Action observation treatment: a novel tool in neurorehabilitation

Learning by observing: the effect of multiple sessions of action-observation training on the spontaneous movement tempo and motor resonance

The present study was designed to explore the changes in motor performance and motor resonance after multiple sessions of action observation (AO) training. Subjects were exposed to the observation of a video showing finger tapping movements executed at 3Hz, a frequency higher than the spontaneous one (2Hz) for four consecutive days. Motor performance and motor resonance were tested before the AO training on the first day, and on the last day. Results showed that multiple sessions of AO training induced a shift of the speed of execution of finger tapping movements toward the observed one and a change in motor resonance. Before the 3Hz-AO training cortical excitability was highest during the observation of the 2Hz video. This motor resonance effect was lost after one single session of 3Hz-AO training whereas after multiple sessions of 3Hz-AO training cortical excitability was highest during the observation of the 3Hz video. Our study shows for the first time that multiple sessions of AO training are able not only to induce performance gains but also to change the way by which the observer's motor system recognizes a certain movement as belonging to the individual motor repertoire. These results may encourage the development of novel rehabilitative protocols based on multiple sessions of action observation aimed to regain a correct movement when its spontaneous speed is modified by pathologies or to modify the innate temporal properties of certain movements.

Patients' Views on a Combined Action Observation and Motor Imagery Intervention for Parkinson's Disease

Background. Action observation and motor imagery activate neural structures involved in action execution, thereby facilitating movement and learning. Although some benefits of action observation and motor imagery have been reported in Parkinson's disease (PD), methods have been based on stroke rehabilitation and may be less suitable for PD. Moreover, previous studies have focused on either observation or imagery, yet combining these enhances effects in healthy participants. The present study explores the feasibility of a PD-specific home-based intervention combining observation, imagery, and imitation of meaningful everyday actions. Methods. A focus group was conducted with six people with mild to moderate PD and two companions, exploring topics relating to the utility and feasibility of a home-based observation and imagery intervention. Results. Five themes were identified. Participants reported their experiences of exercise and use of action observation and motor imagery in everyday activities, and the need for strategies to improve movement was expressed. Motivational factors including feedback, challenge, and social support were identified as key issues. The importance of offering a broad range of actions and flexible training was also highlighted. Conclusions. A home-based intervention utilising action observation and motor imagery would be useful and feasible in mild to moderate PD.

Behavioral and TMS Markers of Action Observation Might Reflect Distinct Neuronal Processes

Transcranial magnetic stimulation (TMS) studies have shown that observing an action induces muscle-specific changes in corticospinal excitability. From a signal detection theory standpoint, this pattern can be related to sensitivity, which here would measure the capacity to distinguish between two action observation conditions. In parallel to these TMS studies, action observation has also been linked to behavioral effects such as motor priming and interference. It has been hypothesized that behavioral markers of action observation could be related to TMS markers and thus represent a potentially cost-effective mean of assessing the functioning of the action-perception system. However, very few studies have looked at possible relationships between these two measures. The aim of this study was to investigate if individual differences in sensitivity to action observation could be related to the behavioral motor priming and interference effects produced by action observation. To this end, 14 healthy participants observed index and little finger movements during a TMS task and a stimulus-response compatibility task. Index muscle displayed sensitivity to action observation, and action observation resulted in significant motor priming+interference, while no significant effect was observed for the little finger in both task. Nevertheless, our results indicate that the sensitivity measured in TMS was not related to the behavioral changes measured in the stimulus-response compatibility task. Contrary to a widespread assumption, the current results indicate that individual differences in physiological and behavioral markers of action observation may be unrelated. This could have important impacts on the potential use of behavioral markers in place of more costly physiological markers of action observation in clinical settings.

