Posts Tagged Motor Skill
Date: September 27, 2018
Source: University of Texas at Dallas
Summary: A novel therapy technique has been shown in a pilot study to double the rate of upper limb recovery in stroke patients, a leap forward in treating the nearly 800,000 Americans who suffer strokes each year.
A novel therapy technique invented by researchers at The University of Texas at Dallas has been shown in a pilot study to double the rate of upper limb recovery in stroke patients, a leap forward in treating the nearly 800,000 Americans who suffer strokes each year.
The results of the study, funded by UT Dallas spinoff company MicroTransponder of Austin, Texas, were published Sept. 27 in the journal Stroke.
The findings indicate that targeted plasticity therapy — which involves stimulation of the vagus nerve — paired with traditional motor-skill rehabilitation is not only safe, but also twice as effective as rehab alone.
Dr. Jane Wigginton, the chief medical officer at UT Dallas’ Texas Biomedical Device Center (TxBDC) and an associate professor of emergency medicine at UT Southwestern Medical Center, led the Dallas site of the clinical trial, which involved 17 people across the country who had suffered a stroke.
“Stroke is too common and too debilitating for us to tolerate the status quo,” Wigginton said. “Patients need a real solution so they can get back to fully living their lives.”
Dr. Michael Kilgard, associate director and chief science officer of the TxBDC, invented targeted plasticity therapy (TPT). Kilgard, who is also the Margaret Fonde Jonsson Professor in the School of Behavioral and Brain Sciences (BBS), said the study results further validate the theories that he and his colleagues based their TPT work on beginning in 2009.
“We set out to design an approach that could transform long-term care and restore quality of life to patients for whom that has thus far been impossible,” said Kilgard, who was not involved in the clinical trial. “These results show our method has immense potential. We’re excited about what this could mean for millions of stroke patients worldwide.”
Researchers affiliated with the TxBDC and BBS developed the therapy technique, which pairs physical movements with precisely timed vagus nerve stimulation (VNS) — electrical stimulus of the nerve via a device implanted on the nerve in the neck.
The vagus nerve controls the parasympathetic nervous system, overseeing many unconscious functions such as circulation and digestion. Stimulating the nerve initiates neural plasticity — reorganization of the brain’s circuitry. The idea behind TPT is that synchronizing VNS with movement accelerates plasticity in a damaged brain, and with it, recovery.
A stroke occurs when blood flow to the brain is interrupted because of a blockage or a ruptured blood vessel. Limb mobility can be affected when nerve cells are damaged. Such forms of brain trauma are often treated with rehabilitation that includes repeated movement of the affected limb in an effort to regain motor skills. The approach is thought to work by helping the brain reorganize.
Several studies of Kilgard’s technique in animal models have previously demonstrated that it is effective in recovering limb function after stroke. A small clinical trial in Europe also provided encouraging data for its potential use in humans.
In 2009, UT Dallas licensed its VNS technique as a stroke and tinnitus treatment to MicroTransponder, which sponsored the new double-blind, placebo-controlled study. Neither the researchers nor the study subjects knew who was getting VNS stimulation and who was not.
Each study subject was a stroke patient whose stroke occurred between four months and five years prior to selection. After they had a VNS device implanted, the subjects received six weeks of in-clinic rehab followed by a home exercise program. About half were treated with active VNS while the rest received control VNS. All were assessed one, 30 and 90 days after therapy with a widely used, stroke-specific measure of performance impairment.
In addition to showing that the technique is safe, the researchers found that subjects receiving active VNS scored more than twice as high as control subjects at the 30- and 90-day intervals, opening the way for larger, more extensive clinical trials, Kilgard said. One such trial is in the recruitment phase and includes a study site in Dallas.
- Teresa J. Kimberley et al. Vagus Nerve Stimulation Paired With Upper Limb Rehabilitation After Chronic Stroke A Blinded Randomized Pilot Study. Stroke, 2018 DOI: 10.1161/STROKEAHA.118.022279
[Abstract] Motor skill changes and neurophysiologic adaptation to recovery-oriented virtual rehabilitation of hand function in a person with subacute stroke: a case study.
