Effects and mechanisms of synchronous virtual reality action observation and electrical stimulation on upper extremity motor function and activities of daily living in patients with stroke: a protocol for a randomized controlled trial

Background

Existing rehabilitation techniques are not satisfactory in improving motor function after stroke, resulting in heavy social burdens. With discovery of mirror neuron system (MNS), action observation (AO) has become a promising strategy to promote motor learning in rehabilitation. Based on MNS theory and virtual reality (VR) technology, we designed an innovative rehabilitative approach: synchronous 360° VR video AO (VRAO) and neuromuscular electrical stimulation (NMES). We hypothesized that VRAO+NMES could enhance MNS activation, thus to improve upper limb motor function and activities of daily living in stroke survivors.

Methods

To explore the efficacy and mechanism of VRAO+NMES, we designed this single center, evaluator blinded, prospective, two arm parallel group randomized controlled trial with 1:1 allocation ratio. The experiment group will receive VRAO+NMES, while the control group will receive VR landscape observation combined with NMES. The Fugl-Meyer Assessment for Upper Extremity is the primary outcome of this study, Brunstrom Recovery Stages for Upper Extremity, Manual Muscle Test, Range of Motion, Modified Barthel Index, and Functional Independence Measure are the secondary outcomes. In addition, functional near-infrared spectroscopy (fNIRS) and surface electromyography (sEMG) will be used to evaluate the activation of MNS brain regions and related muscles, respectively.

Discussion

Applying VR in AO therapy (AOT) has become popular, another study direction to improve AOT is to combine it with peripheral stimulations simultaneously. Due to its full immersive characteristic and multi-sensory input, 360° videos based VRAO+NMES could improve the motivation and engagement level of participants. In addition, fNIRS and sEMG test results may act as good biomarkers to predict rehabilitation outcomes, helping select suitable candidates for this new intervention.

Conclusion

The results of this study will provide evidence for the feasibility and potential clinical efficacy of VRAO+NMES in stroke rehabilitation, thus to promote the clinical applicability and generalize its use in hospital, community, and home rehabilitation settings.

Clinical trial registration

https://www.chictr.org.cn/showproj.html?proj=178276, Identifier [ChiCTR2200063552].

Digital Mirror Therapy and Action Observation Therapy for Chronic Stroke: A Pilot Randomized Controlled Trial

Objective: This study is aimed at testing the immediate and retained treatment efficacies of digital mirror therapy (DMT) and digital action observation therapy (DAOT) on clinical outcomes in chronic stroke patients, in comparison with dose-matched, active control rehabilitation (CR). Methods: Nineteen patients were randomly assigned to the DMT, DAOT, or CR for 3 weeks. Outcome measures, including the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE), Chedoke Arm and Hand Activity Inventory (CAHAI), Revised Nottingham Sensory Assessment, Motor Activity Log (MAL), and visual analogue scale of the EQ-5D-5L, were conducted at preintervention (T0), postintervention (T1), and 1-month follow-up (T2). Results: There were no significant differences among the three groups on the outcomes at different time points. However, in the DMT group, scores were significantly higher on the FMA-UE and the CAHAI at T2 than at T0; in the DAOT group, those on the FMA-UE and the quality of movement subscale of the MAL were significantly higher at T2 than at T0. In the CR group, scores on the FMA-UE and the CAHAI were significantly higher at T1 than at T0. Conclusions: Both DMT and DAOT had retained treatment effects on motor function. DMT and DAOT might be feasible as alternative intervention strategies for chronic stroke patients. Trial Registration: ClinicalTrials.gov identifier: NCT04441190.

Action observation training for improving walking ability and balance of stroke patients: A systematic review and meta-analysis

OBJECTIVE

To determine the effect of action observation training on the walking ability and balance of stroke patients.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, PEDro, and ScienceDirect databases were searched from database inception to March 2024. Randomized controlled trials (RCTs) published in English were included. Two independent reviewers assessed the methodological quality of the trials using the Joanna Briggs Institute (JBI) critical appraisal tool for RCTs and performed data extraction using the JBI data extraction form for observational/experimental studies. Review Manager 5.4 was used for quantitative analyses.

RESULTS

Fourteen RCTs with a total of 367 participants were included in this review. The average quality score of the studies was 8.4 out of 13. The pooled results showed a significant improvement in walking ability measured by the 10-Meter Walk Test (mean difference (MD) = 0.15; p = 0.0001), Timed Up and Go Test (MD = -2.58; p < 0.00001), Dynamic Gait Index (MD = 2.93; p = 0.007), and spatiotemporal gait parameters, including stride length (MD = 9.67; p < 0.0001), step length (MD = 4.41; p = 0.004), cadence (MD = 7.06; p = 0.0003), and gait velocity (MD = 9.31; p < 0.00001). A significant improvement was found in balance measured by the Limit of Stability (MD = 40.50; p < 0.00001), yet the Activities-specific Balance Confidence Scale showed no significant improvement (MD = 10.26; p = 0.10).

