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PTRS SR Final
PTRS SR Final
Enhancing Cortical Activation during Action Observation Therapy for Upper Limb
Rehabilitation in patients with Apraxia after Stroke: A Systematic Review
A Thesis
Presented To
Quezon City
In Partial Fulfillment
By
Cynthia Lucanas
Eloisa Cellona
Trizsha Catral
Paul Ramirez
December 2021
TABLE OF CONTENTS
INTRODUCTION
PURPOSE STATEMENT
A. Significance of the Study
B. Scope and Limitation
PROBLEM STATEMENT
HYPOTHESIS
THEORETICAL FRAMEWORK
SIMULACRUM
RESEARCH METHODOLOGY
ELIGIBILITY
INFORMATION SOURCES
DATA COLLECTION AND DATA ITEMS
SEARCH STRATEGY
DATA SELECTION
HIERARCHY AND METHODOLOGICAL QUALITY
OUTCOME MEASURE
OPERATIONAL DEFINITION OF TERMS
REFERENCES
1.0 ABSTRACT
2.0 INTRODUCTION
imitations, whereas the use of real tools is less affected. Patients that present with IMA know
cognitively what to do but do not know how to execute the movement. The idea or plan for
the action is not damaged, but implementation of the motor plan for turning gestures into
actions is impaired (Park et al., 2021). The deficits linked to apraxia are typically associated
with brain damage of vascular etiology, especially after left hemispheric stroke. Studies
report prevalence rates varying from 10 % to 50 % for the traditional clinical classification of
IA and IMA deficits after lesions in the left parietal and premotor cortical areas . Patients
with right-brain damage and IMA have also been reported, with prevalence rates from 20 %
to 54 %. Apraxia is therefore one of the common cognitive deficits that occur after a stroke.
It can have negative impacts on a patient’s independence in activities of daily living (ADLs)
due to reduced levels of patient autonomy (Dovern et al., 2011). The disorder not only
appears in clinical settings but also in many natural, day-to-day environments where patients
commonly perform ADLs, that is, the daily activities required to live safely and
independently at home. The ecological relevance of apraxia has been reported in the ability
of patients to perform various ADLs, for example, feeding, bathing, toileting, and grooming,
as well as dressing and brushing one’s teeth. Moreover, gesture deficits impact negatively on
patients’ nonverbal communication and the quality of communicative gestures. For this
reason, patients who have apraxia rarely use spontaneous communicative gestures in daily
living settings (Dovern et al., 2012). To promote the independence and safety of apraxia
patients’ daily functional performance, efficient cost effective and evidence-based
intervention strategies for LA are needed (Mármol et al.,2015).
and the superior occipital gyrus. Furthermore, regions such as the posterior area of the middle
temporal gyrus as well as the inferior temporal gyrus of the temporal lobe. It also includes
activation on the fusiform gyrus. These activations show how it affects the functions of an
individual in everyday living. Understanding the tasks in order to be performed is significant
to effectively execute the activities and motor functions and these are significant to be
discussed in order to manage the issues of Apraxia in Neurologic conditions (Bieńkiewicz et
al., 2014).
Cortical areas have been shown to contain mirror neurons that are often
described as a part of an integrated sensorimotor information system underpinned by neural
activity in the frontal, parietal, and superior temporal sulcus areas. This system is called the
action observation network (AON). In humans, these cortical regions mediate the observation
of actions that form a part of the observer's motor repertoire. They also contribute to the
imitation and comprehension of these movements, and are involved in skill acquisition.
(Pazzaglia & Galli, 2019). Neurorehabilitation techniques involving observation strategies
among brain-damaged patients induce long-lasting neural changes in the motor cortex,
potentiating activity in the affected areas. (Pazzaglia & Galli, 2019). Treatment for apraxia
consisted of a behavioral training program comprised of gesture-production exercises, made
up of three sections dedicated to the treatment of gesture with or without symbolic value and
related or unrelated to the use of objects.61 Patients who received treatment for apraxia were
found to improve in both praxis and activities of daily living (ADL), compared to patients
who received conventional treatment for aphasia (Park, 2017). However, there is a
neurorehabilitation method that can contribute to cortical activation as per treatment
improving functional recovery of stroke patients, in addition to Action Observation Therapy.