The complexity of upper extremity (UE) behavior requires recovery of near normal neuromuscular function to minimize residual disability following a stroke. This requirement places a premium on spontaneous recovery and neuroplastic adaptation to rehabilitation by the lesioned hemisphere. Motor skill learning is frequently cited as a requirement for neuroplasticity. Studies examining the links between training, motor learning, neuroplasticity, and improvements in hand motor function are indicated.
This case study describes a patient with slow recovering hand and finger movement (Total Upper Extremity Fugl-Meyer examination score = 25/66, Wrist and Hand items = 2/24 on poststroke day 37) following a stroke. The patient received an intensive eight-session intervention utilizing simulated activities that focused on the recovery of finger extension, finger individuation, and pinch-grasp force modulation.
Over the eight sessions, the patient demonstrated improvements on untrained transfer tasks, which suggest that motor learning had occurred, as well a dramatic increase in hand function and corresponding expansion of the cortical motor map area representing several key muscles of the paretic hand. Recovery of hand function and motor map expansion continued after discharge through the three-month retention testing.
This case study describes a neuroplasticity based intervention for UE hemiparesis and a model for examining the relationship between training, motor skill acquisition, neuroplasticity, and motor function changes. Implications for rehabilitation Intensive hand and finger rehabilitation activities can be added to an in-patient rehabilitation program for persons with subacute stroke. Targeted training of the thumb may have an impact on activity level function in persons with upper extremity hemiparesis. Untrained transfer tasks can be utilized to confirm that training tasks have elicited motor learning. Changes in cortical motor maps can be used to document changes in brain function which can be used to evaluate changes in motor behavior persons with subacute stroke.
Background. Conventionally, change in motor performance is quantified with discrete measures of behavior taken pre- and postpractice. As a high degree of movement variability exists in motor performance after stroke, pre- and posttesting of motor skill may lack sensitivity to predict potential for motor recovery.
Objective. Evaluate the use of predictive models of motor learning based on individual performance curves and clinical characteristics of motor function in individuals with stroke.
Methods. Ten healthy and fourteen individuals with chronic stroke performed a continuous joystick-based tracking task over 6 days, and at a 24-hour delayed retention test, to assess implicit motor sequence learning.
Results. Individuals with chronic stroke demonstrated significantly slower rates of improvements in implicit sequence-specific motor performance compared with a healthy control (HC) group when root mean squared error performance data were fit to an exponential function. The HC group showed a positive relationship between a faster rate of change in implicit sequence-specific motor performance during practice and superior performance at the delayed retention test. The same relationship was shown for individuals with stroke only after accounting for overall motor function by including Wolf Motor Function Test rate in our model.
Conclusion. Nonlinear information extracted from multiple time points across practice, specifically the rate of motor skill acquisition during practice, relates strongly with changes in motor behavior at the retention test following practice and could be used to predict optimal doses of practice on an individual basis.
|1.||Muratori LM, Lamberg EM, Quinn L, Duff SV. Applying principles of motor learning and control to upper extremity rehabilitation. J Hand Ther. 2013;26:94–102. Google Scholar Medline|
|2.||Lohse KR, Lang CE, Boyd LA. Is more better? Using metadata to explore dose-response relationships in stroke rehabilitation. Stroke. 2014;45:2053–2058. Google Scholar CrossRef, Medline|
|3.||Schmidt RA, Lee TD. Motor Control and Learning: A Behavioral Emphasis. 4th ed. Champaign, IL: Human Kinetics; 2005. Google Scholar|
|4.||Boyd L, Winstein C. Explicit information interferes with implicit motor learning of both continuous and discrete movement tasks after stroke. J Neurol Phys Ther. 2006;30:46–57. Google Scholar Medline|
