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Evidence from cognitive neuroscience supports action observation as part of an integrated approach to stroke rehabilitation
Manual Therapy 16 (2011) 40e41
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
3rd International conference on movement dysfunction 2009
Evidence from cognitive neuroscience supports action observation as part of an integrated approach to stroke rehabilitation Paul Holmes* IPR, Department of Exercise and Sports Science, Manchester Metropolitan University, Hassall Road, Alsager, Cheshire, ST7 2HL, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 March 2010 Received in revised form 28 June 2010 Accepted 29 June 2010
This is an invited extended abstract from 3rd ICMD. Ó 2010 Elsevier Ltd. All rights reserved.
Keywords: Stroke Action observation Psychology
This review of cognitive neuroscience research aims to show that observing meaningful actions, for example, using a rowing machine (Fig. 1), can contribute positively to the stroke rehabilitation process. Following a cerebrovascular accident, individuals may be left with chronic motor impairment (e.g. hemiplegia), and cognitive and psychological disability. Fortunately, recent advances in brain imaging have led to a greater understanding of the mechanisms of post-stroke recovery. This knowledge has been essential for optimizing the efficacy of interventions aimed at promoting motor recovery. All forms of neural reorganisation are possible following stroke and include: synaptogenesis; diaschisis, sprouting from surviving neurons; and recruitment of functionally homologous pathways (Rossini, Calautti et al., 2003) Therefore, any functional post-stroke intervention should attempt to enrich and optimise neural stimulation in order to promote this brain plasticity. Unfortunately, many traditional therapies have tended to focus on the recovery of prescriptive physical functions and on the resumption of generic activities of daily living and, in so doing, have neglected previously valued activities which have personal importance to individuals (Cott, Wiles et al., 2007). Research that has attempted to address some of these concerns, by considering the effectiveness of motor imagery after stroke, has suggested some promising results (see Page, 2010 for a review). However, a number of practical and procedural concerns still remain (see Holmes,
* Tel.: þ44 161 247 5342; fax: þ44 161 247 6375. E-mail address: [email protected]. 1356-689X/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2010.06.011
2007). Until recently, video presented practical problems for the amateur user; cost, size of equipment, technological understanding of hardware and editing software were all barriers to its use. The developments in ubiquitous digital media now allow for the quick and easy production of high definition images that can address imagery generation and ability problems, and provide relevant contextual information. As well as the methodological benefits of this approach, action observation has also received support from the neuroscience literature. Cortical activity in parieto-frontal circuits during action observation has been studied extensively over the past two decades; neurons in these areas being proposed to possess mirror properties since they are active during both action execution as well as action observation. Whilst, debate is still ongoing regarding the involvement of these circuits in, for example, social cognition and action and intention understanding, there is growing evidence that they contribute to the motoric understanding of goals and intentions that comes with action observation of self and others. From data in our own studies, we have demonstrated indirect evidence for some of these behaviours to support our work with stroke patients. Using electroencephalography (EEG) during the observation and execution of non-object-related movements, Calmels, Holmes et al. (2006) studied event-related desynchronization and synchronization of brain activity prior to, and during, observation and execution of finger movements (typical of those used in stroke rehabilitation) in four brain frequency bands. The results revealed that there was no significant difference in EEG cortical activity between the action observation condition and the execution conditions. Whilst there was not an identical match of
P. Holmes / Manual Therapy 16 (2011) 40e41
41
MEP amplitude was only modulated in a specific, functional finger muscle (FDI) during the action observation. Taken together, the EEG and TMS data provide evidence for a cortical and skeletomuscular involvement during action observation that could be seen to be facilitative within a stroke rehabilitation context. Using these findings to support our applied work with stroke groups, we follow an in-depth interview procedure to identify: contextually-relevant and meaningful actions; the important stimuli associated with the actions; and patient’s behavioural and emotional responses to such stimuli. These scripts are used to direct highly individualised DVDs to recreate personally meaningful actions. Our findings from case studies (Chatterton, Ewan et al., 2008), and group-based studies (Ewan, Kinmond et al., 2010), provide strong psychosocial and functional activity support for the procedure and the use of action observation as an adjunct to more traditional physical therapies. 1. Summary The research reviewed here provides evidence to support the use of action observation in stroke rehabilitation. The data supports, in part, (i) a spatio-temporal similarity between central markers of action execution and action observation and (ii) increased MEP amplitude during action observation. The application and extension of these findings will reveal how action observation can support physical therapies for improvements in motor function and affective behaviour and allow patients to return to activities which were valued pre-stroke (Robison, Wiles et al., 2009). Fig. 1. Patient engaging with rowing machine DVD. In this example, the visual perspective is first person. The viewing behaviour was selected by the patient. [Photograph used with patient’s permission].
