Mental practice-based rehabilitation training to improve arm function and daily activity performance in stroke patients: a randomized clinical trial.

Abstract

Over 50% of patients with upper limb paresis resulting from stroke face long-term impaired arm function and ensuing disability in daily life. Unfortunately, the number of effective treatments aimed at improving arm function due to stroke is still low. This study aims to evaluate a new therapy for improving arm function in sub-acute stroke patients based on mental practice theories and functional task-oriented training, and to study the predictors for a positive treatment result. It is hypothesized that a six-week, mental practice-based training program (additional to regular therapy) targeting the specific upper extremity skills important to the individual patient will significantly improve both arm function and daily activity performance, as well as being cost effective.
One hundred and sixty sub-acute stroke patients with upper limb paresis (MRC grade 1-3) will participate in a single-blinded, multi-centre RCT. The experimental group will undertake a six-week, individually tailored therapy regime focused on improving arm function using mental practice. The control group will perform bimanual upper extremity exercises in addition to regular therapy. Total contact time and training intensity will be similar for both groups. Measurements will be taken at therapy onset, after its cessation and during the follow-up period (after 6 and 12 months). Primary outcome measures will assess upper extremity functioning on the ICF level of daily life activity (Wolf Motor Function Test, Frenchay Arm Test, accelerometry), while secondary outcome measures cover the ICF impairment level (Brunnstrom-Fu-Meyer test). Level of societal participation (IPA) and quality of life (EuroQol; SS-Qol) will also be tested. Costs will be based on a cost questionnaire, and statistical analyses on MAN(C)OVA and GEE (generalized estimated equations).
The results of this study will provide evidence on the effectiveness of this mental practice-based rehabilitation training, as well as the cost-effectiveness.
Current Controlled Trials [ISRCTN33487341).

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BMC Neurology
Open Access
Study protocol
Mental practice-based rehabilitation training to improve arm
function and daily activity performance in stroke patients: a
randomized clinical trial
Jeanine A Verbunt*1,2,3, Henk AM Seelen1, Feljandro P Ramos4,
Bernard HM Michielsen1,5, Wim L Wetzelaer6 and Martine Moennekens1
Address: 1Rehabilitation Foundation Limburg, Hoensbroek, The Netherlands, 2Department of General Practice, Maastricht University, Maastricht,
The Netherlands, 3Department of Rehabilitation Medicine, Academic Hospital Maastricht, Maastricht, The Netherlands, 4Care And Public Health
Research Institute, Maastricht University, Maastricht, The Netherlands, 5Department of Rehabilitation Medicine, Atrium Medical Center, Heerlen,
The Netherlands and 6Department of Rehabilitation Medicine, VieCuri Medical Center, Venlo, The Netherlands
Email: Jeanine A Verbunt* - jeanine.verbunt@HAG.unimaas.nl; Henk AM Seelen - h.seelen@srl.nl;
Feljandro P Ramos - f.ramos@student.unimaas.nl; Bernard HM Michielsen - b.michielsen@atriummc.nl;
Wim L Wetzelaer - wwetzelaer@viecuri.nl; Martine Moennekens - m.moennekens@srl.nl
* Corresponding author
Abstract
Background: Over 50% of patients with upper limb paresis resulting from stroke face long-term impaired
arm function and ensuing disability in daily life. Unfortunately, the number of effective treatments aimed at
improving arm function due to stroke is still low. This study aims to evaluate a new therapy for improving
arm function in sub-acute stroke patients based on mental practice theories and functional task-oriented
training, and to study the predictors for a positive treatment result. It is hypothesized that a six-week,
mental practice-based training program (additional to regular therapy) targeting the specific upper
extremity skills important to the individual patient will significantly improve both arm function and daily
activity performance, as well as being cost effective.
