Upper limb children action-observation training (UP-CAT): a randomised controlled trial in hemiplegic cerebral palsy

Effectiveness of the home-based training program Tele-UPCAT (Tele-monitored UPper Limb Children Action Observation Training) in unilateral cerebral palsy: a randomized controlled trial

BACKGROUND

The effects of unilateral cerebral palsy (UCP) are largely observed in the upper limb (UL), which represents the main focus of rehabilitation for this disorder. Thanks to an increment in home training and progress in technology innovative systems have been created. The Tele-UPCAT (Tele-monitored UPper Limb Children Action Observation Training) platform is dedicated to the delivery at home of a program for UL rehabilitation, based on action observation therapy (AOT).

AIM

This study aimed to investigate the immediate effectiveness of Tele-UPCAT for promoting UL skills in children with UCP and to determine if immediate effects were retained in the medium and long term.

DESIGN

Tele-UPCAT was conducted on an intention-to-treat basis and was proposed as a randomized, allocation concealed (waitlist controlled) and evaluator-blinded clinical trial with two investigative arms: intensive in-home AOT program and standard care (SC).

SETTING

This is a home-based AOT program delivered with a customized ICT platform.

POPULATION

Thirty children (mean age 11.61±3.55 years) with confirmed diagnosis of spastic UCP with predominant UL involvement and cognitive level within or at normal limits were enrolled in this study. Orthopedic surgery or an intramuscular botulinum toxin A injection in the UL within 6 months prior to enrolment represented an exclusion criteria.

METHODS

Participants were randomized using concealed random allocation. They were assessed according to the study design with the Assisting Hand Assessment (AHA), the Box and Block Test (BBT) and the Melbourne Assessment 2 (MA2). Linear mixed models were used for statistical analysis.

RESULTS

A significant difference between the AOT and SC groups was identified immediately after the training on the AHA (6.406 [2.73] P=0.021) with an effect size (ES) of 1.99, and for the BBT of the less affected hand (9.826 [4.535] P=0.032) with an ES of 1.44. These effects were sustained at medium and long term.

CONCLUSIONS

This study supports the effectiveness of AOT home training in promoting UL skills in children with UCP, with immediate effects lasting for 6 months.

CLINICAL REHABILITATION IMPACT

This should encourage the use of technology for rehabilitative purposes and further applications of the AOT paradigm.

Effectiveness of a Telecare Physical Therapy Program in Improving Functionality in Children and Adolescents with Cerebral Palsy: A Cases Study

Cerebral palsy (CP) is the most common physical disability in childhood and results in motor impairment that is often associated with other disorders. The aim of this study was to assess whether a telecare intervention consisting of Action Observation Therapy with a family-center approach produces improvements in functionality in children and adolescents with CP. Seven girls with CP ages between 6 and 17 participated in this case series study that lasted 12 weeks: 6 weeks of telecare program with a total of six sessions; and a follow-up period of 6 weeks. The outcome variables were Gross Motor Function (Spanish version of the Gross Motor Function Measure), balance (Spanish version of the Pediatric Balance Scale), walking endurance (6-min walk test) and walking speed (10-m walk test). The variables were measured before starting the study, after 6 weeks of intervention and after the 6-week follow-up period. Results showed statistically significant improvements in gross motor function (p = 0.02) after the intervention. After the follow-up period, gross motor function remained statistically significant (p = 0.02), as well as balance (p = 0.04) and walking endurance (p = 0.02). These results show that a telecare program has been beneficial in improving functionality with enhancements in gross motor function, balance and endurance in children and adolescents with CP that will facilitate participation.

Envisioning translational hyperscanning: how applied neuroscience might improve family-centered care

From the very beginning of their life, human beings are immersed in a social and interactive environment that contributes to shaping their social and cognitive development under typical and at-risk conditions. In order to understand human development in its bidirectional relationship with the social environment, we need to develop a 'complexity-sensitive' approach in neuroscience. Recent advances have started to do so with the application of hyperscanning techniques which involve recording adult and child neural activity simultaneously and highlighting the presence of similar patterns of brain activity in the dyad. Numerous studies focused on typically developing children have been published in recent years with the application of this technique to different fields of developmental research. However, hyperscanning techniques could also be extremely beneficial and effective in studying development in atypical and clinical populations. Such application, namely translational hyperscanning, should foster the transition toward a two-brain translational neuroscience. In this paper, we envision how the application of hyperscanning to atypical and clinical child populations can inform family-centered care for children and their parents.

The effect of first-person perspective action observation training on upper extremity function and activity of daily living of chronic stroke patients

The purpose of this study was to investigate the effects of First-Person Perspective Action Observation training and Third-Person Perspective Action Observation training on upper extremity function and activities of daily living of patients with stroke-induced hemiplegia. This was a single-blind randomized study of 20 stroke patients (more than 6 months after the incident stroke) with upper extremity disabilities. The subjects who satisfied the inclusion and exclusion criteria were randomly divided into two groups: First-Person Perspective Action Observation training group and Third-Person Perspective Action Observation training group. The measurements were performed using Action Research Arm Test (ARAT) and Korean Modified Barthel Index (K-MBI) and Motor Activity Log (MAL). The results of this study showed statistically significant differences (p < .05) in the upper extremity function and activity of daily living after the intervention in all two groups. Upon comparison of the amount of change between the experimental group and the control group, there was significant difference in upper extremity function and activity of daily living (p < .05). Action Observation training was found to have an effect on the upper extremity function and activity of daily living on chronic stroke patients. First-Person Perspective Action Observation training was more effective in improving upper limb function and activity of daily living than the Third-Person Perspective Action Observation training.

Are they really motor learning therapies? A scoping review of evidence-based, task-focused models of upper limb therapy for children with unilateral cerebral palsy

PURPOSE

To identify the specific motor learning (ML) theories underpinning evidence-based, task-focused upper limb models of therapy for children with unilateral cerebral palsy; and to document the strategies used in the operationalisation of these theories.

MATERIAL AND METHOD

This scoping review searched for relevant studies using eight electronic databases. A list of 68 ML strategies and accompanying definitions was developed for data extraction. Three classifications; adequate, inadequate or not described were used to rate the description of ML strategies. A corresponding colour-coding system was used to provide a visual summary.

RESULTS

There is a limited description of the ML theories and strategies used to operationalise these theories in existing models of evidence-based upper limb therapy. Of 103 therapy protocols included, only 24 explicitly described the guiding ML theory. When described, there was significant variation in the underlying theories, leading to significantly different focus and content of therapy. Of the 68 ML strategies, only three were adequately described.