CONCLUSIONS

Action observation training led to improvements in the walking ability of stroke patients. There is some evidence to suggest the effectiveness of action observation training for improving the balance ability of stroke patients, however, the number of studies is still very limited.

Video parameters for action observation training in stroke rehabilitation: a scoping review

PURPOSE

Action observation training (AOT) is a therapeutic approach used in stroke rehabilitation. Videos form the core of AOT, and knowledge of constituent parameters is essential to make the intervention robust and generalizable. Currently, there is a dearth of available information on video parameters to be used for AOT. Our purpose was to identify and describe the parameters that constitute AOT videos for stroke rehabilitation.

METHOD

Electronic databases like PubMed, CINAHL, Scopus, Web of Science, ProQuest, and Ovid SP from inception to date according to PRISMA-ScR guidelines. Title, abstract, and full-text screening were done independently by two authors, with a third author for conflict resolution. Data on video parameters like length, quality, perspective, speed, screen size and distance, sound, and control videos were extracted.

RESULTS

Seventy studies were included in this review. The most-reported parameters were video length (85.71%) and perspective of view (62.85%). Movement speed (7.14%) and sound (8.57%) were the least reported. Static landscapes or geometrical patterns were found suitable as control videos.

CONCLUSION

Most video parameters except for length and perspective of view remain underreported in AOT protocols. Future studies with better descriptions of video parameters are required for comprehensive AOT interventions and result generalisation.

Occupational Therapy Practice Guidelines for Adults With Stroke

IMPORTANCE

Stroke is a leading cause of disability. Occupational therapy practitioners ensure maximum participation and performance in valued occupations for stroke survivors and their caregivers.

OBJECTIVE

These Practice Guidelines are meant to support occupational therapy practitioners' clinical decision making when working with people after stroke and their caregivers.

METHOD

Clinical recommendations were reviewed from three systematic review questions on interventions to improve performance and participation in daily activities and occupations and from one question on maintaining the caregiving role for caregivers of people after stroke.

RESULTS

The systematic reviews included 168 studies, 24 Level 1a, 90 Level 1b, and 54 Level 2b. These studies were used as the basis for the clinical recommendations in these Practice Guidelines and have strong or moderate supporting evidence.

CONCLUSIONS AND RECOMMENDATIONS

Interventions with strong strength of evidence for improving performance in activities of daily living and functional mobility include mirror therapy, task-oriented training, mental imagery, balance training, self-management strategies, and a multidisciplinary three-stages-of-care rehabilitation program. Constraint-induced therapy has strong strength of evidence for improving performance of instrumental activities of daily living. Moderate strength of evidence supported cognitive-behavioral therapy (CBT) to address balance self-efficacy, long-term group intervention to improve mobility in the community, and a wearable upper extremity sensory device paired with training games in inpatient rehabilitation to improve social participation. Practitioners should incorporate problem-solving therapy in combination with CBT or with education and a family support organizer program. What This Article Adds: These Practice Guidelines provide a summary of strong and moderate evidence for effective interventions for people with stroke and for their caregivers.

Cortical activation of neuromuscular electrical stimulation synchronized mirror neuron rehabilitation strategies: an fNIRS study

Background

The mirror neuron system (MNS) plays a key role in the neural mechanism underlying motor learning and neural plasticity. Action observation (AO), action execution (AE), and a combination of both, known as action imitation (AI), are the most commonly used rehabilitation strategies based on MNS. It is possible to enhance the cortical activation area and amplitude by combining traditional neuromuscular electrical stimulation (NMES) with other top-down and active rehabilitation strategies based on the MNS theory.

Objective

This study aimed to explore the cortical activation patterns induced by NMES synchronized with rehabilitation strategies based on MNS, namely NMES+AO, NMES+AE, and NMES+AI. In addition, the study aimed to assess the feasibility of these three novel rehabilitative treatments in order to provide insights and evidence for the design, implementation, and application of brain-computer interfaces.

Methods

A total of 70 healthy adults were recruited from July 2022 to February 2023, and 66 of them were finally included in the analysis. The cortical activation patterns during NMES+AO, NMES+AE, and NMES+AI were detected using the functional Near-Infrared Spectroscopy (fNIRS) technique. The action to be observed, executed, or imitated was right wrist and hand extension, and two square-shaped NMES electrodes were placed on the right extensor digitorum communis. A block design was adopted to evaluate the activation intensity of the left MNS brain regions.

