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Adapting Motor Imagery Training Protocols to Surgical Education: A Systematic Review and Meta-Analysis:

Adapting Motor Imagery Training Protocols to Surgical Education: A Systematic Review and... Objective. Motor imagery (MI) is widely used to improve technical skills in sports and has been proven to be effective in neurorehabilitation and surgical education. This review aims to identify the key characteristics of MI protocols for implementation into surgical curricula. Design. This study is a systematic review and meta-analysis. PubMed, MEDLINE, Embase and PsycINFO databases were systematically searched. The primary outcome was the impact of MI training on measured outcomes, and secondary outcomes were study population, MI intervention characteristics, study primary outcome measure and subject rating of MI ability (systematic review registration: PROSPERO CRD42019121895). Results. 456 records were screened, 60 full texts randomising 2251 participants were reviewed and 39 studies were included in meta-analysis. MI was associated with improved outcome in 35/60 studies, and pooled analysis also showed improved outcome on all studies with a standardised mean difference of .39 (95% CI: .12, .67, P = .005). In studies where MI groups showed improved outcomes, the median duration of training was 24 days (mode 42 days), and the median duration of each individual MI session was 30 minutes (range <1 minute-120 minutes). Conclusions. MI training protocols for use in surgical education could have the following characteristics: MI training delivered in parallel to existing surgical training, in a flexible format; inclusion of a brief period of relaxation, followed by several sets of repetitions of MI and a refocusing period. This is a step towards the development of a surgical MI training programme, as a low-cost, low-risk tool to enhance practical skills. Keywords motor imagery, mental training, medical education, surgical education, curricula Introduction cholecystectomy via one-on-one mental training ses- Surgical education has been increasingly reliant on training sions, where trainees memorised the operation primer methods which involve simulation, ranging from simple bench and visualised their inner perception of the operation 1 12 models to virtual reality simulation and box trainers. Motor basedonthis. Louridas et al developed and tested imagery (MI) can be described as a form of simulation; it a script based on MI to perform laparoscopic jejunoje- consists of imagining oneself performing a voluntary move- junostomy, using visual and kinaesthetic (tactile) cues. ment, without physically moving. It has also been called Despite encouraging results, these studies allow limited mental practice (MP), mental training and mental imagery. application for MI training outside of the specificsur- Motor imagery has been proven to be effective at im- gical procedures they were designed for. 3-6 proving technical skills in various fields, and structured The aforementioned areas of neurorehabilitation, sport training programmes which incorporate this concept are psychology and training in specific surgical procedures reported in the literature. In sports psychology, MI has been integrated in several models such as the PETTLEP model MRC Centre for Transplantation, Guy’s Hospital, King’s College which delivers a format of training applicable to different London, UK sports. In the field of neurorehabilitation, Braun’sreview Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, identified the elements which correlate with effective King’s Health Partners, London, UK training outcomes. Corresponding Author: Several studies have successfully shown that this Mary S. L. Goble, BSc, King’s College London, Guy’s Campus, Great 9-11 method can also be adapted to surgical training : Maze Pond, London SE1 1UL, Greater London, UK. Immenroth et al used MI for training in laparoscopy Email: maryslgoble@gmail.com 330 Surgical Innovation 28(3) use common principles of MI to achieve motor improvement. (fMRI), electroencephalograms (EEG), electromyography Current understanding of the neurological mechanism of (EMG), transcutaneous electric nerve stimulation (TENS), MI is dominated in the literature by Jeannerod’s central electroacupuncture or hypnosis. However, studies using 7,13-16 motor theory. It underpins the hypothesis that fMRI, EEG or EMG only as part of pre- and post- a degree of functional equivalence exists between MI, and intervention evaluation, and not during the intervention motor preparation and execution, and that they share period (as may be the case in bio-neurofeedback), were 7,13,14 common neural substrate. Empirical evidence sup- included, providing they met the other eligibility criteria. porting the functional equivalence concept can be seen at different levels of control, namely central (in the frontal Search Strategy and Study Selection and parietal lobes ), peripheral (via increased heart rate and respiratory rate ) and behavioural (via mental The following databases were searched from inception by 18-20 chronometry ). This mechanism is applied to any 2 authors: PubMed, MEDLINE, Embase and PsycINFO. motor development using MI, regardless of the type of The following combination of index terms was used: skill being targeted. Based on this understanding, a cross- ‘randomised controlled trial’, ‘RCT’, ‘mental imagery’, disciplinary use of MI protocols can be explored in order ‘MP’, ‘mental training’ and ‘MI’. Detail of the search to identify important elements of MI training. strategy is presented in Appendix A. There were no Protocols incorporating MI in medical education are registered MeSH terms pertaining to this topic. The last not readily available in the literature, and there has so far date of search was January 12, 2019. Titles of studies were been no rigorous approach regarding the evaluation of the screened for selection. The abstracts were read. Where format in which MI training should be incorporated into necessary, the full text was read. At each step, the studies surgical education programmes. were assessed according to the exclusion and inclusion The aim of this review and meta-analysis is to identify criteria. Studies selected for inclusion were uploaded onto the components necessary to a training protocol for surgical RefWorks and checked for duplication. Both authors education which uses MI. This will be done by gathering completed the search independently and compared results, evidence from fields which have successfully used this incongruities were resolved by discussion. (See Appendix method for decades. The primary outcome will be the B for list of abbreviations used in Tables 1 and 2). effectiveness of a protocol using MI training, measured through different outcome measures due to the diversity of Data collection and Synthesis studies included. The secondary outcomes will be protocol components. Data were extracted by one author using a data extraction This review will be structured according to the form. The primary outcome was the efficacy of the MI PRISMA checklist for systematic reviews and meta- training intervention, measured according to the primary analyses. outcome measure as defined by study authors. The secondary outcomes were protocol characteristics. The following items were extracted: primary outcome measure, study population, Methods MI intervention group characteristics, control group char- acteristics, study primary outcome measure and rating of MI Protocol and Registration ability. The mean and standard deviation of the primary The review has been registered on PROSPERO (regis- outcome measure for each study were converted to a stand- tration number: CRD42019121895). ardisedmeandifference. Where post-intervention scores and follow-up scores were reported, the results of the outcome measured post-intervention only were used. Where there Eligibility Criteria were several MI groups with varying length of MI practice In order to limit this review to evidence of the highest and no data on the results of all MI groups combined, the standard of quality, only randomised controlled trials (RCTs) most effective length of practice only was kept. When studies of the use of MI in any discipline were used. Inclusion compared different types of MP, they were excluded. Where criteria were as follows: RCTs published up until December SDs were not available, they were estimated using IQR/ 2018; studies in English, French and Spanish only; studies of 1.35 , and if the IQR was not available, they were estimated MI training programmes which measured an objective based on the SDs from other studies included in the meta- outcome for a specific voluntary skill; studies which in- analysis. The primary outcome measure used was the primary cluded a protocol based on imagining a movement. Ex- outcome stated as such by authors. Where this was not re- clusion criteria were as follows: studies which were not ported, the outcome measure used was the most complete RCTs; studies in which MI training was combined with measure of progress as described by the study authors, or if simulation training; studies in which MI training was done in this was not available an outcome which reported a single conjunction with functional magnetic resonance imaging measurement. Where performance was measured in different Goble et al 331 Table 1. Main Study Characteristics. Duration of MP Session (minutes) × Total Amount Intervention Group MI Ability N° of Sessions × Intervention Compared to Study Measurement Participants Population Type Interventions Duration (days) Primary Outcome Measures Control Abraham 2018 MIQ-RS, KVIQ- 20 Parkinson’s MP vs control 120 min × 10 × 14 days TUGT, 6-min walk test, FGS, Improved 20 VMIQ-2 disease 30 sec chair stand, 360° turn test and PRT Asa 2014 No 36 Healthy MP only vs PP only vs control 25 min × 1 × 1 days Speed and accuracy of task No difference performance Bathalon 2005 No 44 Healthy MI and KG vs KG alone vs n/a × n/a × 14 days OSCE Improved control Bovend’Eerdt IST 11 Arm spasticity PP vs MP and PP vs control 1.5 min × 32 × 56 days Resistance to passive No difference 2008 movement Braun 2011 VMIQ-2 47 Parkinson’s PP vs MP and PP vs control 20 min × 6 × 42 days Walking performance using No difference disease visual analogue scale Braun 2012 No 36 Stroke patients PP vs MP and PP vs control n/a x 10 × 42 days Numeric rating scales No difference Callow 2017 VMIQ-2 56 Healthy IVI vs IVI and KIN vs control 2 min × 1 × 1 days Time IVI and KIN improved Cho 2013 No 28 Stroke patients MP vs control 15 min × 18 × 42 days FRT, TUGT, 10- m walk test Improved and FMA Coker 2015 VMIQ-2 24 Healthy VI vs KIN vs control 60 min (MP+PP) × 1 × 1 day Hip movements recorded on No difference motion capture system Conlin 2016 MIQ-R 12 Healthy MP vs control n/a × 1 × 1 days TSE and GE of No difference mastoidectomy Cunha 2017 MIQ-RS 15 Transtibial MP vs control 40 min × 12 × 28 days Ground reaction forces Improved amputees Dilek 2018 No 36 Distal radius MP vs control 100 min × 1680 × 56 days Pain, wrist and forearm Improved fracture active ROM, grip strength, DASH questionnaire and MHQ Eldred-Evans No 64 Healthy VRS vs standard training and 30 min × 3 × 6 days Time, precision, accuracy MP groups improved 2013 MP vs VRS training and MP vs and overall performance control on BT and VRS Frenkel 2014 No 18 Healthy MP vs control 15 min × 315 × 21 days ROM Improved Geoffrion 2012 No 79 Healthy MP vs control n/a × 1 × 1 days GRS No difference Gomes 2014 No 60 Healthy MP vs PP vs MP and then PP vs .1 min × 24 × 1 days Time PP, MP and PP and PP PP and then MP vs control and MP improved Guillot 2009 Mental 14 Burn patients MP vs control n/a × 10 × 14 days Goniometric data Improved chronometry Hemayattalab No 40 Intellectually MP vs PP vs MP and then PP vs 30 min × 24 × 24 days Free throw test PP improved most 2009 disabled PP and then MP vs control patients (continued) 332 Surgical Innovation 28(3) Table 1. (continued) Duration of MP Session (minutes) × Total Amount of Intervention Group MI Ability N° Sessions × Intervention Compared to Study Measurement Participants Population Type Interventions Duration (days) Primary Outcome Measures Control Hidalgo-Perez No 40 Healthy MCTE and MI vs control 15 min × 20 × 30 days Craniocervical neuromotor Improved 2015 control, joint position error and fatigue after effort Hosseini 2012 MMSE, VMIQ 30 Healthy OT and MP vs control 15 min × 15 × 35 days TUGT Improved and VVIQ Hoyek 2014 MIQ-R 16 Shoulder MP and PP vs control 15 min × 9 × 21 days Shoulder function, ROM and Improved impingement pain Ietswaart 2011 Task 121 Stroke patients MP and standard rehabilitation 39 min × 20 × 28 days ARAT No difference chronometry vs standard rehabilitation and non-motor mental rehearsal vs control Immenroth No 98 Healthy MP and PP vs PP only vs control 60 min × 2 × 2 days OSATS No difference Jungmann 2011 Mental 40 Healthy MP and VR training vs control 3 min × 4 × 4 days Time, tip trajectory and No difference chronometry instrument collision Kim 2013 VMIQ-2 30 Stroke patients Standard therapy and AO vs 20 min × 20 × 28 days TUGT, FRT, WAQ and FAC Improvement in AO standard therapy and MP vs group control Kim 2018 VMIQ 16 Stroke patients CMIT and MP vs control 10 min × 10 × 14 days Motor evoked potential No difference amplitude, 3-D motion analysis, JT test and motor activity log Komesu 2009 No 68 Healthy MP vs control 20 min × 1 × 1 day GSOP No difference Lebon 2011 No 12 Torn ACL Standard physiotherapy and MP 15 min × 180 × 31 days Muscle activation Improved patients vs control Lim 2016 No 20 Healthy MP and PP vs and control 60 min × 1 × 1 day Technical achievement No difference Liu 2004 No 46 Stroke patients MP and standard rehabilitation 60 min × 15 × 21 days Performance on 15 tasks, No difference vs control FMA and CTT Liu 2009 No 34 Stroke patients MP and conventional therapy vs 60 min × 15 × 21 days Performance on 15 tasks No difference control Liu 2009 No 35 Post-stroke MP and conventional therapy vs 60 min × 15 × 21 days Evaluation of skills No difference patients control Losana-Ferrer MIQ 60 Healthy MP vs AO vs control 6 min × n/a × 10 days Hand grip strength, EMG and Improved (not on IM 2018 IM oxygenation oxygenation) (continued) Goble et al 333 Table 1. (continued) Duration of MP Session (minutes) × Total Amount of Intervention Group MI Ability N° Sessions × Intervention Compared to Study Measurement Participants Population Type Interventions Duration (days) Primary Outcome Measures Control Louridas 2015 MIQ and MIQ-R 20 Healthy PP and MP vs control n/a × n/a × 7 days OSATS and bariatric OSATS No difference Malouin 2009 KVIQ 12 Stroke patients MP and PP vs cognitive training n/a × 12 × 28 days Limb loading Improved and PP vs control Maring 1990 No 26 Healthy MP and PP vs control n/a x 1 x 1 days Upper limb muscle activity Improved Mendoza 1978 No 32 Healthy MP only vs MP with simulated 15 min × 6 × 6 days