Action Observation Therapy for Decreasing Impairments and Improving Functional Capabilities in Individuals with Acute to Subacute Stroke


  • Suweena Khacharoen Faculty of Physical Therapy, Mahidol University
  • Jenjira Thanakamchokchai
  • Fuengfa Khobkhun


Action Observation Therapy, Mirror Neurons, Motor Training, Stroke


Action observation therapy has been widely used in clinical practice over the past 10 years. It has been found that this training combined with functional training or rehabilitation
program could increase muscle strength or improve performance of activity daily of living in all stages of individuals with stroke. Also, this training is required a simple technique and can be recommended for individuals with stroke to continue practicing at home. However, individuals with stroke have the highest rate of recovery and improvement in the performance of activity of daily living only in the early stages of the disease. Therefore, training period during the acute to subacute phase is crucial. There is a limited number of the study which related to action observation training for these stages. Thus, further research is required to investigate with training indications, dose of training, long-term effects of training period of action observation training technique to implement into clinical practice.


Suwanwela NC. Stroke epidemiology in Thailand. J Stroke. 2014;16(1):1-7.

Lekander I, Willers C, von Euler M, Lilja M, Sunnerhagen KS, Pessah-Rasmussen H, et al. Relationship between functional disability and costs one and two years post stroke. PLoS One. 2017;12(4):e0174861.

Lee KB, Lim SH, Kim KH, Kim KJ, Kim YR, Chang WN, et al. Six-month functional recovery of stroke patients: a multi-time-point study. Int J Rehabil Res. 2015;38(2):173-80.

Colombo R, Pisano F, Delconte C, Mazzone A, Grioni G, Castagna M, et al. Comparison of exercise training effect with different robotic devices for upper limb rehabilitation: a retrospective study. Eur J Phys Rehabil Med. 2017;53(2):240-8.

Prange GB, Jannink MJ, Groothuis-Oudshoorn CG, Hermens HJ, Ijzerman MJ. Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after stroke. J Rehabil Res Dev. 2006;43(2):171-84.

Simsek TT, Cekok K. The effects of Nintendo Wii(TM)-based balance and upper extremity training on activities of daily living and quality of life in patients with sub-acute stroke: a randomized controlled study. Int J Neurosci. 2016;126(12):1061-70.

Dromerick AW, Lang CE, Birkenmeier RL, Wagner JM, Miller JP, Videen TO, et al. Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS): A single-center RCT. Neurology. 2009;73(3):195-201.

Kim J, Yim J. Effects of High-Frequency Repetitive Transcranial Magnetic Stimulation Combined with Task-Oriented Mirror Therapy Training on Hand Rehabilitation of Acute Stroke Patients. Med Sci Monit. 2018;24:743-50.

di Pellegrino G, Fadiga L, Fogassi L, Gallese V, Rizzolatti G. Understanding motor events: a neurophysiological study. Exp Brain Res. 1992;91(1):176-80.

Hetu S, Mercier C, Eugene F, Michon PE, Jackson PL. Modulation of brain activity during action observation: influence of perspective, transitivity and meaningfulness. PLoS One. 2011;6(9):e24728.

Bek J, Gowen E, Vogt S, Crawford TJ, Poliakoff E. Action observation and imitation in Parkinson’s disease: The influence of biological and non-biological stimuli. Neuropsychologia. 2021;150:107690.

Aglioti SM, Pazzaglia M. Representing actions through their sound. Exp Brain Res. 2010;206(2):141-51.

Hardwick RM, Caspers S, Eickhoff SB, Swinnen SP. Neural correlates of action: Comparing meta-analyses of imagery, observation, and execution. Neurosci Biobehav Rev. 2018;94:31-44.

Peng TH, Zhu JD, Chen CC, Tai RY, Lee CY, Hsieh YW. 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(8):1277-85.

Mao H, Li Y, Tang L, Chen Y, Ni J, Liu L, et al. Effects of mirror neuron system-based training on rehabilitation of stroke patients. Brain Behav. 2020;10(8):e01729.