CONCLUSIONS

To support treatment fidelity and the implementation of evidence-based, task-focused models of upper limb therapy in clinical practice, future research needs to provide explicit details about the underlying theories and strategies used in the operationalisation of these theories.Implications for rehabilitationEvidence-based models of upper limb therapy purport to be based on motor learning theory, however, most provide a very limited description of the theories and strategies used.Dosage of practice is only one element that is specific to a therapy approach and other elements guided by the principles of type of task and type of feedback should be considered.To support the implementation of evidence-based approaches in clinical practice, and improve treatment fidelity, it is important for researchers to define the theories that guide therapy approaches and explicitly describe the strategies used to operationalise these theories.

Observation of others' actions during limb immobilization prevents the subsequent decay of motor performance

There is rich clinical evidence that observing normally executed actions promotes the recovery of the corresponding action execution in patients with motor deficits. In this study, we assessed the ability of action observation to prevent the decay of healthy individuals' motor abilities following upper-limb immobilization. To this end, upper-limb kinematics was recorded in healthy participants while they performed three reach-to-grasp movements before immobilization and the same movements after 16 h of immobilization. The participants were subdivided into two groups; the experimental group observed, during the immobilization, the same reach-to-grasp movements they had performed before immobilization, whereas the control group observed natural scenarios. After bandage removal, motor impairment in performing reach-to-grasp movements was milder in the experimental group. These findings support the hypothesis that action observation, via the mirror mechanism, plays a protective role against the decline of motor performance induced by limb nonuse. From this perspective, action observation therapy is a promising tool for anticipating rehabilitation onset in clinical conditions involving limb nonuse, thus reducing the burden of further rehabilitation.

Efficacy of the use of unaffected hand containment in unimanual intensive therapy to increase visuomotor coordination in children with hemiplegia: a randomized controlled pilot study

Background:

The capacity of children with hemiplegia to be engaged in anticipatory action planning is affected. There is no balance among spatial, proprioceptive and visual information, thus altering the affected upper limb visuomotor coordination. The objective of the present study was to assess the improvement in visuomotor coordination after the application of a unimanual intensive therapy program, with the use of unaffected hand containment compared with not using unaffected hand containment.

Methods:

A simple blind randomized clinical trial was realized. A total of 16 subjects with congenital infantile hemiplegia participated in the study with an age mean of 5.54 years old (SD:1.55). Two intensive protocols for 5 weeks of modified constraint-induced movement therapy (mCIMT) or unimanual therapy without containment (UTWC) were executed 5 days per week (2 h/day). Affected upper limb visuomotor coordination (reaction time, task total time, active range, dynamic grasp) was measured before–after intensive therapy using a specific circuit with different slopes (10°/15°).

Results:

Statistically significant inter-group differences were found after the intervention, with clinically relevant results for the mCIMT group not seen in UTWC, in the following variables: reaction time 10°slope (p = 0.003, d = 2.44), reaction time 15°slope (p = 0.002, d = 2.15) as well as for the task total time 10°slope (p = 0.002, d = 2.25), active reach 10°slope (p = 0.002, d = 2.7), active reach 15°slope (p = 0.003, d = 2.29) and dynamic grasp 10°/15°slopes (p = <0.001, d = 2.69). There were not statistically significant inter-group differences in the total task time with 15°slope (p = 0.074, d = 1.27).

Conclusions:

The use of unaffected hand containment in mCIMT would allow improvements in the affected upper limb’s visuomotor coordination. Thus, it would favor clinical practice to make decisions on therapeutic approaches to increase the affected upper limb functionality and action planning in children diagnosed with infantile hemiplegia (4–8 years old).

Mirror Therapy and Action Observation Therapy to Increase the Affected Upper Limb Functionality in Children with Hemiplegia: A Randomized Controlled Trial Protocol

The movements of the affected upper limb in infantile hemiplegia are slower and clumsy. This leads to a decrease in the use of the affected hand. The visual effect obtained using the mirror box and the observation of actions in another individual can activate the same structural neuronal cells responsible for the execution of these actions. This research will study the affected upper limb functionality in hemiplegia infantile from 6 to 12 years old after the application of two intervention protocols: observation action therapy and mirror therapy combined with observation action therapy. Children with a diagnose of congenital infantile hemiplegia will be recruited to participate in a randomized controlled trial with two intervention protocols during four weeks (1 h per/day; 5 sessions per/week): Mirror Therapy Action Observation (MTAO) or Action Observation Therapy (AOT). The study variables will be: spontaneous use, measured with the Assisting Hand Assessment (AHA); manual ability measured with the Jebsen Taylor Hand Function Test (JTHFT); surface electromyography of the flexors and extensors muscles of the wrist and grasp strength through a grip dynamometer. Four assessments will be performed: At baseline situation, at the end of treatment, 3 and 6 months after treatment (follow-up assessments). This study will study the effects of these therapies on the use of the affected upper limb in children with hemiplegia.

A new protocol for assessing action observation and imitation abilities in children with Developmental Coordination Disorder: A feasibility and reliability study

AIMS

To develop a new protocol for the assessment of action observation (AO) abilities and imitation of meaningful and non-meaningful gestures, to examine its psychometric properties in children with DCD and typically developing (TD) children.

BACKGROUND

For learning manual skills, AO and imitation are considered fundamental abilities. Knowledge about these modalities in children with DCD is scarce and an assessment protocol is lacking.

METHOD

The protocol consists of 2 tests. The AO test consists of two assembly tasks. The imitation test includes 12 meaningful and 20 non-meaningful gestures. Items of both tests are rated on a 4-point scale. Twelve children with DCD (mean age 8y3m, SD, 1.30) and 11 TD children (mean age 8y2m, SD 1.52) were enrolled. For inter-rater reliability, intraclass correlation coefficients (ICC) were calculated for the total score, weighted kappa and percentage agreement for single items. Known group validity was assessed by comparison of DCD and TD group (Wilcoxon rank sum test). For construct validity, the mABC-2 test was used. The protocol was adapted and confirmed by an intra and inter-rater reliability study (new sample of 11 DCD children, mean age 7y5m, SD 1.37).

