Therapeutic Approach of Motor Imagery in Stroke Rehabilitation

뇌졸중 재활에 있어서 운동심상의 치료적 접근

  • Kim, Sik-Hyun (Department of Physical Therapy, Sunlin University)
  • Received : 2015.05.15
  • Accepted : 2015.06.16
  • Published : 2015.06.30


Purpose: The purpose of this study was to propose a new therapy algorithm that combines motor imagery and physiotherapy as a physiotherapeutic clinical intervention technique that can stimulate the recovery of damaged physical function for patients with stroke. Methods: A variety of scientific research results related to motor imagery were reviewed and analyzed to investigate their applicability to physiotherapy in clinics. Results: As a new therapy algorithm for the therapeutic approach of motor imagery in stroke rehabilitation, a therapy algorithm that combines motor imagery with physiotherapy is proposed, which consists of three stages or steps: STEP 1 motor imagery familiarization, STEP 2 explicit learning stage, and STEP 3 implicit learning. Conclusion: The new therapy algorithm proposed in this study is expected to be a very useful clinical therapeutic approach for stimulating the recovery of damaged physical function in patients with stroke. It is believed that it will be necessary to confirm and standardize the effects of the therapeutic algorithm proposed in this study in the future by conducting diverse clinical studies.


  1. Adeyemo BO, Simis M, Macea DD, et al. Systematic review of parameters of stimulation, clinical trial design characteristics, and motor outcomes in non-invasive brain stimulation in stroke. Frontiers in Psychiatry. 2012;3(88):1-27.
  2. Biernaskie J, Chernenko G, Corbett D. Efficacy of rehabilitative experience declines with time after focal ischemic brain injury. Journal of Neuroscience, 2004;24(5):1245-1254.
  3. Buccino G, Binkofski F, Riggio L. The mirror neuron system and action recognition. Brain and Language. 2004;89(2):370-376.
  4. Butefisch CM, Netz J, Wessling M, et al. Remote changes in cortical excitability after stroke. Brain. 2003;126(2):470-481.
  5. Calautti C, Naccarato M, Jones PS, et al. The relationship between motor deficit and hemisphere activation balance after stroke: a 3T fMRI study. Neuroimage. 2007;34(1):322-331.
  6. Caspers S. Zilles K. Laird AR, et al. ALE meta-analysis of action observation and imitation in the human brain. Neuroimage. 2010;50(3):12.112.
  7. Cramer SC, Lastra L, Lacourse M, et al. Brain motor system function after chronic, complete spinal cord injury. Brain. 2005;128(12):2941-2950.
  8. Cumming J, Hall C, Harwood C, et al. Motivational orientations and imagery use: a goal profiling analysis. Journal of Sports Sciences. 2002;20(2):127-136.
  9. Decety J. Do imagined and executed actions share the same neural substrate? Cognitive Brain Research. 1996;3(2):87-93.
  10. Deiber MP, Wise SP, Honda M, et al. Frontal and parietal networks for conditional motor learning: a positron emission tomography study. Journal of Neurophysiology. 1997;78(2):977-991.
  11. Dickstein R, Deutsch JE. Motor imagery in physical therapist practice. Physical Therapy. 2007;87(7):942-953.
  12. Driskell JE, Copper C, Moran A. Does mental practice enhance performance? Journal of Applied Psychology. 1994;79(4):481-492.
  13. Dunsky A, Dickstein R, Marcovitz,E, et al. Home-based motor imagery training for gait rehabilitation of people with chronic post stroke hemiparesis. Archives of Physical Medicine and Rehabilitation. 2008;89(8):1580-1588.
  14. Fery YA. Differentiating visual and kinesthetic imagery in mental practice. Canadian Journal of Experimental Psychology. 2003;57(1):1-10.
  15. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patient for the clinician. Journal of Psychiatric Research. 1975;12(3):189-198.
