
(1.00-1.67)
1.00
(1.00-1.33)
24.50 1.000
MMSE-K: Mini-Mental State Examination-Korean; VMIQ: Vividness of Movement Imagery Questionnaire
- 11 -
Table 2. Comparison of the general characteristics of experimental and control groups (N=14)
Characteristics Experimental
(n=7)
Control
(n=7)
U or
χ²
p
Age (yr), median (range) 52 (49-74) 66 (49-72) 17.50 .368
Gender, n(%) Male 5 (71.4) 5 (71.4) .000 1.000
Female 2 (28.6) 2 (28.6)
Inpatient or
outpatient, n(%)
Inpatient 3 (42.9) 3 (42.9) .000 1.000
Outpatient 4 (57.1) 4 (57.1)
Affected extremity,
n(%)
Right 5 (71.4) 4 (57.1) .311 .577
Left 2 (28.6) 3 (42.9)
Cerebral infarction or
hemorrhage, n(%)
Infarction 4 (57.1) 4 (57.1) .000 1.000
Hemorrhage 3 (42.9) 3 (42.9)
Years of education (yr),
median (range)
12 (6-15) 11 (8-17) 23.00 .846
Months post-stroke (m),
median (range)
41 (8-120) 65 (3-192) 18.50 .442
Bruunstrom stage,
median (range)
6 (3-6) 6 (3-6) 24.50 1.000
MMSE,
median (range)
30 (28-30) 29 (28-30) 18.00 .367
VMIQ,
median (range)
1.00
(1.00-1.67)
1.00
(1.00-1.33)
24.50 1.000
MMSE-K: Mini-Mental State Examination-Korean; VMIQ: Vividness of Movement Imagery Questionnaire
- 12 -
2. Instruments
2.1 Instruments for participant selection
2.1.1 Mini Mental State Examination-Korean (MMSE-K)
Mini Mental State Examination-Korean (MMSE-K) was used to assess whether
one has a normal level of cognitive ability required to continuously practice mental
practice and mCIMT. MMSE-K is a screening tool for evaluating cognitive function
that was modified to fit the Korean culture. It is comprised of items on time (5 points)
and place (5 points) orientation, registration of memory (3 points), memory
recollection (3 points), attention and calculation (5 points), language function (7
points), understanding and judgment (2 points). Total score could be from 0 to 30
points, and the examinees’ results are interpreted as cognitively normal if 24 points or
more are earned, mildly impaired when 20 to 23 points are earned, moderately
impaired, when 10 to 19 points are earned, and severely impaired when 9 points or
less are earned (Kang, Na, & Hahn, 1997). Sensitivity of the MMSE-K is 97.2% and
specificity is 42.9% (Rhee, Chung, Shin, Lee, & Son, 2002). The inter-rater reliability
of MMSE-K is 0.999 (p<.001) (Kwon & Park, 1989).
2.1.2 Vividness of Movement Imagery Questionnaire (VMIQ)
Vividness of Movement Imagery Questionnaire (VMIQ) was carried out in order to
determine the level at which study participants can imagine. Developed by Isaac,
- 13 -
Marks, and Russell (1986), it is a tool to evaluate the examinee’s ability to vividly
imagine actions. Consisting of total 24 number of questions, each questions are
graded from 1 point (vividly imagines) to 5 points (cannot imagine the action) and the
score of each 24 questions are averaged to make the overall score. The test-retest
reliability of VMIQ is 0.76, and as for validity, its correlation with Vividness of
Visual Imagery Questionnaire (VVIQ) is 0.81 which is very high (Isaac, Marks, &
Russell, 1986). Since the average VMIQ score of healthy subjects is 2.26, in order to
select people with above average imagination ability, people who scored 2.26 or less
in VMIQ were included in this study (Isaac & Marks, 1994).
2.1.3 Brunnstrom’s hand function recovery stage
Brunnstrom's hand function recovery stage was used to include subjects who are
capable of performing somewhat everyday activities while restricting their normal
upper extremity when participating in a mCIMT program. According to the
Bruunstrom, the procedure of hand functional recovery of stroke patients can be
divided into six stages as follow (Brunnstrom, 1966). The stage 1 represent flaccid
hand without any function; persons in stage 2 can slightly flex their fingers
spontaneously; in stage 3, gross grasp and hook grasp is possible but releasing one’s
hand is still impossible; stage 4 is when gross grasp and lateral prehension is capable;
stage 5 is when palmar prehension and spontaneous mass extension of the entire
finger is possible; in stage 6, all types of grasp and spontaneous extension and
individual movements of fingers are possible. In this study, persons with higher
- 14 -
Brunnstrom’s hand function recovery stage than stage 3 were selected because they
were expected to grasp and sustain objects or utensils solely with their affected hand
while their normal arm is being restricted.
2.2 Instruments for outcome measures
2.2.1 Motor-evoked potential (MEP)
Motor-evoked potential (MEP) is a method that can be used to objectively and
quantitatively measure the integrity of the motor nerve pathway (Hendricks, Zwarts,
Plat, & van Limbeek, 2002). MEP of stroke patients is greatly related to the future
upper limb functional recovery together with the Somatosensory-evoked potentials
(SEP) and upper limb functions in the acute phase (Coupar, Pollock, Rowe, Weir, &
Langhorne, 2012). In other words , the presence or absence of the MEP signal can be
used as an indicator to predict the recovery of upper limb movement of hemiplegic
patients with stroke in long-term (van Kuijk, Pasman, Hendricks, Zwarts, & Geurts,
2009). The principle of creating MEP with Transcranial magnetic stimulation is that
when a magnetic field is generated by an electromagnetic coil, the wave and
fluctuation energy of the magnetic field is transmitted to the brain through the skull,
and then induces depolarization of the neurons under the coil. The action potentials of
the distal muscles which was developed by the magnetic field is recorded in
electromyography (EMG) using a surface electrode. In this study, MEP was tested to
determine the effect of the combined therapy of mental practice and mCIMT and
- 15 -
mCIMT alone in changing the amplitude and latency of MEP which represent the
corticospinal excitability.
MagPro R30(Medtronic, Skovlunde, Denmark), a machine for inducing harmless
magnetic stimulation to the human body, was used and it contains an electromagnetic
coil and MEP monitor device (Figure1, C). As for the electromagnetic coil, Circular
coil C100 with the diameter of 110mm was used (Figure1, B). A EMG instrument,
DantecTM
KeyPoint® (Natus, CA, USA) and its components which are PC and
monitor were connected to the magnetic stimulator and used (Figure1, A). The EMG
electrodes which were attached to the skin were active electrode, reference electrode,
and ground electrode and all of them used the Ag/AgCl surface electrodes. Collected
EMG data were analyzed and the results were deduced using Dantec Keypoint. NET
software. EMG activity was filtered using a bandpass of 2 Hz to10 kHz.
Figure 1. (A) DantecTM
KeyPoint®, (B) Circular coil C 100, and (C) MagProR30
(A)
(C) (B)
- 16 -
MEP was tested while the participants were comfortably seating on the
examination bed and relaxing their both hands on the knees in supine (Figure 2, A). In
order to confirm the accurate part to stimulate with the magnetic field and evaluate
the MEP at the very point, MEP test was performed as the following procedure (Kang,
Yoon, Park, & Chun, 1993).
1) Locate the reference point of magnetic stimulation. According to the
international 10-20 system of EEG, C3 on the left cerebral hemisphere (Figure
2, A) and C4 on the right hemisphere (Figure 2, B) are the reference point of
hand area of the cerebral motor cortex. When stimulating the spinal level, the
spinous process of 7th cervical vertebrae (C7) is the reference point for starting
the stimulation with a coil.
2) After positioning the center of the coil at the site of the reference point, the
examiner moved the central portion of the coil at 1cm intervals while magnetic
stimulation started from 50% of the maximal stimulation and increased 2% at a
time. The resting motor threshold (RMT) was when 50 ㎶ or more was
observed 5 times or more out of 10 times.
3) The MEP result that showed the biggest amplitude and shortest latency when
100% of the magnetic stimulation struck the RMT part was recorded as the
MEP amplitude and latency results.
- 17 -
(A)
Figure 2. (A) MEP test position, (B) C3, and (C) C4 on International 10-20 system
The peripheral motor evoked potential generated by the magnetic stimulation was
measured by attaching Ag/AgCl surface electrodes on the recording sites which is the
Abductor Pollicis Brevis of the opposite side of the stimulated cortex (Figure 3).
Among the three electrodes, the active electrode was attached to the APB muscle
belly, reference electrode was attached to the insertion part of the APB muscle which
is the distal part, and ground electrode was located at the dorsum of the hand.
(B)
(C)
- 18 -
Figure 3. Attachment sites of the active and reference electrodes
2.2.2 3-D motion analyzer
3-D motion analysis system (Compact measuring system10, Zebris Medical GmbH,
Isny, Germany) was utilized to measure the qualitative change of movement, such as
the movement speed, time and smoothness while participants perform a feeding
similar action which the author defined. The 3D analyzer is composed of a laptop,
three markers with the diameter of 1cm which output ultrasonic signals, cable
adapters for transmitting information from the markers, and a measurement sensor for
recognizing the ultrasonic signals. The space is defined by X-axis (front-back), Y-axis
(left-right), and Z-axis (top-down), and the sampling rate is 50Hz. WinArm v1.1.16
(Zebris Medical GmbH, Isny, Germany) was used to convert the information obtained
from each marker into 3-D coordinate (Figure 4).
- 19 -
Figure 4. WinArm software
For the 3D motion testing position, the participants were seated in a chair facing a
desk which was 15cm away from them. The height of the desk was adjusted to each
participant for their knee and elbow to be flexed as much as 90°. In order to allow the
participants perform feeding similar action without compensating their limited arm
movement by moving their trunk, their trunk was fixed to the back of the chair with a
belt. The three markers were attached at the middle part of wrist dorsal, lateral part of
elbow, and the beginning of deltoid muscle (Figure 5).
Collected data were analyzed using the 3DAwin1.02 software to determine the
movement speed, time and smoothness of feeding similar action.
- 20 -
Figure 5. Three markers’ placement of 3-D motion analyzer
- 21 -
2.2.3 Jebsen-Taylor Hand Function Test
Jebsen-Taylor Hand Function Test was used to compare the upper extremity
functions of the experimental and control group and before and after the intervention
in each group. To test the level of hand function, this assessment records how fast the
examinee performs each task that are frequently used in daily lives (Jebsen, Taylor,
Trieschmann, Trotter, & Howard, 1969). The seven items of Jebsen-Taylor test are
writing, simulated page turning, lifting small objects, simulated feeding, stacking
checkers, lifting large lightweight objects, and lifting large heavy object. The test-
retest reliability of this tool varies from 0.67 to 0.99 in each of the seven items
(Jebsen et al., 1969).
The order of method is to perform each item as fast as possible first with one’s
affected hand and then using the unaffected hand. The time took to perform each of
the seven items were measured with a stopwatch and recorded in seconds. If the
performance time of a single item exceeded 120 seconds, the examiner ceased the
examinee and the result was recorded as 120 seconds.
2.2.4 Motor Activity Log (MAL)
Motor Activity Log (MAL) was used to evaluate the frequency of participants’
actual amount of using their affected upper limb and how well the movements are in
their daily lives. Using interviews to evaluate the amount and how well of the use of
affected upper limb, it consists of a total 30 items and each item is graded from 0 (did
not use my weaker arm OR my weaker arm was not used at all for that activity) to 5
- 22 -
(used my weaker arm as often as before the stroke OR the ability to use my weaker
arm for that activity was as good as before the stroke) points. The each total score of
amount of use and how well of ADLs are computed by averaging the scores of 30
items. The internal validity of amount of use is α=0.88 and how well is α=0.91
which are considered high (van der Lee, Beckerman, Knol, de Vet, & Bouter, 2004).
The construct validity of MAL with other assessments testing hand functions of
subacute stroke patients are mostly about 0.50 which is fair to moderate (Hammer &
Lindmark, 2010).
- 23 -
3. Experimental Method
3.1 Independent variables
Among the two independent variables of this study, one was mCIMT and the other
one was mental practice with action observation. The experimental group participated
in both mCIMT and mental practice and the control group only partook in the
mCIMT.
3.1.1 modified Constraint-induced Movement Therapy (mCIMT)
Figure 6. A Meshed mitt for constraining the hand
The mCIMT program requires all participants to do their everyday activities while
wearing a hand constraint which is a meshed mitt with an inflexible iron plate on the
palm side for more than six hours a day in 5 days per week of 2 weeks (Figure 6).
- 24 -
During the six hours, participants had to visit the occupational therapy room and
practice ADL tasks repeatedly with an occupational therapist for an hour per day.
