Correction to: Coordination of muscles to control the footpath during over-ground walking in neurologically intact individuals and stroke survivors.

In the original publication of the article, the corrections for the typographical errors in the equations for variance that affects the footpath (VORT) and the total variance (VTOT) should be as following.

Coordination of muscles to control the footpath during over-ground walking in neurologically intact individuals and stroke survivors.

The central nervous system (CNS) is believed to use the abundant degrees of freedom of muscles and joints to stabilize a particular task variable important for task success, such as footpath during walking. Stroke survivors often demonstrate impaired balance and high incidences of falls due to increased footpath variability during walking. In the current study, we use the uncontrolled manifold (UCM) approach to investigate the role of motor abundance in stabilizing footpath during swing phase in healthy individuals and stroke survivors. Twelve stroke survivors and their age- and gender-matched controls walked over-ground at self-selected speed, while electromyographic and kinematic data were collected. UCM analysis partitioned the variance of muscle groups (modes) across gait cycles into "good variance" (i.e., muscle mode variance leading to a consistent or stable footpath) or "bad variance" (i.e., muscle mode variance resulting in an inconsistent footpath). Both groups had a significantly greater "good" than "bad" variance, suggesting that footpath is an important task variable stabilized by the CNS during walking. The relative variance difference that reflects normalized difference between "good" and "bad" variance was not significantly different between groups. However, significant differences in muscle mode structure and muscle mode activation timing were observed between the two groups. Our results suggest that though the mode structure and activation timing are altered, stroke survivors may retain their ability to explore the redundancy within the neuromotor system and utilize it to stabilize the footpath.

Robotic Assist-As-Needed as an Alternative to Therapist-Assisted Gait Rehabilitation.

OBJECTIVE: Body Weight Supported Treadmill Training (BWSTT) with therapists' assistance is often used for gait rehabilitation post-stroke. However, this training method is labor-intensive, requiring at least one or as many as three therapists at once for manual assistance. Previously, we demonstrated that providing movement guidance using a performance-based robot-aided gait training (RAGT) that applies a compliant, assist-as-needed force-field improves gait pattern and functional walking ability in people post-stroke. In the current study, we compared the effects of assist-as-needed RAGT combined with functional electrical stimulation and visual feedback with BWSTT to determine if RAGT could serve as an alternative for locomotor training. METHODS: Twelve stroke survivors were randomly assigned to one of the two groups, either receiving BWSTT with manual assistance or RAGT with functional electrical stimulation and visual feedback. All subjects received fifteen 40-minutes training sessions. RESULTS: Clinical measures, kinematic data, and EMG data were collected before and immediately after the training for fifteen sessions. Subjects receiving RAGT demonstrated significant improvements in their self-selected over-ground walking speed, Functional Gait Assessment, Timed Up and Go scores, swing-phase peak knee flexion angle, and muscle coordination pattern. Subjects receiving BWSTT demonstrated significant improvements in the Six-minute walk test. However, there was an overall trend toward improvement in most measures with both interventions, thus there were no significant between-group differences in the improvements following training. CONCLUSION: The current findings suggest that RAGT worked at least as well as BWSTT and thus may be used as an alternative rehabilitation method to improve gait pattern post-stroke as it requires less physical effort from the therapists compared to BWSTT.

Assist-as-Needed Robot-Aided Gait Training Improves Walking Function in Individuals Following Stroke.

A novel robot-aided assist-as-needed gait training paradigm has been developed recently. This paradigm encourages subjects' active participation during training. Previous pilot studies demonstrated that assist-as-needed robot-aided gait training (RAGT) improves treadmill walking performance post-stroke. However, it is not known if there is an over-ground transfer of the training effects from RAGT on treadmill or long-term retention of the effects. The purpose of the current study was to examine the effects of assist-as-needed RAGT on over-ground walking pattern post-stroke. Nine stroke subjects received RAGT with visual feedback of each subject's instantaneous ankle malleolus position relative to a target template for 15 40-minute sessions. Clinical evaluations and gait analyses were performed before, immediately after, and 6 months post-training. Stroke subjects demonstrated significant improvements and some long-term retention of the improvements in their self-selected over-ground walking speed, Dynamic Gait Index, Timed Up and Go, peak knee flexion angle during swing phase and total hip joint excursion over the whole gait cycle for their affected leg . These preliminary results demonstrate that subjects improved their over-ground walking pattern and some clinical gait measures post-training suggesting that assist-as-needed RAGT including visual feedback may be an effective approach to improve over-ground walking pattern post-stroke.

