Posts Tagged Hemiparetic

[ARTICLE] A novel generation of wearable supernumerary robotic fingers to compensate the missing grasping abilities in hemiparetic upper limb – Full Text PDF


This contribution will focus on the design, analysis, fabrication, experimental characterization and evaluation of a family of prototypes of robotic extra fingers that can be used as grasp compensatory devices for hemiparetic upper limb.

The devices are the results of experimental sessions with chronic stroke patients and consultations with clinical experts. All the devices share a common principle of work which consists in opposing to the paretic hand/wrist so to restrain the motion of an object.

Robotic supernumerary fingers can be used by chronic stroke patients to compensate for grasping in several Activities of Daily Living (ADL) with a particular focus on bimanual tasks.

The devices are designed to be extremely portable and wearable. They can be wrapped as bracelets when not being used, to further reduce the encumbrance. The motion of the robotic devices can be controlled using an Electromyography (EMG) based interface embedded in a cap. The interface allows the user to control the device motion by contracting the frontalis muscle. The performance characteristics of the devices have been measured through experimental set up and the shape adaptability has been confirmed by grasping various objects with different shapes. We tested the devices through qualitative experiments based on ADL involving a group of chronic stroke patients in collaboration with by the Rehabilitation Center of the Azienda Ospedaliera Universitaria Senese.

The prototypes successfully enabled the patients to complete various bi-manual tasks. Results show that the proposed robotic devices improve the autonomy of patients in ADL and allow them to complete tasks which were previously impossible to perform.

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[Abstract] Design and Test of a Closed-Loop FES System for Supporting Function of the Hemiparetic Hand Based on Automatic Detection Using the Microsoft Kinect Sensor

This paper describes the design of a FES system automatically controlled in a closed loop using a Microsoft Kinect sensor, for assisting both cylindrical grasping and hand opening. The feasibility of the system was evaluated in real-time in stroke patients with hand function deficits. A hand function exercise was designed in which the subjects performed an arm and hand exercise in sitting position. The subject had to grasp one of two differently sized cylindrical objects and move it forward or backwards in the sagittal plane. This exercise was performed with each cylinder with and without FES support. Results showed that the stroke patients were able to perform up to 29% more successful grasps when they were assisted by FES. Moreover, the hand grasp-and-hold and hold-and-release durations were shorter for the smaller of the two cylinders. FES was appropriately timed in more than 95% of all trials indicating successful closed loop FES control. Future studies should incorporate options for assisting forward reaching in order to target a larger group of stroke patients.

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[Abstract] Effect of Close Kinematic Chain Exercises on Upper Limb Spasticity in Hemiparetic Adult


Background: As upper limb spasticity is the major hindrance in quality of life in hemiparesis, this project emphasizes on the effect of close kinematic chain exercises on upper limb spasticity. So, the present study was conducted to find out the effect combined effect of conventional exercises with close kinematic chain exercises on spasticity.

Method: Comparative study was conducted at Krishna College of Physiotherapy, Karad.20 subjects with age group between 40–60 years were taken. Participants of Group A (10) were treated with close kinematic chain exercises along with conventional treatment & GroupB(10)only with conventional treatment. Exclusion criteria of the study was: 1. Associated psychological disorder. 2. Perceptual disorders. 3. Any visual & auditory impairment. 4. Any orthopaedic disorder.

Results: Statistical analysis was done using paired, unpaired ”t’’test, Mann Whitney test and Friedman statistics. The results showed statistically significant reduction in spasticity in group A as compared to group B (p<0.001).

Conclusion: The study shows that close kinematic chain exercises helps in normalizing tone, reducing spasticity in upper extremity hemiparesis.

Source: Indian Journals

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[ARTICLE] Late physiotherapy rehabilitation changes gait patterns in post-stroke patients – Full Text PDF

Study aim: To determine whether a physiotherapy protocol improves the electromyographic activation (EA) during the hemiparetic gait in patients with delayed access to rehabilitation. Material and methods: 40 post-stroke patients underwent clinical evaluation and gait assessment at the time of admission and at the end of treatment.

Results: The anterior leg muscles tibialis anterior and rectus femoris had earlier onset (p = 0.0001).

Conclusion: Electromyographic findings showed altered patterns during the hemiparetic gait cycle, even in patients with delayed access to treatment.

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[ARTICLE] Dose-Dependent Effects of Abobotulinumtoxina (Dysport) on Spasticity and Active Movements in Adults With Upper Limb Spasticity: Secondary Analysis of a Phase 3 Study – Full Text



AbobotulinumtoxinA has beneficial effects on spasticity and active movements in hemiparetic adults with upper limb spasticity (ULS). However, evidence-based information on optimal dosing for clinical use is limited.


