Role of Action Observation Therapy in Cortical Reorganization in Patients with Stroke: A Narrative Review

Abstract

Background: Stroke is a leading cause of long-term disability, often resulting in motor, cognitive, and emotional impairments due to cortical damage. Cortical reorganization, which is a key component of post-stroke recovery, involves neuroplastic changes that facilitate functional improvements. Action Observation Therapy (AOT) has emerged as a promising neurorehabilitation approach that enhances neuroplasticity by engaging the mirror neuron system, which links action observation with motor execution.

Purpose: This review aimed to explore the role of AOT in facilitating motor recovery after stroke and its effects on cortical activation and motor network reorganization, and the growing body of evidence supporting its use as a complementary intervention alongside conventional rehabilitation techniques.

Methods: A comprehensive literature search was conducted using PubMed, Cochrane Library, Web of Science, Scopus, and Google Scholar to identify relevant studies published between 2000 and 2024. The following search terms were used: ("Action observation therapy" OR "AOT") AND ("Stroke Rehabilitation" OR "Neurorehabilitation") AND ("Cortical Reorganization" OR "Neuroplasticity" OR "Brain Plasticity") AND ("Functional Recovery" OR "Motor Recovery"). Only randomized controlled trials (RCTs), systematic reviews, meta-analyses, and observational studies published in English were included. Studies that focused solely on psychological outcomes without assessing cortical reorganization or those conducted on animal models were excluded.

Results: AOT interventions have been associated with increased activation in the prefrontal cortex, enhanced functional connectivity in motor and cognitive networks, and improved participation in rehabilitation programs. Neuroimaging studies indicate that AOT-related cognitive restructuring and behavioral activation strategies modulate neural pathways involved in motor and cognitive recovery, particularly in the Inferior Frontal Gyrus, Inferior Parietal Lobule, Premotor Cortex (PMC), Primary Motor Cortex and Supplementary Motor Area (SMA). Furthermore, combining AOT with rehabilitation techniques, such as constraint-induced movement therapy (CIMT), and neurostimulation (tDCS, rTMS), has been shown to optimize recovery outcomes by reinforcing adaptive neuroplasticity.

Conclusion: AOT represents a promising intervention in stroke rehabilitation by targeting both neurological and psychological factors affecting recovery. The evidence supports its role in enhancing neuroplasticity, reducing emotional barriers, and improving functional rehabilitation adherence and integrating AOT into multidisciplinary rehabilitation programs may enhance patient engagement, cortical reorganization, and overall quality of life post-stroke.