Posts Tagged Motor function

[WEB SITE] How Virtual Avatars Help Stroke Patients Improve Motor Function

At USC, Dr. Sook-Lei Liew is testing whether watching a virtual avatar that moves in response to brain commands can activate portions of the brain damaged by stroke.
Dr. Sook-Lei Liew (Photo: Nate Jensen)

Photo: Nate Jensen

I am hooked up to a 16-channel brain machine interface with 12 channels of EEG on my head and ears and four channels of electromyography (EMG) on my arms. An Oculus Rift occludes my vision.

Two inertial measurement units (IMU) are stuck to my wrists and forearms, tracking the orientation of my arms, while the EMG monitors my electrical impulses and peripheral nerve activity.

Dr. Sook-Lei Liew, Director of USC’s Neural Plasticity and Neurorehabilitation Laboratory, and Julia Anglin, Research Lab Supervisor and Technician, wait to record my baseline activity and observe a monitor with a representation of my real arm and a virtual limb. I see the same image from inside the Rift.

“Ready?” asks Dr. Liew. “Don’t move—or think.”

I stay still, close my eyes, and let my mind go blank. Anglin records my baseline activity, allowing the brain-machine interface to take signals from the EEG and EMG, alongside the IMU, and use that data to inform an algorithm that drives the virtual avatar hand.

“Now just think about moving your arm to the avatar’s position,” says Dr. Liew.

I don’t move a muscle, but think about movement while looking at the two arms on the screen. Suddenly, my virtual arm moves toward the avatar appendage inside the VR world.

VR rehab at USC

Something happened just because I thought about it! I’ve read tons of data on how this works, even seen other people do it, especially inside gaming environments, but it’s something else to experience it for yourself.

“Very weird isn’t it?” says David Karchem, one of Dr. Liew’s trial patients. Karchem suffered a stroke while driving his car eight years ago, and has shown remarkable recovery using her system.

“My stroke came out of the blue and it was terrifying, because I suddenly couldn’t function. I managed to get my car through an intersection and call the paramedics. I don’t know how,” Karchem says.

He gets around with a walking stick today, and has relatively normal function on the right side of his body. However, his left side is clearly damaged from the stroke. While talking, he unwraps surgical bandages and a splint from his left hand, crooked into his chest, to show Dr. Liew the progress since his last VR session.

As a former software engineer, Karchem isn’t fazed by using advanced technology to aid the clinical process. “I quickly learned, in fact, that the more intellectual and physical stimulation you get, the faster you can recover, as the brain starts to fire. I’m something of a lab rat now and I love it,” he says.


Karchem is participating in Dr. Liew’s REINVENT (Rehabilitation Environment using the Integration of Neuromuscular-based Virtual Enhancements for Neural Training) project, funded by the American Heart Association, under a National Innovative Research Grant. It’s designed to help patients who have suffered strokes reconnect their brains to their bodies.

VR rehab at USC (Photo: Nate Jensen)“My PhD in Occupational Science, with a concentration in Cognitive Neuroscience, focused on how experience changes brain networks,” explains Dr. Liew. “I continued this work as a Postdoctoral Fellow at the National Institute of Neurological Disorders and Stroke at the National Institutes of Health, before joining USC, in my current role, in 2015.

“Our main goal here is to enhance neural plasticity or neural recovery in individuals using noninvasive brain stimulation, brain-computer interfaces and novel learning paradigms to improve patients’ quality of life and engagement in meaningful activities,” she says.

Here’s the science bit: the human putative mirror neuron system (MNS) is a key motor network in the brain that is active both when you perform an action, like moving your arm, and when you simply watch someone else—like a virtual avatar—perform that same action. Dr. Liew hypothesizes that, for stroke patients who can’t move their arm, simply watching a virtual avatar that moves in response to their brain commands will activate the MNS and retrain damaged or neighboring motor regions of the brain to take over the role of motor performance. This should lead to improved motor function.