Human movement training with a cable driven ARm EXoskeleton (CAREX).

In recent years, the authors have proposed lightweight exoskeleton designs for upper arm rehabilitation using multi-stage cable-driven parallel mechanism. Previously, the authors have demonstrated via experiments that it is possible to apply "assist-as-needed" forces in all directions at the end-effector with such an exoskeleton acting on an anthropomorphic machine arm. A human-exoskeleton interface was also presented to show the feasibility of CAREX on human subjects. The goals of this paper are to 1) further address issues when CAREX is mounted on human subjects, e.g., generation of continuous cable tension trajectories 2) demonstrate the feasibility and effectiveness of CAREX on movement training of healthy human subjects and a stroke patient. In this research, CAREX is rigidly attached to an arm orthosis worn by human subjects. The cable routing points are optimized to achieve a relatively large "tensioned" static workspace. A new cable tension planner based on quadratic programming is used to generate continuous cable tension trajectory for smooth motion. Experiments were carried out on eight healthy subjects. The experimental results show that CAREX can help the subjects move closer to a prescribed circular path using the force fields generated by the exoskeleton. The subjects also adapt to the path shortly after training. CAREX was also evaluated on a stroke patient to test the feasibility of its use on patients with neural impairment. The results show that the patient was able to move closer to a prescribed straight line path with the "assist-as-needed" force field.

Motor equivalence (ME) during reaching: is ME observable at the muscle level?

The concept of motor equivalent combinations of arm muscles, or M-modes, was investigated during reaching to insert a pointer into a cylindrical target with and without an elbow perturbation. Five M-modes across 15 arm/scapula muscles were identified by principal component analysis with factor extraction. The relationship between small changes in the M-modes and changes in the position/orientation of the pointer were investigated by linear regression analyses. The results revealed a motor equivalent organization of the M-modes for perturbed compared with non-perturbed reaches, both with respect to hand position and orientation, especially in the first 100-ms postperturbation. Similar findings were obtained for motor equivalence computed based on changes in the joint configuration, although the kinematically defined motor equivalence was stronger for pointer orientation. The results support the hypothesis that the nervous system organizes muscles into M-modes and flexibly scales M-mode activation to preserve stable values of variables directly related to performance success.

End-state comfort and joint configuration variance during reaching.

This study joined two approaches to motor control. The first approach comes from cognitive psychology and is based on the idea that goal postures and movements are chosen to satisfy task-specific constraints. The second approach comes from the principle of motor abundance and is based on the idea that control of apparently redundant systems is associated with the creation of multi-element synergies stabilizing important performance variables. The first approach has been tested by relying on psychophysical ratings of comfort. The second approach has been tested by estimating variance along different directions in the space of elemental variables such as joint postures. The two approaches were joined here. Standing subjects performed series of movements in which they brought a hand-held pointer to each of four targets oriented within a frontal plane, close to or far from the body. The subjects were asked to rate the comfort of the final postures, and the variance of their joint configurations during the steady state following pointing was quantified with respect to pointer endpoint position and pointer orientation. The subjects showed consistent patterns of comfort ratings among the targets, and all movements were characterized by multi-joint synergies stabilizing both pointer endpoint position and orientation. Contrary to what was expected, less comfortable postures had higher joint configuration variance than did more comfortable postures without major changes in the synergy indices. Multi-joint synergies stabilized the pointer position and orientation similarly across a range of comfortable/uncomfortable postures. The results are interpreted in terms conducive to the two theoretical frameworks underlying this work, one focusing on comfort ratings reflecting mean postures adopted for different targets and the other focusing on indices of joint configuration variance.

Effect of robotic performance-based error-augmentation versus error-reduction training on the gait of healthy individuals.

Effective locomotion training with robotic exoskeletons requires identification of optimal control algorithms to better facilitate motor learning. Two commonly employed training protocols emphasize use of training stimuli that either augment or reduce performance errors. The current study sought to identify which of these training strategies promote better short-term modification of a typical gait pattern in healthy individuals as a framework for future application to neurologically impaired individuals. Ten subjects were assigned to each of a performance-based error-augmentation or error-reduction training group. All subjects completed a 45-min session of treadmill walking at their preferred speed with a robotic exoskeleton. Target templates prescribed an ankle path for training that corresponded to an increased step height. When subjects' instantaneous ankle positions fell below the inferior virtual wall of the target ankle path, robotic forces were applied that either decreased (error-reduction) or increased (error-augmentation) the deviation from the target path. When the force field was turned on, both groups walked with ankle paths better approximating the target template compared to baseline. When the force field was removed unexpectedly during catch and post-training trials, only the error-augmentation group maintained an ankle path close to the target ankle path. Further investigation is required to determine if a similar training advantage is provided for neurologically impaired individuals.

