Effects of Visual Imagery Techniques on Improving Motor Function

of Upper Limb in Chronic Ischemic Stroke Patients:

A Serial Case Report

Edwin Goutama

, Steven Setiono

Department of Physical Medicine and Rehabilitation, Dr. Cipto Mangunkusumo Hospital,

University of Indonesia, Jakarta, Indonesia

Keywords: Chronic Ischemic Stroke, Motor Function, Upper Limb, Visual Imagery.

Abstract: The aim of this study is to report our success in improving the motor function of the paresis hand of chronic

stroke patients using visual imagery techniques. Three patients with chronic ischemic stroke were given

visual imagery therapy carried out twice over three weeks, without stopped the occupational therapy. At the

end of the treatment, an increase in hand function was found in all three cases, using the DASH

questionnaire. In the first case, there was a significant increase in hand function in the activities of holding a

motorcycle and car steering wheel, holding a shopping bag, and cleaning hair. In the second case, there was

an increase in the function of opening and closing the jar, opening the lock, opening the door handle,

attaching the object to the rack, cleaning the back, and holding the motor steering wheel. In the third case,

improved hand function was found in carrying heavy objects, shopping bags, and wearing clothes. There

was no decrease in hand function reported in all three cases after the administration of visual imagery

therapy. This shows that visual imagery therapy as an adjunctive rehabilitation treatment to motor function

in patients with chronic ischemic stroke gives good results.

1 INTRODUCTION

Stroke is the second highest cause of death, and the

third highest cause of disability in the world

(Johnson, et al, 2016). The impact of disability will

hamper daily activities and patient’s readiness to

return to their social environment. One of the

disabilities due to stroke is impaired motor function

of the upper limb. Rehabilitation of upper limb

motor function becomes important because it

supports the activities of daily living (ADL), such as

eating and drinking, wearing clothes, bathing,

combing hair, and so on (Venketasubramanian et al.,

2017). Occupational therapy has been an option as a

task-oriented training in rehabilitation of upper limb

motor functions (Hatem et al., 2016). However, to

achieve a fast recovery process requires continuous

exercise every day, and this is often hampered by

patient compliance. Then another alternative therapy

is needed that can help speed up the recovery

process of motor function of the upper limb. In

recent years, many studies of visual imagery

techniques in improving motor function after stroke.

This technique is done by giving suggestions to the

patient in a state of relaxation (Jones, 2014), and

imagining the paresis limb to perform certain

functional movements (Park et al., 2015). This

technique is the most likely to be done routinely

because without being affected by the motor strength

of stroke patients. Aaron J. Manganiello in 2011

conducted a case study of visual imagery technique

of a 57-year-old man with right hemiplegia. The

result, within 5 weeks, there was an improvement in

the function of the subjects, so that they were able to

walk and move using the right extremities. Liu's

RCT study, published in the 2009 Hongkong Med

Journal, involved 17 subjects with visual imagery

interventions, finding improved sensorimotor

function in post-stroke patients compared with the

conventional rehabilitation group, as measured by

the Fugl-Meyer Assessment of Sensorymotor

Recovery After Stroke. Holroyd et al from the

University of California’s Neurophysciatric Division

gave suggestions to 66-year-old women with

Goutama, E. and Setiono, S.

Effects of Visual Imagery Techniques on Improving Motor Function of Upper Limb in Chronic Ischemic Stroke Patients: A Serial Case Repor t.

DOI: 10.5220/0009090303310336

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 331-336

ISBN: 978-989-758-409-1

331

complete paralysis of the left arm due to carotid

artery blockage. Obtained after 5 times of imagery

interventions to do daily activities that are popular,

there is a movement of the left arm that is much

better than before therapy, and subjects are able to

do daily activities even without help (Liu, 2009).

The main objective of this study is to report our

success in improving the motor function of the

paresis hand of chronic stroke patients using visual

imagery techniques This study also explains how

visual imagery can stimulate neuroplasticity in the

brain and its clinical effect on the functioning of the

paresis hand side.