Constraint-Induced Movement Therapy has been one of the well-established methods for
neurorehabilitation as it significantly increases cortical activation by restricting the use of the
less affected arm during activities that involve repetitive and sensorimotor tasks.
Furthermore, its effects can be evidently seen for early post-stroke patients (Sawaki et al.,
2014). Despite the fact that these treatments may occasionally be effective and assist patients
in returning to the individuals' daily life activities, unfortunately, these treatments did not
attempt to restore long-term circuits in the brain influencing particular tasks via direct or
indirect restoration of functionality (Buccino, 2014).
The action observation therapy is a rehabilitation approach based on the role of the
mirror neuron system in motor learning. It is a motor-based technique with cognitive
strategies concerning stroke motor recovery. In promotion of motor cortical activation,
Action Observation is an effective therapy for the brain in individuals with stroke (Tani et al.,
2018). Action Observation Therapy demonstrates how external stimulus within the
somatosensory feedback significantly influences the cerebral cortex, specifically the
neuroplasticity leading to a recovered cortex. The therapy resulted in improving the
excitability of the pathway, specifically the corticospinal (Yang et al., 2019). Foundas (2013)
states that when an individual performs a movement with one side of the upper limb, the
motor program of the said side of the limb will traverse to the other side through the corpus
callosum to the other side of the premotor cortex. Hence, an activation of the primary motor
cortex for the production of the movement occurred. According to Buccino (2014), Action
Observation Therapy seems to be demanding in relation to the attention that is required for
every task even if it appears to be efficient to utilize. If the patient does not pay attention to it
then it will influence the effectiveness of the treatment. Thus, securing the attentiveness of
the patient is the goal to achieve optimal recovery.
2.1.1.2 Comorbidities
2.1.1.2.1 Speech problems
Problems with verbal communication of the patient could be a linguistic impairment
(aphasia), speech motor execution (dysarthria) and a deficit in planning and programming
speech motor movements (Apraxia of Speech) (Hybinnitte et al., 2021) which is
characterized by articulatory precision, reduced speech rate and leads to less predictable
errors (Basilakos, 2018).
2.1.3 Association Between Elements of Cortical Activation and Action Observation Therapy
Stroke patients acquire upper limb apraxia and are a common consequence of the
condition as a higher motor disorder. (Dovern et al., 2012) In numerous ADLs, the degree of
apraxia indicated the reliance of stroke patients on their caretakers following release from the
rehabilitation facility and it depends on how the condition significantly affects the
rehabilitation (Dovern et al., 2011). Stroke patients suffering from apraxia are less likely to
return to work than stroke patients who do not suffer from apraxia. Rehabilitation options for
apraxia elicit the clinical need of accurately identifying patients who are suffering from
apraxia, in order for the patients to get suitable rehabilitation programs that take apraxia into
consideration (Dovern et al., 2012). The motor program of one side of the upper limb, will go
to the other side via the corpus callosum and to the other side of premotor cortex when a
person executes a movement with one of the upper limbs on one side of the body (Foundas,
2013). It is supported by Pazzaglia et al., (2008) affirming that observing a certain action
makes it easier to carry out and to be done than to perform actions that are distinct from
observing. Moreover, the process of viewing an activity engages frontoparietal circuits,
which are often engaged in the motor planning and execution of the same movements later
on. (Pazzaglia et al., 2008). The mechanism of the motor mirroring shows that the actions
that are done through observation autonomously localize on the particular areas of the brain
that will be significant in understanding how the observed factor is executing. In stroke
patients who acquire limb apraxia following a stroke, AO is indeed a reliable technique for
restoring upper limb function because it increases corticomotor excitation and enhances
motor function.(Tani et al., 2018). Accordingly, the activation of the Mirror Neuron System
is critical in producing motor cortical activity and promoting the functional recovery of the
brain of stroke patients (Tani et al., 2018).
