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Combined action observation and motor imagery therapy: a novel method for post-stroke motor rehabilitation

School of Health and Social Care, Teesside University, Middlesbrough, UK

Cerebral vascular accidents (strokes) are a leading cause of motor deficiency in millions of people worldwide. While a complex range of biological systems is affected following a stroke, in this paper we focus primarily on impairments of the motor system and the recovery of motor skills. We briefly review research that has assessed two types of mental practice, which are currently recommended in stroke rehabilitation. Namely, action observation (AO) therapy and motor imagery (MI) training. We highlight the strengths and limitations in both techniques, before making the case for combined action observation and motor imagery (AO + MI) therapy as a potentially more effective method. This is based on a growing body of multimodal brain imaging research showing advantages for combined AO + MI instructions over the two separate methods of AO and MI. Finally, we offer a series of suggestions and considerations for how combined AO + MI therapy could be employed in neurorehabilitation.
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1. Warlow CP, van Gijn J, Dennis MS, et al. (2008) Stroke: Practical Management (3rd ed.), Oxford: Blackwell Publishing.

2. Barker WH, Mullooly JP (1997) Stroke in a defined elderly population, 1967–1985. A less lethal and disabling but no less common disease. Stroke 28: 284–290.

3. Hendricks HT, van Limbeek J, Geurts AC, et al. (2002) Motor recovery after stroke: a systematic review of the literature. Arch Phys Med Rehabil 83: 1629–1637.    

4. De Vries S, Mulder T (2007) Motor imagery and stroke rehabilitation: a critical discussion. J Rehabil Med 39: 5–13.    

5. Wade DT (1992). Measurement in Neurological Rehabilitation, Oxford: Oxford University Press.

6. Pandyan AD, Gregoric M, Barnes MP, et al. (2005) Spasticity: clinical perceptions, neurological realities and meaningful measurement. Disabil Rehabil 27: 2–6.    

7. Andrews AW, Bohannon RW (1989) Decreased shoulder range of motion on paretic side after stroke. Phys Ther 69: 768–772.    

8. Meskers CG, Koppe PA, Konijnenbelt MH, et. al. (2005) Kinematic alterations in the ipsilateral shoulder of patients with hemiplegia due to stroke. Am J Phys Med Rehabil 84: 97–105.    

9. Chan DYL, Chan CCH, Au DKS (2006) Motor relearning programme for stroke patients: a randomized controlled trial. Clin Rehabil 20: 191–200.    

10. Rossini PM, Calautti C, Pauri F, et al. (2003) Post-stroke plastic reorganisation in the adult brain. Lancet Neurol 2: 493–502.    

11. Hubbard IJ, Parsons MW, Neilson C, et al. (2009) Task-specific training evidence for and translation to clinical practice. Occup Ther Int 16: 175–189.    

12. Arya KN, Pandian S, Verma R, et al. (2011) Movement therapy induced neural reorganization and motor recovery in stroke: a review. J Bodyw Mov Ther 15: 528–537.    

13. Aichner F, Adelwöhrer C, Haring HP (2002) Rehabilitation approaches to stroke, In: Fleischhacker WW, Brooks DJ, Stroke-vascular Diseases, Vienna: Springer, 59–73.

14. Byl N, Roderick J, Mohamed O, et al. (2003) Effectiveness of sensory and motor rehabilitation of the upper limb following the principles of neuroplasticity: patients stable poststroke. Neurorehabil Neural Repair 17: 176–191.    

15. Jang SH, Kim YH, Cho SH, et al. (2003) Cortical reorganization induced by task-oriented training in chronic hemiplegic stroke patients. Neuroreport 14: 137–141.    

16. Langhorne P, Coupar F, Pollock A (2009) Motor recovery after stroke: a systematic review. Lancet Neurol 8: 741–754.    

17. Park SW, Kim JH, Yang, YJ (2018) Mental practice for upper limb rehabilitation after stroke: a systematic review and meta-analysis. Int J Rehabil Res 41: 197–203.

18. Sun Y, Wei W, Luo Z, et al. (2016) Improving motor imagery practice with synchronous action observation in stroke patients. Top Stroke Rehabil 23: 245–253.    

19. Gatti R, Tettamanti A, Gough PM, et al. (2013) Action observation versus motor imagery in learning a complex motor task: a short review of literature and a kinematics study. Neurosci Lett 540: 37–42.    

20. Neuman B, Gray R (2013) A direct comparison of the effects of imagery and action observation on hitting performance. Movement Sport Sci: Sci Motricité 79: 11–21.