  16. Fourkas AD, Avenanti A, Urgesi C, et al. Corticospinal facilitation during first and third person imagery. Experimental Brain Research. 2006;168(1-2):143-151.
  17. Gerardin E, Sirigu A, Lehericy S, et al. Partially overlapping neural networks for real and imagined hand movements. Cerebral Cortex. 2000;10(11):1093-1104.
  18. Glisky W, Kihlstrom JF. Internal and external mental imagery perspectives and performance on two tasks. Journal of Sport Behavior. 1996;19(1):3-18.
  19. Grafton ST, Woods RP, Tyszka JM. Functional imaging of procedural motor learning relating cerebral blood flow with individual subject performance. Human. Brain Mapping. 1994;1(3):221-234.
  20. Gre'zes J, Decety J. Functional anatomy of execution, mental simulation, observation, and verb generation of actions: a meta-analysis. Human Brain Mapping. 2001;12(1):1-19<1::AID-HBM10>3.0.CO;2-V
  21. Guillot A, Collet C, Nguyen VA, et al. Brain activity during visual versus kinesthetic imagery: an fMRI study. Human Brain Mapping. 2009;30(7):2157-2172.
  22. Halsband U, Lange RK. Motor learning in man: A review of functional and clinical studies. Journal of Physiology Paris. 2006;99:(4-6):414-424.
  23. Hazeltine E, Grafton ST, Ivry R. Attention and stimulus characteristics determine the locus of motor-sequence learning: a PET study. Brain. 1997;120(1):123-140.
  24. Humm JL, Kozlowski DA, Bland ST, et al. "Use-dependent exaggeration of brain injury: is glutamate involved?" Experimental Neurology. 1999;157(2):349-358.
  25. Inoue K, Kawashima R, Satoh K, et al. Activity in the parietal area during visuomotor learning with optical rotation. Neuroreport. 1997;8(18):3979-3983.
  26. Jackson PL, Lafleur MF, Malouin F, et al. Potential role of mental practice using motor imagery in neurological rehabilitation. Archives of Physical Medicine and Rehabilitation. 2001;82(8):1133-1141.
  27. Jeannerod M. Mental imagery in the motor context. Neuropsychologia. 1995;33(11):1419-1432.
  28. Jeannerod M. Neural simulation of action: a unifying mechanism for motor cognition. Neuroimage. 2001;14(1):103-109.
  29. Jenkins LH, Brooks DJ, Nixon PD, et al. Motor sequence learning: a study with positron emission tomography. Journal of Neuroscience. 1994;14(6):3775-3779.
  30. Johnson SH. Imagining the impossible: intact motor representations in hemiplegics. Neuroreport. 2000;11(4):729-732.
  31. Johnson SH, Sprehn G, Saykin AJ. Intact motor imagery in chronic upper limb hemiplegics: evidence for activity-independent action representations. Journal of Cognitive Neuroscience. 2002;14(6):841-852.
  32. Johnston MV. Plasticity in the developing brain: implications for rehabilitation. Developmental Disabilities Research Reviews. 2009;15(2):94-101.
  33. Kaneko F, Hayami T, Aoyama T, et al. Motor imagery and electrical stimulation reproduce corticospinal excitability at levels similar to voluntary muscle contraction. Journal of Neuroengineering and Rehabilitation. 2014;11:94.
  34. Kasess CH, Windischberger C, Cunnington R, et al. The suppressive influence of SMA on M1 in motor imagery revealed by fMRI and dynamic causal modeling. NeuroImage. 2008;40(2):828-837.
  35. Keysers C, Kaas JH, Gazzola V. Somatosensation in social perception. Nature Reviews Neuroscience. 2010;11(6):417-428.
  36. Kim JG, Chung ST. Auditory, visual, and kinesthetic imagery on badminton service learning and performance. Journal of Sport and Exercise Psychology. 1998;20:67-67.
