Interventions to improve outdoor mobility among people living with disabilities: A systematic review

Background

Around 15% of the global population live with some form of disabilities and experience worse health outcomes, less participation in the community and are part of fewer activities outside the home. Outdoor mobility interventions aim to improve the ability to move, travel and orient outside the home and could influence the number of activities outside the home, participation and quality of life. However, outdoor mobility interventions may also lead to harm like falls or injuries or have unforeseen effects which could lead to mortality or hospitalization.

Objectives

To assess the efficacy of interventions aiming to improve outdoor mobility for adults living with disabilities and to explore if the efficacy varies between different conditions and different intervention components.

Search Methods

Standard, extensive Campbell search methods were used, including a total of 12 databases searched during January 2023, including trial registries.

Selection Criteria

Only randomized controlled trials were included, focusing on people living with disabilities, comparing interventions to improve outdoor mobility to control interventions as well as comparing different types of interventions to improve outdoor mobility.

Data Collection and Analysis

Standard methodological procedures expected by Campbell were used. The following important outcomes were 1. Activity outside the home; 2. Engagement in everyday life activities; 3. Participation; 4. Health-related Quality of Life; 5. Major harms; 6. Minor harms. The impact of the interventions was evaluated in the shorter (≤6 months) and longer term (≥7 months) after starting the intervention. Results are presented using risk ratios (RR), risk difference (RD), and standardized mean differences (SMD), with the associated confidence intervals (CI). The risk of bias 2-tool and the GRADE-framework were used to assess the certainty of the evidence.

Main Results

The screening comprised of 12.894 studies and included 22 studies involving 2.675 people living with disabilities and identified 12 ongoing studies. All reported outcomes except one (reported in one study, some concerns of bias) had overall high risk of bias. Thirteen studies were conducted in participants with disabilities due to stroke, five studies with older adults living with disabilities, two studies with wheelchair users, one study in participants with disabilities after a hip fracture, and one study in participants with cognitive impairments. Skill training interventions versus control interventions (16 studies) The evidence is very uncertain about the benefits and harms of skill training interventions versus control interventions not aimed to improve outdoor mobility among all people living with disabilities both in the shorter term (≤6 months) and longer term (≥7 months) for Activity outside the home; Participation; Health-related Quality of Life; Major harms; and Minor harms, based on very low certainty evidence. Skill training interventions may improve engagement in everyday life activities among people with disabilities in the shorter term (RR: 1.46; 95% CI: 1.16 to 1.84; I 2 = 7%; RD: 0.15; 95% CI: -0.02 to 0.32; I 2 = 71%; 692 participants; three studies; low certainty evidence), but the evidence is very uncertain in the longer term, based on very low certainty evidence. Subgroup analysis of skill training interventions among people living with disabilities due to cognitive impairments suggests that such interventions may improve activity outside the home in the shorter term (SMD: 0.44; 95% CI: 0.07 to 0.81; I 2 = NA; 118 participants; one study; low certainty evidence). Subgroup analysis of skill training interventions among people living with cognitive impairments suggests that such interventions may improve health-related quality of life in the shorter term (SMD: 0.49; 95% CI: 0.12 to 0.88; I 2 = NA; 118 participants; one study; low certainty evidence). Physical training interventions versus control interventions (five studies) The evidence is very uncertain about the benefits and harms of physical training interventions versus control interventions not aimed to improve outdoor mobility in the shorter term (≤6 months) and longer term (≥7 months) for: Engagement in everyday life activities; Participation; Health-related Quality of Life; Major harms; and Minor harms, based on very low certainty evidence. Physical training interventions may improve activity outside the home in the shorter (SMD: 0.35; 95% CI: 0.08 to 0.61; I 2 = NA; 228 participants; one study; low certainty evidence) and longer term (≥7 months) (SMD: 0.27; 95% CI: 0.00 to 0.54; I 2 = NA; 216 participants; one study; low certainty evidence). Comparison of different outdoor mobility interventions (one study) The evidence is very uncertain about the benefits and harms of outdoor mobility interventions of different lengths in the shorter term (≤6 months) and longer term (≥7 months) for Activity outside the home; Engagement in everyday life activities; Participation; Health-related Quality of Life; Major harms; and Minor harms, based on very low certainty evidence. No studies explored the efficacy of other types of interventions.

Authors’ Conclusions

Twenty-two studies of interventions to improve outdoor mobility for people living with disabilities were identified, but the evidence still remains uncertain about most benefits and harms of these interventions, both in the short- and long term. This is primarily related to risk of bias, small underpowered studies and limited reporting of important outcomes for people living with disabilities. For people with disabilities, skill training interventions may improve engagement in everyday life in the short term, and improve activity outside the home and health-related quality of life for people with cognitive impairments in the short term. Still, this is based on low certainty evidence from few studies and should be interpreted with caution. One study with low certainty evidence suggests that physical training interventions may improve activity outside the home in the short term. In addition, the effect sizes across all outcomes were considered small or trivial, and could be of limited relevance to people living with disabilities. The evidence is currently uncertain if there are interventions that can improve outdoor mobility for people with disabilities, and can improve other important outcomes, while avoiding harms. To guide decisions about the use of interventions to improve outdoor mobility, future studies should use more rigorous design and report important outcomes for people with disabilities to reduce the current uncertainty.

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.

A single session of action observation therapy versus observing a natural landscape in adults with chronic neck pain - a randomized controlled trial

BACKGROUND

Action observation (AO) has emerged as a potential neurorehabilitation therapy for patients with neck pain (NP), but evidence of its effectiveness is scarce. This study aims to assess the effect of a single session of AO when compared to observing a natural landscape on NP intensity, fear of movement, fear-avoidance beliefs, neck muscles' strength, pressure pain threshold, and tactile acuity.

METHODS

Sixty participants with NP were randomly allocated to the AO group (n = 30) or control group (n = 30). Both groups watched an 11-minute video: the AO group watched a video of a person matched for age and sex performing neck exercises, while the control group watched a video of natural landscapes. Neck pain intensity, fear of movement, fear-avoidance beliefs, tactile acuity, pressure pain thresholds, and neck muscle strength were assessed both at baseline and post-intervention. General linear models of repeated measures (ANCOVA of two factors) were used to explore between-group differences at post-intervention.

RESULTS

There was a significant main effect of time for pain intensity (p = 0.02; η2p = 0.09; within-group mean change and 95% CI: AO=-1.44 (-2.28, -0.59); control=-1.90 (-2.74, -1.06), but no time versus group interaction (p = 0.46). A time versus group significant interaction was found for one out of the six measurement sites of two-point discrimination and the neck flexors strength (p < 0.05) favoring the control group. No other statistically significant differences were found for the remaining variables).

CONCLUSIONS

Results suggest a similar acute benefit for both a single session of AO and observing natural landscapes for promoting hypoalgesia, but no impact on kinesiophobia, fear-avoidance beliefs, or pressure pain thresholds. Also, AO had no positive effect on two-point discrimination and muscle strength. Further research is needed, with longer interventions.

TRIAL REGISTRATION

Clinialtrials.gov (NCT05078489).