During the one hour visit to the occupational therapy clinic, participants were directed
to choose five to six tasks from examples of repetitive task in ADL and IADL area
and practice them (Table 3). Among the examples, most chosen tasks were the ones
that could be performed using only the affected hand such as drinking with a cup
from the water purifier, feeding with chopsticks, fork, and spoon, combing hair with a
comb, practicing drawings, or handwriting and putting coins in a moneybox. At this
point, task modification, shaping techniques by the occupational therapist, or adaptive
device were adapted for participants with a variety of functional levels to perform
each task (Figure 7). The occupational therapist provided the participants with
supplies that were needed to perform various tasks during hand restriction time and
their visit to the occupational therapy room. The supplies are stainless cup which does
not break, spoon, fork, Edison Chopsticks™, wooden and steal chopsticks, universal
cuff, built-up handle, hair comb, pencil, notebook, and so on.
Figure 7. Use of shaping technique to make instant coffee
- 25 -
Table 3. Examples of repetitive task in ADL and IADL areas
Occupational performance areas ADL repetitive task examples
Grooming ∙ brushing teeth with a toothbrush
∙ combing hair with a comb
Feeding
∙ drinking with a cup from the water purifier
∙ feeding with chopsticks, fork, and spoon
∙ making instant coffee
Dressing
∙ folding towel and clothes
∙ fastening and undoing button
∙ zip up and lower a zipper,
Communication management
∙ turning pages of a book
∙ practicing drawings, or handwriting
∙ making a phone call or texting message
Financial management ∙ putting coins in a moneybox
Home establishment and
management
∙ spraying detergent sprayer and wiping dining
table, mirror, or window
∙ using vacuum cleaner or mop
∙ opening and closing windows and curtains
∙ opening and locking a door with a key
∙ opening and closing a door
Health management ∙ throwing and catching a ball
- 26 -
3.1.2 Mental practice aided with action observation
The mental practice coupled with action observation was processed by listening to
an audio material while watching a video for ten minutes which were both produced
by the author. Only the participants in the experimental group partook in the mental
practice right after the one hour repetitive ADL training in the occupational therapy
room. The mental practice is about self-feeding a soup by holding a spoon with the
affected hand. The video and audio material of mental practice consists of the
following sequences (Appendix 1).
1) Participants observe the video of spooning soup from a bowl and then
bringing it to one’s mouth and at the same time, listen to its mental
practice for about four minutes.
2) The video blacks out and the participants practice relaxation training for
two minutes.
3) The initially heard mental practice is repeated without the video for four
minutes and then the whole process of mental practice ends by refocusing
the participant’s mind to the room.
The mental practice video and audio materials were produced separately for both
right and left hemiplegic patients of one material on performing self feeding task with
the right(Figure 8, A) and the other with the left hand(Figure 8, B). In other words, if
a participant is a right hemiplegia, a material of performing self feeding task with
- 27 -
right upper extremity was shown and vice versa for the left upper extremity. The
video for action observation was taken from the back of the actor who eats the food
with a spoon, in order to make the participants to observe the video in first-person
perspective as if they are the actor and actually practicing the task themselves
(Figure8). Therefore, the spooned soup that the actor is holding in the screen comes
closer to the participant and they could easily get the image of themselves directly
holding the spoon and eating the soup.
(A) (B)
Figure 8. Action observation training of first-person perspective for right(A) and
left(B) hand
- 28 -
Instructions of mental practice induces the participants to imagine themselves
spooning up and eating the soup with a spoon to be in first-person point of view. Also,
to be a kinesthetic mental practice, information such as the smoothness or feeling of
movement and degree to which the participants should move are included. In addition,
three questions are asked to the participants in the middle of directions to assure that
they are actually concentrating in practice.
After analyzing the activity of spooning soup and self feeding it, the audio
directions for mental practice were written by the author to become in first-person
perspective and kinesthetic mental practice. They were later completed through some
modifications by two occupational therapy professors who had conducted a number
of studies on mental practice including their doctoral thesis. These audio directions
were recorded by a female announcer who has been in charge of the hospital
announcement in W medical center for 17 years. Based on the recorded mental
practice audio, action observation video was shot and then both were edited together.
At the very first part of this material which is the action observation portion, video
and audio come out together, but from the point of relaxation training to the end of
the material after mental practice, the screen goes black and only the audio comes out.
- 29 -
3.2 Dependent variables
3.2.1 Corticospinal excitability
Corticospinal excitability is represented by the MEP latency and amplitude.
3.2.1.1 MEP Latency
MEP latency represents the conduction time of magnetic stimulation from cortex or
C6 level of Spinal cord to reach the APB muscle and it is recorded in msec. Smaller
value of MEP latency is considered as an effective nerve conduction (Kiers, Fernando,
& Tomkins, 1997).
3.2.1.2 MEP Amplitude
MEP amplitude is the conduction size which was stimulated at cortex or C6 level
of Spinal cord, conducted to the APB muscle and measured there (Kim et al., 2006).
MEP amplitude is recorded in ㎶ and bigger value of MEP amplitude is considered
as an effective nerve conduction (Kiers, Fernando, & Tomkins, 1997).
3.2.2 Quality of movement
3.2.2.1 Movement speed
Movement speed is the measurement of the maximum angular velocity. The fastest
angular velocity of the elbow joint during a single movement segment of feeding
similar action operationally defined in this study was recorded. Bigger the value of
- 30 -
maximum angular velocity, faster the movement, and the quality of movement is
interpreted as good.
3.2.2.2 Movement time
The movement time is defined as the time during one movement segment of
feeding similar action which is from the moment acceleration begins in the starting
point of target object to the deceleration stops in the ending point of one’s mouth. The
smaller the value of movement time, quality of movement is considered good.
3.2.2.3 Movement smoothness
The movement smoothness is defined as the number of movement units during a
single feeding similar action which was operationally defined in this study. The
movement unit is divided based on the point at which the angular acceleration passes
through 0 (Rice, Alaimo, & Cook 1999). That is, a single movement unit means from
the moment the angular acceleration passes through the point 0 until the moment of
passing through the next 0 point. Smaller the value of movement smoothness, less
number of times the angular acceleration passes through 0, and it can be seen that the
quality of movement is good.
3.2.3 Upper extremity functions
Functional level of the upper limbs is represented by the result of seven items of
Jebsen-Taylor Hand Function Test. The performance time of seven items such as
writing, simulated page turning, lifting small objects, simulated feeding, stacking
checkers, lifting large lightweight objects, and lifting large heavy objects were
- 31 -
recorded in seconds. Thus, smaller execution time means shorter performance time
and having better functions. If the performance time of a single item exceeds 120
seconds, the examiner immediately stopped the evaluation and recorded as 120
seconds.
3.2.4 Activities of daily living (ADLs)
Motor Activity Log (MAL) was utilized to evaluate the amount of the participants’
actual usage of their affected upper limb and how well the movement is in their daily
lives. The total score of both amount of use and how well the movement were
obtained through averaging the scores of thirty items in each amount and how well. In
both the amount of use and how well the movement is in ADL, larger value is
interpreted as the affected upper limb is more frequently used in daily life or the
quality of movement is better.
- 32 -
4. Procedure
Figure 9. Experimental flow chart
- 33 -
4.1 Subject Recruitment
Participants were recruited through four different occupational therapy room of a
university hospital, general hospital, rehabilitation hospital and welfare center for
people with disabilities in Wonju, Kangwondo, Republic of Korea. A total of sixteen
people who met the inclusion criteria, but not the exclusion criteria and were
interested in this study were introduced to the author by their occupational therapists
or physicians.
4.2 Screening and Randomization
Sixteen participants were divided into experimental (n=8) and control (n=8) group
using stratified randomization. Two persons who have the same gender and are in
similar age group were paired and depending on the toss of a coin, if one of the paired
two became the member of experimental group, the other automatically became the
control group. The participants were not aware to the fact that this study divides them
into groups and provides different interventions to each group. Also the MEP
examiner was blinded to which group the participants were in. All evaluations other
than MEP were conducted by the author who is an occupational therapist with five
years of experience. Interventions were carried out by the author and two students
who are in their third year of majoring in occupational therapy.
- 34 -
4.3 Pre-intervention test
As for the pre-test, participants were tested with 3-D motion analysis, Jebsen-
Taylor Hand Function Test, and Motor Activity Log in random order for three to five
days and MEP for the last.
4.3.1 Motor evoked potential
Before the intervention, all participants were tested with MEP, and only the
experimental group was tested again during mental practice of spooning and self-
feeding soup before and after the intervention to test whether they are faithfully
concentrating in the mental practice. The evaluation procedure of MEP was as
follows.
1) Participant comfortably sat on the test bed.
2) The MEP examiner attached the surface electrodes for testing EMG to the APB
muscle of the participant.
3) Participant was explained that he/she may be startled by the magnetic field
which is harmless to the body.
4) MEP was measured in the order of cortex level of the unaffected side, C6 level
of the unaffected side, cortex level of the affected side, and C6 level of the
affected side.
5) While listening to the audio material of mental practice, the experimental group
repeated the order of 4) once more.
- 35 -
4.3.2 3-D motion analysis
3-D motion analysis was carried out in the following order to evaluate the quality
of movement while participants were actively performing the feeding similar action.
(A) (B)
Figure 10. Starting(A) and ending(B) positions of the simulated feeding task
1) Participant sat on a chair with a backrest making his/her knee to be flexed 90
degrees and the distance between his/her trunk and the desk to be 15cm.
2) The Examiner explained the purpose of this test and that it is harmless nor
painless to the body.
3) Participant rolled up his/her sleeves to the shoulder or undressed the top to
reveal his/her affected upper extremity.
4) Three markers of 3-D motion analysis were attached to the affected arm.
- 36 -
5) Participant’s trunk was fixed to the back of a chair with a strap around his/her
chest (Figure 5).
6) After measuring the length of the participant’s arm (from axillary to wrist), a
wooden target object with a circle shape attached was placed on the table 70%
of the length of his/her arm apart from the sternum of the participant.
7) The examiner instructed the participant to imagine the target object to be a
cookie and conduct a feeding similar action which was operationally defined in
this study.
8) The feeding similar action started with the position of touching the target
object and then ended with the position of touching one’s lips with any part of
the finger (Figure 10).
9) The feeding similar action was repeated five times.
4.4 Intervention phase
4.4.1 mCIMT
Participants started the two week program of mCIMT intervention a day after the
MEP test. They spent six hours per a day, five days per a week, for two weeks,
wearing a hand constraint and then recorded their time table about which time of the
day they wore it. At the same time, participants visited the occupational therapy room
for an hour every weekdays and practiced repetitive ADL tasks with the constraint on.
- 37 -
4.4.2 MP
Mental practice was conducted immediately after the one hour training of
repetitive ADL tasks, for about ten minutes. The mental practice was processed in
the following order.
1) The participant in the experimental group sat on a cushioned chair with a back
support that goes up right beneath the head, and comfortably leaned on the
back support.
2) With earphones on both ears, participant was instructed to stare a computer
monitor in front of him/her (Figure11).
3) Following the verbal instruction that comes out of the audio, the participant
stared at the PC monitor for the initial four minutes to see the action
observation video.
4) The participant closed his/her eyes according to the verbal instruction from the
audio as image blacks out, and relaxation training starts.
5) After completing ten minutes of mental practice, participant opened his/her
eyes and stood up from the chair as the voice instructions.
- 38 -
Figure 11. A participant watching the action observation video and listening to the
audio during the mental practice intervention
Instead of the ten minutes of mental practice that the experimental group
participated, people in the control group listened to classical piano music for the same
amount of time while looking at the same monitor and sitting in the same chair.
4.5 Post-intervention test
After completing the two weeks of intervention, as well as pre-test, participants
were evaluated with 3D motion analysis, Jebsen-Taylor Hand Function Test, and
Motor Activity Log in random order, and then received the MEP test at the end.
- 39 -
5. Data analysis
5.1 3-D motion analysis indicator
The results of the 3-D motion analysis were analyzed using the 3DAWin1.0
software program. A movement segment is defined as the section from the movement
acceleration passes 0 to the point it decelerates back to 0 (Figure12). After analyzing
the value of results from five movement segments, the three consecutive values with
the least standard deviation were selected and averaged. The averaged value was the
ultimate value which was later statistically analyzed as the value of the quality of the
movement, the dependent variable.
Figure 12. Designating a single movement segment
- 40 -
5.1.1 Movement speed
Movement speed refers to the maximum angular velocity measured during a single
movement segment. This is the value at which the velocity of the elbow joint is the
fastest during a single feeding similar action. The absolute value of VWD which is
the greatest in the T-VWD graph was used for statistical analysis (Figure13) .