Success in dart throwing PP improved most movement vs PP only vs control Millard 2001 No 60 Healthy MP vs PP vs MP and PP vs 30 min × 3 × 3 days Wet exit attempts scored MP and PP improved control most Mulla 2012 No 41 Healthy BT vs BT and additional 15 min × 7 × 7 days Assessed on BT and VRS on MP performed worst practice vs VRS training vs MP time, precision, accuracy apart from control vs control and performance Nicholson KVIQ 30 Healthy MP only vs PP only vs control 25 min × 1 × 1 day Gait speed, gait variability No difference 2018 using GAITRite and timed up and go Nilsen 2012 VMIQ-2 19 Stroke patients PP and internal MP vs PP and 18 min × 12 × 42 days FM and JT test Improved external MP vs control Oostra 2015 MIQ-RS 44 Stroke patients Standard rehabilitation and MP 30 min × 30 × 42 days 10-m walk test and FM No difference vs control Page 2005 No 11 Stroke patients PP and MP vs PP only vs control 30 min x 12 × 42 days Motor activity log and ARAT Improved Page 2007 No 32 Stroke patients MP and standard rehabilitation 30 min × 12 × 42 days ARAT and FM Improved vs control Page 2009 No 10 Stroke patients mCIT and MP vs control 30 min × 30 × 70 days ARAT and FM Improved Page, S. 2011 No 29 Stroke patients MP vs MP vs MP (different 40 min × 30 × 70 days FM and ARAT Improved lengths) vs control Park 2015 VMIQ 30 Stroke patients MP and standard rehabilitation 10 min x 20 × 28 days LBT and SCT Improved vs control Sanders 2004 No 65 Healthy 2 sessions PP and 1 MP vs 1 PP 30 min × 3 × 21 days GRS No difference and 2 MP vs control Sanders 2008 Revised 64 Healthy MP vs control 30 min × 2 × 24 days Surgical behaviour Improved Minnesota test Santiago 2015 MIQ-R 20 Parkinson’s MP and standard therapy vs n/a × 1 × 1 day Gait analysis No difference disease control (continued) 334 Surgical Innovation 28(3) Table 1. (continued) Duration of MP Session (minutes) × Total Amount of Intervention Group MI Ability N° Sessions × Intervention Compared to Study Measurement Participants Population Type Interventions Duration (days) Primary Outcome Measures Control Schuster 2012 KVIQ 39 Stroke patients MP added to physio vs MP 45 min × 6 × 14 days Time taken to perform skill No difference embedded into physio vs control Seebacher No 112 MS patients Music and MI vs metronome MI 17 min × 24 × 28 days Walking speed Improved 2017 vs control Sharp 2014 No 18 Spinal cord MP with overground training vs 30 min × 24 × 56 days Gait velocity No difference injury patients control Sidaway 2005 No 24 Healthy MP vs PP vs control 15 min × 12 × 28 days Isometric torque and No difference percentage improvement Stenekes 2009 VMIQ 28 Post flexor MP and conventional therapy vs .6 min × 336 × 42 days Preparation time of finger Improved tendon repair control flexion Timmermans VMIQ 42 Stroke patients Standard therapy and MP vs 10 min × 126 × 42 days FM, FAT, WMFT and No difference and 2013 control accelerometry improved on FAT Vergeer 2006 VVIQ 47 Healthy MI vs SI vs control 30 min × 11 × 28 days Flexibility and comfort Improved in comfort and no difference in flexibility Wilson 2002 No 54 Motor MI vs PP vs control 60 min × 5 × 35 days MABC PP improved most coordination problems Wilson 2016 No 36 Motor MI vs PP 60 min × 5 × 35 days MABC No difference coordination problems Goble et al 335 Table 2. Protocol Components for MI Training. Study MP Protocol Detail Control Group Abraham 2018 16 h training. 5x 2 h sessions every week for 2 weeks. Standard training and in-home learning and exercise Delivered in group by therapist. First session: Introduction programme following the same pattern as the to imagery. Subsequent sessions: 15 min warm-up, 35 min intervention group practice, 35 min practice, 20 min movement session and 5 min cool down. Overall structure: Acquire imagery skills and technique, understand anatomy and function and use imagery for improvement Asa 2014 MP instructions emphasised kinaesthetic imagery, keeping No training eyes closed Bathalon 2005 MI and KG group: KG teaching broke down task into 8 Standard ATLS training steps, students performed task and 5 min teaching of mental imagery. Instructed to perform MI in their own time as often as possible Bovend’Eerdt Closed eyes, imagined limb in mind’s eye and imagined PP and relaxation following the same pattern as the 2008 movement in mind’s eye. Performed the skill (stretch) intervention group physically whilst imagining it. Stretches held for 10-30 secs, 3 repetitions/stretch. MP done immediately prior to PP Braun 2011 MP with therapist, then unguided. 1 log/week completed by Standard physiotherapy and relaxation following the participants to record MP behaviour. 6 weeks standard same pattern as the intervention group physiotherapy, 1 h/week in groups or 30 min 2x/week individually, of which MP for 20 min in groups or 10 min individually Braun 2012 6 weeks rehabilitation, at least 10 sessions of MP Regular rehabilitation + homework practising difficult (conditional) and practice outside supervised therapy time tasks (optional). 4-step programme: Explain concept, develop imagery technique, apply mental practice and consolidate Callow 2017 IVI script: First-person visual perspective. IVI and KIN script: Participants answered arithmetic questions First-person visual perspective and physical feelings Cho 2013 15 min MP: Videos of normal movement shown, explanation Standard physiotherapy only of movement by researcher and imagining normal movement based on visual material using kinaesthetic and visual imagery. 5 min relaxation. 30 min gait training 45 min/day, 3x/week for 6 weeks Coker 2015 Training block of x10 trials of skill to generate feedback. Mental arithmetic task Then, practice sessions alternating PP (x5 repetitions) and MP (visual or kinaesthetic imagery, x20 repetitions of the task). Total blocks had x15 repetitions PP and x60 repetitions MP. Relaxation done before training Conlin 2016 Relaxation, script read out loud and given in written format. Self-directed textbook study Script based on transcript of audio recordings of 3 experts having identified steps in the procedure and reported visual, cognitive and kinaesthetic cues involved. Participants to actively imagine performing skill. Given copy of script to take home and review Cunha 2017 40 min sessions, 3x/week for 4 weeks. First-person Standard training and non-motor task MP perspective and tasks of increasing difficulty. 10 tasks imagined in each session, then described Dilek 2018 Graded motor imagery. 3 stages. 1: 3 weeks of lateralisation: Standard rehabilitation Identifying correct right and left hands from pictures, x3 each hour every day. 2: 3 weeks of MI, visualise own hand moving to posture in image shown, without physically moving, x3 each hour every day. 3: 2 weeks mirror therapy: Move own hand to posture in image shown, x10 every hour every day. All participants instructed to perform home exercise programme (continued) 336 Surgical Innovation 28(3) Table 2. (continued) Study MP Protocol Detail Control Group Eldred-Evans Based on the Mackay nodal model of mental practice. Standard box training and additional self-practice 2013 Relaxation, guided visualisation of nodal points Frenkel 2014 Mental gait training procedure: (1) movement explained; (2) No training describe movement by observing it performed, practicing it on non-tested hand and concentrating on kinaesthetic properties; (3) break down into nodal points and connect points with kinaesthetic perception; (4) practice on non- tested hand with open eyes and closed eyes, perform visual imagery and kinaesthetic imagery and (5) practice on non-tested hand, perform kinaesthetic imagery of task and of an unrelated task. Completed a dairy to record completion of training. 1 × 60 min and then 3 × 30 min guided sessions. Followed by 15 min/day self-guided imagery Geoffrion 2012 MI script enumerated steps from textbook and added visual, Normal surgical training and encouraged to read cognitive and kinaesthetic performance details. textbook on skill Participants performed MP one-on-one with educator, then individually Gomes 2014 Instructions to use internal kinaesthetic perspective. No training Participants closed eyes, signal start of imagining and signal end of imagining Guillot 2009 Script detailing instructions of 2 motor tasks, encouraging Standard rehabilitation and neutral activities following self-representation of movements, sensory and the same pattern as the intervention group kinaesthetic cues, staying immobile. Patients to perform MI during training sessions only. Regularly asked to describe nature of images after MI. Total 2 weeks, 5 MP sessions Hemayattalab Using internal kinaesthetic imagery. PP: 30 repetitions of the No training 2009 skill/session. MP: 30 repetitions of imagining skill. MP and PP: MP for 12 sessions and then PP for 12 sessions. PP and MP: PP for 12 sessions and then MP for 12 sessions Hidalgo-Perez MI done just after PP. 1/day, 5 days/week, 30 days. 4 phases, MCTE only 2015 1 phase/week of intervention: 1- kinaesthetic imagery, 2- visual imagery, 3- movement observation therapy plus MI and 4- exercise execution with mirror feedback. Weekly email and phone reminders Hosseini 2012 15 MP, then 30 min occupational therapy. MP: 5 min Occupational therapy only, for 45 min relaxation, 10 lying supine with eyes closed, asked to imagine skill in first person Hoyek 2014 4 movements imagined using internal visual imagery and Physical therapy training with neutral activities during kinaesthetic imagery. All movements shown before MP. rest time Participants told to imagine movement as slowly and vividly as possible. Imagery script read to them. Each movement imagined 10 times, 5 sets of 2 separated by 30-s rest. 10 long sessions of physical therapy, 3x/week. MP exercises done during therapy sessions in rest times. 45 min physical therapy and 15 min MP. Ietswaart 2011 12 x 45 min sessions with therapist 3 days/week: 30 min MP Standard physiotherapy only actively imagining basic movements, 10 min MP using videos and mirrors and 5 min covert MP, for example mentally rotating visual depiction of hands. 8 × 30 min sessions alone, 2 days/week: Audio tape instructing movements to be imagined. Patients to keep a log book. Total 4 weeks (continued) Goble et al 337 Table 2. (continued) Study MP Protocol Detail Control Group Immenroth Day 1: One-on-one mental training for 90 min. 30 min to No intervention 2007 learn primer by heart, recall wording of primer by external self-talk, relaxation exercise, visualisation in first person under supervision and then alone. Day 2: 30 min session repeating external self-talk and ideomotoric training under supervision Jungmann 2011 Completed 2 sessions VR training. Then, received CD-ROM VR training only with demonstration video of skill, checklist for skill steps and instructions on how to perform MP. Practised MP independently before second VR training session Kim 2013 5x/week, 30 min sessions, over 4 weeks: 20 min audio Standard therapy only instructions and 10 min PP. Kim 2018 Modified constraint-induced movement (CMIT) therapy for CMIT and listened to piano music for 10min 1h and then MP for 10 min. Listened to audio while watching first-person perspective video for 4 min. Close eyes, relaxation for 2 min. Repeat audio only without video for 4 min. Audio included kinaesthetic mental practice. 5 days/week for 2 weeks Komesu 2009 Perform MP 24-48 h before assessment. Imagine performing Standard surgical training and textbook study skill and describe to educator in detail following the same pattern as the intervention group Lebon 2011 Sat with legs extended. Relaxation done in initial few Standard physiotherapy and neutral task following the sessions only. Perceive muscle contractions and joint same pattern as the intervention group tension while imagining movement. 3 blocks of 10 imagined movement, 10 sec rest between imagined movements and 2 min rest between blocks. MP: 28-34 day programme. 12 × 15 min sessions, one every 2 days. Physiotherapy: 30 min every 2 days Lim 2016 60 min scripted mental imagery group training. After 20 min, Low-fidelity simulation training only independent mental rehearsal. After session, performed skill x3 Liu 2004 Increasing difficulty of tasks. First week: Analyse task Standard rehabilitation and neutral activities following sequences with pictures and movies. Second week: the same pattern as the intervention group Identify own problems. Third week: Imagine task being performed by self, physically perform task and videotape, view videotape and adjust problems. Repeat identification of problems and third week steps until proper method is achieved. 15 sessions MP, 1 h/day for 3 weeks and standard physiotherapy, 1 h/day for 5 days/week at a different time of day Liu 2009 MP and conventional therapy, learning tasks of increasing Followed the same pattern of therapy as the difficulty. 1 h physical therapy and 1 h MP 5x/week for intervention group with occupational therapy 3 weeks instead of MP Liu 2009 Chunking-regulation-rehearsal strategy: Truncate task, self- Physical practice and functional rehabilitation reflect on abilities, feedback using video playback, mentally following the same pattern as the intervention group rehearsing and physically practising. MP and conventional therapy, learning tasks of increasing difficulty. 1 h physical therapy and 1 h MP 5x/week for 3 weeks Losana-Ferrer Sit on chair, imagine 10 physical repetitions for 3 sec each Physical practice following the same pattern as 2018 and 20 sec rest in between. 2 min break. Repeat imagery intervention groups whilst also performing skill physically. 10 training days, 1st and 4th supervised and remainder at home. All groups told to practice at home and weekly reminders (continued) 338 Surgical Innovation 28(3) Table 2. (continued) Study MP Protocol Detail Control Group Louridas 2015 Didactic lecture. In-person instructions on MP. Relaxation Standard physical practice only following the same exercise. MP guided by MP script developed by pattern as the intervention group interviewing experts and detailing visual and kinaesthetic cues, including common pitfalls in performance. Given script and videos of didactic teaching, 7 days to perform MP at home, with follow-up calls and feedback Malouin 2009 Approx 1 h training done in quiet room by physical No training therapist. MP done in blocks following one attempt of PP. Briefing on first-person imagery with focus on kinaesthetic imagery (sensory). Close eyes, imagine task. Number of mental repetitions increased with time. Live feedback on performance was given for first few sessions, via outcome measurement tool. 3/week for 4 weeks Maring 1990 Maximum voluntary contraction of muscle, 2 min PP only and task demanding mental attention visualisation with visual and kinaesthetic cues and no following the same pattern as the mental physical movement, physical practice of skill x10. intervention group Repeated x5 Mendoza 1978 MP only: Sit with eyes closed, imagine performing skill whilst No practice being aware of all sensory input, correcting for imagined misses. 