|5.||Boyd LA, Edwards JD, Siengsukon CS, Vidoni ED, Wessel BD, Linsdell MA. Motor sequence chunking is impaired by basal ganglia stroke. Neurobiol Learn Mem. 2009;92:35–44. Google Scholar Medline|
|6.||Boyd LA, Winstein CJ. Implicit motor-sequence learning in humans following unilateral stroke: the impact of practice and explicit knowledge. Neurosci Lett. 2001;298:65–69. Google Scholar Medline|
|7.||Boyd LA, Winstein CJ. Providing explicit information disrupts implicit motor learning after basal ganglia stroke. Learn Mem. 2004;11:388–396. Google Scholar Medline|
|8.||Vidoni ED, Boyd LA. Motor sequence learning occurs despite disrupted visual and proprioceptive feedback. Behav Brain Funct. 2008;4:32. Google Scholar Medline|
|9.||Whitall J. Stroke rehabilitation research: time to answer more specific questions? Neurorehabil Neural Repair. 2004;18:3–8. Google Scholar Link|
|10.||Doyon J, Bellec P, Amsel R, . Contributions of the basal ganglia and functionally related brain structures to motor learning. Behav Brain Res. 2009;199:61–75. Google Scholar Medline|
|11.||Deuschl G, Toro C, Zeffiro T, Massaquoi S, Hallett M. Adaptation motor learning of arm movements in patients with cerebellar disease. J Neurol Neurosurg Psychiatry. 1996;60:515–519. Google Scholar Medline|
|12.||Ioffe ME, Ustinova KI, Chernikova LA, Kulikov MA. Supervised learning of postural tasks in patients with poststroke hemiparesis, Parkinson’s disease or cerebellar ataxia. Exp Brain Res. 2006;168:384–394. Google Scholar Medline|
|13.||Lang CE, Bastian AJ. Cerebellar subjects show impaired adaptation of anticipatory EMG during catching. J Neurophysiol. 1999;82:2108–2119. Google Scholar Medline|
|14.||Lang CE, Bastian AJ. Additional somatosensory information does not improve cerebellar adaptation during catching. Clin Neurophysiol. 2001;112:895–907. Google Scholar Medline|
|15.||Cousineau D, Hélie S, Lefebvre C. Testing curvatures of learning functions on individual trial and block average data. Behav Res Methods Instrum Comput. 2003;35:493–503. Google Scholar Medline|
|16.||Dite W, Langford ZN, Cumming TB, Churilov L, Blennerhassett JM, Bernhardt J. A phase 1 exercise dose escalation study for stroke survivors with impaired walking. Int J Stroke. 2015;10:1051–1056. Google Scholar Abstract|
|17.||Karni A, Meyer G, Rey-Hipolito C, . The acquisition of skilled motor performance: fast and slow experience-driven changes in primary motor cortex. Proc Natl Acad Sci U S A. 1998;95:861–868. Google Scholar Medline|
|18.||Feldman LS, Cao J, Andalib A, Fraser S, Fried GM. A method to characterize the learning curve for performance of a fundamental laparoscopic simulator task: defining “learning plateau” and “learning rate”. Surgery. 2009;146:381–386. Google Scholar Medline|
|19.||Cousineau D, Lacroix GL. Getting parameters from learning data. Tutorials Quant Methods Psychology. 2006;2:77–83. Google Scholar|
|20.||Ritter FE, Schooler LJ. The learning curve. In: Smelser NJ, Baltes PB, eds. International Encyclopedia of the Social & Behavioral Sciences. Amsterdam, Netherlands: Pergamon; 2002:8602–8605.|
|21.||Newell KM. Motor skill acquisition. Annu Rev Psychol. 1991;42:213–237. Google Scholar Medline|
|22.||Sampaio-Baptista C, Filippini N, Stagg CJ, Near J, Scholz J, Johansen-Berg H. Changes in functional connectivity and GABA levels with long-term motor learning. Neuroimage. 2015;106:15–20. Google Scholar Medline|
|23.||Sampaio-Baptista C, Khrapitchev AA, Foxley S, . Motor skill learning induces changes in white matter microstructure and myelination. J Neurosci. 2013;33:19499–19503. Google Scholar CrossRef, Medline|
|24.||Sampaio-Baptista C, Scholz J, Jenkinson M, . Gray matter volume is associated with rate of subsequent skill learning after a long term training intervention. Neuroimage. 2014;96:158–166. Google Scholar Medline|
|25.||Ward NS. Does neuroimaging help to deliver better recovery of movement after stroke? Curr Opin Neurol. 2015;28:323–329. Google Scholar Medline|
|26.||Neva JL, Henriques DY. Visuomotor adaptation and generalization with repeated and varied training. Exp Brain Res. 2013;226:363–372. Google Scholar Medline|
|27.||Heathcote A, Brown S, Mewhort DJ. The power law repealed: the case for an exponential law of practice. Psychon Bull Rev. 2000;7:185–207. Google Scholar CrossRef, Medline|
|28.||Meehan SK, Randhawa B, Wessel B, Boyd LA. Implicit sequence-specific motor learning after subcortical stroke is associated with increased prefrontal brain activations: an fMRI study. Hum Brain Mapp. 2011;32:290–303. Google Scholar Medline|