Results

General linear model results showed that compared with the control condition, the number of channels significantly activated (PFDR < 0.05) in the NMES+AO, NMES+AE, and NMES+AI conditions were 3, 9, and 9, respectively. Region of interest (ROI) analysis showed that 2 ROIs were significantly activated (PFDR < 0.05) in the NMES+AO condition, including BA6 and BA44; 5 ROIs were significantly activated in the NMES+AE condition, including BA6, BA40, BA44, BA45, and BA46; and 6 ROIs were significantly activated in the NMES+AI condition, including BA6, BA7, BA40, BA44, BA45, and BA46.

Conclusion

The MNS was activated during neuromuscular electrical stimulation combined with an AO, AE, and AI intervention. The synchronous application of NMES and mirror neuron rehabilitation strategies is feasible in clinical rehabilitation. The fNIRS signal patterns observed in this study could be used to develop brain-computer interface and neurofeedback therapy rehabilitation devices.

Application of action observation therapy in stroke rehabilitation: A systematic review

BACKGROUND

Numerous studies have described the positive effects of action observation therapy (AOT) on motor recovery among patients with stroke. However, there is no standardized procedure for when and how to intervene with AOT.

OBJECTIVES

Thus, we reviewed and analyzed previous studies to provide a guideline for the application of AOT in stroke rehabilitation.

METHOD

We searched PubMed, Cochrane Library, and EMBASE from inception to October 31 2022, using title and abstract search terms of "action observation" and "stroke" or "hemiplegia." Of 4108 potential articles, 29 articles (sample size = 429 in AOT groups; sample size = 423 in control groups) that met inclusion criteria were included in final analyses.

RESULTS

The results suggested starting adjuvant AOT > 23 days after stroke onset and conducting 30-40 min/session, 3-5 times/week for at least 4 weeks.

CONCLUSION

Based on our results, many factors will impact the effect of AOT on stroke rehabilitation, when to apply (timing) and how to apply (frequency, single, and total duration) should be fully considered when applying AOT as adjuvant therapy in stroke rehabilitation.

"I've got a spring in my step" participants experience of action observation therapy and eccentric exercises, a telehealth study for mid-portion Achilles Tendinopathy: a qualitative study

BACKGROUND

Quantitative research has dominated the field of Achilles Tendinopathy. The use of qualitative research allows in-depth exploration of participants' perspectives, offering great insight in the evaluation of a trial's processes, particularly when exploring a novel intervention such as Action Observation Therapy combined with eccentric exercises which has not been previously researched. This study aimed to qualitatively explore participants' experiences of partaking in a telehealth study including the acceptability of the intervention, motivators for participation, and perspectives on the trial processes.

METHOD

A thematic analysis as guided by Braun and Clarke was used to analyse the semi-structured interviews conducted on a purposive sample of participants with mid-portion Achilles Tendinopathy who recently completed a pilot feasibility study. The study adhered to the criteria for reporting qualitative research guidelines (COREQ).

RESULTS/DISCUSSION

Sixteen participants were interviewed. The five themes identified were: (i) The impact of Achilles Tendinopathy is commonly not prioritised with 'The acceptance and minimisation of pain' as a sub-theme (ii) Therapeutic alliance has the greatest impact on support (iii) Factors which influenced adherence (iv) Action Observation Therapy is valued and recommended (v) Recommendations for future interventions.

CONCLUSION

This study provides insightful recommendations around; exploring the use of Action Observation Therapy in Achilles Tendinopathy, the relative importance of therapeutic alliance rather than mode of therapy delivery, and that sufferers of Achilles Tendinopathy may not prioritise health seeking for this condition.

Enhancing upper-limb neurorehabilitation in chronic stroke survivors using combined action observation and motor imagery therapy

Introduction

For people who have had a stroke, recovering upper-limb function is a barrier to independence. When movement is difficult, mental practice can be used to complement physical therapy. In this within-participants study we investigated the effects of combined action observation and motor imagery (AO + MI) therapy on upper-limb recovery in chronic stroke survivors.

Methods

A Graeco-Latin Square design was used to counterbalance four mental practice conditions (AO + MI, AO, MI, Control) across four cup-stacking tasks of increasing complexity. Once a week, for five consecutive weeks, participants (n = 10) performed 16 mental practice trials under each condition. Each trial displayed a 1st person perspective of a cup-stacking task performed by an experienced model. For AO, participants watched each video and responded to an occasional color cue. For MI, participants imagined the effort and sensation of performing the action; cued by a series of still-images. For combined AO + MI, participants observed a video of the action while they simultaneously imagined performing the same action in real-time. At three time points (baseline; post-test; two-week retention test) participants physically executed the three mentally practiced cup-stacking tasks, plus a fourth unpractised sequence (Control), as quickly and accurately as possible.

Results

Mean movement execution times were significantly reduced overall in the post-test and the retention test compared to baseline. At retention, movement execution times were significantly shorter for combined AO + MI compared to both MI and the Control. Individual participants reported clinically important changes in quality of life (Stroke Impact Scale) and positive qualitative experiences of AO + MI (social validation).