2 × 15 min sessions/day for 6 days Millard 2001 MP group: Watched video, taught mental practice and No training watched video + made entry in diary after each MP session. PP group: Watched demonstration, then did drill 3x/day for 3 days. PP and MP groups did both training Mulla 2012 25 min one-to-one mental training. Description and No training memorisation of motor skills involved, relaxation and internal and external visualisation of skills to perform. Student to practise at home 15 min/day every day Nicholson 2018 Sat in chair. Imagined completing obstacle course in first- 25 min playing mentally stimulating games on iPad person perspective. MP group: 20 imagined repetitions of a task. PP group: 20 physical repetitions of a task. In both: 30 sec rest between each trial and 5 minute rest after every 10 repetitions Nilsen 2012 Listened to audio script of MP with visual and kinaesthetic Occupational therapy and relaxation following the detail. 2 min introduction instructing internal perspective same pattern as the intervention groups (group 1) or external perspective (group 2). 5 min relaxation. 8 min focussed imagery with key components of task repeated several times. 3 min refocusing Oostra 2015 30 min sessions, in quiet room with 2 therapists, sit down Standard rehabilitation and generic relaxation and eyes closed. 2 min relaxation, perform practice from sessions following the same pattern as the internal perspective, with a visual and kinaesthetic mode. intervention group Content of sessions was familiarisation in week 1, specific gait problems week 2 and symmetry and velocity weeks 3 and 4 Page 2005 MP corresponded to focus therapy, which changed weekly. Occupational therapy and relaxation techniques Audio tape: 5 min relaxation, then suggestions for internal, cognitive polysensory images, then 3-5 min refocusing. 30 min occupational therapy (PP) sessions 2 days/week for 6 weeks followed by 30 min MP Page 2007 MP sessions directly after PP. Audio tape. 30 min total: 5 min Standard rehabilitation and relaxation following the relaxation, approx. 20 min suggestions for internal, same pattern as the intervention group cognitive polysensory images of skill performed in PP on the same day (several trials of imaging) and refocusing. Patients instructed not to do additional MP at home (continued) Goble et al 339 Table 2. (continued) Study MP Protocol Detail Control Group Page 2009 Audio tapes read by male psychologist delivered in quiet mCIT only room. 5 min guided relaxation, 15-20 min motor imagery in first person using polysensory cues and 5 min refocusing. Instructed to not do self-directed practice. 3 days/week for 10 weeks Page, S. 2011 Audiotaped MP intervention listened to in private room. Same baseline rehabilitation sessions and audiotaped 5 min relaxation (imagine themselves in nice place and sham intervention directly after the rehabilitation contract/relax muscles), followed by suggestions for session sensory images related to use of the arm and finishing with 5 min refocusing into the room. Opening and closing 5 minutes held constant in varying lengths of MP practice. Group 1: MP for 20 minutes, group 2: MP for 40 min and group 3: 60 min Park 2015 Sit with eyes closed, imagine scene while listening to voice of Standard rehabilitation only instructor for 10 min and give verbal feedback. 10 repetitions of each skill. Break in between skills for relaxation and internal concentration. 5 days/week for 4 weeks Sanders 2004 Relaxation by psychologist, then verbal imagery instruction 3 sessions PP only in making incision, suturing and knot tying by physician while visualising. 30 min long sessions, 1/week Sanders, W. Relaxation by psychologist, then guided imagery instruction Same baseline training and 2 additional sessions of 2008 in making incision and performing sutures. 30 min reading. Same instructional time as the intervention group Santiago 2015 1. Identified problems in gait. 2. Memorised phases of Standard physical practice only following the same normal gait with images, performed gait 5x. 3. Order pattern as the intervention group detailed phases of gait with cards 3x, keyword for each card. 4. Closed eyes and MP done emphasising kinaesthetic perspective, say keyword for each phase. 3 series of 10 repetitions, 30 sec rest. 8 steps/repetition. 5. PP 3 series of 10 repetition, 8 steps/repetition. 6. MP in 2 imagined complex environments. 1 series of 10 repetitions, 8 steps/ repetition in each environment. 7. PP in complex setting Schuster 2012 Group 1 (MP added): Motor task divided into 13 steps, each Standard physiotherapy and neutral task following the step imagined x5 and then practised physically x1. At end, same pattern as the intervention group complete task x8. Individual sessions, supervised by an instructor, task specific, same environment as physical practice, detailed and standardised instructions, internal perspective and eyes closed and no familiarisation with MI before start of intervention. Session time 45-50 min, 5 to 9 visual trials and 2 to 4 kinaesthetic trials in one session. Group 2 (MP embedded): 30 min physiotherapy, then recorded audio: 3.5 min relaxation, 14.5 min description of motor task and 2 min refocusing. Not supervised, different environments to physical practice, internal perspective and eyes closed and no familiarisation with MI before start of intervention. Session time 45-50 min. 6 to 8 visual trials and 1 to 3 kinaesthetic trials in one session. All patients kept diaries. 6 sessions in 2 weeks Seebacher 2017 30-40 min MI familiarisation in groups of 2-3. Study CD with No training music and verbal cueing (group 1) or metronome cues and verbal cueing (group 2). Internal perspective, kinaesthetic mode, weekly change of audio mix, home-based practice and seated position with eyes closed, self-selected time of day, 17 min practice/day, 6 days/week for 4 weeks. Record MI sessions in diary. Weekly phone calls for support and adherence (continued) 340 Surgical Innovation 28(3) Table 2. (continued) Study MP Protocol Detail Control Group Sharp 2014 Practised PP, then 30 min audio recording. 3 days/week for Overground training with relaxation audio recordings 8 weeks Sidaway 2005 Given instructions on kinaesthetic imagery, then performed No training 3 MP trials. 15 min training sessions. 3 sets of 10 repetitions, separated by 10 seconds rest, 3x/week for 4 weeks. MP group: Imagery script at start of session but did mental repetitions instead of physical repetitions. Were placed in the same environment as PP group. PP group: Physical repetitions Stenekes 2009 Active movement performed mentally following Standard post-operative rehabilitation instructions to imagine initial movement, mentally hold thought in mind for 3 sec and imagine following movement. Repeat imaginary movement 10 times/session. Patients to record number of sessions performed every day. 8 sessions/day, 6 weeks Timmermans 6 tasks of increasing difficult. DVD guidance showing first- Standard therapy and exercise therapy following the 2013 person perspective of task being performed, then 5 same pattern as the intervention group repetitions of correct performance shown with no verbal explanation and instructions to mentally practice task, then no guidance. 3x/day for 10 min, for 6 weeks. Performance assessed during intervention and if improved, DVD changed Vergeer 2006 4-week programme, 30 min sessions 3x/week. Movement Physical training only imagery (MI) group: Physical stretching (5-7 min warm-up, 7 stretching exercises) and imagery component (movement demonstrated, then told to imagine leg being stretched whilst simultaneously doing physical task). Stretching imagery (SI) group: Physical stretching and imagery component (told to imagine change at a cellular level previously explained with a CD, hand gestures, images and a CD) Wilson 2002 Delivered by CD-ROM with software. 6 operations: Visual No training imagery exercises with predictive timing, relaxation, visual modelling of motor skills with video watching, mental rehearsal of skills from external perspective, mental rehearsal of skills from internal perspective and overt practice Wilson 2016 6 steps: Visual imagery exercise with predictive timing, No training relaxation protocol and mental preparation, mental rehearsal from external perspective, mental rehearsal from internal perspective and overt practice with mental practice between sets. 5 h individual training in 60 min sessions, 1/week for 5 weeks simulators (e.g. box trainer and virtual reality simulation study compared one group performing MI alone and (VRS)), the simulator which had not been used in training one group performing MI and physical practice. Sub- was used. group analysis was conducted based on length of training, inclusion of a relaxation component to the protocol and selection of participants based on MI Meta-analysis ability. Data were input into Review Manager in order to conduct meta-analysis if it satisfied the following cri- Risk of Bias teria: The mean and standard deviation of the primary outcome measure were available, or could be estimated Risk of bias was assessed using the Cochrane risk of bias according to the methods described previously, and the tool. Goble et al 341 independent measures of time taken, precision and ac- Results curacy in completion of task or a purpose-built checklist. General Study Characteristics The remaining studies used task-specific measures such as 50,56,61 the Fugl-Meyer assessment for stroke or broader Overall, 60 RCTs were identified with a total of 2251 measures of function such as using a goniometer for range participants. A flow diagram of the studies’ selection process 40-43 of motion . is illustrated in Figure 1. Studies were published between 1978 and 2018. Study sample sizes ranged from 10 to 112, and median was 34.5. Participants were healthy in 27 Outcomes studies, had previously had a stroke in 20 studies or in 13 25 (42%) studies found that the intervention group studies had a range of conditions including Parkinson’s using MI did not perform better than the control disease, multiple sclerosis, arm spasticity or amputa- 6,11,24,26-31,34-49 group. tion. 6 studies only had surgical residents or trainees as In 35 studies (58%), the intervention group performed participants, and 12 had healthy students. 3,12,25,32,33,50-79 better than the control group. In 29/35 studies (83%), the intervention group which did MP and Primary Outcome Measures standard physical practice (rehabilitation, physiotherapy The primary outcome was the overall effectiveness of a pro- and surgical training) performed better than the control 3,12,25,32,33,50- tocol using MI; several outcome measures were used group which did only standard physical practice. 70,76,78,79 due to the diversity of studies included. In the 12 There was no trend found between these study 11,12,24-33 studies which had medical students or trainees results and the use of MI ability assessment, the outcome as their population, the primary outcome measures measures used or the length of interventions. were the Objective Standard Assessment of Technical A summary of all data extracted is presented in Tables Skills (OSATS), variations of a Global Rating Scale, 1 and 2. Figure 1. PRISMA flow diagram. 342 Surgical Innovation 28(3) protocols were reported was not consistent across the studies Secondary Outcomes: Intervention Duration and reviewed. In 13 studies, the MI sessions included several Number of Motor Imagery Sessions 40,42,43,51,53, repetitions of MI with periods of rest in between. 55,57,58,60-62,68,75 The median duration of each individual MI session was Out of these, 10 found the intervention 51,53,55,57,58,60-62,68,75 27.5 minutes (range <1 minute-120 minutes). performed better than control. 7studies In studies where the intervention group performed mention a refocusing period at the end of the MI 42,51,59,61,65,69 better than control, the median was 30 minutes (range session. <1 minute-120 minutes). The median number of MI sessions completed was 11 (range 1-1680); and 13 (range Secondary Outcomes: Motor Imagery 1-1680) in studies where the intervention group per- Ability Assessment formed better than control. The median duration of in- tervention across all studies was 22.4 days (mode 1, range Certain studies measured participant ability to conduct 1-70), and in studies where the intervention group per- MI, as MI ability differs in a healthy population, and formed better than control, it was 24 days (mode 42, range can be measured using validated imagery questionnaires, 1-70). such as the Mental Imagery Questionnaire (MIQ), the Mental Imagery Questionnaire Revised, Second Edition (MIQ-RS) or the Vividness of Mental Imagery Ques- Secondary Outcomes: Intervention Content tionnaire (VMIQ). In patients who have a neurological 11,12,24,25,27,29,32,41,42,44,47,48,50,51,53,58,59,61,65, In 22 studies, impairment, the Kinaesthetic and Visual Imagery 66,69,77 the MI sessions began with a brief period of re- Questionnaire (KVIQ) can be used, as can mental laxation lasting <5 minutes. Out of these, 13 of them found chronometry, which has been shown to correlate with MI 12,25,32, the intervention group performed better than control. ability in healthy and non-healthy patients. 23 studies 50,51,53,58,59,61,65,66,69,77 In 7 studies, there was explicit men- (38%) used the MIQ, MIQ-RS, VMIQ, VMIQ-2, VVIQ, tion of the use of sensory cues for visualisation, giving an mental chronometry, KVIQ or time-dependent motor indication of the specificity of the instructions given to imagery (TDMI) to select participants based on MI 3,31,39,51,59,65,69 6,12,24,34,38,40-43,45,47,48,53,55,57,60-62,64,66,68,72,79 participants. The level of detail to which the ability. Figure 2. Forest plot comparing mental training interventions to control. Goble et al 343 Out of these, 12 (52%) reported better outcomes in the in- relaxation and selection of participants based on MI 12,53,55,57,60-62,64,66,68,72,79 tervention group compared to control. ability. Meta-analysis Risk of Bias Assessment Meta-analysis was performed on the 39 studies eligible The risk of ‘other’ bias was classed as high in 26 studies, for inclusion. Figure 2 summarises the results of the primarily due to selecting participants based on MI ability. meta-analysis. Overall, mental imagery was associated The risk of selective reporting bias was unclear for the with improved outcomes (z = 2.79, P = .005) but with majority of studies as only few had previously published high heterogeneity between the studies (I =79%, a protocol which could be referred to. 7 studies had a risk P < .00001). Figures 3-5, respectively, detail the results of bias which was classed as low for 5 or more types of of subgroup analyses based on length of training, bias and unclear for 2 or less types of bias, which the Figure 3. Forest plot comparing mental training interventions of 1 day, 2-4 days, 6-7 days, 14 days, 21 days and >28 days duration. 