ARTICLES The Kinesthetic and Visual Imagery Questionnaire (KVIQ) for Assessing Motor Imagery in Persons with Physical Disabilities: A Reliability and Construct Validity Study Francine Malouin, PT, PhD, Carol L. Richards, PT, PhD, Philip L. Jackson, PhD, Martin F. Lafleur, PhD, Anne Durand, PhD, and Julien Doyon, PhD Purpose: To benefit from mental practice training after stroke, one must be able to engage in motor imagery, and thus reliable motor imagery assessment tools tailored to persons with sensorimotor impairments are needed. The aims of this study were to (1) examine the test-retest reliability of the Kinesthetic and Visual Imagery Questionnaire (KVIQ-20) and its short version (the KVIQ-10) in healthy subjects and subjects with stroke, (2) investigate the internal consistency of both KVIQ versions, and (3) explore the factorial structure of the two KVIQ versions. Methods: The KVIQ assesses on a five-point ordinal scale the clarity of the image (visual: V subscale) and the intensity of the sensations (kinesthetic: K subscale) that the subjects are able to imagine from the first-person perspective. Nineteen persons who had sustained a stroke (CVA group) and 46 healthy persons (CTL group) including an age-matched (aCTL: n 19) control group were assessed twice by the same examiner 10 to 14 days apart. The test-retest reliability was assessed using intraclass correlation coef- ficients (ICCs). The internal consistency (Cronbach ) and the factorial structure of both KVIQ versions were studied in a sample of 131 subjects. Results: In the CVA group, the ICCs ranged from 0.81 to 0.90, from 0.73 to 0.86 in the aCTL group, and from 0.72 to 0.81 in the CTL group. When imagining movements of the affected and unaffected limbs (upper and lower limbs combined) ICCs in the CVA group ranged, respectively, from 0.71 to.87 and from 0.86 to 0.94. Like- wise, when imagining movement of the dominant and nondominant limbs, ICCs in the aCTL group ranged, respectively, from 0.75 to 0.89 and from 0.81 to.92. Cronbach values were, respectively, 0.94 (V) and 0.92 (K) for the KVIQ-20 and 0.89 (V) and 0.87(K) for the KVIQ-10. The factorial analyses indicated that two factors explained 63.4% and 67.7% of total variance, respectively. Conclusion: Both versions of the KVIQ present similar psychomet- ric properties that support their use in healthy individuals and in persons post-stroke. Because the KVIQ-10 can be administered in half the time, however, it is a good choice when assessing persons with physical disabilities. Key words: stroke, mental practice, motor imagery questionnaire, intraclass correlation coefficient, Cronbach���s , standard error of measurement, factorial analysis, test-retest reliability (JNPT 2007 31: 20���29) INTRODUCTION A major difficulty when using mental practice through motor imagery is to determine to what extent a person is able to generate a mental representation of movements. The question is even more problematic after a stroke because results from chronometric studies indicate that, contrary to patients with a lesion in the motor cortex,1 patients with lesions in the superior regions of the parietal cortex may have impaired motor imagery ability.2 In addition, recent findings indicating a slowing of the imagery process after stroke suggest that temporal characteristics of motor imagery could be modified after stroke.3,4 Together these results suggest that some patients may not be able to engage in motor imagery and hence may not benefit from mental practice.5 Therefore, it is important to assess motor imagery ability.6 To this end, movement imagery questionnaires have been developed, two of the most widely used are the Move- ment Imagery Questionnaire (MIQ),7 followed by a revised and shorter version, the MIQ-R8, and the Vividness of Motor Imagery Questionnaire (VMIQ).9 These, however, are self- report questionnaires that have been used largely in young healthy adults. The MIQ was designed to evaluate the vividness of movement imagery in the visual and the kinesthetic dimen- sions. The initial version of the MIQ includes 18-items (nine for the visual subscale, nine for the kinesthetic subscale). Each item involves arm, leg, or whole body movements (eg: arm abduction, jumping, front roll). The MIQ does not measure imagery vividness directly, but rather the ease/ difficulty with which the subject imagines the movement on a seven-point scale (1 very easy to see/feel 7 very hard to see/feel). The administration involves four steps: (1) the Department of Rehabilitation, Laval University and Center for Interdiscipli- nary Research in Rehabilitation and Social Integration (CIRRIS) (F.M., C.L.R.), Quebec City, Quebec, Canada Ecole �� de Psychologie, Laval University and CIRRIS (P.L.J.), Ho ��pital Robert-Giffard (M.F.L.), Que- bec City, Quebec, Canada Institut de Re ��adaptation en De ��ficience Phy- sique de Que ��bec (A.D.), Department of Psychology and Unite �� de Neu- roimagerie Fonctionnelle, Institut Universitaire de Ge ��riatrie (J.D.), University of Montreal, Quebec, Canada Address correspondence to: Francine Malouin, E-mail: Francine.Malouin@ rea.ulaval.ca Copyright �� 2007 by Lippincott Williams & Wilkins ISSN: 1557-0576/07/3101-0020 DOI: 10.1097/01.NPT.0000260567.24122.64 JNPT ��� Volume 31, March 2007 20