Functional synergies underlying control of upright posture during changes in head orientation.

BACKGROUND: Studies of human upright posture typically have stressed the need to control ankle and hip joints to achieve postural stability. Recent studies, however, suggest that postural stability involves multi degree-of-freedom (DOF) coordination, especially when performing supra-postural tasks. This study investigated kinematic synergies related to control of the body's position in space (two, four and six DOF models) and changes in the head's orientation (six DOF model). METHODOLOGY/PRINCIPAL FINDINGS: Subjects either tracked a vertically moving target with a head-mounted laser pointer or fixated a stationary point during 4-min trials. Uncontrolled manifold (UCM) analysis was performed across tracking cycles at each point in time to determine the structure of joint configuration variance related to postural stability or tracking consistency. The effect of simulated removal of covariance among joints on that structure was investigated to further determine the role of multijoint coordination. Results indicated that cervical joint motion was poorly coordinated with other joints to stabilize the position of the body center of mass (CM). However, cervical joints were coordinated in a flexible manner with more caudal joints to achieve consistent changes in head orientation. CONCLUSIONS/SIGNIFICANCE: An understanding of multijoint coordination requires reference to the stability/control of important performance variables. The nature of that coordination differs depending on the reference variable. Stability of upright posture primarily involved multijoint coordination of lower extremity and lower trunk joints. Consistent changes in the orientation of the head, however, required flexible coordination of those joints with motion of the cervical spine. A two-segment model of postural control was unable to account for the observed stability of the CM position during the tracking task, further supporting the need to consider multijoint coordination to understand postural stability.

Mirror gait retraining for the treatment of patellofemoral pain in female runners.

BACKGROUND: Abnormal hip mechanics are often implicated in female runners with patellofemoral pain. We sought to evaluate a simple gait retraining technique, using a full-length mirror, in female runners with patellofemoral pain and abnormal hip mechanics. Transfer of the new motor skill to the untrained tasks of single leg squat and step descent was also evaluated. METHODS: Ten female runners with patellofemoral pain completed 8 sessions of mirror and verbal feedback on their lower extremity alignment during treadmill running. During the last 4 sessions, mirror and verbal feedback were progressively removed. Hip mechanics were assessed during running gait, a single leg squat and a step descent, both pre- and post-retraining. Subjects returned to their normal running routines and analyses were repeated at 1-month and 3-month post-retraining. Data were analyzed via repeated measures analysis of variance. FINDINGS: Subjects reduced peaks of hip adduction, contralateral pelvic drop, and hip abduction moment during running (P<0.05, effect size=0.69-2.91). Skill transfer to single leg squatting and step descent was noted (P<0.05, effect size=0.91-1.35). At 1 and 3 months post retraining, most mechanics were maintained in the absence of continued feedback. Subjects reported improvements in pain and function (P<0.05, effect size=3.81-7.61) and maintained through 3 months post retraining. INTERPRETATION: Mirror gait retraining was effective in improving mechanics and measures of pain and function. Skill transfer to the untrained tasks of squatting and step descent indicated that a higher level of motor learning had occurred. Extended follow-up is needed to determine the long term efficacy of this treatment.

Motor abundance supports multitasking while standing.

Many activities require simultaneous performance of multiple tasks. Motor redundancy may provide a key mechanism for multitasking, ensuring minimal inter-task interference. This study investigated the effect of performing two supra-postural tasks on postural stability. The component of joint configuration variance (JCV) reflecting flexible joint combinations (V(UCM)) that stabilize the center of mass (CoM) position and the component of JCV leading to variability (V(ORT)) of the CoM were determined using the Uncontrolled Manifold (UCM) approach. Subjects executed a targeting task alone or in combination with a ball-balancing task. UCM analysis revealed that the joints were coordinated such that their combined variance reflected primarily V(UCM), without a substantial effect on CoM position stability. Evidence for this flexible control strategy increased when the ball-balancing task was added to targeting, or when the index of difficulty of targeting increased, both without leading to substantial increases in V(ORT) or CoM position variance. The increase in joint variance when performing additional tasks without affecting adversely CoM position stability supports the hypothesis that the nervous system takes advantage of available motor redundancy for the successful performance of multiple tasks concurrently. Future work is needed to investigate the limits of this control scheme.

