Posts Tagged Action observation

[Abstract] Effect of activity-based mirror therapy on lower limb motor-recovery and gait in stroke: A randomised controlled trial

Objective: To determine the effect of activity-based mirror therapy (MT) on motor recovery and gait in chronic poststroke hemiparetic subjects.

Design: A randomised, controlled, assessor-blinded trial.

Setting: Rehabilitation institute.

Participants: Thirty-six chronic poststroke (15.89 ± 9.01 months) hemiparetic subjects (age: 46.44 ± 7.89 years, 30 men and functional ambulation classification of median level 3).

Interventions: Activity-based MT comprised movements such as ball-rolling, rocker-board, and pedalling. The activities were provided on the less-affected side in front of the mirror while hiding the affected limb. The movement of the less-affected lower limb was projected as over the affected limb. Conventional motor therapy based on neurophysiological approaches was also provided to the experimental group. The control group received only conventional management.

Main outcome measures: Brunnstrom recovery stages (BRS), Fugl-Meyer assessment lower extremity (FMA-LE), Rivermead visual gait assessment (RVGA), and 10-metre walk test (10-MWT).

Results: Postintervention, the experimental group exhibited significant and favourable changes for FMA-LE (mean difference = 3.29, 95% CI = 1.23–5.35, p = .003) and RVGA (mean difference = 5.41, 95% CI = 1.12–9.71, p = .015) in comparison to the control group. No considerable changes were observed on 10-MWT.

Conclusions: Activity-based MT facilitates motor recovery of the lower limb as well as reduces gait deviations among chronic poststroke hemiparetic subjects.


via Effect of activity-based mirror therapy on lower limb motor-recovery and gait in stroke: A randomised controlled trial: Neuropsychological Rehabilitation: Vol 0, No 0


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[ARTICLE] Effects of action observation therapy and mirror therapy after stroke on rehabilitation outcomes and neural mechanisms by MEG: study protocol for a randomized controlled trial – Full Text



Loss of upper-extremity motor function is one of the most debilitating deficits following stroke. Two promising treatment approaches, action observation therapy (AOT) and mirror therapy (MT), aim to enhance motor learning and promote neural reorganization in patients through different afferent inputs and patterns of visual feedback. Both approaches involve different patterns of motor observation, imitation, and execution but share some similar neural bases of the mirror neuron system. AOT and MT used in stroke rehabilitation may confer differential benefits and neural activities that remain to be determined. This clinical trial aims to investigate and compare treatment effects and neural activity changes of AOT and MT with those of the control intervention in patients with subacute stroke.


An estimated total of 90 patients with subacute stroke will be recruited for this study. All participants will be randomly assigned to receive AOT, MT, or control intervention for a 3-week training period (15 sessions). Outcome measurements will be taken at baseline, immediately after treatment, and at the 3-month follow-up. For the magnetoencephalography (MEG) study, we anticipate that we will recruit 12 to 15 patients per group. The primary outcome will be the Fugl-Meyer Assessment score. Secondary outcomes will include the modified Rankin Scale, the Box and Block Test, the ABILHAND questionnaire, the Questionnaire Upon Mental Imagery, the Functional Independence Measure, activity monitors, the Stroke Impact Scale version 3.0, and MEG signals.


This clinical trial will provide scientific evidence of treatment effects on motor, functional outcomes, and neural activity mechanisms after AOT and MT in patients with subacute stroke. Further application and use of AOT and MT may include telerehabilitation or home-based rehabilitation through web-based or video teaching.


Stroke is the leading cause of long-term adult disability worldwide [1]. Most patients with stroke experience upper-extremity (UE) motor impairment [2] and show minimal recovery of the affected arm even 6 months after stroke [3]. Due to the potentially severe adverse effects after stroke, it is critical in clinical practice to develop effective and specific stroke interventions to improve arm function and to explore the neural mechanisms involved [45]. Action observation therapy (AOT) and mirror therapy (MT) are two examples of novel approaches concerning stroke motor recovery that are supported by neuroscientific foundations [67]. However, the relative efficacy of AOT versus MT has not been validated in patients with stroke.

AOT is a promising approach grounded in basic neuroscience and the recent discovery of the mirror neuron system (MNS) [6]. AOT commonly includes action observation and action execution and allows patients to safely practice movements and motor tasks. AOT is recommended to help patients with stroke to form accurate images of motor actions [8] and to mediate their motor relearning process after stroke [6]. Researchers have found that AOT can induce stronger cognitive activity than motor imagery in patients with stroke and have suggested that AOT could be an effective approach for patients who have difficulty with motor representation [9]. AOT is a new approach in stroke rehabilitation; therefore, only a few studies have targeted enhancement of UE motor recovery and investigated the effects of AOT in patients with stroke [81011121314]. Based on these studies, AOT has been shown to be a beneficial and effective approach to improve patient motor function. However, the heterogeneity of study designs and small sample sizes of the studies lead to no clear conclusions about the efficacy of AOT in stroke rehabilitation.

