Assisted Movement With Proprioceptive Stimulation Augments Recovery From Moderate-To-Severe Upper Limb Impairment During Subacute Stroke Period: A Randomized Clinical Trial.

BACKGROUND: Robotic assisted movement has become an accepted method of treating the moderately-to-mildly impaired upper limb after stroke. OBJECTIVE: To determine whether, during the subacute phase of recovery, a novel type of robotic assisted training reduces moderate-to-severe impairment in the upper limb beyond that resulting from spontaneous recovery and prescribed outpatient therapy. METHODS: A prospective, randomized, double-blinded, placebo-controlled, semi-crossover study of 83 participants. Over 6- to 9-weeks, participants received 18, 30-min training sessions of the hand and wrist. The test intervention consisted of assisted motion, biofeedback, and antagonist muscle vibration delivered by a robotic device. Test Group participants received the test intervention, and Control Group participants received a placebo intervention designed to have no effect. Subsequently, Control Group participants crossed over to receive the test intervention. RESULTS: At enrollment, the average age (±SD) of participants was 57.0 ± 12.8 year and weeks since stroke was 11.6 ± 5.4. The average Fugl-Meyer baseline score of Test Group participants was 20.9, increasing by 10.8 with training, and in Control Group participants was 23.7 increasing by 6.4 with training, representing a significant difference (4.4) in change scores (P = .01). During the crossover phase, Control Group participants showed a significant increase in FMA-UL score (i.e., 4.7 ± 6.7 points, P = .003) as well as in other, more specific measures of impairment. CONCLUSIONS: Robotic impairment-oriented training, as used in this study, can significantly enhance recovery during the subacute phase of recovery. Spontaneous recovery and prescribed outpatient therapy during this phase do not fully exploit the potential for remediating moderate-to-severe upper limb impairment.ClinicalTrials.gov Registry: NCT00609115-Subacute stroke rehabilitation with AMES.

Clinical impact of gait training enhanced with visual kinematic biofeedback: Patients with Parkinson's disease and patients stable post stroke.

As the world's population ages, falls, physical inactivity, decreased attention and impairments in balance and gait arise as a consequence of decreased sensation, weakness, trauma and degenerative disease. Progressive balance and gait training can facilitate postural righting, safe ambulation and community participation. This small randomized clinical trial evaluated if visual and kinematic feedback provided during supervised gait training would interfere or enhance mobility, endurance, balance, strength and flexibility in older individuals greater than one year post stroke (Gobbi et al., 2009) or Parkinson's disease (PD) (Gobbi et al., 2009). Twenty-four individuals consented to participate. The participants were stratified by diagnosis and randomly assigned to a control (usual gait training (Gobbi et al., 2009)) or an experimental group (usual gait training plus kinematic feedback (Gobbi et al., 2009)). At baseline and 6 weeks post training (18 h), subjects completed standardized tests (mobility, balance, strength, range of motion). Gains were described across all subjects, by treatment group and by diagnosis. Then they were compared for significance using nonparametric statistics. Twenty-three subjects completed the study with no adverse events. Across all subjects, by diagnosis (stroke and PD) and by training group (control and experimental), there were significant gains in mobility (gait speed, step length, endurance, and quality), balance (Berg Balance), range of motion and strength. There were no significant differences in the gain scores between the control and experimental groups. Subjects chronic post stroke made greater strength gains on the affected side than subjects with PD but otherwise there were no significant differences. In summary, during supervised gait training, dynamic visual kinematic feedback from wireless pressure and motion sensors had similar, positive effects as verbal, therapist feedback. A wireless kinematic feedback system could be used at home, to provide feedback and motivation for self correction of gait while simultaneously providing data to the therapist (at a distance).

Poststroke upper limb recovery.

Upper limb recovery after a stroke is suboptimal. Only a few individuals achieve full functional use of the hemiparetic arm. Complex primary and secondary impairments may affect recovery of upper limb function in stroke survivors. In addition, multiple personal, social, behavioral, economic, and environmental factors may interact to positively or negatively influence recovery during the different stages of rehabilitation. The current management of upper limb dysfunction poststroke has become more evidence based. In this article, we review the standard of care for upper limb poststroke rehabilitation, the evidence supporting the treatment modalities that currently exist and the exciting new developments in the therapeutic pipeline.