Discussion

These results indicate that when physical practice is unsuitable, combined AO + MI therapy could offer an effective adjunct for neurorehabilitation in chronic stroke survivors.

Principles into Practice: An Observational Study of Physiotherapists use of Motor Learning Principles in Stroke Rehabilitation

OBJECTIVE(S)

To describe a) how motor learning principles are applied during post stroke physiotherapy, with a focus on lower limb rehabilitation; and b) the context in which these principles are used, in relation to patient and/or task characteristics.

DESIGN

Direct non-participation observation of routine physiotherapy sessions, with data collected via video recording. A structured analysis matrix and pre-agreed definitions were used to identify, count and record: type of activity; repetitions; instructional and feedback statements (frequency and type); strategies such as observational learning and augmented feedback. Data was visualised using scatter plots, and analysed descriptively.

SETTING

6 UK Stroke Units PARTICIPANTS: 89 therapy sessions were observed, involving 55 clinicians and 57 patients.

RESULTS

Proportion of time spent active within each session ranged from 26% to 98% (mean 85, SD 19). The frequency of task repetition varied widely, with a median of 3.7 repetitions per minute (IQR 2.1-8.6). Coaching statements were common (mean 6.46 per minute), with 52% categorised as instructions, 14% as feedback, and 34% as verbal cues/motivational statements. 13% of instructions and 6% of feedback statements were externally focussed. Examining the use of different coaching behaviours in relation to patient characteristics found no associations. Overall, practice varied widely across the dataset.

CONCLUSIONS

To optimise the potential for motor skill learning, therapists must manipulate features of their coaching language (what they say, how much and when) and practice design (type, number, difficulty and variability of task). There is an opportunity to implement motor learning principles more consistently, to benefit motor skill recovery following stroke.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT03792126). CONTRIBUTION OF THE PAPER.

Effects of action observation training on the walking ability of patients post stroke: a systematic review

OBJECTIVE

To determine the effect of action observation (AO) training on the walking ability of patients post stroke.

METHODS

MEDLINE, CINAHL, EMBASE and PEDro were searched systematically for human studies written in English up to August 31st 2021. Two authors screened titles and abstracts against predefined inclusion criteria; a third author resolved discrepancies. Data were analyzed through qualitative synthesis. Articles evaluating the effects of AO training on the walking ability of patients post stroke were included. Methodological quality was assessed using the PEDro scale.

RESULTS

From first search that included 1,578 studies, 7 were included in this review. According to the PEDro scale, most of the studies exhibited a methodological quality between Good and Fair (N = 6). Most of the studies applied a protocol based on a 30-minute training session applied 3 to 5 times per week over a 4-week period (N = 5). Using clinical measures and gait parameters, all studies confirmed the beneficial effects of AO training on walking ability. However, the effects of AO training on walking ability were not confirmed at the long-term follow-up.

CONCLUSIONS

AO training has a positive effect on the walking ability of patients post stroke. Additional studies are needed to confirm these results across the entire spectrum of patient's post stoke including long-term clinical effects.Implications for RehabilitationAction observation training can have potentially positive effects on the walking ability of stroke patients.Clinical measurements (10-meter walk test) and gait parameters (stride length and gait speed) could be used to assess the effect of action observation training on walking ability.The patient's concentration is an important factor to consider when applying observational training.

Effects and Adaptation of Visual-Motor Illusion Using Different Visual Stimuli on Improving Ankle Joint Paralysis of Stroke Survivors—A Randomized Crossover Controlled Trial

Visual-motor illusion (VMI) is an intervention to induce kinesthetic sensation from visual stimuli. We aimed to compare the effects of VMI of different visual stimuli on the paralyzed side ankle joint of stroke hemiplegic patients (hemiplegic patients) and to clarify their indication. We applied two types of VMI images of ankle dorsiflexion: ankle dorsiflexion without resistance (standard VMI (S-VMI)) and maximum effort dorsiflexion with resistance (power VMI (P-VMI)). Twenty-two hemiplegic patients were divided into two groups: Group A, which received S-VMI first and P-VMI one week later (n = 11), and Group B, which received P-VMI first and S-VMI one week later (n = 11). Immediate effects were evaluated. Outcomes were the dorsiflexion angle and angular velocity, degree of sense of agency (SoA), and sense of ownership. Patient’s characteristics of cognitive flexibility were assessed using the Trail making test-B (TMT-B). Fugl-Meyer assessment and the Composite-Spasticity-Scale were also assessed. P-VMI was significantly higher than S-VMI in SoA and dorsiflexion angular velocity. Additionally, the degree of improvement in dorsiflexion function with P-VMI was related to TMT-B and degree of muscle tone. Therefore, P-VMI improves ankle function in hemiplegic patients more than S-VMI but should be performed with cognitive flexibility and degree of muscle tone in mind.