Methods/design: One hundred and sixty sub-acute stroke patients with upper limb paresis (MRC grade
1–3) will participate in a single-blinded, multi-centre RCT. The experimental group will undertake a six-
week, individually tailored therapy regime focused on improving arm function using mental practice. The
control group will perform bimanual upper extremity exercises in addition to regular therapy. Total
contact time and training intensity will be similar for both groups. Measurements will be taken at therapy
onset, after its cessation and during the follow-up period (after 6 and 12 months). Primary outcome
measures will assess upper extremity functioning on the ICF level of daily life activity (Wolf Motor Function
Test, Frenchay Arm Test, accelerometry), while secondary outcome measures cover the ICF impairment
level (Brunnstrom-Fu-Meyer test). Level of societal participation (IPA) and quality of life (EuroQol; SS-Qol)
will also be tested. Costs will be based on a cost questionnaire, and statistical analyses on MAN(C)OVA
and GEE (generalized estimated equations).
Discussion: The results of this study will provide evidence on the effectiveness of this mental practice-
based rehabilitation training, as well as the cost-effectiveness.
Trial registration: Current Controlled Trials [ISRCTN33487341)
Published: 11 April 2008
BMC Neurology 2008, 8:7doi:10.1186/1471-2377-8-7
Received: 31 December 2007
Accepted: 11 April 2008
This article is available from: http://www.biomedcentral.com/1471-2377/8/7
© 2008 Verbunt et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Background
The incidence of stroke in the Netherlands was 2.2/1000
in 2000 [1]. Over 50% of patients with upper limb paresis
resulting from stroke face long-term impaired arm func-
tion and a ensuing disability in daily life [2]. Although
early rehabilitation treatment in the first phase of stroke is
currently advised in clinical guidelines, little evidence is
available on such treatment for improving arm/hand
function in the same period [3]. Recently, constrained
induced movement therapy (CIMT), in which the affected
arm must be used due to immobilizing the other, appears
to have had a positive effect on arm/hand function in sub-
acute stroke patients [4]. However, even long after the
stroke only small arm function improvements are
reported in a select minority of patients, which stands in
contrast to the far better recovery of leg function.
Some studies have shown task-oriented treatment to pos-
itively affect arm function recovery in stroke patients [5].
More recently, 'movement imagery' has emerged, target-
ing the cognitive processes associated with enhanced
motor performance and specific skilled movements in
healthy persons. Regularly applying this technique in
training and competition is called 'mental practice'. Sports
psychology research has shown that mental practice can
optimize athletes' execution of movement and acquisi-
tion of new, skilled behaviors [6,7]. Moreover, combining
mental practice training principles with active movement
training appears more beneficial than mental practice
training alone [6].
In neuroscience, interest in movement imagery has grown
in line with improvements in brain mapping techniques.
Results from brain imaging experiments suggest that exe-
cuted and imagined movements share a common neural
substrate [8-10]. This has led to the hypothesis that men-
tal practice may contribute to the activation of neural
loops and movement patterns for which the brain has a
kind of motor print [11]. Mental practice might be used
alongside physical rehabilitation in patients with neuro-
logical disorders and will probably be most effective in the
early recovery stage during which the reorganization of
brain patterns is most prominent [10].
The possible benefits of movement imagery on motor per-
formance in acute and chronic stroke patients have been
investigated in several studies. Page et al., in a small feasi-
bility study using movement imagery in stroke patients,
found a marked improvement in their arm function com-
pared to that of the control group [12]. Similar effects in
the training of neglect and motor skills have been
reported by Smania et al. and Yoo et al. [13,14]. It seems,
then, that although the brain is damaged by stroke, the
ability to train using mental practice is retained.
The effects of mental practice on small chronic stroke
groups have been reported in several studies [14-22] using
different mental practice techniques and intensities. In
2006, Braun et al. presented a systematic review focusing
on effectiveness of mental practice training in improving
upper extremity functioning, but drew no definite conclu-
sions except that further research using clear definitions of
mental practice content and standardized outcome meas-
urements are needed [21]. In 2007, based on a rand-
omized controlled trial for chronic stroke patients, Page et
al. confirmed the short-term effectiveness of mental prac-
tice in improving upper extremity function [23].
