TMS over the supramarginal gyrus delays selection of appropriate grasp orientation during reaching and grasping tools for use.

Tool use, a ubiquitous part of human behaviour, requires manipulation control and knowledge of tool purpose. Neuroimaging and neuropsychological research posit that these two processes are supported by separate brain regions, ventral premotor and inferior parietal for manipulation control, and posterior middle temporal cortex for tool knowledge, lateralised to the left hemisphere. Action plans for tool use need to integrate these two separate processes, which is likely supported by the left supramarginal gyrus (SMG). However, whether this integration occurs during action execution is not known. To clarify the role of the SMG we conducted two experiments in which healthy participants reached to grasp everyday tools with the explicit instruction to use them directly following their grasp. To study the integration of manipulation control and tool knowledge within a narrow time window we mechanically perturbed the orientation of the tool to force participants to correct grasp orientation 'on-line' during the reaching movement. In experiment 1, twenty healthy participants reached with their left hand to grasp a tool. Double-pulse transcranial magnetic stimulation (TMS) was applied, in different blocks over left or right SMG at the onset of perturbation. Kinematic data revealed delayed and erroneous online correction after TMS over left and right SMG. In Experiment 2 twelve participants reached, in different blocks, with their left or right hand and TMS was applied over SMG ipsilateral to the reaching hand. A similar effect on correction was observed for ipsilateral stimulation when reaching with the left and right hands, and no effect of or interaction with hemisphere was observed. Our findings implicate a bilateral role of the SMG in correcting movements and selection of appropriate grasp orientation during reaching to grasp tools for use.

Action, perception and postural planning when reaching for tools.

The dorsal and ventral streams model of action and perception suggests that reaching to grasp a tool for use involves integrated operation of the two streams. Few attempts have been made to test the limits of this integration in normal subjects. Twenty normal subjects reached for tools or geometric objects which were rotated rapidly during reaching or immediately beforehand. In a first experiment it was shown that reaching for an inverted tool was slower than reaching for objects which required hand inversion due to proximity to a physical barrier. Also, for the right hand, tool rotation during reaching provoked a higher incidence of hand rotation in the wrong direction than did rotation of objects. In a second similar experiment, hand inversion when grasping objects was induced by the need to plan a future action rather than by proximity of a physical barrier. Despite this balancing of complexity of postural planning for tools and objects, hand rotation errors for both hands were more common for tools than objects. This was consistent with the two-stream model in suggesting that there was a process which produced rapid online tracking of stimulus rotation and this had to be overcome by a slower process which dictated grasping in accordance with knowledge of tool use.

Tool-use and the left hemisphere: what is lost in ideomotor apraxia?

Impaired tool related action in ideomotor apraxia is normally ascribed to loss of sensorimotor memories for habitual actions (engrams), but this account has not been tested against a hypothesis of a general deficit in representation of hand-object spatial relationships. Rapid reaching for familiar tools was compared with reaching for abstract objects in apraxic patients (N=9) and in a control group with right hemisphere posterior stroke. The apraxic patients alone showed an impairment in rotating the wrist to correctly grasp an inverted tool but not when inverting the hand to avoid a barrier and grasp an abstract object, and the severity of the impairment in tool reaching correlated with pantomime of tool-use. A second experiment with two apraxic patients tested whether barrier avoidance was simply less spatially demanding than reaching for a tool. However, the patient with damage limited to the inferior parietal lobe still showed a selective problem for tools. These results demonstrate that some apraxic patients are selectively impaired in their interaction with familiar tools, and this cannot be explained by the demands of the task on postural or spatial representation. However, traditional engram theory cannot account for associated problems with imitation of novel actions nor the absence of any correlated deficit in recognition of the methods of grasp of common tools. A revised theory is presented which follows the dorsal and ventral streams model (Milner & Goodale, 2008) and proposes preservation of motor control by the dorsal stream but impaired modulating input to it from the conceptual systems of the left temporal lobe.

