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Akramazad A 10 1528 6 9a4ec16
Akramazad A 10 1528 6 9a4ec16
httpp://mjiri.iums.aac.ir
Med dical Journa al of the Islam
mic Republicc of Iran (MJIRI)
Med J Islam Repub Irran. 2021(31 Decc);35.193. https:///doi.org/10.47176
6/mjiri.35.193
Abstract
Background d: Action Obserrvation Therapy y (AOT) is a toop-down approaach that has been recently intrroduced in the rehabilitation
r o
of
neurological diisorders mainlyy after stroke. The main goal oof this study was to investigate the effects andd feasibility of a new technique
in AOT proceddure (called sellf-AOT) following periods of no treatment an nd routine AOT T intervention on upper limb motor functionn,
occupational peerformance andd neurophysiolo ogical changes iin a stroke patieent.
Methods: A single-subject A-B-A-C desig gn was used annd a 58-year-old d woman with a 3-year historyy of left hemip plegia poststrokke
participated in this study. In the baseline (AA1, A2) phasess, the patient reeceived no treattment. In the fiirst interventionn (B phase), she
received a 4-wweek AOT, andd in the second intervention (C C phase), a 4 week
w of Self-A
AOT was practiiced. In all phaases, upper limbb
motor recoveryy as a target outtcome was evalu uated on 4 occaasions using thee Fugl-Meyer assessment. Uppper limb functio on, dexterity andd
spasticity weree assessed usinng Action Reseearch Arm Tesst, Box-Block Test T and Modiified Modified Ashworth Scaale respectivelyy.
Occupational P Performance/Saatisfaction was assessed with C Canadian Occup pational Performance Measuree and to assess neuroplasticityy,
Motor Evokedd Potential waas recorded by y Transcranial Magnetic Stim mulation. Visual analysis, slo lope, and percentage of nonn-
overlapping daata were used foor assessing the changes betweeen phases.
Results: Perccentage of nonn-overlapping data
d and slopes indicated that motor recoverry had clinically ly relevant imp provements afteer
both interventioons compared to t baselines. Otther outcomes aalso showed im mprovements ex xcept for spasticcity of wrist/elb
bow flexors andd
Motor Evoked Potential of oppponens indicis.
Conclusion: Self-AOT mayy be as effectiv ve as other proocedures of AO OT for improviing upper limbb motor functio on, occupationaal
performance/saatisfaction, and cortical excitabbility post-strokke.
Introduction
Stroke cann lead to suudden disrupttion and advverse chan
nge in perform
mance and enngagement of everyday ac--
________________________________
Corresponding
C auth
hor: Dr Akram Azad
d, azad.a@iums.ac.ir
What is “alreadyy known” in thhis topic:
↑W
1.
Rehabilitation Ressearch Center, Dep partment of Occup pational Therapy, SSchool of As an effective and beneficial m method, AOT is i recently used
Rehabilitation Scieences, Iran Universitty of Medical Sciencces, Tehran, Iran forr stroke rehabbilitation. AOT T is usually available and
2.
Neuromusculoskelletal research centeer, Iran University of o Medical Sciencess, Tehran, ineexpensive. Therrefore such chaaracteristics haave led to morre
3.
Iran inv
vestigations and
d research on thhis new method..
Mental Health Ressearch Center, Scho ool of Behavioral Sciences
S and Mentaal Health,
niversity of Medical Sciences, Tehran, Iran
Tehran Institute off Psychiatry, Iran Un
4. →What
→ this articcle adds:
School of Rehabilittation Sciences, Uniiversity of Ottawa, Ottawa,
O Canada
The feasibility and efficacy off a new proceedure for AOT T
impplementation, here called “Self-AOT”, was tested
succcessfully. Instead of using aanother person as a model foor
film
mmaking in thiss new method, a patient can acct as a model foor
herr/himself. Acco ording to the ressults, Self-AOT
T as like currennt
AOOTs, could imp prove upper lim mb function an nd corticospinaal
exccitation in strok
ke patient.