Only one article has reported on the long-term effect of
mental practice in stroke patients. This was based on an
evaluation conducted just one month after training; the
conclusions were positive [22]. The effectiveness of men-
tal practice in stroke, however, is likely influenced by fac-
tors such as the ability to perform motor imagery,
cognitive functioning, gender, handedness, dysphasia,
precise lesion location and time elapsed since the stroke
[10,24]. Whether these factors are indeed predictive of
therapy outcome and whether mental practice is also
effective over the long term in sub-acute stroke patients is
currently unknown.
Based on the latest body of evidence, it is hypothesized
that mental practice applied in a training regime involving
arm function tasks will lead to a significant and long-last-
ing improvement in stroke patients' arm function. Fur-
thermore, since rehabilitation depends upon the learning
of new behaviors (this is associated with brain plasticity),
the treatment should include much repetition [2], start
early after the stroke [2], be personally rewarding to the
patients and provide as much experience as possible of
various activities.
Aims
The aim of the proposed research project is to systemati-
cally investigate the therapeutic potential of a mental
practice-based therapy in the (partial) restoration of arm/
hand function in sub-acute stroke patients. This aim has
led to the following research questions:
1. Does a six-week, mental practice-based rehabilitation
regime for patients with upper extremity paresis in the
sub-acute stroke phase improve arm function and daily
activity performance as compared to usual care?
2. What are the prognostic factors for a good therapy out-
come?
3. Is a regime such as that described in (1) cost effective as
compared to usual care?

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Methods/Design
Study design
A multi-centre, single-blinded, randomized controlled
trial will be conducted to evaluate the effects of six weeks
of mental practice-based treatment on arm function in
unilateral stroke patients. The evaluation will span the full
post-stroke year. Assessment will take place upon entry to
the study; post-treatment and follow-up assessments will
be performed on three moments during the year (see Fig-
ure 1 flow diagram). The Study protocol was approved by
the Medical Ethical Committee of the Rehabilitation
Foundation Limburg. The study will start in March 2008
and will last till September 2010.
Setting
Patients from rehabilitation departments in the Hoens-
broek rehabilitation centre as well as regional hospitals in
South Limburg, the Netherlands, will be included.
Patients can enter both the intervention and control train-
ing groups.
The design of the study
Figure 1
The design of the study.
T4 12 months
T4 12 months
Long term follow up evaluation Long term follow up evaluation
Stroke Stroke
(inclusion criteria checked
by rehab consultant)by rehab consultant)
T0T0
Baseline assessment
(within 6 weeks after stroke)(within 6 weeks after stroke)
Randomization
(stratification for UEF level and hospital) (stratification for UEF level and hospital)
Control group
Care as usual
and and
additional UE-exercises additional UE-exercises
Intervention group
Care as usual
and
mental practice trainingmental practice training
T1 10 weeks after T0
post treatment evaluationpost treatment evaluation
T2 6 months
T2 6 months
Short term follow up evaluation Short term follow up evaluation
T3 9 months
Additional cost questionnaireAdditional cost questionnaire
(inclusion criteria checked
Baseline assessment
Randomization
Control group
Care as usual
Intervention group
Care as usual
and
T1 10 weeks after T0
T3 9 months

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Study population
Patients who meet the inclusion criteria in Table 1 will be
referred by a consultant in rehabilitation medicine. The
sample size calculation (two groups and two-sided test-
ing) was performed using data derived from Bonifer et
al.'s [25] study in which stroke patients had a mean Wolf
Motor Function Score on the functional ability scale of
3.91 with a standard deviation of 1.11. An assumed clini-
cally relevant difference between groups of at least 10%,
an alpha of 0.05 and a power (1-β) of 0.85 would neces-
sitate 145 patients. With an estimated follow-up loss of
approximately 10%, 160 participants (2 * 80) are thought
to be necessary.