The effects of AOT in recovering the upper limbs in patients after a stroke is
supported by recent neurophysiological evidence that has shown how the observation and the
execution of movements performed by healthy people improve the functional recovery of the
upper limbs and promote autonomy in daily life activities. (Mancuso et al., 2021). AOT
improved the latency of Motor Evoked Potentials (MEPs) and the functioning of the upper
motor neuron in the experimental group, indicating that it had an effect on motor nerve
excitability. (Fu et al., 2017). Furthermore, a recent analysis found that action observation
training had a moderate effect on arm and hand motor outcomes, as well as a moderate to
large effect on everyday functioning. (Peng, T.-H et al., 2019). AO has the ability to activate
the same group of motor neurons both subconsciously and directly as the neurons in the
observer's brain that are responsible for the seen activity (Rizzolatti et al., 2014). AO does, in
fact, improve corticomotor excitability, increase motor function (Nojima et al., 2015), and
appears to be a reliable treatment (Nojima et al., 2015). After a stroke, there is a strategy for
improving upper limb function (Buccino, 2014; Kim, 2015).
The study aims to review the available literature on enhancing cortical activity with
action observation therapy on post-stroke patients suffering from apraxia.
Physical Therapist- To provide a deeper understanding about cortical activity and its
association with the action observation therapy and how it may differ from other
rehabilitation therapy on cognitive aspects in terms of non-invasive, inexpensive and
user-friendly approach.
Researchers - To give a result about the change in cortical activity of post stroke
patients who are suffering from apraxia, also to create a diverse study about the
cortical activity in different neurological conditions.
This study will deal on evaluating the conflicting results between the effect of action
observation therapy on cortical activation based on the available literature. Our study will
focus mainly on the post stroke patients with apraxia.
2.4 Hypothesis
2.5.1. Neuroplasticity
Neuroplasticity can be defined as the ability of the nervous system to respond to
intrinsic or extrinsic stimuli by reorganizing its structure, function and connections (Cramer
et al, 2011). The concept of rehabilitation in stroke is currently based on evidence of
neuroplasticity, considered to be responsible for recovery after a stroke (Filippo et al., 2015).
After stroke, the plasticity process is initiated in an attempt to compensate for both the lesion
itself and its remote effects (Su & Xu, 2020).
experience it and up to one-third require ongoing care, and thus this review would only
include studies within the time frame of five years (2016-2021). Study design should be
Randomized Controlled Trial (RCT)Lastly, studies with free full text available and written in
the English language were included in this review.
Primary and secondary searching was used to identify eligibility of studies; primary
searching involved a comprehensive search of EBSCO host, Science direct, PubMed,
research gate. Delimiters include the year range of publications (2016-2021), stroke patient
participants group were Secondary searching involved pearling references from published
articles in stroke patients with ideomotor apraxia.
The researchers apply the inclusion/exclusion criteria from random and relevant
articles that independently utilize the Boolean Search Strategy to search in the databases. To
categorize the article, three labels were used by each researcher in determining the relevant,
irrelevant, or uncertain outcome. It follows the condition of the combinations of
disagreements determined by the number of researchers. PRISMA flow diagram (figure 2)
outlines the process of selecting the studies. The studies accumulated were appraised by the
researchers, CASP: Critical Appraisal Skills Checklists, attached under Appendix .
PRISMA 2020 flow diagram for new systematic reviews which included searches of
databases, registers and other sources
*Consider, if feasible to do so, reporting the number of records identified from each
database or register searched (rather than the total number across all
databases/registers).**If automation tools were used, indicate how many records were
excluded by a human and how many were excluded by automation tools.From: Page MJ,
McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA
2020 statement: an updated guideline for reporting systematic reviews. BMJ
2021;372:n71. doi: 10.1136/bmj.n71. For more information, visit:http://www.prisma-
statement.org/
Data extracted from each paper satisfying the inclusion criteria was entered into a
summary table in the following categories: authors, year of publication, sample size,
gender .In the current review, prevalence of stroke patients with ideomotor apraxia was
assessed in each study. No ethical approval was required as the systematic review is based on
published data.
The Boolean Operators were utilized in combining search terms. Boolean Operators
used were "OR" to expand "AND" to limit the search. Electronic Searches that were utilized
in searching the terms are the following:
1. PUBMED
2. COCHRANE
3. SCIENCE DIRECT
4. RESEARCH GATE
5. EBSco-Host
The researchers apply the inclusion/exclusion criteria from random and relevant
articles that independently utilize the Boolean Search Strategy to search in the databases. To
categorize the article, three labels were used by each researcher in determining the relevant,
irrelevant, or uncertain outcome. It follows the condition of the combinations of
disagreements determined by the number of researchers. PRISMA flow diagram (figure 2)
outlines the process of selecting the studies. The studies accumulated were appraised by the
researchers, CASP: Critical Appraisal Skills Checklists, attached under Appendix .