Self-Action O
Observation Therapy
T
tivities (1). A
About 70-80% % of stroke su urvivors havee im- whicch the movem ments of the unnaffected limb b are reflectedd
pairments in ttheir upper lim mb (UL) (2). Many of them m do in a mirror that iss placed in froont of the patiient and in thee
not regain fuunctional use of the paretic UL, which can mid--sagittal planee. In this proceess, the brain is deluded andd
affect self-carre and also coommunity lifee participationn (3). the patient feels that the affeccted limb is moving. AOT T
The patients usually remain dependent on some actiivity and MT may hav ve some comm mon points an nd theories buut
of daily livinng, which oftten requires th he use of onne or theirr procedure iss different (199). Scarce stu udies have exx-
both ULs (4)). There are new n rehabilittation methodds to amin ned some of the features oof the MT technique whilee
enhance recovvery of upperr extremity po ost-stroke succh as impllemented in AOT A format iin stroke patiients (19, 20)).
robotics, brainn stimulation,, mirror therap py and actionn ob- Nag gai and Tanak ka reported thhat in healthy y subjects, obb-
servation, althhough researcch is still need ded to investiigate servving one’s ow wn hand provookes more brrain activationn
their variant aaspects of efficacy (5). thann observing oth her’s hand (211). Also, it has been pointedd
Action Obsservation Therrapy (AOT) is a novel rehaabili- out in Bandura’s theories of oobservational learning, thaat
tation strategyy used in patieents with neurrological disoorders the more
m a model that resemblees the observeer performs ann
such as cerebrral palsy, Parkkinson’s diseaase, and strokee (6). activvity successfuully, the more re likely the observer
o is too
In this methood, some movvements and actions of heealthy perfform the activ vity with succcess and self-efficacy (22)..
models are shhown on a viddeo or a live deemonstration;; then Therrefore, feasibility of usingg the patientss as their ownn
the patient m must try to immitate and execute those acctions mod dels in AOT process woulld be a worth hy issue to bee
(7). Neuroscieentific studiess have claimed d that AOT's ttheo- survveyed.
retical basis iis on the eviddence that ob bservation of ggoal- In
n this study, thhe first hypotthesis was thaat AOT, whenn
directed actioon (8) activattes the Mirro or Neuron Syystem incluuded in meaningful tasks aand occupations selected byy
(MNS), whichh is the same neural activee mechanism w while the patient,
p d enhance mottor recovery, spasticity, thee
could
executing thaat action (6).. Functional connections have perfformance of UL,U cortical exxcitability and d also occupaa-
been reportedd between mirrror neuron arreas and the m motor tionaal performancce/satisfactionn. The second d and main hyy-
cortex (9). Thhe activation of MNS during the AOT pro- pothhesis of this sttudy was thatt if AOT coulld be modifiedd
cess stimulattes cortical motor
m represen ntations that may by using
u the mirrored videoss of the patient practicingg
lead to the U UL motor recoovery after strroke (10). Acccord- goall-directed and d meaningful actions with h her/his nonn-
ing to the liteerature, there are
a significan nt improvemennts in pareetic UL (Whille an illusionn of moving and a activity of o
UL motor funnction as a ressult of AOT (7 7, 8, 11), althhough the affected side is created), it could imp prove the outt-
the evidence for using thiis method as an interventioon to commes mentioned d earlier moree than usual AOT. To thee
promote UL motor functiion was estim mated as modderate best of our knowlledge, this is tthe first study y to investigatee
(7). the feasibility and d efficacy of Self-AOT on n UL functionn,
To improvee AOT effectss, this method d has been invvesti- spassticity, cortico
ospinal excitabbility and occcupational perr-
gated in combbination with other treatments such as m mental formmance besides the UL motorr recovery.