RESULTS

Excellent ICCs were reported for intra and inter-rater reliability for the final protocol. A significant difference between DCD and TD group was found for AO abilities (p < .01), for nonmeaningful gestures (p < .001). A significant correlation was reported between the AO test and the mABC-2 test (r = 56;p ≤0.0001). No significant correlations were revealed for the imitation tests.

DISCUSSION AND CONCLUSION

The results support the psychometric properties of this protocol. When fully validated, it may contribute to map the deficits in AO abilities and imitation, to evaluate treatment effects of imitation and AO interventions.

Reorganization of action observation and sensory-motor networks after action observation therapy in children with congenital hemiplegia: A pilot study

New rehabilitation programs based on action observation therapy (AOT) are effective in improving motor function in children with congenital hemiplegia. In this pilot study we tested the potential effects of AOT on the reorganization of the motor system by functional magnetic resonance imaging (fMRI). As part of a randomized trial, eight subjects (age range: 6.2-14.5 years) with congenital hemiplegia were randomly assigned to an experimental (EG) or control (CG) group. All children underwent a clinical and neurophysiological assessment with Assisting Hand Assessment (AHA), MRI, and fMRI at baseline (T0), 1(T1), and 8(T2) weeks after the end of 3-week treatment. For the EG, AOT consisted in the observation of uni/bimanual goal-directed actions followed by their execution. CG watched same-duration computer games and then performed the same actions in the same order used in the EG. fMRI study was carried out using two different paradigms, for exploring sensory-motor network (SMN) localization and action observation network (AON). The pattern of brain activation was generally similar between T0 and T1 for both groups, while it was more widespread at T2, compared to T0 and T1, in the EG. This enlargement was coupled with functional improvement at AHA. Single-subject analysis shows a reduction of lateralization indexes both for the AON and the SMN. This pilot study, despite the small sample, showed the fMRI feasibility for providing relevant biomarkers of brain plasticity for monitoring the AOT response in children with congenital hemiplegia. The study was registered at http://www.clinicaltrials.gov (identifier NCT01016496).

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

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

Application of Low-Intensity Modified Constraint-Induced Movement Therapy to Improve the Affected Upper Limb Functionality in Infantile Hemiplegia with Moderate Manual Ability: Case Series

OBJECTIVE

To assess the functionality of the affected upper limb in children diagnosed with hemiplegia aged between 4 and 8 years after applying low-intensity modified Constraint-Induced Movement Therapy (mCIMT).

METHODS

Prospective case series study. A mCIMT protocol was applied for five weeks, with two hours of containment per day. The study variables were quality of movement of the upper limb, spontaneous use, participation of the affected upper limb in activities of daily living, dynamic joint position, grasp-release action, grasp strength, supination and extension elbow movements. Four measurements were performed, using the quality of upper extremity test (QUEST) scale, the Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) Evaluation, a hand dynamometer and a goniometer.

RESULTS

The sample was composed of eight children with moderate manual ability. Statistically significant differences were detected in all the studied variables (p < 0.05) between the pre-treatment and post-treatment results (Week 0-Week 5), except for upper limb dressing, putting on splints and buttoning up. In the first week, the changes were statistically significant, except for protective extension, grasp strength, grasp-release and all functional variables (level of functionality and participation of the patient's upper limbs) in the SHUEE Evaluation (p > 0.05). The greatest increase occurred in spontaneous use from Assessment 1 to Assessment 4 (p = 0.01), reaching 88.87% active participation in bimanual tasks. The quality of movement of the upper limb exhibited a significant value due to the increase in dissociated movements and grasp (p = 0.01).

CONCLUSION

A low dose (50 h) of mCIMT increased the functionality of children diagnosed with congenital hemiplegia between 4 and 8 years of age with moderate manual ability.

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.

Feasibility of a Home-Based Action Observation Training for Children With Unilateral Cerebral Palsy: An Explorative Study

Unilateral Cerebral Palsy (UCP), the most frequent form of Cerebral Palsy, usually affects more the upper limb (UL) than the lower limb. Rehabilitation programs are addressed to improve manual abilities and UL use. In recent years, Information and Communication Technology (ICT) has been introduced in rehabilitation to increase treatment opportunities for patients, and also in home-based intervention. Moreover, the discovery of the Mirror Neuron System allowed to insert a new paradigm of treatment that is the Action Observation Training (AOT). The aim of the present study was to investigate the feasibility of a new rehabilitative home-based approach, called Tele-UPCAT (Tele-monitored UPper Limb Children Action Observation Training), based on the principles of AOT, in a group of Italian children and adolescents with UCP. This investigation was to provide information about the possibility of introducing ICT in telerehabilitation field. Twenty-nine children aged 11.73 ± 3.65 years (range 6.00–18.75) with a diagnosis of UCP participated in the study. They carried out 15 days of training based on the AOT paradigm with Tele-UPCAT system while wearing Actigraphs on both wrists. The feasibility of both training and study design and procedures was assessed through nine criteria taken from existent literature and from a questionnaire designed and realized ad hoc for the purpose, based on standard items of usability and acceptability. All feasibility criteria were met: 80% of training sessions were completed in the planned time and no significant technical issues were found. From the questionnaire, total scores were all above 82.15%, while the four sections obtained the following scores: (i) customization of exercises 80.00%; (ii) acceptability at home, 77.50%; (iii) required effort 80.00%; and (iv) suitability of manual and software 95.00%. No differences were found for age and sex. Tele-UPCAT demonstrated to be feasible as a home-based AOT for children and adolescents with UCP. Trial registration NCT03094455.

Community-Based Upper Extremity Power Training for Youth with Cerebral Palsy: A Pilot Study

Aim: To examine the effects of an upper-extremity, community-based, and power-training intervention.Methods: Twelve participants with cerebral palsy (CP) [8 males, 4 females; mean age 14 years 6 months (SD 5 years 4 months), range 7-24] were randomly assigned to a rest-training (RT; n = 6) or training-rest (n = 6) group in this randomized, cross-over design. Training took place in participants' home or school, three times per week for 6 weeks. We examined changes in upper extremity average power output (Pavg) in watts (W) and changes in function via the Pediatric Outcomes Data Collection Instrument (PODCI).Results: Each participant completed at least 15 of the 18 total training sessions (91.2% adherence). Pavg increased 92.2% on average among participants (p < .05). There was a significant three-way interaction among treatment, sequence, and period with the data stratified by (Bimanual Fine Motor Function [BFMF]) level on the pain subscale of the PODCI (p = 0.0118). All participants decreased pain after training with the exception of individuals with lower functioning (BFMF II-V) in the RT group.Conclusion: A community-based upper extremity power-training intervention was feasible and effective at improving power among young people with CP and has the potential to improve pain.

