ArticlePDF Available

Effects of a single session of motor imagery and action observation plus physical exercise on lumbo-pelvic sensorimotor function in healthy women: a randomized controlled pilot trial

Authors:

Abstract and Figures

Objectives The main aim of this study was to assess the effects of a single session motor imagery (MI) and action observation (AO) plus physical exercise (PE) on lumbo-pelvic sensorimotor function. Methods Thirty-six healthy women were randomized into three groups: MI (n=12), AO (n=12), or sham observation (SO) group (n=12). All the groups performed PE consisting of a combination of aerobic and strengthening exercises. The outcome measures included lumbo-pelvic motor control, pressure pain threshold (PPT) in lumbar and tibialis anterior region, and pelvic floor muscle (PFM) strength. A pre- and post-intervention evaluation was conducted. Results Regarding the lumbo-pelvic motor control, only the AO group showed significant within-group differences with a moderate effect size (mean difference (MD)=−3.55 mmHg (−6.6 to −0.5), p=0.023, d=−0.56). With respect to the PPT in the lumbar region, only the MI group showed significant within-group differences with a small effect size (MD=0.775 kg/cm² (0.35–1.2), p=0.001, d=0.44). No statistically significant PFM strength gain was found (p>0.05). Finally, no between-group differences were found (p>0.05). Conclusions MI and AO training plus PE had a slight impact on lumbo-pelvic sensorimotor function such as motor control or local pain sensitivity when applied in a single session.
This content is subject to copyright. Terms and conditions apply.
Research Article
Alba Nieves-Gómez, Natalia Millán-Isasi, Amelia Lara-Bolinches, Lucía Marcos-Hernández,
Laura Fuentes-Aparicio, Ferran Cuenca-Martínez* and Núria Sempere-Rubio
Eects of a single session of motor imagery and
action observation plus physical exercise on
lumbo-pelvic sensorimotor function in healthy
women: a randomized controlled pilot trial
https://doi.org/10.1515/jirspa-2024-0018
Received February 22, 2024; accepted July 11, 2024;
published online August 13, 2024
Abstract
Objectives: The main aim of this study was to assess the eects
of a single session motor imagery (MI) and action observation
(AO) plus physical exercise (PE) on lumbo-pelvic sensorimotor
function.
Methods: Thirty-six healthy women were randomized into
three groups: MI (n=12), AO (n=12), or sham observation (SO)
group (n=12). All the groups performed PE consisting of a
combination of aerobic and strengthening exercises. The
outcome measures included lumbo-pelvic motor control,
pressure pain threshold (PPT) in lumbar and tibialis anterior
region, and pelvic oor muscle (PFM) strength. A pre- and
post-intervention evaluation was conducted.
Results: Regarding the lumbo-pelvic motor control, only the
AO group showed signicant within-group dierences with a
moderate eect size (mean dierence (MD)=3.55 mmHg (6.6
to 0.5), p=0.023, d=0.56). With respect to the PPT in the
lumbar region, only the MI group showed signicant within-
group dierences with a small eect size (MD=0.775 kg/cm2
(0.351.2), p=0.001, d=0.44). No statistically signicant PFM
strength gain was found (p>0.05). Finally, no between-group
dierences were found (p>0.05).
Conclusions: MI and AO training plus PE had a slight impact
on lumbo-pelvic sensorimotor function such as motor control
or local pain sensitivity when applied in a single session.
Keywords: womens health; motor imagery; action obser-
vation; physical exercise
Introduction
Motor imagery (MI) is dened as a cognitive ability
that involves the representation of an action, internally,
without its actual motor execution [1]. MI training elicits
an activation of brain areas related to the planning and
execution of voluntary movement in a similar way as
when the action is actually performed [2]. In fact, Lebon
et al [3] argued that the coincidence in cortical activation
of such areas between actual motor execution and motor
imageryisareliablemeanstoassessthequalityofmental
representation. Motor programs stored in procedural
memory systems allow the generation of MI without the
need for an external stimulus although it has been shown
that bringing visual information prior to the MI task
facilitates the imagery task and elicits greater neuro-
physiological activity than if performed in isolation [46].
The MI allows the practice of movements without the need
to physically perform them, and that is why it has been
widely used in the training of technical ability in both
athletes, as well as in neurorehabilitation [7, 8].
On the other hand, action observation (AO) training is also
awidelyusedmovementrepresentationtechniqueintheeld
of rehabilitation and physical performance [9, 10]. AO training
is considered as an internal representation of the set of real
movements evoked by that visualized by the spectator [11]. In
the same way as MI, the AO training is able to elicit neuro-
physiological activation of premotor, supplementary motor,
ANG and NMI contributed equally to this work.
*Corresponding author: Professor Ferran Cuenca-Martínez,
Department of Physiotherapy, University of Valencia, Gascó Oliag 5,
Valencia 46010, Spain, E-mail: Ferran.Cuenca@uv.es. https://orcid.org/
0000-0003-4644-3758
Alba Nieves-Gómez, Natalia Millán-Isasi, Amelia Lara-Bolinches, Lucía
Marcos-Hernández and Núria Sempere-Rubio, Department of
Physiotherapy, University of Valencia, Valencia, Spain. https://orcid.org/
0000-0002-6564-0936 (N. Sempere-Rubio)
Laura Fuentes-Aparicio, Physiotherapy in Motion Multispecialty Research
Group (PTinMOTION), Department of Physiotherapy, University of Valencia,
Valencia, Spain. https://orcid.org/0000-0001-8830-9958
J Imag. Res. Sport Phys. Act. 2024; 19(1): 20240018
Open Access. © 2024 the author(s), published by De Gruyter. This work is licensed under the Creative Commons Attribution 4.0 International License.
primary somatosensory and posterior parietal cortex areas in
a qualitatively equal but quantitatively lesser manner than
when the action is actually performed [2, 12]. Both movement
representation techniques have been shown to result in
greater strength gains [13], greater improvements in motor
control [14], and greater decreases in pain intensity [15] when
added to physical exercise intervention as compared to when
physical exercise is performed in isolation, without mental
practice. However, research using movement representation
techniques such as MI or AO performs several sessions on
dierent days of intervention. We do not know whether
movement representation techniques would have a clinical
impact in a single session. Moreover, the study of movement
representation techniques in womens health is currently
starting [16, 17] and we do not know almost everything at the
moment.Thisisarst pilot study where we want to combine
mentally and physically a set of global exercises to see the
generalization eects on the functioning of the lumbo-pelvic
sensorimotor system as well as the maximal strength of the
pelvic oor musculature (PFM) in healthy women. Women
with musculoskeletal disorders commonly present with loss of
maximal PFM strength [18], as well as lumbo-pelvic pain and
motor control aberrations [19]. If we assume that therapeutic
exercise has a signicant impact on these variables in women
with musculoskeletal disorders [20, 21], it is likely that adding
mental practice will result in greater improvements when
combined with therapeutic exercise than just exercise alone.
