Oriiginal Artiicle

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

Effectiveeness of Self-Actiion Obseervation Therapy y as a Novvel Meth hod on

Paretic UUpper Lim
mb and Cortical
C EExcitabillity Post--Stroke: A Single--Subject
Study
Aryan Shamili1, Afsoon Hasssani Mehraba
an1, Akram Azzad1* , Gholam Reza Raisssi2, Mohsen Shhati3, Ata Fara
ajzadeh4

Received: 13 Feeb 2021 Published: 31 Dec 2021

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.

Keywords: Acction Observatioon Therapy, Miirror Neurons, N

Neuroplasticity
y, Stroke, Upperr Limb

Conflicts of Interesst: None declared

Funding: None

*This work has beeen published underr CC BY-NC-SA 1.0 liicense.

Copyright© Iran University of Mediical Sciences

le as: Shamili A, Hassani Mehrabban A, Azad A, R

Cite this article Raissi GR, Shati M,
M Farajzadeh A. Effectiveness off Self-Action Observation Therapy
as a Novel Metthod on Paretic Upper Limb and d Cortical Excitaability Post-Strok
ke: A Single-Subject Study. Meed J Islam Repub Iran. 2021 (31
Dec);35:193. httpps://doi.org/10.477176/mjiri.35.193
3

