Posts Tagged Motor training

[ARTICLE] Mapping upper-limb motor performance after stroke – a novel method with utility for individualized motor training – Full Text



Chronic upper limb motor impairment is a common outcome of stroke. Therapeutic training can reduce motor impairment. Recently, a growing interest in evaluating motor training provided by robotic assistive devices has emerged. Robot-assisted therapy is attractive because it provides a means of increasing practice intensity without increasing the workload of physical therapists. However, movements practised through robotic assistive devices are commonly pre-defined and fixed across individuals. More optimal training may result from individualizing the selection of the trained movements based on the individual’s impairment profile. This requires quantitative assessment of the degree of the motor impairment prior to training, in relevant movement tasks. However, standard clinical measures for profiling motor impairment after stroke are often subjective and lack precision. We have developed a novel robot-mediated method for systematic and fine-grained mapping (or profiling) of individual performance across a wide range of planar arm reaching movements. Here we describe and demonstrate this mapping method and its utilization for individualized training. We also present a novel principle for the individualized selection of training movements based on the performance maps.

Methods and Results

To demonstrate the utility of our method we present examples of 2D performance maps produced from the kinetic and kinematics data of two individuals with stroke-related upper limb hemiparesis. The maps outline distinct regions of high motor impairment. The procedure of map-based selection of training movements and the change in motor performance following training is demonstrated for one participant.


The performance mapping method is feasible to produce (online or offline). The 2D maps are easy to interpret and to be utilized for selecting individual performance-based training. Different performance maps can be easily compared within and between individuals, which potentially has diagnostic utility.


Impaired upper-limb (UL) function is one of the most common consequences of stroke [123], which can severely hamper activities of daily living and reduce quality of life. Certain intervention methods can promote some recovery of UL motor function though their outcome shows high variability and depends on the intensity (repetition) of the intervention [456789].

Robotic assistive technologies can be beneficial for improving clinical scores of UL motor impairment [910], by allowing intensive training [911121314]. However, currently there is no consistent evidence for the effectiveness of robot-assisted UL therapy for improving daily living activity [15]. One possibility is that the tasks performed with robotic assistance do not generalise to everyday tasks. Another possibility is that the tasks are not optimised for the trained individuals. Currently, in robot-assisted therapy the set of practiced movements are usually pre-determined, with limited regard to the motor profile of the individual (e.g. ‘centre-out’ point-to-point reaches, or forearm pronation/supination, wrist extension/flexion [161718]). However, the effectiveness of training for motor recovery is likely to depend on the difficulty to perform the task due to motor impairment [19]. For example, training focused on unimpaired movements or on tasks that are either too easy or too difficult is likely to contribute relatively little to motor learning and recovery [192021]. An advantage of the robot-mediated approach is that it allows the collection of various accurate and real-time data about motor performance that would be potentially useful for individualized adjustments of the therapy; e.g. selection of training tasks based on the profile of motor performance. Yet, prescribing training conditions based on a motor performance profile requires characterising motor performance across a range of movement conditions for each individual. Here we present a novel computerised method for systematically mapping individuals’ UL motor performance (or impairment) across a wide range of robot-mediated reaching movements. The map can then serve as a basis for individualised and performance-based selection of training movements.

For optimal utilization of a motor performance map, the mapped metrics should reflect basic components of sensorimotor control, so that the map can be directly linked to processes underlying the movements (e.g. muscle activity and movement representation). Continuous metrics, allowing smoothing and interpolation from tested movements to neighbouring untested regions are also valuable. Accordingly, our mapping of reaching performance is done across the two dimensions of target location (in angular coordinates relative to a central position) and of prescribed starting location (again in angular coordinates relative to the selected target, which indicates the dictated movement direction). The range of target and start locations tests both postural and movement-related aspects of motor control, respectively. Importantly, muscle activation patterns and population neural activity in the motor-related cortices show tuning to one or both task dimensions [22232425], and behavioural studies support the essential underlying role of these parameters in planning of reaching movements [2627].

Of course, the usefulness of a motor performance map for prescribing performance-based training also depends on an appropriate principle for the selection of movements to be practiced. Here we demonstrate the utility of our mapping method for individualized task selection based on a principle which we term “steepest gradients” (SG), although the motor performance map can be the basis for alternative task selection principles. The SG principle is founded on the idea that training with tasks performed with an intermediate range of difficulty would allow more improvement and learning-induced plasticity, compared to training with very difficult or easy tasks [1928] .