Action observation training for rehabilitation in brain injuries: a systematic review and meta-analysis

Background

To systematically review and analyse the effects of Action Observation Training on adults and children with brain damage.

Methods

Seven electronic databases (Cochrane, EBSCO, Embase, Eric, PubMed, Scopus and Web of Science) were searched up to 16 September 2018 to select Randomized Controlled Trials focused on adults and children with brain damage that included AOT training on upper and/or lower limb carried out for at least 1 week. Identification of studies and data extraction was conducted with two reviewers working independently. Oxford Centre for Evidence-based Medicine (March2009) – Levels of Evidence and Physiotherapy Evidence Database scale were used to grade studies. The data collected from the articles were analysed using software R, version 3.4.3. Hedge’s g values were calculated and effect size estimates were pooled across studies. Separate meta-analyses were carried out for each ICF domain (i.e. body function and activity) for upper and lower limb.

Results

Out of the 210 records identified after removing duplicates, 22 were selected for systematic review and 19 were included in the meta-analysis. Thirteen studies included in the meta-analysis focused on upper limb rehabilitation (4 in children and 9 in adults) and 6 on lower limb rehabilitation (only studies in adults). A total of 626 patients were included in the meta-analysis. An overall statistically significant effect size was found for upper limb body function (0.44, 95% CI: [0.24, 0.64], p < 0.001) and upper limb activity domain (0.47, 95% CI: [0.30, 0.64], p < 0.001). For lower limb, only the activity domain was analysed, revealing a statistically significant overall effect size (0.56, 95% CI: [0.28, 0.84], p < 0.001).

Conclusions

Action Observation Training (AOT) is an innovative rehabilitation tool for individuals with brain damage, which shows promising results in improving the activity domain for upper and lower limbs, and also the body function domain for the upper limb. However, the examined studies lack uniformity and further well-designed, larger controlled trials are necessary to determine the most suitable type of AOT particularly in children.

Systematic review registration

CRD42019119600.

Exploring the EEG mu rhythm associated with observation and execution of a goal-directed action in 14-month-old preterm infants

Electroencephalographic mu rhythm desynchronization is thought to reflect Mirror Neuron System (MNS) activity and represents an important neural correlate of the coupling between action execution and perception. It is still unclear if the MNS in human ontogeny is already available at the beginning of postnatal life and how early experience impacts its development. Premature birth provides a "natural condition" for investigating the effects of early, atypical extra-uterine experience on MNS. The main aim of the present study was to investigate whether the MNS activity is associated with prematurity. We compared the mu rhythm activity in preterm (PT) and full-term (FT) 14-month old infants during an action observation/execution (AO/AE) task. Mu rhythm desynchronization was computed over frontal, central, parietal and occipital regions. Both groups showed mu rhythm suppression in all the scalp regions during action execution. Different desynchronization patterns emerged during action observation. Specifically, FT infants showed mu suppression in the right frontal, bilateral parietal and occipital regions; whereas PT infants exhibited mu suppression only in the right parietal region. Overall, these preliminary findings indicate that an atypical extra uterine experience might have an impact on the MNS activity.

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.

Action, observation or imitation of virtual hand movement affect differently regions of the mirror neuron system and the default mode network

Virtual reality (VR)-based paradigms use visual stimuli that can modulate visuo-motor networks leading to the stimulation of brain circuits. The aims of this study were to compare the changes in blood-oxygenation level dependent (BOLD) signal when watching and imitating moving real (RH) and virtual hands (VH) in 11 healthy participants (HP). No differences were found between the observation of RH or VH making this VR-based experiment a promising tool for rehabilitation protocols. VH-imitation involved more the ventral premotor cortex (vPMC) as part of the mirror neuron system (MNS) compared to execution and VH-observation conditions. The dorsal-anterior Precuneus (da-Pcu) as part of the Precuneus/posterior Cingulate Cortex (Pcu/pCC) complex, a key node of the Default Mode Network (DMN), was also less deactivated and therefore more involved. These results may reflect the dual visuo-motor roles for the vPMC and the implication of the da-Pcu in the reallocation of attentional and neural resources for bimodal task management. The ventral Pcu/pCC was deactivated regardless of the condition confirming its role in self-reference processes. Imitation of VH stimuli can then modulate the activation of specific areas including those belonging to the MNS and the DMN.

Combining constraint-induced movement therapy and action-observation training in children with unilateral cerebral palsy: a randomized controlled trial

BACKGROUND

Upper limb (UL) deficits in children with unilateral cerebral palsy (uCP) have traditionally been targeted with motor execution treatment models, such as modified Constraint-Induced Movement Therapy (mCIMT). However, new approaches based on a neurophysiological model such as Action-Observation Training (AOT) may provide new opportunities for enhanced motor learning. The aim of this study is to describe a randomised controlled trial (RCT) protocol investigating the effects of an intensive treatment model, combining mCIMT and AOT compared to mCIMT alone on UL function in children with uCP. Additionally, the role of neurological factors as potential biomarkers of treatment response will be analysed.

METHODS

An evaluator-blinded RCT will be conducted in 42 children aged between 6 and 12 years. Before randomization, children will be stratified according to their House Functional Classification Scale, age and type of corticospinal tract wiring. A 2-week day-camp will be set up in which children receive intensive mCIMT therapy for 6 hours a day on 9 out of 11 consecutive days (54 h) including AOT or control condition (15 h). During AOT, these children watch video sequences showing goal-directed actions and subsequently execute the observed actions with the more impaired UL. The control group performs the same actions after watching computer games without human motion. The primary outcome measure will be the Assisting Hand Assessment. Secondary outcomes comprise clinical assessments across body function, activity and participation level of the International Classification of Function, Disability and Health. Furthermore, to quantitatively evaluate UL movement patterns, a three-dimensional motion analysis will be conducted. UL function will be assessed at baseline, immediately before and after intervention and at 6 months follow up. Brain imaging comprising structural and functional connectivity measures as well as Transcranial Magnetic Stimulation (TMS) to evaluate corticospinal tract wiring will be acquired before the intervention.

DISCUSSION

This paper describes the methodology of an RCT with two main objectives: (1) to evaluate the added value of AOT to mCIMT on UL outcome in children with uCP and (2) to investigate the role of neurological factors as potential biomarkers of treatment response.

