AlHashil, Najla
(2023)
Using mental imagery in stroke rehabilitation in
Saudi Arabia.
MPhil thesis, University of Nottingham.
Abstract
Background
Rehabilitation is vital for promoting post-stroke recovery across the world and fast becoming an essential service in recent years in Saudi Arabia.
One potentially cost-effective rehabilitation method is the use of mental imagery (MI) alongside other more conventional methods such as task-oriented training in the field of stroke rehabilitation, which includes repetitive based training to specific tasks. MI is defined as the experience of generating images of movements in the mind using different senses, such as visualising oneself exercising or feeling oneself performing an exercise.
Findings from randomised clinical trials (RCTs) suggest that the practice of MI improves functional stroke recovery. MI can be practised at home without any supervision, requiring less time and costs. However, its impact on outcomes, remains unclear due to scarcity of research and explicit best practice guidelines.
Methods and Findings
A series of three studies were conducted sequentially. The first was a systematic review with a meta-analysis to determine whether MI, combined with task-oriented training, improves performance in activities of daily living (ADL), mobility and recovery after stroke, and which MI practice designs were the most effective for stroke.
The review, which included 12 RCTs, found that combining MI training with conventional physiotherapy and/or occupational therapy sessions for four weeks or more could improve ADL and mobility performance after stroke by increased gait and balance normality levels. However, the trials included highlighted the lack of best practice guidelines for both MI use and its implementation in stroke rehabilitation, which was evident through the heterogeneity of intervention protocols used across all studies. Further investigation was therefore warranted to identify factors enabling MI use in clinical practice in Saudi Arabia.
The second study, a qualitative study, with an inductive approach that included 23 therapists (physiotherapists and occupational therapists) in four focus group discussions that were necessary for data saturation. Additionally, 12 individual interviews with stroke survivors were conducted and were sufficient to reach data saturation for the thematic analysis employed. Results from therapist discussions revealed factors essential for enabling MI use in stroke rehabilitation, highlighting what might help therapists better understand MI and its implementation in practice such as training courses, workshops and other resources that would help facilitate MI training with stroke survivors. Also, the findings from interviews with stroke patients supported therapists’ opinions and suggest its potential use for promoting post stroke recovery in improving safe and unsupervised practice away from the clinic. The interviews with stoke patients indicated a consensus between stroke survivors and therapists regarding the advantages of unsupervised homebased training.
The third study was a Delphi survey conducted with 18 experts in MI use and training in stroke rehabilitation, to agree on a list of statements that were compiled as a result of reviewing existing research on developing therapists’ knowledge and supporting the delivery of MI intervention in stroke rehabilitation. The aim of this survey was to develop consensus on the specific training therapists need to effectively implement MI and the required attributes of stroke survivors to enable their engagement in MI in stroke rehabilitation. A Delphi technique has been suggested as helpful in health research when there is a paucity of experts in clinical and academic intervention use. Findings from the Delphi suggested that the therapists’ knowledge, experience and skills in MI training and management are essential in order to train stroke survivors to use MI in clinical practice. In addition to the required attributes of stroke survivors to enable their engagement in MI in stroke rehabilitation and assessment tools necessary for MI use and training. Furthermore, such knowledge and skills could be extended by improving the undergraduate training of professionals, integrating evidence-based and clinician-informed training courses at post-graduate level, and providing MI workshops and training courses for therapists and professionals across the world and in particular in Saudi Arabia. Similarly, stroke survivor engagement in MI intervention could be improved by recognizing patient cognitive impairment levels and motivation, and monitoring treatment progress. Preparing and incorporating MI content within training plans tailored to personal, achievable goals could make a difference to levels of patient recovery.
Synthesizing the findings from the different studies
involved following a thread method that addresses the issues identified in these studies, such as the need to train therapists, the methods in which therapists acquire their MI experience and skills, and possible areas for improvement in MI training. In addition, it considers the benefits of treatment engagement to stroke survivors eligible for MI training, the assessment tools necessary to identify their levels of imaging or task performance, and the clinical guidelines and protocols required for best practice in MI therapy. In addition to issues related to MI practices, there were also other areas that remained unclear and required further examination, such as which variables involved in the delivery of MI require enhancement and the relevance of environmental and social settings. These issues were not clarified within either the qualitative study or the systemic review. They are discussed in greater depth later in this thesis with reference to their re-inspection within the quantitative study for further answers.
Conclusion
Current evidence suggests that the clinical use of MI improves post-stroke physical functionality. However, poorly defined intervention content can limit the effectiveness of clinical implementation and evidence-based stroke rehabilitation. MI is seen as a novel intervention and is not routinely used by Saudi Arabian therapists due to the lack of Evidence-Based Practice (EBP). Interviews offered insight into therapist and stroke survivor experiences and perceptions of MI use, suggesting the need for best practice recommendations for training both stroke survivors and therapists in how to deliver MI effectively as part of stroke rehabilitation.
The studies in this thesis identified that MI, as with any other interventions, lacks clinical implementation informed by EBP, an issue which needs to be resolved. The consensus-based recommendations for best practice MI use in stroke rehabilitation herein proposed, are underpinned by expert clinical and academic opinions, absent in previous literature. This highlights the importance of providing resources that include training therapists, workshops, and developing strategies into gaining further knowledge and proficiency in how to implement MI in clinical practice as an intervention.
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