Stroke-induced synergistic phase shifting and its possible implications for recovery mechanisms.

Among other diminished motor capabilities, survivors of a stroke often exhibit pathological joint synergies. With respect to the upper limbs, these deficits diminish coordination in reaching, pointing, and daily task performance. Past research on pathological synergies suggests that the synergistic relationship between joints is different for flexion than in extension. One explanation for different flexion and extension synergies is that there exists a time difference between the joint being volitionally moved and the joint that moves in synergy. The goal of this research was to measure these synergistic time differences. The experiment included 11 hemiparetic subjects who performed rhythmic elbow motions at five different frequencies. A motion capture system was used to record the resulting shoulder synergies. Synergistic shoulder rotations were found to exhibit frequency-dependent phase lags (delays) and leads (advances) in the paretic arm. Furthermore, the synergistic leads and lags varied with frequency and were subject specific. We found that timing differences between joints in pathological movements are comparable to differences that were observed by other researchers for normal, able-bodied movement synergies. Moreover, the fact that pathological synergies were evident in rhythmic motion suggests that they are spinal in origin. A significant amount research exists relating to able-bodied spinal synergies. Thus, the supposition that pathological synergies are an expression of normal synergies would tie disabled movement into a larger body of work related to able-bodied synergies. The rehabilitation implications of this possible connection are discussed.

Mechanosensitivity in the upper extremity following breast cancer treatment.

STUDY DESIGN: Descriptive, cross-sectional. INTRODUCTION: Breast cancer (BC) treatments place the nervous system at risk, which may contribute to upper extremity (UE) mechanosensitivity. PURPOSE OF THE STUDY: To evaluate elbow extension range of motion (EE-ROM) during upper limb neurodynamic testing (ULNT) post-BC treatment. METHODS: ULNT EE-ROM was measured for 145 women post-BC treatment. Women were sub-grouped by presence/absence of pain and lymphedema. RESULTS: Mean EE-ROM during ULNT1 was -22.3° (SD 11.9°) on the unaffected limb and -25.99° (SD 13.1°) on the affected limb. The women with pain and lymphedema had the greatest limitation in EE-ROM during ULNT1 testing, particularly of their affected limb (-33.8°, SD 12.9). Symptoms were reported more frequently in the affected chest, shoulder, arm, elbow, and hand. The intensity of symptoms was greater at the affected chest (p = 0.046), shoulder (p = 0.033) and arm (p = 0.039). CONCLUSIONS: Women with lymphedema and pain after BC treatment may present with altered neural mechanosensitivity. LEVEL OF EVIDENCE: 3a.

Robotic unilateral and bilateral upper-limb movement training for stroke survivors afflicted by chronic hemiparesis.

Stroke is the leading cause of long-term neurological disability and the principle reason for seeking rehabilitative services in the US. Learning based rehabilitation training enables independent mobility in the majority of patients post stroke, however, restoration of fine manipulation, motor function and task specific functions of the hemiplegic arm and hand is noted in fewer than 15% of the stroke patients. Brain plasticity is the innate mechanism enabling the recovery of motor skills through neurological reorganization of the brain as a response to limbs' manipulation. The objective of this research was to evaluate the therapeutic efficacy for the upper limbs with a dual arm exoskeleton system (EXO-UL7) using three different modalities: bilateral mirror image with symmetric movements of both arms, unilateral movement of the affected arm and standard care. Five hemiparetic subjects were randomly assigned to each therapy modality. An upper limb exoskeleton was used to provide bilateral and unilateral treatments. Standard care was provided by a licensed physical therapist. Subjects were evaluated before and after the interventions using 13 different clinical measures. Following these treatments all of the subjects demonstrated significant improved of their fine motor control and gross control across all the treatment modalities. Subjects exhibited significant improvements in range of motion of the shoulder, and improved muscle strength for bilateral training and standard care, but not for unilateral training. In conclusion, a synergetic approach in which robotic treatments (unilateral and bilateral depending on the level of the motor control) are supplemented by the standard of care may maximize the outcome of the motor control recover following stroke.