imagery (12)), functional electrical stim mulation (13 ), or
botulinum toxxin injectionss (14). Althou ugh there is noot an
individual staandard protocol for AOT, some s researchh has Methods
M
examined varriations in its characteristics
c s, such as shoowing Exxperimental design
d
videos of acttions recordedd from multip ple angles (11 , 15) Too show the efffectiveness oof a novel meethod of interr-
or at differentt speeds (15). There are also studies that have venttion or to com mpare it withh established interventionss,
used simple m movements or less meanin ngful tasks forr ob- Sing gle-Case Experimental Deesign (SCED)) would be a
servation annd executionn such as thumb addduc- reasonable choicee. We used Sinngle-Case Reporting guidee-
tion/abductionn, squeezinng a ball or transfeerring liness in Behavioraal interventionns (SCRIBE) to observe thee
blocks/pegs (16, 17). Althoough some reesearch has incclud- rigor and quality ofo the study (223).
ed more com mplex and gooal-directed taasks during A AOT, Too consider thee two hypothheses introducced earlier, wee
such as worrking with the t computerr mouse, turrning seleccted a SCED with baselinees and two ph hases of interr-
cards/coins , aand drinking a cup of tea (8, 15), there iis not venttions. This stu udy examinedd the benefitss of Self-AOT T
sufficient reseearch on the use
u of selected d tasks/occupaations commpared to Actiion observatioon using an alternate
a treatt-
by the patiennts which are more meanin ngful to them. It is men nt design withh A1BA2C seqquence. The A phases conn-
believed thatt the mirror neuron system m is more aactive sisteed of baselinee periods of 2 weeks with no treatmentss;
when observiing a complexx and purposeful activity com- A1 before
b phase B and A2 bettween 2 training paradigm ms
pared to a sim mple action, so one way forr more MNS exci- (B and
a C). In thee B phase, thee subject undeerwent 12 sess-
tation might bbe using activvities that are ini line with evvery- sionns (3 times per week for 4w wk) of AOT (watching andd
day activitiess and based on one's exp periences (18)). As imitating healthy model’s task execution vid deos). In the C
mentioned eaarlier, AOT iss based on MNS, M and if M MNS phasse subject undderwent 12 sesssions (3 timees per week foor
function could be augmeented within this techniquue, it 4wk k) of a new AOT proceddure here called Self-AOT T
would enrichh this new neuuro-rehabilitattion treatmentt and (wattching and imitating her ow wn task executtion videos).
contribute to a better motoor recovery an nd performannce in
paretic UL oof stroke patients. Anotherr possible waay to Pa
articipant
improve MNS S excitation could
c be derivved from a neeuro- A 58-year-old woman
w (E.Z) with right paarietal lobe iss-
rehabilitation method callled “Mirror Therapy
T (MT))” in chem
mic stroke resulting in left
ft-sided hemip
plegia was ree-
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mjiri.iums.ac.ir
2 Med J Isslam Repub Iraan. 2021 (31 Deec); 35:193.
A. Shamili, et all.
Table 1. Eatingg related tasks (I-IIV), their subtaskks, and the proceddure time
Task I Task II Task IIII Task IV AO Film Performance
Subtask Pour water from ma Pou ur water from Drink from a glass Eat a piece of carrot Time Time
bottle into a gllass pittcher to glass of waterr with
w fork
A Reach to botttle Reaach to pitcher Reach to glass Re
each to fork 2m 3m
B Grasp the botttle Graasp the pitcher Grasp the glass
g Graasp the fork 2m 3m
C B
Bring the bottle near
n to Bringg pitcher near to Bring glass near
n to Bring fork near to the 2m 3m
the glass the glass the moutth carrot
D P
Pour water into a glass pouur water into a Drink from glass Bringg the carrot to 2m 3m
glass the
t mouth
E Reach out to dessktop Reach h out to desktop Reach out to desktop
d Reachh out to the dish 2m 3m
F Release the bottle Releease the pitcher Release the glass Releease the fork 2m 3m
G Rest arm Rest arm m
Rest arm Rest arm 2m 3m
H Whole Taskk Whole
W Task Whole Taask Whole
W Task 2m 3m
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mjiri.iums.ac.ir
4 Med J Isslam Repub Iraan. 2021 (31 Deec); 35:193.
A. Shamili, et all.
Fig. 2. EZ is waatching and imitaating a video of herself as if she is practicing with her
h left (plegic)
hand in the videeo
crease in the results was seeen toward thhe level of thee first of no
n certain dataa stability in tthe second baaseline prior too
baseline. Oncce again, durinng interventio
on 2 (phase C)), the phasse C. The estiimated slopes of A1, B, A2 and C phases
client demonsstrated a slope in UL moto or recovery w with a weree 0.25, 1.75, (-)2
( and 2.5, rrespectively. AsA a final moo-
tendency towward improvem ment with a beest FMA-UE sscore tor recovery
r resullt, after two m
months of folllow-up, a mildd
attained durinng all phases of the study (46/66).