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-
pairments in ttheir upper lim mb (UL) (2). Many of them m do
not regain fuunctional use of the paretic UL, which can
affect self-carre and also coommunity lifee participationn (3).
The patients usually remain dependent on some actiivity
of daily livinng, which oftten requires th he use of onne or
both ULs (4)). There are new n rehabilittation methodds to
enhance recovvery of upperr extremity po ost-stroke succh as
robotics, brainn stimulation,, mirror therap py and actionn ob-
servation, althhough researcch is still need ded to investiigate
their variant aaspects of efficacy (5).
Action Obsservation Therrapy (AOT) is a novel rehaabili-
tation strategyy used in patieents with neurrological disoorders
such as cerebrral palsy, Parkkinson’s diseaase, and strokee (6).
In this methood, some movvements and actions of heealthy
models are shhown on a viddeo or a live deemonstration;; then
the patient m must try to immitate and execute those acctions
(7). Neuroscieentific studiess have claimed d that AOT's ttheo-
retical basis iis on the eviddence that ob bservation of ggoal-
directed actioon (8) activattes the Mirro or Neuron Syystem
(MNS), whichh is the same neural activee mechanism w while
executing thaat action (6).. Functional connections have
been reportedd between mirrror neuron arreas and the m motor
cortex (9). Thhe activation of MNS during the AOT pro-
cess stimulattes cortical motor
m represen ntations that may
lead to the U UL motor recoovery after strroke (10). Acccord-
ing to the liteerature, there are
a significan nt improvemennts in
UL motor funnction as a ressult of AOT (7 7, 8, 11), althhough
the evidence for using thiis method as an interventioon to
promote UL motor functiion was estim mated as modderate
(7).
To improvee AOT effectss, this method d has been invvesti-
gated in combbination with other treatments such as m mental
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
examined varriations in its characteristics
c s, such as shoowing
videos of acttions recordedd from multip ple angles (11 , 15)
or at differentt speeds (15). There are also studies that have
used simple m movements or less meanin ngful tasks forr ob-
servation annd executionn such as thumb addduc-
tion/abductionn, squeezinng a ball or transfeerring
blocks/pegs (16, 17). Althoough some reesearch has incclud-
ed more com mplex and gooal-directed taasks during A AOT,
such as worrking with the t computerr mouse, turrning
cards/coins , aand drinking a cup of tea (8, 15), there iis not
sufficient reseearch on the use
u of selected d tasks/occupaations
by the patiennts which are more meanin ngful to them. It is
believed thatt the mirror neuron system m is more aactive
when observiing a complexx and purposeful activity com-
pared to a sim mple action, so one way forr more MNS exci-
tation might bbe using activvities that are ini line with evvery-
day activitiess and based on one's exp periences (18)). As
mentioned eaarlier, AOT iss based on MNS, M and if M MNS
function could be augmeented within this techniquue, it
would enrichh this new neuuro-rehabilitattion treatmentt and
contribute to a better motoor recovery an nd performannce in
paretic UL oof stroke patients. Anotherr possible waay to
improve MNS S excitation could
c be derivved from a neeuro-
rehabilitation method callled “Mirror Therapy
T (MT))” in
http://m
mjiri.iums.ac.ir
2 Med J Isslam Repub Iraan. 2021 (31 Deec); 35:193.
whicch the movem ments of the unnaffected limb b are reflectedd
in a mirror that iss placed in froont of the patiient and in thee
mid--sagittal planee. In this proceess, the brain is deluded andd
the patient feels that the affeccted limb is moving. AOT T
and MT may hav ve some comm mon points an nd theories buut
theirr procedure iss different (199). Scarce stu udies have exx-
amin ned some of the features oof the MT technique whilee
impllemented in AOT A format iin stroke patiients (19, 20)).
Nag gai and Tanak ka reported thhat in healthy y subjects, obb-
servving one’s ow wn hand provookes more brrain activationn
thann observing oth her’s hand (211). Also, it has been pointedd
out in Bandura’s theories of oobservational learning, thaat
the more
m a model that resemblees the observeer performs ann
activvity successfuully, the more re likely the observer
o is too
perfform the activ vity with succcess and self-efficacy (22)..
Therrefore, feasibility of usingg the patientss as their ownn
mod dels in AOT process woulld be a worth hy issue to bee
survveyed.
In
n this study, thhe first hypotthesis was thaat AOT, whenn
incluuded in meaningful tasks aand occupations selected byy
the patient,
p d enhance mottor recovery, spasticity, thee
could
perfformance of UL,U cortical exxcitability and d also occupaa-
tionaal performancce/satisfactionn. The second d and main hyy-
pothhesis of this sttudy was thatt if AOT coulld be modifiedd
by using
u the mirrored videoss of the patient practicingg
goall-directed and d meaningful actions with h her/his nonn-
pareetic UL (Whille an illusionn of moving and a activity of o
the affected side is created), it could imp prove the outt-
commes mentioned d earlier moree than usual AOT. To thee
best of our knowlledge, this is tthe first study y to investigatee
the feasibility and d efficacy of Self-AOT on n UL functionn,
spassticity, cortico
ospinal excitabbility and occcupational perr-
formmance besides the UL motorr recovery.
Methods
M
Exxperimental design
d
Too show the efffectiveness oof a novel meethod of interr-
venttion or to com mpare it withh established interventionss,
Sing gle-Case Experimental Deesign (SCED)) would be a
reasonable choicee. We used Sinngle-Case Reporting guidee-
liness in Behavioraal interventionns (SCRIBE) to observe thee
rigor and quality ofo the study (223).
Too consider thee two hypothheses introducced earlier, wee
seleccted a SCED with baselinees and two ph hases of interr-
venttions. This stu udy examinedd the benefitss of Self-AOT T
commpared to Actiion observatioon using an alternate
a treatt-
men nt design withh A1BA2C seqquence. The A phases conn-
sisteed of baselinee periods of 2 weeks with no treatmentss;
A1 before
b phase B and A2 bettween 2 training paradigm ms
(B and
a C). In thee B phase, thee subject undeerwent 12 sess-
sionns (3 times per week for 4w wk) of AOT (watching andd
imitating healthy model’s task execution vid deos). In the C
phasse subject undderwent 12 sesssions (3 timees per week foor
4wk k) of a new AOT proceddure here called Self-AOT T
(wattching and imitating her ow wn task executtion videos).
Pa
articipant
A 58-year-old woman
w (E.Z) with right paarietal lobe iss-
chem
mic stroke resulting in left
ft-sided hemip
plegia was ree-
 A. Shamili, et all.