Motor control theories and their applications.

We describe several influential hypotheses in the field of motor control including the equilibrium-point (referent configuration) hypothesis, the uncontrolled manifold hypothesis, and the idea of synergies based on the principle of motor abundance. The equilibrium-point hypothesis is based on the idea of control with thresholds for activation of neuronal pools; it provides a framework for analysis of both voluntary and involuntary movements. In particular, control of a single muscle can be adequately described with changes in the threshold of motor unit recruitment during slow muscle stretch (threshold of the tonic stretch reflex). Unlike the ideas of internal models, the equilibrium-point hypothesis does not assume neural computations of mechanical variables. The uncontrolled manifold hypothesis is based on the dynamic system approach to movements; it offers a toolbox to analyze synergic changes within redundant sets of elements related to stabilization of potentially important performance variables. The referent configuration hypothesis and the principle of abundance can be naturally combined into a single coherent scheme of control of multi-element systems. A body of experimental data on healthy persons and patients with movement disorders are reviewed in support of the mentioned hypotheses. In particular, movement disorders associated with spasticity are considered as consequences of an impaired ability to shift threshold of the tonic stretch reflex within the whole normal range. Technical details and applications of the mentioned hypo-theses to studies of motor learning are described. We view the mentioned hypotheses as the most promising ones in the field of motor control, based on a solid physical and neurophysiological foundation.

Robot-assisted modifications of gait in healthy individuals.

This study investigated whether short-term modifications of gait could be induced in healthy adults and whether a combination of kinetic (a compliant force resisting deviation of the foot from the prescribed footpath) and visual guidance was superior to either kinetic guidance or visual guidance alone in producing this modification. Thirty-nine healthy adults, 20-33 years old, were randomly assigned to the three groups receiving six 10-min blocks of treadmill training requiring them to modify their footpath to match a scaled-down path. Changes of the footpath, specific joint events and joint moments were analyzed. Persons receiving combined kinetic and visual guidance showed larger modifications of their gait patterns that were maintained longer, persisting up to 2 h after intervening over-ground activities, than did persons receiving training with primarily kinetic guidance or with visual guidance alone. The results emphasize the short-term plasticity of locomotor circuits and provide a possible basis for persons learning to achieve more functional gait patterns following a stroke or other neurological disorders.

Analyses of joint variance related to voluntary whole-body movements performed in standing.

This article investigates two methodological issues resulting from a recent study of center of mass positional stability during performance of whole-body targeting tasks (Freitas et al., 2006): (1) Can identical results be obtained with uncontrolled manifold (UCM) variance analysis when it is based on estimating the Jacobian using multiple linear regression (MLR) analysis compared to that using typical analytic formal geometric model? (2) Are kinematic synergies more related to stabilization of the instantaneous anterior-posterior position of the center of mass (COM(AP)) or the center of pressure (COP(AP))? UCM analysis was used to partition the variance of the joint configuration into 'bad' variance, leading to COM(AP) or COP(AP) variability, and 'good' variance, reflecting the use of motor abundance. Findings indicated (1) nearly identical UCM results for both methods of Jacobian estimation; and (2) more 'good' and less 'bad' joint variance related to stability of COP(AP) than to COM(AP) position. The first result requires further investigation with more degrees of freedom, but suggests that when a formal geometric model is unavailable or overly complex, UCM analysis may be possible by estimating the Jacobian using MLR. Correct interpretation of the second result requires analysis of the singular values of the Jacobian for different performance variables, which indicates how certain amount of joint variance affects each performance variable. Thus, caution is required when interpreting differences in joint variance structure among various performance variables obtained by UCM analysis without first investigating how the different relationships captured by the Jacobian translate those variances into performance-level variance.

Whole limb kinematics are preferentially conserved over individual joint kinematics after peripheral nerve injury.

