Posts Tagged Motor function

[ARTICLE] Including a Lower-Extremity Component during Hand-Arm Bimanual Intensive Training does not Attenuate Improvements of the Upper Extremities: A Retrospective Study of Randomized Trials – Full Text

Hand-Arm Bimanual Intensive Therapy (HABIT) promotes hand function using intensive practice of bimanual functional and play tasks. This intervention has shown to be efficacious to improve upper-extremity (UE) function in children with unilateral spastic cerebral palsy (USCP). In addition to UE function deficits, lower-extremity (LE) function and UE–LE coordination are also impaired in children with USCP. Recently, a new intervention has been introduced in which the LE is simultaneously engaged during HABIT (Hand-Arm Bimanual Intensive Therapy Including Lower Extremities; HABIT-ILE). Positive effects of this therapy have been demonstrated for both the UE and LE function in children with USCP. However, it is unknown whether the addition of this constant LE component during a bimanual intensive therapy attenuates UE improvements observed in children with USCP. This retrospective study, based on multiple randomized protocols, aims to compare the UE function improvements in children with USCP after HABIT or HABIT-ILE. This study included 86 children with USCP who received 90 h of either HABIT (n = 42) or HABIT-ILE (n = 44) as participants in previous studies. Children were assessed before, after, and 4–6 months after intervention. Primary outcomes were the ABILHAND-Kids and the Assisting Hand Assessment. Secondary measures included the Jebsen-Taylor Test of Hand Function, the Pediatric Evaluation of Disability Inventory [(PEDI); only the self-care functional ability domain] and the Canadian Occupational Performance Measure (COPM). Data analysis was performed using two-way repeated-measures analysis of variance with repeated measures on test sessions. Both groups showed similar, significant improvements for all tests (test session effect p < 0.001; group × test session interaction p > 0.05) except the PEDI and COPM. Larger improvements on these tests were found for the HABIT-ILE group (test session effect p < 0.001; group × test session interaction p < 0.05). These larger improvements may be explained by the constant simultaneous UE–LE engagement observed during the HABIT-ILE intervention since many daily living activities included in the PEDI and the COPM goals involve the LE and, more specifically, UE–LE coordination. We conclude that UE improvements in children with USCP are not attenuated by simultaneous UE–LE engagement during intensive intervention. In addition, systematic LE engagement during bimanual intensive intervention (HABIT-ILE) leads to larger functional improvements in activities of daily living involving the LE.


Cerebral palsy (CP) is the most common cause of pediatric motor disability with a prevalence ranging from 2 to 3.6 out of 1,000 children in western countries (12). Motor disorders are often accompanied by sensation, perception, cognition, behavior, communication, and epilepsy disorders (1). Although the lesions are established from birth and are non-progressive, the motor impairments experienced by children with CP affect their autonomy and functional outcomes during their life-span. Moreover, motor symptoms such as impaired ability to walk may worsen during development (3).

One of the most disabling long-term functional deficits in children with unilateral spastic cerebral palsy (USCP) is impaired manual dexterity, i.e., impaired skilled hand movements and precision grip abilities (4). Upper-extremity (UE) impairments may affect functional independence, especially for activities of daily living requiring bimanual coordination (e.g., buttoning one’s shirt). It is now well known that intensive interventions based on motor skill learning principles and goal-directed training are effective for improving UE function in children with USCP (5). Constraint-Induced Movement Therapy (CIMT) was the first intensive intervention adapted to children with USCP (6). CIMT was first designed for adults with stroke and subsequently adapted to children with USCP showing improvements in hand function (5). Taking advantage of the key ingredient of CIMT (intensive practice with the affected UE), Charles and Gordon developed an alternative intensive bimanual approach termed “Hand-Arm Bimanual Intensive Therapy” (HABIT) (7). HABIT was developed with recognition that the combined use of both hands was necessary to increase functional independence in children with USCP (7). Focusing on improving bimanual coordination through structured play and functional activities during HABIT demonstrated efficacy to improve UE function in children with USCP (5).