MT has emerged as another novel stroke-rehabilitation approach during the last decade [151617]. In this treatment, participants are instructed to move their arms and watch the action reflection of the non-affected arm in the mirror, as if it were the affected one. The process creates the visual illusion of the non-affected arm as the affected arm is normally moving. MT focuses on visual and proprioceptive feedback of the non-affected limb, which may provide substitute inputs for absent or reduced proprioceptive feedback from the affected side of the body [18]. A growing amount of academic literature has demonstrated that patients with stroke gain improvements in motor and daily function, movement control strategies, and activities of daily living [1617] after treatment with MT, which supports its use in stroke rehabilitation. In short, MT is potentially a simpler, less expensive, and effective stroke-rehabilitation approach for practical implementation in clinical settings.

Action observation is based on activities of the MNS and mainly involves brain areas of the inferior parietal lobe, inferior frontal gyrus, and ventral premotor cortex [19]. Mirror neurons discharge both during the execution of motor acts or goal-directed actions and during the observation of other people performing the same or similar actions [20]. Experimental studies in healthy adults have demonstrated that the MNS was activated during both the observation and execution of movements, which helped to form new motor patterns during action observation [212223]. In addition, although positive effects of MT have been demonstrated in patients with stroke [24], there is no consensus about the underlying neural mechanisms of MT. Three hypotheses have been recently proposed to explain the beneficial effects of MT on motor recovery [7]. Accordingly, MT may affect perceptual motor processes via three functional neural networks: (1) activation of brain regions associated with MNS [2526], (2) recruitment of ipsilateral motor pathways [27], and (3) substitution of abnormal proprioception from the affected limb with feedback from the non-affected limb [1518]. Few AOT and MT neurophysiological or imaging studies have been conducted in patients with stroke. No studies have directly compared and unraveled the similarities or differences in neural plastic changes between AOT and MT in these patients. It is crucial to compare neuroplasticity mechanisms between these intervention regimens to optimize rehabilitative outcomes.


The main purposes of this clinical trial are to (1) compare the immediate and retention treatment effects of AOT and MT on different outcomes with those of a dose-matched control group and (2) explore and compare the neural mechanisms and changes in cortical neural activity associated with the effects of AOT and MT in stroke patients, using magnetoencephalography (MEG).[…]

Continue —> Effects of action observation therapy and mirror therapy after stroke on rehabilitation outcomes and neural mechanisms by MEG: study protocol for a randomized controlled trial | Trials | Full Text

Fig. 2 Action observation therapy. a Observation of task. b Execution of task

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Imagery, mirror box therapy and action observation are simple, inexpensive and patient led treatments that can be used to aid in the improvement of motor function in both the upper- and lower-extremities post-stroke. This thesis examined the effects of imagery on physical movement post-stroke and therapists’ use of imagery, mirror box therapy and action observation as part of stroke rehabilitation. Study one was a metaanalysis investigating the effect of imagery on upper- and lower-limb movement ability post-stroke. The results revealed that imagery produced a moderate mean treatment effect (p= 0.03; d= 0.48; 95% confidence interval: 0.05 to 0.91). Imagery that was performed in the third person and performance analysis (the identification of incorrect task performance to help facilitate a positive change in performance) showed the largest improvements in movement. However, the effectiveness of imagery during stroke rehabilitation is still uncertain, as indicated by the large confidence interval. The second study investigated the extent to which physiotherapists and occupational therapists in the UK used cognitive therapies during stroke rehabilitation. In addition, how the therapies were conducted and the therapists’ views on their delivery were investigated. The skill audit had a response rate of 25% and showed that during stroke rehabilitation 68% (91/133) of therapists used imagery, 53% (68/129) used action observation and 41% (52/128) used mirror box therapy. Only 12% of therapists had received specific training in these therapies and therapists would like guidance on how to administer cognitive therapies. Unfortunately, due to the poor response rate the skill audit data may not be generalizable to the whole stroke therapy population. To conclude, the metaanalysis and skill audit have highlighted the potential of cognitive therapies and will help inform the production of clinical guidelines on the use of cognitive therapies during stroke rehabilitation. Clinical guidelines would help standardise the delivery of cognitive therapies and inform therapists how to motivate patients’, post-stroke.

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[ARTICLE] Action observation for upper limb function after stroke: evidence-based review of randomized controlled trials – Full Text PDF


[Purpose] The purpose of this study was to suggest evidenced information about action observation to improve upper limb function after stroke.