Moon Y, Bae Y. The effect of backward walking observational training on gait parameters and balance in chronic stroke: randomized controlled study. Eur J Phys Rehabil Med. 2021.

Park HJ, Oh DW, Choi JD, Kim JM, Kim SY, Cha YJ, et al. Action observation training of community ambulation for improving walking ability of patients with post-stroke hemiparesis: a randomized controlled pilot trial. Clin Rehabil. 2017;31(8):1078-86.

Herranz - Gomez A , Gaudiosi C , Angulo-Diaz-Parreno S, Suso-Marti L, La Touche R, Cuenca-Martinez F. Effectiveness of motor imagery and action observation on functional variables: An umbrella and mapping review with meta-meta-analysis. Neurosci Biobehav Rev. 2020;118:828-45.

Murata A, Fadiga L, Fogassi L, Gallese V, Raos V, Rizzolatti G. Object representation in the ventral premotor cortex (area F5) of the monkey. J Neurophysiol. 1997;78(4):2226-30.

Rizzolatti G, Arbib MA. Language within our grasp. Trends Neurosci. 1998;21(5):188-94.

Kohler E, Keysers C, Umilta MA, Fogassi L, Gallese V, Rizzolatti G. Hearing sounds, understanding actions: action representation in mirror neurons. Science. 2002;297(5582):846-8.

Keysers C, Kohler E, Umilta MA, Nanetti L, Fogassi L, Gallese V. Audiovisual mirror neurons and action recognition. Exp Brain Res. 2003;153(4):628-36.

Rizzolatti G, Fogassi L. The mirror mechanism: recent findings and perspectives. Philos Trans R Soc Lond B Biol Sci. 2014;369(1644):20130420.

Fogassi L, Gallese V, Fadiga L, Luppino G, Matelli M, Rizzolatti G. Coding of peripersonal space in inferior premotor cortex (area F4). J Neurophysiol. 1996;76(1):141-57

Murata A, Wen W, Asama H. The body and objects represented in the ventral stream of the parieto-premotor network. Neurosci Res. 2016;104:4-15.

Ge S, Liu H, Lin P, Gao J, Xiao C, Li Z. Neural Basis of Action Observation and Understanding From First- and Third-Person Perspectives: An fMRI Study. Front Behav Neurosci. 2018;12:283.

Errante A, Fogassi L. Activation of cerebellum and basal ganglia during the observation and execution of manipulative actions. Sci Rep. 2020;10(1):12008.

Aridan N, Mukamel R. Activity in primary motor cortex during action observation covaries with subsequent behavioral changes in execution. Brain Behav. 2016;6(11):e00550.

Cowles T, Clark A, Mares K, Peryer G, Stuck R, Pomeroy V. Observation-to-imitate plus practice could add little to physical therapy benefits within 31 days of stroke: translational randomized controlled trial. Neurorehabil Neural Repair. 2013;27(2):173-82.

Franceschini M, Ceravolo MG, Agosti M, Cavallini P, Bonassi S, Dall’Armi V, et al. Clinical relevance of action observation in upper-limb stroke rehabilitation: a possible role in recovery of functional dexterity. A randomized clinical trial. Neurorehabil Neural Repair. 2012;26(5):456-62.

Zhu M-H, Wang J, Gu X-D, Shi M-F, Zeng M, Wang C-Y, et al. Effect of action observation therapy on daily activities and motor recovery in stroke patients. International Journal of Nursing Sciences. 2015;2(3):279-82.

Hsieh YW, Lin YH, Zhu JD, Wu CY, Lin YP, Chen CC. Treatment Effects of Upper Limb Action Observation Therapy and Mirror Therapy on Rehabilitation Outcomes after Subacute Stroke: A Pilot Study. Behav Neurol. 2020;2020:6250524.

Kim C-H, Bang D-H. Action observation training enhances upper extremity function in subacute stroke survivor with moderate impairment: a double-blind, randomized controlled pilot trial. Journal of The Korean Society of Physical Medicine. 2016;11:133-40.

