Observation and execution of upper-limb movements as a tool for rehabilitation of motor deficits in paretic stroke patients: protocol of a randomized clinical trial

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.

Facilitation of imitative movement in patients with chronic hemiplegia triggered by illusory ownership

The sense of body ownership, the feeling that one's body belongs to oneself, is a crucial subjective conscious experience of one's body. Recent methodological advances regarding crossmodal illusions have provided novel insights into how multisensory interactions shape human perception and cognition, underpinning conscious experience, particularly alteration of body ownership. Moreover, in post-stroke rehabilitation, encouraging the use of the paretic limb in daily life is considered vital, as a settled sense of ownership and attentional engagement toward the paralyzed body part may promote increased frequency of its use and prevent learned nonuse. Therefore, in addition to traditional methods, novel interventions using neurorehabilitation techniques that induce self-body recognition are needed. This study investigated whether the illusory experience of a patient's ownership alterations of their paretic hand facilitates the enhancement in the range of motion of succeeding imitation movements. An experiment combining a modified version of the rubber hand illusion with imitation training was conducted with chronic hemiplegia. A larger imitation movement of the paretic hand was observed in the illusion-induced condition, indicating that the feeling of ownership toward the observed limb promotes the induction of intrinsic potential for motor performance. This training, using subjective experience, may help develop new post-stroke rehabilitation interventions.

Action observation for upper limb rehabilitation after stroke

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

PRIMARY OUTCOMES

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

SECONDARY OUTCOMES

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

AUTHORS' CONCLUSIONS

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

Parkinson's patients situation during the SARS CoV-2 pandemic and their interest in telemedicine A cross-sectional study

Background

During the SARS CoV-2 pandemic, telemedicine experienced an enormous boom. Also, for Parkinson’s patients there are upcoming alternatives to regular care.

Objective

The aim of the present study was to interview Parkinson’s patients under the impression of the first lockdown in Germany about their health care situation, but especially about the use of and attitudes towards videotherapy and -consultation.

Methods

Northern German members of the German Parkinson Association were mailed a 16-item questionnaire including demographic questions on a one-time basis. The voluntary participants answered regarding their health care situation during the first German SARS CoV-2 lockdown, as well as attitudes towards videotherapy/-consultations.

Results

The 332 (of 974 questionnaires) responding evaluated their care situation predominantly (58.7%) unchanged during lockdown. There was hardly any previous experience in the areas of videotherapy and -consultations (15.4% and 3%, respectively), but at the same time mostly imaginability of implementation (54.2% and 56%, respectively) and the belief that they could motivate themselves to do so (51.8%). A total of 69% welcomed technical support for the implementation of videotherapy.

Conclusion

In principle, there seems to be both, a need and an interest in telematics in healthcare such as videotherapy and video consultations, even if further barriers such as technical implementation need to be addressed. An expansion of telemedical services and infrastructure seems desirable not only in the pandemic situation, but also in the long term against the backdrop of demographic change, especially in an area like Schleswig-Holstein. Further studies are needed.

A Modular Approach to Combine Postmarket Clinical Follow-Up Studies and Postmarket Surveillance Studies

BACKGROUND

The European Medical Device Regulation 2017/745 (MDR) has its date of application in May 2021. This new legislation has refined and expanded the need of manufacturers to have a postmarket surveillance (PMS) system. According to this legislation, a postmarket clinical follow-up (PMCF) plan is also required. Manufacturers of high-risk medical devices are obliged to conduct both PMCF and PMS studies. There is thus the need to generate evidence from clinical data.

OBJECTIVES

The conduct of several studies for PMS and PMCF can be cumbersome. We therefore aim to present a modular approach to combine PMS and PMCF studies into a single study.

MATERIALS AND METHODS

We extracted the topics listed in the MDR, especially Annex XV, Section 3, the Good Clinical Practice for medical devices (EN 14155:2020, Annex A). In addition, we added topics according to the SPIRIT and the SPIRIT-PRO statement and created a draft clinical investigation plan (CIP).