Complex-value coherence mapping reveals novel abnormal resting-state functional connectivity networks in task-specific focal hand dystonia.

Resting-state imaging designs are powerful in modeling functional networks in movement disorders because they eliminate task performance related confounds. However, the most common metric for quantifying functional connectivity, i.e., bivariate magnitude coherence (Coh), can sometimes be contaminated by spurious correlations in blood-oxygen level dependent (BOLD) signal due to smoothing and seed blur, thereby limiting the identification of true interactions between neighboring neural populations. Here, we apply a novel functional connectivity metric., i.e., imaginary coherence (ICoh), to BOLD fMRI data in healthy individuals and patients with task-specific focal hand dystonia (tspFHD), in addition to the traditional magnitude Coh metric. We reconstructed resting-state sensorimotor, basal ganglia, and default-mode networks using both Coh and ICoh. We demonstrate that indeed the ICoh metric eliminates spatial blur around seed placement and reflects slightly different networks from Coh. We then identified significant reductions in resting-state connectivity within both the sensorimotor and basal ganglia networks in patients with tspFHD, primarily in the hemisphere contralateral to the affected hand. Collectively, these findings direct our attention to the fact that multiple networks are decoupled in tspFHD that can be unraveled by different functional connectivity metrics, and that this aberrant communication contributes to clinical deficits in the disorder.

Chronic stroke survivors achieve comparable outcomes following virtual task specific repetitive training guided by a wearable robotic orthosis (UL-EXO7) and actual task specific repetitive training guided by a physical therapist.

Survivors post stroke commonly have upper limb impairments. Patients can drive neural reorganization, brain recovery and return of function with task specific repetitive training (TSRT). Fifteen community independent stroke survivors (25-75 years, >6 months post stroke, Upper Limb Fugl Meyer [ULFM] scores 16-39) participated in this randomized feasibility study to compare outcomes of upper limb TSRT guided by a robotic orthosis (bilateral or unilateral) or a physical therapist. After 6 weeks of training (18 h), across all subjects, there were significant improvements in depression, flexibility, strength, tone, pain and voluntary movement (ULFM) (p < 0.05; effect sizes 0.49-3.53). Each training group significantly improved ULFM scores and range of motion without significant group differences. Virtual or actual TSRT performed with a robotic orthosis or a physical therapist significantly reduced arm impairments around the shoulder and elbow without significant gains in fine motor hand control, activities of daily living or independence.

Focal task-specific lower extremity dystonia associated with intense repetitive exercise: a case series.

BACKGROUND: Focal task-specific dystonia of the lower extremity associated with intense repetitive exercise has recently been recognized. The clinical course, treatment response and prognosis remain poorly understood. METHODS: Individuals with lower extremity task-specific dystonia evaluated at UCSF's Movement Disorders Center (2004-2012) were eligible for this descriptive case study series if he/she had a history of strenuous and prolonged exercise involving the lower extremity and had no abnormal neurological or medical conditions to explain the involuntary movements. Data was gathered from the medical history and a self-report questionnaire. The findings were compared to 14 cases previously reported in the literature. RESULTS: Seven cases (4M/3F) were identified with a diverse set of exercise triggers (cycling, hiking, long-distance running, drumming). The mean age of symptom onset was 53.7 ± 6.1 years. The median symptom duration prior to diagnosis was 4 (9.5) years. Several patients underwent unnecessary procedures prior to being appropriately diagnosed. Over a median of 2 (3.5) years, signs and symptoms progressed to impair walking. Seven patients had improvement in gait with treatment (e.g. botulinum toxin injections, benzodiazepines, physical therapy, bracing, body weight supported gait training and/or functional electrical stimulation of the peroneal nerve) and six returned to a reduced intensity exercise routine. CONCLUSIONS: Isolated lower extremity dystonia associated with strenuous, repetitive exercise is relatively uncommon, but disabling and challenging to treat. The pathophysiology may be similar to task-specific focal dystonias of the upper limb. Prompt recognition of leg dystonia associated with extreme exercise could minimize unnecessary testing and procedures, and facilitate earlier treatment.

