Abstract
[Purpose] This pilot trial investigated the effects of action observation training on upper limb function and self-care abilities in individuals with mental disorders. [Participants and Methods] Thirty participants with mental disorders were randomly assigned to an action observation training group or a landscape observation training group. Both groups completed 20 sessions over four weeks. The action observation training group observed videos of self-care-related tasks and practiced the corresponding movements, whereas the landscape observation training group observed landscape images and performed free upper-limb movements. Upper limb function was assessed using the Manual Function Test, and self-care abilities were evaluated using the Korean-Modified Barthel Index and Functional Independence Measure. [Results] Significant within-group improvements in Manual Function Test, Korean-Modified Barthel Index, and Functional Independence Measure scores were observed in the action observation training group. Between-group comparisons of change scores showed greater changes in these outcomes in the action observation training group than in the landscape observation training group. [Conclusion] Action observation training may support upper limb function and self-care abilities in individuals with mental disorders. Further studies with larger samples are needed to confirm these preliminary findings.
Key words: Action observation training, Mental disorders, Upper functioning
INTRODUCTION
Individuals with mental illness often experience prolonged psychological, emotional, and physical difficulties due to the chronic nature of their conditions and long-term treatment. These difficulties may interfere with daily activities, independent living, and social participation. In particular, individuals residing in mental healthcare facilities may have limited opportunities to perform self-care activities independently and to maintain meaningful social relationships. Previous research has emphasized that social support from families, community members, and local institutions is important for improving self-care ability in individuals with mental disabilities1). According to the 2022 National Survey on Persons with Disabilities conducted by the Ministry of Health and Welfare, approximately 104,000 individuals in Korea are registered as having mental illnesses, representing 3.9% of all registered disability types. In line with the global trend toward deinstitutionalization, the enactment of the Mental Health Act in 1995 marked a shift in Korea’s mental health policy toward community-based care2). However, some individuals with mental illness continue to reside in mental healthcare facilities because of insufficient family or community support. Individuals living in such facilities may experience restricted opportunities for independent daily activities and social participation compared with those living in the community. Prolonged institutionalization may also be associated with emotional and social vulnerability, low self-esteem, and reduced life satisfaction3). Therefore, rehabilitation approaches that support daily functioning and self-care are needed for individuals with mental illness residing in institutional settings. The importance of a rehabilitation paradigm over traditional therapeutic approaches in the care of individuals with mental illnesses has long been emphasized. Since the 1990s, the American Psychiatric Association (APA) has made ongoing efforts to establish and disseminate mental health service systems based on rehabilitation principles4). The therapeutic paradigm primarily focuses on symptom reduction and restoration of impairments, whereas the rehabilitation paradigm emphasizes functional performance, self-care, community reintegration, and quality of life, even when mental illness or functional limitations remain5). Therefore, in institutional settings, rehabilitation for individuals with mental illness should address not only psychiatric symptoms but also daily functioning and self-care performance. In addition, individuals with mental illness may experience difficulties in social cognition, observational learning, and self-care performance, which may influence their ability to acquire and perform daily living skills6, 7). These considerations suggest the need for rehabilitation approaches that incorporate observation, imitation, and practice of meaningful daily actions7).
Action observation training (AOT) has recently been introduced as a rehabilitation approach based on the observation of goal-directed movements followed by physical practice8). AOT involves cognitive interactions, including action understanding, imitation learning, motor learning, and forming motor memories9). Previous behavioral and neurophysiological studies have suggested that action observation combined with physical practice may activate previously acquired motor memories and contribute to the formation of new motor memories related to movement execution10).
Imitation through action observation aligns the observed movement with the observer’s existing motor schema or repertoire. When new motor patterns are observed, cortical regions involved in movement understanding and execution may become active. During the process of learning new motor patterns, the mirror neuron system (MNS), including the inferior parietal lobule, ventral premotor cortex, and opercular part of the inferior parietal gyrus, activates corresponding motor projection areas and helps integrate observed movements into motor categories11). The MNS contributes to learning by recombining and cycling observed models, thereby activating the human sensorimotor information. Many studies have investigated the effects of AOT on motor learning in individuals with neurological impairments, such as stroke, Parkinson’s disease, multiple sclerosis, cerebral palsy, and autism12).