To describe joint-specific dose effects of abobotulinumtoxinA in adults with ULS.


Secondary analysis of a phase 3 study (NCT01313299).


Multicenter, international, double-blind, placebo-controlled clinical trial.


A total of 243 adults with ULS >6 months after stroke or traumatic brain injury, aged 52.8 (13.5) years and 64.3% male, randomized 1:1:1 to receive a single-injection cycle of placebo or abobotulinumtoxinA 500 U or 1000 U (total dose).


The overall effect of injected doses were assessed in the primary analysis, which showed improvement of angles of catch in finger, wrist, and elbow flexors and of active range of motion against these muscle groups. This secondary analysis was performed at each of the possible doses received by finger, wrist, and elbow flexors to establish possible dose effects.

Main Outcome Measures

Angle of arrest (XV1) and angle of catch (XV3) were assessed with the Tardieu scale, and active range of motion (XA).


At each muscle group level (finger, wrist, and elbow flexors) improvements in all outcome measures assessed (XV1, XV3, XA) were observed. In each muscle group, increases in abobotulinumtoxinA dose were associated with greater improvements in XV3 and XA, suggesting a dose-dependent effect.


Previous clinical trials have established the clinical efficacy of abobotulinumtoxinA by total dose only. The wide range of abobotulinumtoxinA doses per muscle groups used in this study allowed observation of dose-dependent improvements in spasticity and active movement. This information provides a basis for future abobotulinumtoxinA dosing recommendations for health care professionals based on treatment objectives and quantitative assessment of spasticity and active range of motion at individual joints.


Upper limb spasticity (ULS) is a common symptom after stroke and traumatic brain injury (TBI) and is associated with impaired self-care and additional burden of care [1-5]. Among several treatment strategies, guidelines recommend intramuscular botulinum toxin injections as a first-line treatment for adults with ULS [6-11].

Botulinum toxin type A (BoNT-A) injections may target upper extremity muscle groups from the shoulder, to decrease adductor and internal rotation tone, to the elbow, wrist, fingers, and thumb, to decrease flexor tone [12,13]. Specific muscle selection is based on the pattern of muscle overactivity, functional deficits, and patient goals [6]. These goals include increased passive and active range of motion, improved function (feeding and dressing), easier care (palmar and axillary hygiene), and reduction of pain [13].

Evidence-based information on optimal dosing for clinical use is relatively sparse. Dosing is not interchangeable between different BoNT-A products; therefore, improving our understanding of product-specific dosing will minimize confusion among injectors and improve the quality of patient care [13].

Among BoNT-A formulations, abobotulinumtoxinA (Dysport; Galderma Laboratories, LP, Fort Worth, TX) has been shown to decrease muscle tone (as measured by the Modified Ashworth Scale [MAS]) [13-17] and pain [18] and to facilitate goal attainment [19] in adults with ULS. A recent systematic review [13] of 12 randomized controlled trials (RCTs) in ULS concluded that abobotulinumtoxinA (total dose range, 500-1500 U) was generally well-tolerated, with “strong evidence” to support reduced muscle tone.

This paper presents the results of a secondary analysis from a recently published large international clinical trial, demonstrating improved active range of motion after abobotulinumtoxinA treatment in adults with hemiparesis and ULS >6 months after stroke or TBI [20]. This phase 3, randomized, double-blind, placebo-controlled study demonstrated that a total dose of either 500 U or 1000 U abobotulinumtoxinA injected in the upper extremity also resulted in decreased muscle tone and improvements in global physician-assessed clinical benefit compared with placebo.

Apart from a systematic measurement of active range of motion (XA) against finger, wrist, and elbow flexors, another unique aspect of the trial was the assessment of spasticity at the finger, wrist, and elbow flexor groups with the Tardieu scale (TS) [21,22]. The TS is a standardized evaluation used to assess the angle of arrest at slow speed (ie, passive range of motion, XV1) and the angle of catch at fast speed (XV3). The trial demonstrated improvements for finger, wrist, and elbow joints at week 4 in XV3 at both abobotulinumtoxinA doses and in XA at 1000 U; for the 500-U dose, improvements in XA were seen in the finger flexors. Both doses were associated with a favorable safety profile [20]. This analysis aims to provide a detailed description of improvements in spasticity and the active range of motion for individual muscle groups by dose and to provide information on muscle-specific dosing, which can be used in future recommendations for injectors.