21. Guillot A, Collet C (2008) Construction of the motor imagery integrative model in sport: a review and theoretical investigation of motor imagery use. Int Rev Sport Exer P 1: 31–44.    

22. Hardwick RM, Caspers S, Eickhoff SB, et al. (2018) Neural Correlates of Action: Comparing Meta-Analyses of Imagery, Observation, and Execution. Neurosci Biobehav Rev 94: 31–44.    

23. Jeannerod M (2006) Motor Cognition, Oxford: Oxford University Press.

24. Vogt S, Di Rienzo F, Collet C, et al. (2013) Multiple roles of motor imagery during action observation. Front Hum Neurosci 7: 807.

25. Rizzolatti G, Sinigaglia C (2010) The functional role of the parieto-frontal mirror circuit: interpretations and misinterpretations. Nat Rev Neurosci 11: 264–274.    

26. Vogt S, Thomaschke R (2007) From visuo-motor interactions to imitation learning: behavioural and brain imaging studies. J Sports Sci 25: 497–517.    

27. Buccino G (2014) Action observation treatment: a novel tool in neurorehabilitation. Philos Trans R Soc Lond B Biol Sci 369: 20130185.    

28. Ertelt D, Small S, Solodkin A, et al. (2007) Action observation has a positive impact on rehabilitation of motor deficits after stroke. Neuroimage 36: 164–173.    

29. Franceschini M, Ceravolo MG, Agosti M, et al. (2012) Clinical relevance of action observation in upper-limb stroke rehabilitation: a possible role in recovery of functional dexterity. A randomized clinical trial. Neurorehabil Neural Repair 26: 456–462.    

30. Zhang JJQ, Fong KNK, Welage N, et al. (2018) The activation of the mirror neuron system during action observation and action execution with mirror visual feedback in stroke: a systematic review. Neural Plast 2018: 2321045.

31. Cumming J, Eaves DL (2018) The nature, measurement, and development of imagery ability. Imagin Cog Pers 37: 375–393.    

32. Eaves DL, Emerson JR, Binks JA, et al. (2018) Imagery ability: the individual difference gradient and novel training methods (Commentary on Kraeutner et al. (2018)) Eur J Neurosci 47: 1219–1220.    

33. Eaves DL, Riach M, Holmes PS, et al. (2016) Motor imagery during action observation: A brief review of evidence, theory and future research opportunities. Front Neurosci 10: 514.

34. Stinear CM, Byblow WD, Steyvers M, et al. (2006) Kinesthetic, but not visual, motor imagery modulates corticomotor excitability. Exp Brain Res 168: 157–164.    

35. De Vries S, Tepper M, Feenstra W, et al. (2013) Motor imagery ability in stroke patients: the relationship between implicit and explicit motor imagery measures. Front Hum Neurosci 7: 790.

36. Braun S, Kleynen M, van Heel T, et al. (2013) The effects of mental practice in neurological rehabilitation; a systematic review and meta-analysis. Front Hum Neurosci 7: 390.

37. Pascual-Leone A, Nguyet D, Cohen LG, et al. (1995) Modulation of muscle responses evoked by transcranial magnetic stimulation during the acquisition of new fine motor skills. J Neurophysiol 74: 1037–1045.    

38. Jackson PL, Lafleur MF, Malouin F, et al. (2003) Functional cerebral reorganization following motor sequence learning through mental practice with motor imagery. Neuroimage 20: 1171–1180.    

39. Sharma N, Baron JC, Rowe JB (2009) Motor imagery after stroke: relating outcome to motor network connectivity. Ann Neurol: Official J American Neurol Assoc Child Neurol Soc 66: 604–616.

40. Grosprêtre S, Lebon F, Papaxanthis C, et al. (2018) Spinal plasticity with motor imagery practice. J Physiol.

41. Zimmermann-Schlatter A, Schuster C, Puhan MA, et al. (2008) Efficacy of motor imagery in post-stroke rehabilitation: a systematic review. J Neuroeng Rehabil 5: 8.    

42. Machado S, Lattari E, de Sa AS, et al. (2015) Is mental practice an effective adjunct therapeutic strategy for upper limb motor restoration after stroke? A systematic review and meta-analysis. CNS Neurol Disord Drug Targets 14: 567–575.    

43. Winstein CJ, Stein J, Arena R, et al. (2016) Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 47: e98–e169.

44. Hebert D, Lindsay MP, McIntyre A, et al. (2016) Canadian stroke best practice recommendations: stroke rehabilitation practice guidelines, update 2015. Int J Stroke 11: 459–484.    