Fu J, Zeng M, Shen F, Cui Y, Zhu M, Gu X, et al. Effects of action observation therapy on upper extremity function, daily activities and motion evoked potential in cerebral infarction patients. Medicine (Baltimore). 2017;96(42):e8080.

Hioka A, Tada Y, Kitazato K, Kanematsu Y, Mizobuchi Y, Mure H, et al. Activation of mirror neuron system during gait observation in sub-acute stroke patients and healthy persons. J Clin Neurosci. 2019;60:79-83.

Hioka A, Tada Y, Kitazato K, Akazawa N, Takagi Y, Nagahiro S. Action observation treatment improves gait ability in subacute to convalescent stroke patients. J Clin Neurosci. 2020;75:55-61.

Loporto M, McAllister CJ, Edwards MG, Wright DJ, Holmes PS. Prior action execution has no effect on corticospinal facilitation during action observation. Behav Brain Res. 2012;231(1):124-9.

Tanabe J, Morishita M. Effects of Action Observation Therapy with Limited Visual Attention on Walking Ability in Stroke Patients. J Mot Behav. 2021:1-10.

Zhu JD, Cheng CH, Tseng YJ, Chou CC, Chen CC, Hsieh YW, et al. Modulation of Motor Cortical Activities by Action Observation and Execution in Patients with Stroke: An MEG Study. Neural Plast. 2019;2019:8481371.

Shih TY, Wu CY, Lin KC, Cheng CH, Hsieh YW, Chen CL, et al. Effects of action observation therapy and mirror therapy after stroke on rehabilitation outcomes and neural mechanisms by MEG: study protocol for a randomized controlled trial. Trials. 2017;18(1):459.

Jackson PL, Meltzoff AN, Decety J. Neural circuits involved in imitation and perspective-taking. Neuroimage. 2006;31(1):429-39.

Sudo T, Herai T, Mogi K. Egocentric mental transformation of self: effects of spatial relationship in mirror-image and anatomic imitations. Exp Brain Res. 2012;221(1):27-32.

Eaves DL, Haythornthwaite L, Vogt S. Motor imagery during action observation modulates automatic imitation effects in rhythmical actions. Front Hum Neurosci. 2014;8:28.

Emerson JR, Binks JA, Scott MW, Kenny RPW, Eaves DL. Combined action observation and motor imagery therapy: a novel method for post-stroke motor rehabilitation. AIMS Neurosci. 2018;5(4):236-52.

Wieloch T, Nikolich K. Mechanisms of neural plasticity following brain injury. Curr Opin Neurobiol. 2006;16(3):258-64.

Lee HJ, Kim YM, Lee DK. The effects of action observation training and mirror therapy on gait and balance in stroke patients. J Phys Ther Sci. 2017;29(3):523-6.

Spaccavento S, Marinelli CV, Nardulli R, Macchitella L, Bivona U, Piccardi L, et al. Attention Deficits in Stroke Patients: The Role of Lesion Characteristics, Time from Stroke, and Concomitant Neuropsychological Deficits. Behav Neurol. 2019;2019:7835710.

Moseley GL, Butler DS, Beames TB, Giles TJ, Tomkins D. The Graded Motor Imagery Handbook: Neuro Orthopaedic Institute; 2012.

Polli A, Moseley GL, Gioia E, Beames T, Baba A, Agostini M, et al. Graded motor imagery for patients with stroke: a non-randomized controlled trial of a new approach. Eur J Phys Rehabil Med. 2017;53(1):14-23.




How to Cite

Khacharoen S, Thanakamchokchai J, Khobkhun F. Action Observation Therapy for Decreasing Impairments and Improving Functional Capabilities in Individuals with Acute to Subacute Stroke. J Thai Stroke Soc [Internet]. 2022 Apr. 12 [cited 2024 Jun. 20];21(1):43. Available from:



Review article