|29.||Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7:13–31. Google Scholar Medline|
|30.||Hodics TM, Nakatsuka K, Upreti B, Alex A, Smith PS, Pezzullo JC. Wolf Motor Function Test for characterizing moderate to severe hemiparesis in stroke patients. Arch Phys Med Rehabil. 2012;93:1963–1967. Google Scholar Medline|
|31.||Wadden K, Brown K, Maletsky R, Boyd LA. Correlations between brain activity and components of motor learning in middle-aged adults: an fMRI study. Front Hum Neurosci. 2013;7:169. Google Scholar Medline|
|32.||Brown S, Heathcote A. Averaging learning curves across and within participants. Behav Res Methods Instrum Comput. 2003;35:11–21. Google Scholar Medline|
|33.||Krakauer JW, Pine ZM, Ghilardi MF, Ghez C. Learning of visuomotor transformations for vectorial planning of reaching trajectories. J Neurosci. 2000;20:8916–8924. Google Scholar Medline|
|34.||Modabber M, Neva J, Gill M, Budge I, Henriques D. Learning and retaining visuomotor adaptation across time. J Vision. 2008;8:610–610. Google Scholar|
|35.||Haibach P, Reid G, Collier D. Motor Learning and Development. Champaign, IL: Human Kinetics; 2011.Google Scholar|
|36.||Field A. Discovering Statistics Using SPSS. Thousand Oaks, CA: Sage; 2009. Google Scholar|
|37.||Nesselroade JR, Salthouse TA. Methodological and theoretical implications of intraindividual variability in perceptual-motor performance. J Gerontol B Psychol Sci Soc Sci. 2004;59:P49–P55. Google Scholar Medline|
|38.||Lee TD, Simon DA. Contextual interference. In: Williams AM, Hodges NJ, eds. Skill Acquisition in Sport: Research, Theory and Practice. London, England: Routledge; 2004:29–44.|
|39.||Guadagnoli MA, Lee TD. Challenge point: a framework for conceptualizing the effects of various practice conditions in motor learning. J Mot Behav. 2004;36:212–224. Google Scholar Medline|
|40.||Wright D, Verwey W, Buchanen J, Chen J, Rhee J, Immink M. Consolidating behavioral and neurophysiologic findings to explain the influence of contextual interference during motor sequence learning. Psychon Bull Rev. 2016;23:1–21. Google Scholar Medline|
|41.||Haith AM, Krakauer JW. Motor learning: the great rate debate. Curr Biol. 2014;24:R386–R388. Google Scholar Medline|
|42.||Eversbusch A, Grantcharov T. Learning curves and impact of psychomotor training on performance in simulated colonoscopy: a randomized trial using a virtual reality endoscopy trainer. Surg Endosc. 2004;18:1514–1518. Google Scholar Medline|
|43.||Flamme C, Stukenborg-Colsman C, Wirth C. Evaluation of the learning curves associated with uncemented primary total hip arthroplasty depending on the experience of the surgeon. Hip Int. 2005;16:191–197. Google Scholar|
|44.||Hernandez J, Bann S, Munz Y, . Qualitative and quantitative analysis of the learning curve of a simulated surgical task on the da Vinci system. Surg Endosc. 2004;18:372–378. Google Scholar Medline|
|45.||Lundy-Ekman L. Neuroscience: Fundamentals for Rehabilitation. Philadelphia, PA: WB Saunders; 1998.Google Scholar|
|46.||Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198. Google Scholar CrossRef, Medline|
|47.||Wulf G, Schmidt RA. Variability of practice and implicit motor learning. J Exp Psychol Learn Mem Cogn. 1997;23:987–1006. Google Scholar|
|48.||Wadden KP, Woodward TS, Metzak PD, . Compensatory motor network connectivity is associated with motor sequence learning after subcortical stroke. Behav Brain Res. 2015;286:136–145. Google ScholarMedline|
[Abstract] Increased functional connectivity one week after motor learning and tDCS in stroke patients
- Dual-tDCS enhanced motor skill learning and retention in chronic hemiparetic stroke patients (95 /125)
- Dual-tDCS combined to training induced an increase in FC in the ipsilesional M1, PMd (and SMA) that lasted up to 1 week (120 /125)
- Both seed and ICA-based analyses showed a FC reorganisation following dual-tDCS (between ipsilesional M1 and PMd) (114/125)
- This study demonstrated changes of FC lasting well beyond what has been previously reported after a single session of tDCS (125 / 125)
- tDCS, combined with motor learning, has lasting effect upon FC and could be an efficient tool in neurorehabilitation (121 /125)
Recent studies using resting-state functional magnetic resonance imaging (rs-fMRI) demonstrated that changes in functional connectivity (FC) after stroke correlate with recovery.
