Enhanced activation of motor execution networks using action observation combined with imagination of lower limb movements

Walking, Gross Motor Development, and Brain Functional Connectivity in Infants and Toddlers

Infant gross motor development is vital to adaptive function and predictive of both cognitive outcomes and neurodevelopmental disorders. However, little is known about neural systems underlying the emergence of walking and general gross motor abilities. Using resting state fcMRI, we identified functional brain networks associated with walking and gross motor scores in a mixed cross-sectional and longitudinal cohort of infants at high and low risk for autism spectrum disorder, who represent a dimensionally distributed range of motor function. At age 12 months, functional connectivity of motor and default mode networks was correlated with walking, whereas dorsal attention and posterior cingulo-opercular networks were implicated at age 24 months. Analyses of general gross motor function also revealed involvement of motor and default mode networks at 12 and 24 months, with dorsal attention, cingulo-opercular, frontoparietal, and subcortical networks additionally implicated at 24 months. These findings suggest that changes in network-level brain-behavior relationships underlie the emergence and consolidation of walking and gross motor abilities in the toddler period. This initial description of network substrates of early gross motor development may inform hypotheses regarding neural systems contributing to typical and atypical motor outcomes, as well as neurodevelopmental disorders associated with motor dysfunction.

The Bodily Illusion in Adverse Conditions: Virtual Arm Ownership During Visuomotor Mismatch

Classically, body ownership illusions are triggered by cross-modal synchronous stimulations, and hampered by multisensory inconsistencies. Nonetheless, the boundaries of such illusions have been proven to be highly plastic. In this immersive virtual reality study, we explored whether it is possible to induce a sense of body ownership over a virtual body part during visuomotor inconsistencies, with or without the aid of concomitant visuo-tactile stimulations. From a first-person perspective, participants watched a virtual tube moving or an avatar's arm moving, with or without concomitant synchronous visuo-tactile stimulations on their hand. Three different virtual arm/tube speeds were also investigated, while all participants kept their real arms still. The subjective reports show that synchronous visuo-tactile stimulations effectively counteract the effect of visuomotor inconsistencies, but at slow arm movements, a feeling of body ownership might be successfully induced even without concomitant multisensory correspondences. Possible therapeutical implications of these findings are discussed.

EEG Spectral Generators Involved in Motor Imagery: A swLORETA Study

In order to characterize the neural generators of the brain oscillations related to motor imagery (MI), we investigated the cortical, subcortical, and cerebellar localizations of their respective electroencephalogram (EEG) spectral power and phase locking modulations. The MI task consisted in throwing a ball with the dominant upper limb while in a standing posture, within an ecological virtual reality (VR) environment (tennis court). The MI was triggered by the visual cues common to the control condition, during which the participant remained mentally passive. As previously developed, our paradigm considers the confounding problem that the reference condition allows two complementary analyses: one which uses the baseline before the occurrence of the visual cues in the MI and control resting conditions respectively; and the other which compares the analog periods between the MI and the control resting-state conditions. We demonstrate that MI activates specific, complex brain networks for the power and phase modulations of the EEG oscillations. An early (225 ms) delta phase-locking related to MI was generated in the thalamus and cerebellum and was followed (480 ms) by phase-locking in theta and alpha oscillations, generated in specific cortical areas and the cerebellum. Phase-locking preceded the power modulations (mainly alpha-beta ERD), whose cortical generators were situated in the frontal BA45, BA11, BA10, central BA6, lateral BA13, and posterior cortex BA2. Cerebellar-thalamic involvement through phase-locking is discussed as an underlying mechanism for recruiting at later stages the cortical areas involved in a cognitive role during MI.

Home-Based Virtual Reality-Augmented Training Improves Lower Limb Muscle Strength, Balance, and Functional Mobility following Chronic Incomplete Spinal Cord Injury