Although AOT has been widely studied in neurological rehabilitation, evidence regarding its application in individuals with mental illness remains limited. Therefore, this pilot trial aimed to investigate the effects of action observation training on upper limb function and self-care abilities in individuals with mental illness residing in a mental healthcare facility.
PARTICIPANTS AND METHODS
Thirty individuals with mental illness residing in a mental healthcare facility in Korea were included in this study. The participants were selected using the following inclusion and exclusion criteria: The inclusion criteria were as follows: (1) ability to communicate, (2) ability to follow action observation tasks, and (3) a Global Assessment of Functioning (GAF) score of 61 or higher. The exclusion criteria were as follows: (1) presence of dementia, (2) coexisting disabilities other than mental illness, and (3) severe neurological impairment. This study was conducted under the ethical principles of the Declaration of Helsinki. Because this study involved a non-invasive intervention with minimal risk to participants, ethical approval was waived according to the institutional policy of Wonkwang University. All participants were fully informed about the study objectives and procedures, and written informed consent was obtained before participation.
In this pilot randomized controlled trial, a two-group, pre–post experimental design was used. A priori sample size estimation using G*Power 3.1, with an effect size of 0.5, a significance level of 0.05, and statistical power (1–β) of 0.80, showed that 64 participants would be required. However, only 30 participants could be recruited because of the limited number of eligible individuals in the participating mental healthcare facility. As a result, the final sample size was smaller than the estimated requirement. Consequently, the achieved statistical power may have been lower than the planned level (1−β=0.80), which may have increased the possibility of a Type II error. The participants were randomly assigned to either the action observation training group (AOTG) or the landscape observation training group (LOTG). Randomization was conducted by a nurse and physical therapist not involved in the interventions or assessments, using sealed envelopes containing papers marked with “O” or “X”. An independent assessor conducted the baseline assessment before the intervention.
The participants in both groups observed either self-care-related action videos (AOTG) or landscape images (LOTG), followed by physical training. Each intervention was administered for 30 min/day, five days per week, over a four-week period, totaling 20 sessions. Post-intervention assessments were conducted after the 4-week program (Fig. 1).
Fig. 1.
Experimental design.
AOT: action observation training; MFT: manual function test; FIM: functional independence measure; K-MBI: Korea-modified barthel index; LOT: landscape observation training.
For the AOTG, video clips were developed based on the International Classification of Functioning, Disability, and Health (ICF) Self-Care domain (d5). The selected tasks included d5100 washing one’s face, d5200 applying skin lotion, d5400 dressing, d5401 undressing, d550 eating, and d560 drinking. Each participant was instructed to observe the video for 2 min 30 s, followed by 12 min 30 s of physical practice for the observed actions. Each cycle lasted 15 min, and the procedure was repeated twice per session, resulting in a total of 30 min daily. The task difficulty and conditions were adjusted based on each participant’s functional status and physical condition (Fig. 2)13).
Fig. 2.
AOTG video (a. wash up, b. put on lotion & skin, c. dressing, d. undressing, e. eating, f. drinking).
AOTG: action observation training group.
For LOTG, an album of landscape images, including mountains, gardens, grasslands, oceans, valleys, and waterfalls, was prepared. Each participant observed the images for 2 min 30 s, followed by 12 min 30 s of free upper-limb movement. Each cycle lasted 15 min, and the procedure was repeated twice per session, resulting in a total of 30 min daily. As with the AOTG, the task difficulty and conditions were adjusted according to each participant’s functional status and physical condition (Fig. 3). However, the core task components, observation time, practice time, and total intervention duration were kept consistent across participants.
Fig. 3.
LOTG Picture (a. mountain, b. garden, c. grassland, d. ocean, e. valley, f. cataract).
LOTG: landscape observation training group.
