Comparisons between Modified Constraint- induced Movement ... · Comparisons between Modified...

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

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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


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


Figure 20. Changes in movement units in experimental


Figure 21. Changes in amount of use in experimental


Figure 22. Changes in movement quality in experimental


- 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


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



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 -


/ Age

Inpatient or

outpatient

Affected

extremity

Cerebral Infarction

or hemorrhage

Years of

Education

Months

Post-stroke

Brunnstrom

stage

MMSE

-K

VMIQ

Experimental Group















- 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 -


/ Age

Inpatient or

outpatient

Affected

extremity

Cerebral Infarction

or hemorrhage

Years of

Education

Months

Post-stroke

Brunnstrom

stage

MMSE

-K

VMIQ

Experimental Group















- 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 -


/ Age

Inpatient or

outpatient

Affected

extremity

Cerebral Infarction

or hemorrhage

Years of

Education

Months

Post-stroke

Brunnstrom

stage

MMSE

-K

VMIQ

Experimental Group















- 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 -


/ Age

Inpatient or

outpatient

Affected

extremity

Cerebral Infarction

or hemorrhage

Years of

Education

Months

Post-stroke

Brunnstrom

stage

MMSE

-K

VMIQ

Experimental Group















- 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 -


/ Age

Inpatient or

outpatient

Affected

extremity

Cerebral Infarction

or hemorrhage

Years of

Education

Months

Post-stroke

Brunnstrom

stage

MMSE

-K

VMIQ

Experimental Group















- 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)


Experimental group (n=7) Control group (n=7) U 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 -


before


groups

Experi

mental

_Pre

Experi

mental

_Post

Control_P

re

Control_P

ost0

10

20

30M

EP L

aten

cy (m

sec)

*

- 46 -


before


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)



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


- 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)



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


- 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 -


/ Age

Inpatient or

outpatient

Affected

extremity

Cerebral Infarction

or hemorrhage

Years of

Education

Months

Post-stroke

Brunnstrom

stage

MMSE

-K

VMIQ

Experimental Group















- 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 -


/ Age

Inpatient or

outpatient

Affected

extremity

Cerebral Infarction

or hemorrhage

Years of

Education

Months

Post-stroke

Brunnstrom

stage

MMSE

-K

VMIQ

Experimental Group















- 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 -


/ Age

Inpatient or

outpatient

Affected

extremity

Cerebral Infarction

or hemorrhage

Years of

Education

Months

Post-stroke

Brunnstrom

stage

MMSE

-K

VMIQ

Experimental Group















- 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


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


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)



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)



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,

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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,

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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

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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.

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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 -

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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

- 84 -

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.

- 85 -

∙ 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.


movement.





your mouth.


∙ 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?


movement.





your mouth. Can you feel the movement?

- 87 -


∙ 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?


movement.





your mouth. Can you feel the movement?


∙ 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.

Comparisons between Modified Constraint- induced Movement ... · Comparisons between Modified...

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