Neural plasticity and implications for hand rehabilitation after neurological insult.

Experience dependent plasticity refers to ability of the brain to adapt to new experiences by changing its structure and function. The purpose of this paper is to provide a brief review the neurophysiological and structural correlates of neural plasticity that occur during and following motor learning. We also consider that the extent of plastic reorganization is dependent upon several key principals and that the resulting behavioral consequences can be adaptive or maladaptive. In light of this research, we conclude that an increased understanding of the complexities of brain plasticity will translate into enhanced treatment opportunities for the clinician to optimize hand function.

Kinematic data analysis for post-stroke patients following bilateral versus unilateral rehabilitation with an upper limb wearable robotic system.

Robot-assisted stroke rehabilitation has become popular as one approach to helping patients recover function post-stroke. Robotic rehabilitation requires four important elements to match the robot to the patient: realistic biomechanical robotic elements, an assistive control scheme enabled through the human-robot interface, a task oriented rehabilitation program based on the principles of plasticity, and objective assessment tools to monitor change. This paper reports on a randomized clinical trial utilizing a complete robot-assisted rehabilitation system for the recovery of upper limb function in patients post-stroke. In this study, a seven degree-of-freedom (DOF) upper limb exoskeleton robot (UL-EXO7) is applied in a rehabilitation clinical trial for patients stable post-stroke (greater than six months). Patients had a Fugl-Meyer Score between 16-39, were mentally alert (> 19 on the VA Mini Mental Status Exam) and were between 27 and 70 years of age. Patients were randomly assigned to three groups: bilateral robotic training, unilateral robotic training, and usual care. This study is concerned with the changes in kinematics in the two robotic groups. Both patient groups played eight therapeutic video games over 12 sessions (90 min, two times a week). In each session, patients intensively played the different combination of video games that directly interacted with UL-EXO7 under the supervision of research assistant. At each session, all of the joint angle data was recorded for the evaluation of therapeutic effects. A new assessment metric is reported along with conventional metrics. The experimental result shows that both groups of patients showed consistent improvement with respect to the proposed and conventional metrics.

Neurorehabilitation: motor recovery after stroke as an example.

The field of neurorehabilitation aims to translate neuroscience research toward the goal of maximizing functional recovery after neurological injury. A growing body of research indicates that the fundamental principles of neurological rehabilitation are applicable to a broad range of congenital, degenerative, and acquired neurological disorders. In this perspective, we will focus on motor recovery after acquired brain injuries such as stroke. Over the past few decades, a large body of basic and clinical research has created an experimental and theoretical foundation for approaches to neurorehabilitation. Recent randomized clinical trials all emphasize the requirement for intense progressive rehabilitation programs to optimally enhance recovery. Moreover, advances in multimodal assessment of patients with neuroimaging and neurophysiological tools suggest the possibility of individualized treatment plans based on recovery potential. There are also promising indications for medical as well as noninvasive brain stimulation paradigms to facilitate recovery. Ongoing or planned clinical studies should provide more definitive evidence. We also highlight unmet needs and potential areas of research. Continued research built upon a robust experimental and theoretical foundation should help to develop novel treatments to improve recovery after neurological injury.

Aberrant Oscillatory Activity during Simple Movement in Task-Specific Focal Hand Dystonia.