The Reaching Phase of Feeding and Self-Care Actions Optimizes Action Observation Effects in Chronic Stroke Subjects

BACKGROUND

The Action Observation Therapy (AOT) is a well-established post-stroke rehabilitation treatment based on the theoretical framework of the Mirror Neuron System (MNS) activation. However, AOT protocols are still heterogeneous in terms of video contents of observed actions.

OBJECTIVE

The aim of this study was to analyze electroencephalographic (EEG) recordings in stroke patients during the observation of different videos of task-specific upper limb movements, and to define which category of actions can elicit a stronger cortical activation in the observer's brain.

METHODS

Signals were analyzed from 19 chronic stroke subjects observing customized videos that represented 3 different categories of upper limb actions: Finalized Actions, Non-Finalized Actions, and Control Videos. The Event-Related Desynchronization in the µ and β bands was chosen to identify the involvement of the cerebral cortex: the area of the normalized power spectral density was calculated for each category and, deepening, for the reaching and completion sub-phases of Finalized Actions. For descriptive purposes, the time course of averaged signal power was described. The Kruskal-Wallis test (P < .05) was applied.

RESULTS

The analysis showed a greater desynchronization when subjects observed Finalized Actions with respect to Non-Finalized in all recorded areas; Control videos provoked a synchronization in the same areas and frequency bands. The reaching phase of feeding and self-care actions evoked a greater suppression both in µ and β bands.

CONCLUSIONS

The observation of finalized arm movements seems to elicit the strongest activation of the MNS in chronic stroke patients. This finding may help the clinicians to design future AOT-based stroke rehabilitation protocols.

CLINICAL TRIAL REGISTRATION

Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT04047134.

Action observation for upper limb rehabilitation after stroke

BACKGROUND

Action observation (AO) is a physical rehabilitation approach that facilitates the occurrence of neural plasticity through the activation of the mirror-neural system, promoting motor recovery in people with stroke.

OBJECTIVES

To assess whether AO enhances upper limb motor function in people with stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched 18 May 2021), the Cochrane Central Register of Controlled Trials (18 May 2021), MEDLINE (1946 to 18 May 2021), Embase (1974 to 18 May 2021), and five additional databases. We also searched trial registries and reference lists.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of AO alone or associated with physical practice in adults after stroke. The primary outcome was upper limb (arm and hand) motor function. Secondary outcomes included dependence on activities of daily living (ADL), motor performance, cortical activation, quality of life, and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials according to the predefined inclusion criteria, extracted data, assessed risk of bias using RoB 1, and applied the GRADE approach to assess the certainty of the evidence. The reviews authors contacted trial authors for clarification and missing information.

MAIN RESULTS

We included 16 trials involving 574 individuals. Most trials provided AO followed by the practice of motor actions. Training varied between 1 day and 8 weeks of therapy, 10 to 90 minutes per session. The time of AO ranged from 1 minute to 10 minutes for each motor action, task or movement observed. The total number of motor actions ranged from 1 to 3. Control comparisons included sham observation, physical therapy, and functional activity practice.

PRIMARY OUTCOMES

AO improved arm function (standardized mean difference (SMD) 0.39, 95% confidence interval (CI) 0.17 to 0.61; 11 trials, 373 participants; low-certainty evidence); and improved hand function (mean difference (MD) 2.76, 95% CI 1.04 to 4.49; 5 trials, 178 participants; low-certainty evidence).

SECONDARY OUTCOMES

AO did not improve ADL performance (SMD 0.37, 95% CI -0.34 to 1.08; 7 trials, 302 participants; very low-certainty evidence), or quality of life (MD 5.52, 95% CI -30.74 to 41.78; 2 trials, 30 participants; very low-certainty evidence). We were unable to pool the other secondary outcomes (motor performance and cortical activation). Only two trials reported adverse events without significant adverse effects.

AUTHORS' CONCLUSIONS

The effects of AO are small for arm function compared to any control group; for hand function the effects are large, but not clinically significant. For both, the certainty of evidence is low. There is no evidence of benefit or detriment from AO on ADL and quality of life of people with stroke; however, the certainty of evidence is very low. As such, our confidence in the effect estimate is limited because it will likely change with future research.