The effect of exergames on functional strength, anaerobic fitness, balance and agility in children with and without motor coordination difficulties living in low-income communities

Children with Developmental Coordination Disorder (DCD) are physically less active, preferring more sedentary behavior and are at risk of developing health problems or becoming overweight. 18 children (age 6-10years) with lower levels of motor coordination attending a primary school in a low-income community in South Africa (score on Movement Assessment Battery for Children Second edition equal to or below the 5th percentile) were selected to participate in the study and were age-matched with typically developing peers (TD). Both groups of children engaged in 20min of active Nintendo Wii Fit gaming on the balance board, twice a week for a period of five weeks. All children were tested before and after the intervention using the lower limb items of the Functional Strength Measurement, the 5×10 meter sprint test, the 5×10 meter slalom sprint test, and the Balance, Running speed and Agility subtest of the Bruininks Oseretsky Test of Motor Proficiency 2nd edition (BOT-2). After intervention, both groups of children improved in functional strength and anaerobic fitness. The magnitude of these changes was not related to participant's motor coordination level. However, differences in change between the TD and DCD group were apparent on the motor performance tests; children with DCD seemed to benefit more in balance skills of the BOT-2, while the TD children improved more in the Running speed and Agility component of the BOT-2. Compliance to the study protocol over 5weeks was high and the effect on physical functioning was shown on standardized measures of physical performance validated for children with and without DCD.

Influence of Perspective of Action Observation Training on Residual Limb Control in Naïve Prosthesis Usage

Prior work in amputees and partial limb immobilization have shown improved neural and behavioral outcomes in using their residual limb with prosthesis when undergoing observation-based training with a prosthesis-using actor compared to an intact limb. It was posited that these improvements are due to an alignment of user with the actor. It may be affected by visual angles that allow emphasis of critical joint actions which may promote behavioral changes. The purpose of this study was to examine how viewing perspective of observation-based training effects prosthesis adaptation in naïve device users. Twenty nonamputated prosthesis users learned how to use an upper extremity prosthetic device while viewing a training video from either a sagittal or coronal perspective. These views were chosen as they place visual emphasis on different aspects of task performance to the device. The authors found that perspective of actions has a significant role in adaptation of the residual limb while using upper limb prostheses. Perspectives that demonstrate elbow adaptations to prosthesis usage may enhance the functional motor outcomes of action observation therapy. This work has potential implications on how prosthetic device operation is conveyed to persons adapting to prostheses through action observation based therapy.

Cortical Spectral Activity and Connectivity during Active and Viewed Arm and Leg Movement

Active and viewed limb movement activate many similar neural pathways, however, to date most comparison studies have focused on subjects making small, discrete movements of the hands and feet. The purpose of this study was to determine if high-density electroencephalography (EEG) could detect differences in cortical activity and connectivity during active and viewed rhythmic arm and leg movements in humans. Our primary hypothesis was that we would detect similar but weaker electrocortical spectral fluctuations and effective connectivity fluctuations during viewed limb exercise compared to active limb exercise due to the similarities in neural recruitment. A secondary hypothesis was that we would record stronger cortical spectral fluctuations for arm exercise compared to leg exercise, because rhythmic arm exercise would be more dependent on supraspinal control than rhythmic leg exercise. We recorded EEG data while ten young healthy subjects exercised on a recumbent stepper with: (1) both arms and legs, (2) just legs, and (3) just arms. Subjects also viewed video playback of themselves or another individual performing the same exercises. We performed independent component analysis, dipole fitting, spectral analysis, and effective connectivity analysis on the data. Cortical areas comprising the premotor and supplementary motor cortex, the anterior cingulate, the posterior cingulate, and the parietal cortex exhibited significant spectral fluctuations during rhythmic limb exercise. These fluctuations tended to be greater for the arms exercise conditions than for the legs only exercise condition, which suggests that human rhythmic arm movements are under stronger cortical control than rhythmic leg movements. We did not find consistent spectral fluctuations in these areas during the viewed conditions, but effective connectivity fluctuated at harmonics of the exercise frequency during both active and viewed rhythmic limb exercise. The right premotor and supplementary motor cortex drove the network. These results suggest that a similarly interconnected neural network is in operation during active and viewed human rhythmic limb movement.