“In previous occupational therapy sessions, we found many people with severe strokes got frustrated because they didn’t know if they were activating the right neural networks when we asked them to ‘think about moving’ while we physically helped them to do so,” Dr. Liew says. “If they can’t move at all, even if the right neurological signals are happening, they have no biological feedback to reinforce the learning and help them continue the physical therapy to recover.”

For many people, the knowledge that there’s “intent before movement”—in that the brain has to “think” about moving before the body will do so, is news. We also contain a “body map” inside our heads that predicts our spacetime presence in the world (so we don’t bash into things all the time and know when something is wrong). Both of these brain-body elements face massive disruption after a stroke. The brain literally doesn’t know how to help the body move.

What Dr. Liew’s VR platform has done is show patients how this causal link works and aid speedier, and less frustrating, recovery in real life.

From the Conference Hall to the Lab

She got the idea while geeking out in Northern California one day.

“I went to the Experiential Technology Conference in San Francisco in 2015, and saw demos of intersections of neuroscience and technology, including EEG-based experiments, wearables, and so on. I could see the potential to help our clinical population by building a sensory-visual motor contingency between your own body and an avatar that you’re told is ‘you,’ which provides rewarding sensory feedback to reestablish brain-body signals.

“Inside VR you start to map the two together, it’s astonishing. It becomes an automatic process. We have seen that people who have had a stroke are able to ’embody’ an avatar that does move, even though their own body, right now, cannot,” she says.

VR rehab at USC

Dr. Liew’s system is somewhat hacked together, in the best possible Maker Movement style; she built what didn’t exist and modified what did to her requirements.

“We wanted to keep costs low and build a working device that patients could actually afford to buy. We use Oculus for the [head-mounted display]. Then, while most EEG systems are $10,000 or more, we used an OpenBCI system to build our own, with EMG, for under $1,000.

“We needed an EEG cap, but most EEG manufacturers wanted to charge us $200 or more. So, we decided to hack the rest of the system together, ordering a swim cap from Amazon, taking a mallet and bashing holes in it to match up where the 12 positions on the head electrodes needed to be placed (within the 10-10 international EEG system). We also 3D print the EEG clips and IMU holders here at the lab.

VR rehab at USC

“For the EMG, we use off-the-shelf disposable sensors. This allows us to track the electromyography, if they do have trace muscular activity. In terms of the software platform, we coded custom elements in C#, from Microsoft, and implemented them in the Unity3D game engine.”

Dr. Liew is very keen to bridge the gap between academia and the tech industry; she just submitted a new academic paper with the latest successful trial results from her work for publication. Last year, she spoke at SXSW 2017 about how VR affects the brain, and debuted REINVENT at the conference’s VR Film Festival. It received a “Special Jury Recognition for Innovative Use of Virtual Reality in the Field of Health.”

Going forward, Dr. Liew would like to bring her research to a wider audience.


“I feel the future of brain-computer interfaces splits into adaptive, as with implanted electrodes, and rehabilitative, which is what we work on. What we hope to do with REINVENT is allow patients to use our system to re-train their neural pathways, [so they] eventually won’t need it, as they’ll have recovered.

“We’re talking now about a commercial spin-off potential. We’re able to license the technology right now, but, as researchers, our focus, for the moment, is in furthering this field and delivering more trial results in published peer-reviewed papers. Once we have enough data we can use machine learning to tailor the system precisely for each patient and share our results around the world.”

If you’re in L.A., Dr. Liew and her team will be participating in the Creating Reality VR Hackathon from March 12-15 at USC. Details here.

via How Virtual Avatars Help Stroke Patients Improve Motor Function | News & Opinion |


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[Abstract] Mirror therapy for motor function of the upper extremity in patients with stroke: A meta-analysis.



To evaluate the mean treatment effect of mirror therapy on motor function of the upper extremity in patients with stroke.


Electronic databases, including the Cochrane Library, PubMed, MEDLINE, Embase and CNKSystematic, were searched for relevant studies published in English between 1 January 2007 and 22 June 2017.


Randomized controlled trials and pilot randomized controlled trials that compared mirror therapy/mirror box therapy with other rehabilitation approaches were selected.


