Abstract
Perceived ADL performance and satisfaction with performance increased among people with MS when receiving mental practice (MP), MP + skills training, and conventional rehabilitation treatment.
Multiple sclerosis (MS) is a demyelinating illness of the central nervous system that leads to motor and cognitive dysfunctions (Tabrizi, Zangiabadi, et al., 2013), and it is the most common neurodegenerative illness among adults ages 18 to 50 yr (Khan & Amatya, 2017). MS is classified into three subtypes: (1) relapsing–remitting (RRMS, the most common), (2) progressive secondary (PSMS), and (3) progressive primary (PPMS; Tabrizi, Zangiabadi, et al., 2013). The illness is characterized by a decline in muscle strength, loss of coordination in the execution of movements, tremor, and fatigue (Pellegrino et al., 2015), with 66% of the motor alterations affecting the upper limbs (Jamali et al., 2017). In addition, 80% of people with MS display different degrees of sensory decline because MS differentially affects the somatosensory afferent pathways that are essential for providing information on motor activity, human mobility, and motor learning (Jamali et al., 2017).
Activities of daily living (ADLs), such as eating, dressing, and grooming, are determined by the level of functionality of the arms and hands. Even simple tasks, such as moving an object, require complex patterns of muscle activation that can be affected by MS. In addition, the impairments in limb function resulting from MS can lead to decreased motor manipulation skills, resulting in a high level of disability and alterations in occupational performance that negatively affect the quality of life of people with MS (Yu & Mathiowetz, 2014).
Many patients with MS have severe affects, causing a decline in activities and functionality (Jamali et al., 2017) that commonly leads to the need for periods of intensive rehabilitation (Bovend’Eerdt et al., 2010). The complex and intense multidisciplinary neurological rehabilitation required is accompanied by elevated costs (Ma et al., 2014 ; Winser et al., 2020). Although the general process of neurological rehabilitation is effective, the evidence supporting many specific therapeutic rehabilitation techniques is scarce. Currently, intensive, task-oriented practice of activities is considered the basis for effective therapeutic techniques (Braun et al., 2013).
Mental practice (MP) is a training method in which a person mentally rehearses a specific motor act (mental simulation) and later physically executes the movements involved many times to promote learning or to improve motor skills (Machado et al., 2016). In the context of MP, motor imagery (MI) involves the MP of a motor act without physically executing the movements involved. Thus, MI can be performed using different modalities (kinesthetic and visual) from either an internal perspective or an external (observer) perspective; that is, a person can imagine that they or someone else is performing the movements (Tabrizi, Mazhari, et al., 2013).
A limited number of studies have researched the differences in the MI capacities of people with MS, showing that they attain significantly lower scores on the execution of a hand rotation task compared with control participants (Tacchino et al., 2018). Some studies (Harris & Hebert, 2015) have shown that MI activates brain regions related to motor function and increases the intensity of the practice, which can benefit people with MS because it facilitates the adaptation of exercises to be safer and less tiring. Most studies published on MI have stated that use of MI improves levels of fatigue and cognitive status among people with neurological pathologies, including MS (Braun et al., 2013; Park et al., 2018).
Although the available systematic reviews have concluded that MI can be a potential tool for improving motor functions and activities, definitive conclusions cannot be made regarding the effects of MP because relatively little evidence is available (Park et al., 2018). Given the lack of studies on the use of MP to improve motor manipulation skills and the performance of daily tasks among people with MS, additional research is necessary to further understand this technique’s effectiveness. The aim of this study was to determine whether MP or the combination of MP and motor manipulation skills (skills training, or ST) would improve both manipulative dexterity and perceived treatment satisfaction among people with MS.
Method
Participants
Participants were volunteers with MS who were members of the Asociación Mostoleña de Esclerosis Múltiple (Mostoleña Association of Multiple Sclerosis; AMDEM) and Asociación de Esclerosis Múltiple de Valdemoro (Valdemoro Multiple Sclerosis Association; ADEMV) in Madrid, Spain.