TRIAL REGISTRATION

NCT03256357 registered on 21st August 2017 (retrospectively registered).

Reorganization of the Action Observation Network and Sensory-Motor System in Children with Unilateral Cerebral Palsy: An fMRI Study

Little is known about the action observation network (AON) in children with unilateral cerebral palsy (UCP). Using fMRI, we aimed to explore AON and sensory-motor network (SMN) in UCP children and compare them to typically developed (TD) children and analyse the relationship between AON (re-)organization and several neurophysiological and clinical measures. Twelve UCP children were assessed with clinical scales and transcranial magnetic stimulation (TMS). For the fMRI study, they underwent a paradigm based on observation of complex and simple object-manipulation tasks executed by dominant and nondominant hand. Moreover, UCP and TD children carried out a further fMRI session to explore SMN in both an active motor and passive sensory task. AON in the UCP group showed higher lateralization, negatively related to performances on clinical scales, and had greater activation of unaffected hemisphere as compared to the bilateral representation in the TD group. In addition, a good congruence was found between bilateral or contralateral activation of AON and activation of SMN and TMS data. These findings indicate that our paradigm might be useful in exploring AON and the response to therapy in UCP subjects.

Tele-UPCAT: study protocol of a randomised controlled trial of a home-based Tele-monitored UPper limb Children Action observation Training for participants with unilateral cerebral palsy

INTRODUCTION

A new rehabilitative approach, called UPper Limb Children Action Observation Training (UPCAT), based on the principles of action observation training (AOT), has provided promising results for upper limb rehabilitation in children with unilateral cerebral palsy (UCP). This study will investigate if a new information and communication technology platform, named Tele-UPCAT, is able to deliver AOT in a home setting and will test its efficacy on children and young people with UCP.

METHODS AND ANALYSIS

A randomised, allocation concealed (waitlist control) and evaluator-blinded clinical trial with two investigative arms will be carried out. The experimental group will perform AOT at home for 3 weeks using a customised Tele-UPCAT system where they will watch video sequences of goal-directed actions and then complete the motor training of the same actions. The control group will receive usual care for 3 weeks, which may include upper limb training. They will be offered AOT at home after 3 weeks. Twenty-four children with UCP will be recruited for 12 participants per group. The primary outcome will be measured using Assisting Hand Assessment. The Melbourne Assessment 2, ABILHAND, Participation and Environment Measure-Children and Youth and Cerebral Palsy Quality of Life Questionnaire will be included as secondary measures. Quantitative measures from sensorised objects and participants worn Actigraphs GXT3+ will be analysed. The assessment points will be the week before (T0) and after (T1) the period of AOT/standard care. Further assessments will be at T1 plus, the week after the AOT period for the waitlist group and at 8 weeks (T2) and 24 weeks (T3) after AOT training.

ETHICS AND DISSEMINATION

The trial has been approved by the Tuscany Paediatric Ethics Committee (169/2016). Publication of all outcomes will be in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION

NCT03094455.

The Mirror Neurons Network in Aging, Mild Cognitive Impairment, and Alzheimer Disease: A functional MRI Study

The aim of the current study is to investigate the integrity of the Mirror Neurons (MN) network in normal aging, Mild Cognitive Impairment (MCI), and Alzheimer disease (AD). Although AD and MCI are considered “cognitive” diseases, there has been increasing recognition of a link between motor function and AD. More recently the embodied cognition hypothesis has also been developed: it postulates that a part of cognition results from the coupling between action and perception representations. MN represent a neuronal population which links perception, action, and cognition, therefore we decided to characterize MN functioning in neurodegenerative cognitive decline. Three matched groups of 16 subjects (normal elderly-NE, amnesic MCI with hippocampal atrophy and AD) were evaluated with a focused neuropsychological battery and an fMRI task specifically created to test MN: that comprised of an observation run, where subjects were shown movies of a right hand grasping different objects, and of a motor run, where subjects observed visual pictures of objects oriented to be grasped with the right hand. In NE subjects, the conjunction analysis (comparing fMRI activation during observation and execution), showed the activation of a bilateral fronto-parietal network in “classical” MN areas, and of the superior temporal gyrus (STG). The MCI group showed the activation of areas belonging to the same network, however, parietal areas were activated to a lesser extent and the STG was not activated, while the opposite was true for the right Broca's area. We did not observe any activation of the fronto-parietal network in AD participants. They did not perform as well as the NE subjects in all the neuropsychological tests (including tests of functions attributed to MN) whereas the MCI subjects were significantly different from the NE subjects only in episodic memory and semantic fluency. Here we show that the MN network is largely preserved in aging, while it appears involved following an anterior-posterior gradient in neurodegenerative decline. In AD, task performance decays and the MN network appears clearly deficient. The preservation of the anterior part of the MN network in MCI could possibly supplement the initial decay of the posterior part, preserving cognitive performance.

Development of the assisting hand assessment for adults following stroke: a Rasch-built bimanual performance measure

AIMS

To describe the development of a new test of bimanual performance for adults following Stroke, the Adult-Assisting Hand Assessment Stroke, and to report the evidence of internal and external validity.

METHODS

Scale development included: (i) establishing the test situation; (ii) constructing test items; (iii) evaluating internal construct validity by use of Rasch measurement analysis on 144 assessments of adults with hemiparesis, mean age 53 years (SD11.45); and (iv) investigating external validity by correlation to the Jebsen and Taylor Test of Hand Function and the ABILHAND Stroke.

RESULTS

The Adult-Assisting Hand Assessment Stroke scale, scored on 19 items using a four-point rating scale, provided a valid measure of bimanual performance. The rating scale structure, goodness of fit, and principal component analysis demonstrated evidence of a unidimensional construct. The strong reliability and high person separation ratio indicated high probability for the scale to be responsive to change. Correlation to outcomes of the Jebsen and Taylor Test of Hand Function and the ABILHAND Stroke indicated strong external validity.

CONCLUSION

Using two hands together is a critical aspect for performance of most daily life tasks. However, assessments of hand function commonly focus on measuring aspects of unimanual function. The Adult-Assisting Hand Assessment Stroke has the potential to contribute new and clinically important knowledge to stroke rehabilitation by providing an observation-based valid functional measure of bimanual performance. Implications for rehabilitation Hand function assessments commonly focus on unimanual aspects, although the use of two hands together is critical to perform most daily life tasks. The Adult-Assisting Hand Assessment Stroke measures how effectively a patient with a hemiparesis uses his/her affected hand together with the unaffected hand to perform bimanual tasks. The Adult-Assisting Hand Assessment Stroke contributes a new and clinically important aspect to stroke rehabilitation by providing a valid bimanual observation-based measure to guide intervention and measure change over time.