The effect of movement representation techniques on ankle function and performance in persons with or without a lateral ankle sprain: a systematic review and meta-analysis

BACKGROUND

Lateral ankle sprains are highly prevalent and result in tissue damage, impairments of muscle strength, instability, and muscle activation. Up to 74% will experience ongoing symptoms after a lateral ankle sprain. In healthy subjects, motor imagery might induce neural changes in the somatosensory and motor areas of the brain, yielding favourable enhancements in muscular force. However, during motor imagery, difficulties in building a motor image, no somatosensory feedback, and the absence of structural changes at the level of the muscle might explain the differences found between motor imagery and physical practice. In rehabilitation, motor imagery might be supportive in rebuilding motor networks or creating new networks to restore impairments in muscle activation and movement patterns. This systematic review was undertaken to summarize the current body of evidence about the effect on motor imagery, or action observation, on lower leg strength, muscle performance, ankle range of motion, balance, and edema in persons with, and without, a lateral ankle sprain compared to usual care, a placebo intervention, or no intervention.

METHODS

A systematic review with meta-analysis of randomized controlled trials was conducted in healthy participants and participants with a lateral ankle sprain. Motor imagery or action observation in isolation, or in combination with usual care were compared to a placebo intervention, or no intervention. An electronic search of MEDLINE, EMBASE, Cinahl, Psychinfo, Sportdiscus, Web of Science, Cochrane and Google Scholar was conducted, and articles published up to 7th June 2023 were included. Two reviewers individually screened titles and abstracts for relevancy using the inclusion criteria. Variables related to muscle strength, muscle function, range of motion, balance, return to sports tests, or questionnaires on self-reported function or activities were extracted. A risk of bias assessment was done using the Cochrane Risk-of-Bias tool II by two reviewers. Meta-analysis using a random effects model was performed when two or more studies reported the same outcome measures. The Standardized Mean Difference (SMD) was calculated over the change from baseline scores. Review manager 5.4 was used to perform analysis of subgroup differences and test for statistically significant differences. Confidence intervals were visually checked for overlap between subgroups.

RESULTS

Nine studies, six examining healthy participants and three examining participants with an acute lateral ankle sprain, were included. All studies were rated with moderate to high risk of bias overall. Quality of the motor imagery interventions differed largely between studies. Meta-analysis showed a large and significant effect of motor imagery on lower leg strength (SMD 1.47, 95% CI 0.44 to 2.50); however, the evidence was downgraded to very low certainty due to substantial heterogeneity (I2 = 73%), limitations in the studies (some concerns in risk of bias in all studies), and imprecision (n =  < 300). Evidence showed no association with ankle range of motion (SMD 0.25, 95% CI -0.43 to 0.93), edema (SMD -1.11, 95% CI -1.60 to 3.81), the anterior reach direction of the Star Excursion Balance Test (SEBT) (SMD 0.73, 95% CI -0.62 to 2.08), the posterolateral direction (SMD 0.32, 95% CI -0.94 to 1.57), and the posteromedial direction (SMD 0.52, 95% CI -0.07 to 1.10). The certainty of evidence for the different comparisons was very low.

CONCLUSIONS

There is a low certainty, significant, positive effect for motor imagery being able to improve lower leg muscle strength in healthy participants. The effect on balance, range of motion and edema was uncertain and of very low certainty.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021243258.

A rehabilitative approach beyond the acute stroke event: a scoping review about functional recovery perspectives in the chronic hemiplegic patient

Background

Stroke is a main cause of disability worldwide and its neuro-rehabilitative management is not limited to the acute phase but requires continuity in the rehabilitation approach especially in the chronic phase. The aim of this scoping review was to highlight the different treatment opportunities available in neurorehabilitation, effective for patients with chronic stroke sequelae, not only in terms of maintaining motor function but also improving it.

Methods

The literature search was conducted using the following databases: MEDLINE (PubMed), PEDro, Scopus, Web of Science (WOS), Cochrane from 2012 to February 2023. We selected Randomized Clinical Trials in English dealing with neurorehabilitation strategies in chronic hemiplegic patients after stroke focusing on motor function, muscular strength, gait, postural balance, spasticity, and quality of life.

Results

According to the inclusion criteria, 47 articles were selected for our review. All of them were analyzed following the primary outcome and the rehabilitation technique used. Despite the different protocols used within the same technique and despite the chronicity of the disease, all studies report an improvement after the rehabilitation treatment of motor function and quality of life.

Conclusion

The literature analyzed invites us to reflect respect to neurorehabilitation approach to the patient with chronic stroke sequelae often considered to have as its objective the maintenance of the present motor function and contain disability: instead, the review reports how, even in chronicity, the patient always reports margins of statistically and clinically significant improvement. The chronic stroke rehabilitation over 6 months has been proved effective in obtaining recovery in different settings.

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.

Movement Representation Strategies as a Tool for Educational Innovation in Physiotherapy Students: A Randomized Single-Blind Controlled-Pilot Trial

Physiotherapy has a strictly theoretical body of knowledge, but for the most part, the physiotherapist's learning is practical. The practical part is fundamental to acquire clinical skills that the physiotherapist will later use in professional practice. The main aim of this study was to assess the effectiveness of movement representation strategies (MRS) in the improvement of manual skills of physiotherapy students as an educational innovation strategy. We randomly assigned 30 participants to an action observation practice (AOP), motor imagery practice (MIP), or sham observation (SO) group. A high velocity, low amplitude lumbar manipulation technique that is widely used in clinical physiotherapy practice was taught in one session. The primary outcomes were required time and test score. The secondary outcomes were perceived mental fatigue and perceived difficulty for learning. The outcomes were assessed preintervention and immediately after the intervention (postintervention). The main results showed that both AOP and MIP improved the total time required and the test score, as well as entailed less perceived difficulty for learning. However, both strategies showed a higher level of mental fatigue after the intervention, which was higher in the MIP group. Based on the results obtained, it seems that the application of MRS promotes greater learning of manual motor tasks in physiotherapy students and could be used as educational innovation strategies.

The Added Value of Point-Light Display Observation in Total Knee Arthroplasty Rehabilitation Program: A Prospective Randomized Controlled Pilot Study

Background and Objectives: The present study aimed to assess the potential benefit of the observation of rehabilitation-related point-light display in addition to a conventional 3-week rehabilitation program, the objective being to improve functional capacity in patients having undergone total knee arthroplasty. Materials and Methods: Patients randomized in the control group had conventional rehabilitation treatment with two sessions per day 5 days a week of physical therapy (90 min), whereas patients in the experimental group had a program of conventional rehabilitation combined with a point-light display observation two times per day (5 min) and 3 days a week. Results: The patients of both groups had improved their performances by the end of the program, and the pre- and post-test improvement were superior for the experimental group over the control group concerning the total WOMAC score (p = 0.04), the functional WOMAC score (p = 0.03), and correct recognition of point-light displays (p = 0.003). Conclusions: These findings provide new insight favoring systematic point-light display observation to improve functional recovery in patients with total knee arthroplasty.

The effect of action observation training on gait and balance of patients with neurological and musculoskeletal disorders: A systematic review

Background

Various treatment approaches are being applied for recovery of gait after different medical conditions. Action observation is a new motor learning approach, which is considered as a complementary training to the conventional rehabilitation programs such as occupational therapy for this purpose.