Key factors positively influencing rehabilitation and functional recovery after spinal cord injury (SCI) include training variety, intensive movement repetition, and motivating training tasks. Systems supporting these aspects may provide profound gains in rehabilitation, independent of the subject’s treatment location. In the present study, we test the hypotheses that virtual reality (VR)-augmented training at home (i.e., unsupervised) is feasible with subjects with an incomplete SCI (iSCI) and that it improves motor functions such as lower limb muscle strength, balance, and functional mobility. In the study, 12 chronic iSCI subjects used a home-based, mobile version of a lower limb VR training system. The system included motivating training scenarios and combined action observation and execution. Virtual representations of the legs and feet were controlled via movement sensors. The subjects performed home-based training over 4 weeks, with 16–20 sessions of 30–45 min each. The outcome measures assessed were the Lower Extremity Motor Score (LEMS), Berg Balance Scale (BBS), Timed Up and Go (TUG), Spinal Cord Independence Measure mobility, Walking Index for Spinal Cord Injury II, and 10 m and 6 min walking tests. Two pre-treatment assessment time points were chosen for outcome stability: 4 weeks before treatment and immediately before treatment. At post-assessment (i.e., immediately after treatment), high motivation and positive changes were reported by the subjects (adapted Patients’ Global Impression of Change). Significant improvements were shown in lower limb muscle strength (LEMS, P = 0.008), balance (BBS, P = 0.008), and functional mobility (TUG, P = 0.007). At follow-up assessment (i.e., 2–3 months after treatment), functional mobility (TUG) remained significantly improved (P = 0.005) in contrast to the other outcome measures. In summary, unsupervised exercises at home with the VR training system led to beneficial functional training effects in subjects with chronic iSCI, suggesting that it may be useful as a neurorehabilitation tool.

Mental steps: Differential activation of internal pacemakers in motor imagery and in mental imitation of gait

Gait imagery and gait observation can boost the recovery of locomotion dysfunctions; yet, a neurologically justified rationale for their clinical application is lacking as much as a direct comparison of their neural correlates. Using functional magnetic resonance imaging, we measured the neural correlates of explicit motor imagery of gait during observation of in-motion videos shot in a park with a steady cam (Virtual Walking task). In a 2 × 2 factorial design, we assessed the modulatory effect of gait observation and of foot movement execution on the neural correlates of the Virtual Walking task: in half of the trials, the participants were asked to mentally imitate a human model shown while walking along the same route (mental imitation condition); moreover, for half of all the trials, the participants also performed rhythmic ankle dorsiflexion as a proxy for stepping movements. We found that, beyond the areas associated with the execution of lower limb movements (the paracentral lobule, the supplementary motor area, and the cerebellum), gait imagery also recruited dorsal premotor and posterior parietal areas known to contribute to the adaptation of walking patterns to environmental cues. When compared with mental imitation, motor imagery recruited a more extensive network, including a brainstem area compatible with the human mesencephalic locomotor region (MLR). Reduced activation of the MLR in mental imitation indicates that this more visually guided task poses less demand on subcortical structures crucial for internally generated gait patterns. This finding may explain why patients with subcortical degeneration benefit from rehabilitation protocols based on gait observation. Hum Brain Mapp 38:5195-5216, 2017. © 2017 Wiley Periodicals, Inc.

Combined Action Observation and Motor Imagery Neurofeedback for Modulation of Brain Activity

Motor imagery (MI) and action observation have proven to be efficacious adjuncts to traditional physiotherapy for enhancing motor recovery following stroke. Recently, researchers have used a combined approach called imagined imitation (II), where an individual watches a motor task being performed, while simultaneously imagining they are performing the movement. While neurofeedback (NFB) has been used extensively with MI to improve patients' ability to modulate sensorimotor activity and enhance motor recovery, the effectiveness of using NFB with II to modulate brain activity is unknown. This project tested the ability of participants to modulate sensorimotor activity during electroencephalography-based II-NFB of a complex, multi-part unilateral handshake, and whether this ability transferred to a subsequent bout of MI. Moreover, given the goal of translating findings from NFB research into practical applications, such as rehabilitation, the II-NFB system was designed with several user interface and user experience features, in an attempt to both drive user engagement and match the level of challenge to the abilities of the subjects. In particular, at easy difficulty levels the II-NFB system incentivized contralateral sensorimotor up-regulation (via event related desynchronization of the mu rhythm), while at higher difficulty levels the II-NFB system incentivized sensorimotor lateralization (i.e., both contralateral up-regulation and ipsilateral down-regulation). Thirty-two subjects, receiving real or sham NFB attended four sessions where they engaged in II-NFB training and subsequent MI. Results showed the NFB group demonstrated more bilateral sensorimotor activity during sessions 2–4 during II-NFB and subsequent MI, indicating mixed success for the implementation of this particular II-NFB system. Here we discuss our findings in the context of the design features included in the II-NFB system, highlighting limitations that should be considered in future designs.

