PT Classroom - Transforming Thought into Action: The Power of Mental Imagery in Stroke Rehabilitation ׀ by Jennifer Werwie, DPT


Jennifer Werwie, DPT, graduated with her Doctor of Physical Therapy degree from the University of Wisconsin-Madison. She received her BS degree in Kinesiology-Exercise Science from UW-Madison in 2008. Jennifer is also a certified personal trainer and fitness instructor. She is a Kenosha native and is an employee with United Hospital System where she primarily works in the outpatient PT setting.

 Transforming Thought into Action:

The Power of Mental Imagery in Stroke


Many successful sports icons tout mental imagery and rehearsal as a key component in preparing for and executing their physical performances. One super athlete who was famous for using mental rehearsal was the boxer Mohammad Ali. He used the power of intention and outcome expectancy to gain victory after victory, as he noted: "The man that has no imagination has no wings” (1). Famous golfer, Jack Nicklaus, claimed that hitting a good golf shot is 10% swing, 40% stance and setup, and 50% the mental picture of how the swing should occur. As studies have shown, athletes use imagery not only to help their performance but also make their experiences more enjoyable (2).

If mental imagery has been widely accepted and found effective in the sports world for so many years, can an argument be made for the incorporation of mental imagery in the physical rehabilitation of individuals with disabilities, and specifically in individuals who suffer strokes?

Stroke is the leading cause of disability in the United States, and the fourth leading cause of death. It is estimated that after acute stroke approximately 80% of the patients have some form of motor impairment (3). About 20% of these patients regain at least part of their lost motor functions in the subsequent months; thus, of the patients surviving, 50-60% are left with a chronic motor disorder (3). Therefore, much therapeutic effort is invested in functional recovery of motor skills after stroke.

During a stroke, blood flow to the brain is compromised. This can lead to brain anoxia and often irreversible damage results. The role of neuroplasticity, or the ability of the brain to rewire its pathways, is widely recognized in the physical recovery from brain damage after stroke. Could there be a role for mental imagery in activating the same brain centers that lead to functional recovery and plastic changes in patients after stroke? The idea behind this physiological phenomenon is that brain areas that are normally involved in movement execution are also active during the imagination of a movement. Several studies using brain-mapping techniques have found that, during mental imagery, brain areas related to motor execution were activated (5-10), such as the prefrontal cortex, the pre-motor cortex, the supplemental motor area, the cingulate cortex, the parietal cortex and the cerebellum. The discovery of mirror neurons, which fire not only when an action is executed, but also when one observes another person performing the same action, also show that our action system can be used "offline" as well as "online" (5).

Mental imagery is a cognitive task in which a function, a behavior, or a performance is rehearsed mentally, as if the person is actually performing it. There are two main types of mental imagery: external and internal (4). In external imagery, an individual views himself or herself from the perspective of an observer, "seeing" the movement and utilizing their visual senses ("Try to see your heel contacting the ground with each step"). Internal imagery involves a person utilizing their kinesthetic sense to imagine oneself inside his or her own body, "feeling" the action being performed ("Try to feel your heel contacting the ground with each step") (4).

In the past decade, mental imagery has emerged as a promising technique for therapists to utilize in rehabilitation of motor skills. In 2006, Braun et al. published the first systematic review of studies on the use of mental practice in stroke rehab, of which included four randomized controlled trials (RCTs), one controlled clinical trial (CCT), two patient case series, and three case reports (11). The study designs and interventions utilized were all highly heterogeneous, and the sample sizes were rather small and insignificant. Because of this, there remains a great need for the emergence of large, highly-controlled research studies to determine "best practice guidelines" for post-stroke motor imagery.

It is widely known that rehabilitation after stroke aims to improve range of motion, muscle strength, bowel and bladder function, and functional and cognitive abilities. Motor recovery of ambulation is often a major focus of physical therapy in stroke rehabilitation, and is one of the most important factors in an individual's level of physical independence. A study by Dickstein et al (2004) specifically studied the effect mental imagery has on gait rehabilitation. The first 4 weeks of the intervention period focused on the amelioration of specific gait impairments and on improving speed and symmetry, whereas more attention was devoted during the last 2 weeks to the performance of functional task-oriented gait activities (4). Mental motor imagery exercises were applied randomly, under variable circumstances with only intermittent or minimum oral feedback. Each session was composed of: 1. Deep muscle relaxation (1-2 min), 2. External (visual) motor imagery practice ("See") (1-2 min), 3. Internal (kinesthetic) motor imagery practice ("Feel") (3-8 min), 4. Refocusing of attention on the immediate surroundings and on true body position (1 min). Below is an example of the imagery approaches and treatment progression throughout the typical six week gait rehabilitation period (4).