In task-specific focal hand dystonia (tspFHD), the temporal dynamics of cortical activity in the motor system and how these processes are related to impairments in sensory and motor function are poorly understood. Here, we use time-frequency reconstructions of magnetoencephalographic (MEG) data to elaborate the temporal and spatial characteristics of cortical activity during movement. A self-paced finger tapping task during MEG recording was performed by 11 patients with tspFHD and 11 matched healthy controls. In both groups robust changes in beta (12-30 Hz) and high gamma (65-90 Hz) oscillatory activity were identified over sensory and motor cortices during button press. A significant decrease [p < 0.05, 1% False Discovery Rate (FDR) corrected] in high gamma power during movements of the affected hand was identified over ipsilateral sensorimotor cortex in the period prior to (-575 ms) and following (725 ms) button press. Furthermore, an increase (p < 0.05, 1% FDR corrected) in beta power suppression following movement of the affected hand was identified over visual cortex in patients with tspFHD. For movements of the unaffected hand, a significant (p < 0.05, 1% FDR corrected) increase in beta power suppression was identified over secondary somatosensory cortex (S2) in the period following button press in patients with tspFHD. Oscillatory activity within in the tspFHD group was however not correlated with clinical measures. Understanding these aberrant oscillatory dynamics can provide the groundwork for interventions that focus on modulating the timing of this activity.

Mobility training using a bionic knee orthosis in patients in a post-stroke chronic state: a case series.

INTRODUCTION: An emerging area of neurorehabilitation is the use of robotic devices to enhance the efficiency and effectiveness of lower extremity physical therapy post-stroke. Many of the robotic devices currently available rely on computer-driven locomotive algorithms combined with partial bodyweight-supported treadmill training that drive reflex stepping with minimal patient intention during therapy. In this case series, we examined the effect of task-oriented mobility training in patients in a post-stroke chronic state using a novel, wearable, mobile, intention-based robotic leg orthosis. CASE PRESENTATION: Three individuals, all of whom had reached a plateau with conventional bodyweight-supported treadmill training, participated in task-oriented mobility therapy (1.5 hours, two to four times per week for four weeks) with a robotic leg orthosis under supervision by a physical therapist. Participant 1 was a 59-year-old Caucasian man, who had an ischemic left stroke six years previously with resultant right hemiparesis. Participant 2 was a 42-year-old Caucasian woman with left hemiparesis after a right stroke 15 months previously. Participant 3 was a 62-year-old Caucasian woman with a history of a right middle cerebral artery aneurysm with third degree sub-arachnoid hemorrhage 10 years ago.Immediately after training, all participants demonstrated improved gait speed (10 meter walk), stride length and walking endurance (6 minute walk) compared with baseline measurements. Improvements were maintained one month after training. Timed up and go and five times sit-to-stand were maintained for all three participants, with only one individual remaining outside the safety performance norm. CONCLUSIONS: Lower extremity training integrating an intention-based robotic leg orthosis may improve gait speed, endurance and community levels of participation in select patients in a post-stroke chronic state after plateauing within a bodyweight-supported treadmill training program. The wearable, mobile assistive robotic device safely supplemented supervised physical therapy including mobility and balance skill training.

Resting state α-band functional connectivity and recovery after stroke.

After cerebral ischemia, disruption and subsequent reorganization of functional connections occur both locally and remote to the lesion. However, the unpredictable timing and extent of sensorimotor recovery reflects a gap in understanding of these underlying neural mechanisms. We aimed to identify the plasticity of alpha-band functional neural connections within the perilesional area and the predictive value of functional connectivity with respect to motor recovery of the upper extremity after stroke. Our results show improvements in upper extremity motor recovery in relation to distributed changes in MEG-based alpha band functional connectivity, both in the perilesional area and contralesional cortex. Motor recovery was found to be predicted by increased connectivity at baseline in the ipsilesional somatosensory area, supplementary motor area, and cerebellum, contrasted with reduced connectivity of contralesional motor regions, after controlling for age, stroke onset-time and lesion size. These findings support plasticity within a widely distributed neural network and define brain regions in which the extent of network participation predicts post-stroke recovery potential.

Redundancy resolution of the human arm and an upper limb exoskeleton.

The human arm has 7 degrees of freedom (DOF) while only 6 DOF are required to position the wrist and orient the palm. Thus, the inverse kinematics of an human arm has a nonunique solution. Resolving this redundancy becomes critical as the human interacts with a wearable robot and the inverse kinematics solution of these two coupled systems must be identical to guarantee an seamless integration. The redundancy of the arm can be formulated by defining the swivel angle, the rotation angle of the plane defined by the upper and lower arm around a virtual axis that connects the shoulder and wrist joints. Analyzing reaching tasks recorded with a motion capture system indicates that the swivel angle is selected such that when the elbow joint is flexed, the palm points to the head. Based on these experimental results, a new criterion is formed to resolve the human arm redundancy. This criterion was implemented into the control algorithm of an upper limb 7-DOF wearable robot. Experimental results indicate that by using the proposed redundancy resolution criterion, the error between the predicted and the actual swivel angle adopted by the motor control system is less then 5°.

