THE USE OF MENTAL IMAGERY FOR STROKE REHABILITATION: A DELPHI STUDY

N. Alhashil^1,2, E. Kontou¹, K. Radford¹

Background: Mental imagery (MI) involves generating images of movements in the mind. Recent randomised clinical trial findings have suggested its use in rehabilitation programmes to improve functional recovery after stroke; however, there are no guidelines to support its use in clinical practice in Saudi Arabia.

Purpose: This study aimed to develop an agreed list of recommendations for MI use in clinical practice.

Methods: A modified Delphi with expert consensus was used to develop a list of recommendations for MI use in clinical stroke rehabilitation practice. A web-based survey was conducted among experts in MI use, training or research, from around the world. MI experts were identified from published research, local and national networks, and clinical interest groups. Data were analysed using a defined consensus cut-off score of ≥70%.

Results: After three Delphi rounds, experts agreed on 76% of the 122 items in total, with 78% consensus. The study sample included experts in MI use within an academic or clinical profession, including physiotherapists, occupational therapists and psychologists. Experts agreed on 106 items for 13 sets of recommendations for; improving the therapist’s knowledge of MI use and skills; improving MI engagement with patients during MI training; the MI content (why use MI, how to train one to use MI, where to train MI, what types of MI modes and perspectives and how to apply MI in terms of intensity); and MI assessment tools to determine ability and health conditions.

Conclusion(s): These findings highlight therapists may need additional training to optimise their knowledge, skills, and confidence to implement MI in stroke rehabilitation successfully. Certain stroke attributes may also determine its success before training stroke on its use. Poor cognitive function, an inability to imagine and other co-morbidities such as impaired memory may negatively impact on MI use and its outcomes. However, consensus about attributes appears to be based on exclusion criteria from previous research rather than evidence, therefore it remains unclear what sort of cognitive impairments impact patient’s ability and capacity to engage in MI, and how to train them to help them in benefiting from MI. There was no consensus on the best tool for assessing a patient’s capacity for learning how to use MI. The findings highlighted the effectiveness of assessing approximating meaningful life tasks and tailoring interventions for each patient’s specific needs.

Implications: MI is still a novel intervention in Saudi Arabia; therefore, therapists must firstly, gain the necessary knowledge and proficiency to properly assess and train stroke survivors in MI use. Providing resources, including training courses and workshops, for gaining further understanding of MI implementation, can ensure its success. Future work can also include interviewing professionals who are experienced in using imagery with stroke survivors and focusing on optimising MI by restructuring the delivery environment, such as by providing private rooms, and supporting MI use through instructional videos. Future clinical implementation studies are warranted to explore MI training based on these findings in terms of the uptake and use in clinical practice that includes MI content, intensity and its complexity levels. 

Funding, acknowledgements: The research is funded through a PhD scholarship from the University of Imam Abdurrahman Bin Faisal, Kingdome of Saudi Arabia.

Keywords: Mental Imagery, Stroke Rehabilitation, Physiotherapy and Occupational Therapy

Topic: Neurology: stroke

Did this work require ethics approval? Yes

Institution: The University of Nottingham

Committee: The University of Nottingham Medical School Ethics Committee

Ethics number: Ethics reference no. 102-1809