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The motor organization of cerebral cortex and the role of the mirror neuron system. Clinical impact for rehabilitation
Organización motora del córtex cerebral y el papel del sistema de las neuronas espejo. Repercusiones clínicas para la rehabilitación
Laia Sallésa,b,
Corresponding author
lsalles@fub.edu

Corresponding author.
, Xavier Gironèsa, José Vicente Lafuentec,d
a Departamento de Fisioterapia, Universitat Internacional de Catalunya (UIC), Sant Cugat del Vallès, Barcelona, Spain
b Departamento de Fisioterapia, Fundació Universitària del Bages (UAB), Barcelona, Spain
c LaNCE, Departamento de Neurociencias, Universidad del País Vasco/Euskal Herriko Unibertsitatea (UPV/EHU), Leioa, Vizcaya, Spain
d Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Santiago de Chile, Chile
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The knowledge we have about the cortical representation of movement comes&#44; essentially&#44; from the works of Penfield et al&#46;&#44; during the first half of <span class="elsevierStyleSmallCaps">20</span>th century &#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#8211;3</span></a> Those works identified a somatotopic and unique representation of the different parts of the body&#44; and postulated that movement organization followed a sequential order&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Throughout the years&#44; critical ideas about this concept started to appear&#46; The development of new investigative technologies has revealed the existence of multiple cortical representations overlapping onto each other&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This evidence brings about the thought that the organization of movement requires the activation of several structures that work in parallel&#44; integrating sensory and motor information&#44; transforming all into motor actions&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The anatomical and functional complexity of the motor system increased with the contribution of the mirror neuron systems &#40;MNS&#41;&#44; discovered by Rizzolatti and Sinigaglia at the beginning of 1990s&#46; These systems are the neural substrate that allows us to understand the implication of cognitive functions such as observation&#44; imitation and image of the action in the organization and the learning of the movements&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this work is to review the different points of view regarding the cortical organization of movement&#46; In addition&#44; this work includes some considerations about the clinical impact derived from motor organization and its relationship with cognitive functions&#44; regarded as potential therapeutic tools in the recovery of movement&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Development</span><p id="par0030" class="elsevierStylePara elsevierViewall">In 1937&#44; Penfield and Boldrey presented the cortical motor map &#40;homunculus&#41; that represented cortical regions corresponding to different parts of the body&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In 1950&#44; Penfield and Rasmussen&#44; by means of direct stimulation of the cortex in conscious patients during surgical intervention&#44; defined the organization of the first homunculus&#44; obtaining the first map of the motor and sensory cortex separately&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;4</span></a> These maps follow a somatotopic and unique organization &#40;parts of the body represented in anatomic order and in a delimited way&#41; where variations were not considered&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The authors established that motor areas of the brain are exclusively dedicated to executive functions&#46; According to this conception of movement&#44; the brain follows a sequentially organized process following the scheme&#58; perception<span class="elsevierStyleHsp" style=""></span>&#8594;<span class="elsevierStyleHsp" style=""></span>cognition<span class="elsevierStyleHsp" style=""></span>&#8594;<span class="elsevierStyleHsp" style=""></span>movement&#46; These events are associated with different cortical areas&#44; such as language in Broca&#39;s area or motor function in Brodmann&#39;s area 4&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">All of this has an impact on understanding the way the primary motor area &#40;M1&#41; is organized&#58; firstly&#44; every cortical area is solely responsible for controlling a part of the body and its movement&#44; which means that if there is a lesion in a certain cortical area&#44; then the movement that depends on that area will not be recovered and&#44; at the same time&#44; the range of movements will be limited to a finite number of combinations&#46; Secondly&#44; the cortical region activated by the simultaneous movement of several fingers will be larger than that area activated by the movement of only one finger&#44; as the first region would be the result of adding each finger&#39;s territory extension&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;6&#44;9</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Contributions to the knowledge of the anatomo-functional organization</span><p id="par0050" class="elsevierStylePara elsevierViewall">In the second half of the 20th century&#44; the work of Penfield was questioned and considered ambiguous&#46; In fact&#44; Penfield himself warned about the possible inaccuracy of his maps&#46; The use of electrodes that were too large did not allow for more precise research&#46; But even with these warnings&#44; the idea of a somatotopic and unique organization was widespread and exerted a strong influence in the conception of the cortical