Systematic review of the effects of mirror therapy in children with cerebral palsy

[Purpose] To provide data for systematic intervention plans in occupational therapy practice by objectivity showing the value of mirror therapy interventions in children with cerebral palsy. [Subjects and Methods] Medline and EMBASE databases were searched for the key words "cerebral palsy," "mirror movement," "mirror therapy," and "mirror visual feedback." Nine studies that met the inclusion and exclusion criteria were identified. The qualitatively determined level of evidence, period of research, comparisons and interventions, tools used to measure the intervention, and the effects were analyzed. [Results] According to the results analyzed, one (1/9, 11.1%) study showed the same result as the control group, one (1/9, 11.1%) showed a negative effect, and seven (7/9, 77.8%) showed positive effects of mirror-mediated therapy, with meaningful improvement in function, such as hand strength, movement speed, muscle activity, and accuracy of hand matching. [Conclusion] Through this study, the value of mirror-mediated therapeutic interventions in occupational therapy practice targeting cerebral palsy was confirmed. It is expected that this result will be useful in establishing mirror therapy as an interventional program.

Psychometric properties of a revised version of the Assisting Hand Assessment (Kids-AHA 5.0)

AIM

The aim of this study was to scrutinize the Assisting Hand Assessment (AHA) version 4.4 for possible improvements and to evaluate the psychometric properties regarding internal scale validity and aspects of reliability of a revised version of the AHA.

METHOD

In collaboration with experts, scoring criteria were changed for four items, and one fully new item was constructed. Twenty-two original, one new, and four revised items were scored for 164 assessments of children with unilateral cerebral palsy aged 18 months to 12 years. Rasch measurement analysis was used to evaluate internal scale validity by exploring rating-scale functioning, item and person goodness-of-fit, and principal component analysis. Targeting and scale reliability were also evaluated.

RESULTS

After removal of misfitting items, a 20-item scale showed satisfactory goodness-of-fit. Unidimensionality was confirmed by principal component analysis. The rating scale functioned well for the 20 items, and the item difficulty was well suited to the ability level of the sample. The person reliability coefficient was 0.98, indicating high separation ability of the scale. A conversion table of AHA scores between the previous version (4.4) and the new version (5.0) was constructed.

INTERPRETATION

The new, 20-item version of the Kids-AHA (version 5.0), demonstrated excellent internal scale validity, suggesting improved responsiveness to changes and shortened scoring time. For comparison of scores from version 4.4 to 5.0, a transformation table is presented.

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.

Action observation network in childhood: a comparative fMRI study with adults

Very little is known about the action observation network and the mirror neuron system (AON/MNS) in children and its age-related properties compared with those observed in adults. In the present fMRI study we explored the activation of areas belonging to the AON/MNS in children and adults during observation of complex hand-grasping actions, as compared to observation of simple grasping acts executed with the left and the right hand, seen from a first person perspective. The results indicate that during the action observation tasks in children there was activation of a cortical network similar to that found in adults, including the premotor cortex, the posterior part of the inferior frontal gyrus and the posterior parietal lobe. However, the activation in children was more widespread and showed a higher inter-subject variability compared with adults. Furthermore, the activated network seems more lateralized to the left hemisphere in adults and more bilateral in children, with a linear growth of lateralization index as a function of age. Finally, in children the activation in the anterior intraparietal cortex (AIP) of each hemisphere was higher during observation of the contralateral hand (hand identity effect) and during the observation of complex actions relative to simple grasping acts, confirming the role of AIP for action-related hand identity previously described in adults. These results support the assumption that structure and size of action representations are sensitive to mechanisms of development and show physiological plasticity. These properties of the AON/MNS could constitute a powerful tool for spontaneous reorganization and recovery of motor deficits after brain injury in children and in adults, as well as for specific rehabilitation programmes.

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.

Relation between unimanual capacities and bimanual performance in hemiplegic cerebral-palsied children: impact of synkinesis

OBJECTIVE

Analyze the link between unimanual capacities and bimanual performance in cerebral-palsied (CP) hemiplegic children, aged between 5 and 18 years old, studying specifically the impact of synkinesis.

MATERIAL AND METHODS

71 CP hemiplegic children (35 boys and 36 girls - with average age of 8 years and 6 months; MACS levels from I to III; GMFCS from I to IV) took part in a transversal study, assessed - Melbourne Test (MUUL) for unimanual capacities, and Assisting Hand Assessment (AHA) for bimanual performance - with a specific scale to analyze synkinesis during Box and Block test for affected and healthy hands, collecting synkinesis type, duration and intensity.

RESULTS

There is a strong correlation between unimanual capacities (MUUL) and bimanual performance (AHA) (r = 0.871). Neither age nor gender contribute to bimanual performance (AHA). Multiple linear regression shows that MUUL contributes to bimanual performance variance (AHA) by 70%. Synkinesis is partly correlated to capacities (MUUL) and accounts for 10% of the variance of the gap between capacities and bimanual performance.

CONCLUSION

A high relationship between unimanual capacities and bimanual performance is confirmed by this study; some authors demonstrated impact of sensory troubles, we demonstrate that synkinesis influences the use of unimanual capacities in bimanual performance.

Action observation as a tool for neurorehabilitation to moderate motor deficits and aphasia following stroke

The mirror neuron system consists of a set of brain areas capable of matching action observation with action execution. One core feature of the mirror neuron system is the activation of motor areas by action observation alone. This unique capacity of the mirror neuron system to match action perception and action execution stimulated the idea that mirror neuron system plays a crucial role in the understanding of the content of observed actions and may participate in procedural learning. These features bear a high potential for neurorehabilitation of motor deficits and of aphasia following stroke. Since the first articles exploring this principle were published, a growing number of follow-up studies have been conducted in the last decade. Though, the combination of action observation with practice of the observed actions seems to constitute the most powerful approach. In the present review, we present the existing studies analyzing the effects of this neurorehabilitative approach in clinical settings especially in the rehabilitation of stroke associated motor deficits and give a perspective on the ongoing trials by our research group. The data obtained up to date showed significant positive effect of action observation on recovery of motor functions of the upper limbs even in the chronic state after stroke, indicating that our approach might become a new standardized add-on feature of modern neurorehabilitative treatment schemes.