Biomechanics and neurophysiology studies suggest whole limb function to be an important locomotor control parameter. Inverted pendulum and mass-spring models greatly reduce the complexity of the legs and predict the dynamics of locomotion, but do not address how numerous limb elements are coordinated to achieve such simple behavior. As a first step, we hypothesized whole limb kinematics were of primary importance and would be preferentially conserved over individual joint kinematics after neuromuscular injury. We used a well-established peripheral nerve injury model of cat ankle extensor muscles to generate two experimental injury groups with a predictable time course of temporary paralysis followed by complete muscle self-reinnervation. Mean trajectories of individual joint kinematics were altered as a result of deficits after injury. By contrast, mean trajectories of limb orientation and limb length remained largely invariant across all animals, even with paralyzed ankle extensor muscles, suggesting changes in mean joint angles were coordinated as part of a long-term compensation strategy to minimize change in whole limb kinematics. Furthermore, at each measurement stage (pre-injury, paralytic and self-reinnervated) step-by-step variance of individual joint kinematics was always significantly greater than that of limb orientation. Our results suggest joint angle combinations are coordinated and selected to stabilize whole limb kinematics against short-term natural step-by-step deviations as well as long-term, pathological deviations created by injury. This may represent a fundamental compensation principle allowing animals to adapt to changing conditions with minimal effect on overall locomotor function.

Robot assisted gait training with active leg exoskeleton (ALEX).

Gait training of stroke survivors is crucial to facilitate neuromuscular plasticity needed for improvements in functional walking ability. Robot assisted gait training (RAGT) was developed for stroke survivors using active leg exoskeleton (ALEX) and a force-field controller, which uses assist-as-needed paradigm for rehabilitation. In this paradigm undesirable gait motion is resisted and assistance is provided towards desired motion. The force-field controller achieves this paradigm by effectively applying forces at the ankle of the subject through actuators on the hip and knee joints. Two stroke survivors participated in a 15-session gait training study each with ALEX. The results show that by the end of the training the gait pattern of the patients improved and became closer to a healthy subject's gait pattern. Improvement is seen as an increase in the size of the patients' gait pattern, increased knee and ankle joint excursions and increase in their walking speeds on the treadmill.

The organization of intralimb and interlimb synergies in response to different joint dynamics.

We sought to understand differences in joint coordination between the dominant and nondominant arms when performing repetitive tasks. The uncontrolled manifold approach was used to decompose the variability of joint motions into components that reflect the use of motor redundancy or movement error. First, we hypothesized that coordination of the dominant arm would demonstrate greater use of motor redundancy to compensate for interaction forces than would coordination of the nondominant arm. Secondly, we hypothesized that when interjoint dynamics were more complex, control of the interlimb relationship would remain stable despite differences in control of individual hand paths. Healthy adults performed bimanual tracing of two orientations of ellipses that resulted in different magnitudes of elbow interaction forces. For the dominant arm, joint variance leading to hand path error was the same for both ellipsis orientations, whereas joint variance reflecting the use of motor redundancy increased when interaction moment was highest. For the nondominant arm, more joint error variance was found when interaction moment was highest, whereas motor redundancy did not differ across orientations. There was no apparent difference in interjoint dynamics between the two arms. Thus, greater skill exhibited by the dominant arm may be related to its ability to utilize motor redundancy to compensate for the effect of interaction forces. However, despite the greater error associated with control of the nondominant hand, control of the interlimb relationship remained stable when the interaction moment increased. This suggests separate levels of control for inter- versus intra-limb coordination in this bimanual task.

Gait training after stroke: a pilot study combining a gravity-balanced orthosis, functional electrical stimulation, and visual feedback.

RATIONALE: This case report describes the application of a novel gait retraining approach to an individual with poststroke hemiparesis. The rehabilitation protocol combined a specially designed leg orthosis (the gravity-balanced orthosis), treadmill walking, and functional electrical stimulation to the ankle muscles with the application of motor learning principles. CASE: The participant was a 58-year-old man who had a stroke more than three years before the intervention. He underwent gait retraining over a period of five weeks for a total of 15 sessions during which the gravity compensation provided by the gravity-balanced orthosis and visual feedback about walking performance was gradually reduced. OUTCOMES: At the end of five weeks, he decreased the time required to complete the Timed Up and Go test; his gait speed increased during overground walking; gait was more symmetrical; stride length, hip and knee joint excursions on the affected side increased. Except for gait symmetry, all other improvements were maintained one month post-intervention. CONCLUSIONS: This case report describes possible advantages of judiciously combining different treatment techniques in improving the gait of chronic stroke survivors. Further studies are planned to evaluate the effectiveness of different components of this training in both the subacute and chronic stages of stroke recovery.