Continue —> Dose-Dependent Effects of Abobotulinumtoxina (Dysport) on Spasticity and Active Movements in Adults With Upper Limb Spasticity: Secondary Analysis of a Phase 3 Study – ScienceDirect


Figure 1. Change from baseline of Tardieu scale parameters and of active range of motion week 4 postinjection in (A) extrinsic finger flexors, (B) wrist flexors, and (C) elbow flexors. Dose groups were as follows (lowest to highest dose): 500 U/non-PTMG, 500 U/PTMG, 1000 U/non-PTMG, and 1000 U/PTMG. Standard deviations and mean change from baseline values are detailed in Table 3. PTMG = primary targeted muscle group; XV1 = passive range of motion; XV3 = angle of catch at fast speed; XA = active range of motion.

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[ARTICLE] Upper Extremity Motor Impairments and Microstructural Changes in Bulbospinal Pathways in Chronic Hemiparetic Stroke – Full Text

Following hemiparetic stroke, precise, individuated control of single joints is often replaced by highly stereotyped patterns of multi-joint movement, or abnormal limb synergies, which can negatively impact functional use of the paretic arm. One hypothesis for the expression of these synergies is an increased dependence on bulbospinal pathways such as the rubrospinal (RubST) tract and especially the reticulospinal (RetST) tracts, which co-activate multiple muscles of the shoulder, elbow, wrist, and fingers. Despite indirect evidence supporting this hypothesis in humans poststroke, it still remains unclear whether it is correct. Therefore, we used high-resolution diffusion tensor imaging (DTI) to quantify white matter microstructure in relation to severity of arm synergy and hand-related motor impairments. DTI was performed on 19 moderately to severely impaired chronic stroke individuals and 15 healthy, age-matched controls. In stroke individuals, compared to controls, there was significantly decreased fractional anisotropy (FA) and significantly increased axial and radial diffusivity in bilateral corona radiata and body of the corpus callosum. Furthermore, poststroke, the contralesional (CL) RetST FA correlated significantly with both upper extremity (UE) synergy severity (r = −0.606, p = 0.003) and hand impairment (r = −0.609, p = 0.003). FA in the ipsilesional RubST significantly correlated with hand impairment severity (r = −0.590, p = 0.004). For the first time, we separately evaluate RetST and RubST microstructure in chronic stroke individuals with UE motor impairment. We demonstrate that individuals with the greatest UE synergy severity and hand impairments poststroke have the highest FA in the CL RetST a pattern consistent with increased myelination and suggestive of neuroplastic reorganization. Since the RetST pathway microstructure, in particular, is sensitive to abnormal joint coupling and hand-related motor impairment in chronic stroke, it could help test the effects of specific, and novel, anti-synergy neurorehabilitation interventions for recovery from hemiparesis.


Approximately 85% of stroke survivors experience significant motor impairment in the contralesional (CL) arm (1), which can include a loss of independent joint control (2, 3), weakness (4), and spasticity (5). After stroke, precise, individuated control of single joints is often replaced by highly stereotyped patterns of multi-joint movement caused by abnormal muscle co-activation patterns (6). The most prevalent of these patterns is the flexion synergy, which is characterized by an abnormal coupling of shoulder abduction and elbow, wrist, and finger flexion (7, 8). This impairment has a negative impact on reaching ability (9) and hand function (3, 10), both critical components of functional use of the arm during activities of daily living. Despite the debilitating nature of this motor impairment, the underlying neuropathophysiology is not fully understood.

One hypothesis for why the flexion synergy emerges is that following a reduction of corticofugal input from the lesioned hemisphere, there is an increased dependence on CL motor cortex and bulbospinal pathways, such as reticulospinal (RetST) and rubrospinal (RubST) tracts. Therefore, in the present study, we quantify microstructural properties in white matter of both the brain and the brainstem, focusing primarily on corticoreticulospinal and corticorubrospinal systems. We evaluate whether these microstructural properties increase in integrity in relation to arm synergy and hand impairment severity, which could be indicative of increased use.

Although the RetST was previously believed to be predominantly involved in gross movements, such as locomotion (11, 12) and posture (13, 14), recent work in primates suggests the RetST also influences the motor neurons that control forearm and intrinsic hand muscles (15). In the non-human primate, stimulation of the RetST produces ipsilateral wrist flexor, elbow flexor, and shoulder abductor activation (16), mirroring the flexion synergy pattern observed in humans poststroke. Furthermore, stimulating the RetST after a corticospinal tract (CST) lesion elicits increased excitatory post-synaptic potentials in motoneurons innervating the forearm flexor and intrinsic hand muscles (17). This evidence makes the contralesional corticoreticulospinal system a compelling candidate for underlying abnormal joint coupling in humans with hemiparetic stroke.

