How do C6/C7 tetraplegic patients grasp balls of different sizes and weights? Impact of surgical musculo-tendinous transfers.

STUDY DESIGN: Prospective control cohort study. OBJECTIVES: To develop a new test to analyse qualitatively grasping strategies in C6/C7 tetraplegic patients, and to quantify the effect of musculo-tendinous transfers. SETTING: France. METHODS: Twelve C6/C7 tetraplegic adults (17 arms; 31.3+/-7.9 years) and 17 healthy subjects (30.9+/-9.4 years) completed the study. We assessed participants' ability to grasp, move and release standardized balls of variable sizes and weights. OUTCOME MEASURES: Failures, movement duration (MD), grip patterns, forearm orientation during transport. RESULTS: In patients as well as in controls, the number of digits involved in prehension increased proportionally to the size and weight of the ball. C6 non-operated tetraplegic patients failed 38.2% of the tasks. They frequently used supine transport (51.4% of successful tasks). MD was longer, with a large distribution of values. The presence of active elbow extension poorly influenced the amount of failure nor grip configuration, but significantly reduced MD and supine transport (34%). Patients who were evaluated after hand surgery showed a trend towards improved MD and more frequent completion (failure 30%), especially for middle-sized and middle-weighted balls. Grip patterns were deeply modified, and all transports were made in pronation. CONCLUSION: The 'Tetra Ball Test' evidences the characteristics of grasping in tetraplegic patients and those influenced by surgery. It may be useful in understanding effects of surgical procedures. This preliminary study must be completed to evaluate the quantitative responsiveness and reproducibility of this test and to develop instrumented electronic balls to optimise it.

3-D scapular kinematics during arm elevation: effect of motion velocity.

BACKGROUND: No three-dimensional (3-D) data exist on the influence of motion velocity on scapular kinematics. The effect of arm elevation velocity has been studied only in a two-dimensional setting. METHODS: Thirty healthy subjects performed dominant (right) arm elevation in two planes, sagittal and frontal, and at slow and fast self-selected arm speed. Scapular orientation and humeral elevation were measured at 30 Hz recording frequency with use of a 6-degree-of-freedom electromagnetic system (Polhemus Fastraka). Motion was computed according to the International Society of Biomechanics standards. Scapular orientation was also determined with the arm held in different static positions. FINDINGS: We obtained a full 3-D kinematic description of scapula achieving a reliable, complex 3-D motion during humeral elevation and lowering. The maximal sagittal arm elevation showed a characteristic "M"-shape pattern of protraction/retraction curve. Scapular rotations did not differ significantly between slow and fast movements. Moreover, protraction/retraction and tilt angular values did not differ significantly between static and dynamic tasks. However, scapular lateral rotation values differed between static and dynamic measurements during sagittal and frontal arm elevation. Lateral scapular rotation appears to be less in static than in dynamic measurement, particularly in the sagittal plane. INTERPRETATION: Interpolation of statically recorded positions of the bones cannot reflect the kinematics of the scapula.

How to extend the elbow with a weak or paralyzed triceps: control of arm kinematics for aiming in C6-C7 quadriplegic patients.

This study aims to investigate how quadriplegic patients with a C6-C7 spinal lesion coordinate their upper limb to extend the elbow despite the paralysis or weakness of the triceps brachii, and what is the effect of a surgical musculotendinous transfer. For this purpose, aiming movements in a wide workspace were recorded in seven healthy subjects and in patients with incomplete (five cases) or complete (eight cases) triceps paralysis and after musculotendinous transfer (eight cases). We used four electromagnetic field sensors to quantify hand trajectory and to compute the angles describing the rotations at the scapula, glenohumeral joint, elbow and wrist (10 degrees of freedom). Extent and smoothness of the hand trajectories and hand velocity profiles were surprisingly similar between healthy subjects and quadriplegic patients. The reduction of elbow extension observed in patients was compensated by rotations distributed across several degrees of freedom including the scapula. Principal components analysis showed that the joint rotations could be summarized by an additive combination of two synergies, respectively orientating and stretching out the limb, which explained similar amounts of variance in healthy subjects and in patients. The participations of degrees of freedom in the synergies were roughly similar in the different groups of subjects, the main difference concerning scapular medial-lateral rotation, which seems to be critical in patients with a complete triceps paralysis. This demonstrates that elbow extension in quadriplegic patients is due to anticipated mechanical interaction coupling between upper limb segments. We propose that the persisting (incomplete paralysis) or restored (musculotendinous transfer) elbow extensor strength may act by stabilizing the elbow. This counterintuitive preservation of limb kinematics for horizontal aiming movements in quadriplegic patients despite the drastic changes in muscle action provoked by paralysis and/or by surgery strongly suggests that the motor system does not primarily control forces but the morphological aspects of movement, via joint rotation synergies.

