THE ROLE OF MIRROR NEURON SYSTEM ACTIVATION IN FACILITATING GOAL-DIRECTED ACTION OBSERVATION THERAPY FOR CHILDREN WITH UNILATERAL CEREBRAL PALSY

Background: Action Observation Therapy (AOT) shows promise in pediatric neurorehabilitation for improving upper limb function. Its proposed mechanism, mirror neuron system (MNS) activation, is largely inferred from adult studies, creating a significant evidence gap in children with unilateral cerebral palsy (UCP). Objective: This study aimed to directly measure MNS activation via functional MRI (fMRI) in children with UCP during a goal-directed AOT paradigm and correlate it with functional motor improvements. Methods: In a randomized controlled trial, 30 children with UCP (ages 6-12, MACS I-III) were allocated to either AOT (n=15) or control (n=15) groups. The AOT group observed goal-directed actions followed by physical practice, while the control group observed geometric shapes followed by the same practice. Pre- and post-intervention assessments included fMRI scans during action observation and the Assisting Hand Assessment (AHA) and Melbourne Assessment 2 (MA2) for functional evaluation. Results: The AOT group demonstrated significantly greater activation in key MNS regions (inferior frontal gyrus, premotor cortex, inferior parietal lobule) on fMRI (p < 0.001, FWE-corrected). This was coupled with significantly greater improvement on the AHA (mean difference +5.6 points, p=0.002) and MA2 (mean difference +7.1%, p=0.005) compared to the control group. A strong positive correlation was found between the change in MNS activation and the change in AHA scores (r = 0.78, p < 0.001). Conclusion: This study provides the first direct evidence in a pediatric population that functional gains from goal-directed AOT are mediated by the activation of the MNS. It validates AOT as a neuroplasticity-based intervention and underscores the importance of goal-directed action observation in designing effective rehabilitation protocols for children with UCP.