Both HABIT and CIMT focus only on the UE of children with USCP. Though the lower extremity (LE) is generally less affected than UE in children with USCP, impairments observed in the affected LE range from an isolated equine ankle to hip flexion and adduction with a fixed knee (8). Children with USCP are then unable to achieve postural symmetry while standing, systematically presenting with an overload on one bodyside (8). They also frequently encounter limitations in walking abilities (3). Besides the LE impairments, UE–LE coordination is often impaired in children with USCP (910). This coordination is frequently used in daily living activities (e.g., walking while carrying an object in the hand, climbing stairs while using the railing). A program that simultaneously trains the UE and LE in children with USCP is thus of interest since the UE impairments in children with CP remain stable through time (11) while walking and other LE abilities may decline during development (3). In 2014, taking advantage of the key ingredients in HABIT (intensive bimanual practice), Bleyenheuft and Gordon developed a new intervention focusing on both the UE and LE entitled “Hand-Arm Bimanual Intensive Therapy Including Lower Extremities” (HABIT-ILE) (12). Positive effects of this therapy focusing on both the UE and LE through structured play and functional activities have been demonstrated both for the UE and the LE of children with USCP (13) as well as, more recently, for children with bilateral CP (14). However, it is unknown whether the introduction of a systematic LE engagement in addition to a bimanual intervention may lead to attenuated improvements in UE compared to traditional HABIT due to shifts in attention (multitasking). This retrospective study aimed to compare changes in the UE of children with USCP undergoing 90 h of intensive bimanual intervention either with (HABIT-ILE) or without (HABIT) a LE component. We hypothesized that the introduction of systematic LE training simultaneously added to the bimanual training would lead to reduced improvements in the UE during HABIT-ILE compared to traditional HABIT. […]

Continue —> Frontiers | Including a Lower-Extremity Component during Hand-Arm Bimanual Intensive Training does not Attenuate Improvements of the Upper Extremities: A Retrospective Study of Randomized Trials | Neurology


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[ARTICLE] Transcranial direct current stimulation as a motor neurorehabilitation tool: an empirical review – Full Text


The present review collects the most relevant empirical evidence available in the literature until date regarding the effects of transcranial direct current stimulation (tDCS) on the human motor function. tDCS in a non-invasive neurostimulation technique that delivers a weak current through the brain scalp altering the cortical excitability on the target brain area. The electrical current modulates the resting membrane potential of a variety of neuronal population (as pyramidal and gabaergic neurons); raising or dropping the firing rate up or down, depending on the nature of the electrode and the applied intensity. These local changes additionally have shown long-lasting effects, evidenced by its promotion of the brain-derived neurotrophic factor. Due to its easy and safe application and its neuromodulatory effects, tDCS has attracted a big attention in the motor neurorehabilitation field among the last years. Therefore, the present manuscript updates the knowledge available about the main concept of tDCS, its practical use, safety considerations, and its underlying mechanisms of action. Moreover, we will focus on the empirical data obtained by studies regarding the application of tDCS on the motor function of healthy and clinical population, comprising motor deficiencies of a variety of pathologies as Parkinson’s disease, stroke, multiple sclerosis and cerebral palsy, among others. Finally, we will discuss the main current issues and future directions of tDCS as a motor neurorehabilitation tool.


The central nervous system (CNS) works thanks to the communication between more than 100,000 millions of neurons, whose activity and networking is modulated by chemical and electrical processes [1]. Across history, humans have been trying to alter the electrical brain processes to enhance human’s brain function, for the treatment of psychopathologies and for a better understanding of the brain physiology. For example, in the antiquity, modulation of the electrical processes of the brain started with the use of electrical impulses of torpedo fishes applied directly on the CNS, for therapeutic purposes [2]. In 1746, Musschenbroek (1692–1761) used Leyde jars and electrostatic devices to treat neuralgia, contractures and paralysis. The discovery of biometallic electricity and the invention of the voltaic battery augmented the interest in the therapeutic effects of galvanism. Afterwards, Duchenne de Boulogne (1806–1875) upgraded the electrotherapy with volta and magnetofaradaic apparatuses. Fortunately, in the past Century, the technological advances and its integration in health sciences have let us go from uncontrolled and unsafe interventions with side effects to well-controlled, more effective and safe stimulation devices [3].