Interactive virtual feedback improves gait motor imagery after spinal cord injury: An exploratory study

Purpose: Motor imagery can improve motor function and reduce pain. This is relevant to individuals with spinal cord injury (SCI) in whom motor dysfunction and neuropathic pain are prevalent. However, therapy efficacy could be dependent on motor imagery ability, and a clear understanding of how motor imagery might be facilitated is currently lacking. Thus, the aim of the present study was to assess the immediate effects of interactive virtual feedback on motor imagery performance after SCI.

Methods: Nine individuals with a traumatic SCI participated in the experiment. Motor imagery tasks consisted of forward (i.e. simpler) and backward (i.e. more complex) walking while receiving interactive versus static virtual feedback. Motor imagery performance (vividness, effort and speed), neuropathic pain intensity and feasibility (immersion, distraction, side-effects) were assessed.

Results: During interactive feedback trials, motor imagery vividness and speed were significantly higher and effort was significantly lower as compared static feedback trials. No change in neuropathic pain was observed. Adverse effects were minor, and immersion was reported to be good.

Conclusions: This exploratory study showed that interactive virtual walking was feasible and facilitated motor imagery performance. The response to motor imagery interventions after SCI might be improved by using interactive virtual feedback.

Motor Imagery during Action Observation: A Brief Review of Evidence, Theory and Future Research Opportunities

Motor imagery (MI) and action observation (AO) have traditionally been viewed as two separate techniques, which can both be used alongside physical practice to enhance motor learning and rehabilitation. Their independent use has largely been shown to be effective, and there is clear evidence that the two processes can elicit similar activity in the motor system. Building on these well-established findings, research has now turned to investigate the effects of their combined use. In this article, we first review the available neurophysiological and behavioral evidence for the effects of combined action observation and motor imagery (AO+MI) on motor processes. We next describe a conceptual framework for their combined use, and then discuss several areas for future research into AO+MI processes. In this review, we advocate a more integrated approach to AO+MI techniques than has previously been adopted by movement scientists and practitioners alike. We hope that this early review of an emergent body of research, along with a related set of research questions, can inspire new work in this area. We are optimistic that future research will further confirm if, how, and when this combined approach to AO+MI can be more effective in motor learning and rehabilitation settings, relative to the more traditional application of MI or AO independently.

Influence of the actions observed on cervical motion in patients with chronic neck pain: a pilot study

The aim of the present pilot study was to prove if the action-observation (AOb) improved the cervical range of motion (CROM) in patients with nonspecific chronic neck pain (CNP). Double blind pilot study. A total of 28 subjects were randomly assigned to an effective-movement group (n=14) and an ineffective-movement group (n=14). The follow-up consisted of: pretreatment, posttreatment and 10 min after second measurement (motor imagery). Outcome measures were CROM, and pres-sure pain detection thresholds (PPDTs). No statistical differences were found in baseline on CROM and on the PPDT. Test for independent groups revealed significant changes in cervical rotation movement. Both groups in posttreatment (P=0.042; Cohen d=0.81) and after 10 min (P=0.019; Cohen d=0.9). For intragroup PPDT, the Wilcoxon test revealed significant effects in the effective movement at C2 of the pre to 10-min post (P=0.040). However, the ineffective movement revealed a significant reduction in PPDT in zygapophyseal joint of C5-C6 as the pre to post (P=0.010) as the pre to 10-min post (P=0.041) periods. In conclusions this pilot study demonstrated that the effective AOb produced significant changes versus ineffective AOb in the CROM and it could influences in PPT in subject with CNP immediately.

Optimizing Rehabilitation for Phantom Limb Pain Using Mirror Therapy and Transcranial Direct Current Stimulation: A Randomized, Double-Blind Clinical Trial Study Protocol

Background

Despite the multiple available pharmacological and behavioral therapies for the management of chronic phantom limb pain (PLP) in lower limb amputees, treatment for this condition is still a major challenge and the results are mixed. Given that PLP is associated with maladaptive brain plasticity, interventions that promote cortical reorganization such as non-invasive brain stimulation and behavioral methods including transcranial direct current stimulation (tDCS) and mirror therapy (MT), respectively, may prove to be beneficial to control pain in PLP. Due to its complementary effects, a combination of tDCS and MT may result in synergistic effects in PLP.

Objective

The objective of this study is to evaluate the efficacy of tDCS and MT as a rehabilitative tool for the management of PLP in unilateral lower limb amputees.

