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

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

Introduction

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

Methods

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

Results

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

Discussion

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Modulation of Motor Cortical Activities by Action Observation and Execution in Patients with Stroke: An MEG Study

Action observation therapy has recently attracted increasing attention; however, the mechanisms through which action observation and execution (AOE) modulate neural activity in stroke patients remain unclear. This study was aimed at investigating the effects of action observation and two types of AOE on motor cortical activations after stroke using magnetoencephalography. Twenty patients with stroke and 20 healthy controls were recruited for the collection of data on the beta oscillatory activity in the primary motor cortex (M1). All participants performed the conditions of resting, observation only, and video observation combined with execution (video AOE). Stroke patients performed one additional condition of affected hand observation combined with execution (affected hand AOE). The relative change index of beta oscillations was calculated, and nonparametric tests were used to examine the differences in conditions. In stroke patients, the relative change index of M1 beta oscillatory activity under the video AOE condition was significantly lower than that under the observation only and affected hand AOE conditions. Moreover, M1 cortical activity did not significantly differ under the observation only and affected hand AOE conditions. For healthy controls, the relative change index under the video AOE condition was significantly lower than that under the observation only condition. In addition, no significant differences in relative change indices were found under the observation only and video AOE conditions between the 2 groups. This study provides new insight into the neural mechanisms underlying AOE, which supports the use of observing videos of normal movements during action observation therapy in stroke rehabilitation.

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

Objective:

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

Design:

Systematic review and meta-analysis of randomized controlled trials.

Data sources:

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

Review methods:

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

Results:

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

Conclusion:

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

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.

Investigation of Perceptual-Motor Behavior Across the Expert Athlete to Disabled Patient Skill Continuum can Advance Theory and Practical Application

A framework is presented of how theoretical predictions can be tested across the expert athlete to disabled patient skill continuum. Common-coding theory is used as the exemplar to discuss sensory and motor system contributions to perceptual-motor behavior. Behavioral and neural studies investigating expert athletes and patients recovering from cerebral stroke are reviewed. They provide evidence of bi-directional contributions of visual and motor systems to perceptual-motor behavior. Majority of this research is focused on perceptual-motor performance or learning, with less on transfer. The field is ripe for research designed to test theoretical predictions across the expert athlete to disabled patient skill continuum. Our view has implications for theory and practice in sports science, physical education, and rehabilitation.

Action observation training of community ambulation for improving walking ability of patients with post-stroke hemiparesis: a randomized controlled pilot trial

Purpose:

To investigate the effects of action observation training involving community-based ambulation for improving walking ability after stroke.

Design:

Randomized, controlled pilot study.

Setting:

Inpatient rehabilitation hospital.

Subjects:

A total of 25 inpatients with post-stroke hemiparesis were randomly assigned to either the experimental group ( n = 12) or control group ( n = 13).

Intervention:

Subjects of the experimental group watched video clips demonstrating four-staged ambulation training with a more complex environment factor for 30 minutes, three times a week for four weeks. Meanwhile, subjects of the control group watched video clips, which showed different landscape pictures.

Main measures:

Walking function was evaluated before and after the four-week intervention using a 10-m walk test, community walk test, activities-specific balance confidence scale, and spatiotemporal gait measures.

Results:

Changes in the values for the 10-m walk test (0.17 ±0.19 m/s vs. 0.05 ±0.08 m/s), community walk test (–151.42 ±123.82 seconds vs. 67.08 ±176.77 seconds), and activities-specific balance confidence (6.25 ±5.61 scores vs. 0.72 ±2.24 scores) and the spatiotemporal parameters (i.e. stride length (19.00 ±11.34 cm vs. 3.16 ±11.20 cm), single support (5.87 ±5.13% vs. 0.25 ±5.95%), and velocity (15.66 ±12.34 cm/s vs. 2.96 ±10.54 cm/s)) indicated a significant improvement in the experimental group compared with the control group. In the experimental group, walking function and ambulation confidence was significantly different between the pre- and post-intervention, whereas the control group showed a significant difference only in the 10-m walk test.

Conclusions:

Action observation training of community ambulation may be favorably used for improving walking function of patients with post-stroke hemiparesis.