Objective

To find out which patients benefit more from action observation training.

Methods

Electronic databases, including Scopus, PubMed, Web of Science, Science Direct, and PEDro were searched. Prospective studies published in peer-reviewed journals with full text available in English, which investigated the effect of action observation on gait and balance of patients with neurologic or musculoskeletal disorders, were included. The methodological quality of the studies was assessed by the Downs and Black checklist, and the information was presented based on the PICO style.

Results

Nineteen studies recruiting post-orthopedic patients (4 studies), patients with stroke (11 studies), and Parkinson’s disease (4 studies) fulfilled the eligibility criteria. Quality scores ranged from 51.85% to 81.48%. Balance and walking ability were the most reported primary outcomes.

Conclusion

Patients in the chronic phase of stroke might benefit more from action observation training plus occupational therapy in different aspects of gait than orthopedic patients and those with Parkinson’s disease.

Effects of action observation and motor imagery of walking on the corticospinal and spinal motoneuron excitability and motor imagery ability in healthy participants

Action observation (AO) and motor imagery (MI) are used for the rehabilitation of patients who face difficulty walking. Rehabilitation involving AO, MI, and AO combined with MI (AO+MI) facilitates gait recovery after neurological disorders. However, the mechanism by which it positively affects gait function is unclear. We previously examined the neural mechanisms underlying AO and MI of walking, focusing on AO+MI and corticospinal and spinal motor neuron excitability, which play important roles in gait function. Herein, we investigated the effects of a short intervention using AO+MI of walking on the corticospinal and spinal motor neuron excitability and MI ability of participants. Twelve healthy individuals participated in this study, which consisted of a 20 min intervention. Before the experiment, we measured MI ability using the Vividness of Movement Imagery Questionnaire-2 (VMIQ-2). We used motor evoked potential and F-wave measurements to evaluate the corticospinal and spinal motor neuron excitability at rest, pre-intervention, 0 min, and 15 min post-intervention. We also measured corticospinal excitability during MI of walking and the participant’s ability to perform MI using a visual analog scale (VAS). There were no significant changes in corticospinal and spinal motor neuron excitability during and after the intervention using AO+MI (p>0.05). The intervention temporarily increased VAS scores, thus indicating clearer MI (p<0.05); however, it did not influence corticospinal excitability during MI of walking (p>0.05). Furthermore, there was no significant correlation between the VMIQ-2 and VAS scores and changes in corticospinal and spinal motor neuron excitability. Therefore, one short intervention using AO+MI increased MI ability in healthy individuals; however, it was insufficient to induce plastic changes at the cortical and spinal levels. Moreover, the effects of intervention using AO+MI were not associated with MI ability. Our findings provide information about intervention using AO+MI in healthy individuals and might be helpful in planning neurorehabilitation strategies.

Observation and motor imagery balance tasks evaluation: An fNIRS feasibility study

In this study, we aimed at exploring the feasibility of functional near-infrared spectroscopy (fNIRS) for studying the observation and/or motor imagination of various postural tasks. Thirteen healthy adult subjects followed five trials of static and dynamic standing balance tasks, throughout three different experimental setups of action observation (AO), a combination of action observation and motor imagery (AO+MI), and motor imagery (MI). During static and dynamic standing tasks, both the AO+MI and MI experiments revealed that many channels in prefrontal or motor regions are significantly activated while the AO experiment showed almost no significant increase in activations in most of the channels. The contrast between static and dynamic standing tasks showed that with more demanding balance tasks, relative higher activation patterns were observed, particularly during AO and in AO+MI experiments in the frontopolar area. Moreover, the AO+MI experiment revealed a significant difference in premotor and supplementary motor cortices that are related to balance control. Furthermore, it has been observed that the AO+MI experiment induced relatively higher activation patterns in comparison to AO or MI alone. Remarkably, the results of this work match its counterpart from previous functional magnetic resonance imaging studies. Therefore, they may pave the way for using the fNIRS as a diagnostic tool for evaluating the performance of the non-physical balance training during the rehabilitation period of temporally immobilized patients.

The effect of combined action observation therapy and eccentric exercises in the treatment of mid-portion Achilles tendinopathy: study protocol for a feasibility pilot randomised controlled trial

Background

Mid-portion Achilles tendinopathy (AT) is a common overuse injury which can be difficult to successfully rehabilitate. Whilst peripherally directed treatment approaches that strengthen the Achilles tendon complex can be efficacious for some individuals, others will continue to experience long-standing pain and functional deficits. Expanding our rehabilitation approach beyond the tendon mechanical properties to include techniques which target the central neurophysiological changes which can occur in chronic injuries, including mid-portion AT, may improve our rehabilitation outcomes. Action observation therapy (AOT) is one such technique which targets central changes and can enhance motor learning. To our knowledge, there is currently no available information on the combined effect of AOT and eccentric exercises in the rehabilitation of mid-portion AT, nor understanding of the feasibility of conducting randomised controlled trials that investigate this combined centrally and peripherally directed treatment approach. This protocol outlines the design of a remotely conducted parallel-group randomised controlled trial comparing the efficacy of combined AOT and eccentric loading exercises versus eccentric loading exercises alone for mid-portion AT.

Methods

Participants recruited throughout Ireland with mid-portion AT will be randomly assigned to one of the following groups: (i) The AOT group will observe videos of the eccentric exercises prior to the physical performance of the eccentric exercises. (ii) The control group will observe videos of landscapes prior to the performance of the eccentric exercises. This is a 12-week daily intervention as per the Alfredson loading protocol and outcome measures will be assessed at baseline, week 6 and week 12. Primary feasibility outcomes will include data on numbers of eligible participants, recruitment and retention rates, along with exercise compliance and acceptability of treatment. The primary clinical outcome measure will be the Victorian Institution Symptom Assessment-Achilles Questionnaire (VISA-A) assessing disability. Secondary clinical outcomes will address the remaining core domains as outlined by the International Scientific Tendinopathy Symposium consensus (ICON group) including pain, participation, functional, physical function capacity, quality of life and psychological factors. Widespread bodily pain and centralised pain features and patient satisfaction levels will also be evaluated.

Discussion

This study will provide scientific direction for future randomised controlled trials exploring the effect of AOT and eccentric exercises in the treatment of mid-portion AT on pain, centralised pain features, motor and non-motor functions, quality of life and patient satisfaction levels. The feasibility of the conducting a study remotely from participant screening to final follow-up assessment will also be provided.

Trial registration

ISRCTN58161116

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.

