March 2018: Graded Imagery & Advanced Technology in the Treatment of a Patient Post-Stroke

Graded Imagery and Advanced Technology in the Treatment of a Patient Post-Stroke

Lisa Peterkin, SPT

With the advancement of technology comes the advancement of treatment tools that can be used in all areas of physical therapy.  Newer techniques used to treat patients after a cerebrovascular accident (CVA) have become more popular both in and out of the clinic setting to improve function.   

Traditionally, patients who have been affected by a stroke have been treated with Neurodevelopmental Treatment (NDT) techniques that include proper patient positioning and tactile cueing to progress the patient and improve their function.  Once the patient has improved strength, special awareness and normalized tone, they can begin to work with a physical therapist on more functional activities such as transfers and improved ambulation.

More frequently, now, physical therapists are including more advanced techniques such as Graded Motor Imagery (GMI) in their treatment of patients who have had a stroke.  GMI is thought to promote cortical brain activation and promote motor recovery after a stroke, specifically in the upper extremity. Within the category of Graded Motor Imagery are subgroups that include Explicit Motor Imagery (EMI), Implicit Motor Imagery (IMI) and Mirror Therapy (MT).  EMI uses the Kinesthetic and Visual Imagery Questionnaire (KVIQ), which includes 5 movements (shoulder flexion, finger tapping, trunk flexion, hip abduction, and ankle dorsiflexion) that are described to or demonstrated for the patient, then the patient is to imagine themselves performing the movement that was just described or demonstrated.  This Questionnaire is graded on a 5-point scale, from 0, where the patient was unable to imagine demonstrating that movement, to 5, where the patient could imagine it clearly. The next area of IMI incorporates Left/Right Hand Judgement, where the patient is shown 60 images of a hand in various positions, and the patient has to determine whether the picture is of a left or a right hand.  The last intervention is MT, where the patient is angled with their upper extremity next to a mirror so they have a clear view of the mirror with the reflection of their limb. The unaffected arm moves in various ways instructed by a physical therapist, and the illusion is perceived by the patient that their involved arm is moving.

The benefit of using these techniques is that they are simple to teach from one physical therapist to another, and easy for the patient to understand and be able to perform.  However, because patients who have suffered a stroke may have cognitive deficits, their lack of imaginary skills due to the CVA may influence the effectiveness of these techniques.

There have been many studies that assess the effectiveness of using more advanced technology with post-stroke patients.  The H2 robotic exoskeleton is used to improve gait in a post-stroke patient with hemiparesis who was able to walk only short distances at lower speeds.  The robot has 6 joints and focuses on improving an asymmetric, deviant hemiparetic leg during the stance phase of the gait cycle. It allows the patient to walk farther distances and have more stability in the affected leg while ambulating.  

Robot-Assisted Game Training has also been studied on its effectiveness with post-stroke patients.  Patients are given conventional therapy along with a secondary treatment that includes game training.  This includes a robotic arm that allows the patient to adduct and abduct the shoulder, and flex and extend the elbow of the involved arm.  By maneuvering the robotic arm, the patient can navigate through a gaming system on a computer and improve motor planning skills and cognition.  

While these techniques are still new and have minimal research, they open up a new world of treatment possibilities, especially in rural areas that are underserved with healthcare.  With these techniques and newer technology, patients may be able to return home sooner and have effective treatment sessions without going into a clinic, while continuing to show improvement in gross motor skills and cognitive function.


Bortole, M., Venkatakrishnan, A., Zhu, F., Moreno, J. C., Francisco, G. E., Pons, J. L., & Contreras-Vidal, J. L. (2015). The H2 robotic exoskeleton for gait rehabilitation after stroke: early findings from a clinical study. Journal of neuroengineering and rehabilitation, 12(1), 54.

Lee KW, Kim SB, Lee JH, Lee SJ, Kim JW.   Effect of Robot-Assisted Game Training on Upper Extremity Function in Stroke Patients.   Ann Rehabil Med. 2017 Aug;41(4):539-546.

Polli, A., Moseley, G. L., Gioia, E., Beames, T., Baba, A., Agostini, M., … Turolla, A. (2017). Graded motor imagery for patients with stroke: a non-randomized controlled trial of a new approach. European Journal of Physical and Rehabilitation Medicine, 53(1), 14–23.



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