RESULTS

The CIP template is provided as part of the manuscript. The modular concept has passed the required regulatory and legal requirements for one specific study.

CONCLUSION

A modular approach for combining PMCF and PMS studies in a single CIP has been developed and implemented, and it is ready for use. The provided CIP template should enable other researchers and groups to adopt this concept according to their needs.

Increased links between language and motor areas: A proof-of-concept study on resting-state functional connectivity following Personalized Observation, Execution and Mental imagery therapy in chronic aphasia

A tight coupling of language and motor processes has been established, which is consistent with embodied cognition theory. However, very few therapies have been designed to exploit the synergy between motor and language processes to help rehabilitate people with aphasia (PWA). Moreover, the underlying mechanisms supporting the efficacy of such approaches remain unknown. Previous work in our laboratory has demonstrated that personalized observation, execution, and mental imagery therapy (POEM)-a new therapy using three sensorimotor strategies to trigger action verb naming-leads to significant improvements in verb retrieval in PWA. Moreover, these improvements were supported by significant activations in language and sensorimotor processing areas, which further reinforce the role of both processes in language recovery (Durand et al., 2018). The present study investigates resting state functional connectivity (rsFC) changes following POEM in a pre-/post-POEM therapy design. A whole brain network functional connectivity approach was used to assess and describe changes in rsFC in a group of four PWA, who were matched and compared with four healthy controls (HC). Results showed increased rsFC in PWA within and between visuo-motor and language areas (right cuneal cortex-left supracalcarin (SCC) cortex/right precentral gyrus (PreCG)-left lingual gyrus (LG)) and between areas involved in action processing (right anterior parahippocampal gyrus (aPaHC)-left superior parietal lobule (SPL). In comparison to HC, the PWA group showed increased rsFC between the right inferior frontal gyrus (IFG) and left thalamus, which are areas involved in lexico-semantic processing. This proof-of-concept study suggests that the sensorimotor and language strategies used in POEM may induce modifications in large-scale networks, probably derived from the integration of visual and sensorimotor systems to sustain action naming, which is consistent with the embodied cognition theory.

The medical avatar and its role in neurorehabilitation and neuroplasticity: A review

BACKGROUND

One of the most interesting emerging medical devices is the medical avatar - a digital representation of the patient that can be used toward myriad ends, the full potential of which remains to be explored. Medical avatars have been instantiated as telemedical tools used to establish a representation of the patient in tele-space, upon which data about the patient's health can be represented and goals and progress can be visually tracked. Manipulation of the medical avatar has also been explored as a means of increasing motivation and inducing neural plasticity.

OBJECTIVE

The article reviews the literature on body representation, simulation, and action-observation and explores how these components of neurorehabilitation are engaged by an avatar-based self-representation.

METHODS

Through a review of the literature on body representation, simulation, and action-observation and a review of how these components of neurorehabilitation can be engaged and manipulated with an avatar, the neuroplastic potential of the medical avatar is explored. Literature on the use of the medical avatar for neurorehabilitation is also reviewed.

RESULTS

This review demonstrates that the medical avatar has vast potentialities in neurorehabilitation and that further research on its use and effect is needed.

Brain activation induced by different strengths of hand grasp: a functional magnetic resonance imaging study

