274 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No.

To Study the effect of Mental Practice on one Leg Standing Balance in Elderly Population
Vidya V Acharya1, Saraswati Iyer2 M.P.Th., Professor, Seth G.S.Medical College & K.E.M. Hospital, Parel, Mumbai
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ABSTRACT Purpose of study is: to compare "effect of only physical practice" with " effect of physical practice and mental practice" in subjects, for activity of one leg standing. Materials used: table, chair, cassette and record player, stop-watch, newspaper. Methodology: 80 independently ambulatory subjects (age group 50-70yrs) were randomly selected and divided into 2 intervention groups of 40 each. Task was to stand on the preferred leg with arms by side and one legged balance time was measured. Two sessions (1st & 2nd) of the task, of 5 days each, were given to subjects at a periodic gap of 30 days. Baseline and final measurements of one legged balanced time were compared after a three days practice intervention period. Group I (n=40, 20 male s and 20 females) performed only physical practice in both sessions (1st & 2nd) and Group II, (n=40, 20 males and 20 females) performed only physical practice in 1st session and in 2nd session performed physical practice interspersed with mental practice. Mental Practice involved use of idealized visual and kinesthetic mental images provided to subjects through recorded tape. Results: Percentage improvement in balance time in both sessions was compared and statistical analysis was done by paired 't' test and 'z' test. All groups showed improvement, but Group II showed the most improvement in 2nd session, of 33.01% in males and 31% in female's resp. ('p' < 0.001). Comparison of percent improvement between Group I and II, showed an increment of 10% in balance time of group II in its 2nd session('p' < 0.001,HS).Thus showing that balance time increased significantly with physical practice interspersed with mental practice. Conclusion: Our study concludes that Mental Practice along with Physical Practice may hence be an important therapeutic tool to encourage rapid acquisition of a motor skill. Keywords: Mental Practice, Physical Practice, One Leg standing Balance

INTRODUCTION Major concern of physical therapist is movement its acquisition, quality and retention. Primary aim of physical therapist is to maximize patients movement potential. So focus is on physical techniques, for teaching new motor skills to patients.1 However it is not always possible to carry out task under guidance of therapist. Hence Mental practice, which is cognitive rehearsal of a physical skill in absence of any gross muscular movement, can be an utilized as a clinical tool in assisting patients, to rapidly learn a motor task. 1 A major concern of physical therapists with all patients, but especially with elderly, is balance. The increased postural sway seen with age is correlated

with loss of balance and increased incidence of falls in elderly2.Therefore, balance is selected as physical task to test the effect of mental practice on. MATERIAL AND METHOD Materials Table, chair, cassette and record player, stop-watch, newspaper. ii. Method a. Inclusion Criteria Age group: 50 to 70 years. All subjects are independently ambulatory without assistive device.

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b. Exclusion Criteria Subjects with orthopaedic, neurological, uncontrolled diabetes, uncontrolled blood pressure problem, significant hearing and vision loss and psychological problems were excluded. c. Selection of Subjects
Subjects PP and ONLY PP PP and PP + MP Sex FM 2020 Number 2020 2020 Age (yrs) 50-70 50-70 Mean Age (yrs) 59.22 59.12

3. understood satisfactorily 4. understood properly 5. understood properly and completely. Group II subjects Likerts scale response was 4,5 after tape session. So on day 2, 3, 4 group II subjects took
PHYSICAL PRACTICE Tape Session PHYSICAL PRACTICE Tape Session PHYSICAL PRACTICE

Group I II

PP=PHYSICAL PRACTICE MP=MENTAL PRACTICE

FINDINGS Results And Observations Percent improvement in balance time in both sessions was compared and statistical analysis was done by pairedt test and z test. Group I (Males)
Day 1 P. P1st session P. P 2nd session 54 36.57 55.95 36.78 Day 5 62.15 37.13 67.60 38.56 % improvement t- value p- value 17.45 10.37 21.88 10.97 7.52 8.89 < 0.001 < 0.001

d. Study Procedure A short verbal health care history was taken. SESSION I Each subject from group I and group II stood on preferred leg and lifted other foot. Arms were held by side and time was measured using a stopwatch until lifted foot contacted ground. An average of three readings of measured time was taken to have a baseline value on day 1. Group I & II subjects carried out physical practice of activity for next three days. Final value of balance time was taken from an average of three readings on day 5. On day 2,3,4: reading task was given, which distracted attention from original activity. So on day 2,3,4 group I & II subjects took:
PHYSICAL PRACTICE Reading Session PHYSICAL PRACTICE Reading Session PHYSICAL PRACTICE

During 1st session,% improvement in response for balance time is 17.45.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to day 1 due to physical practice. During 2nd session,% improvement in response for balance time is 21.88.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to day 1 due to physical practice. Group I (Females)
Day 1 P. P1 session P. P 2nd session
st

SESSION II After a month Group I subjects took only physical practice same as they took in previous month. Group II took physical practice and mental practice of the activity. Baseline and final measurements of balance time of both groups were taken again on day 1 and day 5 respectively. Group II subjects listened to recorded speech through record player. Speech consisted of details regarding balance activity & relaxation. The capability of subjects to concentrate and perceive recorded speech was measured on Likerts scale. Likerts Scale 1. did not understand 2. understood little

Day 5 70.65 46.54 78.20 49.48

% improvement t- value p- value 19.25 10.62 23.99 12.30 7.52 8.89 < 0.001 < 0.001

59.85 44.70 62.30 45.96

During 1st session,% improvement in response for balance time is 19.25%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to the day 1 due to physical practice. During 2nd session,% improvement in response for the balance time is 23.99%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to day 1 due to physical practice.