Is the velocity-curvature relationship disrupted in apraxic patients?

Velocity and curvature of human movements are linked by a proportionality relationship (power-law) whose origin has been attributed either to functional properties of cortical areas or to peripheral constraints. 3D movements made by apraxic patients show a time-shift between velocity and curvature which has been considered as a disruption of the power-law, supporting the central hypothesis. We analysed the power-law in 2D drawing-like movements in healthy subjects and apraxic patients (correlation and cross-correlation analyses). The power-law remained preserved in apraxic patients, suggesting that the velocity-curvature relationship is not globally disrupted and thus that the power-law cannot be only attributed to central planning mechanisms in those associative brain areas injured in apraxic patients.

Motor compensation and recovery for reaching in stroke patients.

OBJECTIVES: To examine the mechanisms of alternative strategies developed by stroke patients to compensate their motor impairment and their role in recovery. MATERIAL AND METHODS: The three-dimensional kinematics of the upper limb were quantified during unconstrained reaching movements in seven healthy individuals and in 15 stroke patients. Nine patients were followed-up. Individual observations were correlated with anatomical and functional brain imaging described elsewhere (Feydy et al. Stroke 2002;33:1610). RESULTS: Healthy subjects used mainly elbow extension and shoulder flexion, scaled to movement distance. Patients with hemiparesis because of stroke used different patterns of joint recruitment with different scaling rules. Patients with the greatest impairment compensated by recruiting extra degrees of freedom, particularly trunk bending. Improvement was because of a restoration towards a normal movement pattern (recovery) and/or to a reinforcement of compensation, which led to a poorer outcome. CONCLUSION: Individual behavioural data are necessary to discuss the mechanisms of functional improvement following stroke with respect to recovery and/or compensation.

Longitudinal study of motor recovery after stroke: recruitment and focusing of brain activation.

BACKGROUND AND PURPOSE: The goal of this study was to characterize cortical reorganization after stroke and its relation with the site of the stroke-induced lesion and degree of motor recovery using functional MRI (fMRI). METHODS: Fourteen stroke patients with an affected upper limb were studied longitudinally. Three fMRI sessions were performed over a period of 1 to 6 months after stroke. Upper limb recovery, Wallerian degeneration of the pyramidal tract, and responses to transcranial magnetic stimulation were assessed. RESULTS: Two main patterns of cortical reorganization were found. Pattern 1 was focusing, in which, after initial recruitment of additional ipsilateral and contralateral areas, activation gradually developed toward a pattern of activation restricted to the contralateral sensorimotor cortex in 9 patients. Five patients were found to have pattern 2, persistent recruitment, in which there was an initial and sustained recruitment of ipsilateral activity. Occurrence of recruitment or focusing seemed to depend mainly on whether the primary motor cortex (M1) was lesioned; persistent recruitment was observed in 3 of 4 patients with M1 injury, and focusing was seen in 8 of 10 patients with spared M1. These patterns had no relation to the degree of recovery; in particular, focusing did not imply recovery. However, there was a clear relation between the degree of recovery and the degree of Wallerian degeneration. CONCLUSIONS: These results suggest that ipsilateral recruitment after stroke corresponds to a compensatory corticocortical process related to the lesion of the contralateral M1 and that the process of compensatory recruitment will persist if M1 is lesioned; otherwise, it will be transient.

Effect of trunk restraint on the recovery of reaching movements in hemiparetic patients.

