1

Enhancing Cortical Activation during Action Observation Therapy for Upper Limb
Rehabilitation in patients with Apraxia after Stroke: A Systematic Review

A Thesis

Presented To

Our Lady of Fatima University, College of Physical Therapy

Quezon City

In Partial Fulfillment

Of the Requirements for the Degree of

Bachelor of Science in Physical Therapy

By

Paula Bianca Jae Cleofas

Cynthia Lucanas

Leo Dax Garra

Eloisa Cellona

Trizsha Catral

Paul Ramirez

December 2021
 TABLE OF CONTENTS

INTRODUCTION

REVIEW OF RELATED LITERATURE REVIEW

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

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1.0 ABSTRACT

Action observation therapy is a type of neurorehabilitation intervention that enables

the patient to restore, regain and relearn previous activities in daily living. The primary
objective of our study is to gather results on available literature and use systematic review as
a design to evaluate the data. Studies shown that action observation therapy on post-stroke
patients associated with ideomotor apraxia proves effectiveness in rehabilitation settings.

Keywords: Action Observation Therapy, Cortical Activation, Physical Therapist, Ideomotor

Apraxia

2.0 INTRODUCTION

Apraxia is a higher-order disorder of sensorimotor integration, commonly seen

in stroke. It is characterized by loss of the ability to execute or carry out skilled movements
and gestures, despite having the desire and the physical ability to perform (NIH,2019). Limb
apraxia (LA) is a subtype of apraxia covering a wide spectrum of higher motor disorders
caused by acquired brain disease or injury and affecting the performance of skilled learned
movements carried out by the upper limbs. Frequently observed clinical symptoms of LA are
an inability to perform purposeful movements with one’s arms or hands, errors when asked
to demonstrate how to use an object or how to carry out actions involving a single or series of
components of movements, and problems imitating abstract and symbolic gestures. Thus,
with LA, performance is characterized by a series of errors leading to an incomplete,
inaccurate or incorrect gesture. Limb apraxia subtypes are based on the classification of
Hugo Liepmann. The subtypes of this syndrome are usually multimodal because they do not
depend on the modality of perceptual visual, verbal, or tactile stimuli that the person
receives. The two subtypes of apraxia that have been described in the most detail in scientific
literature are (IA) ideational apraxia and ideomotor apraxia (IMA). According to Perrotta
(2020), the IA is characterized by inability to conceptualize a task, despite intact
identification of the tools. IMA is the inability to properly perform gesture pantomimes and

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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).

Apraxia is associated with neurologic conditions, (e.g. stroke, Parkinson’s

disease, traumatic brain injury, multiple sclerosis and cerebral palsy etc.) due to affection on
portions and regions of the brain. The prevalence of apraxia occurs in almost every
neurological condition (Buchmann et al., 2019). When healthy individuals perform various
tasks every day, it demonstrates cortical activation in the brain. It is when areas in the brain
were activated such as the main sites frontal, inferior, and middle cortex as well the frontal
gyrus. It also includes the intraparietal region that covers the anterior up to posterior regions
of the parietal cortex. In the Occipital Cortex, regions were also activated such as the middle

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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

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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 Literature Review

Neurorehabilitation has progressively changed in most recent years, traditional

neurorehabilitation procedures have a limited efficacy on patients with neurologic conditions
(Tambruin et al., 2019) Physical Therapist engage in cognitive rehabilitation deals with
patients who suffer from critical illness that associates with cognitive impairment that is
common and long lasting which typically includes problems with attention and memory
(Smith et al., 2020).

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2.1.1 Risk Factors of Apraxia in post -stroke patients

Stroke manifestations are incorporated depending on the specific lesion of arteries on

the brain, emerging evidence indicating that hypertension, diabetes, and obesity may cause
structural and functional alterations in the brain beyond their effect on incident stroke
(Yousoufuddin & Young, 2019).

2.1.1.1 Aging Factors in Apraxia

Pathological aging affects the visual and cognitive functions of individuals. Age
affects the occurrence of apraxia, older populations are being affected by their activities due
to deficit in visual processing and visual attention (Nagaoka & Ortiz, 2016). In terms of
education level, their performance by higher means of education reflects a high result in
performance (Nagaoka & Ortiz, 2016).

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).

2.1.1.2.2 Hearing Loss

Hearing loss in patients with apraxia leads to poor treatment outcomes due to speech
sound inconsistency and voicing distortions that alters the instructions given and affects their
performance (Siegel et al., 2015). This factor leads to a poor prognosis and requires more
challenging treatment strategies.

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2.1.1.2 Gender factors in Apraxia

The prevalence of apraxia in both verbal and nonverbal shows no direct correlation
with the gender of the patient (Presotto et al., 2015). In some studies, gender-based affects
the functional measures of individual, for example women reports functional limitation in
ADL’s (eg. cooking cleaning etc.) whereas men would not report for some limitations
because they may be less likely to complete those activities (Hawe et al., 2020)

2.1.2 Elements of Cortical Activation in Stroke Patients

2.1.2.1. Perilesional Cortex

After an injury to the Primary Motor Cortex, it has been revealed that the motor
cortex's representation of the hand began to decrease following the lesion, but the cortical
representations of the elbow and shoulder increased. Premotor Cortex ascending fibers are
more dense and more excitatory than the descending fibers. However, descending fibers
extend from the proximal region of the arm. Consequently, activation of the ipsilateral
premotor cortex occasionally hinders the recovery of the motor function of the hand.In the
acute phase, patients who recovered from stroke demonstrate that ipsilateral perilesional
cortical activity is related with functional recovery (Ko & Yoon, 2013).