cruited from tthe occupationnal therapy ouutpatient serviice of item

ms divided intto four subteests (28). Eacch item in thee
the rehabilitattion faculty. She
S had a strooke 2 years annd 11 subttests including grasp, gripp, pinch, and d gross movee-
months beforre the study. At A the time ofo recruitmentt, the men nts, is scored with
w 0, 1, 2, orr 3, with high her scores indii-
subject had seevere motor impairments as a characterizeed by catin
ng better arm m motor perfoormance. If th he total scores
a score of 311 out of 66 in i the Fugl-MMeyer Assesssment are summed
s up inn this test, a m maximum scorre of 57 wouldd
Upper-Extrem mity section. She
S was indep pendent in wallking be gained.
g The AR RAT has beenn found useful in prior studd-
to the researcch center withh the help off a quad-cane,, and ies evaluating
e strroke patients across a wid de spectrum ofo
also, she hadd the tolerance and ability to sit safely on a impaairments. Thee test has beenn reported as valid v and highh
chair for the evaluation/inttervention sesssions. The suubject Interr-rater and intra-rater reliaability have been calculatedd
also had an acceptable cognitive statee (score of 228 in for ARAT
A (28).
Mini-Mental State Examinnation) and no visual probleem so Boox and Block k Test (BBT).. The BBT iss a UL perforr-
she could prooperly particiipate in action n observationn and man nce measurem ment and wass used to deetermine gross
execution prrocedure. Shee was a righ ht-handed naative- man nual dexterity. The test invoolves picking up blocks ouut
Persian speakker who had 13 years of forrmal educationn and of a box and tran nsferring them m over a wall into the otheer
a 4 years bachhelor’s degreee and was retired after 25 yyears side of the box. TheT total scoriing is by coun nting the num
m-
of work as ann accountant. ber of blocks carrried over thee partition from one side too
the other for 60 seconds.
s The BBT has a very v high testt-
Outcome M Measures retesst and inter-raater reliability (24).
All clinicall outcomes were
w evaluatedd before initiiating Modified
M Mod dified Ashwoorth Scale (M MMAS). Thee
the baseline A1, before 4 weeks
w of AOT T (interventionn B), MM MAS is used for f quantifyinng spasticity. It has omittedd
before and affter 2 weeks of o baseline A2, and immediiately the additional
a graade of 1+ andd redefined graade 2 with thee
after 4 weekss of Self-AOT T (intervention n C). A follow w-up aim of improving the reliabilityy and validity of the MMAS S
was conducteed with 1 meeasurement occcasion, 2 moonths (29)). The scoring points are bet etween 0-4: 0 No
N increase inn
after the interrventions werre completed. As the targett out- musscle tone and 4 affected paart(s) rigid in flexion or exx-
come, during each baselinee (A1 and A2), UL motor reecov- tension. In this sttudy to quantiify elbow and d wrist flexorss,
ery was meassured on 4 occcasions, 2 tim mes a week. Duuring the patient
p was assessed
a in thhe supine posiition and withh
intervention phases, thesee evaluationss were perforrmed standard handling gs (30). This sscale has been n used successs-
once a week (4 occasionss for B and 4 occasions ffor C fully
y in clinical trials to evaluuate UL spastticity in strokee
phase). patieents (31). We used the Pers rsian version of
o MMAS thaat
Fugl-Meyerr Assessmentt of Upper Extremity (F FMA- has as very good reliability
r in tthe upper limb
b (29).
UE). FMA-U UE is used to measure mo otor recovery after Motor
M Evoked Potential