In the non-human primate, the RubST also contributes to reaching and grasping movements (18) and has been shown to be important in recovery of hand function after CST damage (19, 20). One study showed that increased white matter integrity in bilateral red nucleus (RN) correlated with worse clinical outcomes in humans with chronic stroke (21); however, the RubST has been reported as relatively insignificant in humans (22, 23). The evidence for whether the RetST and the RubST contribute to abnormal joint coupling and hand impairment in humans poststroke still remains indirect and inconclusive.

We used high-resolution diffusion tensor imaging (DTI) (24) tract-based spatial statistics (TBSS) (25) to perform a voxel-wise comparison of white matter microstructure between stroke and control individuals. We analyzed fractional anisotropy (FA), a measurement typically associated with tract integrity, as well as axial diffusivity (AD) and radial diffusivity (RD), which represent diffusion parallel and perpendicular to the principle direction of diffusion, respectively. Because previous studies have reported altered diffusion properties in lesioned tissue (2628), we excluded potential lesion-compromised voxels from our TBSS analysis to assess changes in normal-appearing white matter. We used the TBSS-derived white matter skeleton to investigate whether microstructural tissue properties within specific regions of the brainstem (CST, RetST, RubST) and subcortical white matter within CL motor areas [primary motor area (M1), premotor area (PM), supplementary motor area (SMA), body of the corpus callosum] are sensitive to upper extremity (UE) motor impairment in chronic stroke individuals.

We evaluated UE motor impairment using the Fugl-Meyer Assessment (FMA), a stroke-specific, performance-based motor impairment index, which measures impairments, such as loss of independent joint function, stretch reflex hyper-excitability, and altered sensation (29). It is one of the most widely used clinical scales of motor impairment poststroke (30). While previous studies have looked at diffusion MRI metrics in relation to the entire FMA score (31, 32), we used only the UE measurements of arm synergies and hand function to determine whether microstructural properties in specific white matter regions of interest (ROIs) were correlated.

In the present study, we hypothesized that microstructural integrity in specific regions of the extrapyramidal brainstem would be increased in chronic stroke in a manner sensitive to synergy and hand-related impairment severity. We demonstrate a significant decrease in FA in bilateral corona radiata and body of the corpus callosum in chronic stroke when compared to controls; however, within stroke subjects, specific brainstem regions show the highest FA in individuals with the most synergy-driven arm and hand impairment. More precisely, we describe the relation between CL RetST integrity and both expression of synergy and hand impairment and between ipsilesional (IL) RubST integrity and hand impairment in chronic hemiparetic stroke individuals.[…]

Continue —> Frontiers | Upper Extremity Motor Impairments and Microstructural Changes in Bulbospinal Pathways in Chronic Hemiparetic Stroke | Neurology

Figure 1. Region of interest masks in Montreal Neurological Institute’s space. (A) Primary motor area (red), supplementary motor area (green), premotor area (blue), (B) body of the corpus callosum (light blue), (C) horizontal midbrain cross-section showing cerebral peduncle (CP) portion of the corticospinal tract (yellow) and red nucleus (RN) (red), (D) horizontal pontine cross-section showing reticular formation (RF) (green), and (E) sagittal brainstem showing RF including reticulospinal (green) and RN including rubrospinal tracts (red).

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[Abstract] The Impact of Shoulder Abduction Loading on Volitional Hand Opening and Grasping in Chronic Hemiparetic Stroke

Background. Up to 60% of individuals with moderate to severe chronic hemiparetic stroke experience excessive involuntary wrist/finger flexion that constrains functional hand movements including hand opening. It’s not known how stroke-induced brain injury impacts volitional hand opening and grasping forces as a result of the expression of abnormal coupling between shoulder abduction and wrist/finger flexion or the flexion synergy.

Objective. The goal of this study is to understand how shoulder abduction loading affects volitional hand opening and grasping forces in individuals with moderate to severe chronic hemiparetic stroke.

Methods. Thirty-six individuals (stroke, 26; control, 10) were recruited for this study. Each participant was instructed to perform maximal hand opening and grasping forces while the arm was either fully supported or lifted with a weight equal to 25% or 50% of the participant’s maximal shoulder abduction torque. Hand pentagon area, defined as the area formed by the tips of thumb and fingers, was calculated during hand opening. Forces were recorded during grasping.

Results. In individuals with moderate stroke, increasing shoulder abduction loading reduced the ability to maximally open the hand. In individuals with severe stroke, who were not able to open the hand, grasping forces were generated and increased with shoulder abduction loading. Stroke individuals also showed a reduced ability to control volitional grasping forces due to the enhanced expression of flexion synergy.

