Review Article

The Activation of the Mirror Neuron System during Action Observation and Action Execution with Mirror Visual Feedback in Stroke: A Systematic Review

Table 3

Characteristics of studies regarding the concurrent effects of single-session or multiple-session experiments on brain activation in stroke patients.

StudyCharacteristics of stroke participantsSeverity of hemiplegiaExperiment conditionsImaging modalityMain results

Garrison et al. [50]12 chronic stroke patients (two to 17 years after stroke), aged 39 to 85.Moderate to severe arm paresis (FMA-UE: 13 to 48).AO (reach to grasp objects by the right or left hand) and fixation.fMRI.Right-hand (paretic side) AO resulted in lateralization toward the left hemisphere, including IFG pars opercularis, IFG pars triangularis, SMG, and precentral gyrus.

Michielsen et al. [53]18 chronic stroke patients (>one year after stroke), aged 54.7 ± 9.9.Brunnstrom stage for the upper extremity III-V.Unimanual exercise (open-and-close action by the unaffected hand) with MVF; unimanual exercise without MVF; bimanual exercise (bilateral open-and-close actions) with MVF; bimanual exercise without MVF.fMRI.Bimanual exercise with MVF significantly increased the activity in precuneus and PCC, more than other conditions.

Szameitat et al. [56]Five chronic right-hemispheric stroke patients (>one year after stroke), aged 57 to 67.Unclear.Action execution (left wrist flexion and extension), MI (MI of the same wrist movement), AO (watching a video showing the same action), passive movement and baseline.fMRI.AO activated right lateral medial anterior PMC and a small focus of right IPL than baseline result.

Wang et al. [57]Five stroke patients (29 to 93 days after stroke), aged 53 to 72.Severe arm paresis (a wrist extension ability of less than 20 degrees and metacarpophalangeal joint extension ability of less than 10 degrees).Unilateral index finger-thumb opposition (by nonparetic hands) with virtual normal visual feedback or virtual MVF.fMRI.Four out of five patients displayed the lateralized activation toward the affected hemisphere (reflected by peak values within the precuneus), evoked by virtual MVF.

Brunner et al. [47]18 stroke patients, aged 41 to 79;
first scan: 8.9 ± 4.1 days after stroke;
second scan: 89.3 ± 8.3 days after stroke.
NHPT < 0.5 (pegs per second).AO (a video of bimanual twisting of a cylindrical device) and its resting condition (a still image of the device being held); action execution (bimanual twisting of a cylindrical device) and its resting condition (hold the device without twisting).fMRI.AO (first scan): involvement of the occipital and temporal visual areas bilaterally with activation maxima in the MTG and ITG and occipital lobe. Patients also showed activation in the parietal and frontal areas and the IPL, SPL, IFG, and M1 were involved; AO (second scan): most activated clusters were observed in ITG and the ventral anterior of the thalamus, also in premotor areas, SMA and M1.

Dettmers et al. [48]18 subcortical stroke patients (nine left stroke patients, aged 59.2 ± 7.1, 28.2 ± 40.9 months after stroke and nine right stroke patients aged 63 ± 10.3, 47.1 ± 89.5 months after stroke).With the ability to grip a small object and release it by the paretic hand.AO (static pictures) of object-related hand action by the paretic side, AO (movies) of object-related hand action by the paretic side, AO (same movies) with imagery (performing the shown action) and fixation.fMRI.AO (movies) elicited activation in visual cortex, SPL, prefrontal cortex, and superior and inferior frontal cortexes in both patient groups. AO (movies) with imagery revealed a very similar network as during AO (movies) alone.

Saleh et al. [55]15 chronic stroke patients (>six months after stroke), aged 54 ± 12.CMA: four to seven; CMH: three to seven.Nonparetic hand action (finger flexion) with veridical feedback or MVF and the control (nonanthropomorphic objects).fMRI (14 data).MVF induced significant activation of the ipsilesional postcentral gyrus, M1, precuneus, contralesional postcentral gyrus, superior bank of the intraparietal sulcus and precuneus, and SMG. Connectivity between BA 1 and M1 and between BA 1 and S1 was significantly stronger after MVF.

Saleh et al. [34]15 chronic stroke patients (>six months after stroke), aged 54 ± 12.CMA: four to seven; CMH: three to seven.Nonparetic hand action (finger flexion) with veridical feedback or MVF and the control (nonanthropomorphic objects).fMRI (12 data).MVF-induced activation of the ipsilesional primary motor cortex arose from the contralesional parietal cortex, in a region along the IPS.

Frenkel-Toledo et al. [49]33 stroke patients aged 24 to 76, 23 to 132 days after stroke.FMA zero to 66.AO (reach and grasp action by left or right hands), observation of nonbiological videos and the eye close condition.EEG.AO induced mu suppression over SMC rather than observation of nonbiological videos; mu suppression was significantly diminished in the ipsilesional SMC (C3 or C4), compared with the contralesional SMC (C3 or C4); right IPL damage lowered mu suppression over the unaffected hemisphere.

Rossiter et al. [54]10 stroke patients aged 56 ± 12, one to 114 months after stroke.ARAT zero to 57.Bilateral open-and-close hand action with MVF of nonparetic hand and bilateral open-and-close hand movement while viewing the paretic hand.MEG.Movement-related beta desynchronization was greater in contralesional compared to ipsilesional hemisphere. The asymmetry in movement-related beta desynchronization was more symmetrical in the condition with MVF.

Frenkel-Toledo et al. [13]36 stroke patients aged 24 to 81 years, 23 to 132 days after stroke.FMA zero to 66.AO (reach and grasp action by left or right hands), observation of nonbiological videos, and the eye close condition.EEG.Failure to imitate correlated with diminished mu suppression in patients with IPL or IFG pars opercularis damage.

Kuk et al. [51]20 chronic stroke patients (>six months after stroke);
EG (): stroke patients aged 60.0 ± 9.36;
CG (): stroke patients aged 59.70 ± 6.58.
With the ability to grasp a small cube (2.5 cm3) by the paretic hand.EG: AO (watching videos of the actions of BBT performed by both hands), followed by performing the same task;
CG: observation of nonbiological videos, followed by performing the same task.
EEG (, only for EG).MTG was not activated after five sessions of AO, compared with pretraining.

Tani et al. [58]11 stroke patients (18 to 1919 days after stroke), aged 64.1 ± 7.8.Brunnstrom stage of the hand III–V.AO (open-and-grasp action by the paretic hand), MI (the same actions by the paretic hand), and fixation.EEG.AO induced stronger mu suppression over the ipsilesional SMC (C3 or C4) than MI.

EG: experimental group; CG: control group; FMA-UE: Fugl-Meyer assessment upper extremity; AO: action observation; IFG: inferior frontal gyrus; SMG: supramarginal gyrus; fMRI: functional magnetic resonance imaging; MVF: mirror visual feedback; PCC: posterior cingular cortex; MI: motor imagery; PMC: premotor cortex; SMC: sensorimotor cortex; S1: primary somatosensory cortex; M1: primary motor cortex; NHPT: nine-hole peg test; MTG: middle temporal gyrus; ITG: inferior temporal gyrus; SPL: superior parietal lobe; IPL: inferior parietal lobe; PMd: dorsal premotor cortex; SMC: sensorimotor cortex; CMA: Chedokee-McMaster motor assessment arm scale; CMH: Chedokee-McMaster motor assessment hand scale; BA: Broadman area; EEG: electroencephalography; IPS: intraparietal sulcus; ARAT: action research arm test; MEG: magnetoencephalography; BBT: box and block test; ERD: event-related desynchronization.