Here we report the details of the mapping methods, and show its efficacy in portraying relevant motor impairment patterns for individual subjects. We also briefly demonstrate its utility for individually-tailored selection of practiced movement using the SG principle. However, our evidence for the utility and benefit of the mapping method for individualizing UL robot-mediated rehabilitation after stroke will be reported in subsequent publications.[…]


Continue —> Mapping upper-limb motor performance after stroke – a novel method with utility for individualized motor training | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 1Schematic description of the experimental setting (top view). a The participant held the handle of a robotic manipulandum (indicated onscreen by a red disc; not shown), which allowed planar reaching movements from a start position (white onscreen disc (here gray) to a target position (blue onscreen disc; here black) and provided assisting and guiding forces as needed. Hand’s grip was maintained via a special glove and the forearm was supported against gravity (not shown). The participant leaned his/her head against a headrest, maintaining upright seating posture (ensured using a harness). The horizontal display occluded the hand and the manipulandum from vision. The start-to-target axis (y) and its perpendicular axis (x) correspond to the axes of the assisting and guiding forces, respectively, which were provided during the arm movement as needed by the robot. Adapted from Howard et al. (2009). b The reaching workspace used for mapping performance. The locations of the 8 targets, used in the mapping sessions, are indicated by small open circles. An example of the arm posture when the hand located at the 90o target is shown. Participants were tested with 5cm reaches to each target from 8 start locations (indicated, for the example target, by small black dots). The dashed circle indicates the extent of the mapped workspace. The drawing reflects the actual relationship of target and start locations and arm posture, based on a photograph taken with a healthy participant


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[Abstract] Upper limb motor training using a Saebo™ orthosis is feasible for increasing task-specific practice in hospital after stroke



Assistive technologies have the potential to increase the amount of movement practice provided during inpatient stroke rehabilitation. The primary aim of this study was to investigate the feasibility of using the Saebo-Flex device in a subacute stroke setting to increase task-specific practice for people with little or no active hand movement. The secondary aim was to collect preliminary data comparing hand/upper limb function between a control group that received usual rehabilitation and an intervention group that used, in addition, the Saebo-Flex device.


Nine inpatients (mean three months (median six weeks) post-stroke) participated in this feasibility study conducted in an Australian rehabilitation setting, using a randomised pre-test and post-test design with concealed allocation and blinded outcome assessment. In addition to usual rehabilitation, the intervention group received eight weeks of daily motor training using the Saebo-Flex device. The control group received usual rehabilitation (task-specific motor training) only. Participants were assessed at baseline (pre-randomisation) and at the end of the eight-week study period. Feasibility was assessed with respect to ease of recruitment, application of the device, compliance with the treatment programme and safety. Secondary outcome measures included the Motor Assessment Scale (upper limb items), Box and Block Test, grip strength and the Stroke Impact Scale.


Recruitment to the study was very slow because of the low number of patients with little or no active hand movement. Otherwise, the study was feasible in terms of being able to apply the Saebo-Flex device and compliance with the treatment programme. There were no adverse events, and a greater amount of upper limb rehabilitation was provided to the intervention group. While there were trends in favour of the intervention group, particularly for dexterity, no between-group differences were seen for any of the secondary outcomes.


This pilot feasibility study showed that the use of assistive technology, specifically the Saebo-Flex device, could be successfully used in a sample of stroke patients with little or no active hand movement. However, recruitment to the trial was very slow. The use of the Saebo-FlexTM device had variable results on outcomes, with some positive trends seen in hand function, particularly dexterity.

Source: Upper limb motor training using a Saebo™ orthosis is feasible for increasing task-specific practice in hospital after stroke – Lannin – 2016 – Australian Occupational Therapy Journal – Wiley Online Library

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[ARTICLE] Democratizing Neurorehabilitation: How Accessible are Low-Cost Mobile-Gaming Technologies for Self-Rehabilitation of Arm Disability in Stroke? – Full Text HTML


Motor-training software on tablets or smartphones (Apps) offer a low-cost, widely-available solution to supplement arm physiotherapy after stroke. We assessed the proportions of hemiplegic stroke patients who, with their plegic hand, could meaningfully engage with mobile-gaming devices using a range of standard control-methods, as well as by using a novel wireless grip-controller, adapted for neurodisability. We screened all newly-diagnosed hemiplegic stroke patients presenting to a stroke centre over 6 months. Subjects were compared on their ability to control a tablet or smartphone cursor using: finger-swipe, tap, joystick, screen-tilt, and an adapted handgrip. Cursor control was graded as: no movement (0); less than full-range movement (1); full-range movement (2); directed movement (3). In total, we screened 345 patients, of which 87 satisfied recruitment criteria and completed testing. The commonest reason for exclusion was cognitive impairment. Using conventional controls, the proportion of patients able to direct cursor movement was 38–48%; and to move it full-range was 55–67% (controller comparison: p>0.1). By comparison, handgrip enabled directed control in 75%, and full-range movement in 93% (controller comparison: p<0.001). This difference between controllers was most apparent amongst severely-disabled subjects, with 0% achieving directed or full-range control with conventional controls, compared to 58% and 83% achieving these two levels of movement, respectively, with handgrip. In conclusion, hand, or arm, training Apps played on conventional mobile devices are likely to be accessible only to mildly-disabled stroke patients. Technological adaptations such as grip-control can enable more severely affected subjects to engage with self-training software.