PRISMA 2020 flow diagram for new systematic reviews which included searches of
databases, registers and other sources
*Consider, if feasible to do so, reporting the number of records identified from each
database or register searched (rather than the total number across all databases/registers).**If
automation tools were used, indicate how many records were excluded by a human and how
many were excluded by automation tools.From: Page MJ, McKenzie JE, Bossuyt PM,
Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated
guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For
more information, visit:http://www.prisma-statement.org/
The Evidence Hierarchy (figure 2) was used to identify the clinical studies for the
Evidence-Based Practice. The Evidence Hierarchy guarantees the quality of the studies that
are accumulated. A designated position in the hierarchy will determine the level of evidence
that is relevant for the research under the methodological quality of the design, validity, and
applicability to patient care. Determining the Systematic limitations, risk of bias is used to
analyze the research that will misreport the result.
3.7 Outcomes
The primary outcome measure tool used in this study was the TheFugl-Meyer
Assessment for Upper Extremity (FMA-UE) was used as the primary outcome measure.
Secondary outcomes included the Box and Block Test (BBT), the Modified Ashworth Scale
(MAS), and the Functional Independence Measure (FIM).
APPENDIX A
Budget:
The following table shows the items and estimated budgeted amounts for each particulars in
preparation and conducting of the study.
Transportation
(per day) PHP 100 6 PHP 600
Personal data
connection PHP 100 6 PHP 600
APPENDIX B
Time Frame:
Presented diagram shows research tasks to be completed within a specific time frame.
APPENDIX C
Letter to the Ethics Committee
Ethics Committee
December 08, 2021
Faculty of College of Physical Therapy Cell Phone no: 09296863128
Re: Ethical approval to conduct study of “Enhancing Cortical Activation during Action
Observation Therapy for Upper Limb Rehabilitation in patients with Apraxia after
Stroke: A systematic Review”
Dear Sir/Madam,
On behalf of the group, I am a 3rd year physical therapy student in Our Lady of Fatima
University - Quezon City Campus and a research proposal is to be submitted as a partial
fulfillment of the course. The topic we have chosen is aimed at conducting a study of
systematic review in “Enhancing Cortical Activation during Action Observation
Therapy for Upper Limb Rehabilitation in Patients with Apraxia after Stroke” This
could benefit the future development of physical therapy practice and management in the
Philippines. Every effort has been in the development of this research proposal to be
sensitive to all ethical issues.
I would greatly appreciate your approval to perform this study through your review of the
ethical consideration. Enclosed please find a copy of the research proposal for your
consideration. Any recommendations or suggestions will be greatly appreciated, considered
and acknowledged. Should you have any questions or concerns, please do not hesitate to
contact me on the above address or cell phone number.
Yours sincerely,
Paul A. Ramirez
Group Leader
References:
● Peng, T.H.; Zhu, J.D.; Chen, C.C.; Tai, R.Y.; Lee, C.Y.; Hsieh, Y.W. Action
observation therapy for improving arm function, walking
● ability, and daily activity performance after stroke: A systematic review and meta-
analysis. Clin. Rehabil. 2019, 33, 1277–1285.
● Fu, J.; Zeng, M.; Shen, F.; Cui, Y.; Zhu, M.; Gu, X.; Sun, Y. Effects of action
observation therapy on upper extremity function, daily
● activities and motion evoked potential in cerebral infarction patients. Medicine 2017,
96
● Mancuso, M., Tondo, S. D., Costantini, E., Damora, A., Sale, P., &Abbruzzese, L.
(2021). Action Observation Therapy for Upper Limb Recovery in Patients with
Stroke: A
● Dovern, A., Fink, G., & Weiss, P. (2011, June). How to diagnose and treat limb
apraxia. Fortschritte der Neurologie-Psychiatrie. Retrieved December 5, 2021, from
https://pubmed.ncbi.nlm.nih.gov/21480158/.