Postural and Balance Disorders in Patients with Parkinson's Disease: A Prospective Open-Label Feasibility Study with Two Months of Action Observation Treatment

Action observation treatment has been proposed as therapeutic option in rehabilitation of patients affected by Parkinson's disease (PD) to improve freezing of gait episodes. The purpose of this prospective open-label feasibility study was to evaluate the impact of 8-week action observation training (video-therapy) for the treatment of postural instability and balance impairment in PD patients. Fifteen PD patients aged under 80 years with scores of 1 to 3 on the Hoehn and Yahr staging and without evidence of freezing of gait were recruited. They underwent 24 sessions of video-therapy training based on carefully watching video clips on motor tasks linked to balance, subsequently performing the same observed movements. No statistically significant differences were observed in the identified outcome measures with the Berg Balance Scale and the Activities-Specific Balance Confidence Scale after two months of follow-up. In the present study, a short course of action observation treatment seems to be not effective in reducing balance impairments and postural instability in patients affected by mild to moderate PD. Further studies with larger samples, longer follow-up period, and standardized protocols of action observation treatment are needed to investigate the effects of this rehabilitation technique in the management of postural and balance disorders of PD patients.

The Efficacy of Movement Representation Techniques for Treatment of Limb Pain--A Systematic Review and Meta-Analysis

Relatively new evidence suggests that movement representation techniques (ie, therapies that use the observation and/or imagination of normal pain-free movements, such as mirror therapy, motor imagery, or movement and/or action observation) might be effective in reduction of some types of limb pain. To summarize the evidence regarding the efficacy of those techniques, a systematic review with meta-analysis was performed. We searched Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, AMED, PsychINFO, Physiotherapy Evidence Database, and OT-seeker up to August 2014 and hand-searched further relevant resources for randomized controlled trials that studied the efficacy of movement representation techniques in reduction of limb pain. The outcomes of interest were pain, disability, and quality of life. Study selection and data extraction were performed by 2 reviewers independently. We included 15 trials on the effects of mirror therapy, (graded) motor imagery, and action observation in patients with complex regional pain syndrome, phantom limb pain, poststroke pain, and nonpathological (acute) pain. Overall, movement representation techniques were found to be effective in reduction of pain (standardized mean difference [SMD] = -.82, 95% confidence interval [CI], -1.32 to -.31, P = .001) and disability (SMD = .72, 95% CI, .22-1.22, P = .004) and showed a positive but nonsignificant effect on quality of life (SMD = 2.61, 85% CI, -3.32 to 8.54, P = .39). Especially mirror therapy and graded motor imagery should be considered for the treatment of patients with complex regional pain syndrome. Furthermore, the results indicate that motor imagery could be considered as a potential effective treatment in patients with acute pain after trauma and surgery. To date, there is no evidence for a pain reducing effect of movement representation techniques in patients with phantom limb pain and poststroke pain other than complex regional pain syndrome.

PERSPECTIVE

In this systematic review we synthesize the evidence for the efficacy of movement representation techniques (ie, motor imagery, mirror therapy, or action observation) for treatment of limb pain. Our findings suggest effective pain reduction in some types of limb pain. Further research should address specific questions on the optimal type and dose of therapy.

Action Observation and Motor Imagery: Innovative Cognitive Tools in the Rehabilitation of Parkinson's Disease

Parkinson's disease (PD) is characterized by a progressive impairment of motor skills with deterioration of autonomy in daily living activities. Physiotherapy is regarded as an adjuvant to pharmacological and neurosurgical treatment and may provide small and short-lasting clinical benefits in PD patients. However, the development of innovative rehabilitation approaches with greater long-term efficacy is a major unmet need. Motor imagery (MI) and action observation (AO) have been recently proposed as a promising rehabilitation tool. MI is the ability to imagine a movement without actual performance (or muscle activation). The same cortical-subcortical network active during motor execution is engaged in MI. The physiological basis of AO is represented by the activation of the "mirror neuron system." Both MI and AO are involved in motor learning and can induce improvements of motor performance, possibly mediated by the development of plastic changes in the motor cortex. The review of available evidences indicated that MI ability and AO feasibility are substantially preserved in PD subjects. A few preliminary studies suggested the possibility of using MI and AO as parts of rehabilitation protocols for PD patients.