2 METHOD

This study is a case series study of 3 people with

chronic ischemic stroke, with weakness of the right

arm and hand. Intervention of visual imagery

techniques is given 2 times a week for 3 weeks to

each subject, without stopping the occupational

therapy that is being undertaken by the subject. The

procedure of visual imagery is to relaxing the

subject using direct suggestion, and guiding the

patient to recall activities that can be carried out with

the paresis side of the upper limb before the subject

suffers from a stroke. The output is an assessment of

hand function using the DASH questionnaire before

and after the intervention.

3 CASE PRESENTATION

3.1 Case 1

Right-handed 50-year-old male, with long-standing

infarction in internal capsule, thalamus and right

putamen, right hemiparesis, motor strength score

with Manual Muscle Testing (MMT) is 4, getting

occupational therapy 2 times a week, and additional

visual imagery therapy 6 sessions. Significant

improvements were found in the activities of holding

the steering wheel of a motorcycle and car, carrying

shopping bags, and washing hair, with a score before

getting intervention was 5, and after getting

intervention was 2 (where the lower the score

showed more improvement). Other activities such as

sweeping the floor and holding a knife also

improved with a score before the intervention was 4,

and the score after the intervention was 2.

Weaknesses in the arms, shoulders, or hands also

experienced significant improvements. The subjects

also rated the subject's confidence in the function of

his arms, hands, or shoulders to increase.

3.2 Case 2

67-year-old, right-handed male with multiple

infarcts in the right subcortical lobe, right-left lateral

periventricle, right basal ganglia, and right-sided

pons, right hemiparesis, motor limb strength scores

over MMT 4, get therapeutic intervention by

technique 6 sessions of visual imagery, as additional

therapy. Subjects received occupational therapy

twice a week in the hospital. Significant

improvements occurred in the opening and closing

of the jar, opening the door handle, and holding the

steering wheel of the motorcycle, with a score of 5

before getting visual imagery intervention, and a

score of 1 after getting visual imagery intervention.

Other activities such as turning a door lock, putting

an object on a shelf, and cleaning your back also

improved, with a score of 5 before the intervention

and a score of 2 after getting the intervention.

Weakness of arms, shoulders, or hands also

experienced significant improvement. Subjects were

also more confident with the development of hand

functions experienced by the subjects during the

study.

3.3 Case 3

A 38-year-old, right-handed woman with right

periventricular frontal lobe infarction, left

hemiparesis, with an upper limb muscle strength

score of MMT 4, received 6-session therapeutic

intervention with visual imagery techniques, as

additional therapy. Subjects received occupational

therapy once a week. Qualitatively, there was a

significant increase in hand function in the activity

of carrying shopping bags, lifting heavy objects, and

wearing clothes, with a score before the intervention

was 4, and after the intervention was 1. Weakness in

the arms, shoulders, or hands did not experience

significant improvement. Subjects still felt

inadequate and lacked confidence in the function of

the arms, shoulders, or hands after the study.

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

332

Table 1: DASH Questionnaire Score.

Score

Subject 1

Subject 2

Subject 3

Pre

Post

Pre

Post

Pre

Post

Open a tight or new jar

Write

Turn a key

Prepare a meal

Push open a heavy door

Place an object on a shelf above · your head

Do heavy household chores (eg · wash walls,

wash floors)

Garden or do yard work

Make a bed

Carry a shopping bag or briefcase

Carry a heavy object (over 10 lbs)

Change a lightbulb overhead

Wash or blow dry your hair

Wash your back

Put on a pullover sweater

Use a knife to cut food

Recreational activities which require little

effort (eg card playing, knitting, etc)

Recreational activities in which you take some

force or impact through your arm, shoulder or

hand (eg golf, hammering, tennis, etc)

Recreational activities in which you move

your arm freely (eg playing frisbee,

badminton, etc)

Hold the steering wheel of a motorcycle or car

Sexual activities

During the past week, to what extent has your

arm, shoulder or hand problem interfered with

your normal social activities with family,

friends, neighbours or groups

During the past week, were you limited in your

work or other regular · daily activities as a

result of your arm, shoulder or hand problem?