Even in specic problems, such as vestibulodynia or in the
immediate postpartum period, movement representation
techniques alone could be applied to improve some clinical
variables of interest, although for the moment, we want to see
what happens in healthy women at the physiological level.
Thereby the main aim of this study was to assess the
eects of a single session motor imagery and action obser-
vation plus physical exercise on lumbo-pelvic sensorimotor
function in healthy women.
Methods
Study design
This study was a randomized, single-blind, placebo
controlled pilot trial, planned, and conducted in accor-
dance with Consolidated Standards of Reporting Trials
(CONSORT) requirements, and was approved by The Ethics
Committee of Research in Humans of the Ethics Commis-
sion in Experimental Research of University of Valencia
(2699494). This study was registered in the United States
Randomized Trials Registry on clinicaltrial.gov (trial reg-
istry number: NCT06073210).
Participants
Between October and December 2023, healthy women were
recruited. Advertisements, social networks, and emails were
used for this purpose. Prior to nal inclusion, all signed the
informed consent. All women participants received a detailed
explanation of the study procedures, which were planned ac-
cording to the ethical standards of the Helsinki Declaration. The
criteria for inclusion were: (1) being an asymptomatic woman,
and (2) be aged between 18 and 30 y/o. The exclusion criteria
were: (1) suering from any pathology that presents pain, (2)
suering pathologies of a pelvic oor origin, (3) having any
musculoskeletal disorders in the upper/lower limbs and (4)
having a metabolic disease, all assessed by personal interview.
Randomization
Randomization was performed using a computer-generated
random sequence table with a balanced three-block design
(GraphPad Software, Inc., CA, USA). An independent researcher
generated the randomization list, and a member of the
research team who was not involved in the assessment of the
participants or the intervention was in charge of the random-
ization and maintained the list. The patients included were
randomly assigned to one of the three groups using the random
sequence list, ensuring concealed allocation.
Blinding
The assessments and interventions were performed by two
dierent physiotherapists. The evaluator was blinded to the
participantsgroup assignment. All the intervention pro-
cedures were performed by the same physiotherapist who
had experience in the womens health eld and was blinded
to the purpose of the study. All participants were blinded to
their group allocation.
Interventions
All women conducted a single intervention session of mental
practice (MI, AO, or sham observation (SO) training) plus PE,
lasting about 1 h.
Physical exercise
All women underwent a PE program that combined aerobic
exercise with strengthening exercises. Firstly, aerobic ex-
ercise was performed for 20 min at an intensity between 12
2Nieves-Gómez et al.: Motor imagery & womens health
and 14/20 on the perceived fatigue scale (somewhat hard)
[22]. The strengthening program consisted of a combo of
three exercises: non-weighted free squats (4 sets of 45 s),
followed by abdominal isometric exercise (4 sets of 30 s) and
specic exercise of the PFM (4 sets of eight maximum
voluntary pelvic oor contractions). Between sets there was
a 30 s rest, and between exercises there was a 1 min rest. In
total, the exercise program lasted approximately 45 min.
Motor imagery
The MI group performed 10 min of mental training prior to
aerobic exercise. The participants were taken to the training
track to see the place where they would later train to facil-
itate the imagining task. MI was dosed as follows: 10 sets of
50 s (followed by a 10 s rest) were performed imagining in
rst person (or egocentric) and kinesthetically (5 sets) and in
third person (or allocentric) and visually (5 sets). Some ver-
bal cues were provided in order to facilitate the imagination:
keep imagining,imagine running faster,imagine how
you overtake the person in front of you,try to feel how
your feet step on the ground,feel how your heart speeds
up,feel how you breathe faster and faster. Subsequently,
4 sets of 30 s each of the strengthening exercises were per-
formed in third person and visually with the exception of the
maximum voluntary contraction of the PFM, which was
performed only kinesthetically to try to feel the contraction
they had just performed in a real way. The MI sets were
performed during the rest between sets of the actual exer-
cises. Therefore, MIs total intervention lasted 16 min.
Action observation
The AO group made a 10 min observation of a womanrunning
on the same training track where they would later train. The
video had two 5 min parts, one where the perspective was in
rst person, and the other, where the perspective wasin third
person. Subsequently, the participants watched for 4 sets of
30 s each of the strengthening exercises in third person
perspective. The AO sets were visualized during the rest be-
tween sets of the actual exercises. The AO training performed
on PFM contraction was through an illustrative video. The
AOs total intervention lasted 16 min.
Sham action observation
Women in this group underwent a SO protocol. This group
performed the same visualization training as the AO group,
but the video showed images of interstellar space (without
visualizing any motor gesture). This kind of SO protocol has
been used in previous research [23, 24]. The duration of this
placebo mental training lasted exactly the same as the two
groups of eective mental practice (16 min).
Outcome measures
Baseline outcomes
Baseline measurements included physical activity levels and
motor imagery ability and were performed to ensure that all
women had the same conditions of physical activity levels
and ability to imagine at the beginning of the study.
Physical activity levels
The level of physical activity was evaluated using the inter-
national physical activity questionnaire (IPAQ) [25]. This
questionnaire has shown an acceptable validity to measure
total physical activity. The level of METs expended in the
previous week is estimated by applying a formula. The
reliability of this questionnaire was approximately 0.65
(r=0.76; 95 % CI 0.730.77) [26].
Motor imagery ability
The motor imagery ability was measured with the revised
version of the movement imagery questionnaire (MIQ-R). The
MIQ-R is an 8-item self-report inventory that assesses visual
and kinaesthetic motor imagery ability. Four dierent move-
ments are included in MIQ-R, which is comprised of four visual
and four kinaesthetic items. Participants are required to read
a description of each movement, physically performed the
movement, and then we were instructed to return to the
starting position before engaging in the mental task, imaging
the movement visually or kinaesthetically. Each participant
then rates the ease or diculty of generating that image on a
7-point scale in which 7 indicates very easy to see/feeland 1
very dicult to see/feel. The internal consistencies of the
MIQ-R have been consistently adequate, with Cronbachsα
coecients above 0.84 for the total scale, 0.80 for the visual
subscale and 0.84 for the kinaesthetic subscale [27].
