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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].

Use of mental practice to improve upper-limb recovery after stroke: a systematic review

DM Nilsen, G Gillen, and AM Gordon.

Review published: 2010.

Link to full article: [Journal publisher]

CRD summary

This review assessed whether upper limb recovery following stroke was improved through mental practice of physical movements. The authors concluded that there was evidence of benefit, but general conclusions were difficult to make. Limitations in the review methods and in the studies that were not acknowledged by the review authors limit the reliability of the authors’ conclusions.

Authors' objectives

To evaluate whether mental practice, whereby a person mentally rehearses a physical skill using motor imagery without using overt physical movements, improves upper limb recovery following stroke.


An electronic search of PubMed, The Cochrane Library, PsycINFO and CINAHL was conducted for the years 1985 to 2009. Search terms were provided. Reference lists of retrieved articles were examined. Searches were limited to studies in English.

Study selection

Studies of any design that included participants with a primary diagnosis of stroke were included. Mental practice could be used alone or alongside other therapies with the aim of reducing upper-extremity impairment or improve upper-extremity function.

Studies included patients with a unilateral right or left cerebrovascular accident, either in the acute or chronic phase. Reported mean time since stroke ranged from 28.7 days to 51.2 months. Reported mean age of included participants ranged from 52.6 to 67.8 years. Mental practice was combined with physical practice and used alone. Mental practice could be facilitated by various methods that included audiotapes, written instructions and pictures and internal (first-person) and external (third-person) imagery perspectives. Imagined tasks included selective opposition finger sequence tasks, simple wrist and forearm movements, line tracing and functional reaching and grasping tasks. Duration of mental practice in the randomised controlled trials (RCTs) ranged from four to five hours over a four- to six-week period to 21 hours over a six-week period. Upper extremity impairment or function was assessed using various instruments that included the Fugl-Meyer Motor Assessment, Motricity Index, Jebsen Test of Hand Function and the Action Research Arm Test.

Study selection was performed by two authors. Disagreements were resolved by consensus.

Assessment of study quality

RCTs and non-RCTs were assessed using the PEDro scale to rate each study’s internal validity (eight-point scale) and statistical reporting (two-point scale); higher scores indicated higher quality. Items assessed included random allocation, concealed allocation, blinding, intention-to-treat analysis, group similarity at baseline and adherence.

Validity assessment was conducted by two authors. Disagreements were resolved by consensus. The review did not state whether the validity assessment was conducted independently.

Data extraction

Data were extracted by two authors. The review did not state whether the data extraction was conducted independently.

Methods of synthesis

A narrative synthesis of studies was conducted.

Results of the review

Fifteen studies (145 participants) were included: four RCTs, two controlled clinical trials (CCTs), one single group pre-post study, six case series and two case studies. Internal validity scores for the six RCTs/CCTs ranged from 2 to 5 out of a possible 8 points. Evidence of allocation concealment, blinding of participants and intention-to-treat analysis was lacking. Five of the six studies scored 2 out of a possible 2 points for statistical reporting.

Considerable between-study heterogeneity was identified in terms of design, patients, interventions and outcomes.

Mental practice was found to have a positive effect on upper-limb recovery in terms of impairment (supported by three RCTs, two CCTs, and nine studies that used less reliable designs) and activity limitations (supported by three RCTs, one CCT and six studies that used less reliable designs). Seven studies showed statistically significant effects; these included five RCTs and CCTs. Five trials showed that mental practice plus physical therapy was better than physical therapy alone or conventional therapy.

Authors' conclusions

The authors’ concluded that although the benefits of mental practice in post-stroke rehabilitation appeared promising, general conclusions were difficult to make.

CRD commentary

The aim of this review was clearly stated. Inclusion criteria were very broad and potentially limited the conclusions that could be drawn from the evidence presented. The literature search focused on electronic sources and made no attempt to identify grey literature, which left potential for publication bias. The search was limited to papers in English, which left potential for language bias. Two authors carried out the main stages of the review, but it was not reported whether this was done independently and so reviewer bias may have been present. A known tool for validity assessment was used for RCTs and CCTs , which allowed the quality of evidence provided by the better designed studies to be judged.

A narrative synthesis of included studies was appropriate given the wide range of study designs and wide inclusion criteria that were applied. The limitations in the review methods and limitations in the studies (design, sample size and heterogeneity of patient populations and interventions applied) seriously limited the conclusions that could be drawn from the evidence presented. As most studies assessed mental practice in addition to physical therapy, the effects of mental practice could not be isolated.

The authors’ conclusions are cautious, but do not fully acknowledge the limitations in the data presented.

Implications of the review for practice and research

Practice: The authors stated that mental practice appeared to be an appropriate intervention strategy to be used during post-stroke rehabilitation.

Research: The authors stated that further research was needed to determine which patients would benefit most from training, what dose of training was needed, the most effective protocols for delivering training, whether observed improvements were retained and whether mental practice affected perceived occupational performance.


Not stated.

Bibliographic details

Nilsen DM, Gillen G, Gordon AM. Use of mental practice to improve upper-limb recovery after stroke: a systematic review. American Journal of Occupational Therapy 2010; 64(5): 695-708. [PubMed: 21073100]

Indexing Status

Subject indexing assigned by NLM


Humans; Imagery (Psychotherapy); Recovery of Function; Stroke /physiopathology /rehabilitation; Treatment Outcome; Upper Extremity /physiopathology



Database entry date


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: 21073100


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