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Technology and Health Care -1 (2018) 1–7 1

DOI 10.3233/THC-181220
IOS Press

1 Effects of live and video form action

2 observation training on upper limb function
3 in children with hemiparetic cerebral palsy

Do Hyun Kima , Duk-Hyun Anb and Won-Gyu Yoob,∗

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a HIP
and MAL Laboratory, Department of Rehabilitation Science, Inje University, Gimhae, Korea
b Departmentof Physical Therapy, College of Biomedical Science and Engineering, Inje University,

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7 Gimhae, Korea

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8 Received 6 February 2018
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9 Accepted 24 March 2018
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10 Abstract.
11 PURPOSE: The purpose of this study was to investigate the effects of live and video form action observation training (AOT)
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12 on upper limb (UL) movement acceleration and function in children with cerebral palsy (CP).
13 METHODS: In total, 12 children (7 boys, 5 girls) with CP participated in this study. The children were allocated randomly to
14 live (experimental) and video (control) AOT groups. All children completed 20 treatment sessions, each 30 minutes in duration,
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15 5 days per week for a month. Mediolateral (ML) and vertical (VT) acceleration data, Jebsen-Taylor Hand Function (JTHF)
16 scores, and Box and Block Test (BBT) scores were obtained at baseline and at 4 weeks after the intervention.
RESULTS: ML and VT movement acceleration and JTHF scores were significantly lower in the live group (p < 0.05). The
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18 BBT score was significantly higher in the live than in the video group (p < 0.05).
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19 CONCLUSIONS: Our findings suggest that live AOT is more effective than video AOT for improving UL movement acceler-
20 ation and function. Clinically, our findings offer important insights for clinicians when planning AOT interventions to reduce
21 UL movement acceleration and improve UL function.
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22 Keywords: Action observation training, hemiparetic cerebral palsy, mirror neuron system, upper limb function
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23 1. Introduction

24 The definition of cerebral palsy (CP) has gradually become more specific over time. In 1964, CP
25 was defined as “a disorder of movement and posture due to a defect or lesion of the immature brain” [1].
26 Mutch et al. [2] described CP as “an umbrella term covering a group of non-progressive, but often chang-
27 ing, motor impairment syndromes secondary to lesions or anomalies of the brain arising in the early
28 stages of development”. This description mainly concentrates on motor aspects of CP, and other com-
29 mon symptoms that influence children’s daily lives are not considered. Recently, Rosenbaum et al. [3]
30 reported that “the motor disorders of CP are frequently accompanied by deficits of sensation, percep-
31 tion, cognition, communication and behavior, by epilepsy, and by secondary musculoskeletal problems.”

∗
Corresponding author: Won-Gyu Yoo, Department of Physical Therapy, College of Biomedical Science and Engineering,
Inje University, 197 Inje-ro, Gimhae, Gyeongsangnam-do 621-749, Korea. Tel.: +82 55 320 3994; E-mail: won7y@inje.ac.kr.

0928-7329/18/$35.00
c 2018 – IOS Press and the authors. All rights reserved
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2 D.H. Kim et al. / Effects of live and video form AOT on UL function in children with hemiparetic CP

32 Because of these clinical features, children with CP have difficulty with movement, mobility, self-care,
33 and social participation [3].
34 The reported worldwide prevalence of CP is 2–3 per 1,000 live births, rising to 40–100 per 1,000
35 live births in premature infants [4,5]. Additionally, the median prevalence among children who were
36 preterm infants and who weighed 1,500–2,499 g at birth was 11.2 per 1,000 live births [4]. In South
37 Korea, the annual prevalence of CP from 2004 to 2008 was 2.2, 2.3, 2.4, 2.8, and 3.2 per 1,000 infants,
38 respectively [6]. The estimated medical cost for people with CP in the US was 11.5 billion US dollars in
39 2000 [7]. In South Korea, the lifetime healthcare cost of CP was 26,383 US dollars per patient, 1.8 times
40 higher than the per person medical costs for the healthy population, of 14,579 US dollars [6].
41 Reaching has been described as a voluntary and purposeful movement of the upper limb (UL) to
42 make contact with objects [8]. Reaching is important for children in the context of activities of daily
43 living, such as dressing, eating, and playing with toys [9]. To perform smooth and successful reaching,
44 the neural and muscular systems must be synchronized [10]. However, children with CP frequently

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45 exhibit clinical UL features including reduced movement speed, coordination, and grasp strength, which
46 reduce their independence and quality of life [3]. Chang et al. [9] demonstrated that movement time

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47 and normalized jerk score were significantly greater in children with spastic CP compared with healthy
children.