Primary outcome
Lumbo-pelvic motor control
Motor control of the lumbar region was evaluated through a
stabilizer pressure biofeedback unit (Chattanooga Group
Inc., Chattanooga, TN). We employed a modication of the
neutral position test (developed by Azevedo et al. [28]) based
Nieves-Gómez et al.: Motor imagery & womens health 3
on the stabilizer instructions; the measurement was based
on a protocol validated in a previous study and presents an
intraclass correlation coecient of 0.94 (95 % condence
interval [CI] 0.870.97) [28]. The women were positioned in
supine decubitus with the stabilizer in the lumbar region
with an initial pressure of 40 mmHg and a knee exion of
90°. The women were then instructed to perform a 90°hip
and knee exion with one limb and then the same action
with the opposite limb. According to the stabilizers treat-
ment protocol, the pressure will increase between 8 and
10 mmHg during the exercise. The evaluator performed
three measurements and calculated the total mean pressure
of both lower limbs.
Secondary outcomes
Pain sensitivity
Pain sensitivity was examined through the pressure pain
threshold (PPT). PPT is dened as the minimum amount of
pressure needed to elicit pain. Measurements of PPT were made
using a digital algometer (Model FDX 10®, Wagner Instruments,
Greenwich, CT, USA). This instrument measures the pressure in
kg/cm2. The PPTs were measured on two locations on the body:
(a) the medial plane of the lumbar zone, just below the fth
lumbar vertebra (local region), and (b) on the dominant leg,
4 cm distal of the tuberositas tibiae (distal region). The evalua-
tion points of the PPTs were chosen following the research work
carried out by Grundström et al. [29]. The average of three
measurements was recorded, with an interval of 30 s between
each measurement to avoid a temporal summation eect. PPT
has shown good reliability and internal consistency [30].
Pelvic oor muscle strength
The PFM strength was objectively measured with a commer-
cially plastic intravaginal dynamometry speculum (Pelvimeter
Phenix, Montpellier, France) in g.Threemaximumeort
PFM contractions was performed and the mean value of the
three trials was retained for analysis as reported by Navarro
Brazález et al. [31]. The test was connected to a Phenix USB2
biofeedback system (Vivaltis, Montpellier, France), interfaced
with an IBM compatible computer, and protected by latex or
polyethylene covers.
Procedures
After consenting to participate, all the women were received
an initial evaluation prior to the intervention process. Once
the pre-intervention assessment was completed, the inter-
vention was performed, which consisted of 45 min of aerobic
and strength training, together with 16 min of mental prac-
tice (depending on the assignment group) in a single session.
Finally, the outcome measures were assessed at the end of
the intervention again.
Data analysis
The statistical data analysis was performed using statistical
SPSS software version 25.0 (SPSS Inc., Chicago, IL, USA). The
normality of the variables was evaluated by the ShapiroWilk
test. Descriptive statistics were used to summarize the data for
continuous variables and are presented as mean±standard
deviation, 95 % condence interval. For the inferential analysis
of continuous variables, a mixed two-factor analysis of vari-
ance (ANOVA) was conducted with a between-subject factor
intervention grouphaving three categories (MI, AO, and SO)
and a within-subject factor time measurementshaving two
categories (pre- and post-intervention). A post hoc analysis with
Bonferroni correction was performed in the case of signicant
ndings for multiple comparisons between variables. Eect
sizes (d) were calculated according to Cohensmethod,inwhich
the magnitude of the eect was classied as small (0.200.49),
moderate (0.500.79)orlarge(0.8)[32].Theαlevel was set at
0.05 for all tests.
Results
A total of 36 women were included in the study, were randomly
allocated into three groups (n=12 per group) (Figure 1). There
were no adverse events reported in either group. All the var-
iables presented a normal distribution. No statistically signi-
cant between-group dierences were found at baseline for any
demographic data or self-report variables (Table 1).
Lumbo-pelvic motor control
The ANOVA revealed signicant changes in the lumbo-pelvic
motor control during time (F=4.102, p=0.048, ƞ
p
2=0.11) but
not, during group*time interaction (F=1.47, p=0.24, ƞ
p
2=0.08).
The post hoc analysis revealed signicant within-group dif-
ferences only in the AO group with a moderate eect size
(mean dierence (MD)=3.55 mmHg (6.6 to 0.5), p=0.023,
d=0.56). No other within-group dierences were found
(p>0.05) (Figure 2). No between-group dierences were
observed (p>0.05) (Table 2). These results show that the AO
group performed the lumbo-pelvic motor control test
4Nieves-Gómez et al.: Motor imagery & womens health
statistically signicantly more accurately at the end of the
session than at the beginning, although this result was not
enough to be statistically dierent from that found in the
rest of the groups at the end of the intervention.
Pain sensitivity
Local pain sensitivity (lumbar region)
The ANOVA revealed signicant changes in the lumbar PPT
during time (F=7.086, p=0.012, ƞ
p
2=0.16) but not, during
group*time interaction (F=2.02, p=0.11, ƞ
p
2=0.09). The post
hoc analysis revealed signicant within-group dierences
only in the MI group with a small eect size (MD=0.775 kg/
cm2(0.351.2), p=0.001, d=0.44). No other within-group
dierences were found (p>0.05) (Figure 3). No between-
group dierences were observed (p>0.05) (Table 2). These
results show that the MI group increased PPTs signicantly
at the end of the session with respect to the PPTs reported
at baseline, although this result was not enough to be sta-
tistically dierent from that found in the rest of the groups
at the end of the intervention.
Distal pain sensitivity (tibialis anterior region)
The ANOVA revealed no signicant dierences in the
tibialis anterior PPT during time (F=0.26, p=0.61, ƞ
p
2=0.01),
nor in during group*time interaction (F=0.04, p=0.96,
ƞ
p
2=0.001).
Figure 1: Flowchart according to CONSORT
statement for the report of randomized trials.
MI, Motor imagery; AO, Action observation;
SO, Sham observation.
Table :Descriptive statistics of baseline outcomes.
