See: Employing visualization exercises, imagery, and mental practice

Another psychological skill that can benefit emergency medical care providers is visualization, or mental practice. This skill allows a provider to walk through the steps of a procedure or skill in his or her mind before actually performing it. This process can act as blueprint or mental video recording of what an effective performance should look like. Olympic swim coach, Bob Bowman, credits visualization exercises as one of the key behaviors that have helped athletes like Michael Phelps become such phenomenal performers:

Phelps would imagine himself jumping off the blocks and, in slow motion, swimming flawlessly. He would visualize his strokes, the walls of the pool, his turns, and the finish. He would imagine the wake behind his body, the water dripping off his lips as his mouth cleared the surface, what it would feel like to rip off his cap at the end.¹

Origins of Mental Practice

The idea of “imagery practice” was introduced by Richardson in 1969. He defined this technique as the “symbolic rehearsal of a motor skill in the absence of any gross muscular movement”². This technique has been well described in the sports psychology literature and has become an important part of training elite athletes.^3,4 It has been employed successfully in to achieve various performance goals including improved concentration, enhanced motivation, strengthened confidence, better-controlled emotional responses, and overall preparation for performance.⁵ In 1983, Feltz and Landers performed a meta-analysis of 60 studies that evaluated the use of imagery in mental practice and found a significant improvement in performance when used.⁶

In 1986, Remsberg initially discussed the used of imagery to perform skills during emergencies, calling his technique “crisis rehearsal.” In his book, The Tactical Edge, he discusses the necessity of deliberate mental rehearsal in high-risk scenarios.⁷ In very stressful, potentially life-threatening situations that are not encountered with great frequency, visualizing your response to the situation can help enhance your ability to perform effectively. Remsberg refers to this as using your “mental movie”. He said, “practicing of proper tactics, physical movements and firearms skills ‘programs’ your nerves and muscles to respond automatically…and lessens your susceptibility to stress interference.”⁷

The Neurological and Cognitive Basis for Visualization Exercises

From a neurological standpoint, visualizing a procedure, task, or scenario can serve as a practice run in the provider’s mind before actually performing the procedure. Rehearsing in your mind is activating the same neurological network needed to successfully perform a task. In fact, according to Weisinger and Pawliw-Fry, “the same neural pathways are recruited and the same neurochemicals are secreted when we visualize doing something as when we engage in the actual activity.”⁸ Roth et al. used fMRI to demonstrate that engaging in mental practice activates the same cortical structures as physical practice.⁹ In addition, mental practice is associated with increased neurologic plasticity with demonstrated increases in cerebral and cerebellar activation as well as structural changes.^10,11

Some evidence suggests that you are doing more than just activating neural pathways. Mental practice can actually develop functional improvements in skills performance. Ranganathan et al. performed a study in which they prospectively evaluated finger strength.¹² Their study examined several cohorts: one group performed mental practice, another physical practice, and another no practice at all. While the group that performed physical practice demonstrated the greatest gains in strength (53% increase), the mental practice only group demonstrated an increase in strength of 35%. The group that performed no practice, not surprisingly, showed no significant change in strength.

Visualization exercises can be used for more than just technical skills, they can also improve cognitive skills. Mental practice can be used to refine how one makes decisions or judgments, as well as solves problems. Driskell et al. performed a meta-analysis of the literature supporting mental practice, reviewing 35 studies that observed more than 3,214 subjects.¹³ They found that not only did visualization significantly improve performance, but the mental practice was more effective at improving cognitive tasks than motor tasks.

Mental Practice In Medicine

The evidence supporting use of visualization and mental practice in medicine is growing. As early as 2002, authors were acknowledging that mental practice could be used to improve the acquisition of certain medical skills.¹⁴ In 2011 the first randomized control trial was conducted by Arora et al. regarding the use of mental practice. Although it was a relatively small, single center investigation, the results demonstrated that practicing using structured mental imagery significantly improved the performance of virtual reality laparoscopic cholecystectomy.¹⁵   In terms of medical resuscitation, Whitelock and Asken propose that using mental imagery and visualization exercises might be particularly helpful in situations that required a structured algorithm or sequenced skills, such as Advanced Cardiac Life Support (American Heart Association).¹⁶

Most recently, attempts to apply visualization and imagery training to the world of trauma resuscitation have shown substantial promise. In 2015, Lorello et al. demonstrated that mental practice could be used to improve the performance of team-based skills in trauma resuscitation. They conducted a prospective, single-blinded, simulation-based study that took anesthesia, emergency medicine, and surgery postgraduate trainees and randomly assigned them into teams of two. Half of the teams were designated as controls (n = 38). The control group received 20 minutes of face-to-face teaching on trauma algorithms and nontechnical aspects of trauma care, such as teamwork and communication. The other half of the two-person teams (n = 40) spent 20 minutes quietly conducting mental practice and rehearsing important aspects of teamwork and trauma management in their minds. Both groups were then evaluated on their performance in a trauma scenario and evaluated using the Mayo High Performance Teamwork Scale (MHPTS), a validated rating scale for teamwork skills. Their results demonstrated that the groups that executed the psychological skills of mental practice and rehearsal prior to the scenario performed significantly better than the teams that did not.¹⁷