The DRESS trial: a feasibility randomized controlled trial of a neuropsychological approach to dressing therapy for stroke inpatients.

OBJECTIVE: To investigate two approaches to treating patients with persistent dressing problems and cognitive difficulties following stroke. DESIGN: Pilot randomized controlled trial. SETTING: Inpatient stroke rehabilitation service. SUBJECTS: Seventy consecutive stroke patients with persistent dressing problems and accompanying cognitive difficulties at two weeks after their stroke. INTERVENTIONS: Patients were randomly allocated to six weeks of either a systematic neuropsychological approach, based on analysis of dressing problems and further cognitive testing, or to the control group who received conventional (functional) dressing practice. Both groups received treatment three times a week in accordance with two separately prepared manuals. MAIN MEASURES: Nottingham Stroke Dressing Assessment (NSDA), Line Cancellation, 10-hole peg transfer test, Object Decision, Gesture Imitation. Patients were assessed at six weeks after randomization by an independent assessor masked to group allocation. RESULTS: Both neuropsychological and functional groups improved performance on the NSDA over the treatment period (31% and 22%, respectively) but there was no significant difference between groups at six weeks. However, the neuropsychological group showed a significantly greater improvement on a line cancellation test of visual neglect (t(62) = 2.1, P < 0.05) and a planned subanalysis for those with right hemisphere damage showed a trend towards better dressing outcome (P = 0.07, one-tailed). CONCLUSIONS: Results demonstrate the potential benefits of a systematic neuropsychological approach to dressing therapy, particularly for patients with right hemisphere damage. This study suggests the need for a phase III study evaluating the efficacy of a systematic neuropsychological approach in treating dressing difficulties, targeting patients with right hemisphere stroke and visuospatial impairments.

Tool use and action planning in apraxia.

Apraxia after left inferior parietal lesions has been widely interpreted as evidence of damage or impaired access to representations of tool-use, but most research has investigated pantomime of tool actions, not handling of actual tools. An alternative account is that inferior parietal damage does not affect tool-use representations but impairs cognitive processing about postural and hand-tool spatial relationships which is necessary for planning and controlling any complex action. Four apraxic patients and 10 age-matched controls were asked to reach rapidly for tools or abstract objects of similar dimensions. Under conditions of time pressure and divided attention, the patients frequently failed to invert the hand to grasp inverted tools by the handle, whereas ability to invert the hand to avoid a barrier and grasp abstract objects was largely unimpaired. Frequency of errors in tool grasping correlated with severity of apraxia. When inverted tools were correctly grasped, rotation of the wrist occurred later during the reaching movement than when inverting the hand to grasp an abstract object. These data are consistent with the theory of degraded access to tool-use representations in apraxia, but this theory cannot account for co-occurring deficits in imitating or matching meaningless hand or body postures.

Effects of immediate feedback and errorless learning on recognition memory processing in young and older adults.

Age-related memory decline appears to be due to impaired recollection whereas familiarity may be intact. An intervention was therefore designed with the aim of optimising use of this intact sense of familiarity. A continuous face recognition paradigm was used which required detection of repeats in a long series. The experimental intervention consisted of immediate feedback on response accuracy and avoidance of errors by discouraging guessing. Experimental and control interventions were compared by recruiting 40 people aged under 30 years or over 60 years for six 45-minute training sessions. The elderly participants initially showed a more lax response criterion than young people but the experimental intervention reversed this effect so that by the end of training the elderly participants were less prone to false alarms than the younger participants. However, there was only limited evidence of generalisation of this training effect to other memory tasks and no effect on recognition sensitivity. This study demonstrates that combined feedback and errorless learning allow elderly people to adjust their response criterion during recognition memory tasks. Taken together with previous encouraging studies, it seems that this training approach might have potential as a therapy for age-related memory impairment. However this would require development of additional methods to enhance generalisation beyond trained tasks and to elicit improvements in sensitivity as well as reduction of false alarms. The separate contributions of feedback and errorless learning also need to be investigated.

