Effects of Motor Imagery and Action Observation on Motor Function in Unilateral Cerebral Palsy

In children with unilateral cerebral palsy (CP), the ability to perform various hand activities is reduced. Sensory and motor impairments observed in the affected upper extremity are the main causes of functional limitations. These impairments restrict the ability to perform simple activities of daily living such as dressing, tooth brushing, hair combing, feeding, and playing, and also lead to limitations in activity and participation within a broader social context. Therefore, one of the primary goals of neurological rehabilitation in this population is to promote the effective use of the affected upper extremity in daily tasks by improving its capacity and performance, and to support the child's independence in daily living activities by enhancing skills and increasing participation in activities. However, approximately 75% of children with unilateral CP continue to demonstrate motor impairments in activities of daily living even when they participate in a comprehensive rehabilitation program including conventional physical therapy, orthotic use, and spasticity management. There is a need for new rehabilitation programs aimed at enhancing the effects of traditional treatments, which mainly involve motor interventions.

In CP rehabilitation, it is recommended to integrate motor training with environmental enrichment and to increase environmental stimuli in order to enhance task performance. These approaches are based on the implementation of real-life activity-based tasks through active movements, with high intensity and individualized goals. In this way, neuroplasticity is supported through attention, motivation, and intensive repetition. Furthermore, it is recommended that activity- and task-oriented motor training be complemented with cognitive interventions such as action observation therapy, motor imagery, and mirror therapy, which combine motor and cognitive rehabilitation approaches.

Motor imagery is the mental simulation of movement without any overt motor action and refers to the capacity to generate kinesthetic representations of motor actions. Motor imagery selectively stimulates the cognitive aspect of motor behavior and is considered a prerequisite for motor planning processes. Recent studies have shown that despite motor deficits related to movement execution in children with CP, the ability to imagine movements may remain preserved. Therefore, interventions focusing on motor planning and imagery have emerged as potential treatment options for CP. However, the number of studies investigating the effectiveness of motor imagery in the CP population is quite limited, and well-designed studies examining the effectiveness of motor imagery training in individuals with CP are needed.

Action Observation Therapy (AOT) is known to be a cognitive intervention used to improve various motor skills in patients with motor impairments. From a rehabilitation perspective, the mirror neuron system plays a major role in the human capacity to learn through imitation. Based on the mirror neuron system, action observation consists of systematically and repeatedly observing actions followed by the reproduction of the observed actions. Findings from studies using AOT have indicated that AOT improves activities of daily living and has been proposed as a novel neurophysiological approach focused on motor learning in CP rehabilitation. Nevertheless, well-designed studies investigating the effectiveness of action observation training in individuals with CP are still needed.

The aim of this study is to evaluate the effects of Action Observation Therapy and motor imagery methods, provided in addition to conventional rehabilitation, on gross motor function, upper and lower extremity functional skills, and quality of life in children with CP.

Inclusion criteria

• Being between 7 and 16 years of age
• Having a diagnosis of unilateral cerebral palsy made by a pediatric neurologist
• Being classified at levels I-II of the Gross Motor Function Classification System (GMFCS)
• Scoring above 24 on the Mini-Mental State Examination for Children
• Having no cognitive impairments (i.e., possessing an appropriate cognitive level to follow task instructions)
• Willingness to participate in the study (child and family)
• Being classified at levels I-III of the Manual Ability Classification System (MACS) -Being classified at levels I-III of the Communication Function Classification System (CFCS) -

Exclusion criteria

• Children with uncontrolled seizures
• Children who have received motor imagery training or action observation therapy within the last 6 months
• Children with contractures
• Children with severe visual and/or hearing impairments
• Being classified at levels III, IV, or V according to the GMFCS
• Scoring below 24 on the Mini-Mental State Examination for Children
• Being classified at levels IV-V of the Manual Ability Classification System (MACS)
• Having undergone orthopedic surgery or botulinum toxin (Botox) treatment within the last 6 months