organization&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;9</span></a> Subsequent studies<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;4&#44;6</span></a> using more sophisticated techniques have questioned the two essential characteristics of the Penfield homunculus&#58; somatotopy and unique representation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Studies confirmed a somatotopic organization in the representation of the big body areas &#40;face&#44; upper and lower extremities&#41;&#59; although&#44; there are controversies about the anatomo-functional organization of minor areas of the body &#40;fingers&#44; wrist&#44; elbow and shoulder in upper extremity representation&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;9&#44;10</span></a> The existence of overlapping between cortical areas connected with each other by horizontal bidirectional connection was revealed&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;10</span></a> The overlapping means different segments share the same neural network&#46; Several authors<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;5</span></a> consider overlapping to be a differential characteristic of M1&#44; transcending the somatotopic organization concept of Penfiel&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;9</span></a> This allows the cooperation between proximal and distal muscles&#44; for example&#44; in upper extremities&#44; enabling better coordination between shoulder&#44; elbow and wrist in the task of reaching an object&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;9</span></a> Other authors<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">11&#44;12</span></a> advocate for the classical opinion&#44; accepting the existence of a certain degree of overlapping and attribute the control of small movements to the somatotopy in M1&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Aflalo and Graziano<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">13&#44;14</span></a> note the importance of motor and learning practices to go from one somatotopic map to another with overlapping representations between the different parts of the body&#46; They suggest that the role of plasticity and the reorganization of the motor cortex are central to this process&#44; and show that the lesser somatotopy&#44; the greater complexity of the movements&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Several studies have shown the existence of multiple motor representations of different parts of the body&#44; with a certain degree of overlapping&#46; A movement may imply the activation of several cortical areas&#44; sometimes distant from each other&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;15</span></a> In the 1980s&#44; Strick and Preston<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">16&#44;17</span></a> discovered two representations of the hand in the monkey motor cortex&#44; and observed that each of them were activated as a response to different somatosensory afferent activities&#58; one reacted to tactile afferents and the other to the proprioceptive afferents&#46; In 1986&#44; Gould et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">6&#44;9</span></a> observed&#44; in anaesthetized monkeys&#44; that M1 presented a tendency to a somatotopy of the representations of the different segments&#44; and the occurrence of the activation in several points of the brain&#44; distributed like a mosaic&#44; in the movement of any part of the body&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In addition&#44; this multiple distribution &#40;mosaic&#41; is present in the posterior part of the parietal lobe&#44; establishing horizontal interconnections with other areas of the brain&#44; which allow for a somatosensory afferent flow to the motor area&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;9&#44;18</span></a> The different motor areas are connected to parietal areas via parieto-frontal circuits&#44; forming a functional system&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">3</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Neuroimaging techniques have shown that in the exploration of objects&#44; when there is no visual control&#44; the tactile and propioceptive somatosensory information was essential&#44; as well as was the fronto-parietal circuit activation in shape and length discrimination by means of active finger movement&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">19&#44;20</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The same thing happens with actions that need vision&#44; where visual information arrives at the parietal lobe&#44; activating parallel and simultaneous parieto-frontal circuits that will produce a visuomotor transformation&#46; This includes several processes&#44; such as placing the object in space&#44; orientation&#44; shape and size&#44; and controlling upper extremity trajectory displacement&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">18</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Knowledge of the complexity of the parallel organization of the motor system allows us to see the possibilities of reorganization after damage&#46; The affectation of any of the structures involved rarely leads to the complete loss of the only element capable of performing a task&#59; a group of neurons can participate in more than one task&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">21</span></a> The cortical area activated to move one finger is larger than the area involved in the simultaneous movement of several fingers&#44; as the fragmented movement required to move only one finger implies greater control and organization&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">6&#44;9&#44;15</span></a> Based on this evidence&#44; the motor