The aim of this study was to explore whether combining motor learning to dual transcranial direct current stimulation (dual-tDCS, applied over both primary motor cortices (M1)) modulated FC in stroke patients. Twenty-two chronic hemiparetic stroke patients participated in a baseline rs-fMRI session. One week later, dual-tDCS/sham was applied during motor skill learning (intervention session); one week later, the retention session started with the acquisition of a run of rs-fMRI imaging.
The intervention + retention sessions were performed once with dual-tDCS and once with sham in a randomised, cross-over, placebo-controlled, double-blind design. A whole-brain independent component analysis based ANOVA demonstrated no changes between baseline and sham sessions in the somatomotor network, whereas a FC increase was observed one week after dual-tDCS compared to baseline (qFDR < 0.05, t(63) = 4.15). A seed-based analysis confirmed specific stimulation-driven changes within a network of motor and premotor regions in both hemispheres. At baseline and one week after sham, the strongest FC was observed between the M1 and dorsal premotor cortex (PMd) of the undamaged hemisphere. In contrast, one week after dual-tDCS, the strongest FC was found between the M1 and PMd of the damaged hemisphere. Thus, a single session of dual-tDCS combined with motor skill learning increases FC in the somatomotor network of chronic stroke patients for one week.
[Abstract] Physiotherapists use a great variety of motor learning options in neurological rehabilitation, from which they choose through an iterative process: a retrospective think-aloud study.
Implications for Rehabilitation
The study provided insight into the way experienced therapist handle the great variety of possible motor learning options, including concrete ideas on how to operationalize these options in specific situations.
Despite differences in patients’ abilities, it seems that therapists use the same underlying clinical reasoning process when choosing a particular motor learning option.
Participating physiotherapists used more than the in guidelines suggested motor learning options and considered more than the suggested factors, hence adding practice based options of motor learning to the recommended ones in the guidelines.
A think-aloud approach can be considered for peer-to-peer and student coaching to enhance discussion on the motor learning options applied and the underlying choices and to encourage research by practicing clinicians.
Source: Physiotherapists use a great variety of motor learning options in neurological rehabilitation, from which they choose through an iterative process: a retrospective think-aloud study – Disability and Rehabilitation –
[ARTICLE] Low Frequency Repetitive Transcranial Magnetic Stimulation to Improve Motor Function and Grip Force of Upper Limbs of Patients With Hemiplegia
…Background: Stroke is the most common and debilitating neurological disorder among adults, and is a sudden onset of neurological signs caused by brain blood vessels impairments.
Objectives: Some new therapeutic methods focus on the use of magnetic stimulation to produce therapeutic effects by inducing the currents. The aim of this study is to determine the effects of rTMS plus routine rehabilitation on hand grip and wrist motor functions in patients with hemiplegia, and compare with pure routine rehabilitation programs.
Patients and Methods: In this study, 12 patients with hemiplegia were randomly divided in two groups. Control group, received the rehabilitation program with placebo magnetic stimulation, and the experimental group, received magnetic stimulation with routine rehabilitation program for 10 sessions for three times per week. Pre and post evaluations of treatment performed using Barthel and Fugl-Meyer indices and dynamometers.
Results: In the control group, Barthel and Fugl-Meyer indices showed significant improvement (P = 0.01, P = 0.00), while in the experimental group, significant improvement in Barthel and Fugl-Meyer indices and dynamometers has been observed (P = 0.01, P = 0.00, P = 0.007).
Conclusions: rTMS can improve hand muscle force and functions of patients with chronic hemiplegia, while conventional treatment is not effective…