Currently, the most used stimulation devices can be divided into invasive techniques, such as deep brain stimulation (DBS), and non-invasive brain stimulation (NiBS) techniques, whose most representative methods are transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) [4].

Although results are variable [5], DBS has reported positive results over the motor function, especially on the motor symptoms of Parkinson’s disease. However, DBS is a technique that needs the implantation of the electrodes on the stimulated area, which is associated with the typical risk derived from surgery, as infections. Therefore, there is an increasing tendence on the search for non-invasive brain stimulation techniques, which can modulate the motor function avoiding those risks.

Hence, NiBS are characterized for its easy and safe use and relatively cheap price, demonstrating also successful results in the treatment of neurological and psychiatric alterations [4]. In the last decades, TMS has been the most researched and developed neuromodulation technique. TMS generates fast changes in the magnetic field delivering electrical currents through the brain, allowing the specific modulation of the cortical excitability through the initiation of action potentials [6]. Multiple studies have already shown its efficacy and safe use for the treatment of multiple pathologies [7], serving also as a useful tool for the functional location of brain areas, especially regarding the motor cortex [8, 9]. However, TMS requires the participation of the participant, and due to its functioning, it is difficult to perform a sham condition, which is highly desirable especially in the research field. In addition, TMS produces in most of the cases undesirable side-effects, as headache [10].

Therefore, the tDCS technique is attracting a strong interest in the neuroscience research field. tDCS has supposed a revolution in the last 15 years of research, solving most of the disadvantages of TMS [10]. tDCS is a neuromodulation tool consisting on a battery connected to two electrodes, the anode and cathode, which are placed directly over the brain scalp and over extracephalic regions. The current flows between both electrodes and induces the depolarization or hyperpolarization of the membrane of the underlying neurons, which depends of the anodal or cathodal nature of the electrode [11], altering the neuronal excitability resulting in the modification of the brain activity [12]. This device is completely portable, as it is provided by built-in rechargeable battery with duration of approximately 6 h stimulation time at 1 mA (0.5–1.5 W of power consumption), and needs approximately 7 h for complete recharging. In addition, including battery, it has a weight of 0.8 kg. Its portability is one of the biggest advantages of tDCS in the context of NiBS. Therefore, tDCS can be considered as a suitable complementary technique on motor rehabilitation therapy, allowing its application in different contexes, during the motor training and even combined with aerobic exercise [13, 14].

This non-invasive brain manipulation has opened the doors for a variety of potential treatments for the major neurological and psychiatry diseases [15], as depression [16], schizophrenia [17], Obsessive–Compulsive disorder [18] and addictions [19], among others.

However, motor functions are the major target for clinical and non-clinical studies regarding tDCS, serving mainly as a potential tool in post-stroke rehabilitation [20], but also in pathologies like Parkinson’s disease [21]. In addition, numerous studies have shown that tDCS produces changes in the brain plasticity processes, generating long-lasting effects that enhances even further its applicability in the neurorehabilitation field [22, 23].

The purpose of this review is to assess the current and future stage of tDCS regarding its use on the human motor function, identifying the empirical cues that point out its benefits as well as its potential limitation, providing a comprehensive framework for designing future research in the field of brain stimulation with tDCS and human motor rehabilitation. The present review is divided in four parts. The first part is based on a detailed definition on what we know about tDCS, the protocols of montage and parameters of stimulation, comprising the mechanisms of action of tDCS, what differs tDCS from other non-invasive neuromodulation techniques, and the main need to-know safety standards. Given the conciseness of this first part, we will present the recent studies focusing exclusively on the empirical data obtained from the use of tDCS in the human motor function, regarding, in the second part, healthy humans; in the third part, its clinical application on deteriorated human motor functions across different pathologies as Parkinson disease, stroke and cerebral palsy. Finally, in the fourth part of this review, we will discuss the main current issues of tDCS applied on the human motor function.[…]