EEG cortical indices, this study provided indirect support for the existence of a mirror neuron system in humans that could support clinical interventions. The nature of the cortical activity revealed in this, and similar studies, suggests actioneobservation may facilitate the physical therapies used during traditional treatments. We have also investigated action observation and the existence of a motor-resonance mechanism in the human brain using transcranial magnetic stimulation (TMS). Observation of an action, in the absence of overt movement, modulates the excitability of the corticospinal pathway with a resultant increase in the amplitude of the motor evoked potentials (MEPs) specific to the muscles involved in the observed action. MEPs during the observation of a ball pinching action (again, similar to tasks in some rehabilitation therapies) was facilitated when compared to observation of a static hand or a blank screen, irrespective of whether participants had performed the same ball pinching action prior to observing it. Furthermore, the
References Calmels C , Holmes PS, Jarry G, Leveque J-M , Stam CJ . Cortical activity prior to, and during, observation and execution of sequential finger movements. Brain Topography 2006;19:77e88. Chatterton H, Ewan L, Kinmond K, Haire A, Smith N, Holmes P. Observation of meaningful activities: a case study of a personalized intervention on poststroke functional state. Journal of Neurologic Physical Therapy 2008;32:52e9. Cott C, Wiles R, Devitt R. Continuity, participation and transition: preparing clients for life in the community post-stroke. Disability and Rehabilitation 2007;29: 1566e74. Ewan LM, Kinmond K, Holmes PS. An observation-based intervention for stroke rehabilitation: Experiences of eight individuals affected by stroke. Disability and Rehabilitation; 2010:1e10. doi:10.3109/09638288.2010.481345. Holmes PS. Theoretical and methodological problem for imagery in stroke rehabilitation: an observation solution. Rehabilitation Psychology 2007;52:1e10. Page SJ. An overview of the effectiveness of motor imagery after stroke: a neuroimaging approach. In: Guillot A, Collet C, editors. The neurophysiological foundations of mental and motor imagery. New York: Oxford University Press; 2010. p. 145e59. Robison J, Wiles R , Ellis-Hill C, McPherson K, Hyndman D, Ashburn A. Resuming previously valued activities post-stroke: who or what helps? Disability and Rehabilitation 2009;31:1555e66. Rossini PM, Calautti C, Pauri F , Baron JC . Post-stroke plastic reorganisation in the adult brain. The Lancet Neurology 2003;2:493e502.
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
3rd International conference on movement dysfunction 2009
Evidence from cognitive neuroscience supports action observation as part of an integrated approach to stroke rehabilitation Paul Holmes* IPR, Department of Exercise and Sports Science, Manchester Metropolitan University, Hassall Road, Alsager, Cheshire, ST7 2HL, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 March 2010 Received in revised form 28 June 2010 Accepted 29 June 2010
This is an invited extended abstract from 3rd ICMD. Ó 2010 Elsevier Ltd. All rights reserved.
Keywords: Stroke Action observation Psychology
This review of cognitive neuroscience research aims to show that observing meaningful actions, for example, using a rowing machine (Fig. 1), can contribute positively to the stroke rehabilitation process. Following a cerebrovascular accident, individuals may be left with chronic motor impairment (e.g. hemiplegia), and cognitive and psychological disability. Fortunately, recent advances in brain imaging have led to a greater understanding of the mechanisms of post-stroke recovery. This knowledge has been essential for optimizing the efficacy of interventions aimed at promoting motor recovery. All forms of neural reorganisation are possible following stroke and include: synaptogenesis; diaschisis, sprouting from surviving neurons; and recruitment of functionally homologous pathways (Rossini, Calautti et al., 2003) Therefore, any functional post-stroke intervention should attempt to enrich and optimise neural stimulation in order to promote this brain plasticity. Unfortunately, many traditional therapies have tended to focus on the recovery of prescriptive physical functions and on the resumption of generic activities of daily living and, in so doing, have neglected previously valued activities which have personal importance to individuals (Cott, Wiles et al., 2007). Research that has attempted to address some of these concerns, by considering the effectiveness of motor imagery after stroke, has suggested some promising results (see Page, 2010 for a review). However, a number of practical and procedural concerns still remain (see Holmes,
* Tel.: þ44 161 247 5342; fax: þ44 161 247 6375. E-mail address: [email protected]. 1356-689X/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2010.06.011
