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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Efficacy of motor imagery in post-stroke rehabilitation: a systematic review

A Zimmermann-Schlatter, C Schuster, MA Puhan, E Siekierka, and J Steurer.

Review published: 2008.

CRD summary

The review concluded that there was modest evidence to suggest that, in addition to conventional physiotherapy or occupational therapy, motor imagery provides benefits for patients undergoing stroke rehabilitation. Given the inclusion of only a limited number of small and often poor-quality studies, the findings appear to be overstated and should be interpreted with caution.

Authors' objectives

To evaluate the effects of combined motor imagery (MI) and conventional therapy compared to conventional therapy only for post-stroke rehabilitation.

Searching

MEDLINE (from inception to August 2005), PEDRO (to August 2005), PsycINFO (1967 to July 2005), PSYNDEXplus (1977 to June 2005), CINAHL (1982 to July 2005), Cochrane Central Register of Controlled Trials (Issue 1, 2004), Scopus (inception to August 2005) were searched. Search terms were reported. No language restrictions were applied. Reference lists of full text articles and reviews were scanned for additional studies.

Study selection

Randomised controlled trials (RCTs) that evaluated MI combined with conventional physiotherapy or occupational therapy compared with conventional physiotherapy or occupational therapy alone in post-stroke rehabilitation were eligible for inclusion. Only studies of participants with a first episode of stroke were eligible for inclusion, although there were no restrictions concerning age or time since onset of stroke. Studies of mental practice based on computer-animated techniques were excluded. Included studies had to assess outcomes that were clinically and functionally relevant (such as performance of specific tasks and activities or health-related quality of life).

Reported interventions included training to carry out specific tasks using MI with conventional physiotherapy, but most of the studies assessed MI (using audio tapes) and occupational therapy. Comparison groups included a combination of occupational and physiotherapy plus education or relaxation tapes. In the included studies time elapsed since stroke ranged from 0.5 months to 24 months. The mean age of participants ranged from 62 years to 73 years and the proportion of men ranged from 48 per cent to 100 per cent. There were variations in the studies in terms of dominant limb and affected side. Outcomes were assessed using the Fugl-Meyer Stroke Assessment (FMSA) upper extremity score and the Action Research Arm Test (ARAT) upper extremity score.

Two reviewers independently selected studies for inclusion.

Assessment of study quality

Validity was assessed using published criteria evaluating participant selection, allocation and concealment, losses to follow up and blinding. Each criterion was categorised either 1 (item is properly addressed), 2 (item is partially addressed), 3 (item is not properly addressed or not stated) or 4 (item is not applicable). Two reviewers independently assessed validity. Disagreements were resolved through discussion with a third reviewer.

Data extraction

Data were extracted for point estimates and 95% confidence intervals (CI) for each individual study. Where 95% CIs were not reported these were estimated using the standard deviation from one study to estimate the CI of the other studies. Two reviewers independently extracted data using a standard form. Disagreements were resolved through discussion with a third reviewer.

Methods of synthesis

Studies were combined in a narrative synthesis. Additional data were presented in tables. Differences in upper extremity change scores were presented in a forest plot.

Results of the review

Four RCTs were included in the review (n=86). Study validity was rated as poor to moderate. Blinding of participants or people who implemented the intervention was not applicable in any of the studies. Blinding of assessors was only properly addressed in two studies.

Three small RCTs assessed differences in FMSA. Only one (n=13) reported a statistically significant difference in effect size in favour of MI, 11 points (95% CI: 1, 21). Of the other two small RCTs assessing differences in ARAT, only one (n=11) reported a statistically significant difference in favour of MI in comparison with control, 15.8 points (95% CI: 0.5, 31.0).

Authors' conclusions

Evidence suggested there was modest evidence that MI provided benefits in addition to conventional physiotherapy or occupational therapy in participants with stroke. Further research was needed to evaluate the effects of MI.

CRD commentary

The review answered a clearly defined research question. Several relevant sources were searched with no language restrictions and search terms were reported. No attempt to locate unpublished studies was reported, raising the possibility of publication bias. Methods were used to minimise reviewer errors and bias in the selection of studies, assessment of validity and extraction of data. Validity was assessed using specified criteria and results of the assessment were reported. In view of the differences between studies, a narrative synthesis was appropriate. Samples sizes were small in the included studies. The included studies evaluated only short term effects. Differences in effect sizes were often not statistically significant. Given the inclusion of only a limited number of small and often poor-quality studies, the findings appear to be overstated and should be interpreted with caution.

Implications of the review for practice and research

Practice: the authors did not state any implications for practice.

Research: the authors stated that further studies of good methodological quality were needed, with larger sample sizes and longer follow-up. Future research should also determine the optimum timing and duration of the intervention and analyse the influence of motivation on the efficacy of MI.

Funding

Not stated.

Bibliographic details

Zimmermann-Schlatter A, Schuster C, Puhan M A, Siekierka E, Steurer J. Efficacy of motor imagery in post-stroke rehabilitation: a systematic review. Journal of Neuroengineering and Rehabilitation 2008; 5:8. [PMC free article: PMC2279137] [PubMed: 18341687]

Indexing Status

Subject indexing assigned by NLM

MeSH

Humans; Imagery (Psychotherapy) /methods; Imagination /physiology; Movement /physiology; Movement Disorders /physiopathology /psychology /rehabilitation; Outcome Assessment (Health Care) /methods; Paresis /physiopathology /psychology /rehabilitation; Randomized Controlled Trials as Topic /standards /statistics & numerical data; Stroke /physiopathology /psychology /rehabilitation; Treatment Outcome

AccessionNumber

12008103848

Database entry date

31/03/2009

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 18341687

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