Inclusion Criteria
The inclusion criteria for this study were as follows: people ages 25 to 60 yr diagnosed with MS of the RRMS and PSMS subtypes, with no flare-ups in the past 3 mo, an Expanded Disability Status Scale (Paltamaa et al., 2008) score of 7 or less, no depressive symptoms (measured as a score of >14, indicating low depression, on the Beck Depression Inventory [Mohr et al., 1997], and no cognitive decline (measured as a score of ≥26 on the Montreal Cognitive Assessment [Nasreddine et al., 2005] or a score of ≥24 on the Mini-Mental State Examination [Beatty & Goodkin, 1990]. They also had to be regularly attending physical therapy or occupational therapy rehabilitation.
Study Procedure
All participants provided informed consent before beginning the study.
Each patient was assessed at three time points (pretreatment, posttreatment, and 3-mo follow-up). All assessments were conducted at AMDEM or ADEMV by a blinded evaluator (Rosa M. Martínez-Piédrola, Patricia Sánchez-Herrera Baeza, or Carlos Sánchez-Camarero), who was not the person who conducted the treatment sessions. All data were collected on a record sheet. Immediately after the initial assessment, the participants were alternately allocated into one of three groups: (1) MP group, (2) MP + ST group, and (3) control group.
The MP and MP + ST groups received a treatment protocol that consisted of two 30-min sessions per week for 6 wk, for a total of 12 sessions and 6 hr of treatment. The participants agreed to this intervention at the beginning of the treatment, and sessions were conducted in participants’ home. In addition, participants had independent work that they were to perform in the home setting, which consisted of performing MP activities for 15 min/day after the 12 treatment sessions. All three groups continued to receive their usual physical therapy or occupational therapy sessions.
Mental Practice
During each treatment session, participants in the MP group were asked to select two tasks from a list of MP activities designed by the authors, graded by level (e.g., opening a drawer, opening a jar, washing a plate). Once the tasks were selected, participants received specific visual or audio instructions and subsequently performed the tasks. The participants viewed the visual instructions 3 times, and the audio instructions were repeated 2 times before participants performed the task. Participants were requested to close their eyes while listening to the audio instructions to aid concentration. After viewing or listening to the recordings, participants were asked to perform the tasks again, practicing what they learned. After the end of each session, participants completed a questionnaire and scored their satisfaction with their performance on each task.
Mental Practice + Skill Training
The MP + ST group received six sessions of MP alternated with six sessions of ST (dexterity and motor manipulation skills). The MP protocol was the same as for the MP group: selecting, performing, viewing the visual instructions, listening to the audio instructions, and scoring the selected tasks. The ST activities were based on the Kamm et al. (2015) protocol and consisted of bimanual tasks (e.g., marker circles, screwing nuts and bolts, knead the therapeutic putty, or fold a towel). After performance of each task, participants were allowed to rest for 1 or 2 min to avoid fatigue.
Control Group
The control group received their usual physical therapy or occupational therapy treatments provided by AMDEM or ADEMV. Treatment mainly consisted of the application of the Bobath concept (with the aim of improving postural control at the dynamic interface between the person and the base of support; Ilett et al., 2016) and the Vojta method (a kind of neuroproprioceptive facilitation, inhibition treatment; Pavlikova et al., 2020), dry needling, myofascial induction therapy, passive mobilization, training in gross and fine motor coordination of the upper limbs, resistance training, and static and dynamic balance training.
Outcome Measures
Kinesthetic and Visual Imagery Questionnaire
The Kinesthetic and Visual Imagery Questionnaire (KVIQ; Malouin et al., 2007) assesses both visual and kinesthetic components of MP. Participants must perform the movement (e.g., neck flexion and extension, knee extension, or elbow flexion and extension) with the dominant hand (failing that, with the nondominant one). The KVIQ is a valid and reliable tool for assessing MP ability among people with MS (Tabrizi, Zangiabadi, et al., 2013). Participants had to obtain a score of 3 or higher on this measure, which ensured that they were able to complete MP treatment.