Measures MI (n=) AO (n=) SO (n=) p-Value
Age, y/o .±..±..±..
BMI, kg/m.±..±..±..
IPAQ ,.±, ,.±, ,.± .
MIQ-R
MIQR-K .±..±..±..
MIQR-V .±..±..±..
MIQ-R (total) .±..±..±..
Values are presented as mean±standard deviation; y/o, Years old;MI, Motor
imagery; AO, Action observation; SO, Sham observation; MIQ-R, the Revised
Movement Imagery Questionnaire; MIQR-K, Kinaesthetic subscale; MIQR-V,
Visual subscale; IPAQ, International Physical Activity Questionnaire. Figure 2: Results of lumbo-pelvic motor control variable.
*p<0.05. mmHg, millimeters of mercury; MI, Motor imagery; AO, Action
observation; SO, Sham observation.
Nieves-Gómez et al.: Motor imagery & womens health 5
Pelvic oor muscle strength
The ANOVA revealed no signicant dierences in the PFM
strength during time (F=0.78, p=0.38, ƞ
p
2=0.02), nor in during
group*time interaction (F=0.05, p=0.95, ƞ
p
2=0.002).
Sample size calculation
The sample size was estimated with the program G*Power
3.1.7 for Windows (G*Power© from University of Dusseldorf,
Germany) [33]. The sample size calculation was considered
as a power calculation to detect statistically signicant
between-group dierences in the primary outcome mea-
sure. We considered three groups (MI, AO, and SO) and two
measurements (pre- and post-intervention) to obtain 80 %
statistical power (1-βerror probability) with an αerror level
probability of 0.05 using ANOVA, repeated measures, be-
tween factors, and an obtained eect size f=0.344 from our
results. This generated a sample size of total of 66 partici-
pants (22 per group).
Discussion
The main aim of this study was to analyze the eects of a
single session MI and AO plus PE on lumbo-pelvic sensori-
motor function in healthy women. The results obtained in
the present study showed that AO training added to PE
resulted in signicant improvements in lumbo-pelvic motor
control. In addition, we also found that adding MI to PE
resulted in improvements in pain sensitivity in the local area
(specically lumbar area) and we found no changes in
maximal PFM strength.
If we consider the rst result, it seems that AO training
facilitates the process of acquisition of ne motor skills, i.e., it
facilitates the motor learning process. This intra-session
change was not found either in the PE group or in the group of
adding MI to PE. AO training is able to improve sensorimotor
control probably because, at the neurophysiological level, the
premotor cortex has a direct functional connection pathway
with the striate cortex. Visual information is integrated into a
brain area that is responsible for planning voluntary move-
ment, so it seems that motor transfer is greater when the
information provided is visual prior to exercise. Pascual-
Leone et al. [34] found the importance of the premotor and
prefrontal cortex in acquiring motor gestures, and its role in
the working memory, the latter of which requires activation
of temporal regions. Visual information, therefore, appears to
play an important role in the functioning of working memory
Figure 3: Results of pain sensitivity variable in lumbar region. *p<0.05;
**p<0.01; kg, kilogram; cm, centimeter; MI, Motor imagery; AO, Action
observation; SO, Sham observation.
Table :Comparative analysis of motor control and pain sensitivity variables.
Measure Group Mean dierence ( % CI);
eect size (d)
Pre Post Pre vs. post
L-P motor control MI .±..±..(.to .); d=.
AO .±..±..a(.to .); d=.
SO .±..±..(.to .); d=.
Mean dierence ( % CI); eect size (d) MI vs. AO .(.to .); d=. .(.to .); d=.
MI vs. SO .(.to .); d=. .(.to .); d=.
AO vs. SO .(.to .); d=. .(.to .); d=.
Lumbar pain sensitivity MI .±..±..b(..); d=.
AO .±..±..(.to .); d=.
SO .±..±..(.to .); d=.
Mean dierence ( % CI); eect size (d) MI vs. AO .(.to .); d=. .(.to .); d=.
MI vs. SO .(.to .); d=. .(.to .); d=.
AO vs. SO .(.to .); d=..(.to .); d=.
ap<.;bp<.; CI, Condence interval; MI, Motor imagery; AO, Action observation; SO, Sham observation; L-P, Lumbo-pelvic.
6Nieves-Gómez et al.: Motor imagery & womens health
and, consequently, in motor learning [35]. The obtained result
in motor control variable is consistent with that found in
other similar investigations. For example, Cuenca-Martínez
et al. [36] found that AO training resulted in improvements in
lumbar motor control signicantly faster when added to an
exercise program than exercise alone. In addition to this,
Cuenca-Martínez et al. also found that AO training resulted in
greater improvements in motor learning, as well as, in the
acquisition of ne motor ability through cervical joint posi-
tion sense in patients with persistent neck pain [36, 37]. All of
these ndings are consistent with those found in this study.
Regarding the pain sensitivity variable, only the group that
combined MI to an exercise program showed statistically sig-
nicant dierences between before and after the intervention.
This result is consistent with others found in the scientic
literature. For example, La Touche et al. [38] found that mental
practice in combination with physical practice applied in the
orofacial region obtained hypoalgesia faster than the group
that only performed physical exercise in isolation. So far, we
do not know the exact mechanisms by which hypoalgesia is
generated by the application of movement representation
techniques such as MI. It is possible that the excitatory sym-
pathetic system participates in this generation of hypoalgesia
as mentioned by Suso-Martí et al. [39]. However, another
mechanism by which hypoalgesia could be explained would
be distraction. This argument has already been used by other
researchers such as Hayashi et al. [40] or Peerdeman et al. [41].
MI involves a conscious process and therefore requires
concentration and high cognitive demand on the part of the
individual, which may involve greater attentional focus than
motor execution [42, 43], especially in complex movements [44].
All this could explain the results obtained.
Finally, we found no improvement in the variable PFM
strength. This result is not surprising as a recent meta-analysis
concluded that several training sessions are necessary to
improve strength through MI with or without combined with
real exercise [45]. However, we wanted to check whether this
also occurred in the PFM, as the Paravlic et al. study does not
include any trials in this body region. It is indeed more than
proven that MI improves strength parameters [8, 13, 46, 47],
however, it seems that a single session is not enough to
improve PFM strength. Therefore, more training sessions
would be necessary in order to observe signicant changes
within, and between groups. Finally, this is an exploratory and
pilot study in a eld yet to be discovered and investigated in
depth in the coming years. This study leads us to think that a
single session is insucient, and that we should add more
intervention sessions if we want to expect more robust results.