Arm, shoulder or hand pain

Arm, shoulder or hand pain when you

performed any specific activity

Tingling (pins and needles) in your · arm,

shoulder or hand

Weakness in your arm, shoulder or hand

Stiffness in your arm, shoulder or hand

During the past week, how much 29 difficulty

have you had sleeping · because of the pain in

your arm, shoulder or hand?

I feel less capable, less confident or 30. less

useful because of my arm, shoulder or hand

problem

Effects of Visual Imagery Techniques on Improving Motor Function of Upper Limb in Chronic Ischemic Stroke Patients: A Serial Case

Report

333

4 DISCUSSION

One of the goals of the rehabilitation program in

patients with chronic ischemic stroke is to restore

the function of limbs affected as optimal as possible.

The process of recovering neuronal damage after

ischemic stroke can occur spontaneously, and or

stimulated by rehabilitation interventions, to

stimulate brain neuroplasticity through the mediation

of Brain Derived Neurotrophic Factor (BDNF)

(Pascotini et al., 2018). Most BDNF is produced in

synapses in the hippocampus after ischemic-induced

brain injury, including stroke.(Lu et al., 2014) The

hippocampus is a center of learning and long-term

memory. By imagining and recalling memory

regarding certain activities with the side of the

paresis arm, the hippocampus will be activated to

recall that memory. Activation of the hippocampus

is thought to stimulate BDNF secretion which

triggers the process of neuroplasticity (Vertes, et al,

2001).

In addition, studies show that when a person

performs visual imagery, it appears that the

distribution of blood flow occurs in the occipital,

parietal, prefrontal, and anterior cingulate cortex

using Positron Emission Tomography (PET) (Jensen

et al., 2015). Activation of these areas turns out to be

the same as when a person gets sensory input and

performs certain motor movements significantly in

response to external stimuli. This shows that

performing visual imagery will have the effect of

increasing the firing rate of neurons in the same way

as doing real movements. Research by Ishai et al

found several studies of imagery that can evoke

response responses in the cortex that are visually

associated, namely occipitotemporal and

occipitoparietal (Ishai, Ungerleider and Haxby,

2000). Although there is no voluntary movement

that occurs during visual imagery, various studies

show that brain neuroplasticity occurs when visual

imagery is carried out, which is characterized by

improved function.

The post-stroke visual imagery technique is done

by giving the patient suggestions in a state of

relaxation, to imagine the body part that the paresis

is moving for a particular purpose. It has been

investigated that visual imagery when the brain is in

theta waves will increase firing and stimulate

neurons to make impulse pathways to the cortical

area, stored as memory, as if the imagery were

actually done and were happening at that time

(Faymonville, Boly and Laureys, 2006).

In this study, the three subjects were right-

handed, namely the dominance of the right hand to

carry out daily activities. Subjects 1 and 2 had right

hemiparesis, and were undergoing occupational

therapy 2 times a week. Whereas subject 3 was left

hemiparesis, and was undergoing occupational

therapy once a week. Improved hand function in

certain activities which is qualitatively significant is

seen to be more common in subjects 1 and 2 than in

subject 3. Similarly, weakness in the arms,

shoulders, or hands improved significantly in

subjects 1 and 2. These results are consistent with

Harris et al in a study concluded that functional

disorders that occur on the dominant side will be

lighter than if the affected side is non-dominant.3 In

addition, a randomized controlled trial (RCT) study

by Liu et al published in the Hong Kong Medical

Journal indicates that patients who received

additional visual imagery interventions for 3 weeks,

doing daily activities better than the group that only

received occupational therapy (Liu et al., 2004).