BACKGROUND AND PURPOSE: Reaching movements made with the affected arm in hemiparetic patients are often accompanied by compensatory trunk or shoulder girdle movements, which extend the reach of the arm. We investigated the effects of the suppression of these compensatory movements on reaching ability in hemiparetic individuals. METHODS: Eleven healthy and 11 hemiparetic individuals participated. Three-dimensional kinematic analysis was used to quantify reaches made to a close and a distant target (near the limit of arm's length). Unrestrained reaches were compared with those in which shoulder girdle and trunk movements were restrained by a harness. RESULTS: During unrestrained reaching, abnormal trunk recruitment and limitations in elbow and shoulder movements were correlated with the degree of clinical stroke severity (r=-0.91 to -0.96) in hemiparetic patients. During trunk restraint, ranges of elbow and shoulder joint movement increased in both groups. In addition, elbow and shoulder interjoint coordination improved. This was caused by increases in the range of joint motion as well as by a better dynamic temporal relation between joints. CONCLUSIONS: Trunk restraint allowed patients with hemiparetic stroke to make use of arm joint ranges that are present but not normally recruited during unrestrained arm-reaching tasks. Thus, the underlying "normal" patterns of movement coordination may not be entirely lost after stroke. Appropriate treatments, such as trunk restraint, may be effective in uncovering latent movement patterns to maximize arm recovery in hemiparetic patients.

Assessment of the accuracy of a human arm model with seven degrees of freedom.

We are proposing a human arm model that consists of three rigid segments with seven degrees of freedom. The shoulder joint was modeled as a ball-and-socket joint and the elbow and wrist joints were modelled as skew-oblique joints. Optimal parameters for this model were calculated on the base of in vivo recordings with a spatial tracking system. The criterion of optimality was defined as the minimum of the mean-square deviation between the experimentally obtained sensor positions and orientations and their positions and orientations calculated by solving the direct kinematics problem. The minimal value of the direct kinematics error was found to be 0.5-0.6cm for sensor positions and 5-7 degrees for sensor orientations. We are proposing that these values serve as the assessment for the accuracy of the arm model.

Kinematics of prehension and pointing movements in C6 quadriplegic patients.

AIMS: C6 quadriplegic patients lack voluntary control of their triceps muscle but can still perform reaching movements to grasp objects or point to targets. The present study documents the kinematic properties of reaching in these patients. MATERIALS AND METHODS: We investigated the kinematics of prehension and pointing movements in four quadriplegic patients and five control subjects. Prehension and pointing movements were recorded for each subject using various object positions (ie different directions and distances from the subject). The 3D motion was analyzed with Fastrack Polhemus sensors. RESULTS: During prehension tasks the velocity profile of control subjects showed two peaks (go and return); the first velocity peak was scaled to the distance of the object. In quadriplegic patients there was a third intermediary peak corresponding to the grasping of the object. The amplitude of the first peak was slightly smaller than in control subjects. Velocity was scaled to the distance of the object, but with a greater dispersion than in control subjects. Total movement time was longer in quadriplegics because of the prolonged grasping phase. There were few differences in the pointing movements of normal and quadriplegic subjects. The scapula contributed more to the reaching phase of both movements in quadriplegic patients. CONCLUSION: In spite of some quantitative differences, the kinematics of the hand during reaching and pointing in quadriplegic patients are surprisingly similar to those of control subjects. Spinal Cord (2000) 38, 354 - 362.

Kinematics of human arm reconstructed from spatial tracking system recordings.

The kinematics of the human arm in terms of angles of rotations in the joints is reconstructed from the spatial tracking system (Fastrack() Polhemus) recordings. The human arm is modeled by three rigid bodies (the upper arm, the forearm and the hand) with seven degrees of freedom (three in the shoulder, two in the elbow and two in the wrist). Joint geometry parameters (orientations of the axes relative to the arm segments, the angles and the distances between the axes) have been calculated on the basis of passive rotations in the joints. The calculated parameters have been used to solve the direct kinematics problem for the reaching movements in different directions. The difference between calculated and recorded positions and accelerations of the hand has been used to assess the accuracy of the proposed method of kinematics reconstruction. The error analysis showed that spatial tracking system recordings and human arm kinematics reconstruction could reliably be used to accurately analyze multijoint movement in humans.

Hand orientation for grasping depends on the direction of the reaching movement.