Motor-cognitive intervention concepts can improve gait in chronic stroke, but their effect on cognitive functions is unclear: A systematic review with meta-analyses

Motor-cognitive intervention concepts are promising to counteract residual gait and cognitive impairments in chronic stroke. There is, however, considerable variation in motor-cognitive intervention types, which may lead to different effects. This systematic review strived to summarize and compare the effects of different motor-cognitive intervention concepts on gait and cognitive functions in chronic stroke. The systematic search identified twenty-nine articles, which were allocated to three types of motor-cognitive training concepts; SEQUENTIAL, SIMULTANEOUS-ADDITIONAL, and SIMULTANEOUS-INCORPORATED. Random-effects meta-analyses revealed that motor-cognitive interventions may be better than non-combined training approaches for improving gait function in chronic stroke (e.g. gait speed: g = 0.43, 95 % CI [0.22, 0.64], p < 0.0001). SIMULTANEOUS-INCORPORATED motor-cognitive training seems the most promising concept. As very few articles measured both, spatiotemporal gait parameters and cognitive outcomes, future studies are warranted to investigate the effects of motor-cognitive intervention concepts on gait control and cognitive functions in chronic stroke.

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.

Effect of Action Observation Therapy in the Rehabilitation of Neurologic and Musculoskeletal Conditions: A Systematic Review

OBJECTIVE

To investigate the effect of action observation therapy (AOT) in the rehabilitation of neurologic and musculoskeletal conditions.

DATA SOURCES

Searches were completed until July 2020 from the electronic databases Allied and Complementary Medicine Database (via OVID SP), Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, EMBASE, MEDLINE, and the Physiotherapy Evidence Database.

STUDY SELECTION

Randomized controlled trials comparing AOT with standard care were assessed. Musculoskeletal (amputee, orthopedic) and neurologic (dementia, cerebral palsy, multiple sclerosis, Parkinson disease, stroke) conditions were included. There were no age limitations. Articles had to be available in English.

DATA EXTRACTION

Two reviewers independently screened titles, abstracts and full extracts of studies for eligibility and assessed the risk of bias of each study using the Cochrane Risk of Bias Tool. Data extraction included participant characteristics and intervention duration, frequency, and type.

RESULTS

The effect of AOT in different outcome measures (OMs) was referenced in terms of body structures and functions, activities and participation, and environmental factors as outlined by the International Classification of Functioning, Disability, and Health (ICF). Of the 3448 articles identified, 36 articles with 1405 patients met the inclusion criteria. Seven of the 11 meta-analyses revealed a significant effect of intervention, with results presented using the mean difference and 95% CI. A best evidence synthesis was used across all OMs. Strong evidence supports the use of AOT in the rehabilitation of individuals with stroke and Parkinson disease; moderate evidence supports AOT in the rehabilitation of populations with orthopedic and multiple sclerosis diagnoses. However, moderate evidence is provided for and against the effect of AOT in persons with Parkinson disease and cerebral palsy.

CONCLUSIONS

This review suggests that AOT is advantageous in the rehabilitation of certain conditions in improving ICF domains. No conclusions can be drawn regarding treatment parameters because of the heterogeneity of the intervention. AOT has been considerably less explored in musculoskeletal conditions.

Effects of Action Observation Therapy with Limited Visual Attention on Walking Ability in Stroke Patients

In this study, we compared the effects of action observation therapy (AOT) on the walking ability of stroke patients between videos with limited visual attention (body part videos) and a video with the whole body (whole body video). We employed a crossover design and conducted 3 AOT sessions (body part videos, whole body video and a scenery video) for 11 stroke patients. The evaluation items were the 10-m walking time and number of steps, cadence, trunk and knee joint angles during walking, and the timed up and go test (TUGT). After body part videos, the 10-m walking time, trunk and knee joint angles and TUGT significantly improved, suggesting them to be an efficient AOT method.

Varied speeds of video demonstration do not influence the learning of a dance skill

The effects of slow-motion and real time video speed demonstration, under mixed-modeling conditions (skilled model plus self-observation), were examined to identify whether there was an optimal demonstration speed, or combination thereof, for learning the dance pirouette en dehors skill. Fifty-one participants were randomly assigned to one of three groups with different video demonstration speeds: (1) slow-motion, (2) real-time, or (3) a combination of slow-motion and real-time. Following a pre-test, participants completed eight blocks of nine training trials (comprised of five physical and four observational practice trials). Physical performance and cognitive representation assessments revealed that participants' scores significantly improved for both assessments throughout acquisition (p's < 0.05), as well as from pre- to post-test (p's < 0.001), indicating learning of the skill. There were no significant differences, however, between the three experimental groups. These findings suggest that both real-time and slow-motion video demonstration, or their combined presentation, do not yield differences in motor learning outcomes related to the pirouette en dehors.

Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury

BACKGROUND

Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.

METHODS

A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.

RESULTS

Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.

DISCUSSION

The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.

LIMITATIONS

As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.

SUMMARY

The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.

DISCLAIMER

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.

Revisiting the Applied Model for the Use of Observation: A Review of Articles Spanning 2011-2018

Purpose: To provide a review of current articles that have used observation interventions to enhance motor skill acquisition or performance of applied tasks, and to situate the research within the Applied Model for the Use of Observation (AMUO) with the goal of forming a basis for evidence-based guidelines for practitioners. Method: Key words (e.g., observation/modeling) were searched in varied data bases (e.g., Google Scholar/PubMed), along with a citation search of the relevant AMUO article, to generate a pool of articles for possible review. Selection criteria included publication between 2011 and 2018, and that the research focus was on the effects of an observation intervention on the acquisition or performance of an applied motor task. Results: Forty-eight articles were reviewed, with 21 of these targeting the basic question of whether observation is effective, and the remaining pertaining to the What, When, Who, and How features of the AMUO. The effectiveness of observation interventions was not only affirmed, but also extended to a wider scope of populations and settings. Greater insight into the necessary information with respect to the demonstration (what) and whether it should be before, after, or during physical practice (when) was obtained. As well, advantages of combining model types (who) and providing control to the learner (how) were reported. Conclusions: While more clarity was brought to certain features of the AMUO that could be used to provide evidence-based guidelines, more research is needed to fully inform practitioners for the effective use of observation interventions.

Phase dependent modulation of cortical activity during action observation and motor imagery of walking: An EEG study

Action observation (AO) and motor imagery (MI) are motor simulations which induce cortical activity related to execution of observed and imagined movements. Neuroimaging studies have mainly investigated where the cortical activities during AO and MI of movements are activated and if they match those activated during execution of the movements. However, it remains unclear how cortical activity is modulated; in particular, whether activity depends on observed or imagined phases of movements. We have previously examined the neural mechanisms underlying AO and MI of walking, focusing on the combined effect of AO with MI (AO+MI) and phase dependent modulation of corticospinal and spinal reflex excitability. Here, as a continuation of our previous studies, we investigated cortical activity depending on gait phases during AO and AO+MI of walking by using electroencephalography (EEG); 64-channel EEG signals were recorded in which participants observed walking with or without imagining it, respectively. EEG source and spectral analyses showed that, in the sensorimotor cortex during AO+MI and AO, the alpha and beta power were decreased, and power spectral modulations depended on walking phases. The phase dependent modulations during AO+MI, but not during AO, were like those which occur during actual walking as reported by previous walking studies. These results suggest that combinatory effects of AO+MI could induce parts of the phase dependent activation of the sensorimotor cortex during walking even without any movements. These findings would extend understanding of the neural mechanisms underlying walking and cognitive motor processes and provide clinically beneficial information towards rehabilitation for patients with neurological gait dysfunctions.