Two authors independently evaluated the searched studies based on the inclusion/exclusion criteria and appraised the quality of included studies according to the criteria of the updated version 5.1.0 of the Cochrane Handbook for Systematic Review of Interventions.


Eleven trials, with a total of 347 patients, were included in the meta-analysis. A moderate effect of mirror therapy (standardized mean difference 0.51, 95% confidence interval (CI) 0.29, 0.73) on motor function of the upper extremity was found. However, a high degree of heterogeneity (χ2 = 25.65, p = 0.004; I2 = 61%) was observed. The heterogeneity decreased a great deal (χ2 = 6.26, p = 0.62; I2 = 0%) after 2 trials were excluded though sensitivity analysis.


Although the included studies had high heterogeneity, meta-analysis provided some evidence that mirror therapy may significantly improve motor function of the upper limb in patients with stroke. Further well-designed studies are needed.

PMID: 29077129


DOI: 10.2340/16501977-2287
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via Mirror therapy for motor function of the upper extremity in patients with stroke: A meta-analysis. – PubMed – NCBI

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[VIDEO] Brain-Machine Interfaces for Restoration of Motor Function and Communication – NIH VideoCast


Jaimie Henderson, M.D. is director of the Stanford program in Stereotactic and Functional Neurosurgery, and co-director (with Prof. Krishna Shenoy, PhD) of the Stanford Neural Prosthetics Translational Laboratory (NPTL). His research interests encompass several areas of stereotactic and functional neurosurgery, including frameless stereotactic approaches for therapy delivery to deep brain nuclei; mechanisms of action of deep brain stimulation; cortical physiology and its relationship to normal and pathological movement; neural prostheses; and the development of novel neuromodulatory techniques for the treatment of neurological diseases. During his residency in the early 1990’s, Dr. Henderson was intimately involved with the development of the new field of image-guided surgery. This innovative technology has revolutionized the practice of neurosurgery, allowing for safer and more effective operations with reduced operating time. Dr. Henderson remains one of the world’s foremost experts on the application of image-guided surgical techniques to functional neurosurgical procedures such as the placement of deep brain stimulators for movement disorders, epilepsy, pain, and psychiatric diseases. His work with NPTL focuses on the creation of clinically viable interfaces between the human brain and prosthetic devices to assist people with severe neurological disability.

NIH Neuroscience Series Seminar
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via NIH VideoCast – Brain-Machine Interfaces for Restoration of Motor Function and Communication

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[Abstract] Effectiveness of Neuromuscular Electrical Stimulation on Lower Limb Hemiplegic Patients following Chronic Stroke: A Systematic Review



To investigate the effectiveness of neuromuscular electrical stimulation (NMES) with or without other interventions in improving lower limb activity after chronic stroke.

Data Source

Electronic databases including PubMed, EMBase, Cochrane Library, PEDro (Physiotherapy Evidence Database) and PsycINFO were searched from the inception to January, 2017.

Study Selection

We selected the randomized controlled trials (RCTs) involving chronic stroke survivors with lower limb dysfunction and comparing NMES or combined with other interventions with control of no electrical-stimulated treatment.

Data Extraction

The primary outcome was defined as lower limb motor function, and the secondary outcomes included gait speed, Berg Balance scale, Timed Up and Go, Six-Minute Walk Test, Modified Ashworth Scale and Range of Motion .

Data Synthesis

Twenty-one RCTs involving 1,481 participants were identified from 5,759 retrieved articles. Pooled analysis showed that NMES had a moderate but statistically significant benefits on lower limb motor function (SMD 0.42, 95% CI 0.26 to 0.58), especially when NMES combined with other interventions or treatment time within either 6 or 12 weeks. NMES also had significant benefits on gait speed, balance, spasticity and range of motion but had no significant difference in walking endurance after NMES.