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49 Known therapeutic interventions for UL movement in neurologically impaired patients include neu-
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50 rodevelopmental therapy [11], constraint-induced movement therapy [12], combined therapeutic training
51 with injections of botulinum toxin [13], and hand–arm bimanual intensive therapy [14], all of which re-
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52 quire considerable time, effort, and cost. Additionally, children with poor physical ability cannot engage
53 with a conventional therapeutic approach. Furthermore, to date, there is little evidence regarding the
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54 merits of such conventional approaches in children with CP.

55 The mirror neuron system (MNS) is a part of the neural system that is activated when animals or
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56 humans execute meaningful actions or observe similar actions performed by others. Neurons of the
57 MNS are located in the inferior parietal lobe, ventral premotor cortex, and inferior frontal gyrus in
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58 humans [15]. These neurons are activated more during the observation of purposeful movements than
59 during observation of simple motions, and are also more active when humans observe movement, such as
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60 in a video, than when they observe photographs [16]. Action observation training (AOT) is a therapeutic
61 approach based on MNS research. Previous studies of AOT found that upper extremity Fugl-Meyer
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62 motor assessment and functional test for the hemiparetic upper extremity scores were significantly higher
63 in an AOT group compared with a sham group of chronic stroke patients [17]. In addition, Kirkpatrick et
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64 al. [18] studied the effects of home-based AOT on UL function in hemiparetic CP cases and found that
65 that Assisting Hand Assessment (AHA), Melbourne assessment-2, and ABILHAND-Kids scores were
66 significantly improved in the group exposed to AOT with repeated practice compared to the group with
67 practice alone [18].
68 Although there have been some studies on AOT, none have compared the effects of live and video
69 versions of AOT in children with CP. Therefore, in this study, we investigated the effect of live and video
70 AOT on UL function in children with CP. We hypothesized that there would be a significant improvement
71 in UL function in both the live and video AOT groups, and a significantly greater improvement in UL
72 function in the live group compared with the video group.

73 2. Methods

74 We designed a single-blind (evaluator) two-group randomized controlled trial to compare the

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D.H. Kim et al. / Effects of live and video form AOT on UL function in children with hemiparetic CP 3

Table 1
Anthropometric and clinical characteristics of the children
Children Group Age Gender Height (cm) Weight (kg) Affected side HFCSa
1 Live 9 B 135.2 33.9 Right 5
2 Live 8 B 134.9 36.2 Left 6
3 Live 10 G 129.3 26.1 Right 5
4 Live 11 G 127.6 29.8 Right 6
5 Live 11 B 146.2 44.7 Right 5
6 Live 9 B 131.6 31.2 Left 6
7 Video 11 B 138.2 37.3 Left 5
8 Video 11 G 129.4 27.4 Right 5
9 Video 10 B 132.3 31.8 Right 4
10 Video 8 G 120.1 36.2 Left 6
11 Video 10 B 129.8 32.5 Left 7
12 Video 9 G 121.2 24.9 Left 5
HFCSa : House Functional Classification System.

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75 therapeutic efficacy of live AOT with that of video AOT. Children were selected according to strict

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76 criteria. Prior to participating in the study, researchers explained the trial protocol to the caregivers, all

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77 of whom signed informed consent forms. The protocol was approved by the Inje University Institutional
78 Review Board (2017-01-012).
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79 2.1. Participants
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80 Twelve children with hemiparetic CP were included in this study. The inclusion criteria were (1) aged
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81 8 to 12 years; (2) able to understand the tasks and researchers’ instructions; (3) in visual impairment. The
82 exclusion criteria were (1) above grade 2 on the modified Ashworth scale; (2) in below grade 4 on the
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83 House Functional Classification System (HFCS); (3) underwent orthopedic surgery or Botox injection
84 in UL within 6 months. Participants were recruited by researchers based at clinics in Gyeongsangbukdo.
The sample size was estimated based on a pilot study including six children. The effect size estimated
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86 from the pilot study was 2.61. To determine a suitable sample size, we carried out power analysis with
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87 G-Power software (ver. 3.1; University of Dusseldorf, Dusseldorf, Germany), for a 2.61 effect size at a
88 significance level of 0.05 and with statistical power of 80%, which showed that a minimum sample size
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89 of five per group was needed for this study. Therefore, we enrolled 12 children with CP (7 boys, 5 girls).
90 The clinical characteristics of the children are listed in Table 1.
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91 2.2. Apparatus