Nine-Hole Peg Test
The Nine-Hole Peg Test (NHPT) measures finger dexterity via the performance of an activity with the dominant hand followed by the nondominant hand (Heller et al., 1987; Wang et al., 2011). The NHPT has adequate reliability, and its validity has been confirmed among people with MS (Carpinella et al., 2014; Gielen et al., 2014; Heldner et al., 2014; Hervault et al., 2017).
Box and Block Test
The Box and Block Test (BBT) measures gross motor dexterity in both dominant and nondominant hands (Slota et al., 2014). Adequate reliability and validity of the BBT have been reported in the assessment of patients with neurological disorders, including those with MS (Platz et al., 2005).
ABILHAND
The ABILHAND is a tool that measures people’s self-perception of their manual skill, defined as the ability to perform ADLs that require the use of the upper limbs without considering the strategies involved (Penta et al., 1998). It is a reliable and valid method for assessing patients with MS (Barrett et al., 2013).
Canadian Occupational Performance Measure
The Canadian Occupational Performance Measure (COPM; Law et al., 2019) is used to detect changes in a person’s perceived occupational performance and satisfaction and identify any related problems. Although the measurement properties of this measure for people with MS are currently unknown, the COPM has been demonstrated to be a reliable and valid measure for people with neurological dysfunctions such as stroke and spinal cord injury (Berardi et al., 2019; Yang et al., 2017).
Ethics Committee
This study was granted approval by the Ethics Committee of the Rey Juan Carlos University according to the ethical principles for medical research involving human subjects stated in the 2013 revision of the Declaration of Helsinki (World Medical Association, 2013).
Statistical Analysis
Descriptive and statistical analyses were performed using IBM SPSS Statistics (Version 20.0). Normal distribution was verified by histograms and confirmed by the Shapiro–Wilk test (Vetter, 2017). Descriptive data were represented as means and standard deviations (variables with normal distribution), medians and interquartile ranges (quantitative variables without a normal distribution), and frequencies and percentages (categorical variables).
For the analysis of clinical and demographic data characterizing the sample, the χ2 test was used to compare proportions of categorical variables; the analysis of variance test was used to compare the quantitative variables. Moreover, linear models were used with mixed effects for repeated measures to assess the effects of the ABILHAND and the COPM Performance and Satisfaction scales. For the mixed-model analysis, the fixed factors were Time and Group, and the random factor was Participants. The Time × Group interaction was included in the model to compare the intragroup differences over time. Also, intragroup and intergroup differences on the BBT and NHPT variables for the affected and nonaffected sides were verified using the Friedman test. The significance values of the pairwise comparisons were adjusted using the Bonferroni correction for several tests. The level of significance for the statistical analyses was set at .05.
Results
In total, 40 patients agreed to participate in the study, however, 5 were lost to follow-up as a result of a flare-up. The final sample therefore consisted of 35 participants divided among three treatment groups: MP (n = 12), MP + ST (n = 13), and control (n = 10). Table 1 displays the sociodemographic and clinical characteristics of the sample; no statistically significant differences were found between the three groups.
Sociodemographic and Clinical Characteristics of the Sample
Note. N = 35. KVIQ = Kinesthetic and Visual Imagery Questionnaire; MP = mental practice; Q1 = first quartile; Q3 = third quartile; ST = skills training.
The study results are presented according to the outcome measures used.
ABILHAND
The effect of the Time × Group interaction was not significant for the ABILHAND, F(4, 28.007) = 1.657, p = .19, indicating that there is no evidence of benefits in the self-perceived performance of ADLs when the three groups are compared. Separately, the Time and Group factors did not present any significant difference (p > .05). Table 2 indicates that no differences were observed in this variable over time, and the groups were homogeneous.
Changes Observed Among Groups on the ABILHAND and COPM
Note. COPM = Canadian Occupational Performance Measure; MP = mental practice; ST = skills training.