NMES combined with or without other interventions has beneficial effects in lower limb motor function in chronic stroke survivors. These data suggest that NMES should be a promising therapy to apply in chronic stroke rehabilitation to improve the capability of lower extremity in performing activities.

via Effectiveness of Neuromuscular Electrical Stimulation on Lower Limb Hemiplegic Patients following Chronic Stroke: A Systematic Review – Archives of Physical Medicine and Rehabilitation

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[ARTICLE] Effects of somatosensory electrical stimulation on motor function and cortical oscillations – Full Text



Few patients recover full hand dexterity after an acquired brain injury such as stroke. Repetitive somatosensory electrical stimulation (SES) is a promising method to promote recovery of hand function. However, studies using SES have largely focused on gross motor function; it remains unclear if it can modulate distal hand functions such as finger individuation.


The specific goal of this study was to monitor the effects of SES on individuation as well as on cortical oscillations measured using EEG, with the additional goal of identifying neurophysiological biomarkers.


Eight participants with a history of acquired brain injury and distal upper limb motor impairments received a single two-hour session of SES using transcutaneous electrical nerve stimulation. Pre- and post-intervention assessments consisted of the Action Research Arm Test (ARAT), finger fractionation, pinch force, and the modified Ashworth scale (MAS), along with resting-state EEG monitoring.


SES was associated with significant improvements in ARAT, MAS and finger fractionation. Moreover, SES was associated with a decrease in low frequency (0.9-4 Hz delta) ipsilesional parietomotor EEG power. Interestingly, changes in ipsilesional motor theta (4.8–7.9 Hz) and alpha (8.8–11.7 Hz) power were significantly correlated with finger fractionation improvements when using a multivariate model.


We show the positive effects of SES on finger individuation and identify cortical oscillations that may be important electrophysiological biomarkers of individual responsiveness to SES. These biomarkers can be potential targets when customizing SES parameters to individuals with hand dexterity deficits. Trial registration: NCT03176550; retrospectively registered.


Despite recent advances in rehabilitation, a substantial fraction of stroke patients continue to experience persistent upper-limb deficits [1]. At best, up to 1 out of 5 patients will recover full arm function, while 50% will not recover any functional use of the affected arm. [2] Improvement in upper limb function specifically depends on sensorimotor recovery of the paretic hand [3]. Yet, there remains a lack of effective therapies readily available to the patient with acquired brain injury for recovery of hand and finger function; a systematic review found that conventional repetitive task training may not be consistently effective for the upper extremity [4]. It is thus critical to explore inexpensive and scalable approaches to restore hand and finger dexterity, reduce disability and increase participation after stroke and other acquired brain injuries.

Sensory threshold somatosensory electrical stimulation (SES) is a promising therapeutic modality for targeting hand motor recovery [5]. It is known to be a powerful tool to focally modulate sensorimotor cortices in both healthy and chronic stroke participants [5678]. Devices such as transcutaneous nerve stimulation (TENS) units can deliver SES and are commercially available, inexpensive, low risk, and easily applied in the home setting [9]. Previous studies have demonstrated short-term and long-term improvements in hand function after SES [5101112131415]. However, the effect of SES on regaining the ability to selectively move a given digit independently from other digits (i.e. finger fractionation) has not been investigated. Poor finger individualization is an important therapeutic target because it is commonly present even after substantial recovery and may account for chronic hand dysfunction [16]. Further, it is unclear if SES is associated with compensatory or restorative mechanisms. Prior studies have largely relied on relatively subjective clinical evaluations of impairment, such as the Fugl-Meyer Assessment, or timed and task-based assessments, such as the Jebson-Taylor Hand Function Test. Biomechanical analyses, on the other hand, can provide important objective and quantitative evidence of improvement in neurologic function and normative motor control [1718]. Therefore, we aimed to determine not only the functional effects, but also the kinematic effects, of SES on chronic hand dysfunction.