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Group II (Males)
Day 1 P. P1st session P. P + M.P2 nd session 50.30 29.30 52.7529.89 Day 5 61.65 34.97 77.20 40.57 % improvement t- value p- value 19.48 9.98 33.01 11.86 8.27 12.44 < 0.001 < 0.001

Group II (Females)
Day 1 P. P1st session P. P + M. P2nd session 52.60 39.51 55.60 38.46 Day 5 61.85 41.38 77.30 42.73 % improvement t- value p- value 19.00 10.001 31.79 12.86 8.48 11.04 < 0.001 < 0.001

During 1st session,% improvement in response for balance time is 19.48%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to day 1 due to physical practice. During the 2nd session,% improvement in response for balance time is 33.01%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to day 1 due to physical practice and mental practice.

During 1st session,% improvement in response for balance time is 19%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to the day 1 due to physical practice. During 2nd session,% improvement in response for balance time is 31.79%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to the day 1 due to physical practice and the mental practice.

Comparison of Average % Improvement Between 1st and 2nd Session in Males and Females.
Subjects Group I Group II Males PP FemalesPP MalesMP + PP FemalesMP + PP % Improvement I 17.45 19.25 19.48 19.00 % Improvement II 21.88 23.99 33.01 31.79 % Difference improvement 4.33 4.74 13.53 12.79 t- value 8.18 6.74 11.67 11.91 p- value P < 0.001 P < 0.001 P < 0.001 P < 0.001

From above table maximum improvement is seen with Group II carrying out physical practice and mental practice in second session. Comparison of Overall Average % Improvement Between Group I and Group II in the 1st and 2nd Session.
Group-I (M+F) % Improvement1st Session % Improvement2nd Session 18.35 + 10.49P.P 22.93 + 11.69P.P Group-II (M+F) 19.24 + 9.999P.P 32.4 + 12.37P.P z- value 0.3 3.53 p- value NS P < 0.001(HS)

From above table we can infer that Comparison between Group I and II is statistically not significant in first session, which indicates that overall improvement between both groups is the same. Difference between them is 0.89%, which is not up to the level of significance. Irrespective of sex of the subjects, physical practice is not enough to increase response in 2nd session for subjects in group I.But with supplement of mental practice response in 2nd session for subjects in group II increased by 10%.This increase is statistically highly significant p<0.001, which indicates that physical practice and mental practice is likely to yield much more

response in 2nd session as compared to only physical practice. Mental Practice interspersed with Physical practice significantly improved balance time in the study. The difference between comparative groups showed highly significant results: Within groups

All groups showed improvement, but the Group II showed the most improvement in 2nd session of 33.01% in males and 31% in females respectively.

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Between both groups

The comparison of percent improvement in Group I and II, showed an increment of 10% in balance time of group II in its 2nd session. Thus showing that the balance time increased with physical practice and mental practice of the activity. Following could be the reasons for significant increase in balance time for Group II subjects. Strengthening of Engram Formation The plausibility that improvement in performance is a direct function of mental practice is related to engram formation. Program of engram formation3 includes i) Perception ii) Precision iii) Perceptual practice. PERCEPTION While carrying out, the act of standing on one leg, perception of sensory inputs are mainly from: proprioception, vision and auditory stimulus from tape session, which provides information about performance to cerebellum and automatic monitoring centre. Mental imaging during tape session and physical practice facilitate process of engram formation, thus enhancing motor learning. This is evident from response of Group II in 2nd session. For Group 1 subjects, it can be inferred that, engram process is not strengthened as those subjects carried out an activity, not related to one leg standing, during reading session. Imaging studies by Shadmer and Holcomb have shown cerebellum to be active during consolidation of a learned internal model of a task4. It acts as adaptive feed forward control system, which programs voluntary movement skills, based on memory of previous sensory inputs and motor outputs. PRECISION Precision of one leg activity is enhanced by mental practice, which entails picturing of standing on one leg, while imagining kinesthetic feel of act and trying to balance on one leg and at the same time correcting imagined mistakes. This occurs in addition to actual physical performance of activity. Perceptual practice Results into excitation of desired neuronal linkages and inhibition of those motor neurons, which should