Hypoalgesic Effects of Aerobic and Isometric Motor Imagery and Action Observation Exercises on Asymptomatic Participants: A Randomized Controlled Pilot Trial

OBJECTIVES

The objective was to explore whether action observation (AO) and motor imagery (MI) of aerobic and isometric exercise could induce hypoalgesic responses in asymptomatic individuals compared with placebo observation (PO).

METHODS

A randomized controlled pilot trial was designed. Twenty-four healthy participants (mean age = 21.9 ± 2.1 years) were randomized into three groups: AO+MI (N = 8), AO, (N = 8), and PO (N = 8). All participants performed an actual aerobic running exercise (three series of 90 seconds at 85% of their VO2max and 30 seconds at 65% of their VO2max) and an isometric exercise protocol (isometric squats). A day later, they all performed the mental intervention, observing or imagining exercise execution performed the day before, according to their allocated group. Pressure pain thresholds (PPTs) of the quadriceps and epicondyle regions were assessed at baseline, postintervention, and 15 minutes postintervention.

RESULTS

Analysis of variance revealed statistically significant differences in the group*time interaction for PPT in the quadriceps. The AO group showed a statistically significant increase at postintervention and at 15 minutes postintervention. The AO+MI group obtained a statistically significant increase in the two PPT regions compared with the PO group at Δpre-post. The AO group obtained a greater increase in the PPT in the quadriceps femoris than the PO group at Δpre-post and Δpre-post 15 minutes.

CONCLUSIONS

AO and MI induce hypoalgesic responses compared with PO. AO isolated training showed pain modulation responses in the PPTs of the quadriceps region in young physically active adults. These findings highlight the potential role of brain training in pain management.

Motor imagery for gait rehabilitation after stroke

BACKGROUND

Motor imagery (MI) is defined as a mentally rehearsed task in which movement is imagined but is not performed. The approach includes repetitive imagined body movements or rehearsing imagined acts to improve motor performance.

OBJECTIVES

To assess the treatment effects of MI for enhancing ability to walk among people following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group registry, CENTRAL, MEDLINE, Embase and seven other databases. We also searched trial registries and reference lists. The last searches were conducted on 24 February 2020.

SELECTION CRITERIA

Randomized controlled trials (RCTs) using MI alone or associated with action observation or physical practice to improve gait in individuals after stroke. The critical outcome was the ability to walk, assessed using either a continuous variable (walking speed) or a dichotomous variable (dependence on personal assistance). Important outcomes included walking endurance, motor function, functional mobility, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials according to pre-defined inclusion criteria, extracted the data, assessed the risk of bias, and applied the GRADE approach to evaluate the certainty of the evidence. The review authors contacted the study authors for clarification and missing data.

MAIN RESULTS

We included 21 studies, involving a total of 762 participants. Participants were in the acute, subacute, or chronic stages of stroke, and had a mean age ranging from 50 to 78 years. All participants presented at least some gait deficit. All studies compared MI training versus other therapies. Most of the included studies used MI associated with physical practice in the experimental groups. The treatment time for the experimental groups ranged from two to eight weeks. There was a high risk of bias for at least one assessed domain in 20 of the 21 included studies. Regarding our critical outcome, there was very low-certainty evidence that MI was more beneficial for improving gait (walking speed) compared to other therapies at the end of the treatment (pooled standardized mean difference (SMD) 0.44; 95% confidence interval (CI) 0.06 to 0.81; P = 0.02; six studies; 191 participants; I² = 38%). We did not include the outcome of dependence on personal assistance in the meta-analysis, because only one study provided information regarding the number of participants that became dependent or independent after interventions. For our important outcomes, there was very low-certainty evidence that MI was no more beneficial than other interventions for improving motor function (pooled mean difference (MD) 2.24, 95% CI -1.20 to 5.69; P = 0.20; three studies; 130 participants; I² = 87%) and functional mobility at the end of the treatment (pooled SMD 0.55, 95% CI -0.45 to 1.56; P = 0.09; four studies; 116 participants; I² = 64.2%). No adverse events were observed in those studies that reported this outcome (seven studies). We were unable to pool data regarding walking endurance and all other outcomes at follow-up.

AUTHORS' CONCLUSIONS

We found very low-certainty evidence regarding the short-term benefits of MI on walking speed in individuals who have had a stroke, compared to other therapies. Evidence was insufficient to estimate the effect of MI on the dependence on personal assistance and walking endurance. Compared with other therapies, the evidence indicates that MI does not improve motor function and functional mobility after stroke (very low-certainty evidence). Evidence was also insufficient to estimate the effect of MI on gait, motor function, and functional mobility after stroke compared to placebo or no intervention. Motor Imagery and other therapies used for gait rehabilitation after stroke do not appear to cause significant adverse events.

Effect of an EMG-FES Interface on Ankle Joint Training Combined with Real-Time Feedback on Balance and Gait in Patients with Stroke Hemiparesis

This study evaluated the effects of an electromyography-functional electrical stimulation interface (EMG-FES interface) combined with real-time balance and gait feedback on ankle joint training in patients with stroke hemiplegia. Twenty-six stroke patients participated in this study. All subjects were randomly assigned to either the EMG-FES interface combined with real-time feedback on ankle joint training (RFEF) group (n = 13) or the EMG-FES interface on ankle joint training (EF) group (n = 13). Subjects in both groups were trained for 20 min a day, 5 times a week, for 4 weeks. Similarly, all participants underwent a standard rehabilitation physical therapy for 60 min a day, 5 times a week, for 4 weeks. The RFEF group showed significant increases in weight-bearing lunge test (WBLT), Tardieu Scale (TS), Timed Up and Go Test (TUG), Berg Balance Scale (BBS), velocity, cadence, step length, stride length, stance per, and swing per (p < 0.05). Likewise, the EF group showed significant increases in WBLT, TUG, BBS, velocity, and cadence (p < 0.05). Moreover, the RFEF group showed significantly greater improvements than the EF group in terms of WBLT, Tardieu Scale, TUG, BBS, velocity, step length, stride length, stance per, and swing per (p < 0.05). Ankle joint training using an EMG-FES interface combined with real-time feedback improved ankle range of motion (ROM), muscle tone, balance, and gait in stroke patients. These results suggest that an EMG-FES interface combined with real-time feedback is feasible and suitable for ankle joint training in individuals with stroke.

Action observation treatment improves gait ability in subacute to convalescent stroke patients

The aim of this study was to investigate the effects of action observation treatment (AOT) on gait ability in patients with subacute to convalescent stroke. Sixteen patients with subacute stroke were divided into a control group (n = 8) and AOT group (n = 8) when admitted to the convalescent ward. The control group received a conventional rehabilitation only. In addition to conventional rehabilitation, the AOT received AOT for 3 months (30 min per day 5 times per week). The AOT involved observing the action of another subject in a comfortable gait situation from the front, sides, and back via video and conducting the actual action. All participants were assessed during the main-assessment period, which included a baseline (i.e., when admitted to the convalescent ward) and 1, 2, and 3 months after baseline. The sub-assessment period at 2 and 3 months after baseline was conducted with participants who could walk independently. The main outcomes of the main-assessment and sub-assessment periods were Functional Ambulation Classification (FAC) and the 10-m walk test (10MWT), respectively. With respect to the FAC, we used a split plot design analysis of covariance to test the interaction between assessment time and group. There was no significant interaction between assessment time and group in FAC. However, a significant improvement of the 10MWT in the sub-assessment period was observed in the AOT group, but not the control group. Our results indicate that AOT may be an effective therapy for patients with subacute to convalescent stroke who can walk independently.