subject assumes a specific starting position (2) the movement is described and the subject is asked to perform it (3) the subject reassumes the starting position and is required to imagine producing the movement (no actual movement is made) (4) the subject is required to rate the ease/difficulty with which they imagine the movement on the seven-point scale. The reliability of the MIQ, studied in 50 young indi- viduals (26 women and 24 men mean age 21 years) has been judged acceptable, with reported Pearson correlation coeffi- cients of 0.83 for both subscales, for test-retest at a 1-week interval, and internal consistency coefficients of 0.87 and 0.91 (Cronbach���s ) for the visual and kinesthetic dimen- sions, respectively.10 Lorant and Gaillot11 reported Pearson correlation coefficients of 0.88 (visual scale) and 0.87 (kin- esthetic scale), for test-retest at a 3-week interval in a group of 32 students in physical education (mean age 20 years) likewise Cronbach values of 0.87 and 0.91 were computed for each scale, respectively. Similar levels of internal consis- tency were found with Cronbach values of 0.89 and 0.88 for the visual and kinesthetic scales, respectively.12 In addi- tion, the bifactorial structure of the MIQ has been confirmed by a common factor analysis,11,12 indicating that the MIQ measures both the visual and kinesthetic dimensions of move- ment imagery. The MIQ was revised in 1997 by Hall and Martin8 resulting in a shorter version: the MIQ-R. The MIQ-R in- cludes only eight items (four items for each subscale) the rating scale was reversed (7 very easy to see/feel 1 very hard to see/feel), and some of the items were reworded to enhance the clarity of the descriptions. Several items were removed from the original version to reduce the length, eliminate redundant items, and, more importantly, get rid of more physically demanding items (such as front roll and 360-degree turn) that some subjects refused to perform physically (step two). Administration of the questionnaire involves the same four steps as described above. Concur- rent validity of the MIQ-R has been studied in a group of 50 subjects (24 men and 26 women (mean age 21 years range: 18���41 years) by Hall and Martin8 who correlated MIQ-R scores to MIQ scores. They reported coefficients of correlation of 0.77 (negative values due to the reversal of the MIQ-R rating scale) for the two subscales suggesting that the MIQ-R is an acceptable revision of the MIQ. More recently, using the scores from 134 healthy subjects (mean age of 24 years and range 17���60 years) who had completed the French version of the MIQ-R, Lorant and Nicolas13 were able to confirm the internal consistency of the MIQ-R with a Cronbach of 0.82 for both subscales as well as the bifactorial structure of the revised version. In the same study, the authors examined the test-retest reliability in a subgroup of 46 subjects who were tested at a 3-week interval. They reported Pearson correlation coefficients of 0.86 and 0.90 for the visual and kinesthetic subscales, respectively,13 indicating reliability levels slightly higher than those reported for the former MIQ4 (r 0.83 for both subscales). The VMIQ, developed by Isaac et al.,9 is a 48-item questionnaire in which subjects are required to rate the vividness of their imagery on a five-point scale (1 as clear and vivid as normal vision clear 5 no image at all) for a series of 24 physical activities under two conditions: (1) while imagining someone else executing the movement (visual subscale) and (2) while imagining themselves per- forming the movements (kinesthetic subscale). Contrary to the MIQ, the subjects are not required to perform phys- ically the movement before imagining it. The test-retest reliability of the VMIQ examined in a group of 220 students (high school and university levels), tested twice at a 3-week interval, yielded a Pearson correlation coefficient of 0.76. Although the VMIQ was developed to assess visual and kinesthetic imagery, a structural factor analysis did not con- firm the bifactorial structure of the VMIQ.14 In addition, when scores from the VMIQ were correlated with scores from a visual imagery test, the VVIQ (the Vividness of Visual Imagery Questionnaire),15 and the visual subscale of the MIQ, it yielded correlation coefficients of 0.78 and 0.65, respectively. In contrast, the correlation between the VMIQ scores and the kinesthetic subscale of the MIQ was only 0.49.8 Altogether, these observations suggest that the VMIQ does not tap into the kinesthetic component of imagery as does the MIQ. Based on the above findings, the MIQ appears to be the measure of choice to assess motor imagery. The MIQ, how- ever, has been developed and used to assess motor imagery ability in healthy adults and athletes,10���13 and its use in rehabilitation raises many difficulties. Mainly because of the self-reporting nature of the MIQ and the high physical de- mands of several items, the MIQ and the MIQ-R are unsuit- able for persons with physical disabilities. For this reason, we have developed the Kinesthetic and Visual Imagery Ques- tionnaire (KVIQ-20). The KVIQ-20 is a motor imagery questionnaire adapted for persons who, for different reasons, have to be guided in the rating of their imagery and who are not able to stand or to perform complex movements. Like the MIQ, the KVIQ-20 was developed to assess both the visual and kinesthetic dimensions of motor imagery and the testing also involves four steps. Importantly, however, the KVIQ is not self-administered. In addition, unlike the MIQ, the rating scale of the KVIQ-20 assesses the vividness of each dimen- sion of motor imagery (clarity of the image/intensity of sensation) on a five-point ordinal scale. Because the admin- istration of the KVIQ-20 may take up to 45 minutes with persons with disability or those who have more difficulty concentrating, a short version has been created (the KVIQ- 10) to make it more suitable for clinical use. Therefore, the purposes of this study were to: (1) examine the test-retest reliability of the KVIQ-20 and its short version (the KVIQ-10) in healthy subjects and subjects with stroke (2) investigate the internal consistency of both KVIQ versions and (3) explore the factorial structure of the two KVIQ versions. METHOD Participants To study the test-retest reliability of the two versions of the KVIQ, 19 persons who sustained a cerebral vascular JNPT ��� Volume 31, March 2007 A Motor Imagery Questionnaire for Persons with Stroke �� 2007 Lippincott Williams & Wilkins 21