Diagnosis and management of focal hand dystonia in a rheumatology practice.

PURPOSE OF REVIEW: This article reviews current evidence on etiology, diagnosis and clinical management of patients with a challenging movement disorder referred to as focal hand dystonia (FHd). RECENT FINDINGS: Patients who present to a rhematologist with a history of repetitive overuse, weakness, pain and involuntary, end-range posturing of the digits when performing a target task may have FHd. The etiology is considered idiopathic and multifactorial. There are no specific laboratory or clinical tests to 'rule in' or 'rule out' the diagnosis. Comparative neuroimaging studies report inadequate inhibition and aberrant sensory and motor processing in patients with FHd. This movement disorder can be recalcitrant to recovery. Current research evidence supports the benefit of quieting muscle contractions with botulinum toxin injections, modifying ergonomics, performance biomechanics, lifestyle, stress, health, personality and practice behaviors and simultaneously beginning a progressive brain-retraining program. SUMMARY: Rheumatologist can facilitate effective management of patients with FHd by making an early, accurate diagnosis, providing patient education about the etiology and risk factors associated with the disorder, managing medications and identifying a team to oversee learning-based sensory and motor retraining.

Robotic Rehabilitation Game Design for Chronic Stroke.

OBJECTIVE: This study investigates games intended for use with an upper-limb exoskeleton robot operated unilaterally and bilaterally. Games are evaluated in terms of usability and preference for stroke survivors. Game design considerations relating to the human to machine interface, are also discussed. SUBJECTS AND METHODS: Ten hemiparetic stroke survivors completed 12 90-minute sessions using an upper-limb robotic exoskeleton unilaterally and bilaterally. During the sessions subjects played seven different games designed for rehabilitation. At the conclusion of their sessions subjects completed an 83-question survey. RESULTS: Subjects preferred static games to dynamic games. Preferred games elicited greater effort. CONCLUSIONS: Intermediate goals in addition to ultimate goals should be set with both static and dynamic games such that even with the patient's limited range of motion, speed, or coordination, the game should be playable and provide a sense of accomplishment to the patient. Marking the games' ultimate goals that can be accomplished only by healthy subjects, such as range of motion and workspace, provide references and encouragement to the patient for improving motor control and performance through the process of playing the game.

Amplitude and timing of somatosensory cortex activity in task-specific focal hand dystonia.

OBJECTIVE: Task-specific focal hand dystonia (tspFHD) is a movement disorder diagnosed in individuals performing repetitive hand behaviors. The extent to which processing anomalies in primary sensory cortex extend to other regions or across the two hemispheres is presently unclear. METHODS: In response to low/high rate and novel tactile stimuli on the affected and unaffected hands, magnetoencephalography (MEG) was used to elaborate activity timing and amplitude in the primary somatosensory (S1) and secondary somatosensory/parietal ventral (S2/PV) cortices. MEG and clinical performance measures were collected from 13 patients and matched controls. RESULTS: Compared to controls, subjects with tspFHD had increased response amplitude in S2/PV bilaterally in response to high rate and novel stimuli. Subjects with tspFHD also showed increased response latency (low rate, novel) of the affected digits in contralateral S1. For high rate, subjects with tspFHD showed increased response latency in ipsilateral S1 and S2/PV bilaterally. Activation differences correlated with functional sensory deficits (predicting a latency shift in S1), motor speed and muscle strength. CONCLUSIONS: There are objective differences in the amplitude and timing of activity for both hands across contralateral and ipsilateral somatosensory cortex in patients with tspFHD. SIGNIFICANCE: Knowledge of cortical processing abnormalities across S1 and S2/PV in dystonia should be applied towards the development of learning-based sensorimotor interventions.