Unilateral arm paralysis is a common symptom of stroke. In stroke patients, we observed that self-guided biomechanical support by the nonparetic arm unexpectedly triggered electromyographic activity with normal muscle synergies in the paretic arm. The muscle activities on the paretic arm became similar to the muscle activities on the nonparetic arm with self-supported exercises that were quantified by the similarity index (SI). Electromyogram (EMG) signals and functional near-infrared spectroscopy (fNIRS) of the patients (n=54) showed that self-supported exercise can have an immediate effect of improving the muscle activities by 40–80% according to SI quantification, and the muscle activities became much more similar to the muscle activities of the age-matched healthy subjects. Using this self-supported exercise, we investigated whether the recruitment of a patient’s contralesional nervous system could reactivate their ipsilesional neural circuits and stimulate functional recovery. We proposed biofeedback training with self-supported exercise where the muscle activities were visualized to encourage the appropriate neural pathways for activating the muscles of the paretic arm. We developed the biofeedback system and tested the recovery speed with the patients (n=27) for 2 months. The clinical tests showed that self-support-based biofeedback training improved SI approximately by 40%, Stroke Impairment Assessment Set (SIAS) by 35%, and Functional Independence Measure (FIM) by 20%.
Stroke is the leading cause of long-term disability worldwide. Of more than 750,000 stroke victims in the United States each year , approximately two-thirds survive and require immediate rehabilitation to recover lost brain functions . These stroke rehabilitation programs, of which direct and indirect costs were estimated to be 73.7 billion dollars in 2010 , aim to help survivors gain physical independence and better quality of life.
Stroke damage typically interrupts blood flow within one brain hemisphere, resulting in unilateral motor deficits, sensory deficits, or both. The preservation of long-term neural and synaptic plasticity is essential for the functional reorganization and recovery of neural pathways disrupted by stroke –. Stroke survivors typically require long-term, intensive rehabilitation training due to the length of time required for these recovery processes , . The typical time course for partial recovery of arm movement after mild to moderate unilateral stroke damage is 2 to 6 months, depending on the severity of tissue damage and the latency of treatment initiation , ; however, patients with severe damage require additional months to years of rehabilitation. Given the economic burden on patients’ families and the medical system, novel rehabilitation methods that promote rapid and complete functional recovery are needed, along with a better understanding of the functional mechanisms and neural circuits that can participate in potential therapeutic processes. The identification of rehabilitation methods that can more effectively recover brain functions in the damaged hemisphere by re-engaging dormant motor functions should be a major global objective, from both economic and societal perspectives. Such an objective would require the interface of biology, medical research, and clinical practice .
Recently, candidate brain areas that become activated during stroke recovery have been identified in patients and animal models . Brain imaging studies during stroke recovery suggest that the extent of functional motor recovery is associated with an increase in neuronal activity in the sensorimotor cortex of the ipsilesional hemisphere –. Other work has suggested that repetitive sensorimotor tasks may promote cortical reorganization and functional recovery in the ipsilesional area by increasing bilateral cortical activity to enhance neuroplasticity . Activation in the contralesional hemisphere is also observed in the early stages of post-stroke patients. This activation has been explained by the emergence of communication in corticospinal projections that are silent in the healthy state , and it may also contribute to movement-related neural activity on the ipsilesional limb , . Functional brain imaging studies show that activity of the contralesional hemisphere is increased early after stroke and gradually declines as recovery progresses . The functional relevance of contralesional recruitment remains unclear , . Some reported studies have linked high abnormal activity to a high inhibitory signaling drive onto the ipsilesional cortex , which may be a major contributor to motor impairment , . Recent studies have also investigated the benefits of activating the contralesional and/or ipsilesional hemispheres in functional motor recovery using brain-computer interface (BCI) and transcranial magnetic stimulation (TMS) therapies , .
Current stroke rehabilitation approaches have largely focused on paretic limb rehabilitation interventions such as muscle strengthening and endurance training , forced-use therapy , constraint-induced exercise , robot therapy with biofeedback , nonparetic limb interventions (e.g., mirror-therapy , ), or bilateral/bimanual training , . However, to date, none have clearly investigated how the use of a patient’s unaffected neural circuits in the healthy cortical hemisphere, or in the local peripheral circuit, affect the impaired limb in terms of functional rehabilitation of the bilateral cortical sensorimotor network .
In this study, we investigated a motor recovery approach for post-stroke unilateral arm impairment that combined sensory feedback, motor control, and motor intention. While observing a patient cohort with unilateral stroke damage and arm movement impairment, we found that a specific self-guided motion, which we termed self-supported exercise, surprisingly reactivated a healthy muscles pattern in the paretic arm. The key of the self-supported exercise is use of the nonparetic arm as a support to help move the paretic arm. First, we will show the observation of appropriate muscle recruitment and reduction of abnormal muscle synergies for post-stroke patients during the self-supported exercise, which are a common problem in stroke recovery . Then, we conduct the experiments of functional imaging and electromyography recordings and characterized the neurobiology and physiology of this self-supported exercise. Based on this mechanism, we designed a rehabilitation program involving biofeedback-aided self-supported exercises that employ a patients’ self-initiated motor intention. The results of the comparative experiments between the feedback training cohorts and the control cohorts show that this method results in efficient recovery from post-stroke motion paralysis. Finally, we discuss the significance of our findings for the design of biologically-based stroke rehabilitation.[…]
via Self-Support Biofeedback Training for Recovery From Motor Impairment After Stroke – IEEE Journals & Magazine
FIGURE 2.The four types of exercises.