Figure 13. Designating the maximum angular velocity in T-VWD graph
5.1.2 Movement time
The movement time refers to time between the participant’s hand starts moving
from the target point and stops reaching in at the end point which is his or her own
mouth. In other words, it is period of time that a single movement segment has
occurred. The dT value displayed on the chart when a movement segment was set was
later used in the statistical analysis (Figure14).
- 41 -
Figure 14. Movement time during a single movement segment
5.1.3 Movement smoothness
Movement smoothness means the number of movement units which are the number
of times that the angular acceleration alternates from positive value to negative one,
or vice versa during a movement segment. The movement units indicating the
movement smoothness were recorded by counting the number of times the angular
acceleration passed through 0 in T-AWD chart (Figure15).
- 42 -
Figure 15. Numbers of movement units corresponding to the movement
smoothness
5.2 Statistical analysis
All statistical analysis were conducted using the SPSS 20.0 for Windows (SPSS
Inc., Chicago, IL). The general characteristics of the participants were analyzed using
the descriptive statistics and Mann-Whitney U test and chi-square test were used to
compare the general characteristics of both group and check whether there is a
significant difference between groups.
In order to, verify whether the level of dependent variables of the experimental and
control group is similar at before and after the intervention, Mann-Whitney U test was
used to verify homogeneity of both group before intervention and the difference in
pre- and post- changes of both group.
Wilcoxon signed rank test was utilized to verify whether the dependent variable of
post-intervention of each group has significantly changed from pre-intervention test.
- 43 -
In the experimental group, Friedman test was used in order to verify the change of
MEP when participating or not participating in mental practice before and after the
intervention.
- 44 -
Results
1. Corticospinal excitability
1.1 MEP
1.1.1 MEP Latency
As a result of the homogeneity test of experimental and control group before
intervention, the MEP latencies stimulated from cortical and C6 level of affected and
unaffected side, all did not show statistically significant difference between the two
group at pre-intervention test (p>.05).
Comparing the difference between pre- and post-intervention test within each
group, the MEP latency from neither cortical nor C6 level to APB muscle showed
significant difference in either group (Table 4).
When verifying the difference between experimental and control group in the
change of MEP latency from pre- to post-intervention test, only the MEP latency of
the cortical level in the affected side(U = 8.000, p = .038) was significantly different
between groups since the cortex MEP latency of experimental group decreased and
that of control group increased in post-intervention test from pre-test (Figure16).
- 45 -
Table 4. Changes in MEP latency in experimental and control group (N=14)
*p<.05 p† is for the comparison between before and after study of the experimental or control group p‡ is for the comparison between experimental and control group in the value of after-before Note: values are group median (minimum - maximum value)
Experimental Group (n=7) Control Group (n=7) U p‡
Before study After study Z p† Before study After study Z p†
Cortex Latency
(msec)
Unaffected side
22.80
(19.60-31.40)
21.70
(20.80-22.70) -1.183 .237
21.20
(18.20-25.20)
21.10
(19.20-23.30) -.338 .735 17.000 .338
Affected side
23.30
(20.70-28.20)
22.30
(19.10-25.80) -1.572 .116
21.70
(.00-23.70)
22.90
(.00-26.40) -1.753 .080 8.000 .038*
C6 Latency
(msec)
Unaffected side
13.20
(11.70-13.70)
13.10
(11.80-13.80) -.341 .733
13.00
(12.10-15.80)
13.80
(12.40-14.60) -.210 .833 23.000 .847
Affected side
14.10
(7.40-14.90)
14.00
(12.10-15.00) -1.101 .271
12.80
(11.30-16.60)
13.10
(11.80-16.10) -1.693 .090 23.500 .898
- 45
-
Tabl
e 4.
Cha
nges
in M
EP la
tenc
y in
exp
erim
enta
l and
con
trol g
roup
(N
=14)
*p<.
05
p† is
for t
he c
ompa
rison
bet
wee
n be
fore
and
afte
r stu
dy o
f the
exp
erim
enta
l or c
ontro
l gro
up
p‡ is
for t
he c
ompa
rison
bet
wee
n ex
perim
enta
l and
con
trol g
roup
in th
e va
lue
of a
fter-
befo
re
Not
e: v
alue
s are
gro
up m
edia
n (m
inim
um -
max
imum
val
ue)
Ex
perim
enta
l Gro
up (n
=7)
Con
trol G
roup
(n=7
) U
p‡
B
efor
e st
udy
Afte
r stu
dy
Z p†
B
efor
e st
udy
Afte
r stu
dy
Z p†
Cor
tex
Late
ncy
(mse
c)
Una
ffect
ed
side
22.8
0
(19.
60-3
1.40
)
21.7
0
(20.
80-2
2.70
) -1
.183
.237
21
.20
(18.
20-2
5.20
)
21.1
0
(19.
20-2
3.30
) -.3
38 .
735
17.0
00
.338
Aff
ecte
d si
de
23.3
0
(20.
70-2
8.20
)
22.3
0
(19.
10-2
5.80
) -1
.572
.116
21
.70
(.00-
23.7
0)
22.9
0
(.00-
26.4
0)
-1.7
53 .0
80 8
.000
.0
38*
C6
Late
ncy
(mse
c)
Una
ffect
ed
side
13.2
0
(11.
70-1
3.70
)
13.1
0
(11.
80-1
3.80
) -.3
41 .
733
13.0
0
(12.
10-1
5.80
)
13.8
0
(12.
40-1
4.60
) -.2
10 .
833
23.0
00
.847
Aff
ecte
d si
de
14.1
0
(7.4
0-14
.90)
14.0
0
(12.
10-1
5.00
) -1
.101
.271
12
.80
(11.
30-1
6.60
)
13.1
0
(11.
80-1
6.10
) -1
.693
.090
23.
500
.898
- 46 -
*p<.05
signifies the comparison between experimental and control group in the value of after-
before
Figure 16. Changes in MEP latency of affected side in experimental and control
groups
Exp
erim
enta
l_Pre
Exp
erim
enta
l_Post
Contr
ol_Pre
Contr
ol_Post
0
10
20
30
ME
P L
ate
nc
y (
ms
ec
)
*
- 47 -
1.1.2 MEP Amplitude
As a result of the homogeneity test of experimental and control group before
intervention, the MEP amplitude stimulated from cortical and C6 level of affected and
unaffected side, all did not show statistically significant difference between the two
group at pre-intervention test (p>.05).
Comparing the difference between pre- and post-intervention test within each
group, the MEP amplitude from neither cortical nor C6 level to APB muscle showed
significant difference in either group (Table 5).
When verifying the difference between experimental and control group in the
change of MEP amplitude from pre- to post-intervention test, only the MEP
amplitude of the cortical level in the affected side(U = 9.000, p = .048) was
significantly different between groups since the cortex MEP amplitude of
experimental group increased and that of control group decreased in post-intervention
test from pre-test (Figure17).
- 48 -
Table 5. Changes in MEP amplitude in experimental and control group (N=14)
*p<.05 p† is for the comparison between before and after study of the experimental or control group p‡ is for the comparison between experimental and control group in the value of after-before Note: values are group median (minimum - maximum value)
Experimental group (n=7) Control group (n=7) U p‡
Before study After study Z p† Before study After study Z p†
Cortex
Amplitude
(㎶)
Unaffected side
2.70
(.43-11.90)
2.50
(.91-10.40) -.169 .866
6.00
(2.00-10.50)
5.00
(1.87-10.40) .000 1.000 24.000 .949
Affected side
2.80
(.48-11.60)
3.40
(.81-13.20) -1.859 .063
.71
(.00-6.00)
.56
(.00-3.50) -.524 .600 9.000 .048*
C6
Amplitude
(㎶)
Unaffected side
8.30
(1.25-17.20)
8.50
(3.30-14.50) -1.014 .310
10.80
(5.10-15.40)
10.10
(2.60-17.80) -1.183 .237 13.500 .159
Affected side
5.70
(.35-13.20)
5.50
(4.10-14.20) -.762 .446
7.90
(4.20-10.50)
7.50
(3.40-10.90) -.339 .735 19.000 .482
- 48
-
Tabl
e 5.
Cha
nges
in M
EP a
mpl
itude
in e
xper
imen
tal a
nd c
ontro
l gro
up
(N=1
4)
*p<.
05
p† is
for t
he c
ompa
rison
bet
wee
n be
fore
and
afte
r stu
dy o
f the
exp
erim
enta
l or c
ontro
l gro
up
p‡ is
for t
he c
ompa
rison
bet
wee
n ex
perim
enta
l and
con
trol g
roup
in th
e va
lue
of a
fter-
befo
re
Not
e: v
alue
s are
gro
up m
edia
n (m
inim
um -
max
imum
val
ue)
Ex
perim
enta
l gro
up (n
=7)
Con
trol g
roup
(n=7
) U
p‡
B
efor
e st
udy
Afte
r stu
dy
Z p†
B
efor
e st
udy
Afte
r stu
dy
Z p†
Cor
tex
Am
plitu
de
(㎶)
Una
ffect
ed
side
2.70
(.43-
11.9
0)
2.50
(.91-
10.4
0)
-.169
.8
66
6.00
(2.0
0-10
.50)
5.00
(1.8
7-10
.40)
.0
00
1.00
0 24
.000
.9
49
Aff
ecte
d si
de
2.80
(.48-
11.6
0)
3.40
(.81-
13.2
0)
-1.8
59
.063
.7
1
(.00-
6.00
)
.56
(.00-
3.50
) -.5
24
.600
9.
000
.048
*
C6
Am
plitu
de
(㎶)
Una
ffect
ed
side
8.30
(1.2
5-17
.20)
8.50
(3.3
0-14
.50)
-1
.014
.3
10
10.8
0
(5.1
0-15
.40)
10.1
0
(2.6
0-17
.80)
-1
.183
.2
37
13.5
00
.159
Aff
ecte
d si
de
5.70
(.35-
13.2
0)
5.50
(4.1
0-14
.20)
-.7
62
.446
7.
90
(4.2
0-10
.50)
7.50
(3.4
0-10
.90)
-.3
39
.735
19
.000
.4
82
- 49 -
E x p e r ime n ta
l_P re
E x p e r ime n ta
l_P o s t
C o n trol_
P re
C o n trol_
P o s t0
5
1 0
1 5M
EP
Am
pli
tud
e (μ
V)
*p<.05 signifies the comparison between experimental and control group in the value of after-
before
Figure 17. Changes in MEP amplitude of affected side in experimental and control
groups
*
- 46 -
*p<.05 signifies the comparison between experimental and control group in the value of after-
before
Figure 16. Changes in MEP latency of affected side in experimental and control
groups
Experi
mental
_Pre
Experi
mental
_Post
Control_P
re
Control_P
ost0
10
20
30M
EP L
aten
cy (m
sec)
*
- 46 -
*p<.05 signifies the comparison between experimental and control group in the value of after-
before
Figure 16. Changes in MEP latency of affected side in experimental and control
groups
Experi
mental
_Pre
Experi
mental
_Post
Control_P
re
Control_P
ost0
10
20
30M
EP L
aten
cy (m
sec)
*
- 50 -
1.1.3 The neurological change by mental practice
To compare neurological changes during mental practice with resting, only the
experimental group was tested with MEP while resting and mentally practicing
feeding activity before and after the intervention period. The MEP amplitude that was
conducted from cerebral cortex to APB muscle showed significant gradual increase
over the tests from resting at pre-intervention test to mental practice at pre-
intervention test, from mental practice at pre-intervention test to resting at post-
intervention test, and from resting at post-intervention test to mental practice at post-
intervention test (χ² = 9.261, p = .026) (Table 6, Figure 18).
- 51 -
Table 6. Comparison of MEP during rest and mental practice in experimental group
(N=7)
*p<.05
p† is to determine the linear change from rest before study to mental practice after study
Note: values are group median (minimum - maximum value)
Before study After study
χ² p†
Rest MP Rest MP
Cortex
Latency
(msec)
23.30
(20.70-28.20)
22.40
(18.40-28.40)
22.30
(19.10-25.80)
21.80
(20.60-27.90)
1.348 .718
Amplitude
(㎶)
2.80
(.48-11.60)
2.40
(.50-11.70)
3.40
(.81-13.20)
5.10
(1.25-13.10) 9.261 .026*
C6
Latency
(msec)
14.10
(7.40-14.90)
14.10
(11.30-14.70)
14.00
(12.10-15.00)
14.20
(13.00-15.00)
3.188 .364
Amplitude
(㎶)
5.70
(.35-13.20)
5.40
(1.21-13.70)
5.50
(4.10-14.20)
6.60
(4.70-13.40) 6.600 .086
- 52 -
*p<.05
signifies the linear change from rest before study to mental practice after study
Figure 18. Change of MEP amplitude from resting in pre-intervention test to mental
practice in post-intervention
Pre
-res
t
Pre
-MP
Post
-res
t
Post
-MP
0
5
10
15
Co
rtex a
mp
litu
de(㎶
)
*
- 53 -
2. Quality of movement
2.1 3-D motion analysis
2.1.1 Movement speed
The movement speed of the experimental and control group was not significantly
different between the group at pre-intervention test (p> .05).