Continue —> Transcranial direct current stimulation as a motor neurorehabilitation tool: an empirical review | BioMedical Engineering OnLine | Full Text

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[Abstract] Computer-aided prediction of extent of motor recovery following constraint-induced movement therapy in chronic stroke


Constraint-induced movement therapy (CI therapy) is a well-researched intervention for treatment of upper limb function. Overall, CI therapy yields clinically meaningful improvements in speed of task completion and greatly increases use of the more affected upper extremity for daily activities. However, individual improvements vary widely. It has been suggested that intrinsic feedback from somatosensation may influence motor recovery from CI therapy. To test this hypothesis, an enhanced probabilistic neural network (EPNN) prognostic computational model was developed to identify which baseline characteristics predict extent of motor recovery, as measured by the Wolf Motor Function Test (WMFT). Individual characteristics examined were: proprioceptive function via the brief kinesthesia test, tactile sensation via the Semmes-Weinstein touch monofilaments, motor performance captured via the 15 timed items of the Wolf Motor Function Test, stroke affected side. A highly accurate predictive classification was achieved (100% accuracy of EPNN based on available data), but facets of motor functioning alone were sufficient to predict outcome. Somatosensation, as quantified here, did not play a large role in determining the effectiveness of CI therapy.

Source: Computer-aided prediction of extent of motor recovery following constraint-induced movement therapy in chronic stroke – ScienceDirect

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[CORDIS Project] Motor Recovery with Paired Associative Stimulation (RecoveriX) – European Commission

Motor Recovery with Paired Associative Stimulation (RecoveriX)


Source: European Commission : CORDIS : Projects and Results : Motor Recovery with Paired Associative Stimulation (RecoveriX)

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[ARTICLE] AExaCTT – Aerobic Exercise and Consecutive Task-specific Training for the upper limb after stroke: Protocol for a randomised controlled pilot study – Full Text


Motor function may be enhanced if aerobic exercise is paired with motor training. One potential mechanism is that aerobic exercise increases levels of brain-derived neurotrophic factor (BDNF), which is important in neuroplasticity and involved in motor learning and motor memory consolidation. This study will examine the feasibility of a parallel-group assessor-blinded randomised controlled trial investigating whether task-specific training preceded by aerobic exercise improves upper limb function more than task-specific training alone, and determine the effect size of changes in primary outcome measures. People with upper limb motor dysfunction after stroke will be allocated to either task-specific training or aerobic exercise and consecutive task-specific training. Both groups will perform 60 hours of task-specific training over 10 weeks, comprised of 3 × 1 hour sessions per week with a therapist and 3 × 1 hours of home-based self-practice per week. The combined intervention group will also perform 30 minutes of aerobic exercise (70–85%HRmax) immediately prior to the 1 hour of task-specific training with the therapist. Recruitment, adherence, retention, participant acceptability, and adverse events will be recorded. Clinical outcome measures will be performed pre-randomisation at baseline, at completion of the training program, and at 1 and 6 months follow-up. Primary clinical outcome measures will be the Action Research Arm Test (ARAT) and the Wolf Motor Function Test (WMFT). If aerobic exercise prior to task-specific training is acceptable, and a future phase 3 randomised controlled trial seems feasible, it should be pursued to determine the efficacy of this combined intervention for people after stroke.

1. Introduction

1.1. Background

Currently 440,000 persons after stroke live in community settings in Australia [1]. Many with stroke experience chronic disability and although two-thirds receive care each day [1], the majority still have unmet needs [2]. Upper limb dysfunction is a persistent and disabling problem present in 69% of persons after stroke in Australia [3]. Upper limb dysfunction is a major contributor to poor well-being and quality-of-life [4]; [5]; [6] ;  [7]. Unsurprisingly, advancing treatments for upper limb recovery is a top ten research priority for persons after stroke and their carers [8].