Likewise, a study by Park et al who divided the two

groups of subjects with stroke. Each group received

occupational therapy 20 minutes a day for five

sessions a week for two weeks. In the intervention

group visual therapy was added as many as five

sessions a week for two weeks. The results obtained

in the intervention group, there was an increase in

upper limb function and Activity Daily Living

(ADL) significantly compared to the control group

(Park et al., 2015).

In all three cases, there was an increase in the

motor function of the subject's hands on the paresis

side in certain activities, as measured by the DASH

questionnaire. Hand function activities that have

improved significantly are related to specific

activities that are carried out repetitively as subjects'

daily lives. Studies by Israely et al mention that

specific hand function exercises such as reaching,

grasping and object manipulation, which are carried

out 4-5 sets with each set of 8-15 reps, will improve

hand function as measured by the Fugl Meyer score

score (Israely, Leisman and Carmeli, 2017).

Literature review from Oujamaa et al showed that

exercise on the wrist and hand side of the paresis is

very important in all phases of the stroke

rehabilitation program. Recent neuroscience data

suggest that ipsilesional corticospinal stimulation

should be a priority. To get optimal functional

outcomes, stroke rehabilitation programs must be

based on specific activities and are repetitive

(Oujamaa et al., 2009).

In this study, psychologically it appears that

feelings of inadequacy, less useful, and lack of

confidence in the function of the arms, shoulders, or

hands of subjects 1 and 2 have improved. This is

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

334

because there is a significant increase in many

activities undertaken by subjects 1 and 2. While the

increase in activities that are still limited to subject 3

has not been able to increase the subject's

confidence. This is consistent with the study by

Dogu et al. That there is a relationship between

impaired hand function and psychological effects on

sufferers of brain injury, where a person's stress

level or depression will improve along with the

improvement in hand function experienced (Dogu et

al., 2014).

Visual imagery technique is an effective and safe

technique. No side effects were reported in this

study. A meta-analysis states that the visual imagery

technique is a safe therapy for various procedures.

Suggestions given by doctors to patients become an

important component in establishing doctor-patient

communication in daily clinical practice (Häuser et

al., 2016).

The limitation of this study is the absence of a

control group, so it cannot be concluded clearly

whether the intervention of visual imagery therapy

significantly improves hand function. In addition,

the occupational therapy that was undertaken by the

patient during the study was not standardized, so that

it could cause bias in the results of the study. Factors

such as a person's ability to imagine, residual

sensorimotor capabilities, ability to follow

commands, attention, and motivation may be crucial

components not considered in these patients (Butler

and Page, 2006). Further studies are needed with a

larger sample size, taking into account these aspects

to increase internal validity in research.

In conclusion, therapy with visual imagery

techniques can be considered an additional therapy

in patients with chronic ischemic stroke, because it

is proven to stimulate brain neuroplasticity, so as to

improve the function of the hands on the paresis

side.

REFERENCES

Butler, A. J. and Page, S. J. 2006 ‘Mental Practice With

Motor Imagery: Evidence for Motor Recovery and

Cortical Reorganization After Stroke’, Archives of

Physical Medicine and Rehabilitation, 87(12 SUPPL.),

pp. 2–11. doi: 10.1016/j.apmr.2006.08.326.

Dogu, B. et al. 2014 ‘The relationship between hand

function, depression, and the psychological impact of

trauma in patients with traumatic hand injury’,

International Journal of Rehabilitation

Research,37(2),pp.105-109.

doi:10.1097/MRR.0000000000000040.

Faymonville, M. E., Boly, M. and Laureys, S. 2006.

‘Functional neuroanatomy of the hypnotic state’,

Journal of Physiology Paris, 99(4–6), pp. 463–469.

doi: 10.1016/j.jphysparis.2006.03.018.

Filipe, J. 2011. Agents and Artificial Intelligence. Edited

by S. Bernadette. Springer.

Hatem, S. M. et al. 2016. ‘Rehabilitation of motor function

after stroke: A multiple systematic review focused on

techniques to stimulate upper extremity recovery’,

Frontiers in Human Neuroscience, 10(SEP2016), pp.