Recruitment and randomization
Patients admitted to the participating institutions will be
evaluated on the basis of the inclusion criteria by a con-
sultant in rehabilitation medicine involved in treatment
within three days of admission to a stroke service. Time
lapsed since the stroke occurred should preferably be less
than two weeks. If the patient is still unconscious or inca-
pacitated at this time, inclusion may take place as appro-
priate within the ensuing four weeks. Standard informed
consent procedures will be used. Participants will then be
randomly allocated to either the intervention or control
group, with the computerized (block) randomization
scheme including pre-stratification according to two vari-
ables: MRC scale of the elbow flexor (dichotomized in
score 1 or scores 2–3); and participating hospital. Two sets
of opaque, numbered envelopes will be prepared for each
site (one each for MRC score 1 and MRC scores 2–3) con-
taining cards indicating the allocated group. When a new
patient is registered, a card will be extracted and the rele-
vant occupational therapist informed of the group alloca-
tion.
Intervention and control group
In accordance with Dutch stroke rehabilitation guidelines,
the intervention group patients will receive their regular
therapy [3] and additional mental practice-based arm
function training. This training will be supervised by the
rehabilitation team occupational therapist. After baseline
measurements are performed, patients will be familiar-
ized with the mental practice-based therapy during the
first session. The patient is educated as to basic imagery
principles and the importance of regular imagery training
in increasing therapy success. During the first week, the
patient will be taught how to use the mental practice tech-
niques to improve arm function by the occupational ther-
apist. A training task tailored to the functional level of the
individual patients will be selected by the occupational
therapist.
Five different mental practice training tasks derived from
the Frenchay Activities Index [26] are available, with grad-
ually increasing difficulty. For all tasks, a training DVD
will guide the patient. Each DVD is programmed in three
steps starting with a relaxation task to focus attention. Per-
formance of all activities is shown from a 1st person per-
spective (an 'over-the-shoulder' view). In the first step,
correct task performance is shown on screen combined
with a verbal explanation. Five repetitions are given. In the
second step, task performance is repeated on screen but
without verbal explanation; patients are asked to mentally
practice the movement. If they are able to actually perform
(part of) the task, they may do so concurrently with the
imagination of the movement. Again, five repetitions are
given. In the third step, no guidance during task perform-
ance is given except a visual and verbal cue indicating the
end of the task performance over five repetitions. Patients
already familiar with this task can immediately start on
step two.
DVDs are available for every task for right- and left-hand-
ers. Patients must practice at least three times a day for ten
minutes each session. During the intervention period,
functional arm/hand progress will be evaluated by the
occupational therapist every two weeks. If functional level
improves, a new task will be chosen and the DVD
changed. The total intervention lasts six weeks.
Patients in the control group receive therapy as usual. In
addition, they will be instructed to practice additional
bimanual upper extremity techniques based on conserva-
tive neurodevelopmental (NDT) principles [27]. These
exercises are a part of the usual training program, and, in
clinical practice, have been accepted as conventional ther-
apy. However, recent studies have questioned NDT's addi-
tional value in stroke patients [28,29]. The control group
patients will receive a booklet explaining all tasks and be
instructed to practice for ten minutes at least three times a
day. Every two weeks, the home-based training sessions
Table 1: Inclusion criteria
- first stroke
- post-stroke time of 2–6 weeks
- clinically diagnosed central paresis of arm/hand with elbow flexor strength MRC grade 1–3
- age 18–85
- no severely impaired cognition
- no severe neurological, orthopedic, rheumatoid or cardiac impairments prior to stroke
- no severely comprehension-impaired communication

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will be evaluated by the team's occupational therapist.
Total contact time with the occupational therapist in the
intervention and control groups will be equal.
Data collection
Measurements will be taken upon entry to the study (T0 =
baseline) and 6 weeks (T1 = post treatment); 6 months
(T2 = short-term follow-up); 9 months (T3 additional cost
questionnaire) and 12 months (T4 = long term follow up)
after T0. They will be performed by a rater blinded for
therapy modality, and administered wherever the patient
is at the time. A blinding check will be performed after
each of the four measurement sessions.
Outcome measures
Outcome measures and assessment moments are pre-
sented in table 2.
Demographic and medical variables
The following socio-demographic variables will be
recorded: age, sex, living situation and educational level.