Simultaneously, it should be noted that although SES can potentially be an effective therapy, not all individuals who are administered SES experience positive effects. While improvement levels as high as 31–36% compared to baseline function have been reported, [1119] about half of one cohort demonstrated minimal or no motor performance improvement after a single session of SES [15]. One method to shed more light on this discrepancy is to identify neurophysiological biomarkers associated with motor responses to SES. Neurophysiological biomarkers are increasingly used to predict treatment effects [2021]. Although some studies have examined biomarkers associated with treatment-induced motor recovery, to our knowledge none have been performed for SES [2223]. A recent study using electroencephalography (EEG) found that changes in patterns of connectivity predicted motor recovery after stroke [24]. At present, little is known about the effect of peripheral neuromodulation on EEG activity, how existing neural dynamics interacts with peripheral stimulation, and whether this interaction is associated with improvements in motor function. Associating EEG activity with treatment response may also provide mechanistic insight regarding the effects of SES on neural plasticity. EEG activity can also potentially be used as a cost-effective real-time metric of the time-varying efficacy of SES. This novel application of EEG information may help tailor treatment efforts while reducing the variability in outcome.

The main goal of this pilot study was to evaluate both changes in finger fractionation in response to SES and identify the associated neural biomarkers through analyses of EEG dynamics. Outcomes from this study have potential in designing targeted SES therapy based on neural biomarkers to modulate and improve hand function after acquired brain injury such as stroke (e.g. enrollment in long-term studies of the efficacy of SES).


Continue —>  Effects of somatosensory electrical stimulation on motor function and cortical oscillations | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 1a Schematic representation of the method used for calculating the FCI. The participant is instructed to flex only the index finger as much as possible without flexing the other digits. b FCI is defined mathematically as the angle traversed by the middle finger (digit A) divided by the angle tranversed by the index finger (digit B) relative to the horizontal starting position. c Statistically significant change in mean fractionation from baseline to immediately after peripheral nerve stimulation. Fractionation improvement is indicated by a decrease in finger coupling index (FCI)


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Movement Therapy of the Upper Extremities with a Robotic Ball in Stroke Patients: Results of a Randomized Controlled Crossover Study – Full Text


Background Stroke is associated with motor impairments of the upper extremities. The defining goal of rehabilitation is independent execution of activities of daily living. New therapy procedures use different hardware components to implement digital therapy contents. These can be useful complements to established therapy protocols.

Objectives The aim of this study was to examine the effect of movement therapy with a robotic ball on motor function parameters in stroke patients.

Materials and Methods 25 patients (60.0±10.0 years, 172.5±13.8 cm, 79.5±13.8 kg, 89.8±72.6 months post-stroke) took part in this crossover study. The intervention and control periods comprised 12 weeks each. Training with the robotic ball was done in addition to standard therapy two times a week for 45 min each. Different game activities were carried out with the help of a tablet and a smartphone.

Results Isometric grip strength improved by 4.5±3.6 kg (p=0.000), and unilateral dexterity increased by 7.5±6.3 successful tries (p=0.000) in the round block test. The self-reported disabilities of the arm, shoulder and hand were assessed using the QuickDASH questionnaire and showed improvements by 12.4±13.0 points (p=0.001).

Conclusions Additional therapy using the robotic ball improved upper extremity motor function and self-perceived health status in chronic stroke patients. However, performance stagnated when standard therapy was implemented alone. Moderately affected patients seem to benefit the most. The presence of very severe motor or cognitive symptoms led, in part, to some dropouts. The results need to be verified using larger patient populations.