● Dovern, A., Fink, G. R., & Weiss, P. H. (2012). Diagnosis and treatment of Upper
Limb Apraxia. Journal of Neurology, 259(7), 1269–1283.
https://doi.org/10.1007/s00415-011-6336-y
● Foundas, A. L., & Duncan, E. S. (2019). Limb apraxia: A disorder of learned skilled
movement. Current Neurology and Neuroscience Reports, 19(10).
https://doi.org/10.1007/s11910-019-0989-9
● Foundas, A. L. (2013). Apraxia. Neurological Rehabilitation, 335–345.
https://doi.org/10.1016/b978-0-444-52901-5.00028-9
● Pazzaglia, M., Smania, N., Corato, E., &Aglioti, S. M. (2008). Neural underpinnings
of gesture discrimination in patients with limb apraxia. Journal of Neuroscience,
28(12), 3030–3041. https://doi.org/10.1523/jneurosci.5748-07.2008
● Tani, M., Ono, Y., Matsubara, M., Ohmatsu, S., Yukawa, Y., Kohno, M., &
Tominaga, T. (2018). Action observation facilitates motor cortical activity in patients
with stroke and Hemiplegia. Neuroscience Research, 133, 7–14.
https://doi.org/10.1016/j.neures.2017.10.002
● Yang, B.-I., Ma, S.-R., & Song, B.-K. (2019). Effects of action observation training
with 1 Hz low frequency repeated transcranial magnetic stimulation on cerebral
cortex activity and hand function in patients with ideomotor apraxia after stroke.
Journal of Magnetics. Retrieved December 5, 2021, from
https://doi.org/10.4283/JMAG.2019.24.4.770.
● Bieńkiewicz, M. M. N., Brandi, M.-L., Goldenberg, G., Hughes, C. M. L.,
&Hermsdörfer, J. (2014, April 23). The tool in the brain: Apraxia in ADL. behavioral
and neurological correlates of apraxia in daily living. Frontiers in psychology.
Retrieved December 5, 2021, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4005934/.
● Yousofuddin& Young, 2019. Aging and Ischemic Stroke.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535078/
● Meaghan Roy-O’Reilly, Louise D McCullough, Age and Sex Are Critical Factors in
Ischemic Stroke Pathology, Endocrinology, Volume 159, Issue 8, August 2018, Pages
3120–3131,https://doi.org/10.1210/en.2018-00465
● Park, J. E. (2017). Apraxia: Review and update. Journal of Clinical Neurology, 13(4),
317. https://doi.org/10.3988/jcn.2017.13.4.317
● Dovern, A., Fink, G. R., & Weiss, P. H. (2012). Diagnosis and treatment of Upper
Limb Apraxia. Journal of Neurology, 259(7), 1269–1283.
https://doi.org/10.1007/s00415-011-6336-y
● Dovern, A., Fink, G., & Weiss, P. (2011, June). How to diagnose and treat limb
apraxia. Fortschritte der Neurologie-Psychiatrie. Retrieved December 5, 2021, from
https://pubmed.ncbi.nlm.nih.gov/21480158/.
● Park, W., Kim, J., & Kim, M. Y. (2021). Efficacy of virtual reality therapy in
Ideomotor Apraxia Rehabilitation. Medicine, 100(28).
https://doi.org/10.1097/md.0000000000026657
● Apraxia Information Page. (NIH, 2019). https://www.ninds.nih.gov/Disorders/All-
Disorders/Apraxia-Information-Page
● Park, J. E. (2017). Apraxia: Review and update. Journal of Clinical Neurology, 13(4),
317. https://doi.org/10.3988/jcn.2017.13.4.317 recent studies designed to use action
observation tasks for the rehabilitation of this devastating disorder (Pazzaglia and
Galli, 2019).
● Buchmann, I., Dangel, M., Finkel, L., Jung, R., Makhkamova, I., Binder, A.,
Dettmers, C., Herrmann, L., Liepert, J., Möller, J. C., Richter, G., Vogler, T., Wolf,
C., & Randerath, J. (2019). Limb apraxia profiles in different clinical samples. The
Clinical Neuropsychologist, 34(1), 217–242.
https://doi.org/10.1080/13854046.2019.1585575