The medical variables include systematically scored,
stroke-related neurological variables: lesion site, stroke
type (hemorrhagic or ischemic), paresis level and co-mor-
bidity. In the questionnaire, information on demograph-
ical variables is retrieved. Medical variables as presented
above are derived from the medical file of the referring
consultant in rehabilitation medicine. Patients will be
asked for permission to use this information of their med-
ical file in the informed consent procedure.
Cognitive functioning
The following aspects of cognitive functioning were meas-
ured.
General level of cognitive functioning
The Cognitive Log (Cog-log) is a 10-item cognitive screen-
ing instrument which measures higher neurocognitive
processes including orientation, memory, concentration
and executive skills [30].
Ability to imagine motor acts
To asses participants' ability to imagine motor acts, the
Vividness of Movement Imagery Questionnaire (VMIQ)
will be used [31]. Individuals are required to rate the viv-
idness of their imagery on a 5-point scale (1 = as perfectly
clear and vivid as normal vision, 5 = no image at all – only
a vague awareness of thinking about the movement) for
24 different movements from both an external (i.e. watch-
ing somebody else) and internal (doing it yourself) per-
spective. VMIQ scores have been linked to improvements
in motor skills [31].
Credibility and expectancy of treatment
The Credibility/Expectancy Questionnaire (CEQ), a sim-
ple scale for measuring rationale credibility and treatment
Table 2: Outcome domains and assessment instruments and moments
DomainAssessment instrumentAbbr.T0 T1 T2T3 T4
Medical information- Brain lesion
- Type of stroke
- Co-morbidity
- Barthel score
- Frenchay Activity Index
- Cognitive Log
- Vividness of Movement Imagery Q.
- Credibility/Expectancy Q.
- Brunnstrom-Fugl-Meyer test
- Strength: part of WMFT
- Spasticity: Tardieu scale
- Wolf Motor Function Test
- Frenchay Arm Test
- Accelerometry
- Impact on Participation and Autonomy questionnaire
- Stroke-Specific Quality of Life
- EuroQol
- Cost questionnaire
- Diary
X
X
X
X
X*
X
X
X
X
X
X
X
X
X
Basic level of functioningBI
FAI
Cog-log
VMIQ
CEQ
FM
WMFT str
MTS
WMFT
FAT
ACC
IPA
SS-Qol
EO-6D
CQ
X
X
X
XX
Cognitive functioning
UEF level of impairmentX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
UEF level of activity
UEF level of participation
X
X
X
XCost
Process evaluation
XX
X
T0 = baseline
UEF = upper extremity functioning
T1 = 10 weeks after T0
T2 = 6 months after T0
T3 = 9 months after T0
T4 = 12 months after T0
* The FAI on T0 retrospectively assesses the pre-morbid activity level

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expectancy in clinical outcome studies will be used. The
credibility and expectancy of mental practice and control
training is scored by the patient. This questionnaire dem-
onstrated high internal consistency and good test-retest
reliability [32].
Upper extremity functioning
Physical functioning will be assessed on three different
levels, in accordance with the International Classification
of Functioning [33]. Patients' performance on impair-
ment, activity and participation levels will be assessed.
1. Upper extremity functioning at the impairment level will be
assessed using two instruments, described below.
1.1 The arm section of the Fugl-Meyer Test (FMT) contains
three different domains: (a) motor function (24 items;
scores range from 0 to 66), (b) sensation (6 items; scores
from 0 to 12) and (c) passive joint motion/joint pain (12
items, scores from 0 to 48)[34]. Each item is scored on a
3-point ordinal scale. The Fugl-Meyer Assessment of the
Upper Extremity (FMA-UE) is the most widely used clini-
cal assessment of post-stroke upper extremity impairment
[35] and showed a very high inter-rater and test-retest reli-
ability (ICC > 0.95) [35,36].
1.2 To score spasticity level, the Tardieu Scale will be used.
The affected limb is passively moved through range at two
velocities – i.e., as fast and as slow as possible (VI). At
both velocities, the quality of the muscle reaction to
stretch is assessed for each muscle group, and the angle at
which the muscle reaction occurred is measured with a
hand-held goniometer after the cessation of movement.