system cannot be reduced to a spatially organized map executor of orders originated in well differentiated areas &#40;as is the Penfield homunculus&#41;&#44; rather it should be considered a multiplicity of structures activated simultaneously in different areas &#40;frontal&#44; parietal&#44; occipital&#44; among others&#41; related to each other by fronto-parietal circuits&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Mirror-neuron systems</span><p id="par0090" class="elsevierStylePara elsevierViewall">The discovery of mirror-neurons &#40;MN&#41; poses aspects related with motor organization such as empathy&#44; the comprehension of actions&#44; and the motivations of others&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;22</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The Parma group discovered the MN while registering the neuronal activity in the F5 area of a monkey &#40;premotor cortex&#41;&#46; They observed that neurons in that area became active the moment the researcher took some food and the monkey remained motionless&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a> They also detected the monkey was selective&#58; the neurons discharged when the movements had a purpose&#44; such as taking something&#44; whereas there was no response when the movement was performed by an isolated part of the body without any intention&#46; Later&#44; they found the same kind of activity in the inferior parietal cortex&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The mirror-neuron systems have been shown to exist in humans by means of non-invasive neurophysiological techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;23</span></a> These neurons constitute a network that activates both when an action is performed by the actor&#44; and when it is only observed by the subject but performed by others&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">23</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Functional magnetic resonance has allowed areas and circuits supporting the mirror-neuron system &#40;MNS&#41; to be localized and identified&#58; <span class="elsevierStyleItalic">the fronto-parietal MNS</span>&#44; constituted by extensive areas of the premotor cortex&#59; the inferior parietal lobe and the posterior part of Broca&#39;s area&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;24</span></a> It is involved in the recognition of voluntary behaviour through parieto-frontal circuits&#44; which allow for the parallel and simultaneous processing of information&#44; necessary to planning and execution of actions&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;18</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">limbic MNS</span> is basically constituted by the insula region and by the anterior cingulate circumvolution&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a> This system is responsible for recognizing emotional behaviour&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">The role of mirror neurons in the action</span><p id="par0115" class="elsevierStylePara elsevierViewall">The MNS transforms sensory information obtained from observation of others actions in a motor format that is very similar to the internal motor generated when the individual imagines himself performing the action or when he is really performing it&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">8&#44;24</span></a> This system is responsible for our capacity to understand the intentions and the actions of others&#44; allowing us to correlate the observed actions with the previous experience of each<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;23&#44;25&#8211;27</span></a> individual&#46; It also has an important role in the learning of motor patterns through the observation of the action&#46; Imitation is a cognitive function that includes observation&#44; image and execution of the action&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a> Its neural substrate organises and performs those actions&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">27&#44;28</span></a> Neuroimaging studies show the importance of MN in the capacity of imitation and of empathy with the others&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;8&#44;23</span></a> Observing an action induces in the observer an implication in first person&#44; as if they themself were performing it&#46; The observer predicts and interprets the behaviour of others because he is capable of picturing himself in the same situation&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">MNS constitutes a rupture with the classical interpretation&#44; in which cognitive functions such as observation&#44; imitation and prediction were attributed to higher mental processes&#46; In the new conception those functions belong to MN circuits&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The MNS gives significance to the observed motor act and also to all the action in which this act is involved&#44; for example&#44; to take a glass to the mouth to drink&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">23&#44;27</span></a> These systems&#44; in humans&#44; become active when observing actions performed by other people&#44; as opposed to the monkey&#44; they allow understand the aim of the action&#44; whether it is performed with the help of tools or not&#46; They also activate when observing isolated movements without a specific purpose&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;8&#44;23&#44;26</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Our motor actions are not separated from emotions&#46; The limbic MNS allows us to understand and share others emotions &#40;perception of pain&#44; happiness&#44; etc&#46;&#41;&#44; activating the same areas of the brain that