344 Surgical Innovation 28(3) Figure 4. Forest plot comparing mental training interventions with a relaxation component to mental training interventions with no relaxation component. authors consider to be an overall low risk of bias. Of these, Performing MI in addition to standard rehabilitation or 12,55 2 found the intervention group performed better than training led to improvements in the majority of trials 24,28,42,43,46 control on outcomes measures and 5 found (83%).This is consistent with the concept that MI is they performed the same or worse. A summary of the risk a valuable tool when added to existing training. Based on of bias is presented in Table 3. current understanding of the neurological processes of MI, it can be speculated that protocols which demonstrate improvement in non-surgical fields can be extrapolated to Discussion surgical training, due to the fact all are focussed on motor This review assessed only RCTs evaluating the effec- skill learning. This could be particularly true for healthy tiveness of various MI protocols across the fields of sports, populations improving on a specific skill - such as ath- neurorehabilitation, education and medical education. The letes. Surgical trainees and athletes have in common aim was to extract the components of a successful MI a healthy physical baseline and the goal of improving protocol. The authors hypothesised these components a specific motor skill. However, the authors acknowledge might be universal to MI training applied to several the methodological limitation of assuming similarities different indications, hence the inclusion of a heteroge- between populations. Overall, there were very few studies neous sample of studies. In addition, MI programmes for which specifically tested MI skills in surgical residents; surgical training remain novel, with few studies having this is a novel method of training in this field which must specifically evaluating its effectiveness on surgeons. be tested further. This method could be used to improve Broadening the search across several disciplines allowed a range of motor skills, ranging from generic surgical skills protocol components never included in surgical training to patient-specific skills. Motor imagery-based training 10,31 programmes to be considered. could be a supplement to standard surgical training. Goble et al 345 Figure 5. Forest plot comparing studies where participants were selected based on mental training ability to studies where participants were not. Studies where the intervention group performed better making direct comparisons of protocols and associated out- than control on outcomes had a median duration of in- comes difficult. However, the following elements could be tervention of 30 minutes, with a median of 15 MI sessions incorporated into the structure of MI protocols in the interest completed in 26 days. This is equivalent to performing MI of standardising their format and enabling direct compari- more than once every 2 days. An online surgical training son of outcomes in future research: a period of relaxation course, where trainees conducted a short amount of im- <5 minutes long prior to starting MI proper; detailed in- agery, regularly and at their convenience, would fit these structions involving specific sensory cues, a predetermined 12,27,30,52,55,60,74 requirements. Indeed, there were 7 stud- number of sets of repetitions of MI to be performed in each ies in which subjects were instructed to perform MI in- session and a refocusing period to close the MI session. dependently at home and record their progress. In the Given that there was no association between MI ability study by Louridas et al, surgical trainees were given and technical performance (when compared to control), 7 days to perform MI at home and had follow-up calls and this indicates that baseline MI ability may not be an feedback. Only 2 of these 7 studies, by Jungmann et al important factor for a MI training programme. and Mulla et al, did not see an improvement in the Given the heterogeneity of study outcomes measured and intervention group compared to control. They were also the variability of populations studied, no extrapolation can be the only 2/7 studies which used medical students as their made of the primary outcome most suitable for measuring the population. This means a MI training protocol for surgical effectiveness of an MI training protocol. Relevant to surgical education could be in a format which allowed subjects to education MI training, a variety of primary outcome measures access training in their own time. were used amongst the medical student and resident pop- Regarding the content of MI interventions, the level of ulations. These were variations of a pre-established check- detail provided across the studies review varied widely, list and objective measurements such as time and accuracy. 346 Surgical Innovation 28(3) Table 3. Risk of Bias. Random Blinding of Blinding of Incomplete Other Sources of Sequence Allocation Participants and Outcome Outcome Selective Bias - MI Ability Study Generation Concealment Personnel Assessment Data Reporting Assessment Abraham 2018 Low Unclear Unclear Unclear Low Unclear Unclear Asa 2014 Unclear Unclear Unclear High Low Unclear High Bathalon 2002 Unclear Unclear Low Low Low Unclear High Bovend’Eerdt Low Unclear High Low Low Unclear Low Braun 2011 Unclear Unclear Unclear Low Low Unclear Low Braun 2012 Low Unclear High Low Low Low High Cho 2013 Low Low Unclear Unclear Low Unclear High Coker 2015 Unclear Unclear Unclear Unclear Low Unclear Low Conlin 2016 Low Unclear Unclear Low Low Low Low Cunha 2017 Unclear Unclear Unclear Unclear High Unclear High Dilek 2018 Low Low Unclear Low Low Unclear High Eldred-Evans Low Low Unclear Low Unclear Unclear High Frenkel 2014 High High Low High Low High Unclear Geoffrion 2012 Low Low Unclear Low Low Unclear High Gomes 2014 Unclear Unclear Unclear Low Low Unclear High Guillot 2009 Unclear Unclear Unclear Unclear Low High Low Hemayattalab Unclear Unclear Unclear Unclear Low Unclear High Hidalgo-Perez Low Low High Low Low Unclear High Hosseini 2012 Unclear Unclear Unclear Low Low Low Low Hoyek 2014 Unclear Unclear High High Low Unclear Low Ietswaart 2011 Low Unclear Low Low Low Unclear Low Immenroth Low Low High Unclear Low Unclear High Jungmann 2011 Unclear Unclear Unclear Unclear Low Unclear Low Kim 2013 Unclear Low Unclear Unclear Low Unclear High Kim 2018 Low Unclear High High Low Low Low Komesu 2009 Low Low Unclear Low Low Unclear High Lebon 2011 Unclear Unclear Low Low Low Unclear High Lim 2016 Low Unclear Low Low Low Unclear Low Liu 2004 Unclear Low Unclear Low Low Unclear High Liu 2008 Unclear Unclear Unclear Low Low Unclear High Liu 2009 Low Low Unclear Low Low Unclear High Losana-Ferrer Low Low Unclear Low Low Unclear Low Louridas 2015 Low Low Low Low Low Low Low Malouin 2009 Low Unclear Unclear Low Low Unclear Low Maring 1990 Unclear Unclear Unclear Unclear Low High High Mendoza 1978 Unclear Unclear Low Low Low Unclear High Millard 2001 Unclear Unclear Unclear Low Low Unclear High Mulla 2012 Low High Unclear Unclear Low Unclear High Nicholson Low Low High Low Low Unclear Low Nilsen 2012 Unclear Unclear Low Low Low Unclear Unclear Oostra 2004 Low Unclear Unclear Low Low Unclear Low Page 2005 Low Unclear High Low Low Low High Page 2007 Low Unclear Low Unclear Low Unclear High Page 2009 Low Unclear Unclear Unclear Low Unclear High (continued) Goble et al 347 Table 3. (continued) Random Blinding of Blinding of Incomplete Other Sources of Sequence Allocation Participants and Outcome Outcome Selective Bias - MI Ability Study Generation Concealment Personnel Assessment Data Reporting Assessment Page 2011 Low High Unclear Low Low Low High Park 2015 Low Unclear Unclear Low Low Unclear Low Sanders 2004 Unclear Low Low Low Unclear Unclear Low Santiago 2015 Low Low Unclear Low Low Unclear Low Schuster 2012 Low Low Low Low Low Low Low Seebacher Low Low High Unclear Low Low High Sharp 2014 Low Low Unclear Low Unclear Unclear High Sidaway 2005 Unclear Unclear Unclear Unclear Low Unclear High Stenekes 2009 Unclear High Unclear Unclear Low Unclear Low Timmermans Low Low High Low Low Low Low Vergeer 2006 Unclear Unclear Unclear Low Low Low Low Wilson 2002 Low Unclear Unclear Low Low Unclear High Wilson 2016 Unclear Unclear High Low Unclear Unclear High 24,27,29,30,34-36,39,40 In 9 of the studies where the in- of this review may aid in constructing a purpose-built MI tervention group performed worse or equivalent to the training programme to evaluate its efficacy on surgical control group, subjects were students or healthy partic- trainees specifically. ipants for whom the benefit of the study was not obvious: they did not have an intrinsic motivation to perform well Conclusions on the outcomes measured such as increased function of This comprehensive systematic review and meta-analysis a limb following a stroke or improved surgical technique. has identified several characteristics linked to successful MI This may indicate that for MI interventions to be suc- training in sports or neurorehabilitation that can be used to cessful, participants need to be self-motivated, and in the construct MI training protocols for use in surgical educa- context of surgical education, surgeons should only un- tion. It must be highlighted that this review and analysis dergo MI training if they see potential benefit in it. included a wide range of studies in different fields. However, this is difficult to establish in the heterogeneous However, certain components found to be linked to suc- group of studies reviewed here and would benefit from cessful programmes could be extrapolated to surgical further research focussed on surgical trainees’ motivation training, based on current understanding of neurological to use MI with their performance after training. Guillot’s processes of MI. A successful MI training programme article did explore the relationship between intrinsic could be delivered in parallel to existing surgical training, motivation and MI in the opposite direction and suggests in a flexible format allowing surgeons to undertake several that MI does enhance intrinsic motivation. MI sessions in a self-directed manner. A single MI session A number of limitations to these results need to be conducted by a senior surgeon could include a brief period considered. The majority of the studies were intrinsically of relaxation, followed by several sets of repetitions of MI, biased as the subjects who received the intervention could and a refocusing period. Providing guidance on the con- not be blinded. Another limitation is the heterogeneity of struction of effective MI training protocols will allow studies included in this review. Studies included repre- replicability of trials investigating the best way to deliver sented many applications of MI training, which may limit MI training. This is a step towards the development of the generalisability of findings. Only 12 studies focussed a surgical MI training programme, as a low-cost, low-risk on the application of MI training directly to surgical tool to enhance practical skills. Further research will be trainees or medical students. Further research is required required to evaluate the use of MI in a purpose-built to demonstrate that the findings from this review can be surgical training programme. translated to surgical education. Furthermore, variations in study methodologies limited pooled analysis. Author Contributions Following this review, more research focussing on the implementation of MI training protocols in surgical ed- Study concept and design: Mary S. L. Goble and Nicholas ucation is needed, in addition to the acceptability of such Riason Acquisition of data: Mary S. L. Goble and Ayah Mekhaimar training measures among trainees and surgeons. The results 348 Surgical Innovation 28(3) Analysis and interpretation: Mary S. L. Goble, Nicholas Riason, 10. Davison S, Raison N, Khan MS, Dasgupta P, Ahmed K. and Kamran Ahmed Mental training in surgical education: A systematic review. Study supervision: Nicholas Riason, Kamran Ahmed, and ANZ J Surg. 2017;87(11):873-878. doi:10.1111/ans.14140 Prokar Dasgupta 11. Immenroth M, Bürger T, Brenner JR, Nagelschmidt M, Eberspacher ¨ H, Troidl H. Mental training in surgical edu- cation. Ann Surg. 2007;245(3):385-391. doi:10.1097/01.sla. Declaration of Conflicting Interest 0000251575.95171.b3 The author(s) declared no potential conflicts of interest with 12. Louridas M, Bonrath EM, Sinclair DA, Dedy NJ, Grantch- respect to the research, authorship, and/or publication of this arov TP. Randomized clinical trial to evaluate mental practice article. in enhancing advanced laparoscopic surgical performance. Br J Surg. 2015;102(1):37-44. doi:10.1002/bjs.9657 Funding 13. Jeannerod M. Mental imagery in the motor context. Neu- The author(s) disclosed receipt of the following financial ropsychologia. 1995;33(11):1419-1432. doi:10.1016/0028- support for the research, authorship, and/or publication of this 3932(95)00073-C article: Grant awarded from the Royal College of Surgeons. 14. Ridderinkhof KR, Brass M. 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J Neurol Phys Ther. 2007;31(1):20. doi:10.1097/01. walking while talking: A pilot randomized-controlled trial NPT.0000260567.24122.64 Goble et al 351 Appendix A Detailed Search Strategy PubMed ((‘Motor imagery’)OR (‘mental imagery’)OR (‘mental practice’)OR (‘mental training’)) AND ((‘randomised controlled study’)OR (‘randomised controlled trial’)) 265 results Ovid (PsycINFO, Embase and MEDLINE) ((Motor imagery) OR (mental imagery) OR (mental practice) OR (mental training)) NOT (computerised OR computer) Filter: Randomised controlled trial 191 results Appendix B. List of Abbreviations Used in Tables 1 and 2. ACL Anterior cruciate ligament AMIT Advanced Mechanical Technology Inc BT Box training CMIT Constraint-induced movement therapy EMG Electromyography FAT Frenchay arm test FM Fugl-Meyer assessment test GRS Global Rating Scale IST Intelligence Structure Test IVI Internal visual imagery KG Kinesiology KIN Kinaesthetic imagery KVIQ-20 Kinaesthetic and visual imagery questionnaire 20 LBT Line bisection test MABC Movement Assessment Battery for children MCTE Motor control therapeutic exercise MI Mental imagery, motor imagery MIQ-RS Motor Imagery Questionnaire-Revised MMSE Mini-mental state examination MP Mental practice n/a Not available OSATS Objective Standard Assessment of Technical Skills OT Occupational therapy PP Physical practice SCT Star cancellation test SI Stretching imagery TDMI Time-dependent motor imagery VMIQ-2 Vividness of Movement Imagery Questionnaire 2 VR Virtual reality VRS Virtual reality simulation http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Surgical Innovation SAGE

Adapting Motor Imagery Training Protocols to Surgical Education: A Systematic Review and Meta-Analysis:

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1553-3506
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10.1177/1553350621990480
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Abstract

Objective. Motor imagery (MI) is widely used to improve technical skills in sports and has been proven to be effective in neurorehabilitation and surgical education. This review aims to identify the key characteristics of MI protocols for implementation into surgical curricula. Design. This study is a systematic review and meta-analysis. PubMed, MEDLINE, Embase and PsycINFO databases were systematically searched. The primary outcome was the impact of MI training on measured outcomes, and secondary outcomes were study population, MI intervention characteristics, study primary outcome measure and subject rating of MI ability (systematic review registration: PROSPERO CRD42019121895). Results. 456 records were screened, 60 full texts randomising 2251 participants were reviewed and 39 studies were included in meta-analysis. MI was associated with improved outcome in 35/60 studies, and pooled analysis also showed improved outcome on all studies with a standardised mean difference of .39 (95% CI: .12, .67, P = .005). In studies where MI groups showed improved outcomes, the median duration of training was 24 days (mode 42 days), and the median duration of each individual MI session was 30 minutes (range <1 minute-120 minutes). Conclusions. MI training protocols for use in surgical education could have the following characteristics: MI training delivered in parallel to existing surgical training, in a flexible format; inclusion of a brief period of relaxation, followed by several sets of repetitions of MI and a refocusing period. This is a step towards the development of a surgical MI training programme, as a low-cost, low-risk tool to enhance practical skills. Keywords motor imagery, mental training, medical education, surgical education, curricula Introduction cholecystectomy via one-on-one mental training ses- Surgical education has been increasingly reliant on training sions, where trainees memorised the operation primer methods which involve simulation, ranging from simple bench and visualised their inner perception of the operation 1 12 models to virtual reality simulation and box trainers. Motor basedonthis. Louridas et al developed and tested imagery (MI) can be described as a form of simulation; it a script based on MI to perform laparoscopic jejunoje- consists of imagining oneself performing a voluntary move- junostomy, using visual and kinaesthetic (tactile) cues. ment, without physically moving. It has also been called Despite encouraging results, these studies allow limited mental practice (MP), mental training and mental imagery. application for MI training outside of the specificsur- Motor imagery has been proven to be effective at im- gical procedures they were designed for. 3-6 proving technical skills in various fields, and structured The aforementioned areas of neurorehabilitation, sport training programmes which incorporate this concept are psychology and training in specific surgical procedures reported in the literature. In sports psychology, MI has been integrated in several models such as the PETTLEP model MRC Centre for Transplantation, Guy’s Hospital, King’s College which delivers a format of training applicable to different London, UK sports. In the field of neurorehabilitation, Braun’sreview Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, identified the elements which correlate with effective King’s Health Partners, London, UK training outcomes. Corresponding Author: Several studies have successfully shown that this Mary S. L. Goble, BSc, King’s College London, Guy’s Campus, Great 9-11 method can also be adapted to surgical training : Maze Pond, London SE1 1UL, Greater London, UK. Immenroth et al used MI for training in laparoscopy Email: maryslgoble@gmail.com 330 Surgical Innovation 28(3) use common principles of MI to achieve motor improvement. (fMRI), electroencephalograms (EEG), electromyography Current understanding of the neurological mechanism of (EMG), transcutaneous electric nerve stimulation (TENS), MI is dominated in the literature by Jeannerod’s central electroacupuncture or hypnosis. However, studies using 7,13-16 motor theory. It underpins the hypothesis that fMRI, EEG or EMG only as part of pre- and post- a degree of functional equivalence exists between MI, and intervention evaluation, and not during the intervention motor preparation and execution, and that they share period (as may be the case in bio-neurofeedback), were 7,13,14 common neural substrate. Empirical evidence sup- included, providing they met the other eligibility criteria. porting the functional equivalence concept can be seen at different levels of control, namely central (in the frontal Search Strategy and Study Selection and parietal lobes ), peripheral (via increased heart rate and respiratory rate ) and behavioural (via mental The following databases were searched from inception by 18-20 chronometry ). This mechanism is applied to any 2 authors: PubMed, MEDLINE, Embase and PsycINFO. motor development using MI, regardless of the type of The following combination of index terms was used: skill being targeted. Based on this understanding, a cross- ‘randomised controlled trial’, ‘RCT’, ‘mental imagery’, disciplinary use of MI protocols can be explored in order ‘MP’, ‘mental training’ and ‘MI’. Detail of the search to identify important elements of MI training. strategy is presented in Appendix A. There were no Protocols incorporating MI in medical education are registered MeSH terms pertaining to this topic. The last not readily available in the literature, and there has so far date of search was January 12, 2019. Titles of studies were been no rigorous approach regarding the evaluation of the screened for selection. The abstracts were read. Where format in which MI training should be incorporated into necessary, the full text was read. At each step, the studies surgical education programmes. were assessed according to the exclusion and inclusion The aim of this review and meta-analysis is to identify criteria. Studies selected for inclusion were uploaded onto the components necessary to a training protocol for surgical RefWorks and checked for duplication. Both authors education which uses MI. This will be done by gathering completed the search independently and compared results, evidence from fields which have successfully used this incongruities were resolved by discussion. (See Appendix method for decades. The primary outcome will be the B for list of abbreviations used in Tables 1 and 2). effectiveness of a protocol using MI training, measured through different outcome measures due to the diversity of Data collection and Synthesis studies included. The secondary outcomes will be protocol components. Data were extracted by one author using a data extraction This review will be structured according to the form. The primary outcome was the efficacy of the MI PRISMA checklist for systematic reviews and meta- training intervention, measured according to the primary analyses. outcome measure as defined by study authors. The secondary outcomes were protocol characteristics. The following items were extracted: primary outcome measure, study population, Methods MI intervention group characteristics, control group char- acteristics, study primary outcome measure and rating of MI Protocol and Registration ability. The mean and standard deviation of the primary The review has been registered on PROSPERO (regis- outcome measure for each study were converted to a stand- tration number: CRD42019121895). ardisedmeandifference. Where post-intervention scores and follow-up scores were reported, the results of the outcome measured post-intervention only were used. Where there Eligibility Criteria were several MI groups with varying length of MI practice In order to limit this review to evidence of the highest and no data on the results of all MI groups combined, the standard of quality, only randomised controlled trials (RCTs) most effective length of practice only was kept. When studies of the use of MI in any discipline were used. Inclusion compared different types of MP, they were excluded. Where criteria were as follows: RCTs published up until December SDs were not available, they were estimated using IQR/ 2018; studies in English, French and Spanish only; studies of 1.35 , and if the IQR was not available, they were estimated MI training programmes which measured an objective based on the SDs from other studies included in the meta- outcome for a specific voluntary skill; studies which in- analysis. The primary outcome measure used was the primary cluded a protocol based on imagining a movement. Ex- outcome stated as such by authors. Where this was not re- clusion criteria were as follows: studies which were not ported, the outcome measure used was the most complete RCTs; studies in which MI training was combined with measure of progress as described by the study authors, or if simulation training; studies in which MI training was done in this was not available an outcome which reported a single conjunction with functional magnetic resonance imaging measurement. Where performance was measured in different Goble et al 331 Table 1. Main Study Characteristics. Duration of MP Session (minutes) × Total Amount Intervention Group MI Ability N° of Sessions × Intervention Compared to Study Measurement Participants Population Type Interventions Duration (days) Primary Outcome Measures Control Abraham 2018 MIQ-RS, KVIQ- 20 Parkinson’s MP vs control 120 min × 10 × 14 days TUGT, 6-min walk test, FGS, Improved 20 VMIQ-2 disease 30 sec chair stand, 360° turn test and PRT Asa 2014 No 36 Healthy MP only vs PP only vs control 25 min × 1 × 1 days Speed and accuracy of task No difference performance Bathalon 2005 No 44 Healthy MI and KG vs KG alone vs n/a × n/a × 14 days OSCE Improved control Bovend’Eerdt IST 11 Arm spasticity PP vs MP and PP vs control 1.5 min × 32 × 56 days Resistance to passive No difference 2008 movement Braun 2011 VMIQ-2 47 Parkinson’s PP vs MP and PP vs control 20 min × 6 × 42 days Walking performance using No difference disease visual analogue scale Braun 2012 No 36 Stroke patients PP vs MP and PP vs control n/a x 10 × 42 days Numeric rating scales No difference Callow 2017 VMIQ-2 56 Healthy IVI vs IVI and KIN vs control 2 min × 1 × 1 days Time IVI and KIN improved Cho 2013 No 28 Stroke patients MP vs control 15 min × 18 × 42 days FRT, TUGT, 10- m walk test Improved and FMA Coker 2015 VMIQ-2 24 Healthy VI vs KIN vs control 60 min (MP+PP) × 1 × 1 day Hip movements recorded on No difference motion capture system Conlin 2016 MIQ-R 12 Healthy MP vs control n/a × 1 × 1 days TSE and GE of No difference mastoidectomy Cunha 2017 MIQ-RS 15 Transtibial MP vs control 40 min × 12 × 28 days Ground reaction forces Improved amputees Dilek 2018 No 36 Distal radius MP vs control 100 min × 1680 × 56 days Pain, wrist and forearm Improved fracture active ROM, grip strength, DASH questionnaire and MHQ Eldred-Evans No 64 Healthy VRS vs standard training and 30 min × 3 × 6 days Time, precision, accuracy MP groups improved 2013 MP vs VRS training and MP vs and overall performance control on BT and VRS Frenkel 2014 No 18 Healthy MP vs control 15 min × 315 × 21 days ROM Improved Geoffrion 2012 No 79 Healthy MP vs control n/a × 1 × 1 days GRS No difference Gomes 2014 No 60 Healthy MP vs PP vs MP and then PP vs .1 min × 24 × 1 days Time PP, MP and PP and PP PP and then MP vs control and MP improved Guillot 2009 Mental 14 Burn patients MP vs control n/a × 10 × 14 days Goniometric data Improved chronometry Hemayattalab No 40 Intellectually MP vs PP vs MP and then PP vs 30 min × 24 × 24 days Free throw test PP improved most 2009 disabled PP and then MP vs control patients (continued) 332 Surgical Innovation 28(3) Table 1. (continued) Duration of MP Session (minutes) × Total Amount of Intervention Group MI Ability N° Sessions × Intervention Compared to Study Measurement Participants Population Type Interventions Duration (days) Primary Outcome Measures Control Hidalgo-Perez No 40 Healthy MCTE and MI vs control 15 min × 20 × 30 days Craniocervical neuromotor Improved 2015 control, joint position error and fatigue after effort Hosseini 2012 MMSE, VMIQ 30 Healthy OT and MP vs control 15 min × 15 × 35 days TUGT Improved and VVIQ Hoyek 2014 MIQ-R 16 Shoulder MP and PP vs control 15 min × 9 × 21 days Shoulder function, ROM and Improved impingement pain Ietswaart 2011 Task 121 Stroke patients MP and standard rehabilitation 39 min × 20 × 28 days ARAT No difference chronometry vs standard rehabilitation and non-motor mental rehearsal vs control Immenroth No 98 Healthy MP and PP vs PP only vs control 60 min × 2 × 2 days OSATS No difference Jungmann 2011 Mental 40 Healthy MP and VR training vs control 3 min × 4 × 4 days Time, tip trajectory and No difference chronometry instrument collision Kim 2013 VMIQ-2 30 Stroke patients Standard therapy and AO vs 20 min × 20 × 28 days TUGT, FRT, WAQ and FAC Improvement in AO standard therapy and MP vs group control Kim 2018 VMIQ 16 Stroke patients CMIT and MP vs control 10 min × 10 × 14 days Motor evoked potential No difference amplitude, 3-D motion analysis, JT test and motor activity log Komesu 2009 No 68 Healthy MP vs control 20 min × 1 × 1 day GSOP No difference Lebon 2011 No 12 Torn ACL Standard physiotherapy and MP 15 min × 180 × 31 days Muscle activation Improved patients vs control Lim 2016 No 20 Healthy MP and PP vs and control 60 min × 1 × 1 day Technical achievement No difference Liu 2004 No 46 Stroke patients MP and standard rehabilitation 60 min × 15 × 21 days Performance on 15 tasks, No difference vs control FMA and CTT Liu 2009 No 34 Stroke patients MP and conventional therapy vs 60 min × 15 × 21 days Performance on 15 tasks No difference control Liu 2009 No 35 Post-stroke MP and conventional therapy vs 60 min × 15 × 21 days Evaluation of skills No difference patients control Losana-Ferrer MIQ 60 Healthy MP vs AO vs control 6 min × n/a × 10 days Hand grip strength, EMG and Improved (not on IM 2018 IM oxygenation oxygenation) (continued) Goble et al 333 Table 1. (continued) Duration of MP Session (minutes) × Total Amount of Intervention Group MI Ability N° Sessions × Intervention Compared to Study Measurement Participants Population Type Interventions Duration (days) Primary Outcome Measures Control Louridas 2015 MIQ and MIQ-R 20 Healthy PP and MP vs control n/a × n/a × 7 days OSATS and bariatric OSATS No difference Malouin 2009 KVIQ 12 Stroke patients MP and PP vs cognitive training n/a × 12 × 28 days Limb loading Improved and PP vs control Maring 1990 No 26 Healthy MP and PP vs control n/a x 1 x 1 days Upper limb muscle activity Improved Mendoza 1978 No 32 Healthy MP only vs MP with simulated 15 min × 6 × 6 days Success in dart throwing PP improved