P (ME EP). One of thhe variables ree-
stroke. The uupper extremiity domain off this test inclludes lated
d to brain phy ysiology and m motor pathwaays that can bee
33 items for U UL motor funnction that aree rated based on a recoorded by the Transcranial
T M
Magnetic Stimmulation (TMS S)
3-point ordinnal scale (0=ccannot perform m, 1=can part rtially deviice is MEP (3 32). Dependinng on the braain stimulationn
perform, 2=can perform fuully). The sum mmation of sccores areaa, there would d be a recorddable MEP prroduced at thee
will be a maxximum of 66. Construct validity, inter-rrater, end of the corticospinal pathwaay, where the target muscles
and intra-rateer reliability of
o this scale have
h been repoorted conttract. The tend don muscles oor finger exteensors are usuu-
as very good (24). ally used for thiss recording ((33). In this study, Centraal
Canadian O Occupational Performance
P Measure
M (CO PM). Mottor Conduction n Time (CMC CT) and amplitude were thee
COPM is a seemi-structuredd interview to o identify patiient’s anallyzed findingss related to thee MEP. To reecord the MEP P
problems in tthe occupationnal areas (self-care, producctivi- usin
ng Magstim 200 stimulatorr the patient had h to sit in a
ty, and leisurre/play) usingg a 0-10-poin nt Likert scalee for quieet room in a sp pecial chair (332). Cerebral cortex
c area M1
scoring. In thiis study, COP PM was used to t identify occcupa- and appendix of the seventh ccervical verteb bra (C7) weree
tional problem ms and also tot measure su ubjects’ percepption seleccted as stimu ulation pointss for Extenso or Indicis andd
of their perfoformance and satisfaction with the seleected Opp ponens Pollicis as target muuscles. Aboutt 3 to 5 waves
tasks before aand after eachh intervention. The validity,, reli- withh good reprodu ucibility and hhigh intensityy were selectedd
ability and reesponsivenesss of the COPM M are reporteed as to reecord the ME EP. The CMC CT was calcu ulated by subb-
acceptable inn many diseasses such as sttroke (25). An in- tractting cervical latency from thhe M1 latency y (34).
crease of twoo or more poinnts indicates a minimum off clin- Alll clinical asseessments weree administered orderly by a
ically significcant change inn this outcomee measure (26)). train
ned occupation nal therapist w with 10 years of experiencee.
Actual Tassk Performancce Assessmen nt. In additionn to To increase
i the reliability
r of assessments, 10 stroke paa-
subjective evaaluation and from
f the patien
nt's point of vview, tientts were assessed before thhe main study y to check thee
to increase thhe validity of the data and the results off the Interr-Observer Agreement
A (IO
OA) between the blind obb-
interventions,, a scale derrived from Chedoke
C arm and serv
ver and another expert assesssor (35). The agreement foor
hand activity inventory waas used as an objective asssess- the outcomes was more than 880%. A physsical medicinee
ment (27). Inn which eatinng sub-tasks that t were use d as and rehabilitation n specialist w with sufficient experience inn
training compponents in thee sessions were scored acccord- the use of TMS assessed the MEP in a seeparate sessionn
ing to the asseessor’s opinioon. from
m other evaluaations. Both aassessors werre blind to thee
Action Ressearch Arm Test T (ARAT).. ARAT is ann as- ordeer of study phaases.
sessment of U UL performannce developed d by Lyle witth 19
http:///mjiri.iums.ac.iir
Med J Islam Repub Iran.
I 2021 (31 D
Dec); 35.193. 3
Self-Action O
Observation Therapy
T