The Effects of Action Observation Therapy as a Rehabilitation Tool in Parkinson’s Disease Patients: A Systematic Review

During Action Observation (AO), patients observe human movements that they then try to imitate physically. Until now, few studies have investigated the effectiveness of it in Parkinson’s disease (PD). However, due to the diversity of interventions, it is unclear how the dose and characteristics can affect its efficiency. We investigated the AO protocols used in PD, by discussing the intervention features and the outcome measures in relation to their efficacy. A search was conducted through MEDLINE, Scopus, Cochrane, and WoS until November 2021, for RCTs with AO interventions. Participant’s characteristics, treatment features, outcome measures, and main results were extracted from each study. Results were gathered into a quantitative synthesis (MD and 95% CI) for each time point. Seven studies were included in the review, with 227 participants and a mean PEDro score of 6.7. These studies reported positive effects of AO in PD patients, mainly on walking ability and typical motor signs of PD like freezing of gait. However, disagreements among authors exist, mainly due to the heterogeneity of the intervention features. In overall, AO improves functional abilities and motor control in PD patients, with the intervention dose and the characteristics of the stimulus playing a decisive role in its efficacy.

Development and user experience of an innovative multi-mode stroke rehabilitation system for the arm and hand for patients with stroke

Many individuals with stroke experience upper-limb motor deficits, and a recent trend is to develop novel devices for enhancing their motor function. This study aimed to develop a new upper-limb rehabilitation system with the integration of two rehabilitation therapies into one system, digital mirror therapy (MT) and action observation therapy (AOT), and to test the usability of this system. In the part I study, the new system was designed to operate in multiple training modes of digital MT (i.e., unilateral and bilateral modes) and AOT (i.e., pre-recorded and self-recorded videos) with self-developed software. In the part II study, 4 certified occupational therapists and 10 stroke patients were recruited for evaluating usability. The System Usability Scale (SUS) (maximum score = 100) and a self-designed questionnaire (maximum score = 50) were used. The mean scores of the SUS were 79.38 and 80.00, and those of the self-designed questionnaire were 41.00 and 42.80, respectively, for the therapists and patients after using this system, which indicated good usability and user experiences. This novel upper-limb rehabilitation system with good usability might be further used to increase the delivery of two emerging rehabilitation therapies, digital AOT and MT, to individuals with stroke.

Motor effects of movement representation techniques and cross-education: a systematic review and meta-analysis

INTRODUCTION

The objective was to assess the impact of movement representation techniques (MRT) through motor imagery (MI), action observation (AO) and visual mirror feedback (VMF) and cross-education training (CE) on strength, range of motion (ROM), speed, functional state and balance during experimental immobilization processes in healthy individuals, in patients with injuries that did not require surgery and in those with surgical processes that did or did not require immobilization.

EVIDENCE ACQUISITION

MEDLINE, EMBASE, CINAHL and Google Scholar were searched. Thirteen meta-analyses were conducted.

EVIDENCE SYNTHESIS

Regarding the immobilized participants, in the healthy individuals, MI showed significant results regarding maintenance of strength and ROM, with low-quality evidence. Regarding the process with no immobilization, VMF and MI techniques showed significant changes in maintaining ROM in patients with injury without surgery, with very low-quality evidence. Results had shown that MI demonstrated significantly higher maintenance of strength and speed in patients undergoing surgery, with low-quality evidence. No significant results were found in ROM. Low-quality evidence showed better results in AO plus usual care compared with usual treatment in isolation with respect to maintenance of functional state and balance. CE training demonstrated maintenance of strength in patients undergoing surgery, with moderate evidence; however, not in healthy experimentally immobilized individuals. VMF did not show significant results in maintaining ROM after surgery without immobilization, nor did MI in maintaining strength after surgery and immobilization.

CONCLUSIONS

MRT and CE training have been shown to have a significant impact on the improvement of various motor variables and on physical maintenance in general.

Development and feasibility testing of action observation training videos in acute stroke survivors: Preliminary findings

Background: Action observation training (AOT) is used for lower limb (LL) stroke rehabilitation in subacute and chronic stages, but concise information regarding the types of activities to be used and the feasibility of administration in the acute stroke population is unknown. The aim of this study was to develop and validate videos of appropriate activities for LL AOT and test administrative feasibility in acute stroke.   Method: A video inventory of LL activities was created after a literature survey and expert scrutiny. Five stroke rehabilitation experts validated the videos per domains of relevance, comprehension, clarity, camera position and brightness. LL AOT was then tested on ten individuals with acute stroke for uncovering barriers for clinical use in a feasibility study. Participants watched the activities and attempted imitation of the same. Determination of administrative feasibility was undertaken via participant interviews.   Results: Suitable LL activities for stroke rehabilitation were identified. Content validation of videos led to improvements in selected activities and video quality. Expert scrutiny led to further video processing to include different perspectives of view and speeds of projected movements. Barriers identified included inability to imitate actions shown in videos and increased distractibility for some participants.    Conclusion: A video catalogue of LL activities was developed and validated. AOT was deemed safe and feasible for acute stroke rehabilitation and may be used in future research and clinical practice.