Motor activation is modulated by visual experience during cyclic gait observation: A transcranial magnetic stimulation study

Transcranial magnetic stimulation (TMS) has been widely utilized to noninvasively explore the motor system during the observation of human movement. However, few studies have characterized motor cortex activity during periodic gait observation. Thus, this study examined the effects of an observer's visual experience and/or intention to imitate on corticospinal excitability during the observation of another's gait. Twenty-six healthy volunteers were included in this study and allocated to two different groups. Participants in the visual experience group had formal experience with gait observation (physical therapist training), while those in the control group did not. Motor-evoked potentials induced by TMS in the tibialis anterior and soleus muscles were measured as surrogates of corticospinal excitability. Participants were seated and, while resting, they observed a demonstrator's gait or observed it with the intention to subsequently reproduce it. Compared with the resting state, cyclic gait observation led to significant corticospinal facilitation in the tibialis anterior and soleus muscles. However, this pattern of corticospinal facilitation in the measured muscles was not coupled to the pattern of crural muscle activity during actual gait and was independent of the step cycle. This motor cortex facilitation effect during gait observation was enhanced by the observer's visual experience in a manner that was not step cycle-dependent, while the observer's intent to imitate did not affect corticospinal excitatory input to either muscle. In addition, visual experience did not modulate corticospinal excitability in gait-related crural muscles. Our findings indicate that motor cortex activity during gait observation is not in line with the timing of muscle activity during gait execution and is modulated by an individual's gait observation experience. These results suggest that visual experience acquired from repetitive gait observation may facilitate the motor system's control on bipedal walking, but may not promote the learning of muscle activity patterns.

Mental practice in isolation improves cervical joint position sense in patients with chronic neck pain: a randomized single-blind placebo trial

Objective

The main objective of this trial was to assess whether action observation (AO) training and motor imagery (MI) produced changes in the cervical joint position sense (CJPS) both at the end of the intervention and 10 min postintervention compared with a placebo intervention in patients with nonspecific chronic neck pain (NSCNP).

Methods

A single-blind placebo clinical trial was designed. A total of 30 patients with NSCNP were randomly assigned to the AO group, MI group or placebo observation (PO) group. CJPS in flexion, extension and rotation movements in both planes were the main variables.

Results

The results obtained in the vertical plane showed that the AO group obtained greater improvements than the PO group in the CJPS in terms of cervical extension movement both at the end of the intervention and 10 min postintervention (p = .001, d = 1.81 and p = .004, d = 1.74, respectively), and also in cervical flexion movement, although only at 10 min after the intervention (p = .035, d = 0.72). In addition, the AO group obtained greater improvements than the MI group in the CJPS only at the end of the intervention in cervical extension movement (p = .041, d = 1.17). Regarding the left rotation cervical movement, both the MI and AO groups were superior to the PO group in both planes at the end of the intervention (p < .05, d > 0.80).

Conclusions

Although both AO and MI could be a useful strategy for CJPS improvement, the AO group showed the strongest results. The therapeutic potential of the application of mental practice in a clinical context in the early stages of rehabilitation of NSCNP should be considered.

Motor Imagery and Action Observation of Specific Neck Therapeutic Exercises Induced Hypoalgesia in Patients with Chronic Neck Pain: A Randomized Single-Blind Placebo Trial

The aim of the present study was to explore the pain modulation effects of motor imagery (MI) and action observation (AO) of specific neck therapeutic exercises both locally, in the cervical region, and remotely. A single-blind, placebo clinical trial was designed. A total of 30 patients with chronic neck pain (CNP) were randomly assigned to an AO group, MI group, or placebo observation (PO) group. Pain pressure thresholds (PPTs) of C2/C3, trapezius muscles, and epicondyle were the main outcome variables. Secondary outcomes included heart rate measurement. Statistically significant differences were observed in PPTs of the cervical region in the AO and MI groups between the preintervention and first postintervention assessment. Significant differences were found in the AO group in the epicondyle between the preintervention, first and second post-intervention assessments. Regarding heart rate response, differences were found in the AO and MI groups between the preintervention and average intervention measurements. AO and MI induce immediate pain modulation in the cervical region and AO also induces remote hypoalgesia. OA appears to lead to greater pain modulation as well as a greater heart rate response, however, both should be clinically considered in patients with CNP.

Differences between the Influence of Observing One's Own Movements and Those of Others in Patients with Stroke

We aimed to investigate differences between the influence of observing one's own actions and those of others in patients with stroke with hemiplegia. Thirty-four patients with stroke who had experienced a right or left hemispheric lesion (RHL: n = 17; LHL: n = 17) participated in this study. Participants viewed video clips (0.5× speed) of their own stepping movements (SO) as well as those of others (OO). After viewing the video clips, participants were asked to evaluate the vividness of the mental image of the observed stepping movement using a five-point scale, in accordance with that utilized in the Kinesthetic and Visual Imagery Questionnaire (KVIQ). We also examined changes in imagery and execution times following action observation. When all patients were considered, there were no significant differences between SO and OO conditions. However, in the RHL subgroup, KVIQ kinesthetic subscore and changes in imagery and execution times were greater in the OO condition than in the SO condition. In the LHL subgroup, changes in imagery times were greater in the SO condition than in the OO condition. These findings indicated that viewing the movements of others led to more vivid imagery and alteration in performance in patients with right-sided stroke, when compared to viewing one's own movements. Therefore, the present study suggests that clinicians should consider the side of the damaged hemisphere when implementing action observation therapy for patients with stroke.

Action observation therapy for improving arm function, walking ability, and daily activity performance after stroke: a systematic review and meta-analysis

Objective:

This study was to investigate the effectiveness of action observation therapy on arm and hand motor function, walking ability, gait performance, and activities of daily living in stroke patients.

Design:

Systematic review and meta-analysis of randomized controlled trials.

Data sources:

Searches were completed in January 2019 from electronic databases, including PubMed, Scopus, the Cochrane Library, and OTseeker.

Review methods:

Two independent reviewers performed data extraction and evaluated the study quality by the PEDro scale. The pooled effect sizes on different aspects of outcome measures were calculated. Subgroup analyses were performed to examine the impact of stroke phases on treatment efficacy.

Results:

Included were 17 articles with 600 patients. Compared with control treatments, the action observation therapy had a moderate effect size on arm and hand motor outcomes (Hedge’s g = 0.564; P < 0.001), a moderate to large effect size on walking outcomes (Hedge’s g = 0.779; P < 0.001), a large effect size on gait velocity (Hedge’s g = 0.990; P < 0.001), and a moderate to large effect size on activities of daily function (Hedge’s g = 0. 728; P = 0.004). Based on subgroup analyses, the action observation therapy showed moderate to large effect sizes in the studies of patients with acute/subacute stroke or those with chronic stroke (Hedge’s g = 0.661 and 0.783).