In Australia, 87% of persons with stroke-attributable upper limb impairments receive task-specific training [3]. Task-specific training is a progressive training strategy that utilises practice of goal-directed, real-world, context-specific tasks that are intrinsically and/or extrinsically meaningful to the person, to enable them to undertake activities of daily living [9] and may improve upper limb motor function after stroke [9]; [10] ;  [11].

Improvements in motor function coincide with structural and functional reorganisation of the brain [12]; [13]; [14] ;  [15]. The brain’s ability to undergo these changes is denoted as neuroplasticity. Capitalisation and enhancement of neuroplasticity in peri-infarct and non-primary motor regions may promote recovery via an increased response to motor training and other neurorehabilitative interventions [16]; [17] ;  [18].

Many studies show that aerobic exercise (prolonged, rhythmical activity using large muscle groups to increase heart rate) enhances neuroplasticity [19], grey matter volume, white matter integrity [20]; [21] ;  [22] and brain activation [23]; [24] ;  [25]. Furthermore increasing evidence indicates that lower limb aerobic exercise increases upper limb motor function. A single bout of aerobic cycling exercise can improve long-term retention of a motor skill in healthy individuals [26], regardless of whether performed immediately before or after motor training [27].

Aerobic exercise increases BDNF [28]. Improvements in motor skill learning and memory induced by aerobic exercise have been associated with increased peripheral blood concentrations of BDNF [26]. BDNF is involved with neurogenesis [29] and neuroprotection [30] in the human brain [31], thereby playing an important role in stroke recovery, including facilitating functional upper limb motor rehabilitation [32].

In chronic stroke, an 8-week programme of lower extremity endurance cycling enhanced upper extremity fine motor control [33]. Also, a single bout of aerobic treadmill exercise improved grasp function of the hemiparetic hand [34]. As aerobic exercise alone can enhance motor function after stroke, motor learning in stroke rehabilitation may be facilitated if aerobic exercise is paired with motor training [35] ;  [36].

1.2. Aims and objectives

The aims of this study are to 1) assess the feasibility of conducting a randomised controlled trial to compare the effects of task-specific training preceded by aerobic exercise to task-specific training alone on upper limb motor function after stroke; and 2) calculate the effect size of changes in primary clinical outcome measures to evaluate proof-of-concept and inform calculation of sample size for a future phase III trial. This includes investigating potential neural correlates of exercise-induced motor function changes using peripheral blood serum BDNF measurement and multi-modal MRI.

2. Methods

2.1. Study design

This is a parallel-group assessor-blinded randomised controlled pilot study (Fig. 1). One group will undertake task-specific training alone and the other group will undertake 30 minutes of aerobic cycling exercise prior to their task-specific training. The interventions will be delivered by a therapist 3 days per week for 10 weeks. Both groups will be provided with an individually-prescribed task-specific training programme to practice at home for 60 minutes, 3 times per week. Assessments will be conducted at baseline, within 1 week from the end of intervention, and 1 and 6 months following the end of the intervention period. Ethics approval has been obtained from the Hunter New England Human Research Ethics Committee (14/12/10/4.07) and registered with the University of Newcastle Human Research Ethics Committee (H-2015-0105). The study is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12616000848404).

Continue —>  AExaCTT – Aerobic Exercise and Consecutive Task-specific Training for the upper limb after stroke: Protocol for a randomised controlled pilot study

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[Abstract] A Longitudinal EMG Study of Complex Upper-limb Movements in Post-stroke Therapy. 1: Heterogeneous EMG Changes despite Consistent Improvements in Clinical Assessments

Post-stroke weakness on the more-affected side may arise from reduced corticospinal drive, disuse muscle atrophy, spasticity, and abnormal co-ordination. This study investigated changes in muscle activation patterns to understand therapy-induced improvements in motor-function in chronic stroke compared to clinical assessments, and to identify the effect of motor-function level on muscle activation changes.

