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.



New Members to the bestPT Network!


Each new member benefits from and contributes to our network strength.

Let’s welcome bestPT Billing’s newest members!

Ehrum Khan   
PT Max, Philadelphia, PA 
Alicia Molloy
Jesslyn Scholl
Morgan Helser
Joshua Castro
PT Max, Philadelphia, PA
Katelyn Smitherman

Everyone Benefits from bestPT’s

New Refer-A-Friend Program!

Looking at the landscape of physical therapy practice management, we see a playing field tipped to benefit the payers and hurt the provider. The relationship between payers and providers is adversarial, but billing networks offer solid strategies that allow providers to get back into–and win–the game.

The “network effect” allows a large number of unique providers to capitalize upon their strength in numbers.  Please help us strengthen that network.

If your friend schedules a demonstration of the system, we’ll send you a $25 Amazon gift card
For each friend that you refer that joins our network, we’ll credit you $50 each month the office is contracted with us through the first year!


Adapt to physical therapy health care changes easily by streamlining paperwork, documentation and billing

Physical therapy billing | health care changes“Because of our partnership with bestPT we are now able to focus more on patient care, more focus on growing our business, less focus on administration and billing and paperwork.”

-Kathleen Pegues, MS, OTR/L

Bit-By-Bit Therapeutic Riding Center

Pompano Beach, Florida  and Davie, Florida

My name is Kathleen Pegues I’m an occupational therapist and the CEO of Bit By Bit Therapeutic Riding Center here in South Florida.

Our practice specializes in hippo-therapy, which is a medical session where the horse is used as a tool in physical, occupational and speech therapy sessions.

One of the difficulties I’m finding as a CEO of a large nonprofit organization here in south Florida is that the changing health care arena is forcing us to adapt very quickly in order to get reimbursed for services. We have to adapt our paperwork, our documentation, the way that we do our billing. We have to adapt the way that we actually interact with our patients in many areas in order to be reimbursed for services.

We had attempted to do our billing internally for a few months and we recognized very quickly that was a complete disaster. The reason was very simple. That when we spend time training one individual all of our hopes and dreams rested on that one individuals shoulders. When that one individual went on vacation or, God forbid, left our organization, then our billing and collections ceased at that moment.

We recognized quickly that we needed to work with a larger organization. Are practices very fragmented. We had one system for scheduling, one system for note keeping, quite a different system for billing and collections. There was no central place that we went to for all of these processes.

“bestPT has essentially saved our organization.”

“Because of our partnership with bestPT we are now able to focus more on patient care, more focus on growing our business, less focus on administration and billing and paperwork.”

Physical Therapists & Insurers: Working Together for the Patient

physical therapists patient carePhysical therapists provide high quality health care that is covered by most health insurance companies. They help restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities of patients with injuries or disease. They also restore, maintain, and promote overall fitness and health. The use of physical therapy benefits both the patient and the insurer. What do physical therapists do?

Physical therapists use the following interventions to achieve patient treatment goals:

  • Therapeutic exercise (including aerobic conditioning)
  • Functional training in self care and home management (including activities of daily living and instrumental activities of daily living)
  • Functional training in community or work reintegration (including activities of daily living and instrumental activities of daily living)
  • Patient/family education
  • Prescription, fabrication, and application of assistive, adaptive, supportive, and protective devices and equipment
  • Manual therapy techniques (including joint mobilization and Manipulation)
  • Airway clearance techniques
  • Physical agents and mechanical and thermal modalities
  • Electrotherapeutic modalities
  • Wound care

What happens during a visit to a physical therapist?

The physical therapist will evaluate a patient’s condition and then will design and implement a treatment program. The objective of physical therapy is to manage and prevent disability, relieve pain, and restore the patient’s functional ability.

Where do physical therapists practice?

Physical therapists practice in a wide variety of settings, such as acute care and rehabilitation hospitals, outpatient clinics, private practices, sub-acute care and skilled nursing facilities, schools, in the home, corporate or industrial health centers, wellness centers, fitness centers, and long-term care facilities.

When Do Patients Need a Physical Therapist?

The following list contains some of the most common reasons patients see a physical therapist:

  • Back conditions
  • Knee problems
  • Shoulder/arm conditions
  • Neck conditions
  • Sprains and muscle strains
  • Ankle/foot problems
  • Carpal tunnel syndrome, hand/wrist problems
  • Hip fracture
  • Post-surgical rehabilitation
  • Rehabilitation after a serious injury (e.g., broken bones, head injury)
  • Stroke rehabilitation
  • Problems with balance
  • Disabilities in newborns
  • Burn rehabilitation
  • Pre-/post-natal programs
  • Incontinence
  • Women’s health
  • Licensure & education

All physical therapists must graduate from an accredited bachelor’s or master’s degree program and approximately 45% have advanced degrees. By 2002, all accredited professional education programs will be at the master’s degree level or higher.

What can you do as an insurer to ensure patients get the quality care they need?

Ask yourself the following questions to determine if your benefits packages give policy holders access to appropriate physical therapy services:

1. Do your health insurance plans cover physical therapy without a physician’s referral? In most states patients may see a physical therapist without a doctor’s referral – saving valuable time and money for patient, doctor and insurer.2. Can patients see an “out-of-plan” provider by paying a co-pay or a percentage of the cost instead of a co-pay? Choosing a physical therapist with whom patients feel comfortable is essential to the success of their therapy.

3. Is your physical therapy benefit “bundled” with those of other providers of care? Physical therapy services should be listed separately in the benefit language so that access to necessary services is not compromised.

4. Does the benefit language permit access to physical therapists for each condition during the year? Benefit language should permit treatment of more than one condition in a calendar year (e.g., ankle fracture in January and low back injury in July).

5. Does the benefit language permit access to physical therapists for each episode of care? A person may require more than one episode of care for the same condition. For example, someone with arthritis may receive physical therapy intervention for knee weakness in an attempt to avoid surgery. While this is often successful, some patients may still require surgery for the knee condition (e.g., total knee replacement), which may require post-operative physical therapy treatment. The benefit language should support each “episode of care.”

6. Does the benefit language ensure coverage that facilitates restoration of function? Benefit language that restricts physical therapy care to a 60- or 90-day period imposes an arbitrary limit on recovery. In determining an appropriate physical therapy benefit that will allow an individual to return to his or her previous level of function, benefit language should reflect the normal amount of time that it takes to recover from an injury or from surgery.

7. Does the benefit language ensure coverage that promotes functional independence for those with chronic conditions? Someone who has a chronic condition may need to be seen periodically by a physical therapist. The physical therapist will determine if the individual’s home program, equipment or adaptive devices should be modified. (For instance, children requiring orthotic devices will need modifications to those devices as they grow.) Benefit language should ensure that someone with a chronic condition may receive the kind of care that promotes personal safety and the greatest degree of function possible.

For more information on how physical therapy may better fit into your health care packages, please contact the APTA Department of Reimbursement at or call (800)999-APTA, ext. 8511.