Clinical evaluation of a non-immersive virtual environment in stroke rehabilitation.

BACKGROUND AND PURPOSE: We describe our attempts to evaluate the effectiveness of a virtual environment developed to rehabilitate stroke patients in the task of making a hot drink. METHODS: Single case studies were performed in 13/138 (9%) stroke patients undergoing rehabilitation in a UK stroke unit. Participants in AB/BA (n = 5) and ABA (n = 2) design studies received 5 one-hour sessions of attention control training (A phase) and 5 one-hour sessions of virtual environment training (B phase). An AB design with random duration of A and B phases (minimum duration of A and B phases 3 and 5 days respectively, with total duration of 3 weeks) was used in 6 participants. RESULTS: Visual inspection of scores across all cases showed a trend towards improvement over time in both real and virtual hot drink making ability in both control and intervention phases. There was no significant difference (Wilcoxon, p > 0.05) in the improvements in real and virtual hot drink making ability during all control and intervention phases in the 13 cases. Ceiling effects limited the evaluation of effectiveness in 5 of the 8 cases in which daily performance measures were used. CONCLUSIONS: Few people in this setting were suitable for this intervention. The case studies showed no evidence of a strong effect of this intervention, but we had great difficulty in performing single case studies. We conclude that more testing and development of this system is required before it is subjected to rigorous testing of clinical effectiveness.

Effects of conventional physical therapy and functional strength training on upper limb motor recovery after stroke: a randomized phase II study.

BACKGROUND: Functional training and muscle strength training may improve upper limb motor recovery after stroke. Combining these as functional strength training (FST) might enhance the benefit, but it is unclear whether this is better than conventional physical therapy (CPT). Comparing FST with CPT is not straightforward. OBJECTIVE: This study aimed at assessing the feasibility of conducting a phase III trial comparing CPT with FST for upper limb recovery. METHODS: Randomized, observer-blind, phase II trial. Subjects had upper limb weakness within 3 months of anterior circulation infarction. Subjects were randomized to CPT (no extra therapy), CPT + CPT, and CPT + FST. Intervention lasted 6 weeks. Primary outcome measure was the Action Research Arm Test (ARAT). Measurements were taken before treatment began, after 6 weeks of intervention, and 12 weeks thereafter. Attrition rate was calculated and differences between groups were interpreted using descriptive statistics. ARAT data were used to inform a power calculation. RESULTS: Thirty subjects were recruited (8% of people screened). Attrition rate was 6.7% at outcome and 40% at follow-up. At outcome the CPT + FST group showed the largest increase in ARAT score and this was above the clinically important level of 5.7 points. Median (interquartile range) increases were 11.5 (21.0) for CPT; 8.0 (13.3) for CPT + CPT; and 19.5 (22.0) for CPT + FST. The estimated sample size for an adequately powered subsequent phase III trial was 279 subjects at outcome. CONCLUSION: Further work toward a phase III clinical trial appears justifiable.

Ideomotor apraxia and functional ability.

The impact of ideomotor apraxia (IMA) on functional ability has been a relatively neglected topic in research. This has been due to the continued focus on performance on gesture imitation and pantomime of tool-use, together with widespread acceptance of anecdotal evidence that IMA has no effect when directly manipulating objects. An increasing number of studies have shown that IMA does in fact result in increased clumsiness when handling objects and may contribute to disability in everyday life. However the effect seems relatively mild compared to the stark abnormalities on gesture imitation and pantomime. The conventional explanation for this is that the cues provided by naturalistic contexts improve retrieval of action representations, but an alternative account concerns task-specific cognitive demands. Performance on simple prehensile tasks can be successfully guided by physical affordances whereas motor tasks may be failed if they require the support of memory or problem solving ability. A central deficit in IMA may be impaired postural representation causing inability to solve the problem of how to manipulate objects where neither affordance nor memory can dictate action. However, this account still fails to explain fully the patterns of error seen on complex naturalistic tasks such as dressing. Future research needs to further our understanding of how IMA maps on to disability, which will have implications for theory building and for therapeutic intervention.