45. Bovend'Eerdt TJ, Dawes H, Sackley C, et al. (2012) Practical research-based guidance for motor imagery practice in neurorehabilitation. Disabil Rehabil 34: 2192–2200.    

46. Page SJ, Fulk GD, Boyne P (2012) Clinically important differences for the upper-extremity Fugl-Meyer scale in people with minimal to moderate impairment due to chronic stroke. Phys Ther 92: 791–798.    

47. Tani M, Ono Y, Matsubara M, et al. (2018). Action observation facilitates motor cortical activity in patients with stroke and hemiplegia. Neurosci Res 133: 7–14.    

48. Burianová H, Marstaller L, Sowman P, et al. (2013) Multimodal functional imaging of motor imagery using a novel paradigm. Neuroimage 71: 50–58.    

49. Kraeutner SN, McWhinney SR, Solomon JP, et al. (2018) Experience modulates motor imagery-based brain activity. Eur J Neurosci 47: 1221–1229.

50. Bar RJ, DeSouza JF (2016) Tracking plasticity: effects of long-term rehearsal in expert dancers encoding music to movement. PloS One 11: e0147731.    

51. Lacourse MG, Orr EL, Cramer SC, et al. (2005) Brain activation during execution and motor imagery of novel and skilled sequential hand movements. Neuroimage 27: 505–519.    

52. Macuga KL, Frey SH (2012) Neural representations involved in observed, imagined, and imitated actions are dissociable and hierarchically organized. Neuroimage 59: 2798–2807.    

53. Nedelko V, Hassa T, Hamzei F, et al. (2012) Action imagery combined with action observation activates more corticomotor regions than action observation alone. J Neurol Phys Ther 36: 182–188.    

54. Villiger M, Estévez N, Hepp-Reymond MC, et al. (2013) Enhanced activation of motor execution networks using action observation combined with imagination of lower limb movements. PLoS One 8: e72403.    

55. Taube W, Mouthon M, Leukel C, et al. (2015) Brain activity during observation and motor imagery of different balance tasks: an fMRI study. Cortex 64: 102–114.    

56. Bian Y, Qi H, Zhao L, et al. (2018) Improvements in event-related desynchronization and classification performance of motor imagery using instructive dynamic guidance and complex tasks. Comput Biol Med 96: 266–273.    

57. Berends HI, Wolkorte R, Ijzerman MJ, et al. (2013) Differential cortical activation during observation and observation-and-imagination. Exp Brain Res 229: 337–345.    

58. Eaves DL, Behmer LP, Vogt S (2016) EEG and behavioural correlates of different forms of motor imagery during action observation in rhythmical actions. Brain Cogn 106: 90–103.    

59. Neuper C, Scherer R, Wriessnegger S, et al. (2009) Motor imagery and action observation: modulation of sensorimotor brain rhythms during mental control of a brain-computer interface. Clin Neurophysiol 120: 239–247.    

60. Mouthon A, Ruffieux J, Wälchli M, et al. (2015) Task-dependent changes of corticospinal excitability during observation and motor imagery of balance tasks. Neuroscience 303: 535–543.    

61. Sakamoto M, Muraoka T, Mizuguchi N, et al. (2009) Combining observation and imagery of an action enhances human corticospinal excitability. Neurosci Res 65: 23–27.    

62. Tsukazaki I, Uehara K, Morishita T, et al. (2012) Effect of observation combined with motor imagery of a skilled hand-motor task on motor cortical excitability: difference between novice and expert. Neurosci Lett 518: 96–100.    

63. Wright DJ, Williams J, Holmes PS (2014) Combined action observation and imagery facilitates corticospinal excitability. Front Hum Neurosci 8: 951.

64. Wright DJ, McCormick SA, Williams J, et al. (2016) Viewing instructions accompanying action observation modulate corticospinal excitability. Front Hum Neurosci 10: 17.

65. Wright DJ, Wood G, Eaves DL, et al. (2018) Corticospinal excitability is facilitated by combined action observation and motor imagery of a basketball free throw. Psychol Sport Exerc 39: 114–121.    

66. Taube W, Lorch M, Zeiter S, et al. (2014) Non-physical practice improves task performance in an unstable, perturbed environment: motor imagery and observational balance training. Front Hum Neurosci 8: 972.

67. Bek J, Poliakoff E, Marshall H, et al. (2016) Enhancing voluntary imitation through attention and motor imagery. Exp Brain Res 234: 1819–1828.    

68. Eaves DL, Haythornthwaite L, Vogt S (2014) Motor imagery during action observation modulates automatic imitation effects in rhythmical actions. Front Hum Neurosci 8: 28.

