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   https://intarchmed.biomedcentral.com/articles/10.1186/1755-7682-6-41

   ” The mirror neuron system in post-stroke rehabilitation

   Diana Carvalho, Silmar Teixeira, Marina Lucas, Ti-Fei Yuan, Fernanda Chaves, Caroline Peressutti, Sergio Machado, Juliana Bittencourt, Manuel Menéndez-González, Antonio Egidio Nardi, Bruna Velasques, Mauricio Cagy, Roberto Piedade, Pedro Ribeiro and Oscar Arias-CarriónEmail author

   International Archives of Medicine20136:41

   https://doi.org/10.1186/1755-7682-6-41

   © Carvalho et al.; licensee BioMed Central Ltd. 2013

   Received: 3 September 2013

   Accepted: 12 October 2013

   Published: 17 October 2013
   Abstract

   Different treatments for stroke patients have been proposed; among them the mirror therapy and motion imagery lead to functional recovery by providing a cortical reorganization. Up today the basic concepts of the current literature on mirror neurons and the major findings regarding the use of mirror therapy and motor imagery as potential tools to promote reorganization and functional recovery in post-stroke patients. Bibliographic research was conducted based on publications over the past thirteen years written in English in the databases Scielo, Pubmed/MEDLINE, ISI Web of Knowledge. The studies showed how the interaction among vision, proprioception and motor commands promotes the recruitment of mirror neurons, thus providing cortical reorganization and functional recovery of post-stroke patients. We conclude that the experimental advances on Mirror Neurons will bring new rational therapeutic approaches to post-stroke rehabilitation.
   Keywords
   ImageryImitationMirror neurons systemMirror therapyRehabilitationStroke
   Introduction

   Different approaches have been employed to investigate post-stroke rehabilitation [1, 2]. It has been shown that the human brain is capable of significant recovery after this type of injury [3, 4]. Among its sequels, hemiparesis has been treated with mirror-therapy which promotes cortical changes [5, 6]. In particular, sensorimotor disorders in post-stroke patients during the execution or observation of motor action have induced changes to the adjacent cortical penumbra area [7]. Moreover, motion imagination studies have demonstrated efficacies in treating the post-stroke population [8]. Th underlying hypothesis is that “mirror neurons” have been activated during such trainings. These cells were firstly discovered in the premotor cortex of rhesus monkeys by Rizzolatti and colleagues when they analyzed the monkeys observing the researchers’ act of eating up a fruit. These cells were then named because of their property to mirror the observed motor act inside the brain of monkeys [9, 10].

   Further experiments have verified the existence of mirror neurons in the parietal-frontal circuit, when an animal was exposed to a task of observing a particular action or intention mad by another animal [11, 12]. Thus, researchers suggested that mirror neurons are part of a neural system where the observation of an action activates the cortical area of the observer’s brain [10, 13, 14, 15]. Therefore, the purpose of this review is to describe basic concepts about the current literature on mirror neurons and the major findings regarding the use of mirror therapy and motor imagery as potential tools to promote cortical reorganization and functional recovery in post-stroke patients. The present review is divided in four sections: i) Introduction to Mirror Neuron System: Evidences in Humans; ii) Imitation: The role played by Mirror Neurons; iii) Mirror Neuron System: The Hypothesis of Motor Imagery, and iv) Contributions of the Mirror Neuron System on Post-Stroke Rehabilitation.
   Mirror neuron system: evidence in humans

   The mirror neuron system is considered a major breakthrough for neuroscience and it represents one important feature during the evolution of the human brain [16, 17]. In this context, several studies analyzed areas where this system participates; in particular, the majority of the experiments in humans and monkeys found mirror neurons in frontal and parietal lobes in tasks involving manual action observation [5, 6, 18, 19, 20]. Moreover, other experiments identified the activation of mirror neurons, specifically in the inferior frontal gyrus and premotor cortex. These findings were replicated in humans during task execution and observation of motor acts with hands, feet and mouth [21, 22, 23].

   Several tools for cortical stimulation and brain mapping have been employed to uncover the mechanisms behind the activity of mirror neurons. Among them, Transcranial Magnetic Stimulation (TMS) has provided relevant information about the participation of the motor cortex during simple action observation [20, 24, 25]. Hari et al., 1998, investigated the involvement of the mirror neuron system during action observation using magnetoencephalography. With this technique, subjects were instructed to observe stationary or moving stimuli. They observed a suppression of the 15 to 25 Hz activity and concluded that the human primary motor cortex is activated during observation as well as execution of motor tasks. Thus, the mirror neuron system seems to play an important role in human mimicking behavior, and it is activated when an individual observes an action performed by another person. Furthermore, its activation does not depend on memory; i.e., the mirror neuron system is able to identify action complexity, and it unconsciously imitates what we see, hear or perceive [26].
   Experiments using electroencephalography (EEG) also demonstrate the existence of mirror neurons in humans during movement observation [27, 28]. Cooper et al. [28] conducted an EEG study in order to analyze the occurrence of alpha band oscillations over the sensorimotor areas while the participants watched other people yawn. To confirm this hypothesis, researchers showed videos with individuals yawning to the subjects and found that mirror neurons are involved in the recognition of yawning. Additionally, Giromini et al. [27], analyzed the EEG μ wave in central areas when subjects watched other people’s movements in different scenarios controlling the amount of external stimuli provided. The results showed that the sensation of motion is capable of triggering activity of mirror neurons even when a small amount of external stimuli is presented. In another study, Oberman et al. [29], examined the EEG μ rhythm on the sensorimotor cortex in individuals with autism when compared with controls of the same age [29]. They found that, when children watched the videos with a moving hand or with a bouncing ball or with any visual stimulus, the mirror-neuron system responded dysfunctionally in children with autism compared with controls, as suggested in the “broken mirror” hypothesis. Taken together, mirror neurons have functions that can explain a wide range of human behaviors and neurological disorders [30, 31] (See Table 1).
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