SYSTEMATIC REVIEW article
Front. Neurol.
Sec. Neurorehabilitation
Volume 16 - 2025 | doi: 10.3389/fneur.2025.1567421
This article is part of the Research TopicCognitive Strategies in motor learning and RehabilitationView all 10 articles
Combined Action Observation and Motor Imagery Practice for Upper-Limb Recovery Following Stroke: A Systematic Review and Meta-Analysis
Provisionally accepted
- 1Teesside University, Middlesbrough, United Kingdom
- 2Newcastle University, Newcastle upon Tyne, North East England, United Kingdom
- 3Kleijnen Systematic Reviews (United Kingdom), York, United Kingdom
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Optimal upper limb recovery requires high-dose physiotherapy; however, this essential component of rehabilitation is under-delivered. Mental practice represents an accessible and cost-effective adjunct to conventional therapy. We therefore evaluated the efficacy of an enhanced mental practice treatment (combined action observation and motor imagery, AO+MI) for promoting upper limb recovery post stroke.Methods: Searching 10 databases, we identified 18 eligible studies (N=336), comprising nine randomised controlled trials (RCTs) and nine non-randomised controlled trials (non-RCTs). RCTs were meta-analysed using upper limb function outcomes (Fugl-Meyer Assessment for upper extremity, FMA-UE; Action Research Arm Test, ARAT). Non-RCTs (not eligible for meta-analysis) were narratively synthesised using upper limb and neuroimaging outcomes.Results: Seven RCTs reported FMA-UE scores (n=189), where the standardised mean difference (SMD) for AO+MI treatments was moderate (SMD=0.58, 95%CI: 0.13-1.04, p=0.02). Two additional RCTs reported ARAT scores. Meta-analysing the combined FMA-UE and ARAT scores (n=239) revealed SMD=0.70 (95%CI: 0.32-1.09, p=0.003). No significant correlations existed between the pooled effect size and several moderators (age, time since stroke, intervention duration, control condition, outcome measure and AO+MI arrangement), indicating consistent AO+MI practice effects. Overall, AO+MI significantly improved upper limb function across all nine RCTs, and all nine narratively synthesised studies, including neuroimaging outcomes. Limitations included inconsistent terminology, intervention design, clarity of reporting, and modality.Discussion: AO+MI practice can promote upper limb recovery following stroke. AO+MI can therefore be used as a bridge between AO therapy (requiring little effort in early recovery), and the more cognitively demanding MI. Researchers must adopt standardised reporting protocols to further establish AO+MI practice efficacy.
Keywords: Combined Action Observation and Motor Imagery1, Mental Practice2, Stroke Survivors3, stroke rehabilitation4, Upper limb Recovery5, Mirror Neurons6, Imitation Learning7, Neuroplasticity8
Received: 27 Jan 2025; Accepted: 30 Jun 2025.
Copyright: © 2025 Lin, Eaves, Franklin, Robinson, Binks and Emerson. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Dan Lin, Teesside University, Middlesbrough, United Kingdom
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