Interventio on Protocol Eaach of the I-IVV activities inncluded functtional compo--

Initially, byy using COPM M, the participant negotiateed to nentts that were briefly explainned to the patiient at the be--
eat as an im mportant occuupation (scoree 8 out of 100 for ginnning of each ofo the three inntervention sessions. To in--
COPM imporrtance sectionn). Thereby so ome eating-reelated creaase procedurall fidelity (23, 35), a written n and detailedd
tasks such as using a fork,, pouring wateer from a botttle to protocol was pro ovided for thhe therapist. According too
glass and drinnking from a glass
g with an affected
a limb (Left Tablle 1, the steps followed inn each session n were as de--
side) were seelected. In an expert panel consisting off one scribbed below:
neuroscientistt and 4 occuupational therrapists workinng in 1)) The video off how to perfoorm each com mponent (Part--
neurologic reehabilitation settings,
s based
d on the eviddence Task k) was played d from 3 anggles for a total of about 2
and expert oppinions, the seelected tasks were
w analyzedd and minu utes (each ang
gle ≈ 3 times)..
divided into sshort part sequuences of the whole task exxecu- 2)) After watch hing the videoo (Action Ob bservation) off
tion (Table 1)). eachh activity commponent, the pparticipant sho ould have per--
Afterward a Fujifilm cam mera X-H1 filmed those acttions formmed the same movements aand tasks for 3 minutes. Iff
and tasks whhile acted by a young, healtthy model to pre- neceessary, in addition to monittoring the inteervention ses--
pare the filmss for interventtion 1 (phase B). After proovid- sionn, the therapisst provided aappropriate physical assis--
ing a final version of the edited
e video fo ootage, to idenntify tancce for the patieent to complette the activity..
the time requuired for asseessments and to ensure paatient 3)) Before the end
e of each ssession and affter observingg
safety and teechnical considerations, a one-week ppilot and performing all a the compoonents, the wh hole task wass
AOT study w was conducteed with anoth her stroke pattient. show wn for about 3 minutes in 3 angles (i.e., each
e angle forr
Then, the maain study wass initiated with the particiipant 1 miinute).
E.Z. 4)) After watchiing the wholee task video, thet participantt
For the seccond intervention (Phase C), C we recordded a shou uld have practticed the same
me movements and tasks forr
video from thhe E.Z executting the samee selected taskks as 3 miinutes.
analyzed prevviously and within
w the samme technical pro- No ote that the prrocess of AO
OT sessions fo or interventionn
cess. The onlyy difference with
w the previo ous videos (shhown phasses B and C were
w as same aas above with the differencee
in phase B) w was that the model
m for the films was thee pa- that in phase B, th he patient hadd to watch and d imitate vide--
tient herself eexecuting thee same tasks (I-IV in Tablle 1) os of
o a healthy acctor (Fig. 1), iin contrast, inn phase C, thee
with her intaact UL (Rightt side). Due to t motor learrning patieent had to waatch and imitaate mirrored videos
v of her--
theories and aapproaches (336, 37) we provided 3 sesssions self as if she was practicing tthe tasks with h her affectedd
to observe annd practice eacch task, so a to otal of 12 sesssions hand d (Fig. 2). Thhe training prorotocol was leed by the firstt
were consideered for the four
fo tasks. To o maintain thee ef- authhor, who is an n experiencedd occupationaal therapist inn
fects of the pprevious praccticed task, att the end of each strokke rehabilitation.
task practice pperiod (after 3 sessions) and at the beginnning
of the next ssessions (for 6 minutes), th he previous ttasks Sttatistical Anallysis
had been view wed as a commplete task an nd then perforrmed In
n this single case
c experimeental study, visual
v analysis
as a whole. F For example, the activity I was selectedd for was used to depict the FMA-U UE changes during
d variouus
the first 3 sesssions and acttivity II for th
he next 3 sessiions. phasses through grraphic data (223). Also, the Percentage ofo
Therefore, in the fourth sesssion of study,, before obserrving Nonn-overlapping Data (PND) method was used in whichh
and performinng the compoonents of activ vity II, whole task by calculating
c th
he results of ddata points and
a comparingg
observation/eexecution of activity
a I shou
uld have been per- them
m with the results of the bbaseline, it was
w possible too
formed for 6 minutes (3 minutes
m observvation + 3 minnutes anallyze the increase or decreaase in the resuults. The slopee
execution). and trend of the data
d points we were estimated and the overr-

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

Note: AO: Actionn Observation

http://m
mjiri.iums.ac.ir
4 Med J Isslam Repub Iraan. 2021 (31 Deec); 35:193.
 A. Shamili, et all.

Fig. 1. EZ is waatching and imitaating a video of a Healthy Model ((AOT)

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

laps and imm mediacy were also checked d (38). To proovide Re

esults
an initial baseeline (phase A1), a series of
o data points were FM
MA-UE
collected beffore the first intervention (phase B), w which Th
he results of ULU motor recoovery assessed d by FMA-UE E
was then folloowed by data points gathereed during phaase B. are shown in Figure 3. The staability of the results is evii-
After withdraawing the firstt intervention,, data point coollec- dentt in the first baaseline (A1).
tion was conttinued during baseline A2 anda also durinng the he slope in thee 1st interventtion (phase B)) demonstratedd
Th
second intervvention (phasse C). All oth her measurem ments channge when com mpared to thee baseline ph hase, and alsoo,
were just anaalyzed before and
a after each h phase, by sim mply accoording to its PND,
P it was hhighly effectiv
ve for the parr-
comparing thee scores. pant (PND waas 100%). Afteerward when intervention 1
ticip
was withdrawn, in i the secondd baseline (A2 phase), a dee-
http:///mjiri.iums.ac.iir
Med J Islam Repub Iran.
I 2021 (31 D
Dec); 35.193. 5
Self-Action O
Observation Therapy
T

Fig. 3. Multiplle data points (177 occasions) for th

he target outcomee measure upper extremity motor recovery (FMA-U
UE). Trend of ch
hanges in phases
A1, B, A2, C.