As a result of comparing the change in the movement speed before and after
intervention within each group and between the groups, although the movement speed
of the experimental group increased and that of control group reduced, the changes
was not significant in either way (Table7).
2.1.2 Movement time
The movement time of the experimental and control group was not significantly
different between groups at pre-intervention test (p> .05).
When comparing the movement time at pre- and post-intervention test in each
group, the movement time of the experimental group decreased significantly (Z = -
2.028, p = .043) (Figure19). Although the movement time of control group decreased
as well, the change was not significant.
The result of verifying the difference between the experimental and control group
in the change of movement time from pre- to post-intervention test showed that the
difference between groups were not significant (Table7).
- 54 -
Table 7. Changes in quality of movement in experimental and control group (N=14)
Experimental group (n=7) Control group (n=7) U p‡
Before study After study Z p† Before study After study Z p†
Speed (º/s) 116.30
(112.93-205.03)
156.21
(112.42-218.18) -1.352 .176
124.89
(78.39-138.04)
112.97
(95.09-149.51) .000 1.000 18.000 .406
Time (ms) 1393.33
(1066.67-2253.33)
866.67
(760.00-
1426.67)
-2.028 .043*
1273.33
(1073.33-3846.67)
1060.00
(900.00-1346.67) -1.859 .063 22.000 .749
Smoothness
(number)
13.33
(9.67-21.67)
7.33
(3.00-14.67) -2.197 .028* 11.67
(7.67-50.33)
11.00
(4.33-13.00) -1.992 .046* 16.000 .277
*p<.05 p† is for the comparison between before and after study of the experimental or control group p‡ is for the comparison between experimental and control group in the value of after-before Note: values are group median (minimum - maximum value)
- 54
-
Tabl
e 7.
Cha
nges
in q
ualit
y of
mov
emen
t in
expe
rimen
tal a
nd c
ontro
l gro
up
(
N=1
4)
Ex
perim
enta
l gro
up (n
=7)
Con
trol g
roup
(n=7
) U
p‡
B
efor
e st
udy
Afte
r stu
dy
Z p†
B
efor
e st
udy
Afte
r stu
dy
Z p†
Spee
d (º/
s)
116.
30
(112
.93-
205.
03)
156.
21
(112
.42-
218.
18)
-1.3
52
.176
12
4.89
(78.
39-1
38.0
4)
112.
97
(95.
09-1
49.5
1)
.000
1.
000
18.0
00 .
406
Tim
e (m
s)
1393
.33
(106
6.67
-225
3.33
)
866.
67
(760
.00-
1426
.67)
-2.0
28 .
043*
1273
.33
(107
3.33
-384
6.67
)
1060
.00
(900
.00-
1346
.67)
-1.
859
.063
22
.000
.74
9
Smoo
thne
ss
(num
ber)
13.3
3
(9.6
7-21
.67)
7.33
(3.0
0-14
.67)
-2
.197
.02
8*
11.6
7
(7.6
7-50
.33)
11.0
0
(4.3
3-13
.00)
-1
.992
.04
6*
16.0
00 .
277
*p<.
05
p† is
for t
he c
ompa
rison
bet
wee
n be
fore
and
afte
r stu
dy o
f the
exp
erim
enta
l or c
ontro
l gro
up
p‡ is
for t
he c
ompa
rison
bet
wee
n ex
perim
enta
l and
con
trol g
roup
in th
e va
lue
of a
fter-
befo
re
Not
e: v
alue
s are
gro
up m
edia
n (m
inim
um -
max
imum
val
ue)
- 54 -
Table 7. Changes in quality of movement in experimental and control group (N=14)
Experimental group (n=7) Control group (n=7) U p‡
Before study After study Z p† Before study After study Z p†
Speed (º/s) 116.30
(112.93-205.03)
156.21
(112.42-218.18) -1.352 .176
124.89
(78.39-138.04)
112.97
(95.09-149.51) .000 1.000 18.000 .406
Time (ms) 1393.33
(1066.67-2253.33)
866.67
(760.00-
1426.67)
-2.028 .043*
1273.33
(1073.33-3846.67)
1060.00
(900.00-1346.67) -1.859 .063 22.000 .749
Smoothness
(number)
13.33
(9.67-21.67)
7.33
(3.00-14.67) -2.197 .028* 11.67
(7.67-50.33)
11.00
(4.33-13.00) -1.992 .046* 16.000 .277
*p<.05 p† is for the comparison between before and after study of the experimental or control group p‡ is for the comparison between experimental and control group in the value of after-before Note: values are group median (minimum - maximum value)
- 54
-
Tabl
e 7.
Cha
nges
in q
ualit
y of
mov
emen
t in
expe
rimen
tal a
nd c
ontro
l gro
up
(
N=1
4)
Ex
perim
enta
l gro
up (n
=7)
Con
trol g
roup
(n=7
) U
p‡
B
efor
e st
udy
Afte
r stu
dy
Z p†
B
efor
e st
udy
Afte
r stu
dy
Z p†
Spee
d (º/
s)
116.
30
(112
.93-
205.
03)
156.
21
(112
.42-
218.
18)
-1.3
52
.176
12
4.89
(78.
39-1
38.0
4)
112.
97
(95.
09-1
49.5
1)
.000
1.
000
18.0
00 .
406
Tim
e (m
s)
1393
.33
(106
6.67
-225
3.33
)
866.
67
(760
.00-
1426
.67)
-2.0
28 .
043*
1273
.33
(107
3.33
-384
6.67
)
1060
.00
(900
.00-
1346
.67)
-1.
859
.063
22
.000
.74
9
Smoo
thne
ss
(num
ber)
13.3
3
(9.6
7-21
.67)
7.33
(3.0
0-14
.67)
-2
.197
.02
8*
11.6
7
(7.6
7-50
.33)
11.0
0
(4.3
3-13
.00)
-1
.992
.04
6*
16.0
00 .
277
*p<.
05
p† is
for t
he c
ompa
rison
bet
wee
n be
fore
and
afte
r stu
dy o
f the
exp
erim
enta
l or c
ontro
l gro
up
p‡ is
for t
he c
ompa
rison
bet
wee
n ex
perim
enta
l and
con
trol g
roup
in th
e va
lue
of a
fter-
befo
re
Not
e: v
alue
s are
gro
up m
edia
n (m
inim
um -
max
imum
val
ue)
- 10 -
Table 1. Demographic characteristics (N=14) Participant Gender
/ Age
Inpatient or
outpatient
Affected
extremity
Cerebral Infarction
or hemorrhage
Years of
Education
Months
Post-stroke
Brunnstrom
stage
MMSE
-K
VMIQ
Experimental Group
1 M/49 Inpatient Lt. hemorrhage 15 20 6 30 1.19
2 M/51 Outpatient Lt. Infarction 12 93 4 30 1.67
3 M/61 Inpatient Rt. Infarction 9 43 3 30 1
4 F/52 Outpatient Rt. Infarction 9 120 6 30 1
5 M/51 Outpatient Rt. hemorrhage 12 41 6 30 1
6 F/74 Outpatient Rt. Infarction 6 8 6 28 1
7 M/53 Inpatient Rt. hemorrhage 14 20 6 28 1 Control Group
1 M/49 Inpatient Rt. hemorrhage 11 34 6 30 1.33
2 M/52 Outpatient Lt. Infarction 9 120 6 29 1.31
3 M/67 Inpatient Rt. Infarction 16 25 6 30 1
4 M/52 Inpatient Lt. Hemorrhage 12 96 3 29 1
5 F/66 Outpatient Rt. Hemorrhage 8 192 6 29 1
6 M/72 Outpatient Rt. Infarction 9 3 4 29 1
7 F/68 Outpatient Lt. Infarction 17 65 6 28 1 MMSE-K: Mini-Mental State Examination-Korean; VMIQ: Vividness of Movement Imagery Questionnaire
- 10
-
Tabl
e 1.
Dem
ogra
phic
cha
ract
eris
tics
(N
=14)
Pa
rtici
pant
G
ende
r
/ Age
Inpa
tient
or
outp
atie
nt
Aff
ecte
d
extre
mity
Cer
ebra
l Inf
arct
ion
or h
emor
rhag
e
Yea
rs o
f
Educ
atio
n
Mon
ths
Post
-stro
ke
Bru
nnst
rom
stag
e
MM
SE
-K
VM
IQ
Expe
rim
enta
l Gro
up
1 M
/49
Inpa
tient
Lt
. he
mor
rhag
e 15
20
6
30
1.19
2 M
/51
Out
patie
nt
Lt.
Infa
rctio
n 12
93
4
30
1.67
3 M
/61
Inpa
tient
R
t. In
farc
tion
9 43
3
30
1
4 F/
52
Out
patie
nt
Rt.
Infa
rctio
n 9
120
6 30
1
5 M
/51
Out
patie
nt
Rt.
hem
orrh
age
12
41
6 30
1
6 F/
74
Out
patie
nt
Rt.
Infa
rctio
n 6
8 6
28
1
7 M
/53
Inpa
tient
R
t. he
mor
rhag
e 14
20
6
28
1 C
ontr
ol G
roup
1
M/4
9 In
patie
nt
Rt.
hem
orrh
age
11
34
6 30
1.
33
2 M
/52
Out
patie
nt
Lt.
Infa
rctio
n 9
120
6 29
1.
31
3 M
/67
Inpa
tient
R
t. In
farc
tion
16
25
6 30
1
4 M
/52
Inpa
tient
Lt
. H
emor
rhag
e 12
96
3
29
1
5 F/
66
Out
patie
nt
Rt.
Hem
orrh
age
8 19
2 6
29
1
6 M
/72
Out
patie
nt
Rt.
Infa
rctio
n 9
3 4
29
1
7 F/
68
Out
patie
nt
Lt.
Infa
rctio
n 17
65
6
28
1 M
MSE
-K: M
ini-M
enta
l Sta
te E
xam
inat
ion-
Kor
ean;
VM
IQ: V
ivid
ness
of M
ovem
ent I
mag
ery
Que
stio
nnai
re
- 10 -
Table 1. Demographic characteristics (N=14) Participant Gender
/ Age
Inpatient or
outpatient
Affected
extremity
Cerebral Infarction
or hemorrhage
Years of
Education
Months
Post-stroke
Brunnstrom
stage
MMSE
-K
VMIQ
Experimental Group
1 M/49 Inpatient Lt. hemorrhage 15 20 6 30 1.19
2 M/51 Outpatient Lt. Infarction 12 93 4 30 1.67
3 M/61 Inpatient Rt. Infarction 9 43 3 30 1
4 F/52 Outpatient Rt. Infarction 9 120 6 30 1
5 M/51 Outpatient Rt. hemorrhage 12 41 6 30 1
6 F/74 Outpatient Rt. Infarction 6 8 6 28 1
7 M/53 Inpatient Rt. hemorrhage 14 20 6 28 1 Control Group
1 M/49 Inpatient Rt. hemorrhage 11 34 6 30 1.33
2 M/52 Outpatient Lt. Infarction 9 120 6 29 1.31
3 M/67 Inpatient Rt. Infarction 16 25 6 30 1
4 M/52 Inpatient Lt. Hemorrhage 12 96 3 29 1
5 F/66 Outpatient Rt. Hemorrhage 8 192 6 29 1
6 M/72 Outpatient Rt. Infarction 9 3 4 29 1
7 F/68 Outpatient Lt. Infarction 17 65 6 28 1 MMSE-K: Mini-Mental State Examination-Korean; VMIQ: Vividness of Movement Imagery Questionnaire
- 10
-
Tabl
e 1.
Dem
ogra
phic
cha
ract
eris
tics
(N
=14)
Pa
rtici
pant
G
ende
r
/ Age
Inpa
tient
or
outp
atie
nt
Aff
ecte
d
extre
mity
Cer
ebra
l Inf
arct
ion
or h
emor
rhag
e
Yea
rs o
f
Educ
atio
n
Mon
ths
Post
-stro
ke
Bru
nnst
rom
stag
e
MM
SE
-K
VM
IQ
Expe
rim
enta
l Gro
up
1 M
/49
Inpa
tient
Lt
. he
mor
rhag
e 15
20
6
30
1.19
2 M
/51
Out
patie
nt
Lt.