The 3D orientation of the hand for grasping was studied while subjects reached for objects placed at several locations on a horizontal board, with movements starting from three initial hand positions. The hand movements were recorded with electromagnetic sensors giving 3D position and orientation information. The study focused on the azimuth, which is the projection of the hand orientation in a horizontal plane. The hand azimuth for grasping was linearly correlated with the direction of the reaching movement and not with the object direction in head- or shoulder-centered coordinates. This relationship was valid regardless of the initial hand position. A control experiment with constant movement direction showed a weaker, probably postural, effect of object direction in shoulder-centered coordinates. We suggest that hand orientation for grasping is mainly controlled in relation to the reaching movement direction.

Anticipatory responses to a self-applied load in normal subjects and hemiparetic patients.

A bimanual loading task was studied in eight right-handed normal subjects and nine hemiparetic patients in order to detect anticipatory adjustments and to analyse the reflex and voluntary, responses induced by the perturbation. The left forearm (or the impaired side in patients) was flexed at approximately 90 degrees and free to rotate in a vertical sagittal plane. It was held to resist a load (2-3 kg) dropped either by an experimenter (control situation), or by the subject himself with no visual control (self-applied situation). The load was dropped from the right hand by normal subjects and from the unimpaired hand by hemiparetic patients. The initial distance the load fell was 0.05-0.35 m. The elbow movements of the limb receiving the load were recorded with a linear accelerometer at the wrist, a potentiometer at the elbow and via the EMG signals from flexor muscles. Normal subjects always made an anticipatory flexion movement prior to the impact in the self-applied situation, but not in the control situation. The anticipatory flexion of hemiparetic patients was slower and longer. The amplitude of the anticipatory flexion at the time of impact and its duration were correlated with the mass of the load and the initial distance between the two hands in both groups. The anticipatory flexion reduced the distance through which the load fell and thus its kinetic energy at impact. The impact induced a brisk extension which was always smaller in the self-applied situation for a given kinetic energy. In normal subjects, the amplitude of the monosynaptic reflex (MSR) following the impact in flexor muscles was usually greater in the self-applied situation, but its gain was either reduced or unchanged. The gain of the functional stretch reflex (FSR) was consistently reduced in the self-applied situation. Depression of the FSR gain occurred in only two hemiparetic patients who had the best recovered motor function. Anticipation always ended up minimizing the perturbation following different motor strategies. The normal subjects fell into two groups. One group adjusted the anticipatory forearm flexion to correct the extension disturbance as fast as possible; the second group relied on an accurate adjustment of the final position. Hemiparetic patients showed idiosyncratic intermediate behavior.

Evidence for a spinal stepping generator in man. Electrophysiological study.

We present some evidence favouring the presence of a spinal stepping generator in humans. Electrophysiological studies have shown that the spinal cord even deprived of supraspinal influence can generate rhythmic activity, and that some elements of the spinal circuitry on which the generation of stepping rhythmic relies in lower vertebrates exist in man. Moreover, comparison of the variations of the polysynaptic spinal flexor reflex in normal subjects and paraplegic patients brought about some evidence that normal subjects use a spinal locomotor center. Nevertheless, these studies do not absolutely prove the existence of a central pattern generator in man.

Learning a new visuomotor transformation: error correction and generalization.

The use of an aiming tool requires learning a new transformation between visual and proprioceptive information and motor command. We have examined this question by quantifying the kinematics of the movement during the transitory phase of adaptation to a rotational bias (60 degrees counterclockwise, then clockwise) added to a standard mouse-cursor device in the plane of the screen. Control-aiming movements were almost linear with a bell-shaped velocity profile. The bias induced an equivalent initial directional error which was usually corrected within 20 trials. The learning trajectories were combinations of spirals and fast or slow straight movements. The posture of the hand was slightly (less than 10 degrees) modified by the bias. These features suggest three corrective processes: on-line continuous correction based on evaluation of the relative cursor-to-target position, discrete correction based on assessment of the discrepancy angle between the cursor-to-target direction and the effective cursor direction, and memorization of trial-to-trial correction. These results are interpreted in the light of neurophysiological data and neural net modeling, which suggest that the visuomotor transformation performed by cortical areas for reaching is effected by projecting the visual information on a reference frame that rotates with the arm. The initial directional error reappeared when the direction of the target was changed and increased with degree of change. The limited generalization suggests that bias correction is stored in relation to the coding of the target direction and that movement towards a new direction is computed as a projection of the previously learned bias on the new visual direction.

Trophic effects on testes in paraplegics.