  37. Kim JW, Roh HM, Son EB, Jang EJ. PNF dance and mirror neuron: Comparative analysis of electroencephalographic difference between action observation and motor performance. Journal of Sunlin College Physical Therapy. 2014;1-12.
  38. Kuhtz-Buschbeck JP, Mahnkopf C, Holzknecht C, et al. Effector-independent representations of simple and complex imagined finger movements: a combined fMRI and TMS study. European Journal of Neuroscience. 2003;18(12):3375-3387.
  39. Liepert J, Hamzei F, Weiller C. Motor cortex disinhibition of the unaffected hemisphere after acute stroke. Muscle and Nerve. 2000;23(11):1761-1763.<1761::AID-MUS14>3.0.CO;2-M
  40. Liu H, Song L, Zhang T. Changes in brain activation in stroke patients after mental practice and physical exercise: a functional MRI study. Neural Regeneration Research. 2014;9(15):1474-1484.
  41. Lledo PM, Alonso M, Grubb MS. Adult neurogenesis and functional plasticity in neural circuits. Nature Reviews Neuroscience. 2006;7:179-193.
  42. Lotze M, Halsband U. Motor imagery. Journal of Physiology (Paris). 2006;99(4-6):386-395.
  43. Maeda F, Kleiner-Fisman G, Pascual-Leone A. Motor facilitation while observing hand action: specificity of the effect and role of observer's orientation. Journal of Neurophysiology. 2002;87(3):1329-1335.
  44. Magill RA. Motor learning: concepts and applications. New York. McGraw Hill. 1998.
  45. Malouin F, Belleville S, Desrosiers J, et al. Working memory and mental practice after stroke. Archives of Physical Medicine and Rehabilitation. 2004;85(2):177-183.
  46. Malouin F, Richards CL, Jackson PL, et al. The kinesthetic and visual imagery questionnaire (KVIQ) for assessing motor imagery in persons with physical disabilities: are liability and construct validity study. Journal of Neurologic Physical Therapy. 2007;31(1):20-29.
  47. Malouin F, Richards CL, Belleville S, et al. Training mobility tasks after stroke with combined mental and physical practice: a feasibility study. Neurorehabilitation Neural Repair. 2004;18(2):66-75.
  48. Malouin F, Richards CL, Durand A, et al. Reliability of mental chronometry for assessing motor imagery ability after stroke. Archives of Physical Medicine and Rehabilitation. 2008;89(2):311-319.
  49. Malouin F, Richards CL, Jackson PL, et al. Brain activations during motor imagery of locomotor-related tasks: a PET study. Human Brain Mapping. 2003;19(1):47-62.
  50. Malouin F, Richards CL, Jackson PL, et al. The Kinesthetic and Visual Imagery Questionnaire (KVIQ) for assessing motor imagery in persons with physical disabilities: a reliability and construct validity study. Journal of Neurologic Physical Therapy. 2007;31(1):20-29.
  51. Mulder Th, Hochstenbach J. Motor control and learning: implications for neurological rehabilitation. In: Greenwood RJ (ed) Handbook of neurological rehabilitation. New York. Psychology Press. 2003.
  52. Munzert J, Lorey B, Zentraf K. Cognitive motor processes: The role of motor imagery in the study of motor representations-. Brain Research Reviews. 2009;60:306-326.
  53. Murphy SM. Imagery interventions in sport. Medicine and Science in Sports and Exercise. 1994;26(4):486-494.
  54. Page SJ, Levine P, Leonard AC. Effects of mental practice on affected limb use and function in chronic stroke. Archives of Physical Medicine and Rehabilitation. 2005;86(3):399-402.
  55. Page SJ. Imagery improves upper extremity motor function in chronic stroke patients: a pilot study. Occupational Therapy Journal of Research. 2000;20(3):200-215.
