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

Investigation of the Effects of Motor Imagery and Action Observation Therapy on Gross Motor Function, Upper Extremity Functional Skills, Activity, and Participation in Children With Unilateral Cerebral Palsy

The aim of this study is to evaluate the effects of action observation therapy and motor imagery methods, provided in addition to a conventional physiotherapy and rehabilitation program, on gross motor function, upper and lower extremity functional skills, and quality of life in children with cerebral palsy.

Study Overview

• Status: Recruiting
• Conditions: Cerebral Palsy (CP)
• Intervention / Treatment: Other: motor imagery; Other: Action observation therapy; Other: Conventional physiotherapy group

Detailed Description

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.

• Study Type: Interventional
• Enrollment (Estimated): 48
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Betul Unal; Phone Number: +905314070105; Email: betul.unal1@bahcesehir.edu.tr

Study Locations

• Turkey (Türkiye)
  • Istanbul, Turkey (Türkiye)
    • Recruiting
    • Kurtkoy Ozel Egitim ve Rehabilitasyon Merkezi
    • Contact: Burak Yaşar; Phone Number: +905050181505; Email: bynsunal@gmail.com
    • Principal Investigator: Betul Unal, PhD (C)

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child
• Accepts Healthy Volunteers: No

Description

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Motor Imagery Group; Mental imagery practice will be applied in addition to conventional physiotherapy. A total of 10 movements supporting activities of daily living, including unimanual and bimanual upper extremity activities, walking, and balance activities, will be practiced from both first-person and third-person perspectives. The intervention will be administered for 50 minutes per session, twice a week, for 8 weeks. The intervention protocol will consist of 20 minutes of conventional physiotherapy followed by 30 minutes of motor imagery practice.	Other: motor imagery; Participants will receive treatment for 16 sessions in total, with 2 sessions per week for 8 weeks. Each session will last 50 minutes. The motor imagery practice will consist of a total of 10 movements including unimanual and bimanual, walking and balance activities, and will be performed by participants from both first-person and third-person perspectives. Balance activities: Single-leg standing balance; Sit and stand up with your arms crossed in front of you while sitting in the chair. Walking activities: The child gets up from the chair without support, walks 3 meters, then returns and sits back down in the chair; Walking sideways and backward on different surfaces Bimauel upper extremity activities; Putting on a blouse; Putting on and zipping up/down a dress with a front zipper.; Putting on shoes and tying the laces. Unimanual upper extremity activities; Taking food from the plate with a spoon and putting it in the mouth; Combing hair; Holding the doorknob and opening
Active Comparator: Action Observation Therapy Group: Action observation therapy will be applied in adition to conventional physiotherapy. A total of 10 movements supporting activities of daily living, including unimanual and bimanual upper extremity activities, walking, and balance activities, will be practiced. In action observation therapy, after participants observe the movement (observation phase), they will be asked to imitate the observed movement (execution phase). The intervention will be administered for 50 minutes per session, twice a week, for 8 weeks. The intervention protocol will consist of 20 minutes of conventional physiotherapy followed by 30 minutes of action observation therapy.	Other: Action observation therapy; Participants will receive treatment for 16 sessions in total, with 2 sessions per week for 8 weeks. Each session will last 50 minutes. Action observation therapy will consist of a total of 10 movements including unimanual and bimanual, walking and balance activities. After participants observe the movement (observation phase), they are asked to imitate the movement they observed (execution phase). Balance activities: Single-leg standing balance; Sit and stand up with your arms crossed in front of you while sitting in the chair. Walking activities: The child gets up from the chair without support, walks 3 meters, then returns and sits back down in the chair; Walking sideways and backward on different surfaces Bimauel upper extremity activities; Putting on a blouse; Putting on and zipping up/down a dress with a front zipper.; Putting on shoes and tying the laces. Unimanual upper extremity activities; Taking food from the plate with a spoon and putting it in the mouth
Active Comparator: Conventional physiotherapy group; Conventional physiotherapy training will be structured according to the child's symptoms and needs, and will consist of stretching, strengthening, normal walking training, postural control training, and weight-bearing training in different positions (sitting, standing, side-lying, prone).	Other: Conventional physiotherapy group; Participants will receive treatment for 16 sessions in total, with 2 sessions per week for 8 weeks. Each session will last 50 minutes. Conventional physiotherapy training will be structured according to the child's symptoms and needs, and will consist of stretching, strengthening, normal walking training, postural control training, and weight-bearing training in different positions (sitting, standing, side-lying, prone).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
ABILHAND-Kids	Manual ability in daily activities assessed using the ABILHAND-Kids questionnaire for children with cerebral palsy (measured as logit score using Rasch analysis). ABILHAND-Kids evaluates the child's perceived difficulty in performing daily bimanual activities, such as dressing (buttons, zippers), eating with utensils, using scissors or pencils, opening containers, handling small objects. Contains a list of everyday manual tasks Each item is rated based on difficulty: Impossible, difficult, easy. Higher scores indicate better manual ability. Time Frame: 8 weeks	0th week; 8th week