Walking indoors, walking outdoors: an fMRI study

An observation/execution matching system for walking has not been assessed yet. The present fMRI study was aimed at assessing whether, as for object-directed actions, an observation/execution matching system is active for walking and whether the spatial context of walking (open or narrow space) recruits different neural correlates. Two experimental conditions were employed. In the execution condition, while being scanned, participants performed walking on a rolling cylinder located just outside the scanner. The same action was performed also while observing a video presenting either an open space (a country field) or a narrow space (a corridor). In the observation condition, participants observed a video presenting an individual walking on the same cylinder on which the actual action was executed, the open space video and the narrow space video, respectively. Results showed common bilateral activations in the dorsal premotor/supplementary motor areas and in the posterior parietal lobe for both execution and observation of walking, thus supporting a matching system for this action. Moreover, specific sectors of the occipital–temporal cortex and the middle temporal gyrus were consistently active when processing a narrow space versus an open one, thus suggesting their involvement in the visuo-motor transformation required when walking in a narrow space. We forward that the present findings may have implications for rehabilitation of gait and sport training.

Translating novel findings of perceptual-motor codes into the neuro-rehabilitation of movement disorders

The bidirectional flow of perceptual and motor information has recently proven useful as rehabilitative tool for re-building motor memories. We analyzed how the visual-motor approach has been successfully applied in neurorehabilitation, leading to surprisingly rapid and effective improvements in action execution. We proposed that the contribution of multiple sensory channels during treatment enables individuals to predict and optimize motor behavior, having a greater effect than visual input alone. We explored how the state-of-the-art neuroscience techniques show direct evidence that employment of visual-motor approach leads to increased motor cortex excitability and synaptic and cortical map plasticity. This super-additive response to multimodal stimulation may maximize neural plasticity, potentiating the effect of conventional treatment, and will be a valuable approach when it comes to advances in innovative methodologies.

Task-Based Mirror Therapy Augmenting Motor Recovery in Poststroke Hemiparesis: A Randomized Controlled Trial

BACKGROUND

To establish the effect of the task-based mirror therapy (TBMT) on the upper limb recovery in stroke.

METHODS

A pilot, randomized, controlled, assessor-blinded trial was conducted in a rehabilitation institute. A convenience sample of 33 poststroke (mean duration, 12.5 months) hemiparetic subjects was randomized into 2 groups (experimental, 17; control, 16). The subjects were allocated to receive either TBMT or standard motor rehabilitation-40 sessions (5/week) for a period of 8 weeks. The TBMT group received movements using various goal-directed tasks and a mirror box. The movements were performed by the less-affected side superimposed on the affected side. The main outcome measures were Brunnstrom recovery stage (BRS) and Fugl-Meyer assessment (FMA)-FMA of upper extremity (FMA-UE), including upper arm (FMA-UA) and wrist-hand (FMA-WH).

RESULTS

The TBMT group exhibited highly significant improvement on mean scores of FMA-WH (P < .001) and FMA-UE (P < .001) at postassessment in comparison to the control group. Furthermore, there was a 12% increase in the number of subjects at BRS stage 5 (out of synergy movement) in the experimental group as compared to a 0% rise at the same stage in the control group.

CONCLUSIONS

This pilot trial confirmed the role of TBMT in improving the wrist-hand motor recovery in poststroke hemiparesis. MT using tasks may be used as an adjunct in stroke rehabilitation.