  56. Pascual-Leone A, Nguyet D, Cohen LG, et al. Modulation of muscle responses evoked by transcranial magnetic stimulation during the acquisition of new fine motor skills. Journal of Neurophysiology. 1995;74(#):1037-1045.
  57. Rauch SL, Savage CR, Brown HD, et al. A PET investigation of implicit and explicit sequence learning. Human Brain Mapping. 1995;3(4):271-286.
  58. Reis J, Robertson EM, Krakauer JW, et al. Consensus: can transcranial direct current stimulation and transcranial magnetic stimulation enhance motor learning and memory formation? Brain Stimulation. 2008;1(4):363-369.
  59. Rizzolatti G, Fogassi L, Gallese V. Motor and cognitive functions of the ventral premotor cortex. Current Opinion in Neurobiology. 2002;12(2):149-154.
  60. Rizzolatti G, Sinigaglia C. The functional role of the parieto-frontal mirror circuit : interpretations and misinterpretations. Nature Reviews Neuroscience. 2010;11(4):264-274.
  61. Rizzolatti G. The mirror neuron system and imitation. In: Hurley S, Chater N, eds. Perspectives on imitation: from cognitive neuroscience to social science. Cambridge, MA: MIT Press; 2005;55-77.
  62. Ruby P, Decety J. Effect of subjective perspective taking during simulation of action: a PET investigation of agency. Nature Neuroscience. 2001;4(5):546-50.
  63. Sabate' M, Gonzalez B, Rodiguez M. Brain lateralization of motor imagery: motor planning asymmetry as a cause of movement lateralization. Neuropsychologia. 2004;42(8):1041-1049.
  64. Sacco K, Cauda F, Cerliani L, et al. Motor imagery of walking following training in locomotor attention: the effect of "the tango lesson." Neuroimage. 2006;32(3):1441-1449.
  65. Sakai K, Hikosaka G, Miyauchi S, et al. Transition of brain activations from frontal to parietal areas in visuomotor sequencing learning. Journal of Neuroscience. 1998;18(5):1740-1827.
  66. Sanes JN, Donoghue JP. Plasticity and primary motor cortex. Annual Review of Neuroscience. 2000;23:393-415.
  67. Sharma N, Pomeroy VM, Baron JC. Motor imagery: a backdoor to the motor system after stroke? Stroke. 2006;37(7):1941-1952.
  68. Sirigu A, Duhamel JR, Cohen L, et al. The mental representation of hand movements after parietal cortex damage. Science. 1996;273(5281):1564-1568.
  69. Takeuchi N, Oouchida Y, Izumi S. Motor control and neural plasticity through interhemispheric interactions. Neural Plasticity. 2012;2012(823285):1-13.
  70. Van Mier H, Tempel LW, Perlmutter JS, et al. Changes in brain activity during motor learning measured with PET: effects of hand of performance and practice. Journal of Neurophysiology. 1999;80(4):2177-2199.
  71. Vries S. Mulder T. Motor imagery and stroke rehabilitation: a critical discussion. Journal of Rehabilitation Medicine. 2007;39(1):5-13.
  72. Webster BR, Celnik PA, Cohen LG. Noninvasive brain stimulation in stroke rehabilitation. NeuroRx. 2006;3(4):474-481.
  73. Weiller C, May A, Sach M, et al. Role of functional imaging in neurological disorders. Journal of Magnetic Resonance Imaging. 2006;23(6):840-850.
  74. Wright DJ, Williams J, Holmes PS. Combined action observation and imagery facilitates corticospinal excitability. Frontiers in Human Neuroscience. 2014;8(951):1-9.
  75. Yang YR, Wang RY, Wang PS. Early and late treadmill training after focal brain ischemia in rats. Neuroscience Letters. 2003;339(2):91-94.
  76. Zanette G, Manganotti P, Fiaschi A, et al. Modulation of motor cortex excitability after upper limb immobilization. Clinical Neurophysiology. 2004;115(6):1264-1275.