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pediatric Quality of Life Inventory (PedsQL)	Quality of life assessed using the Pediatric Quality of Life Inventory (PedsQL) 3.0 Cerebral Palsy Module Child and Parent Reports. The 35-item questionnaire evaluates daily activities, school activities, movement and balance, pain, fatigue, eating activities, and speech and communication in children with cerebral palsy. Items are scored on a 5-point Likert scale and transformed to a 0-100 scale. Higher scores indicate better quality of life.	0th week; 8th week
Jebsen-Taylor Hand Function Test	Hand function assessed using the Jebsen-Taylor Hand Function Test (JTHFT), a standardized measure of fine and gross motor hand function during simulated activities of daily living. The test consists of seven subtests, including writing, page turning, lifting small objects, simulated feeding, stacking, and lifting light and heavy objects. Performance is measured as completion time in seconds for each subtest and total test time using a stopwatch. Measurement method: Each task is performed as quickly as possible. Time is measured in seconds with a stopwatch. Each task is recorded separately. Scoring system: Time elapsed for each subtest (in seconds) is used. Total score: sum of subtest times or total time separately for each hand. Lower completion time indicates better hand function.	0th week; 8th week
The Child and Adolescent Scale of Participation (CASP)	The CASP questionnaire assesses an individual's community participation in home, school, and neighborhood settings. It consists of 20 questions in total, with 4 sub-sections: Home participation (6 questions), neighborhood and community participation (4 questions), school Participation (5 questions), and home and community activities (5 questions). Scoring system: 4 = expected for their age (full participation), 3= somewhat limited, very limited, 2=unable, and 1=not applicable. Total and/or domain scores are calculated, and scores transformed to a standardized 0-100 scale. Higher scores indicate better levels of participation in daily life activities.	0th week; 8th week
Gross Motor Function Measure (GMFM)	Gross motor function assessed using the Gross Motor Function Measure (GMFM-88), a standardized assessment tool for children with cerebral palsy. The scale consists of 88 items across five domains: lying and rolling, sitting, crawling and kneeling, standing, and walking/running/jumping. Items are scored on a 4-point Likert scale according to the child's level of performance. Total scores range from 0 to 264, with higher scores indicating better gross motor function.	0th week; 8th week
Timed Up and Go Test	Functional mobility assessed using the Timed Up and Go Test (TUG). Participants are instructed to stand up from a chair, walk 3 meters, turn around, return to the chair, and sit down. Completion time is measured in seconds using a stopwatch. Lower completion times indicate better functional mobility.	0th week; 8th week
Five Times Sit-to-Stand Test	Lower extremity functional strength assessed using the Five Times Sit-to-Stand Test (5xSTS). Participants are instructed to stand up and sit down five times as quickly as possible from a standard chair without using upper extremity support. Completion time is measured in seconds using a stopwatch. Lower completion times indicate better functional performance.	0th week; 8th week