The most important intervention shown to improve physical function after stroke is repetitive, task-directed exercises, supervised by a physiotherapist, with higher intensity leading to faster and greater recovery. In practice, access to physiotherapy is significantly limited by resource availability . For example, 55% of UK stroke in-patients receive less than half the recommended physiotherapy time of 45 minutes per day.

One solution to inadequate physiotherapy is robotic technology, that enables patients to self-practice, with mechanical assistance, via interaction with adapted computer games. While a range of rehabilitation robotics have been marketed over the last decade, and shown to be efficacious, they are not widely used due to factors such as high-cost (typically, $10,000–100,000), cumbersome size, and restriction to patients with high baseline performance, and who have access to specialist rehabilitation centres.

An alternative approach to self-rehabilitation, are medical applications (Apps), or gaming software, run on mobile media devices e.g. tablets or smartphones. Because such devices are low-cost ($200–500), and ubiquitous, they have the potential to democratize computerized-physiotherapy, especially in under-resourced settings, e.g. chronically-disabled in the community. Furthermore, their portability enables home use, while their employment of motivational gaming strategies can potentiate high-intensity motor practice. Accordingly, increasing numbers of motor-training Apps for mobile devices have been commercialised in recent years, and clinical trials are under way. However, since these devices are designed for able-person use, it is questionable as to how well disabled people can access them, and engage meaningfully and repeatedly with rehabilitation software.

This study assesses the degree of motor interaction that can be achieved by hemiplegic stroke patients using four types of conventional hand-control methods (finger swipe, tap, joystick and tilt) for mobile devices. An adapted controller of the same mobile devices, whose materials cost ~$100, was evaluated alongside. Since the latter interface exploits the fact that handgrip is relatively spared in stroke hemiplegia, and is sensitive to subtle forces, we expected that this would increase the range of arm-disability severities able to achieve meaningful computer-game control. In order to assess motor control, with minimal cognitive confounding (given that many softwares also have cognitive demands), we used a simple 1-dimensional motor assessment for all controller types.

Continue —> PLOS ONE: Democratizing Neurorehabilitation: How Accessible are Low-Cost Mobile-Gaming Technologies for Self-Rehabilitation of Arm Disability in Stroke?

Fig 1. Control methods and devices trialled. Conventional control mechanisms were trialled using standard tablet and smartphone (A, B). Subjects were required only to move a cursor along a single vertical path, full-range, and then to an indicated vertical level (they were not tested on playing the underlying game). B shows software used for assessing swipe, with varying cursor size. There was no improvement in accessibility using a larger cursor. The novel control mechanism (C) is a wireless grip-force sensor that detects both finger-flexion and extension movements, the latter assisted by a fingerstrap holding the device within a partially-extended hand. Control software for C entailed moving a circle in a vertical plane towards a target star. Cursor and target stimuli dimensions and contrast are similar between all methods.

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[Abstract] Nerve Stimulation Enhances Task-Oriented Training in Chronic, Severe Motor Deficit After Stroke. A Randomized Trial


Background and Purpose— A sensory-based intervention called peripheral nerve stimulation can enhance outcomes of motor training for stroke survivors with mild-to-moderate hemiparesis. Further research is needed to establish whether this paired intervention can have benefit in cases of severe impairment (almost no active movement).

Methods— Subjects with chronic, severe poststroke hemiparesis (n=36) were randomized to receive 10 daily sessions of either active or sham stimulation (2 hours) immediately preceding intensive task-oriented training (4 hours). Upper extremity movement function was assessed using Fugl–Meyer Assessment (primary outcome measure), Wolf Motor Function Test, and Action Research Arm Test at baseline, immediately post intervention and at 1-month follow-up.

Results— Statistically significant difference between groups favored the active stimulation group on Fugl–Meyer at postintervention (95% confidence interval [CI], 1.1–6.9; P =0.008) and 1-month follow-up (95% CI, 0.6–8.3; P =0.025), Wolf Motor Function Test at postintervention (95% CI, −0.21 to −0.02; P =0.020), and Action Research Arm Test at postintervention (95% CI, 0.8–7.3; P =0.015) and 1-month follow-up (95% CI, 0.6–8.4; P =0.025). Only the active stimulation condition was associated with (1) statistically significant within-group benefit on all outcomes at 1-month follow-up and (2) improvement exceeding minimal detectable change, as well as minimal clinically significant difference, on ≥1 outcomes at ≥1 time points after intervention.

Conclusions— After stroke, active peripheral nerve stimulation paired with intensive task–oriented training can effect significant improvement in severely impaired upper extremity movement function. Further confirmatory studies that consider a larger group, as well as longer follow-up, are needed.