Infa
rctio
n 12
93
4
30
1.67
3 M
/61
Inpa
tient
R
t. In
farc
tion
9 43
3
30
1
4 F/
52
Out
patie
nt
Rt.
Infa
rctio
n 9
120
6 30
1
5 M
/51
Out
patie
nt
Rt.
hem
orrh
age
12
41
6 30
1
6 F/
74
Out
patie
nt
Rt.
Infa
rctio
n 6
8 6
28
1
7 M
/53
Inpa
tient
R
t. he
mor
rhag
e 14
20
6
28
1 C
ontr
ol G
roup
1
M/4
9 In
patie
nt
Rt.
hem
orrh
age
11
34
6 30
1.
33
2 M
/52
Out
patie
nt
Lt.
Infa
rctio
n 9
120
6 29
1.
31
3 M
/67
Inpa
tient
R
t. In
farc
tion
16
25
6 30
1
4 M
/52
Inpa
tient
Lt
. H
emor
rhag
e 12
96
3
29
1
5 F/
66
Out
patie
nt
Rt.
Hem
orrh
age
8 19
2 6
29
1
6 M
/72
Out
patie
nt
Rt.
Infa
rctio
n 9
3 4
29
1
7 F/
68
Out
patie
nt
Lt.
Infa
rctio
n 17
65
6
28
1 M
MSE
-K: M
ini-M
enta
l Sta
te E
xam
inat
ion-
Kor
ean;
VM
IQ: V
ivid
ness
of M
ovem
ent I
mag
ery
Que
stio
nnai
re
- 10 -
Table 1. Demographic characteristics (N=14) Participant Gender
/ Age
Inpatient or
outpatient
Affected
extremity
Cerebral Infarction
or hemorrhage
Years of
Education
Months
Post-stroke
Brunnstrom
stage
MMSE
-K
VMIQ
Experimental Group
1 M/49 Inpatient Lt. hemorrhage 15 20 6 30 1.19
2 M/51 Outpatient Lt. Infarction 12 93 4 30 1.67
3 M/61 Inpatient Rt. Infarction 9 43 3 30 1
4 F/52 Outpatient Rt. Infarction 9 120 6 30 1
5 M/51 Outpatient Rt. hemorrhage 12 41 6 30 1
6 F/74 Outpatient Rt. Infarction 6 8 6 28 1
7 M/53 Inpatient Rt. hemorrhage 14 20 6 28 1 Control Group
1 M/49 Inpatient Rt. hemorrhage 11 34 6 30 1.33
2 M/52 Outpatient Lt. Infarction 9 120 6 29 1.31
3 M/67 Inpatient Rt. Infarction 16 25 6 30 1
4 M/52 Inpatient Lt. Hemorrhage 12 96 3 29 1
5 F/66 Outpatient Rt. Hemorrhage 8 192 6 29 1
6 M/72 Outpatient Rt. Infarction 9 3 4 29 1
7 F/68 Outpatient Lt. Infarction 17 65 6 28 1 MMSE-K: Mini-Mental State Examination-Korean; VMIQ: Vividness of Movement Imagery Questionnaire
- 10
-
Tabl
e 1.
Dem
ogra
phic
cha
ract
eris
tics
(N
=14)
Pa
rtici
pant
G
ende
r
/ Age
Inpa
tient
or
outp
atie
nt
Aff
ecte
d
extre
mity
Cer
ebra
l Inf
arct
ion
or h
emor
rhag
e
Yea
rs o
f
Educ
atio
n
Mon
ths
Post
-stro
ke
Bru
nnst
rom
stag
e
MM
SE
-K
VM
IQ
Expe
rim
enta
l Gro
up
1 M
/49
Inpa
tient
Lt
. he
mor
rhag
e 15
20
6
30
1.19
2 M
/51
Out
patie
nt
Lt.
Infa
rctio
n 12
93
4
30
1.67
3 M
/61
Inpa
tient
R
t. In
farc
tion
9 43
3
30
1
4 F/
52
Out
patie
nt
Rt.
Infa
rctio
n 9
120
6 30
1
5 M
/51
Out
patie
nt
Rt.
hem
orrh
age
12
41
6 30
1
6 F/
74
Out
patie
nt
Rt.
Infa
rctio
n 6
8 6
28
1
7 M
/53
Inpa
tient
R
t. he
mor
rhag
e 14
20
6
28
1 C
ontr
ol G
roup
1
M/4
9 In
patie
nt
Rt.
hem
orrh
age
11
34
6 30
1.
33
2 M
/52
Out
patie
nt
Lt.
Infa
rctio
n 9
120
6 29
1.
31
3 M
/67
Inpa
tient
R
t. In
farc
tion
16
25
6 30
1
4 M
/52
Inpa
tient
Lt
. H
emor
rhag
e 12
96
3
29
1
5 F/
66
Out
patie
nt
Rt.
Hem
orrh
age
8 19
2 6
29
1
6 M
/72
Out
patie
nt
Rt.
Infa
rctio
n 9
3 4
29
1
7 F/
68
Out
patie
nt
Lt.
Infa
rctio
n 17
65
6
28
1 M
MSE
-K: M
ini-M
enta
l Sta
te E
xam
inat
ion-
Kor
ean;
VM
IQ: V
ivid
ness
of M
ovem
ent I
mag
ery
Que
stio
nnai
re
- 55 -
Exper
imen
tal_
Pre
Exper
imen
tal_
Post
Contr
ol_Pre
Contr
ol_Post
0
1000
2000
3000
4000
5000M
ov
em
en
t ti
me
(m
s)
*p<.05
signifies the comparison between before and after study of the experimental group
Figure 19. Changes in movement time in experimental and control groups
*
- 56 -
2.1.3 Movement smoothness
Movement smoothness of the experimental and control group was not significantly
different between groups at pre-intervention test (p> .05).
When comparing the movement smoothness of pre- and post-intervention test in
each group, the movement unit corresponding to the movement smoothness of both
experimental (Z = -2.197, p = .028) and control (Z = -1.992, p = .046) group
decreased significantly (Figure20).
The result of verifying the difference between groups in the change of movement
smoothness from pre- to post-intervention test were not significantly different
between the two groups (Table7).
- 57 -
Exper
imen
tal_
Pre
Exper
imen
tal_
Post
Contr
ol_Pre
Contr
ol_Post
0
20
40
60M
ov
em
en
t s
mo
oth
ne
ss
(u
nit
)
*p<.05
signifies the comparison between before and after study of the experimental or control
group
Figure 20. Changes in movement units in experimental and control groups
* *
- 58 -
3. Upper extremity function
3.1 Jebsen-Taylor Hand Function Test
Results on all seven items of Jebsen-Taylor Hand Function Test showed that upper
extremity functions of the experimental and control group were not significantly
different between groups at pre-intervention test (p> .05).
As a result of comparing the upper limb functions of pre- and post-intervention test
within each group, only the experimental group showed statistically significant
decrease in performance time in four out of seven items which are writing (Z=-2.366,
p=.018), simulated page turning (Z=-2.023, p=.043), stacking checkers (Z=-1.992,
p=.046), and lifting large and light weighted objects (Z=-2.201, p=.028) (Table 8).
Task performance time of other items performed by the experimental group also
decreased but the change was not statistically significant. The task performance time
of the control group decreased in all items except for the simulated page turning, but
the change was not significant.
As a result of verifying the difference between groups in the change of upper
extremity function from pre- to post-intervention test, the experimental group showed
significantly greater decrease in performance time than the control group in two out
of seven items of writing (U=6.000, p=.018) and simulated page turning (U=8.500,
p=.041) (Table 8).
- 59 -
Table 8. Changes in upper extremity function in experimental and control group (N=14) Experimental group (n=7) Control group (n=7)
U p‡ Before study After study Z p† Before study After study Z p†
Writing 47.28
(31.03-120.00)
30.87
(20.84-54.34) -2.366 .018*
58.72
(30.59-120.00)
45.09
(26.75-120.00) -.734 .463 6.000 .018*
Page turning 26.56
(10.69-120.00)
14.12
(7.56-120.00) -2.023 .043*
16.75
(10.53-120.00)
17.19
(10.09-120.00) .000 1.000 8.500 .041*
Small objects 21.41
(15.72-120.00)
14.56
(9.31-120.00) -.674 .500
34.72
(11.12-120.00)
34.40
(15.09-120.00) -.405 .686 15.000 .220
Feeding 19.37
(10.78-120.00)
13.16
(9.19-98.84) -1.355 .176
27.38
(10.75-120.00)
19.13
(10.40-113.78) -1.183 .237 11.000 .084
Stacking 11.35
(9.25-120.00)
9.10
(6.32-120.00) -1.992 .046*
24.16
(6.34-120.00)
14.03
(5.72-120.00) -1.572 .116 22.500 .798
Large lightweight
objects
9.06
(7.16-120.00)
8.00
(4.91-120.00) -2.201 .028*
10.59
(6.03-120.00)
8.85
(5.35-120.00) -1.572 .116 12.500 .125
Large heavy
objects
8.47
(6.40-120.00)
6.40
(4.44-120.00) -.943 .345
12.78
(5.72-120.00)
10.16
(5.41-120.00) -1.782 .075 16.500 .305
*p<.05, p† is for the comparison between before and after study of the experimental or control group p‡ is for the comparison between experimental and control group in the value of after-before Note: values are group median (minimum - maximum value), all units are sec
- 59
-
Tabl
e 8.
Cha
nges
in u
pper
ext
rem
ity fu
nctio
n in
exp
erim
enta
l and
con
trol g
roup
(
N=1
4)
Ex
perim
enta
l gro
up (n
=7)
Con
trol g
roup
(n=7
) U
p‡
B
efor
e st
udy
Afte
r stu
dy
Z p†
B
efor
e st
udy
Afte
r stu
dy
Z p†
Writ
ing
47.2
8
(31.
03-1
20.0
0)
30.8
7
(20.
84-5
4.34
) -2
.366
.0
18*
58.7
2
(30.
59-1
20.0
0)
45.0
9
(26.
75-1
20.0
0)
-.734
.4
63
6.00
0 .0
18*
Page
turn
ing
26.5
6
(10.
69-1
20.0
0)
14.1
2
(7.5
6-12
0.00
) -2
.023
.0
43*
16.7
5
(10.
53-1
20.0
0)
17.1
9
(10.
09-1
20.0
0)
.000
1.
000
8.50
0 .0
41*
Smal
l obj
ects
21
.41
(15.
72-1
20.0
0)
14.5
6
(9.3
1-12
0.00
) -.6
74
.500
34
.72
(11.
12-1
20.0
0)
34.4
0
(15.
09-1
20.0
0)
-.405
.6
86
15.0
00
.220
Feed
ing
19.3
7
(10.
78-1
20.0
0)
13.1
6
(9.1
9-98
.84)
-1
.355
.1
76
27.3
8
(10.
75-1
20.0
0)
19.1
3
(10.
40-1
13.7
8)
-1.1
83
.237
11
.000
.0
84
Stac
king
11
.35
(9.2
5-12
0.00
)
9.10
(6.3
2-12
0.00
) -1
.992
.0
46*
24.1
6
(6.3
4-12
0.00
)
14.0
3
(5.7
2-12
0.00
) -1
.572
.1
16
22.5
00
.798
Larg
e lig
htw
eigh
t
obje
cts
9.06
(7.1
6-12
0.00
)
8.00
(4.9
1-12
0.00
) -2
.201
.0
28*
10.5
9
(6.0
3-12
0.00
)
8.85
(5.3
5-12
0.00
) -1
.572
.1
16
12.5
00
.125
Larg
e he
avy
obje
cts
8.47
(6.4
0-12
0.00
)
6.40
(4.4
4-12
0.00
) -.9
43
.345
12
.78
(5.7
2-12
0.00
)
10.1
6
(5.4
1-12
0.00
) -1
.782
.0
75
16.5
00
.305
*p<.