become active when experiencing those emotions in first person&#46; This is the prerequisite of empathic behaviour&#44; basic to establishing healthy interpersonal relationships&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;22&#44;23</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinical consequences</span><p id="par0135" class="elsevierStylePara elsevierViewall">The knowledge analysed contributes new expectations for clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">30</span></a> It is crucial to develop and to apply treatments that take this knowledge into account about movement organization&#44; about the multiple representations and the overlapping between areas and the role of MN&#46; To understand how different therapeutic approaches act over neural substrate will allow us to achieve better results in clinical practice&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">30&#8211;32</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Several authors<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">33&#44;34</span></a> have researched the neuroplasticity phenomenon&#44; considered to be the process of continuous remodelling in the short&#44; medium and long term to optimize the functioning of neuronal networks&#46; Regarding rehabilitation&#44; neuroplasticity is the mechanism that allows us to understand the effects of therapeutic interventions on the recovery of movement affectations&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">33&#44;35&#44;36</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Representations of cortical areas are modified according to afferent information&#44; experiences and learning&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The immobilization of the upper extremity&#44; with the consequential loss of motor and sensory <span class="elsevierStyleItalic">inputs</span>&#44; implies a cortical reorganization with a reduction in the thickness of the cortical grey matter in M1 and of the somatosensory cortex in the contralateral hemisphere due to the use of the healthy extremity&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">37</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Considering the investigation on multiple representation<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">6&#44;10&#44;16&#44;17</span></a> that shows different areas become active according to the type of afferent information received and those studies on MNS&#44;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;8&#44;23&#44;26</span></a> we can confirm the importance of providing the patient with experiences of his own body&#44; or with the interaction with the therapist&#44; or with different objects&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The loss or the reduction of functions&#44; such as walking or handling objects&#44; reduces the flow of information received by the brain&#44; and as a result of this the experiences of the patient start to impoverish&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">38</span></a> To perform these functions in a correct and coordinated way could be useful&#44; regarding the overlapping of the cortical representations and the existence of parieto-frontal circuits&#44; to implement a therapy that includes tasks and rehabilitation exercises involving multi-joint movement&#44; where several articulations cooperate simultaneously&#44; instead of those of single-joint movement&#46; That is to say&#44; to promote an environment filled with motor and sensory experiences&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">39</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Another option is to progressively increase the level of exercise&#44; adjusting to the motor possibilities of the patient&#44; but always increasing the complexity of the exercises by introducing new things to stimulate learning&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a> In patients with ictus&#44; it is very important to influence the motor system&#44; promoting plasticity through implementation of observation&#44; image of the action and imitation&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a> strategies that consider perceptive&#44; cognitive and motor aspects of the action&#46; These three processes allow the motor learning to persist over time&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Therapeutic intervention puts the patient in contact with experiences and information&#59; if the patient is not put in contact with them for days&#44; weeks or months&#44; changes will occur that reflect the lack of practice and the difficulty of rehabilitation&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">37</span></a> The systematic use of observation and movement image is possible from the acute phase of the treatment to benefit&#44; from early stages&#44; from the activation of motor representation produced with no need of executing the action&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">28</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Several clinical studies on action observation and on motor image used as a complement to therapeutic exercises<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">28&#44;40&#8211;42</span></a> have valued the utility of those techniques as treatment tools to improve the movement affectations presented in patients with acute&#44; subacute and chronic ictus&#46; Those studies concluded that beneficial effects exist related to motor deficits&#58; they increase the use of the affected extremity&#44; favouring the motor learning transferring it to less trained tasks&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="par0180" class="elsevierStylePara elsevierViewall">There is no consensus on the existence or nonexistence of somatotopy between