Methods

A prospective, randomized, placebo-controlled, double-blind, factorial, superiority clinical trial will be carried out. Participants will be eligible if they meet the following inclusion criteria: lower limb unilateral traumatic amputees that present PLP for at least 3 months after the amputated limb has completely healed. Participants (N=132) will be randomly allocated to the following groups: (1) active tDCS and active MT, (2) sham tDCS and active MT, (3) active tDCS and sham MT, and (4) sham tDCS and sham MT. tDCS will be applied with the anodal electrode placed over the primary motor cortex (M1) contralateral to the amputation side and the cathode over the contralateral supraorbital area. Stimulation will be applied at the same time of the MT protocol with the parameters 2 mA for 20 minutes. Pain outcome assessments will be performed at baseline, before and after each intervention session, at the end of MT, and in 2 follow-up visits. In order to assess cortical reorganization and correlate with clinical outcomes, participants will undergo functional magnetic resonance imaging (fMRI) and transcranial magnetic stimulation (TMS) before and after the intervention.

Results

This clinical trial received institutional review board (IRB) approval in July of 2015 and enrollment started in December of 2015. To date 2 participants have been enrolled. The estimate enrollment rate is about 30 to 35 patients per year; thus we expect to complete enrollment in 4 years.

Conclusions

This factorial design will provide relevant data to evaluate whether tDCS combined with MT is more effective than each therapy alone, as well as with no intervention (sham/sham) in patients with chronic PLP after unilateral lower limb amputation. In addition, this randomized clinical trial will help to investigate the neurophysiological mechanisms underlying the disease, which could potentially provide relevant findings for further management of this chronic condition and also help to optimize the use of this novel intervention.

Trial Registration

Clinicaltrials.gov NCT02487966; https://clinicaltrials.gov/ct2/show/NCT02487966 (Archived by WebCite at http://www.webcitation.org/6i3GrKMyf)

Online and Offline Performance Gains Following Motor Imagery Practice: A Comprehensive Review of Behavioral and Neuroimaging Studies

There is now compelling evidence that motor imagery (MI) promotes motor learning. While MI has been shown to influence the early stages of the learning process, recent data revealed that sleep also contributes to the consolidation of the memory trace. How such "online" and "offline" processes take place and how they interact to impact the neural underpinnings of movements has received little attention. The aim of the present review is twofold: (i) providing an overview of recent applied and fundamental studies investigating the effects of MI practice (MIP) on motor learning; and (ii) detangling applied and fundamental findings in support of a sleep contribution to motor consolidation after MIP. We conclude with an integrative approach of online and offline learning resulting from intense MIP in healthy participants, and underline research avenues in the motor learning/clinical domains.

Spinal cord injury affects the interplay between visual and sensorimotor representations of the body

The brain integrates multiple sensory inputs, including somatosensory and visual inputs, to produce a representation of the body. Spinal cord injury (SCI) interrupts the communication between brain and body and the effects of this deafferentation on body representation are poorly understood. We investigated whether the relative weight of somatosensory and visual frames of reference for body representation is altered in individuals with incomplete or complete SCI (affecting lower limbs’ somatosensation), with respect to controls. To study the influence of afferent somatosensory information on body representation, participants verbally judged the laterality of rotated images of feet, hands, and whole-bodies (mental rotation task) in two different postures (participants’ body parts were hidden from view). We found that (i) complete SCI disrupts the influence of postural changes on the representation of the deafferented body parts (feet, but not hands) and (ii) regardless of posture, whole-body representation progressively deteriorates proportionally to SCI completeness. These results demonstrate that the cortical representation of the body is dynamic, responsive, and adaptable to contingent conditions, in that the role of somatosensation is altered and partially compensated with a change in the relative weight of somatosensory versus visual bodily representations.