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

Table 2. Resuults of outcome measures

m before an
nd after interventiion 1 and 2 and also
a after 2 month
hs follow-up
Outcome meaasures Prior tto After
A Prior to After Follow-up
Interventtion 1 interv
vention 1 In
ntervention 2 Intervention 2
Arm 18 28 23 27 22
FMA-UE Wrist 2 4 2 6 4
Hand 5 5 4 8 8
Coordinatioon 5 5 5 5 5
Total 30 42 34 46 39
COPM (Perfoormance) 2 7 8 10 10
COPM (Satisffaction) 3 8 8 10 10
Task 1 (pouuring water) 1 2 2 4 4
Actual Task Task 2 (drinnking from glass)) 1 2 2 3 3
Performance Task 3 (forkk) 1 3 3 4 4
score Task 4 (cuttting meat) 1 2 2 4 4
Grasp 1 10 12 17 14
ARAT Grip 2 2 2 2 2
Pinch 0 0 0 0 0
Gross Moveement 3 4 3 5 3
Total 6 16 17 24 19
BBT 7.333 10 7.66 10.30 10
MMAS (Elbow flexors) 2 2 2 2 1
MMAS (Wrisst flexors) 3 2 2 2 2
MEP CMCT 11.400 11.60 10.80 11.10
(Opponenens Policis) Amplitude 0.800 1.20
1 0.60 0.80 N/A
MEP CMCT 11.900 10.20 9.20 8.90
(Extensor Indiicis) Amplitude 0.200 0.40
0 0.40 0.60 N/A
Note: COPM: C
Canadian Occupatioonal Performance Measure,
M FMA: Fugll-Meyer Assessmennt, ARAT: Action Research Arm Test, M
MMAS: Modified Modified Ashworth Scalle,
MEP: Motor Evvoked Potential, CM
MCT: Central Motorr Conduction Time N/A: Non-Applicab
ble

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6 Med J Isslam Repub Iraan. 2021 (31 Deec); 35:193.
 A. Shamili, et all.

COPM imprroving effectss on motor reccovery.