Action processing and mirror neuron function in patients with amyotrophic lateral sclerosis: an fMRI study

Amyotrophic lateral sclerosis (ALS) is a highly debilitating and rapidly fatal neurodegenerative disease. It has been suggested that social cognition may be affected, such as impairment in theory of mind (ToM) ability. Despite these findings, research in this area is scarce and the investigation of neural mechanisms behind such impairment is absent. Nineteen patients with ALS and eighteen healthy controls participated in this study. Because the mirror neuron system (MNS) is thought to be involved in theory of mind, we first implemented a straightforward action-execution and observation task to assess basic MNS function. Second, we examined the social-cognitive ability to understand actions of others, which is a component of ToM. We used fMRI to assess BOLD activity differences between groups during both experiments. Theory of mind was also measured behaviorally using the Reading the Mind in the Eyes test (RME). ALS patients displayed greater BOLD activity during the action-execution and observation task, especially throughout right anterior cortical regions. These areas included the right inferior operculum, premotor and primary motor regions, and left inferior parietal lobe. A conjunction analysis showed significantly more co-activated voxels during both the observation and action-execution conditions in the patient group throughout MNS regions. These results support a compensatory response in the MNS during action processing. In the action understanding experiment, healthy controls performed better behaviorally and subsequently recruited greater regions of activity throughout the prefrontal cortex and middle temporal gyrus. Lastly, action understanding performance was able to cluster patients with ALS into high and lower performing groups, which then differentiated RME performance. Collectively, these data suggest that social cognition, particularly theory of mind, may be affected in a subset of patients with ALS. This impairment may be related to functioning of the MNS and other regions related to action processing and understanding. Implications for future research are discussed.

Different visual exploration of tool-related gestures in left hemisphere brain damaged patients is associated with poor gestural imitation

According to the direct matching hypothesis, perceived movements automatically activate existing motor components through matching of the perceived gesture and its execution. The aim of the present study was to test the direct matching hypothesis by assessing whether visual exploration behavior correlate with deficits in gestural imitation in left hemisphere damaged (LHD) patients. Eighteen LHD patients and twenty healthy control subjects took part in the study. Gesture imitation performance was measured by the test for upper limb apraxia (TULIA). Visual exploration behavior was measured by an infrared eye-tracking system. Short videos including forty gestures (20 meaningless and 20 communicative gestures) were presented. Cumulative fixation duration was measured in different regions of interest (ROIs), namely the face, the gesturing hand, the body, and the surrounding environment. Compared to healthy subjects, patients fixated significantly less the ROIs comprising the face and the gesturing hand during the exploration of emblematic and tool-related gestures. Moreover, visual exploration of tool-related gestures significantly correlated with tool-related imitation as measured by TULIA in LHD patients. Patients and controls did not differ in the visual exploration of meaningless gestures, and no significant relationships were found between visual exploration behavior and the imitation of emblematic and meaningless gestures in TULIA. The present study thus suggests that altered visual exploration may lead to disturbed imitation of tool related gestures, however not of emblematic and meaningless gestures. Consequently, our findings partially support the direct matching hypothesis.

Activating the motor system through action observation: is this an efficient approach in adults and children?

Observing an action performed by another person to learn a new movement is a frequent experience in adult daily life, such as in sports. However, it is an especially common circumstance during the development of motor skills in childhood. Studies on healthy humans indicate that action observation induces a facilitation in the observer's motor system. This effect is supported by an action-perception matching mechanism available both in adults and in children. Because of the simplicity of action observation, it has been proposed to apply this method in clinical contexts. After a brief, non-exhaustive introduction of the essential features underlying action observation in healthy people, we review recent studies reporting beneficial effects of rehabilitative training based on a combination of action perception and execution. We focus on therapeutic interventions for patients with upper-limb motor disabilities such as adults after stroke or children with hemiplegia due to cerebral palsy. Further, we consider data from basic science demonstrating that the facilitation induced by visual perception of the action can be modulated by the combination of multimodal stimuli related to the movement (e.g. visual and acoustic action-related inputs). In line with this, we discuss possible new directions to improve basic knowledge and therapeutic applications of action observation.