Clinical feasibility of action observation training for walking function of patients with post-stroke hemiparesis: a randomized controlled trial

Objective:

To identify the effects of action observation training (AOT) on the walking ability of subjects with post-stroke hemiparesis.

Design:

Randomized, single-blind, controlled pilot study.

Setting:

Inpatient rehabilitation hospital.

Subjects:

Twenty-one subjects with post-stroke hemiparesis were randomly allocated to either the experimental group (EG) or the control group (CG), with 11 and 10 patients, respectively.

Interventions:

The subjects in the EG and CG watched video clips demonstrating four functional walking tasks and showing different landscape images, respectively. All subjects subsequently performed the walking tasks (a total of 30 min, once a day, 3 times weekly for a 4-week period).

Main measures:

10-m walk test, figure-of-8 walk test (time and steps), dynamic gait index (DGI), and gait symmetry score (swing and stance phases, and stride length) before and after the intervention.

Results:

The changes between the pre- and post-test values of the 10-m walk test (median [interquartile range], -5.10 [-15.80–-1.60] versus 0.00 [-6.60–4.06]), figure-of-8 walk test (time: -3.50 [-12.60–-2.00] versus -1.25 [-4.98–0.25]; steps:-5.00 [-8.00–-2.00] versus 0.00 [-3.25–0.25]), and DGI (4.00 [3.00–6.00] versus 1.00 [-4.00–3.00]) showed significant differences between the EG and CG ( p < 0.05). In the EG, the 10-m walk test, time and steps of figure-of-8 walk test, DGI, and gait symmetry score in the stance phase showed significant differences between pre- and post-test ( p < 0.05).

Conclusions:

The findings suggest that AOT can be beneficial in enhancing walking ability of patients with post-stroke hemiparesis, and may be clinically feasible as a practical adjunct to routine rehabilitation therapy. A power calculation on our data showed that 20 subjects in each group were required for further definitive studies.

Assessment of motor imagery in cerebral palsy via mental chronometry: the case of walking

Recent studies show varying results on whether motor imagery capacity is compromised in individuals with cerebral palsy (CP). Motor imagery studies in children predominantly used the implicit hand laterality task. In this task participants judge the laterality of displayed hand stimuli. A more explicit way of studying motor imagery is mental chronometry. This paradigm is based on the comparison between the movement durations of actually performing a task and imagining the same task. The current study explored motor imagery capacity in CP by means of mental chronometry of a whole body task. Movement durations of 20 individuals with CP (mean age=13 years, SD=3.6) were recorded in two conditions: actual walking and imagined walking. Six unique trajectories were used that varied in difficulty via manipulation of walking distance and path width. We found no main effect of condition (actual walking versus imagining) on movement durations. Difficulty of the walking trajectory did affect movement durations. In general, this was expressed by an increase in movement durations with increasing difficulty of the task. No interaction between task difficulty and movement condition was found. Our results show that task difficulty has similar effects on movement durations for both actual walking and imagined walking. These results exemplify that the tested individuals were able to use motor imagery in an explicit task involving walking. Previous studies using the implicit hand laterality task showed varying results on motor imagery capacity in CP. We therefore conclude that motor imagery capacity is task dependent and that an explicit paradigm as the one used in this study may reveal the true motor imagery capacity. The implications of these findings for the use of motor imagery training are discussed.

Impaired motor planning and motor imagery in children with unilateral spastic cerebral palsy: challenges for the future of pediatric rehabilitation

Compromised action performance is one of the most characteristic features of children with unilateral spastic cerebral palsy (USCP). Current rehabilitation efforts predominantly aim to improve the capacity and performance of the affected arm. Recent evidence, however, suggests that compromised motor planning may also negatively affect performance of activities of daily living. In this paper we will first discuss the recent evidence for this motor planning deficit, followed by studies on motor imagery in this population. Motor imagery is an experimental approach in which the contents of the motor plan become overt. Converging evidence indicates a compromised motor imagery ability in USCP. As the neural structures of both motor planning and motor imagery overlap, rehabilitation by motor imagery training may alleviate motor problems in USCP. Increasing evidence for this approach exists in older adults with stroke. We conclude this review with recommendations on such a training approach for children with USCP.

Effect of task-based mirror therapy on motor recovery of the upper extremity in chronic stroke patients: a pilot study

BACKGROUND AND AIMS

Mirror therapy (MT) is an alternative therapeutic intervention that uses the interaction of visuomotor-proprioception inputs to enhance movement performance of the impaired limb. Despite strong evidence for task-specific training in stroke, MT has been investigated using nontask movements. The aim of this pilot study was to assess the effectiveness of task-based MT on motor recovery of the upper extremity in chronic stroke patients.

METHOD

In a pretest-posttest single-group design, a convenience sample of 13 chronic stroke patients at an occupational therapy department of a rehabilitation institute was assessed on a task-based MT intervention. Participants received a task-based MT program, performing various tasks by the less affected upper extremity and observing in the mirror box along with conventional management, 4 days per week for 4 weeks. Fugl-Meyer Assessment (FMA), which includes subsection upper extremity (FMA-UE) and subpart upper arm (FMA-UA) and hand (FMA-WH), was used as an outcome measure.

RESULTS

Participants showed no significant improvement for FMA-UE and FMA-UA at postassessment. FMA-UE changed from 43% to 51%. Post FMA-UA score showed only 2% improvement. However, there was statistically significant improvement on mean scores of FMA-WH at postassessment (16.21 ± 3.06) as compared with the prescores (12.29 ± 3.1; P < .05). FMA-WH improved from 41% to 54%.

CONCLUSIONS

The preliminary findings suggest that task-based MT is effective in improving wrist and hand motor recovery in chronic stroke patients. Further studies in the form of randomized trials are needed to validate its effectiveness.