Testicular biopsies and hormone profiles were obtained from 23 paraplegic patients who had sustained a complete spinal cord section. The hormone profiles were normal, but patients with a spinal lesion including the T10-L2 metameres showed a particular pattern of germinal cell abnormalities. The atrophy is multifactorial, but may well include destruction of the sympathetic innervation of the testis by the lesion.

Effect of intrathecal baclofen on the monosynaptic reflex in humans: evidence for a postsynaptic action.

Intrathecal baclofen is a very powerful antispastic agent. Its mechanism of action on the monosynaptic H-reflex in spinal patients was investigated. It could inhibit rapidly and profoundly monosynaptic reflexes in lower limbs, but did not modify Ia vibratory inhibition of the soleus H-reflex. To assess more precisely its effect on Ia afferents, an experimental paradigm using Ia heteronymous facilitation of the soleus H-reflex was used. Intrathecal baclofen did not modify the amount of monosynaptic facilitation of the soleus H-reflex brought about by stimulation of the femoral nerve. This demonstrates that the main part of the inhibitory effect of baclofen on the H-reflex in spinal patients is not due to a presynaptic effect, suggesting a postsynaptic site of action.

Inhibitory effects on flexor reflexes in patients with a complete spinal cord lesion.

The inhibitory effects on flexors of electrical stimulation of a distal peripheral nerve were investigated in 7 paraplegic patients having a complete spinal cord section. The stimuli (3-50 mA) were applied to the sural nerve. Their effects were investigated on: 1) the ipsi- and contralateral H reflex of the Tibialis Anterior (TA); 2) the continuous EMG activity reflexly elicited in TA by a sustained pinch of the foot and 3) on the reflexes evoked in TA by contralateral sural nerve stimulation. Sural nerve stimulation induced two peaks of facilitation of the ipsilateral TA H reflex that could be replaced by inhibition as the stimulus intensity was increased. The comparison of the effect on H reflexes and the EMG activity suggests presynaptic inhibition of Ia fibres at time intervals longer than 300 ms. The stimulation could depress the sustained EMG reflex activity and induce a period of silence whose duration increased with the intensity of the stimulation. As shown in a previous study, a sural nerve stimulation induced a reflex in TA with a prolonged (more than 130 ms) latency. This late reflex could be selectively inhibited by a contralateral sural nerve stimulation, probably at an interneuronal level. These results confirm that the late reflex in TA is similar to the one observed after Flexor Reflex Afferent (FRA) stimulation in the acute spinal cat with DOPA. In addition, they show that at least some part of the "half centre" organization which has been described in the acute spinal cat with DOPA is also present in the human spinal cord chronically deprived of supraspinal control.

The influence of a reduced plantar support surface area on the compensatory reactions to a forward fall.

The influence of altered plantar support area on the compensatory reactions to forward fall was studied. The forward fall was provoked from an initial forward inclined posture, and balance was recovered by making steps. Alteration of the support area was unilateral and was obtained using two rods on which the subject stood. The rods were under either the starting foot or the stance foot. The configuration of the plantar support area, flat or reduced, did not change the latency of Soleus electromyographic activity. In contrast, the unilateral reduction of the plantar support area had powerful bilateral effects on the magnitude of Soleus activity. The reduction of the plantar support area on the swing side significantly reduced the ipsilateral Soleus response. The reduction of plantar support area on the stance side did not alter the initial part of the ipsilateral soleus response, but did change the late response (corresponding to the unipedal stance). Reduction of plantar support surface area resulted in earlier step execution and earlier heel-contact, i.e. faster balance recovery. These changes suggest that there is an integration of the spinal reflexes, as well as the stepping motor program.

[Physiopathology of spasticity and flexion spasms]. / Physiopathologie de la spasticité et des spasmes en flexion.

Spasticity, flexion and extension spasms occur after lesions of motor descending pathways. Three different mechanisms can explain these disorders of tone: pure muscular alterations, segmental synaptic sprouting and liberation of spinal reflex activity. This last mechanism, which is also the most classically described has been studied long ago. Amongst all hypotheses which can explain spasticity (hyperexcitability of alpha motoneuron, gamma motoneuron, or reduction of presynaptic inhibition) reduction of presynaptic inhibition is the only one to have been clearly demonstrated. A new treatment is proposed: intrathecal Baclofen. It seems to act by reducing the excitability of alpha motoneuron.