Mirror neuron system can be activated by observation and execution of an action. It has an important function of action understanding. We investigated brain activations in humans by observing the strength of a hand grasp using functional magnetic resonance imaging. Twenty right-handed healthy individuals, consisting of 10 males and 10 females, aged 22.40 ± 2.04 years, were recruited into this study from September to November 2017 via posters. Light hand grasp task video showed a hand lightly grasping and releasing a ball repeatedly. Powerful hand grasp task video showed a hand tightly grasping and releasing a ball repeatedly. Functional magnetic resonance imaging block design paradigm comprised five stimulation blocks alternating with five baseline blocks. Stimulation blocks were presented with two stimulus tasks, consisting of a light grasp and a powerful grasp. Region of interest was defined around the inferior parietal lobule, inferior frontal gyrus, and superior temporal sulcus which have been called mirror neuron system. The inferior parietal lobule, fusiform, postcentral, occipital, temporal, and frontal gyri were activated during light and powerful grasp tasks. The BOLD signal response of a powerful grasp was stronger than that of a light grasp. These results suggest that brain activation of the inferior parietal lobule, which is the core brain region of the mirror neuron system, was stronger in the powerful grasp task than in the light grasp task. We believe that our results might be helpful for instructing rehabilitation of brain injury. This study was approved by the Institutional Review Board of Daegu Oriental Hospital of Daegu Haany University on September 8, 2017 (approval No. DHUMC-D-17020-PRO-01).

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.

Community-based rehabilitation for physically impaired earthquake victims: An evidence-based practice protocol and its pre-post experimental study

BACKGROUND

A natural disaster like earthquake is a sudden event that causes not only the loss of life but also mental, emotional, and physical disabilities. An earthquake of 7.8 magnitudes hit Nepal and injured more than 18,500 people in 2015. There was a critical need to develop rehabilitation protocols. Therefore, we aimed to structure community-based rehabilitation protocols for physically impaired earthquake victims and to investigate immediate effect of the intervention to address disability and reduce public health burden.

MATERIALS AND METHODS

Evidence-based rehabilitation protocols for various injuries were structured to address the victims' impairments and activity limitations. The protocols were administered to 13 victims of one of the most affected community sites, for 60 min/day, 12 days in 2 weeks at their own doors. Local resources were used to make the protocols sustainable. An immediate effect of the protocols was evaluated within the group. The World Health Organization Disability Assessment Schedule, numerical pain rating scale, and time up and go (TUG) test were used to measure disability level, pain, and mobility status, respectively. Wilcoxon's signed rank test was used to analyze pre-post data.

RESULTS

All participants completed the rehabilitation without adverse effects. The treatment demonstrated significant reduction in disability level (P < 0.001, effect size = 0.63) and pain level (P = 0.007). However, change with TUG was not significant.

CONCLUSION

The evidence-based, structured community rehabilitation protocols demonstrated benefits in improving the victim's quality of life. Follow-ups will be continued to explore sustainability and long-term effects of the interventions.

Action observation for upper limb rehabilitation after stroke

BACKGROUND

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

OBJECTIVES

To assess whether action observation enhances motor function and upper limb motor performance and cortical activation in people with stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched 4 September 2017), the Central Register of Controlled Trials (24 October 2017), MEDLINE (1946 to 24 October 2017), Embase (1974 to 24 October 2017) and five additional databases. We also searched trial registries and reference lists.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 12 trials involving 478 individuals. A number of trials showed a high risk of bias and others an unclear risk of bias due to poor reporting. The quality of the evidence was 'low' for most of the outcomes and 'moderate' for hand function, according to the GRADE system. In most of the studies, AO was followed by some form of physical activity.

PRIMARY OUTCOME

the impact of AO on arm function showed a small significant effect (standardized mean difference (SMD) 0.36, 95% CI 0.13 to 0.60; 8 studies; 314 participants; low-quality evidence); and a large significant effect (mean difference (MD) 2.90, 95% CI 1.13 to 4.66; 3 studies; 132 participants; moderate-quality evidence) on hand function.

SECONDARY OUTCOMES

there was a large significant effect for ADL outcome (SMD 0.86, 95% CI 0.11 to 1.61; 4 studies, 226 participants; low-quality evidence). We were unable to pool other secondary outcomes to extract the evidence. Only two studies reported adverse effects without significant adverse AO events.