In addition, MI and AO training should be implemented on
what you intend to improve (e.g., imagining and observing
motor control exercises if you want to improve motor control)
as there seems to beno generalization eect of the results. This
initial and pilot work would make more sense in a population
that had diculty performing the global exercises (aerobic
and strengthening), since through mental practice, one could
help them to perform them, and thus, secondarily, have a
greater clinical impact on the variables of interest. However,
before going to patients, we wanted to evaluate what happens
in healthy people.
Study limitations
The present study has a number of limitations that should be
considered. First, the present study is a pilot study, so the
sample size is very small.This is an important limitation asthe
results should be interpreted with considerable caution. In
addition, this is a preliminary study and should be considered
as such, to see a rst general idea of the behavior of the data in
this eld of study. Finally, this research was conducted in
healthy women. It is not possible to extrapolate the results to
patients who have pain or sensorimotor disorders.
Conclusions
In conclusion, our results showed that MI and AO training
plus PE had a slight impact on lumbo-pelvic sensorimotor
function such as motor control or lumbar pain sensitivity
when applied in a single session. Future studies are needed
to evaluate the impact of applying movement representation
techniques together with therapeutic exercise-based reha-
bilitation programs on strength or somatosensory variables
in women with pelvic oor musculoskeletal disorders and
related structures.
Acknowledgments: We would like to thank Marta Aznar
Marín for the help provided during the interventions in this
research.
Research ethics: This study was approved by The Ethics
Committee of Research in Humans of the Ethics Commis-
sion in Experimental Research of University of Valencia
(2699494).
Informed consent: Prior to nal inclusion, all signed the
informed consent.
Author contributions: FCM and NRS: Conceptualization;
Methodology; Formal analysis; Investigation; Data curation;
Writing original draft; Writing review and editing;
Visualization and Supervision. LFA: Methodology; Investi-
gation; Writing original draft; Writing review and editing
and Visualization. All authors: Investigation and Writing
original draft.
Nieves-Gómez et al.: Motor imagery & womens health 7
Competing interests: None declared.
Research funding: None declared.
Data availability: Contact with the corresponding author.
References
1. Decety J. The neurophysiological basis of motor imagery. Behav Brain
Res 1996;77:4552.
2. Hardwick RM, Caspers S, EickhoSB, Swinnen SP. Neural correlates of
action: comparing meta-analyses of imagery, observation, and
execution. Neurosci Biobehav Rev 2018;94:3144.
3. Lebon F, Byblow WD, Collet C, Guillot A, Stinear CM. The modulation of
motor cortex excitability during motor imagery depends on imagery
quality. Eur J Neurosci 2012;35:32331.
4. Sakamoto M, Muraoka T, Mizuguchi N, Kanosue K. Combining
observation and imagery of an action enhances human corticospinal
excitability. Neurosci Res 2009;65:237.
5. Taube W, Mouthon M, Leukel C, Hoogewoud H-M, Annoni J-M, Keller M.
Brain activity during observation and motor imagery of dierent
balance tasks: an fMRI study. Cortex 2015;64:10214.
6. Vogt S, Rienzo FD, Collet C, Collins A, Guillot A. Multiple roles of motor
imagery during action observation. Front Hum Neurosci 2013;7:807.
7. Grabherr L, Jola C, Berra G, Theiler R, Mast FW. Motor imagery training
improves precision of an upper limb movement in patients with
hemiparesis. NeuroRehabilitation 2015;36:15766.
8. Scott M, Taylor S, Chesterton P, Vogt S, Eaves DL. Motor imagery during
action observation increases eccentric hamstring force: an acute non-
physical intervention. Disabil Rehabil 2017;40:144351.
9. Mattar AAG, Gribble PL. Motor learning by observing. Neuron 2005;46:
15360.
10. Villafañe JH, Pirali C, Isgrò M, Vanti C, Buraschi R, Negrini S. Eects of
action observation therapy in patients recovering from total hip
arthroplasty arthroplasty: a prospective clinical trial. J Chiropr Med
2016;15:22934.
11. Buccino G. Action observation treatment: a novel tool in
neurorehabilitation. Phil Trans Biol Sci 2014;369:20130185.
12. Munzert J, Zentgraf K, Stark R, Vaitl D. Neural activation in cognitive
motor processes: comparing motor imagery and observation of
gymnastic movements. Exp Brain Res 2008;188:43744.
13. Losana-Ferrer A, Manzanas-López S, Cuenca-Martínez F, Paris-
Alemany A, La Touche R. Eects of motor imagery and action
observation on hand grip strength, electromyographic activity and
intramuscular oxygenation in the hand gripping gesture: a randomized
controlled trial. Hum Mov Sci 2018;58:11931.
14. Cuenca-Martínez F, León-Hernández J. V., Suso-Martí L, Sánchez-
Martín D, Soria-Soria C, Serrano-Santos J, Paris-Alemany A. Eects of
motor imagery and action observation on lumbo-pelvic motor control,
trunk muscles strength and level of perceived fatigue: a randomized
controlled trial. Res Q Exerc Sport 2020;91:3446.
15. Cuenca-Martínez F, Reina-Varona Á, Castillo-García J, La Touche R,
Angulo-Díaz-Parreño S, Suso-Martí L. Pain relief by movement
representation strategies: an umbrella and mapping review with meta-
meta-analysis of motor imagery, action observation and mirror
therapy. Eur J Pain 2022;26:284309.
16. Díaz-Mohedo E, González-Roldán G, Muñoz-Gámez I, Padilla-Romero V,
Castro-Martín E, Cabrera-Martos I, et al. Implicit motor imagery for
chronic pelvic pain: a cross-sectional case-control study. J Clin Med
2023;12:4738.
17. Jager L, Schulte-Frei B. Motor imagery in the context of pelvic oor
disorders. J Dis Global Health 2017;9:13847.
18. Loving S, Thomsen T, Jaszczak P, Nordling J. Pelvic oor muscle
dysfunctions are prevalent in female chronic pelvic pain: a cross-
sectional population-based study. Eur J Pain 2014;18:125970.
19. Beales DJ, Ther MM, OSullivan PB, Bria NK. Motor control patterns
during an active straight leg raise in chronic pelvic girdle pain subjects.
Spine 2009;34:86170.