The Manual Function Test (MFT) was administered to assess independent arm movements and functional performance. The MFT is a clinical tool used to evaluate upper limb movements and functional tasks. It includes eight items: four for arm movements, two for grasping, and two for finger manipulation. The scores range from 0 (severe impairment) to 32 (complete upper limb function). The total score was converted to a 100-point manual function score. The test–retest and inter-rater reliability of the MFT were reported as high, with r=0.95 and a Cronbach’s α of 0.9514).
The Korean-Modified Barthel Index (K-MBI) was used to assess independent functioning and activities of daily living (ADLs). The K-MBI includes 11 items: personal hygiene, bathing, feeding, toileting, stair climbing, dressing, bowel control, bladder control, ambulation, wheelchair use, and chair-bed transfer. Since the wheelchair item is used only when ambulation is impossible, a maximum of 10 items is typically scored. Each item is rated on a 1–5 Likert scale, with a total score of 100 indicating complete independence in ADL. The inter-rater reliability of the K-MBI was reported to range from 0.93 to 0.98, and Cronbach’s α was reported as 0.84, showing high reliability15).
The Functional Independence Measure (FIM) was used to evaluate performance in ADL. Developed by the Uniform Data System for Medical Rehabilitation, the FIM includes 18 items: 13 motor and five cognitive items. Each item is rated on a 7-point scale, ranging from 1 (total assistance) to 7 (complete independence), with a total score ranging from 18 to 126. The 13 motor items include eating, grooming, bathing, upper- and lower-body dressing, toileting, bladder and bowel management, transfers (chair, bed, toilet, and bathtub), ambulation or wheelchair use, and stair climbing. The five cognitive items assessed comprehension, expression, social interaction, problem-solving, and memory. The inter-rater reliability of the FIM was reported to be high (r=0.83)16).
All statistical analyses were conducted using SPSS software (version 22.0; IBM Corp., Armonk, NY, USA). Descriptive statistics were used to present the participants’ general characteristics as means and standard deviations. The normality of the data was tested using the Kolmogorov–Smirnov test, and all variables were found to be normally distributed. Between-group homogeneity of demographic and clinical characteristics was examined using independent t-tests. Within-group changes from pre-test to post-test were analyzed using paired t-tests. Change scores were calculated by subtracting pre-test scores from post-test scores. Between-group differences in change scores were analyzed using independent t-tests. The effect sizes were calculated using Cohen’s d, with values of 0.2, 0.5, and 0.8 interpreted as small, medium, and large effects, respectively. Statistical significance was set at p<0.05.
RESULTS
Overall, 30 participants were included in this study, with 15 participants assigned to the AOTG and 15 to the LOTG. The gender distribution was eight males and seven females in the AOTG and seven males and eight females in the LOTG. No significant differences were observed between the groups in terms of age, body weight, height, body mass index (BMI), Global Assessment of Functioning (GAF) score, Manual Function Test (MFT) score, Korean-Modified Barthel Index (K-MBI) score, or Functional Independence Measure (FIM) score at baseline. The general characteristics of the participants are shown in Table 1.
Table 1. General characteristics of participants (n=30).
| Characteristics | AOTG (n=15) | LOTG (n=15) |
| Gender (male/female) | 8/7 | 7/8 |
| Age (years) | 69.3 ± 7.5a | 67.1 ± 5.1 |
| Weight (kg) | 68.5 ± 8.9 | 66.7 ± 12.4 |
| Height (cm) | 164.3 ± 6.6 | 163.8 ± 10.8 |
| GAF (score) | 67.6 ± 3.3 | 68.2 ± 2.4 |
| BMI (kg/m2) | 23.2 ± 2.1 | 23.0 ± 2.1 |
| MFT (score) | 21.3 ± 1.9 | 21.4 ± 2.3 |
| FIM (score) | 102.1 ± 3.9 | 100.7 ± 4.5 |
Value are presented as mean ± SD. AOTG: action observation training group; LOTG: landscape observation training group; GAF: global assessment function; BMI: body mass index; MFT: manual function test; FIM: functional independence measure.