Impaired imitation of meaningless gestures in ideomotor apraxia: a conceptual problem not a disorder of action control? A single case investigation.

A defining characteristic of ideomotor apraxia is an inability to imitate meaningless gestures. This is widely interpreted as being due to difficulties in the formulation or execution of motor programs for complex action, but an alternative view is that there is a higher level cognitive problem in conceptualisation of the target posture. In a single case with inferior left parietal and temporal damage, severely impaired imitation was accompanied by preserved motor skill and spatial awareness but inability to make a conceptual match between the fingers of his own hand and an observed hand. Also, he was able to match pictures of visually similar gestures but not cartoon drawings of gestures which were conceptually the same but visually dissimilar. Knowledge of body structure seemed largely intact as he was only slightly inaccurate in showing correspondences between locations on drawings of a human figure and his own body, or a visually dissimilar figure. This indicated that difficulty on matching gestures was specific to representation of body posture rather than body structure, or that gesture imitation tasks place higher demand on a structural representation of the body. These data imply that for at least some cases of ideomotor apraxia, impaired gesture imitation is due to a deficit in representing the observed posture and is not a deficit in memory for action or of motor control.

Action errors and dressing disability after stroke: an ecological approach to neuropsychological assessment and intervention.

A combination of detailed observation of dressing behaviour and neuropsychological assessment was used to identify the cognitive barriers to independent dressing in a series of eight stroke patients. For those with right hemisphere damage, dressing was disrupted by visuospatial problems or poor sustained attention. Those with left hemisphere damage and ideomotor apraxia were unable to learn the correct procedure to compensate for hemiparesis when dressing. The value of a therapeutic approach based on these observations was assessed in a single-blind randomised multiple-baseline experiment. A baseline phase of conventional dressing therapy which takes no account of individual patterns of cognitive impairment was contrasted with an approach which was formulated for each case. A permutation test demonstrated that there was a significant treatment effect for the right hemisphere cases but there was no therapy-related improvement for those with left or bilateral damage and apraxia. Observation of a naturalistic but controlled task (dressing with a standard item of clothing) appears to allow greater insight into the impact of specific neuropsychological deficits than has been found for more complex naturalistic tasks. The benefits of this ecological approach over conventional approaches to dressing therapy need to be evaluated further in a randomised clinical trial.

Validity of a virtual environment for stroke rehabilitation.

BACKGROUND AND PURPOSE: Virtual environments for use in stroke rehabilitation are in development, but there has been little evaluation of their suitability for this purpose. We evaluated a virtual environment developed for the rehabilitation of the task of making a hot drink. METHODS: Fifty stroke patients undergoing rehabilitation in a UK hospital stroke unit were involved. The performance of stroke rehabilitation patients when making a hot drink had the neurological impairments associated with performance of this task, and the errors observed were compared for standardized task performance in the real world and in a virtual environment. Neurological impairments were measured using standardized assessments. Errors in task performance were assessed rating video recordings and classified into error types. RESULTS: Real-world and virtual environment performance scores were not strongly associated (rho=0.30; P<0.05). Performance scores in both settings were associated with age, Barthel ADL score, Mini Mental State Examination score, and tests of visuospatial function. Real-world performance only was associated with arm function and sequencing ability. Virtual environment performance only was associated with language function and praxis. Participants made different errors during task performance in the real world and in the virtual environment. CONCLUSIONS: Although this virtual environment was usable by stroke rehabilitation patients, it posed a different rehabilitation challenge from the task it was intended to simulate, and so it might not be as effective as intended as a rehabilitation tool. Other virtual environments for stroke rehabilitation in development require similar evaluation.

Neuroplasticity, learning and recovery after stroke: a critical evaluation of constraint-induced therapy.