most movement vs PP only vs control Millard 2001 No 60 Healthy MP vs PP vs MP and PP vs 30 min × 3 × 3 days Wet exit attempts scored MP and PP improved control most Mulla 2012 No 41 Healthy BT vs BT and additional 15 min × 7 × 7 days Assessed on BT and VRS on MP performed worst practice vs VRS training vs MP time, precision, accuracy apart from control vs control and performance Nicholson KVIQ 30 Healthy MP only vs PP only vs control 25 min × 1 × 1 day Gait speed, gait variability No difference 2018 using GAITRite and timed up and go Nilsen 2012 VMIQ-2 19 Stroke patients PP and internal MP vs PP and 18 min × 12 × 42 days FM and JT test Improved external MP vs control Oostra 2015 MIQ-RS 44 Stroke patients Standard rehabilitation and MP 30 min × 30 × 42 days 10-m walk test and FM No difference vs control Page 2005 No 11 Stroke patients PP and MP vs PP only vs control 30 min x 12 × 42 days Motor activity log and ARAT Improved Page 2007 No 32 Stroke patients MP and standard rehabilitation 30 min × 12 × 42 days ARAT and FM Improved vs control Page 2009 No 10 Stroke patients mCIT and MP vs control 30 min × 30 × 70 days ARAT and FM Improved Page, S. 2011 No 29 Stroke patients MP vs MP vs MP (different 40 min × 30 × 70 days FM and ARAT Improved lengths) vs control Park 2015 VMIQ 30 Stroke patients MP and standard rehabilitation 10 min x 20 × 28 days LBT and SCT Improved vs control Sanders 2004 No 65 Healthy 2 sessions PP and 1 MP vs 1 PP 30 min × 3 × 21 days GRS No difference and 2 MP vs control Sanders 2008 Revised 64 Healthy MP vs control 30 min × 2 × 24 days Surgical behaviour Improved Minnesota test Santiago 2015 MIQ-R 20 Parkinson’s MP and standard therapy vs n/a × 1 × 1 day Gait analysis No difference disease control (continued) 334 Surgical Innovation 28(3) Table 1. (continued) Duration of MP Session (minutes) × Total Amount of Intervention Group MI Ability N° Sessions × Intervention Compared to Study Measurement Participants Population Type Interventions Duration (days) Primary Outcome Measures Control Schuster 2012 KVIQ 39 Stroke patients MP added to physio vs MP 45 min × 6 × 14 days Time taken to perform skill No difference embedded into physio vs control Seebacher No 112 MS patients Music and MI vs metronome MI 17 min × 24 × 28 days Walking speed Improved 2017 vs control Sharp 2014 No 18 Spinal cord MP with overground training vs 30 min × 24 × 56 days Gait velocity No difference injury patients control Sidaway 2005 No 24 Healthy MP vs PP vs control 15 min × 12 × 28 days Isometric torque and No difference percentage improvement Stenekes 2009 VMIQ 28 Post flexor MP and conventional therapy vs .6 min × 336 × 42 days Preparation time of finger Improved tendon repair control flexion Timmermans VMIQ 42 Stroke patients Standard therapy and MP vs 10 min × 126 × 42 days FM, FAT, WMFT and No difference and 2013 control accelerometry improved on FAT Vergeer 2006 VVIQ 47 Healthy MI vs SI vs control 30 min × 11 × 28 days Flexibility and comfort Improved in comfort and no difference in flexibility Wilson 2002 No 54 Motor MI vs PP vs control 60 min × 5 × 35 days MABC PP improved most coordination problems Wilson 2016 No 36 Motor MI vs PP 60 min × 5 × 35 days MABC No difference coordination problems Goble et al 335 Table 2. Protocol Components for MI Training. Study MP Protocol Detail Control Group Abraham 2018 16 h training. 5x 2 h sessions every week for 2 weeks. Standard training and in-home learning and exercise Delivered in group by therapist. First session: Introduction programme following the same pattern as the to imagery. Subsequent sessions: 15 min warm-up, 35 min intervention group practice, 35 min practice, 20 min movement session and 5 min cool down. Overall structure: Acquire imagery skills and technique, understand anatomy and function and use imagery for improvement Asa 2014 MP instructions emphasised kinaesthetic imagery, keeping No training eyes closed Bathalon 2005 MI and KG group: KG teaching broke down task into 8 Standard ATLS training steps, students performed task and 5 min teaching of mental imagery. Instructed to perform MI in their own time as often as possible Bovend’Eerdt Closed eyes, imagined limb in mind’s eye and imagined PP and relaxation following the same pattern as the 2008 movement in mind’s eye. Performed the skill (stretch) intervention group physically whilst imagining it. Stretches held for 10-30 secs, 3 repetitions/stretch. MP done immediately prior to PP Braun 2011 MP with therapist, then unguided. 1 log/week completed by Standard physiotherapy and relaxation following the participants to record MP behaviour. 6 weeks standard same pattern as the intervention group physiotherapy, 1 h/week in groups or 30 min 2x/week individually, of which MP for 20 min in groups or 10 min individually Braun 2012 6 weeks rehabilitation, at least 10 sessions of MP Regular rehabilitation + homework practising difficult (conditional) and practice outside supervised therapy time tasks (optional). 4-step programme: Explain concept, develop imagery technique, apply mental practice and consolidate Callow 2017 IVI script: First-person visual perspective. IVI and KIN script: Participants answered arithmetic questions First-person visual perspective and physical feelings Cho 2013 15 min MP: Videos of normal movement shown, explanation Standard physiotherapy only of movement by researcher and imagining normal movement based on visual material using kinaesthetic and visual imagery. 5 min relaxation. 30 min gait training 45 min/day, 3x/week for 6 weeks Coker 2015 Training block of x10 trials of skill to generate feedback. Mental arithmetic task Then, practice sessions alternating PP (x5 repetitions) and MP (visual or kinaesthetic imagery, x20 repetitions of the task). Total blocks had x15 repetitions PP and x60 repetitions MP. Relaxation done before training Conlin 2016 Relaxation, script read out loud and given in written format. Self-directed textbook study Script based on transcript of audio recordings of 3 experts having identified steps in the procedure and reported visual, cognitive and kinaesthetic cues involved. Participants to actively imagine performing skill. Given copy of script to take home and review Cunha 2017 40 min sessions, 3x/week for 4 weeks. First-person Standard training and non-motor task MP perspective and tasks of increasing difficulty. 10 tasks imagined in each session, then described Dilek 2018 Graded motor imagery. 3 stages. 1: 3 weeks of lateralisation: Standard rehabilitation Identifying correct right and left hands from pictures, x3 each hour every day. 2: 3 weeks of MI, visualise own hand moving to posture in image shown, without physically moving, x3 each hour every day. 3: 2 weeks mirror therapy: Move own hand to posture in image shown, x10 every hour every day. All participants instructed to perform home exercise programme (continued) 336 Surgical Innovation 28(3) Table 2. (continued) Study MP Protocol Detail Control Group Eldred-Evans Based on the Mackay nodal model of mental practice. Standard box training and additional self-practice 2013 Relaxation, guided visualisation of nodal points Frenkel 2014 Mental gait training procedure: (1) movement explained; (2) No training describe movement by observing it performed, practicing it on non-tested hand and concentrating on kinaesthetic properties; (3) break down into nodal points and connect points with kinaesthetic perception; (4) practice on non- tested hand with open eyes and closed eyes, perform visual imagery and kinaesthetic imagery and (5) practice on non-tested hand, perform kinaesthetic imagery of task and of an unrelated task. Completed a dairy to record completion of training. 1 × 60 min and then 3 × 30 min guided sessions. Followed by 15 min/day self-guided imagery Geoffrion 2012 MI script enumerated steps from textbook and added visual, Normal surgical training and encouraged to read cognitive and kinaesthetic performance details. textbook on skill Participants performed MP one-on-one with educator, then individually Gomes 2014 Instructions to use internal kinaesthetic perspective. No training Participants closed eyes, signal start of imagining and signal end of imagining Guillot 2009 Script detailing instructions of 2 motor tasks, encouraging Standard rehabilitation and neutral activities following self-representation of movements, sensory and the same pattern as the intervention group kinaesthetic cues, staying immobile. Patients to perform MI during training sessions only. Regularly asked to describe nature of images after MI. Total 2 weeks, 5 MP sessions Hemayattalab Using internal kinaesthetic imagery. PP: 30 repetitions of the No training 2009 skill/session. MP: 30 repetitions of imagining skill. MP and PP: MP for 12 sessions and then PP for 12 sessions. PP and MP: PP for 12 sessions and then MP for 12 sessions Hidalgo-Perez MI done just after PP. 1/day, 5 days/week, 30 days. 4 phases, MCTE only 2015 1 phase/week of intervention: 1- kinaesthetic imagery, 2- visual imagery, 3- movement observation therapy plus MI and 4- exercise execution with mirror feedback. Weekly email and phone reminders Hosseini 2012 15 MP, then 30 min occupational therapy. MP: 5 min Occupational therapy only, for 45 min relaxation, 10 lying supine with eyes closed, asked to imagine skill in first person Hoyek 2014 4 movements imagined using internal visual imagery and Physical therapy training with neutral activities during kinaesthetic imagery. All movements shown before MP. rest time Participants told to imagine movement as slowly and vividly as possible. Imagery script read to them. Each movement imagined 10 times, 5 sets of 2 separated by 30-s rest. 10 long sessions of physical therapy, 3x/week. MP exercises done during therapy sessions in rest times. 45 min physical therapy and 15 min MP. Ietswaart 2011 12 x 45 min sessions with therapist 3 days/week: 30 min MP Standard physiotherapy only actively imagining basic movements, 10 min MP using videos and mirrors and 5 min covert MP, for example mentally rotating visual depiction of hands. 8 × 30 min sessions alone, 2 days/week: Audio tape instructing movements to be imagined. Patients to keep a log book. Total 4 weeks (continued) Goble et al 337 Table 2. (continued) Study MP Protocol Detail Control Group Immenroth Day 1: One-on-one mental training for 90 min. 30 min to No intervention 2007 learn primer by heart, recall wording of primer by external self-talk, relaxation exercise, visualisation in first person under supervision and then alone. Day 2: 30 min session repeating external self-talk and ideomotoric training under supervision Jungmann 2011 Completed 2 sessions VR training. Then, received CD-ROM VR training only with demonstration video of skill, checklist for skill steps and instructions on how to perform MP. Practised MP independently before second VR training session Kim 2013 5x/week, 30 min sessions, over 4 weeks: 20 min audio Standard therapy only instructions and 10 min PP. Kim 2018 Modified constraint-induced movement (CMIT) therapy for CMIT and listened to piano music for 10min 1h and then MP for 10 min. Listened to audio while watching first-person perspective video for 4 min. Close eyes, relaxation for 2 min. Repeat audio only without video for 4 min. Audio included kinaesthetic mental practice. 5 days/week for 2 weeks Komesu 2009 Perform MP 24-48 h before assessment. Imagine performing Standard surgical training and textbook study skill and describe to educator in detail following the same pattern as the intervention group Lebon 2011 Sat with legs extended. Relaxation done in initial few Standard physiotherapy and neutral task following the sessions only. Perceive muscle contractions and joint same pattern as the intervention group tension while imagining movement. 3 blocks of 10 imagined movement, 10 sec rest between imagined movements and 2 min rest between blocks. MP: 28-34 day programme. 12 × 15 min sessions, one every 2 days. Physiotherapy: 30 min every 2 days Lim 2016 60 min scripted mental imagery group training. After 20 min, Low-fidelity simulation training only independent mental rehearsal. After session, performed skill x3 Liu 2004 Increasing difficulty of tasks. First week: Analyse task Standard rehabilitation and neutral activities following sequences with pictures and movies. Second week: the same pattern as the intervention group Identify own problems. Third week: Imagine task being performed by self, physically perform task and videotape, view videotape and adjust problems. Repeat identification of problems and third week steps until proper method is achieved. 15 sessions MP, 1 h/day for 3 weeks and standard physiotherapy, 1 h/day for 5 days/week at a different time of day Liu 2009 MP and conventional therapy, learning tasks of increasing Followed the same pattern of therapy as the difficulty. 1 h physical therapy and 1 h MP 5x/week for intervention group with occupational therapy 3 weeks instead of MP Liu 2009 Chunking-regulation-rehearsal strategy: Truncate task, self- Physical practice and functional rehabilitation reflect on abilities, feedback using video playback, mentally following the same pattern as the intervention group rehearsing and physically practising. MP and conventional therapy, learning tasks of increasing difficulty. 1 h physical therapy and 1 h MP 5x/week for 3 weeks Losana-Ferrer Sit on chair, imagine 10 physical repetitions for 3 sec each Physical practice following the same pattern as 2018 and 20 sec rest in between. 2 min break. Repeat imagery intervention groups whilst also performing skill physically. 10 training days, 1st and 4th supervised and remainder at home. All groups told to practice at home and weekly reminders (continued) 338 Surgical Innovation 28(3) Table 2. (continued) Study MP Protocol Detail Control Group Louridas 2015 Didactic lecture. In-person instructions on MP. Relaxation Standard physical practice only following the same exercise. MP guided by MP script developed by pattern as the intervention group interviewing experts and detailing visual and kinaesthetic cues, including common pitfalls in performance. Given script and videos of didactic teaching, 7 days to perform MP at home, with follow-up calls and feedback Malouin 2009 Approx 1 h training done in quiet room by physical No training therapist. MP done in blocks following one attempt of PP. Briefing on first-person imagery with focus on kinaesthetic imagery (sensory). Close eyes, imagine task. Number of mental repetitions increased with time. Live feedback on performance was given for first few sessions, via outcome measurement tool. 3/week for 4 weeks Maring 1990 Maximum voluntary contraction of muscle, 2 min PP only and task demanding mental attention visualisation with visual and kinaesthetic cues and no following the same pattern as the mental physical movement, physical practice of skill x10. intervention group Repeated x5 Mendoza 1978 MP only: Sit with eyes closed, imagine performing skill whilst No practice being aware of all sensory input, correcting for imagined misses. 