( The PND decrrease in the score is reportedd (FMA-UE= =39).
C was also 100% compareed to
of interventioon 2 (phase C) Thhe results of other
o outcomee measures beefore and afteer
the first baseline. We cannnot calculate an exact PND D for eachh intervention are presentedd in Table 2.
intervention 2 compared with
w the second d baseline beccause
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mjiri.iums.ac.ir
6 Med J Isslam Repub Iraan. 2021 (31 Deec); 35:193.
A. Shamili, et all.
of tasks (I-IV
V) used in the interventions
i that are not foocus- apprroximately co onfirm the efffectiveness off Self-AOT inn
ing on pinch aand grip skillss. In contrast to BBT and F FMA, the range of AO OT effectivenness. In variaables such as a
no decrease in ARAT tottal scores waas reported duuring FMA A-UE, the Seelf-AOT sloppe and chang ges were evenn
baseline 2. TThis might bee explained by the relationn be- greaater and moree significant tthan the AOT T interventionn.
tween extensoor indicis ME EP improvemeents and ascennding With h regard to thee spasticity, oonly wrist and elbow flexorrs
scores of ARA AT’s grasp suub-test during the research pphas- weree evaluated, so s it is suggessted to consid der the fingerrs
es. The graspp section of ARAT
A is mainnly about grassping spassticity in futu ure research. Since washo out periods inn
and releasingg different siizes of block ks; the largerr the outccome measures such as COPPM are not op perational, andd
blocks the moore finger exteension is need ded. So, the reesults the effect
e of learn
ning is likely tto affect task repetitions
r andd
of the grasp section mighht be approved by descennding pracctice at home and consequuently the ressults, it is noot
trend of extennsor indicis MEP
M as a reprresentative foor ex- posssible to state with
w certainty tthat the secon nd interventionn
tensor musclees improvemennt. is suuperior to the first one. If rrandomized cllinical trial ree-
search with an appropriate sam ample size is performed onn
Effects on M
MMAS these two types of interventionns, their effectiveness can bee
In the casee of spasticityy in the elboww and wrist fl flexor commpared more acccurately.
muscles, no sspecific changge is reported in our results.. In a It can be proposed that in sittuations wheree it is not poss-
survey compaaring an AOT T group with a control grouup of siblee to make film ms from healtthy models an nd spend timee
patients with sub-acute strroke, Kim an nd colleagues (15) prepparing multiplle films, the SSelf-AOT method is probaa-
couldn’t repoort a significannt difference in spasticity reeduc- bly a proper choice because, w with the assistaance of familyy
tion between the two grouups. Similar to o the tasks useed in or thherapist, many y patient-seleccted activities can be filmedd
our research,, the tasks exxercised in Kim’s
K study were fromm the non-affeected side andd in preferred setting withinn
some routine tasks. One way to reduce spasticity
s is reepeti- a short time. The exercise and m movement vid deos of his/heer
tive and dynnamic stretchiing (42), and d although duuring heallthy side can beb mirrored annd edited via a simple techh-
routine daily activities, maany muscles may be elonggated niquue that is availlable in most m mobile phonees and computt-
they generallyy don’t reach the maximal length and prroba- ers. Although this technique hhas some sim milar aspects too
bly do not imp
mprove in musccle tone. So without
w any adjdjunct mirrror therapy, an nd they both teend to make visual
v illusionns
techniques foor managing spasticity,
s obsservation and exe- and to trick the brrain but they have their ow wn uniquenesss.
cution of eatinng activities and
a other daily y activities rooutine In MT
M because of the size andd the situation n of the mirroor
tasks may noot affect spastticity. In contrrast to the prresent box,, the patient may be limiited to watch h and perform m
study, in a cllinical trial, Zhu
Z et al. repo orted a signifficant somme desktop task ks through 1 aangle and cann not see her/his
spasticity reduuction after AOT.
