Body Schema as Assessed by Upper Limb Left/Right Judgment Tasks Is Altered in Stroke: Implications for Motor Imagery Training

Abstract

Background and Purpose: Individuals with stroke often experience significant impairment of the upper limb. Rehabilitation interventions targeting the upper limb are typically associated with only small to moderate gains. The knowledge that body schema can be altered in other upper limb conditions has contributed to the development of tailored rehabilitation approaches. This study investigated whether individuals with stroke experienced alterations in body schema of the upper limb. If so, this knowledge may have implications for rehabilitation approaches such as motor imagery. Methods: An observational study performed online consisting of left/right judgment tasks assessed by response time and accuracy of: (i) left/right direction recognition; (ii) left/right shoulder laterality recognition; (iii) left/right hand laterality recognition; (iv) mental rotation of nonembodied objects. Comparisons were made between individuals with and without stroke. Secondary comparisons were made in the stroke population according to side of stroke and side of pain if experienced. Results: A total of 895 individuals (445 with stroke) participated. Individuals with stroke took longer for all tasks compared to those without stroke, and were less accurate in correctly identifying the laterality of shoulder (P < 0.001) and hand (P < 0.001) images, and the orientation of nonembodied objects (P < 0.001). Moreover, the differences observed in the hand and shoulder tasks were greater than what was observed for the control tasks of directional recognition and nonembodied mental rotation. No significant differences were found between left/right judgments of individuals with stroke according to stroke-affected side or side of pain. Discussion and Conclusions: Left/right judgments of upper limb are frequently impaired after stroke, providing evidence of alterations in body schema. The knowledge that body schemas are altered in individuals with longstanding stroke may assist in the development of optimal, well-accepted motor imagery programs for the upper limb. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A394).

An Overview of the Body Schema and Body Image: Theoretical Models, Methodological Settings and Pitfalls for Rehabilitation of Persons with Neurological Disorders

“…GMI includes three phases: left/right discrimination, motor imagery exercises and mirror therapy [98,99]. Right/left discrimination is the primary goal of this treatment because it has been observed that patients with phantom limb pain, but also stroke patients with upper-limb impairment, are less accurate and slower than controls in identifying the laterality of a stimulus (e.g., left or right limb) [100,101]. This reflects the presence of a weak body schema or its alteration.…”