Randomized Trial of Observation and Execution of Upper Extremity Actions Versus Action Alone in Children With Unilateral Cerebral Palsy

Background. The properties of the mirror neuron system suggest a new type of upper limb (UL) rehabilitation in children with unilateral cerebral palsy (UCP), based on observation of action therapy followed by execution of a variety of observed movements (AOT). Objective. We tested the effects of AOT in the Upper Limb Children Action Observation Training (UP-CAT) trial. Methods. In a randomized, evaluator-blinded, block-designed trial, 24 UCP children with mild to moderate hand impairment were assigned to 2 groups. The experimental group observed, 1 hour per day for 3 consecutive weeks, video sequences of unimanual or bimanual goal-directed actions and subsequently executed observed actions with the hemiparetic UL or both ULs. The control group performed the same actions in the same order as the experimental sample, but had watched computer games. The Assisting Hand Assessment (AHA) scale was the primary outcome measure; the Melbourne assessment and ABILHAND-Kids were secondary ones. Outcomes were assessed at 1 week (T1), 8 weeks (T2), and 24 weeks (T3) after the end of the training. Results. The experimental group improved more ( P = .008) in score changes for the AHA at the primary endpoints T1 ( P = .008), T2 ( P = .019), and T3 ( P = .049). No between-group significant changes were found for ABILHAND-Kids or Melbourne assessment. Conclusions. UP-CAT improved daily UL activities in UCP children, suggesting a new rehabilitation approach based on a neurophysiological model of motor learning.

UP-BEAT (Upper Limb Baby Early Action-observation Training): protocol of two parallel randomised controlled trials of action-observation training for typically developing infants and infants with asymmetric brain lesions

INTRODUCTION

Infants with asymmetric brain lesions are at high risk of developing congenital hemiplegia. Action-observation training (AOT) has been shown to effectively improve upper limb motor function in adults with chronic stroke. AOT is based on action observation, whereby new motor skills can be learnt by observing motor actions. This process is facilitated by the Mirror Neuron System, which matches observed and performed motor actions. This study aims to determine the efficacy of AOT in: (1) influencing the early development of reaching and grasping of typically developing infants and (2) improving the upper limb activity of infants with asymmetric brain lesions.

METHODS AND ANALYSIS

This study design comprises two parallel randomised sham-controlled trials (RCTs) in: (1) typically developing infants (cohort I) and (2) infants with asymmetric brain lesions (eg, arterial stroke, venous infarction, intraventricular haemorrhage or periventricular leukomalacia; cohort II). Cohort II will be identified through a neonatal ultrasound or neonatal MRI. A sham control will be used for both RCTs, taking into consideration that it would be unethical to give no intervention to an at-risk population. Based on a two-tailed t test of two independent means, with a significance (α) level of 0.05, 80% power, predicted effect size of 0.8 and a 90% retention rate, we require 20 participants in each group (total sample of 40) for cohort I. The sample size for cohort II was based on the assumption that the effect size of the proposed training would be similar to that found by Heathcock et al in preterm born infants (n=26) with a mean effect size of 2.4. Given the high effect size, the calculation returned a sample of only four participants per group, on a two-tailed t test, with a significance (α) level of 0.05 and 80% power. As cohort II will consist of two subgroups of lesion type (ie, arterial stroke and venous infarction), we have quadrupled the sample to include 16 participants in each group (total sample of 32). Infants will be randomised to receive either AOT or standard Toy Observation Training (TOT). Both interventions will be of 4 weeks' duration, from the infant's 9th-13th post-term week of age. Three sessions of 5 min each will be performed each day for 6 days/week (total of 6 h over 28 days). Parents of the AOT group will repeatedly show the infant a grasping action on a set of three toys, presented in random order. Parents of the TOT group will show the infant the same set of three toys, in random order, without demonstrating the grasping action. At 14, 16 and 18 weeks, the quantity and quality of reaching and grasping will be measured using the Grasping and Reaching Assessment of Brisbane; symmetry of reaching and grasping will be measured using the Hand Assessment of Infants (HAI) and pressure of grasping for each hand with a customised pressure sensor. At 6 months' corrected age, the primary outcome measures will be the HAI and Bayley Scales of Infant and Toddler Development (third edition; BSID III), to measure cognitive and motor development. At 8 months, HAI and EEG will be used to measure brain activity and cortical coherence. At 12 months, the primary outcome measures will again be HAI and BSID III.

DISSEMINATION

This paper outlines the theoretical basis, study hypotheses and outcome measures for two parallel RCTs comparing the novel intervention Action-observation training with standard TOT in: (1) influencing the early development of reaching and grasping of typically developing infants and (2) improving the upper limb motor activity of infants with asymmetric brain lesions.

TRIAL REGISTRATION

ACTRN1261100991910. Web address of trial http://www.ANZCTR.org.au/ACTRN12611000991910.aspx.

Brain network involved in visual processing of movement stimuli used in upper limb robotic training: an fMRI study

Background

The potential of robot-mediated therapy and virtual reality in neurorehabilitation is becoming of increasing importance. However, there is limited information, using neuroimaging, on the neural networks involved in training with these technologies. This study was intended to detect the brain network involved in the visual processing of movement during robotic training. The main aim was to investigate the existence of a common cerebral network able to assimilate biological (human upper limb) and non-biological (abstract object) movements, hence testing the suitability of the visual non-biological feedback provided by the InMotion2 Robot.

Methods

A visual functional Magnetic Resonance Imaging (fMRI) task was administered to 22 healthy subjects. The task required observation and retrieval of motor gestures and of the visual feedback used in robotic training. Functional activations of both biological and non-biological movements were examined to identify areas activated in both conditions, along with differential activity in upper limb vs. abstract object trials. Control of response was also tested by administering trials with congruent and incongruent reaching movements.

Results

The observation of upper limb and abstract object movements elicited similar patterns of activations according to a caudo-rostral pathway for the visual processing of movements (including specific areas of the occipital, temporal, parietal, and frontal lobes). Similarly, overlapping activations were found for the subsequent retrieval of the observed movement. Furthermore, activations of frontal cortical areas were associated with congruent trials more than with the incongruent ones.

Conclusions

This study identified the neural pathway associated with visual processing of movement stimuli used in upper limb robot-mediated training and investigated the brain’s ability to assimilate abstract object movements with human motor gestures. In both conditions, activations were elicited in cerebral areas involved in visual perception, sensory integration, recognition of movement, re-mapping on the somatosensory and motor cortex, storage in memory, and response control. Results from the congruent vs. incongruent trials revealed greater activity for the former condition than the latter in a network including cingulate cortex, right inferior and middle frontal gyrus that are involved in the go-signal and in decision control. Results on healthy subjects would suggest the appropriateness of an abstract visual feedback provided during motor training. The task contributes to highlight the potential of fMRI in improving the understanding of visual motor processes and may also be useful in detecting brain reorganisation during training.