Following the intervention, change scores were calculated by subtracting pre-test scores from post-test scores. Between-group comparisons of change scores showed significantly greater changes in the AOTG than in the LOTG for MFT, K-MBI, and FIM scores. Specifically, the change in MFT score was significantly greater in the AOTG than in the LOTG (AOTG: 4.33 ± 1.04 vs. LOTG: 0.53 ± 0.64, p=0.007). Similarly, the changes in K-MBI score (AOTG: 9.33 ± 2.58 vs. LOTG: 2.53 ± 2.56, p=0.002) and FIM score (AOTG: 10.06 ± 0.25 vs. LOTG: 4.93 ± 2.84, p<0.001) were significantly greater in the AOTG than in the LOTG.
Within-group analyses showed significant improvements in MFT, K-MBI, and FIM scores in the AOTG after the intervention. In the LOTG, numerical improvements were observed in MFT, K-MBI, FIM, and GAF scores, but these changes were not statistically significant. GAF scores increased numerically in both groups, from 67.61 ± 3.31 to 74.20 ± 3.45 in the AOTG and from 68.20 ± 2.36 to 70.13 ± 2.58 in the LOTG. The effect sizes for MFT, K-MBI, FIM, and GAF were 0.49, 0.47, 0.44, and 0.42 in the AOTG, respectively, and 0.12, 0.18, 0.16, and 0.11 in the LOTG, respectively. Detailed pre- and post-intervention values, within-group comparisons, between-group comparisons of change scores, and effect sizes are presented in Table 2.
Table 2. The within-group and between-group comparisons for the outcome measures.
| Measurement | Group | Pre-test | Post-test | Effect size |
| MFT (score) | AOTG (n=15) | 21.33 ± 1.92 | 25.67 ± 1.63*† | 0.49 |
| LOTG (n=15) | 21.40 ± 2.26 | 21.93 ± 2.05 | 0.12 | |
| K-MBI (score) | AOTG (n=15) | 81.47 ± 3.27 | 90.80 ± 4.07*† | 0.47 |
| LOTG (n=15) | 79.93 ± 3.36 | 82.47 ± 3.44 | 0.18 | |
| FIM (score) | AOTG (n=15) | 102.07 ± 3.94 | 112.13 ± 3.85*† | 0.44 |
| LOTG (n=15) | 100.73 ± 4.48 | 105.67 ± 4.21 | 0.16 | |
| GAF (score) | AOTG (n=15) | 67.61 ± 3.31 | 74.20 ± 3.45 | 0.42 |
| LOTG (n=15) | 68.20 ± 2.36 | 70.13 ± 2.58 | 0.11 |
Values are presented as mean ± SD. *p<0.05 compared with pre-test (within-group). †p<0.05 compared of change scores calculated as post-test minus pre-test (between-group). Cohen’s d values of 0.2, 0.5, and 0.8 indicate small, medium, and large effects, respectively. AOTG: action observation training group; LOTG: landscape observation training group; MFT: manual function test: K-MBI; Korea-modified barthel index; FIM: functional independence measure; GAF: global assessment of functioning.
DISCUSSION
Individuals with mental illness often need assistance because of impairments in physical function, activity limitations, and restrictions in participation. The primary goal of rehabilitation for this population is to enhance the functional performance in areas of physical function, activities of daily living, and social participation. Psychosocial rehabilitation focuses on educating patients and their families, training in daily life skills, social integration, and vocational reintegration. Particularly important is the enhancement of upper limb movement and self-care abilities, which are essential for adapting to daily life and improving the quality of life.
The effects of AOT on upper limb function and self-care in individuals with mental illness were investigated in this pilot trial. The findings indicated significant within-group improvements in MFT, K-MBI, and FIM scores in the AOTG. In addition, between-group comparisons of change scores showed greater changes in these outcomes in the AOTG than in the LOTG.