92 A tri-axial accelerometer (Fitmeter; Fit.Life, Inc., Suwon, Korea) was used to assess mediolateral
93 (ML) and vertical (VT) movement acceleration. The device, which was 35 × 35 × 13 mm (length ×
94 width × height) in size and weighed 13.7 g, was firmly attached to participants’ third metacarpal bone.
95 All acceleration data were assessed at 30 Hz and processed by Fitmeter Manager 2 software (Fit.Life,
96 Inc.).

97 2.3. Interventions

98 Random allocation software was used to assign the children to the live AOT (experimental) or video
99 AOT (control) group. All children completed 20 treatment sessions, each 30 minutes in duration, 5 days
100 per week for a month. The treatment consisted of three successive goal-directed components of AOT:
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4 D.H. Kim et al. / Effects of live and video form AOT on UL function in children with hemiparetic CP

Table 2
Tasks for intervention
Uni-manual Bi-manual
Press a rubber stamp Open a bottle lid
Stack cups Fold towel
Drink water with a cup Open a box
Grab a pen Put candies in a box
Flip cards Put Buttons
Put rings on a stick Make holes using a punch in a paper

101 observation, execution with instructor guidance, and repeated practice. Prior to the training, the children
102 were allowed to play with attractive toys for 5 minutes so that they could adapt to the laboratory environ-
103 ment. For the live AOT group, a researcher sat facing the child and performed six uni- or bimanual-tasks
104 for 3 minutes as the child watched (Table 2). During the next 3-minute period, the therapist provided
verbal instructions for proper task execution. Then, the child was asked to repeat the demonstrated tasks

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106 for 3 minutes. A 1-minute break was provided between tasks. For the video AOT group, a 19-inch com-
puter monitor was positioned on the table in front of the child. The child observed a 3-minute video clip,

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108 which displayed simultaneous front, side, and rear views of the therapist performing the task. Subsequent

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109 experimental procedures were the same as for the live AOT group. fv
110 2.4. Outcome measures
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111 There were five outcome measures at baseline and at 4 weeks after the intervention ended: the ML
and VT movement acceleration data and scores on the Jebsen-Taylor Hand Function (JTHF) test and the
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113 Box and Block Test (BBT). All data were evaluated by the same researcher. For ML and VT acceleration
114 assessment, the child was seated on a therapeutic table without back or foot support, and with the elbows
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115 flexed at about 90◦ and the forearm pronated. During reaching, the child leaned his or her body forward
116 and extended both elbows in a synchronized manner to touch a target (small green ball) positioned
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117 at shoulder height, and then returned to the starting position [19]. ML and VT acceleration data were
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118 collected as the child performed the reaching task three times. A 10-second rest period was provided
119 after each trial. For the JTHF, all children performed seven tasks: writing, card turning, holding common
small objects, simulated feeding, playing checkers, picking up large lightweight objects, and picking up
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121 large heavy objects. The evaluator measured the time it took for the child to perform all tasks. For the
BBT, the child had 60 seconds to move wooden blocks (2.5 × 2.5 × 2.5 cm) from one box to another,
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123 and the researcher recorded the number of blocks moved. All tasks were repeated three times, and the
124 mean values were analyzed.

125 2.5. Statistical analysis

126 The Mann-Whitney U test was used to compare the outcomes (ML and VT acceleration, JTHF
127 and BBT scores) between the live and video groups. PASW Statistics software (ver. 20.0; SPSS Inc.,
128 Chicago, IL, USA) was used for all statistical analyses, and statistical significance was set at α = 0.05.

129 3. Results

130 The acceleration data showed that ML acceleration was significantly lower in the live group (0.44
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D.H. Kim et al. / Effects of live and video form AOT on UL function in children with hemiparetic CP 5

Table 3
Main outcome data
Live group Video group p
MLa acceleration (m/s2 ) 0.44 ± 0.10 0.65 ± 0.08 0.013∗
VTb acceleration (m/s2 ) 0.46 ± 0.07 0.59 ± 0.11 0.044∗
JTHFc (s) 167.61 ± 10.66 181.27 ± 9.51 0.037∗
BBTd (EA) 59.66 ± 8.86 47.83 ± 2.2 0.037∗
MLa : Mediolateral; VTb : Vertical; JTHFTc : Jebsen Taylor Hand Function Test; BBTd : Box and Blocks Test.

