{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,2]],"date-time":"2026-11-02T11:29:19Z","timestamp":1793618959463,"version":"4.5.0"},"reference-count":122,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,7,23]],"date-time":"2025-07-23T00:00:00Z","timestamp":1753228800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:sec><jats:title>Introduction<\/jats:title><jats:p>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\u202f+\u202fMI) for promoting upper limb recovery post stroke.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Searching 10 databases, we identified 18 eligible studies (<jats:italic>N<\/jats:italic>\u202f=\u202f336), 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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Seven RCTs reported FMA-UE scores (<jats:italic>n<\/jats:italic>\u202f=\u202f189), where the standardized mean difference (SMD) for AO\u202f+\u202fMI treatments was moderate (SMD\u202f=\u202f0.58, 95%CI: 0.13\u20131.04, <jats:italic>p<\/jats:italic>\u202f=\u202f0.02). Two additional RCTs reported ARAT scores. Meta-analyzing the combined FMA-UE and ARAT scores (<jats:italic>n<\/jats:italic>\u202f=\u202f239) revealed SMD\u202f=\u202f0.70 (95%CI: 0.32\u20131.09, <jats:italic>p<\/jats:italic>\u202f=\u202f0.003). No significant correlations existed between the pooled effect size and several moderators (age, time since stroke, intervention duration, control condition, outcome measure and AO\u202f+\u202fMI arrangement), indicating consistent AO\u202f+\u202fMI practice effects. Overall, AO\u202f+\u202fMI 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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Discussion<\/jats:title><jats:p>AO\u202f+\u202fMI practice can promote upper limb recovery following stroke. AO\u202f+\u202fMI 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\u202f+\u202fMI practice efficacy.<\/jats:p><\/jats:sec><jats:sec><jats:title>Systematic review registration<\/jats:title><jats:p>The review was registered with PROSPERO under the registration number CRD42023418370. The registration is publicly accessible at the following URL: <jats:uri>https:\/\/www.crd.york.ac.uk\/PROSPERO\/view\/CRD42023418370<\/jats:uri>.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fneur.2025.1567421","type":"journal-article","created":{"date-parts":[[2025,7,23]],"date-time":"2025-07-23T16:37:15Z","timestamp":1753288635000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":11,"title":["Combined action observation and motor imagery practice for upper limb recovery following stroke: a systematic review and meta-analysis"],"prefix":"10.3389","volume":"16","author":[{"given":"Dan","family":"Lin","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel Lloyd","family":"Eaves","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John Derek","family":"Franklin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan Richard","family":"Robinson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jack Aaron","family":"Binks","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan Reyes","family":"Emerson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2025,7,23]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"129","DOI":"10.1016\/S0140-6736(20)31179-X","article-title":"Stroke","volume":"396","author":"Campbell","year":"2020","journal-title":"Lancet"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"806","DOI":"10.1177\/1747493019881353","article-title":"World stroke organization (WSO): global stroke fact sheet 2019","volume":"14","author":"Lindsay","year":"2019","journal-title":"Int J Stroke"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"e153","DOI":"10.1161\/CIR.0000000000001052","article-title":"Heart disease and stroke statistics-2022 update: a report from the American Heart Association","volume":"145","author":"Tsao","year":"2022","journal-title":"Circulation"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"439","DOI":"10.1161\/CIRCRESAHA.116.308413","article-title":"Global burden of stroke","volume":"120","author":"Feigin","year":"2017","journal-title":"Circ Res"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"783","DOI":"10.1177\/1747493019873519","article-title":"Standardized measurement of quality of upper limb movement after stroke: consensus-based core recommendations from the second stroke recovery and rehabilitation roundtable","volume":"14","author":"Kwakkel","year":"2019","journal-title":"Int J Stroke"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"357","DOI":"10.1080\/096382899297459","article-title":"The long-term outcome of arm function after stroke: results of a follow-up study","volume":"21","author":"Broeks","year":"1999","journal-title":"Disabil Rehabil"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"118","DOI":"10.1186\/s12955-015-0314-5","article-title":"Potential predictors for health-related quality of life in stroke patients undergoing inpatient rehabilitation","volume":"13","author":"Chen","year":"2015","journal-title":"Health Qual Life Outcomes"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"2529","DOI":"10.1161\/01.STR.0000143153.76460.7d","article-title":"Effects of augmented exercise therapy time after stroke: a meta-analysis","volume":"35","author":"Kwakkel","year":"2004","journal-title":"Stroke"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"498","DOI":"10.1136\/jnnp-2018-319954","article-title":"Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the queen square programme","volume":"90","author":"Ward","year":"2019","journal-title":"J Neurol Neurosurg Psychiatry"},{"key":"ref10","year":"2023"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"107","DOI":"10.1177\/1545968316666957","article-title":"Effects of robot-assisted therapy for the upper limb after stroke","volume":"31","author":"Veerbeek","year":"2017","journal-title":"Neurorehabil Neural Repair"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"478","DOI":"10.7861\/clinmedicine.17-5-478","article-title":"The latest national clinical guideline for stroke","volume":"17","author":"Rudd","year":"2017","journal-title":"Clin Med (Lond)"},{"key":"ref13","year":"2021"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"763","DOI":"10.1177\/1747493019897843","article-title":"Canadian stroke best practice recommendations: rehabilitation, recovery, and community participation following stroke. 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