05,
p† is
for t
he c
ompa
rison
bet
wee
n be
fore
and
afte
r stu
dy o
f the
exp
erim
enta
l or c
ontro
l gro
up
p‡ is
for t
he c
ompa
rison
bet
wee
n ex
perim
enta
l and
con
trol g
roup
in th
e va
lue
of a
fter-
befo
re
Not
e: v
alue
s are
gro
up m
edia
n (m
inim
um -
max
imum
val
ue),
all u
nits
are
sec
- 59 -
Table 8. Changes in upper extremity function in experimental and control group (N=14) Experimental group (n=7) Control group (n=7)
U p‡ Before study After study Z p† Before study After study Z p†
Writing 47.28
(31.03-120.00)
30.87
(20.84-54.34) -2.366 .018*
58.72
(30.59-120.00)
45.09
(26.75-120.00) -.734 .463 6.000 .018*
Page turning 26.56
(10.69-120.00)
14.12
(7.56-120.00) -2.023 .043*
16.75
(10.53-120.00)
17.19
(10.09-120.00) .000 1.000 8.500 .041*
Small objects 21.41
(15.72-120.00)
14.56
(9.31-120.00) -.674 .500
34.72
(11.12-120.00)
34.40
(15.09-120.00) -.405 .686 15.000 .220
Feeding 19.37
(10.78-120.00)
13.16
(9.19-98.84) -1.355 .176
27.38
(10.75-120.00)
19.13
(10.40-113.78) -1.183 .237 11.000 .084
Stacking 11.35
(9.25-120.00)
9.10
(6.32-120.00) -1.992 .046*
24.16
(6.34-120.00)
14.03
(5.72-120.00) -1.572 .116 22.500 .798
Large lightweight
objects
9.06
(7.16-120.00)
8.00
(4.91-120.00) -2.201 .028*
10.59
(6.03-120.00)
8.85
(5.35-120.00) -1.572 .116 12.500 .125
Large heavy
objects
8.47
(6.40-120.00)
6.40
(4.44-120.00) -.943 .345
12.78
(5.72-120.00)
10.16
(5.41-120.00) -1.782 .075 16.500 .305
*p<.05, p† is for the comparison between before and after study of the experimental or control group p‡ is for the comparison between experimental and control group in the value of after-before Note: values are group median (minimum - maximum value), all units are sec
- 59
-
Tabl
e 8.
Cha
nges
in u
pper
ext
rem
ity fu
nctio
n in
exp
erim
enta
l and
con
trol g
roup
(
N=1
4)
Ex
perim
enta
l gro
up (n
=7)
Con
trol g
roup
(n=7
) U
p‡
B
efor
e st
udy
Afte
r stu
dy
Z p†
B
efor
e st
udy
Afte
r stu
dy
Z p†
Writ
ing
47.2
8
(31.
03-1
20.0
0)
30.8
7
(20.
84-5
4.34
) -2
.366
.0
18*
58.7
2
(30.
59-1
20.0
0)
45.0
9
(26.
75-1
20.0
0)
-.734
.4
63
6.00
0 .0
18*
Page
turn
ing
26.5
6
(10.
69-1
20.0
0)
14.1
2
(7.5
6-12
0.00
) -2
.023
.0
43*
16.7
5
(10.
53-1
20.0
0)
17.1
9
(10.
09-1
20.0
0)
.000
1.
000
8.50
0 .0
41*
Smal
l obj
ects
21
.41
(15.
72-1
20.0
0)
14.5
6
(9.3
1-12
0.00
) -.6
74
.500
34
.72
(11.
12-1
20.0
0)
34.4
0
(15.
09-1
20.0
0)
-.405
.6
86
15.0
00
.220
Feed
ing
19.3
7
(10.
78-1
20.0
0)
13.1
6
(9.1
9-98
.84)
-1
.355
.1
76
27.3
8
(10.
75-1
20.0
0)
19.1
3
(10.
40-1
13.7
8)
-1.1
83
.237
11
.000
.0
84
Stac
king
11
.35
(9.2
5-12
0.00
)
9.10
(6.3
2-12
0.00
) -1
.992
.0
46*
24.1
6
(6.3
4-12
0.00
)
14.0
3
(5.7
2-12
0.00
) -1
.572
.1
16
22.5
00
.798
Larg
e lig
htw
eigh
t
obje
cts
9.06
(7.1
6-12
0.00
)
8.00
(4.9
1-12
0.00
) -2
.201
.0
28*
10.5
9
(6.0
3-12
0.00
)
8.85
(5.3
5-12
0.00
) -1
.572
.1
16
12.5
00
.125
Larg
e he
avy
obje
cts
8.47
(6.4
0-12
0.00
)
6.40
(4.4
4-12
0.00
) -.9
43
.345
12
.78
(5.7
2-12
0.00
)
10.1
6
(5.4
1-12
0.00
) -1
.782
.0
75
16.5
00
.305
*p<.
05,
p† is
for t
he c
ompa
rison
bet
wee
n be
fore
and
afte
r stu
dy o
f the
exp
erim
enta
l or c
ontro
l gro
up
p‡ is
for t
he c
ompa
rison
bet
wee
n ex
perim
enta
l and
con
trol g
roup
in th
e va
lue
of a
fter-
befo
re
Not
e: v
alue
s are
gro
up m
edia
n (m
inim
um -
max
imum
val
ue),
all u
nits
are
sec
- 60 -
4. ADLs
4.1 Motor Activity Log (MAL)
As a result of comparing the ADLs performance by the affected upper extremity of
the experimental and control group, both subtests of the amount of use and how well
the movement is were not significantly different between groups at pre-intervention
test (p> .05).
When comparing the ADLs performance of pre- and post-intervention tests within
each group, the experimental group showed statistically significant increase in ADL
scores in both subtests of the amount of use (Z=-2.366, p=.018) and how well the
movement is (Z=-2.366, p=.018) (Table 9). The control group showed significant
increase in only the how well the movement is (Z = -2.197, p = .028).
As a result of verifying the difference between groups in the change of ADLs
performance from pre- to post-intervention test, the experimental group showed
significantly greater increase in the ADLs scores than the control group in both
amount of use (U=5.000, p=.013) (Figure 21) and how well the movement is
(U=1.000, p=.003) (Figure 22).
- 61
-
Tabl
e 9.
Cha
nges
in A
DLs
in e
xper
imen
tal a
nd c
ontro
l gro
up
(N
=14)
Ex
perim
enta
l gro
up (n
=7)
Con
trol g
roup
(n=7
) U
p‡
B
efor
e st
udy
Afte
r stu
dy
Z p†
B
efor
e st
udy
Afte
r stu
dy
Z p†
Am
ount
1.
10
(.23-
2.17
)
3.73
(2.3
3-4.
93)
-2.3
66
.018
* 1.
37
(.07-
2.70
)
2.40
(.13-
4.67
) -1
.859
.0
63
5.00
0 .0
13*
How
wel
l 1.
93
(.87-
2.47
)
3.67
(2.3
3-4.
33)
-2.3
66
.018
* 2.
07
(.07-
2.97
)
2.43
(.90-
3.73
) -2
.197
.0
28*
1.00
0 .0
03*
*p<.
05
p† is
for t
he c
ompa
rison
bet
wee
n be
fore
and
afte
r stu
dy o
f the
exp
erim
enta
l or c
ontro
l gro
up
p‡ is
for t
he c
ompa
rison
bet
wee
n ex
perim
enta
l and
con
trol g
roup
in th
e va
lue
of a
fter-
befo
re
Not
e: v
alue
s are
gro
up m
edia
n (m
inim
um -
max
imum
val
ue),
all u
nits
are
scor
e
- 61 -
Table 9. Changes in ADLs in experimental and control group (N=14)
Experimental group (n=7) Control group (n=7) U p‡
Before study After study Z p† Before study After study Z p†
Amount 1.10
(.23-2.17)
3.73
(2.33-4.93) -2.366 .018*
1.37
(.07-2.70)
2.40
(.13-4.67) -1.859 .063 5.000 .013*
How well 1.93
(.87-2.47)
3.67
(2.33-4.33) -2.366 .018*
2.07
(.07-2.97)
2.43
(.90-3.73) -2.197 .028* 1.000 .003*
*p<.05 p† is for the comparison between before and after study of the experimental or control group p‡ is for the comparison between experimental and control group in the value of after-before Note: values are group median (minimum - maximum value), all units are score
- 61
-
Tabl
e 9.
Cha
nges
in A
DLs
in e
xper
imen
tal a
nd c
ontro
l gro
up
(N
=14)
Ex
perim
enta
l gro
up (n
=7)
Con
trol g
roup
(n=7
) U
p‡
B
efor
e st
udy
Afte
r stu
dy
Z p†
B
efor
e st
udy
Afte
r stu
dy
Z p†
Am
ount
1.
10
(.23-
2.17
)
3.73
(2.3
3-4.
93)
-2.3
66
.018
* 1.
37
(.07-
2.70
)
2.40
(.13-
4.67
) -1
.859
.0
63
5.00
0 .0
13*
How
wel
l 1.
93
(.87-
2.47
)
3.67
(2.3
3-4.
33)
-2.3
66
.018
* 2.
07
(.07-
2.97
)
2.43
(.90-
3.73
) -2
.197
.0
28*
1.00
0 .0
03*
*p<.
05
p† is
for t
he c
ompa
rison
bet
wee
n be
fore
and
afte
r stu
dy o
f the
exp
erim
enta
l or c
ontro
l gro
up
p‡ is
for t
he c
ompa
rison
bet
wee
n ex
perim
enta
l and
con
trol g
roup
in th
e va
lue
of a
fter-
befo
re
Not
e: v
alue
s are
gro
up m
edia
n (m
inim
um -
max
imum
val
ue),
all u
nits
are
scor
e
- 61 -
Table 9. Changes in ADLs in experimental and control group (N=14)
Experimental group (n=7) Control group (n=7) U p‡
Before study After study Z p† Before study After study Z p†
Amount 1.10
(.23-2.17)
3.73
(2.33-4.93) -2.366 .018*
1.37
(.07-2.70)
2.40
(.13-4.67) -1.859 .063 5.000 .013*
How well 1.93
(.87-2.47)
3.67
(2.33-4.33) -2.366 .018*
2.07
(.07-2.97)
2.43
(.90-3.73) -2.197 .028* 1.000 .003*
*p<.05 p† is for the comparison between before and after study of the experimental or control group p‡ is for the comparison between experimental and control group in the value of after-before Note: values are group median (minimum - maximum value), all units are score
- 62 -
*p<.05
signifies the comparison between before and after study of the experimental group and
the comparison between experimental and control group in the value of after-before
Figure 21. Changes in amount of use in experimental and control groups
*
Exper
imen
tal_
Pre
Exper
imen
tal_
Post
Contr
ol_Pre
Contr
ol_Post
0
2
4
6
Am
ou
nt
of
us
e (
sc
ore
)
*
*
- 63 -
*p<.05
signifies the comparison between before and after study of the experimental and control
group and the comparison between experimental and control group in the value of after-before
Figure 22. Changes in movement quality in experimental and control groups
Exper
imen
tal_
Pre
Exper
imen
tal_
Post
Contr
ol_Pre
Contr
ol_Post
0
1
2
3
4
5
Ho
w w
ell (
sc
ore
)
* *
*
- 64 -
Discussion
This study compared the combined therapy of mental practice and mCIMT with
mCIMT alone in developing more effective neurological changes, enriching the
quality of movement, improving hand functions of the affected upper extremity, and
changing the performance in ADLs of people who have had stroke.
When applied the combined therapy of mental practice and mCIMT and only
mCIMT respectively to the homogeneous two groups, both groups improved in the
quality of movement and ADLs functions of the affected side. In the experimental
group, changes in upper extremity functions also appeared, and changes from pre- to
post-intervention test were significantly greater in neurological, functional, and ADLs
aspect compared to that of the control group.
In terms of neurological changes, application of the combined therapy of mental
practice and mCIMT positively changed the corticospinal excitability by reducing the
latency of neural signals conducting from cortex to peripheral muscles and increasing
the signal’s amplitude compared to that of applying mCIMT alone. As well as the
fMRI, measuring the MEP after a magnetic field is induced by Transcranial Magnetic
Stimulation (TMS) is utilized to test the functional integrity of the corticospinal tract
following stroke (Stinear et al., 2007). The increase in MEP amplitude and decrease
in MEP latency in stroke patients indicate that the excitability of the motor neurons
from the damaged cerebral hemisphere has increased (Liepert et al., 1998). Lacourse,
- 65 -
Turner, Randolph-Orr, Schandler, and Cohen (2004) studied the changes of motor
task performance time and neurological changes from MRI by dividing populations of
healthy university students into three groups of a physical exercise group, mental
practice group, and control group without any treatment and comparing the groups
after a week of interventions. As a the result, the performance improved in the order
of the physical exercise, mental practice and control group. The neurological change
in MRI showed that even though the striatal activation increased and cerebellar
activation decreased in the physical practice group, all cerebellar, premotor, and
striatal activation increased in the mental practice group. Similarly, in our study, after
two-week intervention of mental practice and mCIMT combined, the increase in
amplitude and decrease in latency of neural conduction from the magnetic field in
motor cortex to target muscle were both significantly greater than that of the
intervention of mCIMT alone which was a type of physical practice.