In Germany, up to 75% of the approx. 196,000 initial and 66,000 repeated strokes are survived [1] [2] [3] [4]. For the affected patients, it is often the trigger for persistent physical limitations, which in 85% of the cases are manifested by the cardinal symptom of spastic or flaccid hemiparesis of the upper extremities. Restriction or even loss of function of the hand and arm drastically impacts the daily life of the affected individual [1] [5] [6] [7]. Demographic change has increased the incidence of stroke. Improved acute care has enabled more people to survive the event, resulting in a greater number of patients and a growing demand for therapy [1] [2] [6]. Reduced range of motion, pain, sensory disturbances and increased muscle tone are characteristic patient symptoms [8] [9]. Loss of arm function is the consequence in about half of stroke cases [8], unlike rehabilitation of independent mobility, which can be achieved in up to 85% of patients [10]. Consequently, relatively less time is devoted to recovery of hand and arm function [11]. In addition to effects on motor function there are often psychological and social consequences [12]. A variety of physical activity measures should contribute to the compensation and restoration of skills and abilities [13] [14]. Since it is still possible to make progress even weeks after a stroke, it is imperative to develop more effective therapeutic methods, especially in the case of sustained loss of upper extremity function [8]. Thus the severity and location of the cerebral insult as well as comorbidities are decisive for the further rehabilitation process [15] [16]. The success of Constraint-induced Movement Therapy (CIMT) [7] [17] [18] [19] [20] [21] [22] [23] [24] demonstrates the necessity and possible benefit of using the upper extremities during training and everyday life.

In this context as well as due to innovative developments in technology-supported concepts and components [25] [26] [27] [28] [29] [30] in the field of stroke rehabilitation such as exergaming, [31] [32] [33] [34] the “Sphero 2.0” robotic ball was reviewed in combination with game-playing applications as a supplemental therapeutic activity [35]. The potential benefit for stroke patients regarding improving motor parameters has been documented in review articles on technology-supported therapeutic measures [36] [37]. Hardware and software components from the entertainment industry or telecommunications are used to develop new therapy activities. There are examples of the Microsoft Kinect webcam used in stroke rehabilitation [30] [38] [39] [40] [41] [42] [43] [44] as well as for game consoles such as the Nintendo Wii [45] [46] [47], Sony Playstation [48] or Microsoft XBox [44]. In addition, smartphones [34], tablets [49] [50] [51] [52] or virtual reality goggles [53] are being used to employ generally commercially available games with potential therapeutic benefits, or to use their sensor systems for movement detection and control. Therapeutic content can be found in commercial video games such as Wii Sports [54] or Kinect Sports [44] as well as games programmed specifically for therapeutic applications [42] [55]. Their common element is the required use of the affected body half to achieve the respective game objective. The activity can reflect daily activities such as grasping and moving a glass [56], cooking [38], or striking selected piano keys [38] [49]. […]

Continue —> Thieme E-Journals – Neurology International Open / Full Text

Fig. 2 The “Sphero 2.0” robotic ball by Orbotix (Boulder, CO, USA).

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[WEB SITE] VR on par with traditional rehab in restoring motor function in stroke patients

 - Stroke, endovascular. neuroimaging, neuro
Using virtual reality training to restore motor function after a stroke is just as effective as traditional physical therapy, reports a new study published in the medical journal Neurology.

Danish first author Iris Brunner, PhD, and colleagues evaluated a pool of 120 stroke patients, all of whom had experienced a stroke within 12 weeks of the study’s baseline and were having difficulty restoring full function in their upper extremities. The group was split in half, with one cohort randomized to virtual reality rehabilitation training and the other randomized to conventional therapy. All results were stratified based on the severity of hand paresis, muscle weakness and wrist and arm strength.

Study patients participated in a minimum of 16 hour-long therapy sessions over the course of four weeks, Brunner and co-authors wrote. Process was measured through the primary outcome measure, the Action Research Arm Test, and secondary outcome measures like the Box and Blocks Test and Functional Independence Measure.

Those randomized to virtual reality training used a screen and gloves with sensors to navigate a variety of games that incorporated arm, hand and finger movements, according to the research. The virtual reality system isn’t immersive, Brunner said in a release from the American Academy of Neurology (AAN)—goggles aren’t a part of the system yet.

“We can only speculate whether using virtual reality goggles or other techniques to create a more immersive experience would increase the effect of the training,” she said.

High-tech goggles or not, virtual reality patients seemed to see the same benefits as those who underwent traditional physical and occupational therapy.

“Both groups had substantial improvement in their functioning, but there was no difference between the two groups in the results,” Brunner said. “These results suggest that either type of training could be used, depending on what the patient prefers.”