Electromyography (EMG) was recorded from 5 upper-limb muscles on the more-affected side of 24 patients during early- and late-therapy sessions of an intensive 14-day program of Wii-based Movement Therapy, and for a subset of 13 patients at 6-month follow-up. Patients were classified according to residual voluntary motor capacity with low, moderate or high motor-function. The area under the curve was calculated from EMG amplitude and movement duration. Clinical assessments of upper-limb motor-function pre- and post-therapy included the Wolf Motor Function Test, Fugl-Meyer Assessment and Motor Activity Log Quality of Movement scale.

Clinical assessments improved over time (p<0.01) with an effect of motor-function level (p<0.001). The pattern of EMG change by late-therapy was complex and variable, with differences between patients with low compared to moderate or high motor-function. The area under the curve (p=0.028) and peak amplitude (p=0.043) during Wii-tennis backhand increased for patients with low motor-function whereas EMG decreased for patients with moderate and high motor-function. The reductions included: movement duration during Wii-golf (p=0.048, moderate; p=0.026, high), and Wii-tennis backhand (p=0.046, moderate; p=0.023, high) and forehand (p=0.009, high); and the area under the curve during Wii-golf (p=0.018, moderate) and Wii-baseball (p=0.036, moderate). For the pooled data over time there was an effect of motor-function (p=0.016) and an interaction between time and motor-function (p=0.009) for Wii-golf movement duration. Wii-baseball movement duration decreased as a function of time (p=0.022). There was an effect on Wii-tennis forehand duration for time (p=0.002) and interaction of time and motor-function (p=0.005); and an effect of motor-function level on the area under the curve (p=0.034) for Wii-golf.

This study demonstrated different patterns of EMG changes according to residual voluntary motor-function levels despite heterogeneity within each level that was not evident following clinical assessments alone. Thus, rehabilitation efficacy might be underestimated by analyses of pooled data.

Source: Frontiers | A Longitudinal EMG Study of Complex Upper-limb Movements in Post-stroke Therapy. 1: Heterogeneous EMG Changes despite Consistent Improvements in Clinical Assessments | Neurology

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[Abstract] Music-based interventions in neurological rehabilitation


During the past ten years, an increasing number of controlled studies have assessed the potential rehabilitative effects of music-based interventions, such as music listening, singing, or playing an instrument, in several neurological diseases. Although the number of studies and extent of available evidence is greatest in stroke and dementia, there is also evidence for the effects of music-based interventions on supporting cognition, motor function, or emotional wellbeing in people with Parkinson’s disease, epilepsy, or multiple sclerosis. Music-based interventions can affect divergent functions such as motor performance, speech, or cognition in these patient groups. However, the psychological effects and neurobiological mechanisms underlying the effects of music interventions are likely to share common neural systems for reward, arousal, affect regulation, learning, and activity-driven plasticity. Although further controlled studies are needed to establish the efficacy of music in neurological recovery, music-based interventions are emerging as promising rehabilitation strategies.

Source: Music-based interventions in neurological rehabilitation

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[ARTICLE] Using Brain Oscillations and Corticospinal Excitability to Understand and Predict Post-Stroke Motor Function – Full Text

What determines motor recovery in stroke is still unknown and finding markers that could predict and improve stroke recovery is a challenge. In this study, we aimed at understanding the neural mechanisms of motor function recovery after stroke using neurophysiological markers by means of cortical excitability (Transcranial Magnetic Stimulation – TMS) and brain oscillations (electroencephalography – EEG). In this cross-sectional study, fifty-five subjects with chronic stroke (62±14 yo, 17 women, 32±42 months post-stroke) were recruited in two sites. We analyzed TMS measures (i.e. motor threshold – MT – of the affected and unaffected sides) and EEG variables (i.e. power spectrum in different frequency bands and different brain regions of the affected and unaffected hemispheres) and their correlation with motor impairment as measured by Fugl-Meyer. Multiple univariate and multivariate linear regression analyses were performed to identify the predictors of good motor function. A significant interaction effect of MT in the affected hemisphere and power in beta bandwidth over the central region for both affected and unaffected hemispheres was found. We identified that motor function positively correlates with beta rhythm over the central region of the unaffected hemisphere, while it negatively correlates with beta rhythm in the affected hemisphere. Our results suggest that cortical activity in the affected and unaffected hemisphere measured by EEG provides new insights on the association between high frequency rhythms and motor impairment, highlighting the role of excess of beta in the affected central cortical region in poor motor function in stroke recovery.