AUTHORS' CONCLUSIONS

We found evidence that AO is beneficial in improving upper limb motor function and dependence in activities of daily living (ADL) in people with stroke, when compared with any control group; however, we considered the quality of the evidence to be low. We considered the effect of AO on hand function to be large, but it does not appear to be clinically relevant, although we considered the quality of the evidence as moderate. As such, our confidence in the effect estimate is limited because it will likely change with future research.

Application of motor learning in neurorehabilitation: a framework for health-care professionals

Learning motor skills is an essential part of most rehabilitation processes. Facilitating and supporting motor learning is particularly challenging in neurological rehabilitation: patients who suffer from neurological diseases experience both physical limitations and difficulties of cognition and communication that affect and/or complicate the motor learning process. Therapists (e.g. physiotherapists and occupational therapists) who work in neurorehabilitation are therefore continuously searching for the best way to facilitate patients during these intensive learning processes. To support therapists in the application of motor learning, a framework was developed, integrating knowledge from the literature and the opinions and experiences of international experts. This article presents the framework, illustrated by cases from daily practice. The framework may assist therapists working in neurorehabilitation in making choices, implementing motor learning in routine practice, and supporting communication of knowledge and experiences about motor learning with colleagues and students. The article discusses the framework and offers suggestions and conditions given for its use in daily practice.

Enhanced Upper Extremity Functions with a Single Session of Action-Observation-Execution and Accelerated Skill Acquisition Program in Subacute Stroke

BACKGROUND

Action-observation-execution (AOE) primes physical training. We examined the immediate effect of AOE with accelerated skill acquisition program (ASAP) on dexterity in subacute stroke.

METHODS

Twelve individuals from 1 to 6 months after stroke were allocated into two groups by matching age and side of stroke. After AOE of 30 minutes, the experimental group received ASAP for 60 minutes whereas the control group received dose-equivalent usual care. The movement time (MT) and functional ability (FA) of hand items of the Wolf motor function test (WMFT), hand functions and global recovery of stroke impact scale (SIS), and intrinsic motivation items of stroke rehabilitation motivation scale were assessed at baseline, after training, and during one-week follow-up. Data were analyzed within and between the groups.

RESULTS

AOE significantly decreased MT of flipping cards of WMFT and hand functions of SIS. Total MT was markedly reduced. AOE with ASAP demonstrated significant group-by-time interactions on MT of lifting pencil of WMFT, total MT, and global recovery. Grip strength, FA, and hand functions were significantly improved only in the experimental group. Both groups improved motivation significantly.

CONCLUSIONS

The AOE with ASAP enhanced dexterity, which persisted for at least a week. This intervention might improve dexterity in subacute stroke.

TRIAL REGISTRATION NUMBER

This trial is registered with TCTR20161007001.

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.

[Neurofeedback-based motor imagery training for rehabilitation after stroke]

Mental training, including motor observation and motor imagery, has awakened much academic interest. The presumed functional equivalence of motor imagery and motor execution has given hope that mental training could be used for motor rehabilitation after a stroke. Results obtained from randomized controlled trials have shown mixed results. Approximately half of the studies demonstrate positive effects of motor imagery training but the rest do not show an additional benefit. Possible reasons why motor imagery training has so far not become established as a robust therapeutic approach are discussed in detail. Moreover, more recent approaches, such as neurofeedback-based motor imagery or closed-loop systems are presented and the potential importance for motor learning and rehabilitation after a stroke is discussed.