Visual Attention and Motion Visibility Modulate Motor Resonance during Observation of Human Walking in Different Manners

To advance our knowledge on the motor system during cyclic gait observation, we aimed to explore the effects of gaze fixation on corticospinal excitability evaluated by single-pulse transcranial magnetic stimulation (TMS). Fourteen healthy adult volunteers watched a video of a demonstrator walking on a treadmill under three different conditions: (1) observing the right lower limb, (2) observing the right ankle joint, and (3) observing the right lower limb on a video focused on the area below the knee. In each condition, motor-evoked potentials elicited by TMS in the tibialis anterior (TA) muscle were measured synchronously with the demonstrator’s initial contact and toe-off points. Directing visual attention to the ankle joint and focusing on its movements caused corticospinal facilitation in the TA muscle compared with watching the video without any visual fixation. In addition, phase-dependent differences in corticospinal excitability between the initial contact and toe-off points were only detected when the visibility range was restricted to below the knee. Our findings indicated that motor resonance during cyclic gait observation is modulated by visual attention and motion visibility in different activation manners.

The role of mirror mechanism in the recovery, maintenance, and acquisition of motor abilities

While it is well documented that the motor system is more than a mere implementer of motor actions, the possible applications of its cognitive side are still under-exploited, often remaining as poorly organized evidence. Here, we will collect evidence showing the value of action observation treatment (AOT) in the recovery of impaired motor abilities for a vast number of clinical conditions, spanning from traumatological patients to brain injuries and neurodegenerative diseases. Alongside, we will discuss the use of AOT in the maintenance of appropriate motor behavior in subjects at risk for events with dramatic physical consequences, like fall prevention in elderly people or injury prevention in sports. Finally, we will report that AOT can help to tune existing motor competencies in fields requiring precise motor control. We will connect all these diverse dots into the neurophysiological scenario offered by decades of research on the human mirror mechanism, discussing the potentialities for individualization. Empowered by modern technologies, AOT can impact individuals' safety and quality of life across the whole lifespan.

Action Observation Therapy for Upper Limb Recovery in Patients with Stroke: A Randomized Controlled Pilot Study

Due to the complexity of the interventions for upper limb recovery, at the moment there is a lack of evidence regarding innovative and effective rehabilitative interventions. Action Observation Training (AOT) constitutes a promising rehabilitative method to improve upper limb motor recovery in stroke patients. The aim of the present study was to evaluate the potential efficacy of AOT, both in upper limb recovery and in functional outcomes when compared to patients treated with task oriented training (TOT). Both treatments were added to traditional rehabilitative treatment. Thirty-two acute stroke patients at 15.6 days (±8.3) from onset, with moderate to severe upper limb impairment at baseline following their first-ever stroke, were enrolled and randomized into two groups: 16 in the experimental group (EG) and 16 in the control group (CG). The EG underwent 30 min sessions of AOT, and the CG underwent 30 min sessions of TOT. All participants received 20 sessions of treatment for four consecutive weeks (five days/week). The Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Box and Block Test (BBT), Functional Independence Measure (FIM) and Modified Ashworth Scale (MAS) were administered at baseline (T0) and at the end of treatment (T1). No statistical differences were found at T0 for inclusion criteria between the CG and EG, whereas both groups improved significantly at T1. After the treatment period, the rehabilitative gain was greater in the EG compared to the CG for FMA-UE and FIM (all p < 0.05). Our results suggest that AOT can contribute to increased motor recovery in subacute stroke patients with moderate to severe upper limb impairment in the early phase after stroke. The improvements presented in this article, together with the lack of adverse events, confirm that the use of AOT should be broadened out to larger pools of subacute stroke patients.

Effectiveness of Action Observation Training on Upper Limb Motor Function in Children with Hemiplegic Cerebral Palsy: A Systematic Review of Randomized Controlled Trials

The purpose of this review was to evaluate and examine the current best evidence for the effectiveness of action observation therapy on upper limb function rehabilitation in children with hemiplegic cerebral palsy. A comprehensive search of literature published between September 2010 and May 2020 was conducted using the following electronic databases: PubMed, Google Scholar, the Physiotherapy Evidence Database (PEDro), EMBASE, Cochrane library, and Scopus. Only randomized controlled trials evaluating the effect of action observation therapy on upper limb motor function in children with hemiplegic cerebral palsy were included. PEDro scale was used to assess the risk of bias of included trials. This study was reported according to the guideline of the PRISMA statement. The overall methodological quality of the studies was done using the PEDro scale and GRADE approach. The primary outcome measures of this review were the Melbourne Assessment Scale, Assisting Hand Assessment scale to evaluate physical function and structures. Furthermore, the ABILHAND-Kids test, and Box and Block Test primary outcome measures were used to determine the subjects’ activities and participation. Nine randomized controlled trials involving 234 participants were analyzed. The overall quality of evidence was rated from moderate to high. This review suggests action observation therapy was found to be a promising intervention for upper limb rehabilitation in children with cerebral palsy.