131 ± 0.10 m/s2 ) than in the video group (0.61 ± 0.07 m/s2 ) at the follow-up evaluation (p = 0.013). VT
132 acceleration was also significantly lower in the live group (0.46 ± 0.07 m/s2 ) than in the video group
133 (0.59 ± 0.11 m/s2 ) (p = 0.044). In terms of the functional measures, JTHF scores were significantly
134 better for the live group (167.61 ± 10.66 s) than for the video group (181.27 ± 9.51 s) at the follow-up
135 test (p = 0.037). Scores on the BBT were significantly higher in the live group (59.66 ± 8.86 EA) than

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136 in the video group (47.83 ± 2.92 EA) at the follow-up test (p = 0.037) (Table 3).

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137 4. Discussion

138

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To our knowledge, this is the first study to compare the effects of live AOT and video AOT on UL func-
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139 tion in children with hemiparetic CP. As expected, our study showed significantly greater improvement
140 in UL function with live AOT compared with video AOT. The main reason for these findings is that neu-
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141 rological responses to observation of live actions differ from those to observation of video. Video AOT
142 provides a two-dimensional (2D) visual experience, whereas live AOT involves three-dimensional (3D)
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143 visual perceptions [20]. DeLoache [21] reported that young children cannot represent 2D video models
144 as 3D actual models. Similarly, using electroencephalographic (EEG) data, Ruysschaert et al. [22] found
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145 that mu rhythm suppression during observation of live hand movements was significantly greater than
146 that during observation of videotaped hand movements in 68 infants.
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147 The movement acceleration data revealed that ML and VT acceleration were reduced more in the live
148 group (by 20% and 15%, respectively) than in the video group (6% and 1%, respectively). These findings
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149 are consistent with previous studies that examined movement coordination during reaching in children
150 with CP. Ronnqvist and Rosblad [23] demonstrated that children with hemiplegic CP had longer reach
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151 and grasp duration than did typically developing children. Additionally, Yoo et al. [24] reported that
152 ML and VT acceleration were significantly reduced after electromyographic (EMG) feedback training
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153 in children with CP. JTHF scores were significantly improved, by 5%, in the live group. BBT scores
154 also improved, by 15%, after live AOT. These findings are consistent with those of Buccino et al. [25],
155 who demonstrated that the improvement in functional scores on the Melbourne assessment scale was
156 significantly greater in an AOT group than in a sham AOT group [25]. In a recent randomized controlled
157 trial, Sgandurra et al. [26] demonstrated that AHA and Melbourne assessment scale outcomes were
158 improved by 42% and 7%, respectively, after AOT plus practice compared with scores for action training
159 alone in hemiplegic CP.
160 In summary, our results showed that ML and VT acceleration and JTHF scores were reduced, and the
161 BBT score was increased, in the live AOT group, demonstrating that live AOT was more effective than
162 video AOT. Clinically, we recommend that clinicians use live action observation when designing AOT
163 interventions to improve UL acceleration or coordination and function in children with hemiparetic CP.
164 Some limitations of this study should be considered in future research. First, the sample size of this
165 study was small, although we estimated the required sample size based on a power analysis. Neverthe-
166 less, since the sample size is small, it is necessary to pay attention to the interpretation, and in order to
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6 D.H. Kim et al. / Effects of live and video form AOT on UL function in children with hemiparetic CP

167 generalize it, a larger sample size study will be necessary. Second, to confirm the mechanism underlying
168 the observed differences between the two AOT approaches, neuroimaging validation, such as by EEG,
169 functional magnetic resonance imaging, or functional near-infrared spectroscopy, is required. Finally, in
170 our study, we did not follow up after the intervention. Future studies will require follow-up studies on
171 sustained effects.

172 5. Conclusions

173 This is the first clinical study highlighting the effects of live AOT on UL movement acceleration and
174 function in children with hemiparetic CP. Our findings suggest that live AOT is more effective than video
175 AOT for improving UL movement acceleration and function. Clinically, our findings offer important
176 insights for clinicians when planning successful AOT intervention to reduce UL movement acceleration

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177 and improve UL function.

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178 Conflict of interest fv
179 The authors have no conflict of interest to report.
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180 References
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