Viewing Instructions Accompanying Action Observation Modulate Corticospinal Excitability

Action observation interventions may have the potential to contribute to improved motor function in motor (re)learning settings by promoting functional activity and plasticity in the motor regions of the brain. Optimal methods for delivering such interventions, however, have yet to be established. This experiment investigated the effect on corticospinal excitability of manipulating the viewing instructions provided to participants (N = 21) prior to action observation. Specifically, motor evoked potential responses measured from the right hand muscles following single-pulse transcranial magnetic stimulation (TMS) to the left motor cortex were compared when participants were instructed to observe finger-thumb opposition movement sequences: (i) passively; (ii) with the intent to imitate the observed movement; or (iii) whilst simultaneously and actively imagining that they were performing the movement as they observed it. All three action observation viewing instructions facilitated corticospinal excitability to a greater extent than did observation of a static hand. In addition, the extent to which corticospinal excitability was facilitated was greater during combined observation and imagery, compared to passive observation. These findings have important implications for the design of action observation interventions in motor (re)learning settings, where instructions that encourage observers to simultaneously imagine themselves performing the observed movement may offer the current optimal method for improving motor function through action observation.

Differential Neural Processing during Motor Imagery of Daily Activities in Chronic Low Back Pain Patients

Chronic low back pain (chronic LBP) is both debilitating for patients but also a major burden on the health care system. Previous studies reported various maladaptive structural and functional changes among chronic LBP patients on spine- and supraspinal levels including behavioral alterations. However, evidence for cortical reorganization in the sensorimotor system of chronic LBP patients is scarce. Motor Imagery (MI) is suitable for investigating the cortical sensorimotor network as it serves as a proxy for motor execution. Our aim was to investigate differential MI-driven cortical processing in chronic LBP compared to healthy controls (HC) by means of functional magnetic resonance imaging (fMRI). Twenty-nine subjects (15 chronic LBP patients, 14 HC) were included in the current study. MI stimuli consisted of randomly presented video clips showing every-day activities involving different whole-body movements as well as walking on even ground and walking downstairs and upstairs. Guided by the video clips, subjects had to perform MI of these activities, subsequently rating the vividness of their MI performance. Brain activity analysis revealed that chronic LBP patients exhibited significantly reduced activity compared to HC subjects in MI-related brain regions, namely the left supplementary motor area and right superior temporal sulcus. Furthermore, psycho-physiological-interaction analysis yielded significantly enhanced functional connectivity (FC) between various MI-associated brain regions in chronic LBP patients indicating diffuse and non-specific changes in FC. Current results demonstrate initial findings about differences in MI-driven cortical processing in chronic LBP pointing towards reorganization processes in the sensorimotor network.

Towards multiple interactions of inner and outer sensations in corporeal awareness

Under normal circumstances, different inner- and outer-body sources are integrated to form coherent and accurate mental experiences of the state of the body, leading to the phenomenon of corporeal awareness. How these processes are affected by changes in inner and outer inputs to the body remains unclear. Here, we aim to present empirical evidence in which people with a massive sensory and motor disconnection may continue to experience feelings of general body state awareness without complete control of their inner and outer states. In these clinical populations, the activity of the neural structures subserving inner and outer body processing can be manipulated and tuned by means of body illusions that are usually based on multisensory stimulation. We suggest that a multisensory therapeutic approach could be adopted in the context of therapies for patients suffering from deafferentation and deefferentation. In this way, these individuals could regain a more complete feeling and control of the sensations they experience, which vary widely depending on their neurological condition.

Brain Activity during Lower-Limb Movement with Manual Facilitation: An fMRI Study

Brain activity knowledge of healthy subjects is an important reference in the context of motor control and reeducation. While the normal brain behavior for upper-limb motor control has been widely explored, the same is not true for lower-limb control. Also the effects that different stimuli can evoke on movement and respective brain activity are important in the context of motor potentialization and reeducation. For a better understanding of these processes, a functional magnetic resonance imaging (fMRI) was used to collect data of 10 healthy subjects performing lower-limb multijoint functional movement under three stimuli: verbal stimulus, manual facilitation, and verbal + manual facilitation. Results showed that, with verbal stimulus, both lower limbs elicit bilateral cortical brain activation; with manual facilitation, only the left lower limb (LLL) elicits bilateral activation while the right lower limb (RLL) elicits contralateral activation; verbal + manual facilitation elicits bilateral activation for the LLL and contralateral activation for the RLL. Manual facilitation also elicits subcortical activation in white matter, the thalamus, pons, and cerebellum. Deactivations were also found for lower-limb movement. Manual facilitation is stimulus capable of generating brain activity in healthy subjects. Stimuli need to be specific for bilateral activation and regarding which brain areas we aim to activate.