1–22. doi: 10.3389/fnhum.2016.00442.

Häuser, W. et al. 2016. ‘Wirksamkeit, Sicherheit und

Anwendungsmöglichkeiten medizinischer Hypnose:

Eine systematische Übersicht von Metaanalysen’,

Deutsches Arzteblatt International, 113(17), pp. 289–

296. doi: 10.3238/arztebl.2016.0289.

Ishai, A., Ungerleider, L. G. and Haxby, J. V. 2000.

‘Distributed neural systems for the generation of

visual images’, Neuron, 28(3), pp. 979–990. doi:

10.1016/S0896-6273(00)00168-9.

Israely, S., Leisman, G. and Carmeli, E. 2017.

‘Improvement in arm and hand function after a stroke

with task-oriented training’, BMJ Case Reports, 2017,

pp. 1–7. doi: 10.1136/bcr-2017-219250.

Jensen, M. P. et al. 2015. ‘Mechanisms of hypnosis:

Toward the development of a biopsychosocial model’,

International Journal of Clinical and Experimental

Hypnosis. Routledge, 63(1), pp. 34–75. doi:

10.1080/00207144.2014.961875.

Johnson, W., Onuma, O. and Sachdev, S. 2016. ‘Stroke : a

global response is needed. Bulletin of the World

Health Organization 94(9), 634-634A’. doi:

10.2471/blt.16.181636.

Jones, D. 2014. Advanced Ericksonian Hypnotherapy

Script. 2nd edn. Lulu Publishing.

Liu, K. P. et al. 2004. ‘Mental imagery for promoting

relearning for people after stroke: A randomized

controlled trial’, Archives of Physical Medicine and

Rehabilitation, 85(9), pp. 1403–1408. doi:

10.1016/j.apmr.2003.12.035.

Liu, K. P. Y. 2009. ‘Use of mental imagery to improve

task generalisation after a stroke’, Hong Kong Medical

Journal, 15(3 SUPP4), pp. 37–41.

Lu, J. et al. 2014. ‘Synthesis , Trafficking and Release of

BDNF’, pp. 1955–1971. doi: 10.1007/978-1-4614-

5836-4.

Oujamaa, L. et al. 2009. ‘Rehabilitation of arm function

after stroke. Literature review’, Annals of Physical and

Rehabilitation Medicine, 52(3), pp. 269–293. doi:

10.1016/j.rehab.2008.10.003.

Park, J. H. et al. 2015. ‘Effects of mental practice on

stroke patients’ upper extremity function and daily

activity performance’, Journal of Physical Therapy

Science, 27(4), pp. 1075–1077. doi:

10.1589/jpts.27.1075.

Pascotini, M. E. T. et al. 2018. ‘Brain-Derived

Neurotrophic Factor Levels are Lower in Chronic

Stroke Patients: A Relation with Manganese-

dependent Superoxide Dismutase ALA16VAL Single

Nucleotide Polymorphism through Tumor Necrosis

Effects of Visual Imagery Techniques on Improving Motor Function of Upper Limb in Chronic Ischemic Stroke Patients: A Serial Case

Report

335

Factor-α and Caspases Pathways’, Journal of Stroke

and Cerebrovascular Diseases. Elsevier Inc., 27(11),

pp.3020–3029.doi:

10.1016/j.jstrokecerebrovasdis.2018.06.032.

Venketasubramanian, N. et al. 2017. ‘Stroke

Epidemiology in South , East , and South-East Asia :

A Review’, 19(3), pp. 286–294.

Vertes, R. P., Albo, Z., & Di Prisco, G. V. 2001. ‘Theta-

rhythmically firing neurons in the anterior thalamus:

Implications for mnemonic functions of Papez’s

circuit.’, pp. 619–625. doi: 10.1016/s0306-

4522(01)00131-2.

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Medicine and Rehabilitation Association

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