Spasticity will be scored from 0–4 during the fast stretch-
ing velocity. In patients with severe brain injury and
impaired consciousness, the Modified Tardieu Scale pro-
vides higher test-retest and inter-rater reliability than the
Modified Ashworth Scale and may therefore provide a
more valid spasticity scale for adults [37].
2. Upper extremity functioning at the activity level will meas-
ured using the following three instruments.
2.1 The Wolf Motor Function Test (WMFT) test contains
15 timed and 2 strength tasks (lifting of weighted limb
and grip strength), ranging from simple to complex and
administered sequentially to each upper extremity while
controlling for patient positioning. Trained observers rate
quality of movement using a 6-point functional ability
scale (0 = no attempt; 5 = normal movement). Strength
and performance time will be recorded by the test admin-
istrators. The psychometric properties of the WMFT
appear solid [4,38-40].
2.2 The Frenchay Arm Test (FAT) will be used to assess the
degree to which the patient is able to actually perform arm
hand functions and tasks. It includes an evaluation of per-
formance on five different tasks, and has shown good reli-
ability and validity in stroke patients [26].
2.3 Accelerometery (ACC) will be used to assess upper
extremity use in a daily life situation. Patients will wear a
'watch' with an accelerometer inside (Actiwatch [41]) on
both wrists for three days, during waking hours. This Acti-
watch includes two uniaxial piezoresistive accelerometers
used to record the amount of movement based on accel-
erations. Within both watches the rectified and integrated
acceleration from two directions over one minute are reg-
istrated. The number of occasions on which this signal
exceeds a predefined threshold is then calculated. The out-
come is expressed in counts per minute, based on wrist
accelerations. Data collection will continue uninterrupted
for three days, with output stored in a data memory chip
within the accelerometer and read out by a computer after
this time.
The Actiwatch has shown good validity for assessing daily
life activities [41]. In stroke, several studies have shown
that accelerometry provides an objective, real-world index
of arm activity with strong psychometric properties [42-
45]. In the present study, an activity index will be calcu-
lated as a ratio between the activity of the impaired arm
movement and that of the unimpaired arm movement.
Uswatte et al. found that in stroke patients, a ratio score
controls adequately for variations in overall levels of phys-
ical activity, and is a reliable and valid real-world measure
of upper extremity treatment outcome [39].
3. Functional performance on the level of participation in soci-
ety and perceived quality of life will be measured using three
methods.
3.1 The Impact on Participation and Autonomy (IPA)
questionnaire. This 39-item questionnaire focuses on two
aspects of participation: the perceived participation level
in different domains, and the problems encountered
[46,47].
3.2 The Stroke-Specific Quality of Life (SS-Qol) scale. This
includes an overall evaluation of the patient's quality of
life compared with their pre-stroke state. Twelve domains
are included: personality, energy, language, mobility,
vision, upper extremity function, thinking, mood, work/
productivity, self care and family and social roles [48].
3.3 The EuroQol 6D (EQ-6D). This is a generic measure
scoring quality of life using six domains: mobility, self-
care, usual activities, pain/discomfort, anxiety/depression
and cognition. Each domain consists of three answer pos-

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sibilities. Participants are also to rate their current health
state on a visual analogue scale from 0 to 100 [49].
In brief, primary outcome measures for the evaluation of
upper extremity functioning focus on the activity level
(WMFT, FAT, ACC), whereas secondary outcome meas-
ures focus on both the impairment (FMT) and participa-
tion level (IPA, SS-Qol).
Process evaluation
After completing the intervention, participants will be
asked to evaluate it by way of a questionnaire. In addition,
treatment compliance in both groups will be monitored
using diaries recording the daily amount of time patients
spend on mental practice training (intervention group)
and NDT-based upper extremity training (control group).
Compliance can be an important issue in studying
patients in the sub-acute stroke phase [10]: poor compli-
ance can negate interpretation of the outcome as reflecting
the therapy's effectiveness. Through diary use, however,
compliance is rendered objective. The intervention proc-
ess will also be evaluated based on information provided
by occupational therapists, who will record the following
items: the number of consultations, the provision of
information per consultation, the kind of problems pre-
sented, completion of the intervention according to pro-
tocol and reasons for non-compliance (where applicable).