Canadian Occupational Performance Measure
The Time × Group interaction indicates that no statistically significant difference was observed over time for both the COPM Performance scale, F(4, 22.333) = 2.124, p = .11, and the COPM Satisfaction scale, F(4, 24.626) = 0.701, p = .60. However, a significant increase in both scores was found from pretreatment to posttreatment (COPM Performance, p = .02; COPM Satisfaction, p = .04), indicating an increase in participants’ perceived satisfaction and perceived improvement in the performance of activities, independent of the treatment received (see Table 2).
Nine-Hole Peg Test
No statistically significant differences were found between NHPT scores for the affected and nonaffected upper limbs (p > .05), indicating that no improvement was found in the participants’ fine motor skills; thus, there is no evidence of effectiveness or additional benefits for either MT or MT + ST (Table 3).
Changes Observed Among Groups on the NHPT
Note. Mdn = median; MP = mental practice; NHPT = Nine-Hole Peg Test; Q1 = first quartile; Q3 = third quartile; ST = skills training.
Box and Block Test
No statistically significant differences were found in BBT scores for the affected side for either the MT or the MT + ST groups (p > .05; Table 4). Significant intergroup differences were found for the affected side, identified using the Friedman test for the pretreatment (p = .045) and posttreatment (p = .037) periods. However, because of the correction for multiplicity, the only difference found was between the control group and the MP + ST group in the postintervention period (p = .032). During this period, the control group had a median score of 55.5, whereas the MP + ST group had a median score of 40.5, indicating that both groups improved their gross motor coordination, although the control group had greater improvement (see Table 4).
Changes Observed Among Groups on the BBT
Note. BBT = Box and Block Test; Mdn = median; MP = mental practice; Q1 = first quartile; Q3 = third quartile ; ST = skills training.
Discussion
The aim of this study was to determine whether the use of MP or MP + ST would improve manipulative skills and perceived treatment satisfaction among patients with MS. The results of this study show that neither of the interventions significantly improved participants’ manipulation skills compared with conventional treatments.
Different studies have indicated that MP may be an appropriate treatment method when combined with conventional therapy because it can be adapted to a multitude of activities and provide greater functional benefits in addition to improving the recovery of the upper limbs. However, previous reports have not specified the type of treatment used or the duration or frequency of conventional treatments (Bragado Rivas & Cano-de la Cuerda, 2016; Braun et al., 2013; García Carrasco & Aboitiz Cantalapiedra, 2016; Harris & Hebert, 2015; Malouin et al., 2013; Nilsen et al., 2010; Park et al., 2015, 2018; Santos-Couto-Paz et al., 2013). The lack of consensus on what constitutes conventional treatment may have influenced the lack of statistically significant results in our study as a result of the limited hours of conventional treatment combined with MP received by the patients in our study. However, in a similar study (30 min exercise 3 days/wk), participants’ scores did not significantly change from immediately postintervention to 10 wk postintervention (Page, 2018).
No statistically significant benefits of the isolated use of MP as a substitute for conventional treatment have been found; however, slightly positive changes have been reported (Oh et al., 2016). The lack of statistically significant benefits may be because there is no consensus on the ideal duration and frequency of MP sessions (Malouin et al., 2013; Nilsen et al., 2010; Page et al., 2011; Park et al., 2015) in the treatment of patients with neurological illnesses, including those with cerebrovascular accident, Parkinson’s disease, or MS. In addition, there is a certain heterogeneity in interventions, which range from 5 to 54 wk (García Carrasco & Aboitiz Cantalapiedra, 2016). However, the average duration of MP generally varies from 4 to 5 hr, 3×/wk, over a period of 4 to 6 wk (an average of 21 hr; Bragado Rivas & Cano-de la Cuerda, 2016; Braun et al., 2013). Our study used a shorter time period, which may explain the lack of significant positive outcomes, as the number of MP sessions was less than that reported in previous studies. The protocol used in this study included independent work that participants were to perform in the home setting, which consisted of performing MP activities for 15 min/day in addition to the 12 treatment sessions. In 2011, Ietswaart et al. also included independent MP (30 min/day, 2×/wk for 4 wk), with no significant positive results of the treatment on motor recovery, similar to the results of our study. However, participants in our study did perceive a subjective improvement in their performance and satisfaction, although not in the self-perception of ADL performance, which was similar for all three treatments.