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

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

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 for upper limb function after stroke: evidence-based review of randomized controlled trials

[Purpose] The purpose of this study was to suggest evidenced information about action observation to improve upper limb function after stroke. [Methods] A systematic review of randomized controlled trials involving adults aged 18 years or over and including descriptions of action observation for improving upper limb function was undertaken. Electronic databases were searched, including MEDLINE, CINAHL, and PEDro (the Physiotherapy Evidence Database), for articles published between 2000 to 2014. Following completion of the searches, two reviewers independently assessed the trials and extracted data using a data extraction form. The same two reviewers independently documented the methodological quality of the trials by using the PEDro scale. [Results] Five randomized controlled trials were ultimately included in this review, and four of them (80%) reported statistically significant effects for motor recovery of upper limb using action observation intervention in between groups. [Conclusion] This review of the literature presents evidence attesting to the benefits conferred on stroke patints resulting from participation in an action observation intervention. The body of literature in this field is growing steadily. Further work needs to be done to evaluate the evidence for different conditions after stroke and different duration of intervention.

Exploring Biological Motion Processing in Parkinson's Disease Using Temporal Dilation

Biological motion (BM) perception is the compelling ability of the visual system to perceive complex animated movements effortlessly and promptly. A recent study has shown that BM can automatically lengthen perceived temporal duration independent of global configuration. The present study aimed mainly to investigate this temporal dilation effect of BM signals in Parkinson’s disease (PD) patients. We used the temporal dilation effect as an implicit measure of visual processing of BM. In all, 32 PD patients (under off-therapy conditions) and 32 healthy controls (HCs) participated in our study. In each trial, an upright BM sequence and an inverted BM sequence were presented within an interval in the center of the screen. We tested both canonical and scrambled BM sequences; the scrambled ones were generated by disturbing the global configuration of the canonical ones but preserving exactly the same local motion components. Observers were required to make a verbal two-alternative forced choice response to indicate which interval (the first or the second) appeared longer. Statistical analyses were conducted on the points of subjective equality (PSEs). We found that the temporal dilation effect was significantly reduced for PD patients compared with HCs in both canonical and scrambled BM conditions. Moreover, no temporal dilation effects of scrambled BM were shown in both early- and late-stage PD patients, while the temporal dilation effect of canonical BM was relatively preserved in the early stages.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Emerging treatments for motor rehabilitation after stroke

Although numerous treatments are available to improve cerebral perfusion after acute stroke and prevent recurrent stroke, few rehabilitation treatments have been conclusively shown to improve neurologic recovery. The majority of stroke survivors with motor impairment do not recover to their functional baseline, and there remains a need for novel neurorehabilitation treatments to minimize long-term disability, maximize quality of life, and optimize psychosocial outcomes. In recent years, several novel therapies have emerged to restore motor function after stroke, and additional investigational treatments have also shown promise. Here, we familiarize the neurohospitalist with emerging treatments for poststroke motor rehabilitation. The rehabilitation treatments covered in this review will include selective serotonin reuptake inhibitor medications, constraint-induced movement therapy, noninvasive brain stimulation, mirror therapy, and motor imagery or mental practice.

[The motor organization of cerebral cortex and the role of the mirror neuron system. Clinical impact for rehabilitation]

The basic characteristics of Penfield homunculus (somatotopy and unique representation) have been questioned. The existence of a defined anatomo-functional organization within different segments of the same region is controversial. The presence of multiple motor representations in the primary motor area and in the parietal lobe interconnected by parieto-frontal circuits, which are widely overlapped, form a complex organization. Both features support the recovery of functions after brain injury. Regarding the movement organization, it is possible to yield a relevant impact through the understanding of actions and intentions of others, which is mediated by the activation of mirror-neuron systems. The implementation of cognitive functions (observation, image of the action and imitation) from the acute treatment phase allows the activation of motor representations without having to perform the action and it plays an important role in learning motor patterns.

