Metacognitive Strategies for Training of Daily Living Skills in People with Brain Damage: The Self-Regulation and Mental Imagery Program

Abstract

Metacognitive strategies are thought to assist people suffering from brain damage in relearning daily living tasks. The use of self-regulation and mental imagery as metacognitive strategies used in an intervention program is described. The program requires the clients’ active participation. The evidence is gathered from two case reports, four randomized clinical trials, and one meta-analysis paper.

The use of metacognitive strategies has demonstrated the positive effects to improve clients’ relearning and performance of simple motor function as well as complicated daily tasks. Generalization of skills learnt is also observed.

Clinical Case Study

The Effect of Self-regulation and Mental Imagery Program on Maria’s Regain in Function After a Stroke

Keywords

Stroke, self-regulation, mental imagery, functional regain

Introduction

The theme of this case study looked into the effect of Maria’s participation in a 3-week self-regulation and mental imagery program aimed to enhance Maria’s performance at daily tasks.

The students’ task includes:

• 1. Understanding what self-regulation and mental imagery are

• 2. Understanding how self-regulation and mental imagery can be used in the activities of daily living training

• 3. Explaining the effect of mental imagery on one’s daily task performance and upper extremity motor function

• 4. Understanding how self-regulation can be combined with other commonly used treatment strategies (such as constraint-induced movement therapy) to further promote people’s regain in function

As a starting point, the students should use the following references to gather information:

Functional Independence Measure (FIM). For example

https://www.google.se/search?q=functional+independence+measure+%28fim%29&source=lnms&tbm=isch&sa=X&ei=G3R7UoniEoXf4QTYhoGYAg&ved=0CAkQ_AUoAQ&biw=960&bih=456. Retrieved 2013/11/07

Kho AY, Liu KPY, Chung RCK (2013) Meta-analysis on the effect of mental imagery on motor recovery of the hemiplegic upper extremity function. Aust Occup Ther J. doi: doi: 10.1111/1440–1630.12084

Leung DPK, Liu KPY (2011) Review of self-awareness and its clinical application in stroke rehabilitation. Int J Rehabil Res 34:187–195

Liu KPY, Chan CCH, Lee TMC, Hui-Chan CWY (2004a) Mental imagery for promoting relearning for people after stroke: a randomized controlled trial. Arch Phys Med Rehabil 85:1403–1408

Liu KPY, Chan CCH, Lee TMC, Hui-Chan CWY (2004b) Mental imagery for relearning of people after brain injury. Brain Inj 18:1163–1172

Liu KPY, Chan CCH, Lee TMC, Li LSW, Hui-Chan CWY (2002) Case reports on self-regulatory learning and generalization for people with brain injury. Brain Inj 16:817–824

Liu KPY, Chan CCH, Wong RSM, Kwan IWL, Yau CSF, Li LSW, Lee TMC (2009) A randomized controlled trial of mental imagery augment generalization of learning in acute poststroke patients. Stroke 40:2222–2225

Overview of the Content

The major goal of the intervention was to teach Maria in utilizing self-regulation and mental imagery effectively so that it could help her to promote the performance at daily tasks.

Learning Objectives

After the work, students will be able to:

• Explain what self-regulation and mental imagery are

• Explain the effect of self-regulation and/or mental imagery on one’s daily task function or upper extremity motor function

• Understand how self-regulation and mental imagery could be integrated in the activities of daily living training for people with stroke

• Further explore how self-regulation can be combined with other commonly used treatment strategies (such as constraint-induced movement therapy) to further promote people’s regain in function

The Background History of the Clinical Case Study

Personal Data and Occupational Needs

Maria was a 68-year-old lady when she joined the mental imagery program after a stroke. Before the stroke , she was a housewife and performed all of self-care and instrumental daily (IADL) tasks. Her husband Peter and she also looked after their 2-year-old grandson during daytime when their son and daughter-in-law went for work.

Medical Diagnose and Disability Description

Maria had sustained an internal capsule infarction to the right hemisphere of the brain and this resulted in left hemiplegia.

Internal and External Environmental Circumstances

Maria had a supportive husband. Her son and daughter-in-law were also supportive but could only spend the weekend taking care of her. They lived in a single-storey house with easily accessible rooms, bathroom, and kitchen. However, a big step in front of the house entrance created a challenge for Maria in terms of accessibility outside the house.

Reason for Seeking Occupational Therapy

Maria had a stroke and was referred to the occupational therapy department for functional training.

Occupational Performance Issues

Maria was independent in all self-care and instrumental activities of daily living tasks before the stroke. After the stroke, she required maximal level of assistance to perform self-care activities. Her performance at instrumental activities of daily living was also greatly affected.

The mental imagery program commenced 11 days after the onset of the stroke. At the time Maria was admitted to the program, her scores on the Functional Independence Measure (FIM) were 30/91 for the motor subscale and 30/35 for the cognitive subscale. This reflected that Maria relied on the maximal level of assistance to perform self-care activities but was fairly independent in communication and problem solving.

Progress and Outcome

Maria showed improvements in performance on all of the 15 trained tasks. She achieved a two- or three-point improvement in most of the tasks. Her performance at the trained tasks was found to be maintained 1 month after the program. The results of her performance at the five untrained tasks assessed at the end of the third week were also very encouraging. Two of the tasks were performed with minimal assistance and the other three with modified independence. However, for her results in cognitive and motor function, Maria did not show much improvement after the program. In the Color Trails Test (a test of her attention and sequential processing), the changes in scores were 223 to 145 s for Part 1 and 412 to 190 s for Part 2. In the Fugl–Meyer Assessment (a test of motor function), Maria scored 0/60 and 5/60 on the upper extremity subscale both before and after the training, and 10/28 and 15/28 on the lower extremity subscale before the training and after the training, respectively.

In the first week of the program, Maria needed help from the therapist in identifying the problems with the task performance and generating solutions to enhance the performance. With a relatively low level of motor functioning at the extremities, Maria was able to plan her actions to compensate in the trained tasks. For example, when performing the task tidy the table after a meal, she leaned onto the table edge for gaining more balance before she reached forward and got the dishes. Maria practiced the mental imagery very well before she actually performed the task. She found that the technique was useful especially for the less frequently performed tasks such as helping her grandson to get dressed.

This case study suggested that the self-regulation and mental imagery program is able to enhance stroke persons’ relearning and generalization of function that promotes their resumption of independent lives.

The Student’s Report

The following guiding questions have been identified in developing possible solutions to Maria. These questions are generated from the available literature references and our clinical experiences.

Questions

• 1. What is self-regulation? How is it applied in a functional training?

• 2. What is mental imagery? How is it applied in a functional training?

• 3. What is metacognition and how do self-regulation and mental imagery fit into the concept?

• 4. Please explain the 3-week program of self-regulation and mental imagery for people with stroke.

• 5. What area(s) of improvement can be observed using self-regulation and/or ­mental imagery?

• 6. What would be the added benefit when self-regulation is combined with ­constraint-induced movement therapy?