Action observation combined with gait training to improve gait and cognition in elderly with mild cognitive impairment A randomized controlled trial

Owing to advancement of medical technology and current knowledge, the population has a longer life expectancy, leading to an increase in the proportion of elderly.

Visual feedback therapy for restoration of upper limb function of stroke patients

Objective

To investigate the effects of mirror neuron theory-based visual feedback therapy (VFT) on restoration of upper limb function of stroke patients and motor-related cortical function using functional magnetic resonance imaging (fMRI).

Methods

Hemiplegic stroke patients were randomly divided into two groups: a VFT group and a control (CTL) group. Sixteen patients in the VFT group received conventional rehabilitation (CR) and VFT for 8 weeks, while 15 patients in the CTL group received only CR. The Barthel Index (BI) was used to assess the activities of daily living at baseline and the 8^th week of the recovery training period. The Fugl–Meyer assessment (FMA) scale, somatosensory evoked potential (SEP), and fMRI were used to evaluate the recovery effect of the training therapies. The latencies and amplitudes of N9 and N20 were measured. Before recovery training, fMRI was performed for all patients in the VFT and CTL groups. In addition, 17 patients (9 in the VFT group and 8 in the CTL group) underwent fMRI for follow-up 2 months after treatment. Qualitative data were analyzed using the χ² test. The independent sample t-test was used to compare normally distributed data among different groups, the paired sample t-test was used to compare data between groups, and the non-parametric test was used to comparing data without normal distribution among groups.

Results

There were no significant differences between the VFT and CTL group in all indexes. However, after 8 weeks of recovery training, these indexes were all significantly improved (P < 0.05). As compared with the CTL group, the FMA scores, BI, and N9/N20 latencies and amplitudes of SEP in the VFT group were significantly improved (P < 0.05). Two months after recovery training, fMRI showed that the degree of activation of the bilateral central anterior gyrus, parietal lobe, and auxiliary motor areas was significantly higher in the VFT group than the CTL group (P < 0.05).

Conclusions

VFT based on mirror neuron theory is an effective approach to improve upper extremity motor function and daily activity performance of stroke patients. The therapeutic mechanism promotes motor relearning by activating the mirror neuron system and motor cortex. SEP amplitudes increased only for patients who participated in visual feedback. VFT promotes sensory-motor plasticity and behavioral changes in both the motor and sensory domains.

The Effects of Instruction Manipulation on Motor Performance Following Action Observation

The effects of action observation (AO) on motor performance can be modulated by instruction. The effects of two top-down aspects of the instruction on motor performance have not been fully resolved: those related to attention to the observed task and the incorporation of motor imagery (MI) during AO. In addition, the immediate vs. 24-h retention test effects of those instruction’s aspects are yet to be elucidated. Forty-eight healthy subjects were randomly instructed to: (1) observe reaching movement (RM) sequences toward five lighted units with the intention of reproducing the same sequence as fast and as accurate as possible (Intentional + Attentional group; AO+At); (2) observe the RMs sequence with the intention of reproducing the same sequence as fast and as accurate as possible and simultaneously to the observation to imagine performing the RMs (Intentional + attentional + MI group; AO+At+MI); and (3) observe the RMs sequence (Passive AO group). Subjects’ performance was tested before and immediately after the AO and retested after 24 h. During each of the pretest, posttest, and retest, the subject performed RMs toward the units that were activated in the same order as the observed sequence. Occasionally, the sequence order was changed by beginning the sequence with a different activated unit. The outcome measures were: averaged response time of the RMs during the sequences, difference between the response time of the unexpected and expected RMs and percent of failures to reach the target within 1 s. The averaged response time and the difference between the response time of the unexpected and expected RMs were improved in all groups at posttest compared to pretest, regardless of instruction. Averaged response time was improved in the retest compared to the posttest only in the Passive AO group. The percent of failures across groups was higher in pretest compared to retest. Our findings suggest that manipulating top-down aspects of instruction by adding attention and MI to AO in an RM sequence task does not improve subsequent performance more than passive observation. Off-line learning of the sequence in the retention test was improved in comparison to posttest following passive observation only.

Action observation therapy in pediatric patients with neuromotor deficits of the upper limbs secondary to central nervous system tumors

This study reports a case series of patients with upper limb neuromotor deficits following pediatric central nervous system tumor and treated with rehabilitative therapy according to action observation therapy (AOT). AOT is based on the “mirror neurons” system and had positive results in various non-oncologic neurologic pathologies. This study is the first experience in the oncology field, and included 6 patients, 4 of whom were fully evaluated at 6-month follow-up. In all patients, therapy showed improvement in all assessment tests. These promising results lead to further studies to confirm their effectiveness.