[Methods] A systematic review of randomized controlled trials involving adults aged 18 years or over and including descriptions of action observation for improving upper limb function was undertaken. Electronic databases were searched, including MEDLINE, CINAHL, and PEDro (the Physiotherapy Evidence Database), for articles published between 2000 to 2014. Following completion of the searches, two reviewers independently assessed the trials and extracted data using a data extraction form. The same two reviewers independently documented the methodological quality of the trials by using the PEDro scale.

[Results] Five randomized controlled trials were ultimately included in this review, and four of them (80%) reported statistically significant effects for motor recovery of upper limb using action observation intervention in between groups.

[Conclusion] This review of the literature presents evidence attesting to the benefits conferred on stroke patints resulting from participation in an action observation intervention. The body of literature in this field is growing steadily. Further work needs to be done to evaluate the evidence for different conditions after stroke and different duration of intervention.

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Source: Action observation for upper limb function after stroke: evidence-based review of randomized controlled trials

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[ARTICLE] Rehabilitation with Poststroke Motor Recovery: A Review with a Focus on Neural Plasticity – Full Text HTML


Motor recovery after stroke is related to neural plasticity, which involves developing new neuronal interconnections, acquiring new functions, and compensating for impairment. However, neural plasticity is impaired in the stroke-affected hemisphere. Therefore, it is important that motor recovery therapies facilitate neural plasticity to compensate for functional loss. Stroke rehabilitation programs should include meaningful, repetitive, intensive, and task-specific movement training in an enriched environment to promote neural plasticity and motor recovery. Various novel stroke rehabilitation techniques for motor recovery have been developed based on basic science and clinical studies of neural plasticity. However, the effectiveness of rehabilitative interventions among patients with stroke varies widely because the mechanisms underlying motor recovery are heterogeneous. Neurophysiological and neuroimaging studies have been developed to evaluate the heterogeneity of mechanisms underlying motor recovery for effective rehabilitation interventions after stroke. Here, we review novel stroke rehabilitation techniques associated with neural plasticity and discuss individualized strategies to identify appropriate therapeutic goals, prevent maladaptive plasticity, and maximize functional gain in patients with stroke.

Continue —> Rehabilitation with Poststroke Motor Recovery: A Review with a Focus on Neural Plasticity.

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[ARTICLE] Multisensory Stimulation in Stroke Rehabilitation – Full Text

The brain has a large capacity for automatic simultaneous processing and integration of sensory information. Combining information from different sensory modalities facilitates our ability to detect, discriminate, and recognize sensory stimuli, and learning is often optimal in a multisensory environment. Currently used multisensory stimulation methods in stroke rehabilitation include motor imagery, action observation, training with a mirror or in a virtual environment, and various kinds of music therapy. Non-invasive brain stimulation has showed promising preliminary results in aphasia and neglect. Patient heterogeneity and the interaction of age, gender, genes, and environment are discussed. Randomized controlled longitudinal trials starting earlier post-stroke are needed. The advance in brain network science and neuroimaging enabling longitudinal studies of structural and functional networks are likely to have an important impact on patient selection for specific interventions in future stroke rehabilitation. It is proposed that we should pay more attention to age, gender, and laterality in clinical studies.


We live in a multisensory environment and the interaction between our genes and the environment shapes our brains. The brain has a large capacity for automatic simultaneous processing and integration of sensory information, and multisensory influences are integral to primary as well as higher order cortical operations (Ghazanfar and Schroeder, 2006). Combining information from different sensory modalities facilitates our ability to detect, discriminate, and recognize sensory stimuli (Driver and Noesselt, 2008; Shams and Seitz, 2008; Gentile et al., 2011). Non-invasive brain stimulation does not only affect the targeted local regions but also activity in remote interconnected regions. Although repetitive transcranial magnetic stimulation (rTMS) cannot directly target subcortical structures, the activity in thalamus can be modulated by stimulation of parietal cortex, an observation that open up new possibilities for studies of cortical–subcortical interactions in multisensory processing (Blankenburg et al., 2008, 2010). Multisensory enhancement of detection sensitivity for low-contrast visual stimuli by sounds reflects a brain network involving not only established multisensory and sensory-specific cortex but also visual and auditory thalamus (Noesselt et al., 2010). Diffusion tensor imaging and tractography have enhanced the opportunity to study white matter tract networks and compare structural and functional connectivity in humans (Ciccarelli et al., 2008). Combining non-invasive brain stimulation with neuroimaging offers an opportunity to study causal relations between specific brain regions and individual cognitive and perceptual functions (Driver and Noesselt, 2008; Driver et al., 2009; Bolognini and Maravita, 2011; Zamora-López et al., 2011). Non-invasive brain stimulation techniques have the advantage that they can be used both as diagnostic tools and in treatment.

Figure 1. Dendritic branching and spines in pyramidal neurons in parietal cortex in rats housed in standard laboratory cages (A) and rats in enriched environment with opportunity for various activities (B), Johansson and Belichenko (2002).