20. Fuentes-Aparicio L, Cuenca-Martínez F, Muñoz-Gómez E, Mollà-
Casanova S, Aguilar-Rodríguez M, Sempere-Rubio N. Eects of
therapeutic exercise in primary dysmenorrhea: an umbrella and
mapping review. Pain Med 2023;24:138695.
21. Klotz SGR, Schön M, Ketels G, Löwe B, Brünahl CA. Physiotherapy
management of patients with chronic pelvic pain (CPP): a systematic
review. Physiother Theory Pract 2019;35:51632.
22. Borg GAV. Psychophysical bases of perceived exertion. Med Sci Sports
Exerc 1982;14:37781.
23. Bang D-H, Shin W-S, Kim S-Y, Choi J-D. The eects of action
observational training on walking ability in chronic stroke patients: a
double-blind randomized controlled trial. Clin Rehabil 2013;27:111825.
24. Buccino G, Arisi D, Gough P, Aprile D, Ferri C, Serotti L, et al. Improving
upper limb motor functions through action observation treatment: a
pilot study in children with cerebral palsy. Dev Med Child Neurol 2012;
54:8228.
25. Roman-Viñas B, Serra-Majem L, Hagströmer M, Ribas-Barba L,
Sjöström M, Segura-Cardona R. International physical activity
questionnaire: reliability and validity in a Spanish population. Eur J
Sport Sci 2010;10:297304.
26. Mantilla Toloza SC, Gómez-Conesa A. El Cuestionario Internacional de
Actividad Física. Un instrumento adecuado en el seguimiento de la
actividad física poblacional. Rev Iberoam Fisioter Kinesiol 2007;10:
4852.
27. Campos A, González MÁ. Spanish version of the revised movement
image questionnaire (MIQ-R): psychometric properties and validation.
Rev Psic Dep 2010;19:26575.
28. Azevedo DC, Lauria AC, Pereira ARS, Andrade GT, Ferreira ML,
Ferreira PH, et al. Intraexaminer and interexaminer reliability of
pressure biofeedback unit for assessing lumbopelvic stability during 6
lower limb movement tests. J Manipulative Physiol Therapeut 2013;36:
3343.
29. Grundström H, Gerdle B, Alehagen S, Berterö C, Arendt-Nielsen L,
Kjølhede P. Reduced pain thresholds and signs of sensitization in
women with persistent pelvic pain and suspected endometriosis. Acta
Obstet Gynecol Scand 2019;98:32736.
30. Lacourt TE, Houtveen JH, van Doornen LJP. Experimental pressure-pain
assessments: test-retest reliability, convergence and dimensionality.
Scand J Pain 2012;3:317.
31. Navarro Brazález B, Torres Lacomba M, de la Villa P, Sánchez Sánchez B,
Prieto Gómez V, Asúnsolo del Barco Á, et al. The evaluation of pelvic
oor muscle strength in women with pelvic oor dysfunction: a
reliability and correlation study. Neurourol Urodyn 2018;37:26977.
32. Cohen J. Statistical power analysis for the behavioral sciences. In:
Statistical power analysis for the behavioral sciences. Hillsdale:
Lawrence Erlbaum Associates; 1988, 2:567 p.
33. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: a exible statistical
power analysis program for the social, behavioral, and biomedical
sciences. Behav Res Methods 2007;39:17591.
34. Pascual-Leone A, Wassermann E, Grafman J, Hallett M. The role of the
dorsolateral prefrontal cortex in implicit procedural learning. Exp Brain
Res 1996;107:47985.
8Nieves-Gómez et al.: Motor imagery & womens health
35. Salmon E, Van der Linden M, Collette F, Delore G, Maquet P,
Degueldre C, et al. Regional brain activity during working memory
tasks. Brain 1996;119:161725.
36. Cuenca-Martínez F, La Touche R, León-Hernández JV, Suso-Martí L.
Mental practice in isolation improves cervical joint position sense in
patients with chronic neck pain: a randomized single-blind placebo
trial. PeerJ 2019;7:e7681.
37. Cuenca-Martínez F, Suso-Martí L, León-Hernández JV, La Touche R.
Eects of movement representation techniques on motor learning of
thumb-opposition tasks. Sci Rep 2020;10:12267.
38. La Touche R, Herranz-Gómez A, Destenay L, Gey-Seedorf I, Cuenca-
Martínez F, Paris-Alemany A, et al. Eect of brain training through
visual mirror feedback, action observation and motor imagery on
orofacial sensorimotor variables: a single-blind randomized controlled
trial. J Oral Rehabil 2020;47:62035.
39. Suso-MartíL, León-Hernández JV, La ToucheR, Paris-Alemany A, Cuenca-
Martínez F. Motor imagery and action observation of specicneck
therapeutic exercises induced hypoalgesia in patients with chronic neck
pain: a randomized single-blind placebo trial. J Clin Med 2019;8:1019.
40. Hayashi K, Aono S, Shiro Y, Ushida T. Eects of virtual reality-based exercise
imagery on pain in healthy individuals. BioMed Res Int 2019;2019:19.
41. Peerdeman KJ, van Laarhoven AIM, Bartels DJP, Peters ML, Evers AWM.
Placebo-like analgesia via response imagery. Eur J Pain 2017;21:136677.
42. Cuenca-Martínez F, Suso-Martí L, León-Hernández JV, Touche RL. The
role of movement representation techniques in the motor learning
process: a neurophysiological hypothesis and a narrative review. Brain
Sci 2020;10:2748.
43. Dahm S, Rieger M. Errors in imagined and executed typing. Vision 2019;
3:66.
44. Oshea H, Moran A. Are fast complex movements unimaginable?
Pupillometric studies of motor imagery in Expert Piano playing. J Mot
Behav 2019;51:37184.
45. Paravlic AH, Slimani M, Tod D, Marusic U, Milanovic Z, Pisot R. Eects
and doseresponse relationships of motor imagery practice on
strength development in healthy adult populations: a systematic
review and meta-analysis. Sports Med 2018;48:116587.
46. Cuenca-Martínez F, Angulo-Díaz-Parreño S, Feijóo-Rubio X,
Fernández-Solís M, León-Hernández JV, La Touche R, et al. Motor
eects of movement representation techniques and cross-
education: a systematic review and meta-analysis. Eur J
Phys Rehabil Med 2021;58:94107.