Upper limb function is essential for performing daily living activities and maintaining an independent life. Since most daily activities require using the arms, assessing upper limb function is an important clinical indicator. Kim et al.17) reported significant improvements in upper limb function following a five-week intervention that combined digital action observation–based education with task-oriented occupational therapy. Similarly, Lee and Kim18) demonstrated that a three-week action observation training program led to significant gains in upper limb function. These findings are consistent with the results of the present study. The observed improvements may be attributed to the participants observing self-care tasks essential for daily life, such as washing the face, applying lotions, dressing, undressing, eating, and drinking, and subsequently practicing the corresponding upper-limb movements, thereby facilitating motor learning.
Improved finger manipulation and upper limb motor control may have important functional implications for individuals with chronic mental illness. Self-care activities, including dressing, grooming, feeding, and hygiene management, require coordinated reaching, grasping, and object manipulation skills. Therefore, the observed improvement in MFT performance may be related to better performance of daily self-care activities, as reflected by the positive changes in K-MBI and FIM scores. According to the ICF, the d5 self-care domain encompasses activities, including washing and drying oneself, bathing, dressing and undressing, drinking, and maintaining health. The activity and participation domains of the ICF correspond closely to the items of the K-MBI, including bathing, dressing, feeding, personal hygiene, defecation, voiding, toileting, bed transfer, ambulation, wheelchair use, and stair climbing. Studies reported that self-care activities in the ICF show the highest correlation with K-MBI functional performance levels, making their evaluation a critical clinical indicator19).
Han and Park20) demonstrated significant improvements in K-MBI scores after a six-week program of progressively reduced AOT. These findings align with those of this study. The observed improvements may be explained by aligning the action observation tasks with K-MBI items and by repeated exposure to observational conditions, which likely enhanced the participants’ motor repertoire and facilitated familiarity with functional tasks.
ADL in individuals with mental illness is closely associated with learning through observing the actions and behaviors of others. AOT reportedly activates the motor cortex and improves hand manipulation skills and enhances upper limb function through goal-directed activities21). Furthermore, AOT has been shown to exert positive effects on upper limb function and performance of ADL in diverse populations22).
Lee et al.23) demonstrated significant improvements in FIM scores after a four-week client-centered AOT program. These findings are consistent with the results of the present study. These improvements may be attributed to the direct involvement of functional upper limb movements required for daily living, which likely enhances motivation and self-confidence. Additionally, activating motor projection areas and observation–execution matching regions may have contributed to the increased effectiveness of movement execution.
This study had several limitations. First, the sample size was insufficient to meet the number suggested by the a priori power analysis, which may limit the statistical power and generalizability of the findings. Therefore, the results should be interpreted as preliminary findings from a pilot randomized controlled trial. Second, this study was conducted in a single mental healthcare facility, and the unique clinical environment may have introduced uncontrolled extraneous variables. Third, although the core intervention protocol was kept consistent, task difficulty and conditions were adjusted according to each participant’s functional status and physical condition, which may have influenced the interpretation of the intervention effects. Fourth, this study did not investigate changes in a wider range of functional activities involving the upper limbs. Future studies should include larger sample sizes, more diverse clinical settings, and broader functional outcome measures.
Nevertheless, our findings show that combining AOT with conventional rehabilitation can yield additional benefits by allowing patients to observe functional activities and engage in focused practices. Future research should include a broader variety of daily living tasks, a broader range of upper limb movements and larger-scale clinical trials to further validate these results.
This pilot trial suggests that a four-week action observation training program may support upper limb function and self-care performance in individuals with mental illness. These preliminary findings indicate that AOT may have potential clinical value as a rehabilitation approach for promoting functional independence through motor learning and goal-directed task practice. However, larger-scale studies with more detailed clinical characterization are needed to confirm these findings and clarify the applicability of AOT in psychosocial rehabilitation settings.
Funding
This paper (exhibition, performance, practice, etc.) was supported by Wonkwang University in 2026.
Conflict of interest
The authors declare that there are no other conflicts of interest.
Funding Statement
This paper (exhibition, performance, practice, etc.) was supported by Wonkwang University in 2026.
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