JMIR Publications

ABSTRACT

Background:

Stroke represents a major cause of long-term adult disability worldwide1. About 60%2 of stroke patients will have different degrees of limb dysfunction, which will not only have a significant impact on the quality of life of patients and caregivers but also increase additional economic burden3,4. Action Observation (AO) refers to the process of observing movements with the eyes5. It is a new therapeutic approach aimed at activating the mirror neuron system to promote the recovery of advanced brain functions. Motor Imagery (MI) refers to the specific process of visualization of movement in mind but not represented in physical movements and is a mental exercise involving the internal generation of the visual and kinesthetic aspects of the movement6. Both AO and MI can activate the neurons in the motor area7,8,9 and positively affect the motor behavior and performance of the patients10, which are considered effective interventions to promote motor learning and rehabilitation11,12. In recent years, systematic reviews have been conducted to analyze the effectiveness of motor imagery or action observation on limb function rehabilitation of stroke patients6,13,14,15. When patients with hemiplegia after stroke cannot achieve complete rehabilitation training, AO or MI can replace or supplement traditional rehabilitation training and become a feasible therapy. More and more scholars have recently focused on the combined intervention of AO and MI(AO+MI) in motor learning and rehabilitation rather than their independent use. Previous studies have shown that the combination of AO and MI can more effectively increase activity in brain regions associated with movement and boost patients' ability to learn motor learning. Bek J's study16 found that healthy participants who were instructed to imagine the observed action made a simulated action closer to the original demonstration action than those who only observed the action. The training measures of AO combined with MI have been applied to athletes17, Parkinson's disease18, and limb injuries19. The combination of AO and MI has two modes: synchronous and asynchronous. In synchronous mode, motion imagines the same state of action as the specific action observed. In asynchronous mode, the motion imagined action state is associated with, but not the same as, the observed action. However, the jury is still on the merits of the two approaches22. Some studies 20,21 have applied AO+MI to rehabilitating limb function in stroke patients. However, most of these studies are small sample trials, and there is heterogeneity among the results of the studies, so the validity is unclear. No relevant meta-analysis or systematic review has analyzed its feasibility and effectiveness in the last three years. Therefore, our systematic review and meta-analysis aim to explore (1) whether AO +MI has more advantages in limb function rehabilitation of stroke patients compared with conventional rehabilitation training. (2) Whether AO+ MI has an advantage in limb function rehabilitation of stroke patients compared with their independent use. (3) Whether there are differences in limb function rehabilitation of stroke patients between synchronous AO +MI and asynchronous AO+MI. Through this review, we discuss the feasibility and effectiveness of applying motor imagery combined with movement observation in the rehabilitation of limb function in patients with stroke to provide evidence-based evidence for clinical practice.We hope that this systematic review can provide clinical rehabilitation therapists with some implications for alternative therapy in post-stroke limb rehabilitation.

Objective:

To assess the efficacy of action observation (AO) combined with motor imagery (MI) training in improving limb motor function in stroke patients.

Methods:

A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. Databases (PubMed, Cochrane Library, Web of Science, Embase, Proquest, Physiotherapy Evidence Database, ClinicalTrials.gov, and ChiCTR) were searched up to November 2024. Two independent reviewers screened studies, extracted data, and assessed risk of bias using the Cochrane Tool. Meta-analysis was performed with RevMan 5.3 and Stata.

Results:

Twelve RCTs (363 patients) were included. AO+MI significantly improved limb motor function compared to conventional therapy (SMD=0.65, 95% CI:0.07–1.23; P<0.05), AO alone (SMD=1.40, 95% CI:0.29–2.51; P<0.05), and MI alone (SMD=0.97, 95% CI:0.13–1.80; P<0.05). No significant difference was found between synchronous and asynchronous AO+MI combinations (SMD=0.62, 95% CI:-0.42–1.67).

Conclusions:

AO combined with MI effectively enhances post-stroke limb motor function and is a viable rehabilitation strategy. Clinical Trial: The systematic review was registered priori to PROSPERO (CRD42023488270) and reported following the preferred reporting items stated in Systematic Review and Meta-Analysis (PRISMA).