How to Structure Visualization Exercises

There are some important aspects of how, precisely, to successfully develop effective mental imagery. As it turns out, imagery is most effective when specific, vivid details about the environment, how things sound, appear, taste and feel, are included. Also, connecting emotions experienced during certain performance situations improves the effectiveness of the imagery exercise. Holmes and Collins underscored important, evidence-based elements that are summarized in their acronym “PETTLEP”:¹⁸

• The PHYSICAL nature of a task
• The specics of the ENVIRONMENT the task will be performed in
• The TYPE of task
• The TIMING of individual steps or movements
• LEARNING the content of the movement
• The EMOTION of task completion
• The PERSPECTIVE of the person

These aspects of imagery development have been evaluated in a number of academic investigations and the results support their implementation.^19,20,21

In conclusion, a clinical example of this is to visualize the steps necessary to intubate a patient. Imagine the following scenario:

A 68 year old man is in acute hypoxic respiratory failure refractory to non-invasive interventions and you decide that intubation is necessary. As you set up your intubation equipment you imagine yourself gripping the laryngoscope, slowly inserting it into the mouth, and sliding down the tongue until you visualize the epiglottis. Then, as you lift upward and forward, you see the glottis. You feel the bougie in your dominant hand as you insert it into the trachea and sense it sliding over the cartilaginous rings. Finally, you picture the endotracheal tube sliding over the bougie and see it passing through the vocal chords.

References

1. Duhigg C. The Power of Habit: Why We Do What We Do in Life and Business. New York, NY: Random House; 2012.
2. Richardson, Mental Imagery. London: Routledge & Kegan Paul; 1969.
3. Martin KA, Moritz SE, Hall CR. Imagery use in sport: A literature review and applied model. The Sport Psychologist. 1999;13(3):245-268.
4. Weinberg Does imagery work? Effects on performance and mental skills. Journal of Imagery Research in Sport and Physical Activity. 2008;3(1).
5. Weinberg, R., & Gould, (2014). Foundations of Sport and Exercise Psychology 6th Edition With Web Study Guide (6 edition). Champaign, IL: Human Kinetics.
6. Feltz DL, Landers The effects of mental practice on motor skill learning and performance: A meta- analysis. Journal of Sport Psychology. 1983;5(1):25-57.
7. Remsberg, Charles, The Tactical Edge: Surviving High Risk Patrol, Calibre Press, Inc. (Northbrook, IL: 1986).
8. Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business;
9. Roth M, Decety J, Raybaudi M, Massarelli R, Delon-Martin C, Segebarth C, Morand S, Gemignani A, Décorps M, Jeannerod M. Possible involvement of primary motor cortex in mentally simulated movement: a functional magnetic resonance imaging study. NeuroReport. 1996; 7(7): 1280-4.
10. Debarnot U, Sperduti M, Di Rienzo F, Guillot A. Experts bodies, experts minds: how physical and mental training shape the brain. Hum Neurosci. 2014; 8: 20.
11. Lacourse MG, Turner JA, Randolph-Orr E, Schandler SL, Cohen MJ. Cerebral and cerebellar sensorimotor plasticity following motor imagery-based mental practice of a sequential movement. J Rehabil Res Dev. 2004; 41(4): 505-24.
12. Ranganathan VK, Siemionow V, Liu JZ, Sahgal V, Yue GH. From mental power to muscle power—gaining strength by using the mind. Neuropsychologia. 2004; 42(7): 944-56.
13. Driskell JE, Copper C, Moran A. Does mental practice enhance performance? J App Psychol. 1994; 79(4): 481-492.
14. Hall JC. Imagery practice and the development of surgical skills. Am J Surg. 2002;184(5):465-470.
15. Arora S, Aggarwal R, Sirimanna P, et al. Mental practice enhances surgical technical skills: a randomized controlled study. Ann Surg. 2011; 253(2): 265-270.
16. Whitelock & Asken. Code Calm on the Streets: Mental Toughness Skills for Prehospital Emergency Personnel. Mechanicsburg, PA: Sunbury Press;
17. Lorello, G. R., Hicks, C. M., Ahmed, S.-A., Unger, , Chandra, D., & Hayter, M. A. (2015). Mental practice: a simple tool to enhance team-based trauma resuscitation. Can J Emerg Med. 2016; 18(2): 136-42.
18. Holmes PS, Collins DJ. The PETTLEP Approach to Motor Imagery: A Functional Equivalence Model for Sport Psychologists. J Appl Sport Psychol. 2001; 13(1): 60-83.
19. Smith D, Wright C, Allsopp A, Westhead It’s All in the Mind: PETTLEP-Based Imagery and Sports Performance. Journal of Applied Sport Psychology. 2007;19(1):80-92.
20. Smith D, Wright CJ, Cantwell Beating the Bunker. Research Quarterly for Exercise and Sport. 2008;79(3):385-391.
21. Wright CJ, Smith D. The effect of PETTLEP imagery on strength performance. International Journal of Sport and Exercise Psychology. 2009;7(1):18-31.

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Mike Lauria

Regular Contributor at EMCrit.org

Emergency Medicine Resident
University of New Mexico Health Sciences Center
Former US Air Force Pararescue and Critical Care/Flight Paramedic

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