2.1.2.2. Contralesional Cortex

According to Ko & Yoon (2013), Coactivation occurs during recovery in the relative
area in the contralateral cortex. The benefit of contralateral cortical activation, on the other
hand, remains up for debate at this time. To achieve functional recovery in the patients due to
the required balance of cortical activation, a reduction of activation can be seen in patients
with stroke. Unstable mapping of the cortex is associated with nonoptimal recovery can be
seen in continual coactivation of mirror cortex.

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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).

2.1.4 Effects of Action Observation Therapy on Stroke patients with Apraxia

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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).

2.2 Purpose Statement

The study aims to review the available literature on enhancing cortical activity with
action observation therapy on post-stroke patients suffering from apraxia.

This study will benefit the following:

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.

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Scope and Limitation

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.

2.3 Problem Statement

This study will answer the following questions:

2.3.1 What are the characteristics of the subjects in terms of:
2.3.1.1 Age
2.3.1.2 Comorbidities
2.3.2 What is the subject’s improvement in cortical activity?
2.3.4 What is the effect of Action Observation therapy on enhancing the cortical activity post
stroke patients with apraxia?

2.4 Hypothesis

This study hypothesizes that:

This study hypothesizes that:

HO1: There is an improvement of functional recovery through enhancing cortical
activation
HO2: There is no improvement of functional recovery through enhancing cortical
activation

2.5 Theoretical Framework

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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).

2.5.2 Conceptual Production-Model (Roy, 1996)

A model developed by Roy (1996) consists of three systems composed of
sensory/perceptual, conceptual and production systems which focus on the environmental
aspect; it could be visual input, auditory, or tactile. The conceptual system which stores the
knowledge about the specific tools or actions. The production system consists of several
subsystems subserving such functions as response selection, image generation,

Theoretical Framework (Figure 1)

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2.6 Research Simulacrum (Figure 2)

Risk Factors of DV Dependent Variable Independent Variable

Age
Comorbidities Apraxia in Stroke Action Observation Therapy
-Hearing problems
-Speech problems
Gender

3.0 RESEARCH METHODS

3.1 Eligibility

Studies reporting on stroke patients with ideomotor apraxia, effects of enhancing

cortical activation, action observation therapy for upper limb rehabilitation, disorder in
cognitive motor, reduced patients’ independence in activities of daily living. Upper limb
dysfunction is a significant contributor to disability. As many as 75% of poststroke patients

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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.

3.2 Information Sources

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.

3.3 Research Subjects/Study selection

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

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*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/

3.4 Data Collection and Data Items

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.

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3.5 Search Strategy

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

3.5 Data Selection

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 .

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Effect of Enhancing Cortical Activation during Action Observation……..

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/

3.6 Hierarchy and Methodological Quality

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.

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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).

OPERATIONAL DEFINITION OF TERMS

1. Cortical - relating to, or consisting of cortex
2. Stroke - sudden impairment or loss of consciousness, sensation, and voluntary motion
that is caused by rupture or obstruction (as by a clot) of a blood vessel supplying the
brain, and is accompanied by permanent damage of brain tissue.
3. Ideomotor - not reflex but motivated by an idea

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4. Apraxia - loss or impairment of the ability to execute complex coordinated

movements without muscular or sensory impairment
5. Rehabilitation - restoration especially by therapeutic means to an improved condition
of physical function
6. Physical Therapist - therapy for the preservation, enhancement, or restoration of
movement and physical function impaired or threatened by disease, injury, or
disability that utilizes therapeutic exercise, physical modalities, assistive devices, and
patient education and training.

APPENDIX A

Budget:

The following table shows the items and estimated budgeted amounts for each particulars in
preparation and conducting of the study.

Table 1. Research Budget

Item Cost Quantity Total

Reviewer PHP 5,000 1 PHP 5,000

Transportation
(per day) PHP 100 6 PHP 600

Personal data
connection PHP 100 6 PHP 600

Other necessities PHP 300 1 PHP 300

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APPENDIX B

Time Frame:

Presented diagram shows research tasks to be completed within a specific time frame.

Diagram 1. Time Frame

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APPENDIX C
Letter to the Ethics Committee

Ethics Committee
December 08, 2021
Faculty of College of Physical Therapy Cell Phone no: 09296863128

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Effect of Enhancing Cortical Activation during Action Observation……..

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.

Thank you for your time.

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.

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● 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

● Randomized Controlled Pilot Study. Brain Sciences, 11(3), 290.

doi:10.3390/brainsci11030290
● Rizzolatti, G., Cattaneo, L., Fabbri-Destro, M., Rozzi, S., 2014. Cortical mechanisms
underlying the organization of goal-directed actions and mirror neuron-based action
understanding. Physiol Rev. 94, 655-706.
● Nojima, I., Koganemaru, S., Kawamata, T., Mima, T., 2015. Action observation with
kinesthetic illusion can produce human motor plasticity. European Journal of
Neuroscience. 41(12), 1614-1623.
● Buccino, G., 2014. Action observation treatment: a novel tool in neurorehabilitation.
Philosophical Transactions of the Royal Society of London Series B. 369(1644),
20130185.
● Kim, K., 2015. Action observation for upper limb function after stroke: evidence-
based review of randomized controlled trials. Journal of Physical Therapy Science.
27(10), 3315-3317.
● Pérez-Mármol, J. M., García-Ríos, M. C., Barrero-Hernandez, F. J., Molina-Torres,
G., Brown, T., & Aguilar-Ferrándiz, M. E. (2015). Functional rehabilitation of upper
limb apraxia in poststroke patients: Study protocol for a randomized controlled trial.
Trials, 16(1), 508. https://doi.org/10.1186/s13063-015-1034-1
● Sarasso, E., Gemma, M., Agosta, F., Filippi, M., &Gatti, R. (2015). Action
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