Conclusion:

This review suggests that action observation therapy is an effective approach for stroke patients to improve arm and hand motor function, walking ability, gait velocity, and daily activity performance.

Action Observation for Neurorehabilitation in Apraxia

Neurorehabilitation and brain stimulation studies of post-stroke patients suggest that action-observation effects can lead to rapid improvements in the recovery of motor functions and long-term motor cortical reorganization. Apraxia is a clinically important disorder characterized by marked impairment in representing and performing skillful movements [gestures], which limits many daily activities and impedes independent functioning. Recent clinical research has revealed errors of visuo-motor integration in patients with apraxia. This paper presents a rehabilitative perspective focusing on the possibility of action observation as a therapeutic treatment for patients with apraxia. This perspective also outlines impacts on neurorehabilitation and brain repair following the reinforcement of the perceptual-motor coupling. To date, interventions based primarily on action observation in apraxia have not been undertaken.

Three-Dimensional Balance Training Using Visual Feedback on Balance and Walking Ability in Subacute Stroke Patients: A Single-Blinded Randomized Controlled Pilot Trial

BACKGROUND

Trunk-activating exercises for balance are important because trunk weakness is relevant to the functional performance of individuals with stroke. This study aimed to explore the effects of three-dimensional balance training using visual feedback on balance and walking ability in subacute stroke patients.

METHODS

Twenty-four participants with subacute stroke were randomly assigned to the experimental or control group. Each group underwent twenty sessions (30 min/day, 5 days/week for 4 weeks). Patients were assessed using the Berg balance scale, gait parameters (gait speed, cadence, step length, and double-limb support period) using GAITRite, and activity-specific balance confidence score, before and after the intervention.

RESULTS

The three-dimensional balance training using visual feedback exhibited greater changes in the Berg balance scale, gait speed, cadence, step length, double-limb support period, and activity-specific balance confidence compared with the control group. Statistical analyses showed significant differences in Berg balance scale (P = .012; 95% CI, 2.585-6.415), gait speed (P = .001; 95% CI, .079-.155), cadence (P = .001; 95% CI, 1.622-4.392), step length (P = .003; 95% CI, 1.864-3.908), double-limb support period (P = .003; 95% CI, -3.259 to -0.761) and activity-specific confidence (P = .008; 95% CI, 6.964-14.036) between groups.

CONCLUSION

Three-dimensional balance training using visual feedback may be more effective than conventional training in improving balance, walking ability, and activity-specific balance confidence in patients with subacute stroke.

Activation of mirror neuron system during gait observation in sub-acute stroke patients and healthy persons

The observation of walking improves gait ability in chronic stroke survivors. It has also been suggested that activation of the mirror neuron system contributes to this effect. However, activation of the mirror neuron system during gait observation has not yet been assessed in sub-acute stroke patients. The objective of this study was to clarify the activation of mirror neuron system during gait observation in sub-acute stroke patients and healthy persons. In this study, we sequentially enrolled five sub-acute stroke patients who had undergone gait training and nine healthy persons. We used fMRI to detect neuronal activation during gait observation. During the observation period in the stroke group, neural activity in the left inferior parietal lobule, right and left inferior frontal gyrus was significantly higher than during the rest period. In the healthy group, neural activity in the left inferior parietal lobule, left inferior frontal gyrus, left middle frontal gyrus, left superior temporal lobule and right and left middle temporal gyrus was significantly higher than during the rest period. The results indicate that the mirror neuron system was activated during gait observation in sub-acute stroke patients who had undergone gait training and also in healthy persons. Our findings suggest that gait observation treatment may provide a promising therapeutic strategy in sub-acute stroke patients who have experienced gait training.

Changing Artificial Playback Speed and Real Movement Velocity Do Not Differentially Influence the Excitability of Primary Motor Cortex during Observation of a Repetitive Finger Movement

Action observation studies have investigated whether changing the speed of the observed movement affects the action observation network. There are two types of speed-changing conditions; one involves “changes in actual movement velocity,” and the other is “manipulation of video speed.” Previous studies have investigated the effects of these conditions separately, but to date, no study has directly investigated the differences between the effects of these conditions. In the “movement velocity condition,” increased velocity is associated with increased muscle activity; however, this change of muscle activities is not shown in the “video speed condition.” Therefore, a difference in the results obtained under these conditions could be considered to reflect a difference in muscle activity of actor in the video. The aim of the present study was to investigate the effects of different speed-changing conditions and spontaneous movement tempo (SMT) on the excitability of primary motor cortex (M1) during action observation, as assessed by motor-evoked potentials (MEPs) amplitudes induced by transcranial magnetic stimulation (TMS). A total of 29 healthy subjects observed a video clip of a repetitive index or little finger abduction movement under seven different speed conditions. The video clip in the movement velocity condition showed repetitive finger abduction movements made in time with an auditory metronome, at frequencies of 0.5, 1, 2, and 3 Hz. In the video speed condition, playback of the 1-Hz movement velocity condition video clip was modified to show movement frequencies of 0.5, 2, or 3 Hz (Hz-Fake). TMS was applied at the time of maximal abduction and MEPs were recorded from two right-hand muscles. There were no differences in M1 excitability between the movement velocity and video speed conditions. Moreover, M1 excitability did not vary across the speed conditions for either presentation condition. Our findings suggest that changing playback speed and actual differences in movement velocity do not differentially influence M1 excitability during observation of a simple action task, such as repetitive finger movement, and that it is not affected by SMT. In simple and meaningless observational task, people might not be able to recognize the difference in muscle activity of actor in the video.

Action observation in the modification of postural sway and gait: Theory and use in rehabilitation

The discovery of cortical neurons responsive to both the observation of another individual's movement and one's own physical movement has spurred scientists into utilising this interplay for rehabilitation. The idea that humans can quickly transfer motor programmes or refine existing motor strategies through observation has only recently gained interest in the context of gait rehabilitation but may offer significant promise as an adjunctive therapy to routine balance training. This review is the first dedicated to action observation in postural control or gait in healthy individuals and patients. The traditional use of action observation in rehabilitation is that the observer has to carefully watch pre-recorded or physically performed actions and thereafter imitate them. Using this approach, previous studies have shown improved gait after action observation in stroke, Parkinson's disease and knee or hip replacement patients. In healthy subjects, action observation reduced postural sway from externally induced balance perturbations. Despite this initial evidence, future studies should establish whether patients are instructed to observe the same movement to be trained (i.e., replicate the observed action(s)) or observe a motor error in order to produce postural countermeasures. The best mode of motor transfer from action observation is yet to be fully explored, and may involve observing live motor acts rather than viewing video clips. Given the ease with which action observation training can be applied in the home, it offers a promising, safe and economical approach as an adjunctive therapy to routine balance training.

Effects of robot-assisted gait training on spatiotemporal gait parameters and balance in patients with chronic stroke: A randomized controlled pilot trial

BACKGROUND

Body weight-supported treadmill training assisted by a robotic gait orthosis is a helpful tool for restoring a symmetrical gait pattern in people with gait discrepancies.