69. Scott M, Taylor S, Chesterton P, et al. (2018) Motor imagery during action observation increases eccentric hamstring force: an acute non-physical intervention. Disabil Rehabil 40: 1443–1451.    

70. Romano-Smith S, Wood G, Wright DJ, et al. (2018) Simultaneous and alternate action observation and motor imagery combinations improve aiming performance. Psychol Sport Exerc 38: 100–106.    

71. Marusic U, Giordani B, Moffat SD, et al. (2018) Computerized cognitive training during physical inactivity improves executive functioning in older adults. Aging Neuropsychol Cogn 25: 49–69.    

72. Bek J, Gowen E, Vogt S, et al. (2018) Combined action observation and motor imagery influences hand movement amplitude in Parkinson's disease. Parkinsonism Relat Disord.

73. Cisek P, Kalaska JF (2010) Neural mechanisms for interacting with a world full of action choices. Annu Rev Neurosci 33: 269–298.    

74. Eaves DL, Turgeon M, Vogt S (2012) Automatic imitation in rhythmical actions: kinematic fidelity and the effects of compatibility, delay, and visual monitoring. PLoS One 7: e46728.    

75. McInnes K, Friesen C, Boe S (2016) Specific brain lesions impair explicit motor imagery ability: a systematic review of the evidence. Arch Phys Med Rehabil 97: 478–489.    

76. Oostra KM, Van Bladel A, Vanhoonacker AC, et al. (2016) Damage to fronto-parietal networks impairs motor imagery ability after stroke: a voxel-based lesion symptom mapping study. Front Behav Neurosci 10: 5.

77. Evans C, Edwards MG, Taylor LJ, et al. (2016) Perceptual decisions regarding object manipulation are selectively impaired in apraxia or when tDCS is applied over the left IPL. Neuropsychologia 86: 153–166.    

78. Kraeutner SN, Keeler LT, Boe SG (2016) Motor imagery-based skill acquisition disrupted following rTMS of the inferior parietal lobule. Exp Brain Res 234: 397–407.    

79. Pinter MM, Brainin M (2012) Rehabilitation after stroke in older people. Maturitas 71: 104–108.    

80. Pinter MM (2015) Rehabilitation in Stroke Patients: Focusing on the Future. Hamdan Medical J, 8: 321–330.    

81. Heyes C (2011) Automatic imitation. Psychol Bull 137: 463–483.    

82. Holmes PS, Collins DJ (2001) The PETTLEP approach to motor imagery: a functional equivalence model for sport psychologists. J Appl Sport Psychol 13: 60–83.    

83. Cumming J, Cooley SJ, Anuar N, et al. (2017) Developing imagery ability effectively: a guide to layered stimulus response training. J Sport Psychol Action 8: 23–33.    

84. Lang PJ (1977) Imagery in therapy: an information processing analysis of fear. Behav Ther 8: 862–886.    

85. Lang PJ (1979) A bio-informational theory of emotional imagery. Psychophysiology 16: 495–512.    

86. Ventola CL (2014) Mobile devices and apps for health care professionals: uses and benefits. Pharmacy Theraputics 39: 356–364.

87. Mosa AS, Yoo I, Sheets L (2012) A systematic review of healthcare applications for smartphones. BMC Med Inform Decis Mak 12: 67.    

88. Sureshkumar K, Murthy GV, Munuswamy S, et al. (2015) 'Care for Stroke', a web-based, smartphone-enabled educational intervention for management of physical disabilities following stroke: feasibility in the Indian context. BMJ Innov 1: 127–136.    

89. Goodney A, Jung J, Needham S, et al. (2012) Dr Droid: assisting stroke rehabilitation using mobile phones, International Conference on Mobile Computing, Applications and Services, Berlin, Heidelberg: Springer, 231–242.

90. Carr JH, Shepherd RB (2012) An excellent initiative. J Physiother 58: 134–135.    

91. Intercollegiate Stroke Working Party (2012) National Clinical Guideline for Stroke, 4th edition, London: Royal College of Physicians.

92. Wolpaw JR, Birbaumer N, McFarland DJ, et al. (2002) Brain-computer interfaces for communication and control. Clin Neurophysiol 113: 767–791.    

93. Cervera MA, Soekadar SR, Ushiba J, et al. (2018) Brain-computer interfaces for post-stroke motor rehabilitation: a meta-analysis. Ann Clin Transl Neurol 5: 651–663.    

© 2018 the Author(s), licensee AIMS Press. This is an open access article distributed under the terms of the Creative Commons Attribution Licese (http://creativecommons.org/licenses/by/4.0)

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