2 × 15 min sessions/day for 6 days Millard 2001 MP group: Watched video, taught mental practice and No training watched video + made entry in diary after each MP session. PP group: Watched demonstration, then did drill 3x/day for 3 days. PP and MP groups did both training Mulla 2012 25 min one-to-one mental training. Description and No training memorisation of motor skills involved, relaxation and internal and external visualisation of skills to perform. Student to practise at home 15 min/day every day Nicholson 2018 Sat in chair. Imagined completing obstacle course in first- 25 min playing mentally stimulating games on iPad person perspective. MP group: 20 imagined repetitions of a task. PP group: 20 physical repetitions of a task. In both: 30 sec rest between each trial and 5 minute rest after every 10 repetitions Nilsen 2012 Listened to audio script of MP with visual and kinaesthetic Occupational therapy and relaxation following the detail. 2 min introduction instructing internal perspective same pattern as the intervention groups (group 1) or external perspective (group 2). 5 min relaxation. 8 min focussed imagery with key components of task repeated several times. 3 min refocusing Oostra 2015 30 min sessions, in quiet room with 2 therapists, sit down Standard rehabilitation and generic relaxation and eyes closed. 2 min relaxation, perform practice from sessions following the same pattern as the internal perspective, with a visual and kinaesthetic mode. intervention group Content of sessions was familiarisation in week 1, specific gait problems week 2 and symmetry and velocity weeks 3 and 4 Page 2005 MP corresponded to focus therapy, which changed weekly. Occupational therapy and relaxation techniques Audio tape: 5 min relaxation, then suggestions for internal, cognitive polysensory images, then 3-5 min refocusing. 30 min occupational therapy (PP) sessions 2 days/week for 6 weeks followed by 30 min MP Page 2007 MP sessions directly after PP. Audio tape. 30 min total: 5 min Standard rehabilitation and relaxation following the relaxation, approx. 20 min suggestions for internal, same pattern as the intervention group cognitive polysensory images of skill performed in PP on the same day (several trials of imaging) and refocusing. Patients instructed not to do additional MP at home (continued) Goble et al 339 Table 2. (continued) Study MP Protocol Detail Control Group Page 2009 Audio tapes read by male psychologist delivered in quiet mCIT only room. 5 min guided relaxation, 15-20 min motor imagery in first person using polysensory cues and 5 min refocusing. Instructed to not do self-directed practice. 3 days/week for 10 weeks Page, S. 2011 Audiotaped MP intervention listened to in private room. Same baseline rehabilitation sessions and audiotaped 5 min relaxation (imagine themselves in nice place and sham intervention directly after the rehabilitation contract/relax muscles), followed by suggestions for session sensory images related to use of the arm and finishing with 5 min refocusing into the room. Opening and closing 5 minutes held constant in varying lengths of MP practice. Group 1: MP for 20 minutes, group 2: MP for 40 min and group 3: 60 min Park 2015 Sit with eyes closed, imagine scene while listening to voice of Standard rehabilitation only instructor for 10 min and give verbal feedback. 10 repetitions of each skill. Break in between skills for relaxation and internal concentration. 5 days/week for 4 weeks Sanders 2004 Relaxation by psychologist, then verbal imagery instruction 3 sessions PP only in making incision, suturing and knot tying by physician while visualising. 30 min long sessions, 1/week Sanders, W. Relaxation by psychologist, then guided imagery instruction Same baseline training and 2 additional sessions of 2008 in making incision and performing sutures. 30 min reading. Same instructional time as the intervention group Santiago 2015 1. Identified problems in gait. 2. Memorised phases of Standard physical practice only following the same normal gait with images, performed gait 5x. 3. Order pattern as the intervention group detailed phases of gait with cards 3x, keyword for each card. 4. Closed eyes and MP done emphasising kinaesthetic perspective, say keyword for each phase. 3 series of 10 repetitions, 30 sec rest. 8 steps/repetition. 5. PP 3 series of 10 repetition, 8 steps/repetition. 6. MP in 2 imagined complex environments. 1 series of 10 repetitions, 8 steps/ repetition in each environment. 7. PP in complex setting Schuster 2012 Group 1 (MP added): Motor task divided into 13 steps, each Standard physiotherapy and neutral task following the step imagined x5 and then practised physically x1. At end, same pattern as the intervention group complete task x8. Individual sessions, supervised by an instructor, task specific, same environment as physical practice, detailed and standardised instructions, internal perspective and eyes closed and no familiarisation with MI before start of intervention. Session time 45-50 min, 5 to 9 visual trials and 2 to 4 kinaesthetic trials in one session. Group 2 (MP embedded): 30 min physiotherapy, then recorded audio: 3.5 min relaxation, 14.5 min description of motor task and 2 min refocusing. Not supervised, different environments to physical practice, internal perspective and eyes closed and no familiarisation with MI before start of intervention. Session time 45-50 min. 6 to 8 visual trials and 1 to 3 kinaesthetic trials in one session. All patients kept diaries. 6 sessions in 2 weeks Seebacher 2017 30-40 min MI familiarisation in groups of 2-3. Study CD with No training music and verbal cueing (group 1) or metronome cues and verbal cueing (group 2). Internal perspective, kinaesthetic mode, weekly change of audio mix, home-based practice and seated position with eyes closed, self-selected time of day, 17 min practice/day, 6 days/week for 4 weeks. Record MI sessions in diary. Weekly phone calls for support and adherence (continued) 340 Surgical Innovation 28(3) Table 2. (continued) Study MP Protocol Detail Control Group Sharp 2014 Practised PP, then 30 min audio recording. 3 days/week for Overground training with relaxation audio recordings 8 weeks Sidaway 2005 Given instructions on kinaesthetic imagery, then performed No training 3 MP trials. 15 min training sessions. 3 sets of 10 repetitions, separated by 10 seconds rest, 3x/week for 4 weeks. MP group: Imagery script at start of session but did mental repetitions instead of physical repetitions. Were placed in the same environment as PP group. PP group: Physical repetitions Stenekes 2009 Active movement performed mentally following Standard post-operative rehabilitation instructions to imagine initial movement, mentally hold thought in mind for 3 sec and imagine following movement. Repeat imaginary movement 10 times/session. Patients to record number of sessions performed every day. 8 sessions/day, 6 weeks Timmermans 6 tasks of increasing difficult. DVD guidance showing first- Standard therapy and exercise therapy following the 2013 person perspective of task being performed, then 5 same pattern as the intervention group repetitions of correct performance shown with no verbal explanation and instructions to mentally practice task, then no guidance. 3x/day for 10 min, for 6 weeks. Performance assessed during intervention and if improved, DVD changed Vergeer 2006 4-week programme, 30 min sessions 3x/week. Movement Physical training only imagery (MI) group: Physical stretching (5-7 min warm-up, 7 stretching exercises) and imagery component (movement demonstrated, then told to imagine leg being stretched whilst simultaneously doing physical task). Stretching imagery (SI) group: Physical stretching and imagery component (told to imagine change at a cellular level previously explained with a CD, hand gestures, images and a CD) Wilson 2002 Delivered by CD-ROM with software. 6 operations: Visual No training imagery exercises with predictive timing, relaxation, visual modelling of motor skills with video watching, mental rehearsal of skills from external perspective, mental rehearsal of skills from internal perspective and overt practice Wilson 2016 6 steps: Visual imagery exercise with predictive timing, No training relaxation protocol and mental preparation, mental rehearsal from external perspective, mental rehearsal from internal perspective and overt practice with mental practice between sets. 5 h individual training in 60 min sessions, 1/week for 5 weeks simulators (e.g. box trainer and virtual reality simulation study compared one group performing MI alone and (VRS)), the simulator which had not been used in training one group performing MI and physical practice. Sub- was used. group analysis was conducted based on length of training, inclusion of a relaxation component to the protocol and selection of participants based on MI Meta-analysis ability. Data were input into Review Manager in order to conduct meta-analysis if it satisfied the following cri- Risk of Bias teria: The mean and standard deviation of the primary outcome measure were available, or could be estimated Risk of bias was assessed using the Cochrane risk of bias according to the methods described previously, and the tool. Goble et al 341 independent measures of time taken, precision and ac- Results curacy in completion of task or a purpose-built checklist. General Study Characteristics The remaining studies used task-specific measures such as 50,56,61 the Fugl-Meyer assessment for stroke or broader Overall, 60 RCTs were identified with a total of 2251 measures of function such as using a goniometer for range participants. A flow diagram of the studies’ selection process 40-43 of motion . is illustrated in Figure 1. Studies were published between 1978 and 2018. Study sample sizes ranged from 10 to 112, and median was 34.5. Participants were healthy in 27 Outcomes studies, had previously had a stroke in 20 studies or in 13 25 (42%) studies found that the intervention group studies had a range of conditions including Parkinson’s using MI did not perform better than the control disease, multiple sclerosis, arm spasticity or amputa- 6,11,24,26-31,34-49 group. tion. 6 studies only had surgical residents or trainees as In 35 studies (58%), the intervention group performed participants, and 12 had healthy students. 3,12,25,32,33,50-79 better than the control group. In 29/35 studies (83%), the intervention group which did MP and Primary Outcome Measures standard physical practice (rehabilitation, physiotherapy The primary outcome was the overall effectiveness of a pro- and surgical training) performed better than the control 3,12,25,32,33,50- tocol using MI; several outcome measures were used group which did only standard physical practice. 70,76,78,79 due to the diversity of studies included. In the 12 There was no trend found between these study 11,12,24-33 studies which had medical students or trainees results and the use of MI ability assessment, the outcome as their population, the primary outcome measures measures used or the length of interventions. were the Objective Standard Assessment of Technical A summary of all data extracted is presented in Tables Skills (OSATS), variations of a Global Rating Scale, 1 and 2. Figure 1. PRISMA flow diagram. 342 Surgical Innovation 28(3) protocols were reported was not consistent across the studies Secondary Outcomes: Intervention Duration and reviewed. In 13 studies, the MI sessions included several Number of Motor Imagery Sessions 40,42,43,51,53, repetitions of MI with periods of rest in between. 55,57,58,60-62,68,75 The median duration of each individual MI session was Out of these, 10 found the intervention 51,53,55,57,58,60-62,68,75 27.5 minutes (range <1 minute-120 minutes). performed better than control. 7studies In studies where the intervention group performed mention a refocusing period at the end of the MI 42,51,59,61,65,69 better than control, the median was 30 minutes (range session. <1 minute-120 minutes). The median number of MI sessions completed was 11 (range 1-1680); and 13 (range Secondary Outcomes: Motor Imagery 1-1680) in studies where the intervention group per- Ability Assessment formed better than control. The median duration of in- tervention across all studies was 22.4 days (mode 1, range Certain studies measured participant ability to conduct 1-70), and in studies where the intervention group per- MI, as MI ability differs in a healthy population, and formed better than control, it was 24 days (mode 42, range can be measured using validated imagery questionnaires, 1-70). such as the Mental Imagery Questionnaire (MIQ), the Mental Imagery Questionnaire Revised, Second Edition (MIQ-RS) or the Vividness of Mental Imagery Ques- Secondary Outcomes: Intervention Content tionnaire (VMIQ). In patients who have a neurological 11,12,24,25,27,29,32,41,42,44,47,48,50,51,53,58,59,61,65, In 22 studies, impairment, the Kinaesthetic and Visual Imagery 66,69,77 the MI sessions began with a brief period of re- Questionnaire (KVIQ) can be used, as can mental laxation lasting <5 minutes. Out of these, 13 of them found chronometry, which has been shown to correlate with MI 12,25,32, the intervention group performed better than control. ability in healthy and non-healthy patients. 23 studies 50,51,53,58,59,61,65,66,69,77 In 7 studies, there was explicit men- (38%) used the MIQ, MIQ-RS, VMIQ, VMIQ-2, VVIQ, tion of the use of sensory cues for visualisation, giving an mental chronometry, KVIQ or time-dependent motor indication of the specificity of the instructions given to imagery (TDMI) to select participants based on MI 3,31,39,51,59,65,69 6,12,24,34,38,40-43,45,47,48,53,55,57,60-62,64,66,68,72,79 participants. The level of detail to which the ability. Figure 2. Forest plot comparing mental training interventions to control. Goble et al 343 Out of these, 12 (52%) reported better outcomes in the in- relaxation and selection of participants based on MI 12,53,55,57,60-62,64,66,68,72,79 tervention group compared to control. ability. Meta-analysis Risk of Bias Assessment Meta-analysis was performed on the 39 studies eligible The risk of ‘other’ bias was classed as high in 26 studies, for inclusion. Figure 2 summarises the results of the primarily due to selecting participants based on MI ability. meta-analysis. Overall, mental imagery was associated The risk of selective reporting bias was unclear for the with improved outcomes (z = 2.79, P = .005) but with majority of studies as only few had previously published high heterogeneity between the studies (I =79%, a protocol which could be referred to. 7 studies had a risk P < .00001). Figures 3-5, respectively, detail the results of bias which was classed as low for 5 or more types of of subgroup analyses based on length of training, bias and unclear for 2 or less types of bias, which the Figure 3. Forest plot comparing mental training interventions of 1 day, 2-4 days, 6-7 days, 14 days, 21 days and >28 days duration. 