OBJECTIVE

This study's aim was to compare the effects of robot-assisted gait training (RAGT) versus treadmill gait training (TGT) on spatiotemporal gait parameters, balance, and activities-specific balance confidence with stroke patients.

METHODS

Eighteen participants with stroke were randomly assigned to RAGT or TGT. Each group underwent twenty sessions (1 h/d, 5 d/wk for 4 weeks). Patients were assessed with gait parameters (gait speed, cadence, step length, and double limb support period) using the GAITRite, the Berg Balance Scale (BBS) score, and the activities-specific balance confidence (ABC) score before and after the intervention.

RESULTS

Gait speed (P = 0.003), cadence (P = 0.002), step length (P = 0.004), the BBS score (P = 0.048), and the ABC score (P = 0.017) were significantly higher in the RAGT group than in the TGT group, while the double limb support period was significantly lower in the RAGT group (P = 0.043).

CONCLUSION

RAGT using Lokomat may be more effective than TGT in improving waking ability, balance, and balance confidence in patients with chronic stroke.

Effect of inspiratory muscle training on respiratory capacity and walking ability with subacute stroke patients: a randomized controlled pilot trial

[Purpose] To investigate the effects of inspiratory muscle training on respiratory capacity and walking ability in subacute stroke patients. [Subjects and Methods] The subjects were randomly assigned to an experimental group (n=6) or a control group (n=6). Patients in the experimental group received inspiratory muscle training for 30 minutes (six sets of five-minutes) and traditional physical therapy once a day, five days a week, for four weeks. The control group received aerobic exercise for 30 minutes and traditional physical therapy for 30 minutes a day, five days a week, for four weeks. [Results] After the intervention, both groups showed significant improvements in the forced vital capacity, forced expiratory volume in one second, 10-meter walking test, and six-minute walking test over the baseline results. There were significant between-group differences for the forced vital capacity, forced expiratory volume in one second, and six-minute walking test. No statistically significant differences were observed for measures of saturation pulse oximetry oxygen and 10-meter walking test between the groups. [Conclusion] These findings gave some indications that inspiratory muscle training may benefit in patients with subacute stroke, and it is feasible to be included in rehabilitation program with this population.

External validity of post-stroke interventional gait rehabilitation studies

Gait rehabilitation is a major component of stroke rehabilitation, and is supported by extensive research. The objective of this review was to examine the external validity of intervention studies aimed at improving gait in individuals post-stroke. To that end, two aspects of these studies were assessed: subjects' exclusion criteria and the ecological validity of the intervention, as manifested by the intervention's technological complexity and delivery setting. Additionally, we examined whether the target population as inferred from the titles/abstracts is broader than the population actually represented by the reported samples.

METHODS

We systematically researched PubMed for intervention studies to improve gait post-stroke, working backwards from the beginning of 2014. Exclusion criteria, the technological complexity of the intervention (defined as either elaborate or simple), setting, and description of the target population in the titles/abstracts were recorded.

RESULTS

Fifty-two studies were reviewed. The samples were exclusive, with recurrent stroke, co-morbidities, cognitive status, walking level, and residency being major reasons for exclusion. In one half of the studies, the intervention was elaborate. Descriptions of participants in the title/abstract in almost one half of the studies included only the diagnosis (stroke or comparable terms) and its stage (acute, subacute, and chronic).

CONCLUSIONS

The external validity of a substantial number of intervention studies about rehabilitation of gait post-stroke appears to be limited by exclusivity of the samples as well as by deficiencies in ecological validity of the interventions. These limitations are not accurately reflected in the titles or abstracts of the studies.

Effect of body awareness training on balance and walking ability in chronic stroke patients: a randomized controlled trial

[Purpose] To investigate the effects of body awareness training on balance and walking ability in chronic stroke patients. [Subjects] The subjects were randomly assigned to a body awareness training group (n=6) and a control group (n=6). [Methods] Patients in the body awareness training group received body awareness training for 20 minutes, followed by walking training for 30 minutes a day, 5 days a week for 4 weeks. The control group received walking training for 30 minutes a day, 5 days a week for 4 weeks. [Results] After the intervention, both groups showed significant improvements in the Berg Balance Scale, Timed Up and Go Test, and 10 m walk test compared with baseline results. The body awareness training group showed more significant improvements in the Berg Balance Scale and Timed Up and Go Test than the control group. There was no significant difference in the 10 m walk test between the groups. [Conclusion] The results of this study suggest that body awareness training has a positive effect on balance in patients with chronic stroke.

Action observation training to improve motor function recovery: a systematic review

Following the discovery of Mirror Neuron System (MNS), Action Observation Training (AOT) has become an emerging rehabilitation tool to improve motor functions both in neurologic and orthopedic pathologies. The aim of this study is to present the state of the art on the use of AOT in experimental studies to improve motor function recovery in any disease. The research was performed in PubMed, PEDro, Embase, CINAHL and Cochrane Central Register of Controlled Trials (last search July 2015). Randomized controlled trials (RCTs) that analyse efficacy of AOT for recovery of motor functions, regardless of the kind of disease, were retrieved. The validity of the included studies was assessed using the Cochrane Collaboration tool for evaluating risk of bias. Twenty RCTs were eligible. Four studies showed AOT efficacy in improving upper limb functional recovery in participants with chronic stroke, two studies in sub-acute ones and one in acute ones. Six articles suggested its effectiveness on walking performance in chronic stroke individuals, and three of them also suggested an efficacy in improving balance. The use of AOT was also recommended in individuals with Parkinson's disease to improve autonomy in activities of daily living, to improve spontaneous movement rate of self-paced finger movements and to reduce freezing of gait. Other two studies also indicated that AOT improves upper limb motor function in children with cerebral palsy. The last two studies, showed the efficacy of AOT in improving motor recovery in postsurgical orthopedic participants. Overall methodological quality of the considered studies was medium. The majority of analyzed studies suggest the efficacy of AOT, in addition to conventional physiotherapy, to improve motor function recovery in individuals with neurological and orthopedic diseases. However, the application of AOT is very heterogeneous in terms of diseases and outcome measures assessed, which makes it difficult to reach, to date, any conclusion that might influence clinical practice.

Effect of combination of transcranial direct current stimulation and feedback training on visuospatial neglect in patients with subacute stroke: a pilot randomized controlled trial

[Purpose] To investigate the effects of a combination of transcranial direct current stimulation (tDCS) and feedback training (FT) on subacute stroke patients with unilateral visuospatial neglect. [Subjects] The subjects were randomly assigned to a tDCS + FT group (n=6) and a FT group (n=6). [Methods] Patients in the tDCS + FT group received tDCS for 20 minutes and then received FT for 30 minutes a day, 5 days a week for 3 weeks. The control group received FT for 30 minutes a day, 5 days a week for 3 weeks. [Results] After the intervention, both groups showed significant improvements in the Motor-Free Visual Perception Test (MVPT), line bisection test (LBT), and modified Barthel index (MBI) over the baseline results. The comparison of the two groups after the intervention revealed that the rDCS + FT group showed more significant improvements in MVPT, LBT, and MBI. [Conclusion] The results of this study suggest that tDCS combined with FT has a positive effect on unilateral visuospatial neglect in patients with subacute stroke.

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.