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Combined Action Observation and Motor Imagery Practice for Upper-Limb Recovery Following Stroke: A Systematic Review and Meta-Analysis

Lookup NU author(s): Dr Daniel EavesORCiD, Jack Binks

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This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).

Abstract

Introduction: Optimal upper limb recovery requires high-dose physiotherapy; however, this essential component of rehabilitation is under-delivered. Mental practice represents an accessible and cost-effective adjunct to conventional therapy. We therefore evaluated the efficacy of an enhanced mental practice treatment (combined action observation and motor imagery, AO + MI) for promoting upper limb recovery post stroke. Methods: Searching 10 databases, we identified 18 eligible studies (N = 336), comprising nine randomized controlled trials (RCTs) and nine non-randomized controlled trials (non-RCTs). RCTs were meta-analyzed using upper limb function outcomes (Fugl-Meyer Assessment for upper extremity, FMA-UE; Action Research Arm Test, ARAT). Non-RCTs (not eligible for meta-analysis) were narratively synthesized using upper limb and neuroimaging outcomes. Results: Seven RCTs reported FMA-UE scores (n = 189), where the standardized mean difference (SMD) for AO + MI treatments was moderate (SMD = 0.58, 95%CI: 0.13–1.04, p = 0.02). Two additional RCTs reported ARAT scores. Meta-analyzing the combined FMA-UE and ARAT scores (n = 239) revealed SMD = 0.70 (95%CI: 0.32–1.09, p = 0.003). No significant correlations existed between the pooled effect size and several moderators (age, time since stroke, intervention duration, control condition, outcome measure and AO + MI arrangement), indicating consistent AO + MI practice effects. Overall, AO + MI significantly improved upper limb function across all nine RCTs, and all nine narratively synthesized studies, including neuroimaging outcomes. Limitations included inconsistent terminology, intervention design, clarity of reporting, and modality.Discussion: AO + MI practice can promote upper limb recovery following stroke. AO + MI can therefore be used as a bridge between AO therapy (requiring little effort in early recovery), and the more cognitively demanding MI. Researchers must adopt standardized reporting protocols to further establish AO + MI practice efficacy.

Publication metadata

Author(s): Lin D, Eaves DL, Franklin JD, Robinson J, Binks JA, Emerson JR

Publication type: Article

Publication status: Published

Journal: Frontiers in Neurology

Year: 2025

Volume: 16

Online publication date: 23/07/2025

Acceptance date: 30/06/2025

Date deposited: 19/09/2025

ISSN (electronic): 1664-2295

Publisher: Frontiers Media SA

URL: https://doi.org/10.3389/fneur.2025.1567421

DOI: 10.3389/fneur.2025.1567421

Data Access Statement: The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author/s.

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