Determination of costs
Both direct non-medical and indirect costs will be meas-
ured using a cost questionnaire administered to the partic-
ipants or their proxies at the time of the T0-T4 assessments
[50]. An additional cost questionnaire will be sent to the
patient at 9 months. With society's perspective for the eco-
nomic evaluation, all relevant rehabilitation costs will be
determined using a micro-costing approach. This means
that the unit size of the resource used will be multiplied
by the respective unit cost across patients to estimate the
aggregate cost for society [51]. Healthcare resources used
in administering the intervention as well as direct medical
costs would include contact with professionals (e.g., phy-
sicians, therapists and rehabilitation nurses or formal car-
egivers), equipment and materials (e.g., orthoses),
assessment tools, and medications (particularly anti-spas-
modics and muscle relaxants). Along with allocated over-
head costs, these measures will determined through the
institutions' administrative records.
Direct non-medical costs include patient times, transpor-
tation and out-of-pocket expenses not covered by insur-
ance. Indirect costs would cover productivity losses and
informal care by the family or significant others. In line
with recommendations in the Dutch manual for costing
in economic healthcare evaluations, standardized costs
will be used [52]. Medications will be valued based on the
Daily Defined Dosage (DDD) price list from the Dutch
Pharmacotherapeutic Compass [53]. Productivity losses
will be valued using the friction cost method, which bases
calculations on the 'friction period,' or the time needed to
replace a sick employee. Informal care (considered unpaid
work) would be valued using shadow prices.
Statistical analysis
Effect evaluation
The number of dropouts (patients who prematurely end
their participation) and follow-up losses in both training
groups will be reported based on descriptive data. Base-
line characteristics of compliant and non-compliant par-
ticipants will be compared. Before examining the
intervention's effectiveness, possible differences between
the two groups will be determined by comparing baseline
characteristics using independent sample T-tests (normal
distribution) or Mann Whitney U-tests (non-normal dis-
tribution) in the event of continuous variables. In cases of
dichotomous variables, a chi-square test will be used.
The effects of mental practice-based therapy on arm func-
tion outcome will be evaluated using MAN(C)OVA and
GEE (generalized estimated equations) analyses. Devia-
tions from the therapy protocols will be analyzed accord-
ing to the 'intention-to-treat' principle. If either T2 or T4
data are missing, the 'last-observation-carried-forward'
principle will be used. Losses of T0 and/or T1 data will
lead to exclusion, and an additional participant will be
entered into the project. Subgroup analysis will be per-
formed for potential effect modifiers.
To assess whether protocol deviations or care provided
outside the intervention have caused bias, the results of
the intention-to-treat analysis will be compared to the on-
treatment analysis.
Prognosis of therapy outcome
To identify the prognostic outcome variables on upper
extremity functioning, a regression analysis will be per-
formed on the group which received mental practice train-
ing. The WMFT scores at 6 and 12 months will be
introduced as the dependent variable in the model, and
the following hypothesized predictors as independent
variables: age, sex, brain lesion site, ability to imagine
motor acts (Vividness of Movement Imagery Question-
naire; VMIQ), cognitive level (Cog-log), credibility and
expectancy of training (CEQ), general arm muscle
strength (WMFTtaskstrength on T0) (as presented in Table
3). The model will be adjusted for possible baseline differ-
ences on the WMFT.

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Process evaluation
Entries in the patients' diaries and both the process evalu-
ation of the patient and the occupational therapist will be
analyzed descriptively.
Economic evaluation
Incremental ratios of differences in costs to outcomes
between the intervention and control groups will be cal-
culated. Outcomes for an incremental cost-effectiveness
ratio will be changes in upper limb function primarily
measured by the WMFT. QALYs generated through the
utility values estimated by a specific QoL measure will be
used for the incremental cost-utility ratio. These ratios will
be plotted on the cost-effectiveness/utility plane to deter-
mine the economic use of one intervention over another.