Week 1: Motor Imagery Practice
Example: "Try to imagine hearing the sound of your footsteps on the floor."

Week 2: Emphasis on Gait Impairments
Example: "Try to 'see' your left knee flex as high as your right knee."
"Try to 'feel' your left knee flex as high as your right knee."

Week 3: Emphasis on Affected Side and Increased Gait Speed
Example: "Feel that you stand on your paretic leg longer."
"Feel that you move each of your feet farther ahead."

Week 4: Emphasis on Increasing Symmetry
Example: "Try to 'see' both of your legs making the same movements."
"Feel each foot going up the same height as the other."

Week 5 & 6: Imagery Practice for Different Environments
Example: "Imagine that you are walking on a sidewalk at normal speed, just as you used to walk before the stroke." "While walking in the street, try to feel the same self-confidence that you always had."

These progressions can be used in clinical practice, and tailored to each patient based on their functional and cognitive status, learning preferences, and overall motivation. There is no denying that proper rehabilitation is essential for functional recovery after stroke. Of all the varying approaches to stroke rehabilitation, supplementing traditional treatments with mental imagery techniques may prove to be a safe and effective way to increase patient recovery.

Mohammed Ali utilized mental imagery to prepare for and expect victory. Patients who suffer from strokes can utilize mental imagery in much the same way: to practice and prepare to spread their wings towards their own personal victories. It just may be that thought can be transformed into action, that mental imagery can be a powerful player in a patient’s road to recovery.

Last revised: September 18, 2012
by Jennifer Werwie, DPT

1) Kim Bryan, BH. (2006). Use of exercise-related mental imagery by middle-aged adults. Graduate thesis: University of Florida. (1): 1.
2) Hall, CR. (1995). The motivational function of mental imagery for participation in sport and exercise. In J. Annett, B. Cripps, & H. Steinberg (Eds.), Exercise Addiction:
Motivation for participation in sport and exercise (pp. 15-21). Leicester England:
British Psychological Society.
3) "Stroke Facts." (2011). Centers for Disease Control and Prevention: Division for Heart Disease and Stroke Prevention. <>
4) Dickstein R, Dunsky A, Marcovitz E. (2004). Motor imagery for gait rehabilitation in post-stroke hemiparesis. Physical Therapy (84)12; 1167-1177.
5) Vries, SD, Mulder, T. (2007). Motor imagery and stroke rehabilitation: a critical discussion. Centre for Human Movement Sciences, University Medical Centre Groningen, J Rehabil Med; 39: 5–13.
6) Malouin F, Richards CL, Jackson PL, Dumas F, Doyon J. (2003). Brain activations during motor imagery of locomotor-related tasks: a PET study. Hum Brain Mapp. 19: 47-62.
7) Gerardin E, Sirigu A, Lehericy S, Poline JB, Gaymard B, Marsault C, et al. (2000). Partially overlapping neural networks for real and imagined hand movements. Cereb Cortex. 10: 1093–1104.
8) Porro CA, Cettolo V, Francescato MP, Baraldi P. (2000). Ipsilateral involvement of primary motor cortex during motor imagery. Eur J Neurosci; 12: 3059–3063.
9) Hanakawa T, Immisch I, Toma K, Dimyan MA, Van Gelderen P, Hallett M. (2003). Functional properties of brain areas associated with motor execution and imagery. J Neurophysiol; 89: 989–1002.
10) de Lange FP, Hagoort P, Toni I. (2005). Neural topography and content of movement representations. J Cogn Neurosci; 17: 97–112.
11) Braun SM, Beurskens AJ, Borm PJ, Schack T, Wade DT. (2006). The effects of mental practice in stroke rehabilitation: a systematic review. Arch Phys Med Rehabil. 87(6):842-52.

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