representations of the different segments of one same area of the body&#46; There is consensus in the existence of a certain degree of overlapping between the cortical areas involved and in the existence of multiple representations&#46; The current knowledge about motor organization confirms that motor and sensory information have a common neural substrate in the parieto-frontal circuits that enables the creation of a motor system that includes different cognitive functions&#44; such as perception&#44; imitation&#44; comprehension of gestures and intentions of other actors&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In contrast with the unique and differentiated organization proposed by Penfield&#44; the complex organization would support the better recovery of functions&#44; in the case of damage of the nervous system&#44; and an increased learning of motor patterns&#44; in the case of healthy subjects&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Observation&#44; image of the action&#44; and imitation are cognitive functions based on the features of the MNS that represent a way to access and to influence the motor system without the need to perform the action&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Regarding this&#44; what is the role of the use of protocols in imagining a movement or simply observing or to imitating it&#63; All are perceptive and cognitive actions that do not imply motor activity in the patient&#44; yet&#44; all the same&#44; they generate experience and flows of afferent information similar to those produced by the performance of the actual movement&#46; Are they a significant motor learning mechanism in the recovery of deficits caused by disease&#63;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In addition to being an original management&#44; with no adverse effects&#44; low-cost and easy to implement&#44; the benefits of this management are still greater when actions are related to motor experiences prior to the disease and when combined with therapeutic exercises&#46; Also&#44; the improvements obtained during the treatment persist over time beyond therapy&#44; demonstrating the involvement of learning&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Finally&#44; it is important in clinical practice to consider this knowledge to find the most appropriate way of intervening and guiding those afferences that promote plasticity&#46; It is not only a matter of inducing reorganization but also of controlling it&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Funding</span><p id="par0210" class="elsevierStylePara elsevierViewall">This work has been possible with the support of the scholarship from the Societat Catalano-Balear de Fisioter&#224;pia &#40;SCBF&#41;&#44; 2012&#44; with the general subvention GIC &#40;794&#47;13&#41; of the Basque Government and UFI 11&#47;32 of the Universidad del Pa&#237;s Vasco&#47;Euskal Herriko Unibertsitatea&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interests</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The basic characteristics of Penfield homunculus &#40;somatotopy and unique representation&#41; have been questioned&#46; The existence of a defined anatomo-functional organization within different segments of the same region is controversial&#46; The presence of multiple motor representations in the primary motor area and in the parietal lobe interconnected by parieto-frontal circuits&#44; which are widely overlapped&#44; form a complex organization&#46; Both features support the recovery of functions after brain injury&#46; Regarding the movement organization&#44; it is possible to yield a relevant impact through the understanding of actions and intentions of others&#44; which is mediated by the activation of mirror-neuron systems&#46; The implementation of cognitive functions &#40;observation&#44; image of the action and imitation&#41; from the acute treatment phase allows the activation of motor representations without having to perform the action and it plays an important role in learning motor patterns&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las caracter&#237;sticas b&#225;sicas del hom&#250;nculo de Penfield &#40;somatotop&#237;a y representaci&#243;n &#250;nica&#41; han sido cuestionadas&#46; La existencia de una organizaci&#243;n anatomofuncional definida en la corteza cerebral entre segmentos de una misma regi&#243;n es controvertida&#46; La presencia en el &#225;rea motora primaria y en el l&#243;bulo parietal de m&#250;ltiples representaciones motoras interconectadas por circuitos parietofrontales y profusamente solapadas configuran una organizaci&#243;n compleja&#46; Todo ello sustenta la recuperaci&#243;n funcional despu&#233;s de un da&#241;o cerebral&#46; En la organizaci&#243;n del movimiento se puede incidir a trav&#233;s de la comprensi&#243;n de las acciones y de las intenciones de los otros&#44; lo que est&#225; mediado por la activaci&#243;n de los sistemas de neuronas espejo&#46; El uso de funciones cognitivas &#40;observaci&#243;n&#44; imagen de la acci&#243;n e imitaci&#243;n&#41; desde la fase aguda del tratamiento permite la activaci&#243;n de las representaciones motoras sin necesidad de ejecutar la acci&#243;n&#44; y tiene un papel importante en el aprendizaje de patrones motores&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Sall&#233;s L&#44; Giron&#232;s X&#44; Lafuente JV&#46; Organizaci&#243;n motora del c&#243;rtex cerebral y el papel del sistema de las neuronas espejo&#46; Repercusiones cl&#237;nicas para la rehabilitaci&#243;n&#46; Med Clin &#40;Barc&#41;&#46; 2015&#59;144&#58;30&#8211;34&#46;</p>"
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ISSN: 23870206
Original language: English
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