Changes beefore and afteer both treatmeents were equual to Coonsidering thee PND (=75% %) and the 12--point changes
or greater thaan 2 COPM scores,
s which clinically inddicate of FMA-UE
F in phase C comppared to phasee A2, it can bee
the effectivenness of the treaatments used (26).
( The exteent of stateed that this neew method (SSelf-AO) has acceptable eff-
increase afterr the first inntervention was more thann the fectiiveness. Comp paring the firrst and second
d interventionns
changes calcuulated for the second interv vention. How wever, (B and
a C), since the t slope of chhanges in the process of thee
this might be as a result off maintained effects
e of interrven- first and second interventions was 1.75 an nd 2.5, respecc-
tion 1 even affter withdrawiing the first in
ntervention. tivelly, it can probbably be reporrted that Self-AOT caused a
channge in FMA-UE slightly m more than AOT,
A which too
Actual Taskk Performancce ensuure this further claim researrch is needed in the form of o
All the 4 taasks assessed show an incrrease of 1-2 sccores stronnger evidencee such as randoomized contro ol trials.
before and aafter both inteerventions wiithout an obvvious Thhe decrease in i the UL reecovery score during the 2
superiority beetween two interventions Taable 2. mon nths follow-up p was lesser thhan the 2 weeeks of baselinee
A2. Therefore, it might be saidd that Self-AO had a moree
ARAT lastiing effect thaan the routine ne AOT. Amo ong FMA-UE E
ARAT had an increasingg score in botth B and C sttages, subsscales, most sections
s had improvementts during bothh
without any ddecline in timee between the two interventtions. interrventions exceept the coordiination subscaale. The causee
migh ht be that the observed andd practiced eatting tasks weree
not speed-depend dent and couldd not enhance the time ass-
BBT
sessed in this subsscale.
In contrast to ARAT, a decrease
d in reesults of BBT after
intervention 1 is seen.
Eff
ffects on COPM M
Acccording to chhange in COPPM scores, pattient’s occupaa-
MMAS
tionaal performancce and satisffaction show an increasingg
There was no change in elbow flexorrs spasticity beefore trendd in both inteervention phasses. This is inn line with thee
and after bothh treatments. And the onlyy change in eelbow theoory and eviden nce that the m more functionnal and meann-
extensors wass a 1 score deecrease pre-po
ost B phase am
mong ingfful the intervention, the betttter the occupational perforr-
all phases. man nce/satisfactionn results (36)). The maintennance and duu-
rabillity of the CO
OPM scores aafter withdraw wing the interr-
MEP venttions were rem markable. Hoowever, this maintained
m eff-
MEP of oppponens’ musscle did not show
s a signifficant fect after treatmeent 1 (during phase A2) lim mits a definitee
improvement although CMMCT and am mplitude relateed to commparison betweeen Self-AOT T and AOT.
the MEP of extensor inddices muscle were slightlyy im-
proved. Eff
ffects on Actual Task Perfor ormance
Th he results of tasks evaluaation rated by y the assessoor
weree completely in line with C COPM scores and indicatedd
Discussion
n the potential
p usefu
fulness of bothh intervention
ns. It should bee
Effects on FFMA-UE noteed that there iss a difference between the level
l of patiennt
The effect of AOT intterventions on o UL motorr im- perfformance scorres from herr own point of view (viaa
provement haas been reportted in previou us studies (8, 15) , COP PM) and that of the assesssor, but both have reportedd
which mostlyy used predeteermined activities in their prroce- posiitive trends. This
T mismatchh between perrceived perforr-
dure. With thhe aim of makking the interv vention moree pur- mannce and actual performance scores has beeen reported inn
poseful and cooperative for f the patien nt, in the prresent a preevious study (41).
(
study, the pattient-selected activities were used in plannning
and arrangingg AOT sessionns. As like as most routine A AOT ffects on BBT
Eff
studies (11, 339, 40), indivvidualized an nd patient-seleected To o some extentt, the trend off changes in BBT
B outcomes
action observvation also im mproved the patient's
p UL mmotor was similar to thee FMA-UE treend and had positive
p changg-
recovery (FM MA-UE) in thee first phase of o the intervenntion es affter both interrvention periodds. A similar effect on BBTT
with a 12-poiint change, which
w is cliniccally importannt ac- is reeported in reccent related rresearch (15, 39, 40). Likee
cording to tthe minimal clinical imp portant detecctable FMA A, the BBT outcome meaasure decreased after withh-
change of FM MA-UE test. ThisT rate of change consideering drawwing the first intervention,
i aalthough this drop was lesss-
the stability oof the initial baseline posssibly indicatees the er affter the second interventionn and at the tiime of followw-
effectiveness of 1st intervenntion. up evaluation.
e
After 4 weeeks of AOT, during
d the 2nd Baseline (A2)), the
decrease in F FMA-UE scorres shows thaat the effect oof the ffects on ARAT
Eff T
first treatmennt (AOT) was discontinued d. FMA-UE sccores Co onsidering thee changes in ARAT (Tablee 2), it can bee
were not stabble after 1st inntervention withdrawal
w (A
AOT), stateed that both AOT
A and Self-A
AOT probably have benefii-
although thesse scores had not declined to t the level beefore cial effects on ARAT,
A mainlly on the graasp and gross
intervention. After the 2ndd baseline, Self-AO had sim milar mov vement sub-caategories. Thiss might be du
ue to the form
m
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Med J Islam Repub Iran.
I 2021 (31 D
Dec); 35.193. 7
 Self-Action O
Observation Therapy
T

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.

Limitationss and suggesttions Accknowledgm

ment
In the pressent study, although theree were limitaations We
W would like to thank (E.Z)) the stroke paatient who hadd
such as havinng just one paarticipant, lack
k of control grroup, greaat cooperation during this sttudy.
and non-randdom order off intervention ns, the resultss can
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8 Med J Isslam Repub Iraan. 2021 (31 Deec); 35:193.
 A. Shamili, et all.

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.
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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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