Furthermore, this study determined the gradual increase in activation from resting
state at pre-intervention test, mental practice state at pre-intervention test, resting state
at post-intervention test, and mental practice state at post-intervention test,
respectively, in the group that participated in the combined therapy of mental practice
and mCIMT. This result is consistent with the study by Kasai, Kawai, Kawanishi, and
Yahagi (1997) that compared MEP amplitude during mentally practicing wrist
flexion with that of the resting state in healthy male and female participants in their
20s to 40s. Their result showed increased MEP amplitude stimulated from cortex and
assessed at the Flexor carpi radialis muscle during mental practice compared to
- 66 -
resting. In addition, the result of this study is consistent with that of Stinear, Byblow,
Steyvers, Levin, and Swinnen (2006) in that, unlike the visual mental practice which
use visual information to imagine about the target movement, the kinesthetic mental
practice which focus on the movement significantly increases the MEP amplitude
from cortex to Abductor pollicis brevis muscle. However, this study has great
meaning in that it verified the gradual change in terms of neural activation from pre-
to post- intervention test of two-week combined therapy of mental practice and
mCIMT as well as the immediate neural activation that appears during the mental
practice.
Appropriate methods of mental practice for stroke patients were designed in this
study. Patients with stroke have possibilities of having trouble vividly imagining or
having temporal coupling which is their abnormal movement hindering them from
imagining normal movement (Sharma, Pomeroy, & Baron, 2006). Accordingly,
action observation of observing normal movement is occasionally used as a mean to
help the mental practice of patients with stroke (Cha, 2013). According to the results
of a recent research attempted to confirm the effect of the action observation, the
electroencephalogram (EEG) when observing motion in the video was 80% identical
with the EEG when actually performing a motion (Neuper, Scherer, Reiner, &
Pfurtscheller, 2005). Further, in a study compared the MEP which indicates the
corticospinal excitability in three conditions of only observing a motor task,
imagining one, and doing both, the corticospinal excitability activated only in the
third condition of partaking in both observation and mental practice (Sakamoto,
- 67 -
Muraoka, Mizuguchi, & Kanosue, 2009). In particular, at the time of observation,
rather than the third-person perspective of watching the actor in the video who is
performing an activity from the front, the first-person perspective of showing the
performance of activities in the video as if the observer is the actor in the video and
performing the activity resulted in significant change in MEP (Maeda, Kleiner-
Fisman, & Pascual-Leone, 2002). Therefore, since this study grafted the first-person
perspective action observation onto mental practice to apply appropriate mental
practice methods for patients with stroke, it might have influenced positively to the
result of this study by helping the participants to imagine easily.
In the aspect of changes in the quality of movement of the affected upper extremity,
the movement of the experimental group improved in time and smoothness and only
the movement smoothness improved in the control group that conducted only the
mCIMT. Yet, the changes in each group were not significantly different between
groups. This means that even though only the combined therapy of mental practice
and mCIMT resulted in significant change and mCIMT alone did not, the difference
between groups was not significantly different in the movement time. Also, even
though both group had meaningful changes within their groups, the difference
between group was not significant, so comparing the superiority between the groups
was not possible in the movement smoothness.
In various upper extremity functions, the experimental group participated in
combined therapy of mental practice and mCIMT showed change from pre- to post-
intervention test in writing, simulated page turning, stacking checkers, and lifting
- 68 -
large and light-weighted objects. Among the activities, after treating with both mental
practice and mCIMT, the upper extremity functions more effectively improved than
only treating with mCIMT in writing and simulated page turning. This result is
consistent with the results of a study by Page et al.(2009) in that upper extremity
functions improve more when applied mental practice and mCIMT together, but it is
not consistent to the previous study in that both group improved in upper extremity
functions because the control group only partook in mCIMT did not improve in upper
extremity functions in our study. The intervention period of only being two weeks
compared to ten weeks of interventions in the study of Page et al.(2009) might be a
reason for this difference in results with the previous study. Moreover, different from
most of the previous studies that promoted the function and damage of the affected
upper limb after two weeks of CIMT intervention intended for stroke patients in their
acute phases, in this study, most participants were in their chronic phases of stroke
(Nijland, Kwakkel, Bakers, & van Wegen, 2011). Thus most of recovery already may
have reached their plateau. Further study is needed to validate the effects of longer
period of mCIMT intervention in the future.
Among the elements of ADLs evaluated using the MAL, only the experimental
group showed meaningful change from pre- to post-intervention test in the amount of
use, and both group showed meaningful change from pre- to post-intervention test in
the how well they use in ADLs. The experimental group had significantly greater
changes in both ADLs elements of amount and how well of use. This might be related
to the results of quality of movement in that the movement smoothness which
- 69 -
influence greatly the how well one uses their affected side improves but other
elements related to speed does not improve in the control group. On the other hand,
the experimental group additionally improved in both, the movement time associated
with speed and amount of use in ADLs elements.
Limitations of this study are as follows and they must be complemented in future
research. Firstly, the number of participants is too small to generalize the results of
the present study to greater population with stroke. Secondly, the possibility of
intervened examiner’s bias on the test results cannot be excluded since single blinding
to this study was possible which means only the participants were blinded to the study
but the examiner was not except for the MEP test. Thirdly, since the intervention
period is only for two weeks which is much shorter period of time than many of the
mCIMT studies of three to ten weeks, it is hard to conclude that the effect of mCIMT
fully revealed in this study (Shi, Tian, Yang, & Zhao, 2011). Further study is
necessary to evaluate the difference of the combined therapy of mental practice and
mCIMT and mCIMT alone through long-term studies with more participants in
diverse institutions and double blinding research design.
- 70 -
Conclusion
The aim of this study was to compare whether the effect of combined therapy of
mental practice and mCIMT on neurological changes, qualitative improvement of the
affected upper extremity, enhanced upper extremity functions, and changes in
everyday activities is more effective than that of the mCIMT intervention alone. In
order to measure the changes in corticospinal excitability, quality of movement, upper
extremity functions, and ADLs, motor evoked potential (MEP), 3-D motion analysis,
Jebsen-Taylor hand function test, and Motor Ativity Log (MAL) was used,
respectively.
As results, changes in quality of movement and ADLs appeared in both group. The
experimental group treated with the combined therapy of mental practice and mCIMT
had additional changes in upper extremity function and their changes in neurological
activations, upper extremity functions, and performance in ADLs were significantly
greater than that of the control group. However, the superiority of a group in the
change of quality of movement has not been proven. In addition, we confirmed that
mental practice trigger neurological changes by testing the change in MEP signals
during resting and mental practice state. Through these results, the combined therapy
of mental practice and mCIMT was verified to be an effective intervention method for
patients with stroke and it could be effectively utilized in clinical fields.
- 71 -
References
Braun, S., Kleynen, M., Schols, J., Schack, T., Beurskens, A., & Wade, D. (2008).
Using mental practice in stroke rehabilitation: A framework. Clinical
Rehabilitation, 22, 579-591. doi: 10.1177/0269215508090066
Brunnstrom, S. (1966). Motor testing procedures in hemiplegia: Based on sequential
recovery stages. Physical Therapy, 46, 357.
Cha, Y. J. (2013). Effects of Mental Practice with Action Observation Training on
Occupational Performance Following Stroke. (Doctoral dissertation). Yonsei
University, Seoul.
Cha, Y-J., Yoo, E-Y., Jung, M-Y., Park, S-H., & Park, J-H. (2012). Effects of
functional task training with mental practice in stroke: A meta analysis.
NeuroRehabilitation, 30, 239-246.
Coupar, F., Pollock, A., Rowe, P., Weir, C., & Langhorne, P. (2012). Predictors of
upper limb recovery after stroke: A systematic review and meta-analysis.
Clinical Rehabilitation, 26, 291-313.
- 72 -
Dahl, A. E., Askim, T., Stock, R., Langørgen, E., Lydersen, S., & Indredavik, B.
(2008). Short-and long-term outcome of constraint-induced movement therapy
after stroke: A randomized controlled feasibility trial. Clinical Rehabilitation, 22,
436-447.
de Groot, M. H., Phillips, S. J., & Eskes, G. A. (2003). Fatigue associated with stroke
and other neurologic conditions: Implications for stroke rehabilitation. Archives
of Physical Medicine and Rehabilitation, 84, 1714-1720. doi: 10.1053/s0003-
9993(03)00346-0
Feltz, D. L., & Landers, D. M. (1983). The effects of mental practice on motor skill
learning and performance: A meta-analysis. Journal of Sport Psychology, 5, 25-
57.
Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Borden, W.
B., ... & Stroke, S. S. (2013). Heart disease and stroke statistics--2013 update: A
report from the American Heart Association. Circulation, 127, e6.
Hakkennes, S., & Keating, J. L. (2005). Constraint-induced movement therapy
following stroke: A systematic review of randomised controlled trials.
Australian Journal of Physiotherapy, 51, 221-231.
- 73 -
Hammer, A. M., & Lindmark, B. (2010). Responsiveness and validity of the Motor
Activity Log in patients during the subacute phase after stroke. Disability &
Rehabilitation, 32, 1184-1193.
Hendricks, H. T., Zwarts, M. J., Plat, E. F., & van Limbeek, J. (2002). Systematic
review for the early prediction of motor and functional outcome after stroke by
using motor-evoked potentials. Archives of Physical Medicine and
Rehabilitation, 83, 1303-1308. doi: http://dx.doi.org/10.1053/apmr.2002.34284
Ietswaart, M., Johnston, M., Dijkerman, H. 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. doi:
10.1093/brain/awr077
Isaac, A., & Marks, D. F. (1994). Individual differences in mental imagery
experience: Developmental changes and specialization. British Journal of
Psychology, 85, 479-500.
Isaac, A., Marks, D. F., & Russell, D. G. . (1986). An instrument for assessing
imagery of movement: The Vividness of Movement Imagery Questionnaire
(VMIQ). Journal of Mental Imagery, 10, 23-30.
- 74 -
Jebsen, R. H., Taylor, N., Trieschmann, R. B., Trotter, M. J., & Howard, L. A. (1969).
An objective and standardized test of hand function. Archives of Physical
Medicine and Rehabilitation, 50, 311-319.
Kang, M. J., Yoon, T. S., Park, C. I., & Chun, S-I. (1993). Motor evoked potential in
stroke. Journal of Korean Academy of Rehabilitation Medicine, 17, 26-35.
Kang, Y. W., Na, D. L., & Hahn, S. H. (1997). A validity study on the Korean mini-
mental state examination (K-MMSE) in dementia patients. Korean Journal of
Neurology, 15, 300-308.
Kasai, T., Kawai, S., Kawanishi, M., & Yahagi, S. (1997). Evidence for facilitation of
motor evoked potentials (MEPs) induced by motor imagery. Brain research, 744,
147-150.
Kiers, L., Fernando, B., & Tomkins, D. (1997). Facilitatory effect of thinking about
movement on magnetic motor-evoked potentials. Electroencephalography and
Clinical Neurophysiology/Electromyography and Motor Control, 105, 262-268.
Kim, Y. H., You, S. H., Ko, M. H., Park, J. W., Lee, K. H., Jang, S. H., . . . Hallett, M.
(2006). Repetitive transcranial magnetic stimulation-induced corticomotor
- 75 -
excitability and associated motor skill acquisition in chronic stroke. Stroke, 37,
1471-1476. doi: 10.1161/01.str.0000221233.55497.51
Kwon, Y. C., & Park, J-H. (1989). Korean Version of Mini-Mental State Examination
(MMSE-K) Part 1: Developement of the test for the elderly. Journal of Korean
Neuropsychiatric Association, 28, 125-135.
Lacourse, M. G., Orr, E. L. R., Cramer, S. C., & Cohen, M. J. (2005). Brain activation
during execution and motor imagery of novel and skilled sequential hand
movements. Neuroimage, 27, 505-519. doi: 10.1016/j.neuroimage.2005.04.025
Lacourse, M. G., Turner, J. A., Randolph-Orr, E., Schandler, S. L., & Cohen, M. J.
(2004). Cerebral and cerebellar sensorimotor plasticity following motor imagery-
based mental practice of a sequential movement. Journal of Rehabilitation
Research and Development, 41, 505-523. doi: 10.1682/jrrd.2004.04.0505
Liepert, J., Miltner, W. H. R., Bauder, H., Sommer, M., Dettmers, C., Taub, E., &
Weiller, C. (1998). Motor cortex plasticity during constraint-induced movement
therapy in stroke patients. Neuroscience Letters, 250, 5-8.
Liu, K. P., Chan, C. C., Lee, T. M., & Hui-Chan, C. W. (2004). Mental imagery for
promoting relearning for people after stroke: A randomized controlled trial.