Conclusions. Shoulder abduction loading reduced the ability to volitionally open the hand and control grasping forces after stroke. Neural mechanisms and clinical implications of these findings are discussed.

Source: The Impact of Shoulder Abduction Loading on Volitional Hand Opening and Grasping in Chronic Hemiparetic Stroke – Mar 08, 2017

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[ARTICLE] Validity of gait asymmetry estimation by using an accelerometer in individuals with hemiparetic stroke – Full Text PDF


[Purpose] The purpose of this study was to evaluate the validity of estimating step time and length asymmetries, using an accelerometer against force plate measurements in individuals with hemiparetic stroke.

[Subjects and Methods] Twenty-four individuals who previously had experienced a stroke were asked to walk without using a cane or manual assistance on a 16-m walkway. Step time and length were measured using force plates, which is the gold standard for assessing gait asymmetry. In addition to ground reaction forces, trunk acceleration was simultaneously measured using an accelerometer. To estimate step time asymmetry using accelerometer data, the time intervals between forward acceleration peaks for each leg were calculated. To estimate step length asymmetry using accelerometer data, the integration of the positive vertical accelerations following initial contact of each leg was calculated. Asymmetry was considered the affected side value divided by the unaffected side value.

[Results] Significant correlations were found between the accelerometer and the force plates for step time and length asymmetries (rho=0.83 and rho=0.64, respectively).

[Conclusion] An accelerometer might be useful for assessing step time and length asymmetries in individuals with hemiparetic stroke, although improvements are needed for estimating the accuracy of step length asymmetry.

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[WEB SITE] ReGrasp by Rehabtronics

The ReGrasp FES hand stimulator system is the most state-of-the-art hand stimulator available.

more —>: ReGrasp by Rehabtronics

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[ARTICLE] Effect of home-based training using a slant board with dorsiflexed ankles on walking function in post-stroke hemiparetic patients – Full Text PDF


[Purpose] To investigate the effects of a 30-day rehabilitation program using a slant board on walking function in post-stroke hemiparetic patients.

[Subjects and Methods] Six hemiparetic patients with gait disturbance were studied. The patients were instructed to perform a home-based rehabilitation program using a slant board, thrice daily for 30 days, the exercise included standing on the slant board for 3 minutes, with both ankles dorsiflexed without backrest. For all patients, the Brunnstrom Recovery Stage, Barthel Index, range of motion of the ankle joint, modified Ashworth scale scole for calf muscle, sensory impairments with Numeral Rating Scale, maximum walking speed, number of steps, and Timed “Up and Go” test were serially evaluated at the beginning and end of the 30-day program.

[Results] The program significantly increased walking velocity, decreased the number of steps in the 10-m walking test, and decreased Timed “Up and Go” test performance time.

[Conclusion] This rehabilitation program using the slant board was safe and improved walking function in patients. The improvement in walking function could be due to a forward shift of the center of gravity, which can be an important part of motor learning for gait improvement.

Fig. 1. The slant board used in this study The slant angle was set at 20 degrees

Stroke is a leading cause of long-term disability, and the absolute number of patients with stroke is increasing. Of the neurological sequelae that cause functional disability, hemiparesis is the most common. The incidence of gait disturbance due to hemiparesis is reportedly relatively high among chronic stroke patients1, 2). The occurrence of this disability leads to marked impairment of quality of life and the sense of well-being3, 4). In addition, the burden of caregivers is anticipated to increase when patients are in need of assistance for walking5). Improved walking ability is one of the most common goals for post-stroke hemiparetic patients6, 7). A slant board has been used as a therapeutic device for patients with spastic lower hemiparesis. Standing on the toe-up inclination surface stretches the calf muscles, which reduces the pathologically increased lower limb muscle tone in post-stroke hemiparetic patients. Standing without a back rest on the slant board can produce a forward shift in the center of pressure in healthy adults and hemiparetic patients, as reported in our previous study. Kluzak reported that standing on an inclined surface resulted in an after-effect of learning in healthy, blindfolded subjects when they returned to standing on a horizontal surface8). Subjects leaned forward after they stood on a toes-up inclination surface. Recent reports described other benefits of using the board in healthy adults and hemiparetic patients, such as movement of “center of pressure”9), and possible increase in the maximum range of “center of gravity” in the antero-posterior direction10).
Neurophysiological studies have also demonstrated increased contraction of the anterior tibialis muscle in healthy subjects standing on the slant board11). Daily home-based rehabilitation using the slant board was hypothesized to improve gait in post-stroke hemiparetic patients. To test the hypothesis, the present study investigated the effects of a 30-day home-based daily rehabilitation program using the slant board on walking function in post-stroke hemiparetic patients.

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