344 Surgical Innovation 28(3) Figure 4. Forest plot comparing mental training interventions with a relaxation component to mental training interventions with no relaxation component. authors consider to be an overall low risk of bias. Of these, Performing MI in addition to standard rehabilitation or 12,55 2 found the intervention group performed better than training led to improvements in the majority of trials 24,28,42,43,46 control on outcomes measures and 5 found (83%).This is consistent with the concept that MI is they performed the same or worse. A summary of the risk a valuable tool when added to existing training. Based on of bias is presented in Table 3. current understanding of the neurological processes of MI, it can be speculated that protocols which demonstrate improvement in non-surgical fields can be extrapolated to Discussion surgical training, due to the fact all are focussed on motor This review assessed only RCTs evaluating the effec- skill learning. This could be particularly true for healthy tiveness of various MI protocols across the fields of sports, populations improving on a specific skill - such as ath- neurorehabilitation, education and medical education. The letes. Surgical trainees and athletes have in common aim was to extract the components of a successful MI a healthy physical baseline and the goal of improving protocol. The authors hypothesised these components a specific motor skill. However, the authors acknowledge might be universal to MI training applied to several the methodological limitation of assuming similarities different indications, hence the inclusion of a heteroge- between populations. Overall, there were very few studies neous sample of studies. In addition, MI programmes for which specifically tested MI skills in surgical residents; surgical training remain novel, with few studies having this is a novel method of training in this field which must specifically evaluating its effectiveness on surgeons. be tested further. This method could be used to improve Broadening the search across several disciplines allowed a range of motor skills, ranging from generic surgical skills protocol components never included in surgical training to patient-specific skills. Motor imagery-based training 10,31 programmes to be considered. could be a supplement to standard surgical training. Goble et al 345 Figure 5. Forest plot comparing studies where participants were selected based on mental training ability to studies where participants were not. Studies where the intervention group performed better making direct comparisons of protocols and associated out- than control on outcomes had a median duration of in- comes difficult. However, the following elements could be tervention of 30 minutes, with a median of 15 MI sessions incorporated into the structure of MI protocols in the interest completed in 26 days. This is equivalent to performing MI of standardising their format and enabling direct compari- more than once every 2 days. An online surgical training son of outcomes in future research: a period of relaxation course, where trainees conducted a short amount of im- <5 minutes long prior to starting MI proper; detailed in- agery, regularly and at their convenience, would fit these structions involving specific sensory cues, a predetermined 12,27,30,52,55,60,74 requirements. Indeed, there were 7 stud- number of sets of repetitions of MI to be performed in each ies in which subjects were instructed to perform MI in- session and a refocusing period to close the MI session. dependently at home and record their progress. In the Given that there was no association between MI ability study by Louridas et al, surgical trainees were given and technical performance (when compared to control), 7 days to perform MI at home and had follow-up calls and this indicates that baseline MI ability may not be an feedback. Only 2 of these 7 studies, by Jungmann et al important factor for a MI training programme. and Mulla et al, did not see an improvement in the Given the heterogeneity of study outcomes measured and intervention group compared to control. They were also the variability of populations studied, no extrapolation can be the only 2/7 studies which used medical students as their made of the primary outcome most suitable for measuring the population. This means a MI training protocol for surgical effectiveness of an MI training protocol. Relevant to surgical education could be in a format which allowed subjects to education MI training, a variety of primary outcome measures access training in their own time. were used amongst the medical student and resident pop- Regarding the content of MI interventions, the level of ulations. These were variations of a pre-established check- detail provided across the studies review varied widely, list and objective measurements such as time and accuracy. 346 Surgical Innovation 28(3) Table 3. Risk of Bias. Random Blinding of Blinding of Incomplete Other Sources of Sequence Allocation Participants and Outcome Outcome Selective Bias - MI Ability Study Generation Concealment Personnel Assessment Data Reporting Assessment Abraham 2018 Low Unclear Unclear Unclear Low Unclear Unclear Asa 2014 Unclear Unclear Unclear High Low Unclear High Bathalon 2002 Unclear Unclear Low Low Low Unclear High Bovend’Eerdt Low Unclear High Low Low Unclear Low Braun 2011 Unclear Unclear Unclear Low Low Unclear Low Braun 2012 Low Unclear High Low Low Low High Cho 2013 Low Low Unclear Unclear Low Unclear High Coker 2015 Unclear Unclear Unclear Unclear Low Unclear Low Conlin 2016 Low Unclear Unclear Low Low Low Low Cunha 2017 Unclear Unclear Unclear Unclear High Unclear High Dilek 2018 Low Low Unclear Low Low Unclear High Eldred-Evans Low Low Unclear Low Unclear Unclear High Frenkel 2014 High High Low High Low High Unclear Geoffrion 2012 Low Low Unclear Low Low Unclear High Gomes 2014 Unclear Unclear Unclear Low Low Unclear High Guillot 2009 Unclear Unclear Unclear Unclear Low High Low Hemayattalab Unclear Unclear Unclear Unclear Low Unclear High Hidalgo-Perez Low Low High Low Low Unclear High Hosseini 2012 Unclear Unclear Unclear Low Low Low Low Hoyek 2014 Unclear Unclear High High Low Unclear Low Ietswaart 2011 Low Unclear Low Low Low Unclear Low Immenroth Low Low High Unclear Low Unclear High Jungmann 2011 Unclear Unclear Unclear Unclear Low Unclear Low Kim 2013 Unclear Low Unclear Unclear Low Unclear High Kim 2018 Low Unclear High High Low Low Low Komesu 2009 Low Low Unclear Low Low Unclear High Lebon 2011 Unclear Unclear Low Low Low Unclear High Lim 2016 Low Unclear Low Low Low Unclear Low Liu 2004 Unclear Low Unclear Low Low Unclear High Liu 2008 Unclear Unclear Unclear Low Low Unclear High Liu 2009 Low Low Unclear Low Low Unclear High Losana-Ferrer Low Low Unclear Low Low Unclear Low Louridas 2015 Low Low Low Low Low Low Low Malouin 2009 Low Unclear Unclear Low Low Unclear Low Maring 1990 Unclear Unclear Unclear Unclear Low High High Mendoza 1978 Unclear Unclear Low Low Low Unclear High Millard 2001 Unclear Unclear Unclear Low Low Unclear High Mulla 2012 Low High Unclear Unclear Low Unclear High Nicholson Low Low High Low Low Unclear Low Nilsen 2012 Unclear Unclear Low Low Low Unclear Unclear Oostra 2004 Low Unclear Unclear Low Low Unclear Low Page 2005 Low Unclear High Low Low Low High Page 2007 Low Unclear Low Unclear Low Unclear High Page 2009 Low Unclear Unclear Unclear Low Unclear High (continued) Goble et al 347 Table 3. (continued) Random Blinding of Blinding of Incomplete Other Sources of Sequence Allocation Participants and Outcome Outcome Selective Bias - MI Ability Study Generation Concealment Personnel Assessment Data Reporting Assessment Page 2011 Low High Unclear Low Low Low High Park 2015 Low Unclear Unclear Low Low Unclear Low Sanders 2004 Unclear Low Low Low Unclear Unclear Low Santiago 2015 Low Low Unclear Low Low Unclear Low Schuster 2012 Low Low Low Low Low Low Low Seebacher Low Low High Unclear Low Low High Sharp 2014 Low Low Unclear Low Unclear Unclear High Sidaway 2005 Unclear Unclear Unclear Unclear Low Unclear High Stenekes 2009 Unclear High Unclear Unclear Low Unclear Low Timmermans Low Low High Low Low Low Low Vergeer 2006 Unclear Unclear Unclear Low Low Low Low Wilson 2002 Low Unclear Unclear Low Low Unclear High Wilson 2016 Unclear Unclear High Low Unclear Unclear High 24,27,29,30,34-36,39,40 In 9 of the studies where the in- of this review may aid in constructing a purpose-built MI tervention group performed worse or equivalent to the training programme to evaluate its efficacy on surgical control group, subjects were students or healthy partic- trainees specifically. ipants for whom the benefit of the study was not obvious: they did not have an intrinsic motivation to perform well Conclusions on the outcomes measured such as increased function of This comprehensive systematic review and meta-analysis a limb following a stroke or improved surgical technique. has identified several characteristics linked to successful MI This may indicate that for MI interventions to be suc- training in sports or neurorehabilitation that can be used to cessful, participants need to be self-motivated, and in the construct MI training protocols for use in surgical educa- context of surgical education, surgeons should only un- tion. It must be highlighted that this review and analysis dergo MI training if they see potential benefit in it. included a wide range of studies in different fields. However, this is difficult to establish in the heterogeneous However, certain components found to be linked to suc- group of studies reviewed here and would benefit from cessful programmes could be extrapolated to surgical further research focussed on surgical trainees’ motivation training, based on current understanding of neurological to use MI with their performance after training. Guillot’s processes of MI. A successful MI training programme article did explore the relationship between intrinsic could be delivered in parallel to existing surgical training, motivation and MI in the opposite direction and suggests in a flexible format allowing surgeons to undertake several that MI does enhance intrinsic motivation. MI sessions in a self-directed manner. A single MI session A number of limitations to these results need to be conducted by a senior surgeon could include a brief period considered. The majority of the studies were intrinsically of relaxation, followed by several sets of repetitions of MI, biased as the subjects who received the intervention could and a refocusing period. Providing guidance on the con- not be blinded. Another limitation is the heterogeneity of struction of effective MI training protocols will allow studies included in this review. Studies included repre- replicability of trials investigating the best way to deliver sented many applications of MI training, which may limit MI training. This is a step towards the development of the generalisability of findings. Only 12 studies focussed a surgical MI training programme, as a low-cost, low-risk on the application of MI training directly to surgical tool to enhance practical skills. Further research will be trainees or medical students. Further research is required required to evaluate the use of MI in a purpose-built to demonstrate that the findings from this review can be surgical training programme. translated to surgical education. Furthermore, variations in study methodologies limited pooled analysis. Author Contributions Following this review, more research focussing on the implementation of MI training protocols in surgical ed- Study concept and design: Mary S. L. Goble and Nicholas ucation is needed, in addition to the acceptability of such Riason Acquisition of data: Mary S. L. Goble and Ayah Mekhaimar training measures among trainees and surgeons. The results 348 Surgical Innovation 28(3) Analysis and interpretation: Mary S. L. Goble, Nicholas Riason, 10. Davison S, Raison N, Khan MS, Dasgupta P, Ahmed K. and Kamran Ahmed Mental training in surgical education: A systematic review. Study supervision: Nicholas Riason, Kamran Ahmed, and ANZ J Surg. 2017;87(11):873-878. doi:10.1111/ans.14140 Prokar Dasgupta 11. Immenroth M, Bürger T, Brenner JR, Nagelschmidt M, Eberspacher ¨ H, Troidl H. Mental training in surgical edu- cation. Ann Surg. 2007;245(3):385-391. doi:10.1097/01.sla. Declaration of Conflicting Interest 0000251575.95171.b3 The author(s) declared no potential conflicts of interest with 12. Louridas M, Bonrath EM, Sinclair DA, Dedy NJ, Grantch- respect to the research, authorship, and/or publication of this arov TP. Randomized clinical trial to evaluate mental practice article. in enhancing advanced laparoscopic surgical performance. Br J Surg. 2015;102(1):37-44. doi:10.1002/bjs.9657 Funding 13. Jeannerod M. Mental imagery in the motor context. Neu- The author(s) disclosed receipt of the following financial ropsychologia. 1995;33(11):1419-1432. doi:10.1016/0028- support for the research, authorship, and/or publication of this 3932(95)00073-C article: Grant awarded from the Royal College of Surgeons. 14. Ridderinkhof KR, Brass M. 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J Neurol Phys Ther. 2007;31(1):20. doi:10.1097/01. walking while talking: A pilot randomized-controlled trial NPT.0000260567.24122.64 Goble et al 351 Appendix A Detailed Search Strategy PubMed ((‘Motor imagery’)OR (‘mental imagery’)OR (‘mental practice’)OR (‘mental training’)) AND ((‘randomised controlled study’)OR (‘randomised controlled trial’)) 265 results Ovid (PsycINFO, Embase and MEDLINE) ((Motor imagery) OR (mental imagery) OR (mental practice) OR (mental training)) NOT (computerised OR computer) Filter: Randomised controlled trial 191 results Appendix B. List of Abbreviations Used in Tables 1 and 2. ACL Anterior cruciate ligament AMIT Advanced Mechanical Technology Inc BT Box training CMIT Constraint-induced movement therapy EMG Electromyography FAT Frenchay arm test FM Fugl-Meyer assessment test GRS Global Rating Scale IST Intelligence Structure Test IVI Internal visual imagery KG Kinesiology KIN Kinaesthetic imagery KVIQ-20 Kinaesthetic and visual imagery questionnaire 20 LBT Line bisection test MABC Movement Assessment Battery for children MCTE Motor control therapeutic exercise MI Mental imagery, motor imagery MIQ-RS Motor Imagery Questionnaire-Revised MMSE Mini-mental state examination MP Mental practice n/a Not available OSATS Objective Standard Assessment of Technical Skills OT Occupational therapy PP Physical practice SCT Star cancellation test SI Stretching imagery TDMI Time-dependent motor imagery VMIQ-2 Vividness of Movement Imagery Questionnaire 2 VR Virtual reality VRS Virtual reality simulation

Journal

Surgical InnovationSAGE

Published: Mar 12, 2021

Keywords: motor imagery; mental training; medical education; surgical education; curricula

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