Source: Nerve Stimulation Enhances Task-Oriented Training in Chronic, Severe Motor Deficit After Stroke | Stroke

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[Abstract] Plasticity and Reorganization in the Rehabilitation of Stroke. The Constraint-Induced Movement Therapy (CIMT) Example

Source: Plasticity and Reorganization in the Rehabilitation of Stroke: Plasticity and Reorganization in the Rehabilitation of Stroke: Zeitschrift für Psychologie: Vol 224, No 2

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[Abstract] Ipsilesional anodal tDCS enhances the functional benefits of rehabilitation in patients after stroke.

Stimulating motor recovery in stroke

Rehabilitation of movement after stroke requires repeated practice and involves learning and brain changes. In a new study, Allman et al. tested whether delivering brain stimulation during a 9-day course of hand and arm training improved movement in patients after stroke. The authors found greater improvements in movement in patients who received real compared to sham (placebo) brain stimulation. Better scores in patients who received real stimulation were still present 3 months after training ended. These findings suggest that brain stimulation could be added to rehabilitative training to improve outcomes in stroke patients.


Anodal transcranial direct current stimulation (tDCS) can boost the effects of motor training and facilitate plasticity in the healthy human brain. Motor rehabilitation depends on learning and plasticity, and motor learning can occur after stroke.

We tested whether brain stimulation using anodal tDCS added to motor training could improve rehabilitation outcomes in patients after stroke. We performed a randomized, controlled trial in 24 patients at least 6 months after a first unilateral stroke not directly involving the primary motor cortex. Patients received either anodal tDCS (n = 11) or sham treatment (n = 13) paired with daily motor training for 9 days. We observed improvements that persisted for at least 3 months post-intervention after anodal tDCS compared to sham treatment on the Action Research Arm Test (ARAT) and Wolf Motor Function Test (WMFT) but not on the Upper Extremity Fugl-Meyer (UEFM) score.

Functional magnetic resonance imaging (MRI) showed increased activity during movement of the affected hand in the ipsilesional motor and premotor cortex in the anodal tDCS group compared to the sham treatment group. Structural MRI revealed intervention-related increases in gray matter volume in cortical areas, including ipsilesional motor and premotor cortex after anodal tDCS but not sham treatment. The addition of ipsilesional anodal tDCS to a 9-day motor training program improved long-term clinical outcomes relative to sham treatment in patients after stroke.

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A rehabilitation device, comprising a movement element capable of controlling at least one motion parameter of a portion of a patient; a brain monitor which generates a signal indicative of brain activity; and circuitry including a memory having stored therein rehabilitation information and which inter-relates said signal and movement of said movement element as part of a rehabilitation process which utilizes said rehabilitation information.


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[ARTICLE] The application of virtual reality in neuro-rehabilitation: motor re-learning supported by innovative technologies – Full Text PDF

The motor function impairment resulting from a stroke injury has a negative impact on autonomy, the activities of daily living thus the individuals affected by a stroke need long-term rehabilitation. Several studies have demonstrated that learning new
motor skills is important to induce neuroplasticity and functional recovery.

Innovative technologies used in rehabilitation allow one the possibility to enhance training throughout generated feedback. It seems advantageous to combine traditional motor rehabilitation with innovative technology in order to promote motor re-learning and skill re-acquisition by means of enhanced training.

An environment enriched by feedback involves multiple sensory modalities and could promote active patient participation. Exercises in a virtual environment contain elements necessary to maximize motor learning, such as repetitive and differentiated task practice and feedback on the performance and results. The recovery of the limbs motor function in post-stroke subjects is one of the main therapeutic aims for patients and physiotherapist alike.

Virtual reality as well as robotic devices allow one to provide specific treatment based on the reinforced feedback in a virtual environment (RFVE), artificially augmenting the sensory information coherent with the real-world objects and events. Motor training based on RFVE is emerging as an effective motor learning based techniques for the treatment of the extremities.

more –> Full Text PDF

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[ARTICLE] ReHoblet – A Home-Based Rehabilitation Game on the Tablet – Full Text PDF

Abstract. We present ReHoblet; a physical rehabilitation game on tablets, designed to be used in a residential setting. ReHoblet trains two gross motor movements of the upper limbs by lifting (up-down) and transporting (leftright) the tablet to control a simple platform game. By using its accelerometers and gyroscope, the tablet is capable of detecting movements made by the user and steer the interaction based on this data. A formative evaluation with five Multiple Sclerosis (MS) patients and their therapists showed high appreciation for ReHoblet. Patients stated they liked ReHoblet not only to improve their physical abilities, but to train on performing technology-related tasks. Based on the results, we reflect on tablet-based games in home-based rehabilitation…

–> Full Text PDF

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