Constraint-induced movement therapy (CIMT) has been hailed as a radical new approach to stroke rehabilitation. The guiding theory is that impairment of hand function is exacerbated by learned non-use and that this in turn leads to a loss of cortical representation of the upper limb. It is claimed that these processes can be reversed by two weeks of constraint of the unaffected limb combined with intensive practice in use of the paretic hand, and numerous small-scale studies have suggested that CIMT can lead to large improvements in function more than a year after stroke. However, the theory of learned non-use is open to question and there is uncertainty about the nature of the improvements induced by CIMT. The greatest effect seems to be increased spontaneous use of the hand, either through reduction of learned non-use or by overcoming the sense of effort during movement. There is also evidence of some improvement on dexterity tests but no studies have analysed in detail whether this reflects reduction of basic motor impairment or learning of compensatory movement strategies. The current weight of evidence is in favour of compensatory learning. Cortical changes detected by transcranial magnetic stimulation (TMS) or functional imaging may reflect this compensatory motor skill learning rather than restoration of representations lost due to the infarct or non-use of the limb. If future studies confirm this then the clinical implication is that direct teaching of unimanual or bimanual compensatory strategies might be a more productive approach than constraint.

fMRI signal decreases in ipsilateral primary motor cortex during unilateral hand movements are related to duration and side of movement.

Interactions between the primary motor cortices of each hemisphere during unilateral hand movements appear to be inhibitory, although there is evidence that the strengths of these interactions are asymmetrical. In the present study, functional magnetic resonance imaging (fMRI) was used to investigate the effects of motor task duration and hand used on unilateral movement-related BOLD signal increases and decreases in the hand region of primary motor cortex (M1) of each hemisphere in six right-handed volunteers. Significant task-related BOLD signal decreases were observed in ipsilateral M1 during single and brief bursts of unilateral movements for both hands. However, these negative-to-baseline responses were found to intensify with increasing movement duration in parallel with greater task-related increases in contralateral M1. Movement-related BOLD signal decreases in ipsilateral M1 were also stronger for the right, dominant hand than for the left hand in our right-handed subjects. These findings would be consistent with the existence of interhemispheric interactions between M1 of each hemisphere, whereby increased neuronal activation in M1 of one hemisphere induces reduced neuronal activity in M1 of the opposite hemisphere. The observation of a hemispheric asymmetry in inhibition between M1 of each hemisphere agrees well with previous neuroimaging and electrophysiological data. These findings are discussed in the context of current understanding of the physiological origins of negative-to-baseline BOLD responses.

Intensive, time-series measurement of upper limb recovery in the subacute phase following stroke.

OBJECTIVES: To discover if intensive monitoring of wrist extension would produce consistent recovery curves during the subacute period, and whether any impact of additional physiotherapy could be detected. We also investigated improved approaches to statistical analysis in single-case experiments. DESIGN: A randomized multiple-baseline experiment with very frequent assessment. SETTING: Stroke rehabilitation unit. SUBJECTS: Four patients with some active wrist movement less than seven weeks after stroke. INTERVENTIONS: Wrist extension was measured twice daily with an electrogoniometer for 3-4 weeks. Additional upper limb physiotherapy 115 minutes, twice per day) commenced after a randomly determined period. MAIN OUTCOME MEASURES: Speed and range of wrist movement. RESULTS: A logarithmic function was fitted to the data to produce recovery curves. In all cases, active range and maximum velocity of wrist extension rose gradually over time. Mean variability in range was <5%, but with occasional outliers. Range of passive movement decreased in two cases in association with pain and increased tone. There were no large improvements coinciding with additional physiotherapy but autoregression analysis indicated statistically significant changes in three cases. A randomization test confirmed an increase in active range associated with additional physiotherapy. CONCLUSIONS: Intensive electrogoniometry provided a detailed recovery pattern for each of these patients. The data were surprisingly consistent over time, showing that it is feasible to use a time-series approach to investigate subacute recovery. Changes associated with additional physiotherapy were observed on some measures, demonstrating the potential of this approach for exploratory evaluation of interventions.