Level of confidence regarding economic determination
will be quantified through non-parametric bootstrap sim-
ulations of the incremental ratios at the 2.5 and 97.5 per-
centile marks. The net-benefit framework will further
validate this level by describing the acceptability probabil-
ity of the net (monetary/health) benefit as a function of
the ceiling ratio, or society's maximum willingness to pay.
A 4-state Markov with 6-month cycle to approximate the
time span between medical follow-ups will be used to
simulate a long-term, 4-year period. Discounting of costs
and outcomes will be undertaken at 4% [52]. Uncertainty
about methodology and generalizability will be handled
using a multi-way sensitivity analysis in which more than
one study element (e.g., baseline subject characteristics
and discounting) is varied.
Discussion
In this study, the (cost) effectiveness of a mental practice-
based training regime in improving arm function and
daily activity performance in stroke patients will be evalu-
ated. In addition, prognostic factors for a strong training
outcome will be examined. A number of issues were taken
into account in designing this study protocol.
Firstly, we intend to include tasks that would be appealing
for all patients. For this reason, ordinary daily life activi-
ties have been chosen. Individual patients will be desig-
nated an activity that is currently just out of the reach of
their functional abilities; this ought to trigger motivation.
Reaching a point where they can perform the task will
directly result in an improvement and facilitation of daily
life, which will be the participants' reward for good prac-
tice. In order to maintain this cycle, the tasks' complexity
level will constantly increase depending on improvement
in upper extremity function.
Secondly, the current intervention training program was
tested for feasibility. Patients who fulfilled the inclusion
criteria and participated in an outpatient program of
Heerlen's hospital department of rehabilitation medicine
were included. After a variable baseline period with train-
ing as part of usual care, mental practice was added to the
program. Patients trained at home were supervised by the
rehabilitation team's occupational therapist. In a ques-
tionnaire, the compliance and feasibility of the training
regime were scored. Participants appeared to experience
no problems performing DVD-guided mental practice
training guided twice a day for 7 days a week over 6 weeks,
and reported good concentration levels during the 10-
minute sessions. Only one participant, who showed rapid
recovery in functional level, reported a decrease in moti-
vational level. He was able to complete the most complex
task (pouring water out of a can) in real life within the
training period. Occupational therapists reported that the
training program was feasible within the rehabilitation
setting; these results were taken into account in designing
the study protocol.
Thirdly, in choosing the current outcome measures, three
different domains of the International Classification of
Functioning (impairment, activity and participation)
were included. The second domain – level of activity – was
chosen as the primary outcome measure level, since
changes in this domain seem most clinically relevant in
daily life performance. Both the ability to perform daily
activities (to be measured by the Wolf Motor Function
Test) and the level of activity in a daily life situation (to be
assessed using accelerometry), are included. In our opin-
ion, additional assessment of real-world impaired arm
activity by way of accelerometry is important, since dis-
crepancies between motor capacity as measured by labo-
ratory performance tests and its actual use in daily life can
exist.
To conclude, this paper described the design of a rand-
omized controlled clinical trial to study the effectiveness
of mental practice training aimed at improving upper
extremity functioning in stroke patients. The results of this
study will provide evidence as to the (cost) effectiveness of
the training as well as indicators for effective mental prac-
tice training in stroke patients.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Table 3: Hypothesized predictors for treatment outcome
- age
- sex
- brain lesion site
- training expectancy and credibility
- ability to imagine motor acts
- cognitive level
- general arm muscle strength

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Authors' contributions
JAV is the main researcher and had an initiating role in
writing this manuscript. HAS made important contribu-
tions during all phases of the study design. FRA designed
the cost effectiveness part of the study. BHM, WWE and
MMO had an important role in the design of the interven-
tion and will have an important role in study-coordina-
tion on the various locations. All authors read and
approved the final manuscript.
Acknowledgements
The authors want to thank Renske van Wijk and Rachma van Woerden for
their valuable contribution to the preparation of the study protocol. This
study is being funded by the Netherlands Organisation for Health Research
and Development (ZonMw).
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