Collaborators and Investigators

• Sponsor: Bahçeşehir University
• Investigators: Study Chair: Hasan K. Alptekin, Prof. Dr., Bahcesehir university; Study Director: Pelin Pisirici, Assoc. Prof., Bahcesehir university

Publications and helpful links

General Publications

• Steenbergen B, Jongbloed-Pereboom M, Spruijt S, Gordon AM. Impaired motor planning and motor imagery in children with unilateral spastic cerebral palsy: challenges for the future of pediatric rehabilitation. Dev Med Child Neurol. 2013 Nov;55 Suppl 4:43-6. doi: 10.1111/dmcn.12306.
• Alamer A, Melese H, Adugna B. Effectiveness of Action Observation Training on Upper Limb Motor Function in Children with Hemiplegic Cerebral Palsy: A Systematic Review of Randomized Controlled Trials. Pediatric Health Med Ther. 2020 Sep 15;11:335-346. doi: 10.2147/PHMT.S266720. eCollection 2020.
• Sgandurra G, Ferrari A, Cossu G, Guzzetta A, Fogassi L, Cioni G. Randomized trial of observation and execution of upper extremity actions versus action alone in children with unilateral cerebral palsy. Neurorehabil Neural Repair. 2013 Nov-Dec;27(9):808-15. doi: 10.1177/1545968313497101. Epub 2013 Jul 25.
• Buccino G, Molinaro A, Ambrosi C, Arisi D, Mascaro L, Pinardi C, Rossi A, Gasparotti R, Fazzi E, Galli J. Action Observation Treatment Improves Upper Limb Motor Functions in Children with Cerebral Palsy: A Combined Clinical and Brain Imaging Study. Neural Plast. 2018 Jul 4;2018:4843985. doi: 10.1155/2018/4843985. eCollection 2018.
• Demeco A, Molinaro A, Ambroggi M, Frizziero A, Fazzi E, Costantino C, Buccino G. Cognitive approaches in the rehabilitation of upper limbs function in children with cerebral palsy: a systematic review and meta-analysis. Eur J Phys Rehabil Med. 2024 Jun;60(3):445-457. doi: 10.23736/S1973-9087.24.08288-1. Epub 2024 Mar 21.
• Shin YK, Lee DR, Hwang HJ, You SJ, Im CH. A novel EEG-based brain mapping to determine cortical activation patterns in normal children and children with cerebral palsy during motor imagery tasks. NeuroRehabilitation. 2012;31(4):349-55. doi: 10.3233/NRE-2012-00803.

Study record dates

Study Major Dates

• Study Start (Actual): May 15, 2026
• Primary Completion (Estimated): October 1, 2026
• Study Completion (Estimated): October 1, 2026

Study Registration Dates

• First Submitted: May 15, 2026
• First Submitted That Met QC Criteria: May 23, 2026
• First Posted (Actual): May 28, 2026

Study Record Updates

• Last Update Posted (Actual): May 28, 2026
• Last Update Submitted That Met QC Criteria: May 23, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: quality of life; Cognitive Training; motor imagery; Mirror Neurons
• Additional Relevant MeSH Terms: Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Brain Damage, Chronic; Cerebral Palsy
• Other Study ID Numbers: E-78097791-020-5100

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: IPD will be made available upon reasonable request after publication of the study results. Requests will be evaluated and approved by the principal investigator to ensure that the proposed use is methodologically sound and in accordance with ethical and institutional regulations. Data will be shared for academic and non-commercial research purposes only.
• IPD Sharing Time Frame: After publication of the study results
• IPD Sharing Access Criteria: De-identified individual participant data will be available upon reasonable request. Requests will be reviewed and approved by the principal investigator for non-commercial academic research purposes only.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No