47. Ferrer-Peña R, Cuenca-Martínez F, Romero-Palau M, Flores-Román LM,
Arce-Vázquez P, Varangot-Reille C, et al. Eects of motor imagery on
strength, range of motion, physical function, and pain intensity in
patients with total knee arthroplasty: a systematic review and meta-
analysis. Braz J Phys Ther 2021;25:698708.
Nieves-Gómez et al.: Motor imagery & womens health 9
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Implicit motor imagery (IMI), with an image laterality discrimination (LD) task, has been proposed as a useful therapeutic tool to restore body schema in patients with chronic pelvic pain (CPP). The aim of this study was to analyse the existence of differences between patients with CPP and healthy individuals in order to justify the use of IMI. An observational, cross-sectional study with non-probabilistic sampling was designed as a one-to-one matched case–control study. Through a web link designed for this purpose, a total of 40 abdominoperineal images were shown to 130 participants during the laterality task. Outcome measures were pain intensity (visual analogue scale, VAS), accuracy, response time (RT), and CPPQ-Mohedo score (Chronic Pelvic Pain Questionnaire—Mohedo). This was an observational, cross-sectional study with a total of 64 CPP patients and 66 healthy individuals. The comparative analysis between groups revealed significant differences in accuracy, CPPQ-Mohedo and VAS (p < 0.001), but not in RT; in patients with CPP, accuracy was correlated with a lower CPPQ-Mohedo score and RT and, the greater the pain intensity, the higher the CPPQ-Mohedo score and RT, and the lower the accuracy. In the LD task, the patients with CPP made more mistakes than the healthy individuals. IMI could be a useful and complementary tool in the therapeutic approach for patients with CPP.
Article
Full-text available
The present work is the first study that assess long run change after motor learning. The study’s main objective was to evaluate the short to medium-term impact of motor imagery (MI) and action observation (AO) on motor learning of a sequence of thumb-opposition tasks of increasing complexity. We randomly assigned 45 participants to an AO, MI, or placebo observation (PO) group. A sequence of 12 thumb-opposition tasks was taught for 3 consecutive days (4 per day). The primary outcome was accuracy. The secondary outcomes were required time and perfect positioning. The outcomes were assessed immediately after the intervention and at 1 week, 1 month and 4 months postintervention. Regarding the primary outcome, AO group had significantly higher accuracy than the MI or PO group until at least 4 months (p < 0.01, d> 0.80). However, in the bimanual positions, AO was not superior to MI at 1 week postintervention. Regarding secondary outcomes, AO group required less time than the MI group to remember and perform the left-hand and both-hand gestures, with a large effect size (p < 0.01, d> 0.80). In terms of percentage of perfect positions, AO group achieved significantly better results than the MI group until at least 4 months after the intervention in the unimanual gestures (p < 0.01, d> 0.80) and up to 1 month postintervention in the bimanual gestures (p= 0.012, d= 1.29). AO training resulted in greater and longer term motor learning than MI and placebo intervention. If the goal is to learn some motor skills for whatever reason (e.g., following surgery or immobilization.), AO training should be considered clinically.
Article
Full-text available
We present a neurophysiological hypothesis for the role of motor imagery (MI) and action observation (AO) training in the motor learning process. The effects of movement representation in the brain and those of the cortical-subcortical networks related to planning, executing, adjusting, and automating real movements share a similar neurophysiological activity. Coupled with the influence of certain variables related to the movement representation process, this neurophysiological activity is a key component of the present hypothesis. These variables can be classified into four domains: physical, cognitive-evaluative, motivational-emotional, and direct-modulation. The neurophysiological activity underlying the creation and consolidation of mnemonic representations of motor gestures as a prerequisite to motor learning might differ between AO and MI. Together with variations in cognitive loads, these differences might explain the differing results in motor learning. The mirror neuron system appears to function more efficiently through AO training than MI, and AO is less demanding in terms of cognitive load than MI. AO might be less susceptible to the influence of variables related to movement representation.
Article
Full-text available
In motor imagery (MI), internal models may predict the action effects. A mismatch between predicted and intended action effects may result in error detection. To compare error detection in MI and motor execution (ME), ten-finger typists and hunt-and-peck typists performed a copy-typing task. Visibility of the screen and visibility of the keyboard were manipulated. Participants reported what type of error occurred and by which sources they detected the error. With covered screen, fewer errors were reported, showing the importance of distal action effects for error detection. With covered screen, the number of reported higher-order planning errors did not significantly differ between MI and ME. However, the number of reported motor command errors was lower in MI than in ME. Hence, only errors that occur in advance to internal modeling are equally observed in MI and ME. MI may require more attention than ME, leaving fewer resources to monitor motor command errors in MI. In comparison to hunt-and-peck typists, ten-finger typists detected more higher-order planning errors by kinesthesis/touch and fewer motor command errors by vision of the keyboard. The use of sources for error detection did not significantly differ between MI and ME, indicating similar mechanisms.
Article
Full-text available
Objective The main objective of this trial was to assess whether action observation (AO) training and motor imagery (MI) produced changes in the cervical joint position sense (CJPS) both at the end of the intervention and 10 min postintervention compared with a placebo intervention in patients with nonspecific chronic neck pain (NSCNP). Methods A single-blind placebo clinical trial was designed. A total of 30 patients with NSCNP were randomly assigned to the AO group, MI group or placebo observation (PO) group. CJPS in flexion, extension and rotation movements in both planes were the main variables. Results The results obtained in the vertical plane showed that the AO group obtained greater improvements than the PO group in the CJPS in terms of cervical extension movement both at the end of the intervention and 10 min postintervention ( p = .001, d = 1.81 and p = .004, d = 1.74, respectively), and also in cervical flexion movement, although only at 10 min after the intervention ( p = .035, d = 0.72). In addition, the AO group obtained greater improvements than the MI group in the CJPS only at the end of the intervention in cervical extension movement ( p = .041, d = 1.17). Regarding the left rotation cervical movement, both the MI and AO groups were superior to the PO group in both planes at the end of the intervention ( p < .05, d > 0.80). Conclusions Although both AO and MI could be a useful strategy for CJPS improvement, the AO group showed the strongest results. The therapeutic potential of the application of mental practice in a clinical context in the early stages of rehabilitation of NSCNP should be considered.