Continue —>  Frontiers | Multisensory Stimulation in Stroke Rehabilitation | Frontiers in Human Neuroscience.

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[ARTICLE] A Mirror Therapy–Based Action Observation Protocol to Improve Motor Learning After Stroke – Full Text HTML


Background. Mirror therapy is a priming technique to improve motor function of the affected arm after stroke.

Objective. To investigate whether a mirror therapy–based action observation (AO) protocol contributes to motor learning of the affected arm after stroke.

Methods. A total of 37 participants in the chronic stage after stroke were randomly allocated to the AO or control observation (CO) group. Participants were instructed to perform an upper-arm reaching task as fast and as fluently as possible. All participants trained the upper-arm reaching task with their affected arm alternated with either AO or CO. Participants in the AO group observed mirrored video tapes of reaching movements performed by their unaffected arm, whereas participants in the CO group observed static photographs of landscapes. The experimental condition effect was investigated by evaluating the primary outcome measure: movement time (in seconds) of the reaching movement, measured by accelerometry.

Results. Movement time decreased significantly in both groups: 18.3% in the AO and 9.1% in the CO group. Decrease in movement time was significantly more in the AO compared with the CO group (mean difference = 0.14 s; 95% confidence interval = 0.02, 0.26; P = .026).

Conclusion. The present study showed that a mirror therapy–based AO protocol contributes to motor learning after stroke.

Continue Full Text HTML —> A Mirror Therapy–Based Action Observation Protocol to Improve Motor Learning After Stroke.

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[ARTICLE] Motor Priming in Neurorehabilitation.


Priming is a type of implicit learning wherein a stimulus prompts a change in behavior. Priming has been long studied in the field of psychology. More recently, rehabilitation researchers have studied motor priming as a possible way to facilitate motor learning. For example, priming of the motor cortex is associated with changes in neuroplasticity that are associated with improvements in motor performance.

Of the numerous motor priming paradigms under investigation, only a few are practical for the current clinical environment, and the optimal priming modalities for specific clinical presentations are not known. Accordingly, developing an understanding of the various types of motor priming paradigms and their underlying neural mechanisms is an important step for therapists in neurorehabilitation. Most importantly, an understanding of the methods and their underlying mechanisms is essential for optimizing rehabilitation outcomes.

The future of neurorehabilitation is likely to include these priming methods, which are delivered prior to or in conjunction with primary neurorehabilitation therapies. In this Special Interest article, we discuss those priming paradigms that are supported by the greatest amount of evidence, including

  • (i) stimulation-based priming,
  • (ii) motor imagery and action observation,
  • (iii) sensory priming,
  • (iv) movement-based priming, and
  • (v) pharmacological priming.

via Motor Priming in Neurorehabilitation. : Journal of Neurologic Physical Therapy.

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[ARTICLE] “Video Therapy”: Promoting Hand Function after Stroke by Action Observation Training – a Pilot Randomized Controlled Trial – Full Text


Background: Action observation improves excitability of the primary motor cortex and the encoding of motor engrams as well as motor-learning.

Objective: The intention of our pilot-study was to evaluate the feasibility of a six weeks home-based action observation training (video therapy) in stroke patients.

Methods: 56 patients (age 58 ± 13; time since onset 40 ± 82 months; NIHSS 3.5 ± 1.8) with a hand paresis following stroke were recruited from two rehabilitation clinics. Before discharge from the clinic the intervention group received a DVD displaying ten object-related motor tasks of varying difficulty, each lasting five minutes. Patients were requested to imitate the motor tasks one hour daily for six weeks (“video group”). A control group performed the same tasks with written instructions without observation/imitation (“text group”). A second control group was discharged without specific homework (“usual care group”).

Results: There was no dropout in the video group. Quality and speed of the Motor Activity Log (MAL) increased significantly in the video and text group. Nine Hole Peg test (NHPT) and Stroke Impact Scale (SIS) improved only in the video group. Questionnaires (MAL and SIS), obtained twelve months after training in fourteen and eleven participants of both active groups, indicated significant differences in favor of the video group.

Conclusions: Video training is easy to deliver and highly accepted by patients. Six weeks of home based training suggests improvement of hand function, activities of daily living and quality of life. Video-therapy appears to be promising, as an adjunct to conventional neurorehabilitation – especially with regards to non-supervised, home-based training.

via “Video Therapy”: Promoting Hand Function after Stroke by Action Observation Training – a Pilot Randomized Controlled Trial | Open Access | OMICS Publishing Group.

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[ARTICLE] A Mirror Therapy-Based Action Observation Protocol to Improve Motor Learning After Stroke


A mirror therapy-based AO protocol significantly contributes to motor learning of the affected in patients in the chronic stage after stroke…

via A Mirror Therapy-Based Action Observation Protocol to Improve Motor Learning After Stroke – Archives of Physical Medicine and Rehabilitation.

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