Patients in virtual reality therapy improved 12 points from the study’s baseline to the postintervention assessment, the authors wrote, and improved 17 points from baseline to a three-month follow-up. Similarly, participants randomized to conventional therapy improved 13 and 17 points, respectively.

Though additional upper extremity virtual reality training didn’t top traditional methods as a rehab alternative, Brunner and colleagues wrote the new technique could be an alternative or supplement to traditional rehabilitation.

“Virtual reality training may be a motivating alternative for people to use as a supplement to their standard therapy after a stroke,” Brunner said in the AAN release. “Future studies could also look at whether people could use virtual reality therapy remotely from their homes, which could lessen the burden and cost of traveling to a medical center for standard therapy.”


via VR on par with traditional rehab in restoring motor function in stroke patients | Cardiovascular Business

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[Abstract+References] Longitudinal Structural and Functional Differences Between Proportional and Poor Motor Recovery After Stroke

Background. Evolution of motor function during the first months after stroke is stereotypically bifurcated, consisting of either recovery to about 70% of maximum possible improvement (“proportional recovery, PROP”) or in little to no improvement (“poor recovery, POOR”). There is currently no evidence that any rehabilitation treatment will prevent POOR and favor PROP. Objective. To perform a longitudinal and multimodal assessment of functional and structural changes in brain organization associated with PROP. Methods. Fugl-Meyer Assessments of the upper extremity and high-density electroencephalography (EEG) were obtained from 63 patients, diffusion tensor imaging from 46 patients, at 2 and 4 weeks (T0) and at 3 months (T1) after stroke onset. Results. We confirmed the presence of 2 distinct recovery patterns (PROP and POOR) in our sample. At T0, PROP patients had greater integrity of the corticospinal tract (CST) and greater EEG functional connectivity (FC) between the affected hemisphere and rest of the brain, in particular between the ventral premotor and the primary motor cortex. POOR patients suffered from degradation of corticocortical and corticofugal fiber tracts in the affected hemisphere between T0 and T1, which was not observed in PROP patients. Better initial CST integrity correlated with greater initial global FC, which was in turn associated with less white matter degradation between T0 and T1. Conclusions. These findings suggest links between initial CST integrity, systems-level cortical network plasticity, reduction of white matter atrophy, and clinical motor recovery after stroke. This identifies candidate treatment targets.

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via Longitudinal Structural and Functional Differences Between Proportional and Poor Motor Recovery After StrokeNeurorehabilitation and Neural Repair – Adrian G. Guggisberg, Pierre Nicolo, Leonardo G. Cohen, Armin Schnider, Ethan R. Buch, 2017

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[Abstract] The Use of Repetitive Transcranial Magnetic Stimulation for Stroke Rehabilitation: A Systematic Review


Stroke is a leading cause of disability. Alternative and more effective techniques for stroke rehabilitation have been sought to overcome limitations of conventional therapies. Repetitive transcranial magnetic stimulation (rTMS) arises as a promising tool in this context. This systematic review aims to provide a state of the art on the application of rTMS in stroke patients and to assess its effectiveness in clinical rehabilitation of motor function.


Studies included in this review were identified by searching PubMed and ISI Web of Science. The search terms were (rTMS OR “repetitive transcranial magnetic stimulation”) AND (stroke OR “cerebrovascular accident” OR CVA) AND (rehab OR rehabilitation OR recover*). The retrieved records were assessed for eligibility and the most relevant features extracted to a summary table.


Seventy out of 691 records were deemed eligible, according to the selection criteria. The majority of the articles report rTMS showing potential in improving motor function, although some negative reports, all from randomized controlled trials, contradict this claim. Future studies are needed because there is a possibility that a bias for non-publication of negative results may be present.


rTMS has been shown to be a promising tool for stroke rehabilitation, in spite of the lack of standard operational procedures and harmonization. Efforts should be devoted to provide a greater understanding of the underlying mechanisms and protocol standardization.

Source: The Use of Repetitive Transcranial Magnetic Stimulation for Stroke Rehabilitation: A Systematic Review – ScienceDirect

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[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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