Stroke is a leading cause of morbidity, mortality, and disability worldwide (12). Among the sequels of stroke, motor impairment is one of the most relevant, since it conditions the quality of life of patients, it reduces their capability to perform their daily activities and it impairs their autonomy (3). Despite the advancements of the acute stroke therapy, patients require an intensive rehabilitation program that will partially determine the extent of their recovery (4). These rehabilitation programs aim at stimulating cortical plasticity to improve motor performance and functional recovery (5). However, what determines motor improvement is still unknown. Indeed, finding markers that could predict and enhance stroke recovery is still a challenge (6). Different types of biomarkers exist: diagnostic, prognostic, surrogate outcome, and predictive biomarkers (7). The identification of these biomarkers is critical in the management of stroke patients. In the field of stroke research, great attention has been put to biomarkers found in the serum, especially in acute care. However, research on biomarkers of stroke recovery is still limited, especially using neurophysiological tools.

A critical research area in stroke is to understand the neural mechanisms underlying motor recovery. In this context, neurophysiological techniques such as transcranial magnetic stimulation (TMS) and electroencephalography (EEG) are useful tools that could be used to identify potential biomarkers of stroke recovery. However, there is still limited data to draw further conclusions on neural reorganization in human trials using these techniques. A few studies have shown that, in acute and sub-acute stage, stroke patients present increased power in low frequency bands (i.e., delta and theta bandwidths) in both affected and unaffected sides, as well as increased delta/alpha ratio in the affected brain area; these patterns being also correlated to functional outcome (811). Recently, we have identified that, besides TMS-indexed motor threshold (MT), an increased excitability in the unaffected hemisphere, coupled with a decreased excitability in the affected hemisphere, was associated with poor motor function (12), as measured by Fugl-Meyer (FM) [assessing symptoms severity and motor recovery in post-stroke patients with hemiplegia—Fugl-Meyer et al. (13); Gladstone et al. (14)]. However, MT measurement is associated with a poor resolution as it indexes global corticospinal excitability. Therefore, combining this information with direct cortical measures such as cortical oscillations, as measured by EEG, can help us to understand further neural mechanisms of stroke recovery.

To date, there are very few studies looking into EEG and motor recovery. For that reason, we aimed, in the present study, to investigate the relationship between motor impairment, EEG, and TMS variables. To do so, we conducted a prospective multicenter study of patients who had suffered from a stroke, in which we measured functional outcome using FM and performed TMS and EEG recordings. Based on our preliminary work, we expected to identify changes in interhemispheric imbalances on EEG power, especially in frequency bands associated with learning, such as alpha and beta bandwidths. […]

Continue —> Frontiers | Using Brain Oscillations and Corticospinal Excitability to Understand and Predict Post-Stroke Motor Function | Neurology

Figure 1. Topoplots showing the topographic distribution of high-beta bandwidth (25 Hz) for every individual. Red areas represent higher high-beta activity, while blue areas represent lower high-beta activity. Central region (C3 or C4) in red stands for the affected side. For patients with poor motor function, a higher beta activity of the affected central region as compared to the affected side is observed in 16 out of 28 individuals. For patients with good motor function, a similar activity over central regions bilaterally, or higher activity over the unaffected central area can be identified in 21 out of 27 individuals. FM = Fugl-Meyer.