not be performing in pattern of the one leg standing activity. This helps into minimizing leg muscle work & facilitating muscle work with appropriate force and direction5, thus developing a more efficient balance & co-ordination. So Mental Practice substitutes Physical Practice in process of engram formation. This image would then create a perception of motor act, that would activate automatic monitoring center and facilitate consolidation of engram formation. With engram development, volitional excitation4 takes place, which is strengthened during Physical Practice of the activity and this adds for improvement in performance in Group II. Effect of Auditory Stimulus Mental Practice given in form of auditory cue helped in facilitation of mental picture, by guiding activity of balancing on one leg. Use of background music induces relaxation response. Commands used during tape session affect tone regulation, attention, arousal. This in turn enhances performance by increasing focus to be achieved4. EFFECT OF PRACTICE During Physical Practice Subjects carry out Procedural learning6 i.e. repeated exposure of activity-hence strategies applicable to changing stimulus configuration, within task must be acquired through practice. Procedural Learning is supported by circuits involving Prefronto-caudate-striosmal topographic projections6 . Saint and Taylor propose that straitums role involved with mobilizing new procedures to select among known procedures by acting as procedural memory buffer7 . i. During Mental Practice Subjects carry out Perceptual learning & Declarative learning. Declarative learning results in ability to store and consciously recall tape session during actual practice session. Temporal-cortico-caudate projections are involved (neo striatum)6.

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iii. Acquisition of procedural knowledge through repeated practice may eventually result into development of declarative knowledge of task. iv. Conversely development of declarative knowledge of task may hasten acquisition of procedural knowledge8. v. With repetitive information through mental and physical input, Group II showed significant improvement in average balance time during second session. This improvement in the task can be supported by the research: Neuro-imaging Studies In mental simulation of motor act, cerebral blood flow studies suggest that prefrontal cortex, supplementary motor area, basal ganglia, cerebellum, structures required for performance of actual movement, are active5. PET studies have shown changes in local cerebral blood flow associated with state of information processing i.e. activation when hearing words. (Stephan H Koslow, George V. Coelho)9

CONCLUSION In elderly population, Mental Practice coupled with Physical Practice has shown to improve one leg balance time more significantly than Physical Practice alone. This improvement in balance, which is fundamental component of human movement, suggests that Mental Practice has promising usefulness in health care. Because efficacy of mental practice increases with increasing task familiarity, it could be useful modality for rehabilitation. Therapeutic exercise could be supplemented with mental imaging during rest period. Patients confined to bed can use visualization techniques to prepare for future retraining in gait and activities of daily living. It could easily be incorporated into patients home program. Mental rehearsal encourages patients to assume responsibility for their recovery. Thus, Mental Practice may be an important therapeutic tool to encourage rapid acquisition of a motor skill. ACKNOWLEDGEMENT My heartfelt thanks to the Dean of Institute, Head of Physical Therapy Department, Bio-statistician, all my subjects, departmental staff and colleagues. Conflict of Interest - Nil. REFERENCES 1. Claudia, L.Fansler, Cathy L. Poff, Katherine F Shepard: Effects of mental practice on balance in elderly women. Physical Therapy, September 1985, Vol.65, No.9. Antonio Nardone, Rosella Siliotto: Influence of aging on keg muscle reflex response to stance perturbation. Arch Phys Med Rehabilitation, February 1995, Vol 76. Frederic J Kottke, Daniel Halpern: The training of co-ordination.Arch phys Med Rehabil, December 1978, Vol.59.

Effect on Memory Function Hippocampus 10 provides drive that causes translation of short term memory to long term i.e. it transmits signals which seems to make mind rehearse over & over new information. Consolidation of long term memory of verbal type takes place within hippocampi.

Effect of Motivation Motivation hypothesis postulates that Mental Practice increases the subjects motivation to improve1. Following structures are involved in motivation: prefrontal cortex, limbic structures, hypothalamus, thalamus, brainstem, motor cortex (structures are also active during mental practice)11.

Effect of Neurotransmitter Activity Noradrenergic, dopamine, serotonin systems influence operations of neural systems for decision making12. These systems have cognitive appraisals often without conscious awareness.

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Darcy A Umphred: Interventions for Neurological Disability, Neurological Rehabilitation 4 th Ed. Janet Carr, Roberta Shepherd: Training motor control, increasing strength and fitness and promoting skill acquisition, Neurological Rehabilitation. Optimising Motor Performance. J.A.SaintCyr, Ann.E.Taylor, A.E.Lang: Procedural Learning and Neo-straital Dysfunctions in man, Brain 1988, 111,941-959. P.Soliveri, R.G.Brown, M.Jahanshahi: Learning manual pursuit tracking skills in patients with Parkinsonss Disease. Brain 1997, 120, 1325-1337. Pascual Leone, J Grafman, K.Clark, M.Stewart:Procedural learning in Parkinsons Disease and Cerebellar Degeneration.Annals of Neurology,July-Dec 1993,Vol.34,1-6.

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Stephan H.Koslow, George V.Coelho: Functional Mapping of the Human Brain.Decade of the Brain. 10. Guyton and Hall: Behavioral and Motivational Mechanisms of the Brain. Textbook of Medical physiology.9th Ed. 11. Paul D Cheney: Role of cerebral cortex in voluntary movements.A Review. Physical Therapy, May 1985, Vol65, No5. 12. R E OCaroll, B P Papps: Decision making in Humans: The Effects of manipulating the central noradrenergic systems.J Neurology Neurosurgery Psychiatry 2003:74:376-378.

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