Early intervention to improve hand function in hemiplegic cerebral palsy

Children with hemiplegic cerebral palsy often have marked hand involvement with excessive thumb adduction and flexion and limited active wrist extension from infancy. Post-lesional aberrant plasticity can lead to progressive abnormalities of the developing motor system. Disturbances of somatosensory and visual function and developmental disregard contribute to difficulties with hand use. Progressive soft tissue and bony changes may occur, leading to contractures, which further limit function in a vicious cycle. Early intervention might help to break this cycle, however, the precise nature and appropriateness of the intervention must be carefully considered. Traditional approaches to the hemiplegic upper limb include medications and botulinum toxin injections to manage abnormalities of tone, and surgical interventions. Therapist input, including provision of orthoses, remains a mainstay although many therapies have not been well evaluated. There has been a recent increase in interventions for the hemiplegic upper limb, mostly aimed outside the period of infancy. These include trials of constraint-induced movement therapy (CIMT) and bimanual therapy as well as the use of virtual reality and robot-assisted therapy. In future, non-invasive brain stimulation may be combined with therapy. Interventions under investigation in the infant age group include modified CIMT and action observation therapy. A further approach which may be suited to the infant with thumb-in-palm deformity, but which requires evaluation, is the use of elastic taping. Enhanced cutaneous feedback through mechanical stimulation to the skin provided by the tape during movement has been postulated to modulate ongoing muscle activity. If effective, this would represent a low-cost, safe, widely applicable early intervention.

Excitability of the primary motor cortex increases more strongly with slow- than with normal-speed presentation of actions

Introduction

The aim of the present study was to investigate how the speed of observed action affects the excitability of the primary motor cortex (M1), as assessed by the size of motor evoked potentials (MEPs) induced by transcranial magnetic stimulation (TMS).

Methods

Eighteen healthy subjects watched a video clip of a person catching a ball, played at three different speeds (normal-, half-, and quarter-speed). MEPs were induced by TMS when the model's hand had opened to the widest extent just before catching the ball (“open”) and when the model had just caught the ball (“catch”). These two events were locked to specific frames of the video clip (“phases”), rather than occurring at specific absolute times, so that they could easily be compared across different speeds. MEPs were recorded from the thenar (TH) and abductor digiti minimi (ADM) muscles of the right hand.

Results

The MEP amplitudes were higher when the subjects watched the video clip at low speed than when they watched the clip at normal speed. A repeated-measures ANOVA, with the factor VIDEO-SPEED, showed significant main effects. Bonferroni's post hoc test showed that the following MEP amplitude differences were significant: TH, normal vs. quarter; ADM, normal vs. half; and ADM, normal vs. quarter. Paired t-tests showed that the significant MEP amplitude differences between TMS phases under each speed condition were TH, “catch” higher than “open” at quarter speed; ADM, “catch” higher than “open” at half speed.

Conclusions

These results indicate that the excitability of M1 was higher when the observed action was played at low speed. Our findings suggest that the action observation system became more active when the subjects observed the video clip at low speed, because the subjects could then recognize the elements of action and intention in others.

Multiple roles of motor imagery during action observation

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

Effect of observation of simple hand movement on brain activations in patients with unilateral cerebral palsy: an fMRI study

The aim of this functional magnetic resonance imaging (fMRI) study was to examine and compare brain activation in patients with unilateral cerebral palsy (CP) during observation of simple hand movement performed by the paretic and nonparetic hand. Nineteen patients with clinical unilateral CP (14 male, mean age 14 years, 7-21 years) participated in the study. Hand motor impairment was assessed using the sequential finger opposition task. Using fMRI block design, brain activation was examined following observation at rest of a simple opening-closing hand movement, performed by either the left or right hand of an actor. Eighteen fMRI dataset were analyzed. Observing hand movement produced large bilateral activations in temporo-parieto-fronto-occipital network, comprising most of the nodes of the well described action-observation network. For either side, observing hand movements recruits the primary motor cortex (M1), contralateral to the viewed hand, as would be expected in healthy persons. Viewing movement performed by an actor's hand representing the paretic side of patients activated more strongly ipsilesional M1 than viewing movement performed by an actor's hand representing the nonparetic side of patients. Observation of hand movement in patients with CP engaged the motor execution network regardless of the degree of motor impairment.