- 76 -
Archives of Physical Medicine and Rehabilitation, 85, 1403-1408. doi:
http://dx.doi.org/10.1016/j.apmr.2003.12.035
Maeda, F., Kleiner-Fisman, G., & Pascual-Leone, A. (2002). Motor facilitation while
observing hand actions: Specificity of the effect and role of observer's
orientation. Journal of Neurophysiology, 87, 1329-1335. doi:
10.1152/jn.00773.2000
Mulder, T. (2007). Motor imagery and action observation: Cognitive tools for
rehabilitation. Journal of Neural Transmission, 114, 1265-1278.
Neuper, C., Scherer, R., Reiner, M., & Pfurtscheller, G. (2005). Imagery of motor
actions: Differential effects of kinesthetic and visual-motor mode of imagery in
single-trial EEG. Cognitive Brain Research, 25, 668-677. doi:
10.1016/j.cogbrainres.2005.08.014
Nijland, R., Kwakkel, G., Bakers, J., & van Wegen, E. (2011). Constraint-induced
movement therapy for the upper paretic limb in acute or sub-acute stroke: A
systematic review. International Journal of Stroke, 6, 425-433.
- 77 -
Page, S. J., Levine, P., & Hill, V. (2007a). 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.
Page, S. J., Levine, P., & Khoury, J. C. (2009). Modified Constraint-induced Therapy
combined with mental practice: Thinking through better motor outcomes. Stroke,
40, 551-554. doi: 10.1161/strokeaha.108.528760
Page, S. J., Levine, P., & Leonard, A. (2007b). Mental practice in chronic stroke:
Results of a randomized, placebo-controlled trial. Stroke, 38, 1293-1297. doi:
10.1161/01.STR.0000260205.67348.2b
Page, S. J., Levine, P., Sisto, S., Bond, Q., & Johnston, M. V. (2002). Stroke patients'
and therapists' opinions of constraint-induced movement therapy. Clinical
Rehabilitation, 16(1), 55-60.
Peurala, S. H., Kantanen, M. P., Sjögren, T., Paltamaa, J., Karhula, M., & Heinonen,
A. (2012). Effectiveness of constraint-induced movement therapy on activity and
participation after stroke: A systematic review and meta-analysis of randomized
controlled trials. Clinical Rehabilitation, 26, 209-223.
- 78 -
Rhee, J. A., Chung, E. K., Shin, M. H., Lee, Y. J., & Son, E. J. (2002). Comparison of
the time and change test and K-MMSE for screening of dementia in the elderly.
Korean Journal of Research in Gerontology, 11, 27-41.
Rice, M. S., Alaimo, A. J., & Cook, J. A. (1999). Movement dynamics and
occupational embeddedness in a grasping and placing task. Occupational
Therapy International, 6, 298–307.
Sakamoto, M., Muraoka, T., Mizuguchi, N., & Kanosue, K. (2009). Combining
observation and imagery of an action enhances human corticospinal excitability.
Neuroscience Research, 65, 23-27. doi: 10.1016/j.neures.2009.05.003
Sharma, N., Pomeroy, V. M., & Baron, J. C. (2006). Motor imagery a backdoor to the
motor system after stroke?. Stroke, 37, 1941-1952.
Shi, Y. X., Tian, J. H., Yang, K. H., & Zhao, Y. (2011). Modified constraint-induced
movement therapy versus traditional rehabilitation in patients with upper-
extremity dysfunction after stroke: A systematic review and meta-analysis.
Archives of Physical Medicine and Rehabilitation, 92, 972-982.
Statistics Korea. (2013). Cause of death Statistics in 2012. Daejeon, Republic of
Korea: author.
- 79 -
Stinear, C. M., Barber, P. A., Smale, P. R., Coxon, J. P., Fleming, M. K., & Byblow,
W. D. (2007). Functional potential in chronic stroke patients depends on
corticospinal tract integrity. Brain, 130, 170-180.
Stinear, C. M., Byblow, W. D., Steyvers, M., Levin, O., & Swinnen, S. P. (2006).
Kinesthetic, but not visual, motor imagery modulates corticomotor excitability.
Experimental Brain Research, 168, 157-164.
Tatemichi, T. K., Desmond, D. W., Stern, Y., Paik, M., Sano, M., & Bagiella, E.
(1994). Cognitive impairment after stroke: Frequency, patterns, and relationship
to functional abilities. Journal of Neurology, Neurosurgery & Psychiatry, 57,
202-207. doi: 10.1136/jnnp.57.2.202
van der Lee, J. H., Beckerman, H., Knol, D. L., de Vet, H. C., & Bouter, L. M. (2004).
Clinimetric properties of the motor activity log for the assessment of arm use in
hemiparetic patients. Stroke, 35, 1410-1414. doi:
10.1161/01.STR.0000126900.24964.7e
van Kuijk, A. A., Pasman, J. W., Hendricks, H. T., Zwarts, M. J., & Geurts, A. C.
(2009). Predicting hand motor recovery in severe stroke: The role of motor
evoked potentials in relation to early clinical assessment. Neurorehabilitation
and Neural Repair, 23, 45-51.
- 80 -
Williams, J., Pearce, A. J., Loporto, M., Morris, T., & Holmes, P. S. (2012). The
relationship between corticospinal excitability during motor imagery and motor
imagery ability. Behavioural Brain Research, 226, 369-375. doi:
10.1016/j.bbr.2011.09.014
Wolf, S. L., Blanton, S. , Baer, H. , Breshears, J. , & Butler, A. J. . (2002). Repetitive
task practice: A critical review of constraint-induced movement therapy in stroke.
Neurologist, 8, 325-338.
Wolf, S. L., Winstein, C. J., Miller, J. P., Taub, E., Uswatte, G., Morris, D., ... &
EXCITE investigators. (2006). Effect of constraint-induced movement therapy
on upper extremity function 3 to 9 months after stroke: The EXCITE
randomized clinical trial. JAMA, 296, 2095-2104.
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국문 요약
뇌졸중을 위한 강제유도운동치료와 상상연습을
병행한 훈련의 효과 비교
연세대학교 대학원
작업치료학과
김 희
본 연구는 뇌졸중 편마비 환자에게 수정된 강제유도운동치료(modified
Constraint-induced movement therapy; mCIMT)에 상상연습(Mental practice)을
결합한 치료 중재를 하였을 때, mCIMT 단독 중재를 했을 때에 비해서 더
효과적인 신경학적 변화와 손상측 움직임의 질적 향상 여부, 상지 기능의
증진과 더 나아가 일상생활 기능에 효과가 있는지 비교하고자 하였다.
본 연구의 대상자인 14 명의 뇌졸중 환자를 층화추출법을 사용하여
실험군 7 명과 대조군 7 명으로 나누었다. 신경학적 변화를 측정하기
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위해서 운동유발전위(MEP)를, 운동의 질적 변화를 측정하기 위해서 3 차원
동작분석을, 기능적 변화를 보기 위해서 젭슨-테일러 손기능 검사를,
일상생활의 변화를 보기 위해서 Motor Ativity Log(MAL)를 측정하였다.
모든 대상자들은 2 주 동안 mCIMT 치료에 참여하였고, 실험군만 매일
10 분간 추가로 먹기 활동에 대한 상상연습을 병행하였다.
그 결과, mCIMT 와 상상연습을 결합한 치료와 mCIMT 만을 단독으로
적용하였을 때, 두 집단 모두에서 뻗기 움직임의 질적과 일상생활
수행수준의 향상이 있었다(p<.05). 그러나 mCIMT 와 상상연습을 결합한
중재를 받은 실험군에서는 상지의 기능적 향상(p<.05)이 추가로 나타났으며,
신경학적 활성도, 상지 기능, 일상생활 수행의 변화가 대조군에 비해
유의하게 향상되었다(p<.05). 또한 중재 시작 전과 후에 각각 휴식과
상상연습을 수행하는 동안의 4 가지 조건에서 신경학적 활성도를
측정하였을 때, 중재 전의 휴식, 중재 전의 상상연습, 중재 후의 휴식, 중재
후의 상상연습으로 갈수록 점차적으로 증가된 활성화가 통계적으로
유의미하였다(p<.05).
본 연구를 통하여 mCIMT 와 상상연습을 병행하여 치료할 경우
mCIMT 만을 사용한 경우보다 뇌졸중 환자의 신경학적 활성도, 상지 기능,
그리고 일상생활의 측면에서 더욱 효과적인 호전이 보임을 확인하였다.
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그러므로 상상연습과 mCIMT 의 결합 치료는 뇌졸중 환자의 상지 재활을
위해 임상적으로 유용한 중재 방법으로 사용 가능할 것으로 사료된다.
핵심 되는 말: 신경 활성도, 운동 상상, 작업수행, 층화추출, 과제기반 훈련,
뇌졸중
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Appendix 1
Instructions for Mental Practice
∙ Look at the computer screen.
∙ You are now comfortably sitting in a chair.
∙ Put your hands on your knees, and your feet to touches the ground in the
most comfortable way as you can.
Video observation
(First-person perspective of holding a spoon and taking food from the bowl to
the mouth)
∙ From now on you will see a movement of spooning the soup from the bowl
and bringing it to the mouth using a spoon by the computer monitor.
∙ On a desk in front of you, there is a soup half full in the bowl. There is a
spoon beside it. Can you see it?
∙ Move both your hands from your knees and gently place them beside the
bowl and the spoon.
∙ You see a spoon at your right side.
∙ Now lift your right hand gently and firmly hold the handle of the spoon.
∙ Lift the spoon, and try not to drop your wrist with some strength.
∙ Take the spoon to the bowl.
∙ Gently rotate your wrist to scoop soup with your spoon.
∙ Now slowly take spoon to your mouth. Try not to spill it with smooth gentle
movement.
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∙ Relax your shoulder and lift the spoon higher than your elbow or your
shoulder and closer to your mouth.
∙ Keep holding your head up adequately.
∙ When the spoon is close enough, open your mouth wide and put the soup in
your mouth.
∙ Very good. Now you ate the soup using the spoon with your right hand.
∙ Let's try it one more time.
∙ Now extend your elbow and lower the spoon towards the bowl again.
∙ Gently rotate your wrist and scoop some soup with your spoon.
∙ Now slowly take spoon to your mouth. Try not to spill it with smooth gentle
movement.
∙ Relax your shoulder and lift the spoon higher than your elbow or your
shoulder and closer to your mouth.
∙ Keep holding your head up adequately.
∙ When the spoon is close enough, open your mouth wide and put the soup in
your mouth.
∙ Very good. Now you ate the soup using the spoon with your right hand.
∙ Place your right hand on the desk as the starting position.
Relaxation Training
∙ From now on make the most comfortable posture as possible.
∙ Place your head and back against the chair, your arms on the armrest.
∙ Now close your eyes.
∙ Slowly follow my instructions.
∙ Slowly breathe in. One-Two-Three.
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∙ Now breathe out. One-Two-Three-Four
∙ Slowly breathe in. One-Two-Three.
∙ Now breathe out. One-Two-Three-Four
Kinesthetic motor imagery (KMI)
∙ From now on, you are going to imagine the movement of holding a spoon,
scooping some soup in a bowl and bringing it to your mouth.
∙ For the questions during the imagination, please answer yes or no.
∙ On a desk in front of you, there is a soup half full in the bowl. There is a
spoon beside it. Does that occur to your mind?
∙ Move both your hands from your knees and gently place them beside the
bowl and the spoon.
∙ You see a spoon at your right side.
∙ Now lift your right hand gently and firmly hold the handle of the spoon.
∙ Lift the spoon, and try not to drop your wrist with some strength.
∙ Take the spoon to the bowl.
∙ Gently rotate your wrist to scoop soup with your spoon. Can you feel the
movement?
∙ Now slowly take spoon to your mouth. Try not to spill it with smooth gentle
movement.
∙ Relax your shoulder and lift the spoon higher than your elbow or your
shoulder and closer to your mouth.
∙ Keep holding your head up adequately.
∙ When the spoon is close enough, open your mouth wide and put the soup in
your mouth. Can you feel the movement?
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∙ Very good. Now you ate the soup using the spoon with your right hand.
∙ Let's try it one more time.
∙ Now extend your elbow and lower the spoon towards the bowl again.
∙ Gently rotate your wrist and scoop some soup with your spoon. Can you feel
the movement?
∙ Now slowly take spoon to your mouth. Try not to spill it with smooth gentle
movement.
∙ Relax your shoulder and lift the spoon higher than your elbow or your
shoulder and closer to your mouth.
∙ Keep holding your head up adequately.
∙ When the spoon is close enough, open your mouth wide and put the soup in
your mouth. Can you feel the movement?
∙ Very good. Now you ate the soup using the spoon with your right hand.
∙ Place your right hand on the desk as the starting position.
Refocusing to room
∙ Now you are done with practicing scooping and eating a soup in a bowl
holding a spoon. Well done.
∙ From now on you can eat your soup with your right hand holding the spoon
without spilling or pouring.
∙ Now open your eyes.