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[Abstract] Low-frequency rTMS of the unaffected hemisphere in stroke patients: A systematic review


The aim of this review was to summarize the evidence for the effectiveness of low-frequency (LF) repetitive transcranial magnetic stimulation (rTMS) over the unaffected hemisphere in promoting functional recovery after stroke. We performed a systematic search of the studies using LF-rTMS over the contralesional hemisphere in stroke patients and reviewed the 67 identified articles. The studies have been gathered together according to the time interval that had elapsed between the stroke onset and the beginning of the rTMS treatment. Inhibitory rTMS of the contralesional hemisphere can induce beneficial effects on stroke patients with motor impairment, spasticity, aphasia, hemispatial neglect and dysphagia, but the therapeutic clinical significance is unclear. We observed considerable heterogeneity across studies in the stimulation protocols. The use of different patient populations, regardless of lesion site and stroke aetiology, different stimulation parameters and outcome measures means that the studies are not readily comparable, and estimating real effectiveness or reproducibility is very difficult. It seems that careful experimental design is needed and it should consider patient selection aspects, rTMS parameters and clinical assessment tools. Consecutive sessions of rTMS, as well as the combination with conventional rehabilitation therapy, may increase the magnitude and duration of the beneficial effects. In an increasing number of studies, the patients have been enrolled early after stroke. The prolonged follow-up in these patients suggests that the effects of contralesional LF-rTMS can be long-lasting. However, physiological evidence indicating increased synaptic plasticity, and thus, a more favourable outcome, in the early enrolled patients, is still lacking. Carefully designed clinical trials designed are required to address this question. LF rTMS over unaffected hemisphere may have therapeutic utility, but the evidence is still preliminary and the findings need to be confirmed in further randomized controlled trials.

Source: Low-frequency rTMS of the unaffected hemisphere in stroke patients: A systematic review – Sebastianelli – 2017 – Acta Neurologica Scandinavica – Wiley Online Library

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[ARTICLE] Impact of virtual reality games on psychological well-being and upper limb performance in adults with physical disabilities: A pilot study – Full Text PDF


Introduction: There is limited information regarding the effects of interactive virtual reality (VR) games on psychological and physical well-being among adults with physical disabilities. We aimed to examine the impact of VR games on psychological well-being, upper limb motor function and reaction time in adults with physical disabilities.

Methods: Fifteen participants completed the intervention using Wii VR games in this pilot study. Depressive, Anxiety and Stress Scales (DASS) and Capabilities of Upper Extremity (CUE) questionnaires were used to measure psychological well-being and upper limb motor function respectively. Upper limb reaction time was measured using reaction time test.

Results: Results showed that there was a significant difference (p<0.05) in DASS questionnaire and average reaction time score after intervention.

Conclusion: There is a potential for using interactive VR games as an exercise tool to improve psychological wellbeing and upper limb reaction time among adults with disabilities.


Adults with disabilities around the world have been estimated to be around one billion, which consist of 15% of the world’s population.1 In Malaysia, there are approximately 300,000 adults with disabilities.2 Impairments in cardiovascular fitness, balance, motor control, sensation, proprioception and coordination are common in adults with physical disabilities.3 These impairments can lead to functional dependence, poor quality of life, limited mobility and decreased participation in leisure activities.

Opportunities to participate in regular exercise are especially important for groups that are less physically active than the
general population. This is because adults with disabilities are more prone to secondary complications such as pain, fatigue and de-conditioning.4 Virtual reality (VR) games are games played in a stimulated 3-dimensional (3D) environment. VR games have been developed for leisure activities but we found VR to be beneficial for rehabilitation in our local studies.5-7

Involvement in physical activity among people with disabilities is limited. Utilisation of technology may promote adherence, motivation and participation in physical activity and exercise programmes. However, as opposed to conventional rehabilitation and physiotherapy for adults with disabilities, evidence of VR games in improving function is limited. Therefore, the aim of this study was to examine the impact of VR games on psychological well-being, upper limb motor function and reaction time in adults with physical disabilities. …

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