A Besides the observatioon of who ole body situaation. In contrrast, Self-AOT can providee
tasks in the AAOT group, theyt provided
d a combinatioon of more complicated d and routine ttasks such as hair combingg,
simple but m multi-joint movvements such as fingers addduc- toothh brushing an nd such taskss in which oth her body partts
tion/abductionn and foreaarm supinatio on/pronation that may y be needed to o be seen from m different anngles. Besidess,
might have been the reasonn for spasticitty improvemeent in MT is based on liive demonstraations of the patients’
p intacct
both groups (8). hand ds via a mirro or box, but Seelf-AO is reco orded and cann
be watched
w anytimme and anywhhere just by ussing a TV, Lapp
Effects on mmotor evoked d potentials tab or
o smartphonee.
There are a few studies that t investigatted the MEP after Beesides contin nuing researchh on Self-AO with moree
AOT
A as an outtcome measurre of cortical representation
r n (16, stronng study desig gns, it is sugggested to applly and test this
39). The resullts of the preesent study in n MEP latenccy of techhnique in new w technologiees and approaaches such as a
Extensor
E Indicces showed a gradual and d lasting decrrease virtuual reality or game
g therapy..
during
d the inteerventions, allthough the change
c in ME EP of
opponents’
o muuscles was nott interpretablee. Clenik et al.. (16)
sttated a signifiicant effect onn corticospinall excitability w
when Co
onclusion
th
humb movem ments are in congruence with the thhumb Thhis study show ws that if a ppatient with sttroke is filmedd
movement’s
m video seen in the action ob bservation proocess. whille performing meaningfuul activities with her/his
In
n another studdy, Fu et al. (440) showed th hat when combbined heallthy side and then mirroreed versions off those videos
with
w traditionaal rehabilitation, AOT cou uld increase M MEP are shown
s and prracticed in thee form of Selff-AOT, it mayy
amplitude and also decreasee the MEP lateency. In our w work, imprrove occupatiional perform mance/satisfacttion and cortii-
although the m muscles used for recording g the corticosspinal cal excitability
e as well as UL fufunction. Self-AOT as a new w
excitability weere not as sam me as the musccles assessed iin the apprroach to the action observaation process seems
s to be as
a
mentioned
m studdies, in one of two muscless evaluated Exxten- effecctive as previous AOT metthods, althoug gh it may raisee
so
or Indicis, sim milar results were
w seen. Opponenens Poolicis more cooperation n and enthusiaasm for the paatient watchingg
muscle
m didn’t sshow a certainn MEP changee trend. and imitating her//his own videoos.
Compliancee with ethicall guidelines GM M. A mirror therapy–based actionn observation pro otocol to improvve
mo otor learning after stroke. Neurorehabil Neural Repairr.
This study was ethicallyy approved byy the Ethics C
Com- 2015;29(6):509-16.
mittee of Iraan University of Medical Sciences (IU UMS), 20. Steel KA, Mudie K, Sandoval R, Anderson D, D Dogramaci S, S
Tehran, Irann (Ethical Coode: IR.IUM MS.REC.1397.8840). Reehmanjan M, et al. a Can video sellf-modeling imprrove affected limb mb
The subject signed a writteen informed consent beforee par- reaach and grasp ability in str troke patients? J Mot Behavv.
2018;50(2):117-26.
ticipating in thhis study. 21. Nagai
N H, Tanaka a T. Action obsservation of own n hand movemennt
enh hances event-related desynchronnization. IEEE Trans T Neural Sysst
Conflict of IInterests Reehabil Eng. 2019;27(7):1407-15.
The authors ddeclare that they have no co
ompeting interrests. 22. Bandura
B A. Social foundations oof thought and action. Englewood
Cliiffs, NJ. 1986;1986:23-8.
23. Krasny-Pacini
K A,
A Evans J. Singgle-case experim mental designs to t
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