Article
Purpose: Primary dysmenorrhea (PD) is one of the most prevalent gynecologic conditions. The main aim of this umbrella review was to assess the effects of therapeutic exercise (TE) on PD. Methods: A systematic search was carried out in PubMed, Embase, SPORTDiscus, CINAHL, and PEDro (December 10th-2022). The outcome measures assessed were menstrual pain intensity, menstrual pain duration, and quality of life. Methodological quality was analyzed using the AMSTAR and ROBIS scales, and the strength of evidence was established according to the advisory committee grading criteria guidelines. Results: Nine systematic reviews were included. The results showed that TE, regardless of the exercise model and intensity, has a clinical effect in improving menstrual pain intensity in women with PD with moderate quality of evidence. In addition, the results showed that TE has a clinical effect in improving the duration of menstrual pain in women with PD with a limited quality of evidence. However, the results are controversial on the improvement of quality of life in women with PD with a limited quality of evidence. Conclusions: TE seems an effective option to implement in women with PD to improve the intensity and duration of menstrual pain. We cannot draw robust results for quality of life due to the low number of primary studies. More research in this field can help us establish more robust conclusions, as well as to assess whether there is one exercise model or intensity of training that is more effective than others.
Article
Background In the early stages of total knee arthroplasty (TKA) rehabilitation, in which physical function in general can be affected, motor imagery (MI) might play a relevant role. Objective To assess the impact of MI on strength, active range of motion (ROM), pain intensity, and physical function in patients with TKA. Methods We conducted a systematic review and meta-analysis of randomised controlled trials. Pooled effects were calculated as standardised mean differences (SMDs) and 95% confidence intervals (CIs) for the relevant outcomes using random effects model. The certainty of evidence was assessed with GRADE approach. Results This review included 7 articles. The addition of MI to standard therapy, based on low quality of evidence, showed a moderate increase in quadriceps strength (4 studies; SMD: 0.88; 95% CI: 0.42, 1.34) and a small reduction in pain intensity (SMD: 0.63; 95% CI: 0.08, 1.19). It is unclear whether MI can provide beneficial effects for active ROM and function. Conclusions There is low to very low-quality evidence that adding an MI intervention to standard rehabilitation for patients with TKA may improve quadriceps strength and pain intensity, but the effects of MI on ROM and physical function is unclear.
Article
Objective To develop a mapping and umbrella review with a meta-meta-analysis (MMA) to critically evaluate the current evidence of motor imagery (MI), action observation and mirror therapy (MT) on pain intensity. Methods The study involved a systematic search of PubMed, PEDro, Scielo, EBSCO and Google Scholar, Results Ten systematic reviews were included in the qualitative synthesis, 70% of which showed high methodological quality. Three reviews found significant reduction in chronic musculoskeletal pain as the result of applying movement representation methods (MRM) plus usual-care (UC), with a large clinical effect (standardised mean difference [SMD] of −1.47; 95% CI −2.05 to −0.88; heterogeneity Q=1.66; p=0.44; I²=0%). However, two reviews showed no statistically significant reduction in acute and postsurgical pain as a result of applying MI plus UC. Four reviews showed no significant reduction in phantom limb pain (PLP) as a result of applying MT plus UC interventions. In four reviews, the MMA showed significant reduction in complex regional pain syndrome (CRPS) as a result of applying MT plus UC, with a large clinical effect (SMD −1.27; 95% CI −1.87 to −0.67; heterogeneity Q=3.95; p=0.27; I²=24%). In 2 reviews, the MMA showed no significant differences in poststroke pain as a result of applying MT plus UC. Conclusion Results show that MRM could be effective for chronic musculoskeletal pain, with low to moderate-quality evidence. The results also show a reduction in pain intensity through MT interventions in patients with CRPS, although these results were not found in patients with PLP or poststroke pain.
Article
INTRODUCTIONː The objective was to assess the impact of movement representation techniques (MRT) through motor imagery (MI), action observation (AO) and visual mirror feedback (VMF) and cross-education training (CE) on strength, range of motion (ROM), speed, functional state and balance during experimental immobilisation processes in healthy individuals, in patients with injuries that did not require surgery and in those with surgical processes that did or did not require immobilisation. EVIDENCE ACQUISITIONː MEDLINE, EMBASE, CINAHL and Google Scholar were searched. 13 meta-analyses were conducted. EVIDENCE SYNTHESISː Regarding the immobilised participants, in the healthy individuals, MI showed significant results regarding maintenance of strength and ROM, with low-quality evidence. Regarding the process with no immobilisation, VMF and MI techniques showed significant changes in maintaining ROM in patients with injury without surgery, with very low-quality evidence. Results had shown that MI demonstrated significantly higher maintenance of strength and speed in patients undergoing surgery, with low-quality evidence. No significant results were found in ROM. Low-quality evidence showed better results in AO plus usual care compared with usual treatment in isolation with respect to maintenance of functional state and balance. CE training demonstrated maintenance of strength in patients undergoing surgery, with moderate evidence; however, not in healthy experimentally immobilised individuals. VMF did not show significant results in maintaining ROM after surgery without immobilisation, nor did MI in maintaining strength after surgery and immobilisation. CONCLUSIONSː MRT and CE training have been shown to have a significant impact on the improvement of various motor variables and on physical maintenance in general.
Article
Objectives: The main objective was to evaluate the effects of action observation (AO), visual mirror feedback (VMF), and motor imagery (MI), combined with an orofacial exercise program, on sensorimotor variables in asymptomatic participants. Methods: We designed a randomized, single-blind, controlled trial that included 52 asymptomatic participants who were randomly assigned to 4 groups, 13 to each of the VMF, MI, and AO groups and 13 to the control group (CG), which only performed the exercise program. The primary outcomes were pain pressure sensitivity and tongue muscle strength. The secondary outcomes were maximum mouth opening, tongue length, and the ability to generate mental motor images. Each group underwent a 3-session intervention using their respective exercise. Measurements were performed before starting the intervention and after each of the 3 sessions (pre, mid1, mid2, and post). Results: ANOVA revealed significant changes in PPTs in the masseter muscle region in the MI and AO groups in the pre-post and mid1-post changes. ANOVA revealed significant differences in tongue muscle strength in the anterior direction only in the AO group in the pre-mid2 and pre-post changes. Conclusions: AO and MI, in conjunction with exercise, could induce changes in PPTs for the masseter muscle. In addition, only AO produced changes in tongue muscle strength. More research is needed to determine the role of brain representation techniques in the orofacial region and transferring this exercise to the rehabilitation setting.