Few studies have focused on improving the manipulation skills of people with MS. The existing studies (Agència d’Informació, Avaluació i Qualitat en Salut & Fundación Esclerosis Múltiple/Centre d’Esclerosi Múltiple de Catalunya, 2012; Carpinella et al., 2012; Kalron et al., 2013; Kamm et al., 2015; Spooren et al., 2012) have no consensus on duration, patient characteristics, outcome measures, techniques used, and observation of benefits in terms of functionality, skill, tremor, sensitivity, or kinematics of the upper limb, among others. This lack of consensus on duration of treatment protocols, which range from 15 to 29 sessions, during interventions performed at the person’s home or in the clinical environment, means that the outcomes are unclear in terms of improvements in the functionality and sensitivity of the upper limb, and the techniques that offer the greatest benefits (Bonzano et al., 2014; Gatti et al., 2015; Spooren et al., 2012). Treatment protocols with more sessions and longer treatment times have obtained statistically significant differences in manipulative dexterity or the performance of ADLs that require this dexterity (Kalron et al., 2013; Kamm et al., 2015; Waliño-Paniagua et al., 2019).
In this pilot study, we carried out a treatment protocol aimed at improving the manipulative skills of people with MS, conducting the intervention in people’s home and thus facilitating the generalization of learning. With respect to the generalization of learning, the most significant aspect was that participants selected the activity to be practiced from an extensive range of proposed activities, thus encouraging meaningful activities and active participation. Although we did not find statistically significant results for improvement in manipulation skills, participants perceived an improvement in performance of the activity. This may be a result of the low number of sessions dedicated to ST (6 sessions) compared with studies reported in the literature, which used an average of 20 sessions.
It is well known that people with MS can experience a complex pattern of disability. Studies that have evaluated the perceptions people with MS have of their disability have found that they experience problems related to all areas of daily life activities. However, few investigations have analyzed how people with MS perceive their performance of daily activities and satisfaction with that performance after rehabilitation.
The results of our study indicated significant changes in self-perceived performance and satisfaction from pretreatment to posttreatment (COPM Performance, p = .02; COPM Satisfaction, p = .04), indicating an improvement in participants’ perceived satisfaction and perceived improvement in the performance of activities, independent of the treatment received. This is also in agreement with similar studies (Kos et al., 2016; Lexell et al., 2014).
Future studies are necessary with a larger sample, as well as longer treatment times and a greater number of sessions, to further study the effectiveness of MP in the performance of ADLs among people with MS.
Study Limitations
This study has several limitations. First, we did not conduct a statistical power calculation, which may have resulted in low power for demonstrating the potential benefits of the implementation of MP alone or MP + ST on manipulative dexterity and the perceived performance satisfaction of people with MS posttreatment. However, as a pilot study, it provides insights for future studies, which should consider not only larger sample sizes with adequate power but also longer treatment times and a greater number of sessions to further study the effectiveness of MP in the ADL performance of people with MS. Also, we did not consider the level of kinesthetic and visual imagination the participants presented despite the administration of a specific MI scale (the KVIQ).
Implications for Occupational Therapy Practice
The results of this study have the following implications for occupational therapy practice: During occupational therapy treatment, training in MP may be considered a complementary tool in the rehabilitation of people with MS because it improves clients’ motivation and satisfaction with performance. MP combined with conventional treatment could contribute to patients perceiving improved performance of ADLs. MP requires a specific treatment protocol for people with MS to obtain benefits because execution protocol is highly variable. Self-report outcome measures, such as the COPM, could provide highly valuable information about occupational performance that may not match the objective evidence.
Conclusion
The use of MP, and of MP + ST, does not lead to significant differences in improvement in manipulative dexterity among people with MS, compared with traditional rehabilitation treatment. The performance of activities and satisfaction with that performance increases among people with MS who receive MP, MP + ST, and conventional rehabilitation treatment.