2007). Until recently, video presented practical problems for the amateur user; cost, size of equipment, technological understanding of hardware and editing software were all barriers to its use. The developments in ubiquitous digital media now allow for the quick and easy production of high definition images that can address imagery generation and ability problems, and provide relevant contextual information. As well as the methodological benefits of this approach, action observation has also received support from the neuroscience literature. Cortical activity in parieto-frontal circuits during action observation has been studied extensively over the past two decades; neurons in these areas being proposed to possess mirror properties since they are active during both action execution as well as action observation. Whilst, debate is still ongoing regarding the involvement of these circuits in, for example, social cognition and action and intention understanding, there is growing evidence that they contribute to the motoric understanding of goals and intentions that comes with action observation of self and others. From data in our own studies, we have demonstrated indirect evidence for some of these behaviours to support our work with stroke patients. Using electroencephalography (EEG) during the observation and execution of non-object-related movements, Calmels, Holmes et al. (2006) studied event-related desynchronization and synchronization of brain activity prior to, and during, observation and execution of finger movements (typical of those used in stroke rehabilitation) in four brain frequency bands. The results revealed that there was no significant difference in EEG cortical activity between the action observation condition and the execution conditions. Whilst there was not an identical match of
P. Holmes / Manual Therapy 16 (2011) 40e41
41
MEP amplitude was only modulated in a specific, functional finger muscle (FDI) during the action observation. Taken together, the EEG and TMS data provide evidence for a cortical and skeletomuscular involvement during action observation that could be seen to be facilitative within a stroke rehabilitation context. Using these findings to support our applied work with stroke groups, we follow an in-depth interview procedure to identify: contextually-relevant and meaningful actions; the important stimuli associated with the actions; and patient’s behavioural and emotional responses to such stimuli. These scripts are used to direct highly individualised DVDs to recreate personally meaningful actions. Our findings from case studies (Chatterton, Ewan et al., 2008), and group-based studies (Ewan, Kinmond et al., 2010), provide strong psychosocial and functional activity support for the procedure and the use of action observation as an adjunct to more traditional physical therapies. 1. Summary The research reviewed here provides evidence to support the use of action observation in stroke rehabilitation. The data supports, in part, (i) a spatio-temporal similarity between central markers of action execution and action observation and (ii) increased MEP amplitude during action observation. The application and extension of these findings will reveal how action observation can support physical therapies for improvements in motor function and affective behaviour and allow patients to return to activities which were valued pre-stroke (Robison, Wiles et al., 2009). Fig. 1. Patient engaging with rowing machine DVD. In this example, the visual perspective is first person. The viewing behaviour was selected by the patient. [Photograph used with patient’s permission].
EEG cortical indices, this study provided indirect support for the existence of a mirror neuron system in humans that could support clinical interventions. The nature of the cortical activity revealed in this, and similar studies, suggests actioneobservation may facilitate the physical therapies used during traditional treatments. We have also investigated action observation and the existence of a motor-resonance mechanism in the human brain using transcranial magnetic stimulation (TMS). Observation of an action, in the absence of overt movement, modulates the excitability of the corticospinal pathway with a resultant increase in the amplitude of the motor evoked potentials (MEPs) specific to the muscles involved in the observed action. MEPs during the observation of a ball pinching action (again, similar to tasks in some rehabilitation therapies) was facilitated when compared to observation of a static hand or a blank screen, irrespective of whether participants had performed the same ball pinching action prior to observing it. Furthermore, the
References Calmels C , Holmes PS, Jarry G, Leveque J-M , Stam CJ . Cortical activity prior to, and during, observation and execution of sequential finger movements. Brain Topography 2006;19:77e88. Chatterton H, Ewan L, Kinmond K, Haire A, Smith N, Holmes P. Observation of meaningful activities: a case study of a personalized intervention on poststroke functional state. Journal of Neurologic Physical Therapy 2008;32:52e9. Cott C, Wiles R, Devitt R. Continuity, participation and transition: preparing clients for life in the community post-stroke. Disability and Rehabilitation 2007;29: 1566e74. Ewan LM, Kinmond K, Holmes PS. An observation-based intervention for stroke rehabilitation: Experiences of eight individuals affected by stroke. Disability and Rehabilitation; 2010:1e10. doi:10.3109/09638288.2010.481345. Holmes PS. Theoretical and methodological problem for imagery in stroke rehabilitation: an observation solution. Rehabilitation Psychology 2007;52:1e10. Page SJ. An overview of the effectiveness of motor imagery after stroke: a neuroimaging approach. In: Guillot A, Collet C, editors. The neurophysiological foundations of mental and motor imagery. New York: Oxford University Press; 2010. p. 145e59. Robison J, Wiles R , Ellis-Hill C, McPherson K, Hyndman D, Ashburn A. Resuming previously valued activities post-stroke: who or what helps? Disability and Rehabilitation 2009;31:1555e66. Rossini PM, Calautti C, Pauri F , Baron JC . Post-stroke plastic reorganisation in the adult brain. The Lancet Neurology 2003;2:493e502.