Combined action observation and imagery facilitates corticospinal excitability

Observation and imagery of movement both activate similar brain regions to those involved in movement execution. As such, both are recommended as techniques for aiding the recovery of motor function following stroke. Traditionally, action observation and movement imagery (MI) have been considered as independent intervention techniques. Researchers have however begun to consider the possibility of combining the two techniques into a single intervention strategy. This study investigated the effect of combined action observation and MI on corticospinal excitability, in comparison to either observation or imagery alone. Single-pulse transcranial magnetic stimulation (TMS) was delivered to the hand representation of the left motor cortex during combined action observation and MI, passive observation (PO), or MI of right index finger abduction-adduction movements or control conditions. Motor evoked potentials (MEPs) were recorded from the first dorsal interosseous (FDI) and abductor digiti minimi (ADM) muscles of the right hand. The combined action observation and MI condition produced MEPs of larger amplitude than were obtained during PO and control conditions. This effect was only present in the FDI muscle, indicating the facilitation of corticospinal excitability during the combined condition was specific to the muscles involved in the observed/imagined task. These findings have implications for stroke rehabilitation, where combined action observation and MI interventions may prove to be more effective than observation or imagery alone.

Effector-independent brain activity during motor imagery of the upper and lower limbs: an fMRI study

We utilized functional magnetic resonance imaging (fMRI) to evaluate the common brain region of motor imagery for the right and left upper and lower limbs. The subjects were instructed to repeatedly imagined extension and flexion of the right or left hands/ankles. Brain regions, which included the supplemental motor area (SMA), premotor cortex and parietal cortex, were activated during motor imagery. Conjunction analysis revealed that the left SMA and inferior frontal gyrus (IFG)/ventral premotor cortex (vPM) were commonly activated with motor imagery of the right hand, left hand, right foot, and left foot. This result suggests that these brain regions are activated during motor imagery in an effector independent manner.

Motor imagery during action observation modulates automatic imitation effects in rhythmical actions

We have previously shown that passively observing a task-irrelevant rhythmical action can bias the cycle time of a subsequently executed rhythmical action. Here we use the same paradigm to investigate the impact of different forms of motor imagery (MI) during action observation (AO) on this automatic imitation (AI) effect. Participants saw a picture of the instructed action followed by a rhythmical distractor movie, wherein cycle time was subtly manipulated across trials. They then executed the instructed rhythmical action. When participants imagined performing the instructed action in synchrony with the distractor action (AO + MI), a strong imitation bias was found that was significantly greater than in our previous study. The bias was pronounced equally for compatible and incompatible trials, wherein observed and imagined actions were different in type (e.g., face washing vs. painting) or plane of movement, or both. In contrast, no imitation bias was observed when MI conflicted with AO. In Experiment 2, motor execution synchronized with AO produced a stronger imitation bias compared to AO + MI, showing an advantage in synchronization for overt execution over MI. Furthermore, the bias was stronger when participants synchronized the instructed action with the distractor movie, compared to when they synchronized the distractor action with the distractor movie. Although we still observed a significant bias in the latter condition, this finding indicates a degree of specificity in AI effects for the identity of the synchronized action. Overall, our data show that MI can substantially modulate the effects of AO on subsequent execution, wherein: (1) combined AO + MI can enhance AI effects relative to passive AO; (2) observed and imagined actions can be flexibly coordinated across different action types and planes; and (3) conflicting AO + MI can abolish AI effects. Therefore, combined AO + MI instructions should be considered in motor training and rehabilitation.

Multiple roles of motor imagery during action observation

Over the last 20 years, the topics of action observation (AO) and motor imagery (MI) have been largely studied in isolation from each other, despite the early integrative account by Jeannerod (1994, 2001). Recent neuroimaging studies demonstrate enhanced cortical activity when AO and MI are performed concurrently ("AO+MI"), compared to either AO or MI performed in isolation. These results indicate the potentially beneficial effects of AO+MI, and they also demonstrate that the underlying neurocognitive processes are partly shared. We separately review the evidence for MI and AO as forms of motor simulation, and present two quantitative literature analyses that indeed indicate rather little overlap between the two bodies of research. We then propose a spectrum of concurrent AO+MI states, from congruent AO+MI where the contents of AO and MI widely overlap, over coordinative AO+MI, where observed and imagined action are different but can be coordinated with each other, to cases of conflicting AO+MI. We believe that an integrative account of AO and MI is theoretically attractive, that it should generate novel experimental approaches, and that it can also stimulate a wide range of applications in sport, occupational therapy, and neurorehabilitation.