Bimanual training in stroke: How do coupling and symmetry-breaking matter?

Background  

The dramatic consequences of stroke on patient autonomy in daily living activities urged the need for new reliable therapeutic strategies. Recently, bimanual training has emerged as a promising tool to improve the functional recovery of upper-limbs in stroke patients. However, who could benefit from bimanual therapy and how it could be used as a part of a more complete rehabilitation protocol remain largely unknown. A possible reason explaining this situation is that coupling and symmetry-breaking mechanisms, two fundamental principles governing bimanual behaviour, have been largely under-explored in both research and rehabilitation in stroke.     

An FPGA hardware/software co-design towards evolvable spiking neural networks for robotics application

This paper presents an approach that permits the effective hardware realization of a novel Evolvable Spiking Neural Network (ESNN) paradigm on Field Programmable Gate Arrays (FPGAs). The ESNN possesses a hybrid learning algorithm that consists of a Spike Timing Dependent Plasticity (STDP) mechanism fused with a Genetic Algorithm (GA). The design and implementation direction utilizes the latest advancements in FPGA technology to provide a partitioned hardware/software co-design solution. The approach achieves the maximum FPGA flexibility obtainable for the ESNN paradigm. The algorithm was applied as an embedded intelligent system robotic controller to solve an autonomous navigation and obstacle avoidance problem.     

Mirror symmetric bimanual movement priming can increase corticomotor excitability and enhance motor learning

Repetitive mirror symmetric bilateral upper limb may be a suitable priming technique for upper limb rehabilitation after stroke. Here we demonstrate neurophysiological and behavioural after-effects in healthy participants after priming with 20 minutes of repetitive active-passive bimanual wrist flexion and extension in a mirror symmetric pattern with respect to the body midline (MIR) compared to an control priming condition with alternating flexion-extension (ALT). Transcranial magnetic stimulation (TMS) indicated that corticomotor excitability (CME) of the passive hemisphere remained elevated compared to baseline for at least 30 minutes after MIR but not ALT, evidenced by an increase in the size of motor evoked potentials in ECR and FCR. Short and long-latency intracortical inhibition (SICI, LICI), short afferent inhibition (SAI) and interhemispheric inhibition (IHI) were also examined using pairs of stimuli. LICI differed between patterns, with less LICI after MIR compared with ALT, and an effect of pattern on IHI, with reduced IHI in passive FCR 15 minutes after MIR compared with ALT and baseline. There was no effect of pattern on SAI or FCR H-reflex. Similarly, SICI remained unchanged after 20 minutes of MIR. We then had participants complete a timed manual dexterity motor learning task with the passive hand during, immediately after, and 24 hours after MIR or control priming. The rate of task completion was faster with MIR priming compared to control conditions. Finally, ECR and FCR MEPs were examined within a pre-movement facilitation paradigm of wrist extension before and after MIR. ECR, but not FCR, MEPs were consistently facilitated before and after MIR, demonstrating no degradation of selective muscle activation. In summary, mirror symmetric active-passive bimanual movement increases CME and can enhance motor learning without degradation of muscle selectivity. These findings rationalise the use of mirror symmetric bimanual movement as a priming modality in post-stroke upper limb rehabilitation.     

From rehabilitation to recovery: protocol for a randomised controlled trial evaluating a goal-based intervention to reduce depression and facilitate participation post-stroke

Background  

There is much discourse in healthcare about the importance of client-centred rehabilitation, however in the realm of community-based therapy post-stroke there has been little investigation into the efficacy of goal-directed practice that reflects patients' valued activities. In addition, the effect of active involvement of carers in such a rehabilitation process and their subsequent contribution to functional and emotional recovery post-stroke is unclear. In community based rehabilitation, interventions based on patients' perceived needs may be more likely to alter such outcomes. In this paper, we describe the methodology of a randomised controlled trial of an integrated approach to facilitating patient goal achievement in the first year post-stroke. The effectiveness of this intervention in reducing the severity of post-stroke depression, improving participation status and health-related quality of life is examined. The impact on carers is also examined.     

Cortical propagation tracks functional recovery after stroke

Stroke is a debilitating condition affecting millions of people worldwide. The development of improved rehabilitation therapies rests on finding biomarkers suitable for tracking functional damage and recovery. To achieve this goal, we perform a spatiotemporal analysis of cortical activity obtained by wide-field calcium images in mice before and after stroke. We compare spontaneous recovery with three different post-stroke rehabilitation paradigms, motor training alone, pharmacological contralesional inactivation and both combined. We identify three novel indicators that are able to track how movement-evoked global activation patterns are impaired by stroke and evolve during rehabilitation: the duration, the smoothness, and the angle of individual propagation events. Results show that, compared to pre-stroke conditions, propagation of cortical activity in the subacute phase right after stroke is slowed down and more irregular. When comparing rehabilitation paradigms, we find that mice treated with both motor training and pharmacological intervention, the only group associated with generalized recovery, manifest new propagation patterns, that are even faster and smoother than before the stroke. In conclusion, our new spatiotemporal propagation indicators could represent promising biomarkers that are able to uncover neural correlates not only of motor deficits caused by stroke but also of functional recovery during rehabilitation. In turn, these insights could pave the way towards more targeted post-stroke therapies.     

Robust Brain-computer Interface for virtual Keyboard (RoBIK): Project results

Brain-Computer Interface (BCI) is a technology that translates the brain electrical activity into a command for a device such as a robotic arm, a wheelchair or a spelling device. BCIs have long been described as an assistive technology for severely disabled patients because they completely bypass the need for muscular activity. The clinical reality is however dramatically different and most patients who use BCIs today are doing so as part of constraining clinical trials. To achieve the technological transfer from bench to bedside, BCI must gain ease of use and robustness of both measure (electroencephalography [EEG]) and interface (signal processing and applications). The Robust Brain-computer Interface for virtual Keyboard (RoBIK) project aimed at the development of a BCI system for communication that could be used on a daily basis by patients without the help of a trained team of researchers. To guide further developments clinicians first assessed patients’ needs. The prototype subsequently developed consisted in a 14 felt-pad electrodes EEG headset sampling at 256 Hz by an electronic component capable of transmitting signals wirelessly. The application was a virtual keyboard generating a novel stimulation paradigm to elicit P300 Evoked Related Potentials (ERPs) for communication. Raw EEG signals were treated with OpenViBE open-source software including novel signal processing and stimulation techniques.     

Recovery in stroke rehabilitation through the rotation of preferred directions induced by bimanual movements: a computational study

Stroke patients recover more effectively when they are rehabilitated with bimanual movement rather than with unimanual movement; however, it remains unclear why bimanual movement is more effective for stroke recovery. Using a computational model of stroke recovery, this study suggests that bimanual movement facilitates the reorganization of a damaged motor cortex because this movement induces rotations in the preferred directions (PDs) of motor cortex neurons. Although the tuning curves of these neurons differ during unimanual and bimanual movement, changes in PD, but not changes in modulation depth, facilitate such reorganization. In addition, this reorganization was facilitated only when encoding PDs are rotated, but decoding PDs are not rotated. Bimanual movement facilitates reorganization because this movement changes neural activities through inter-hemispheric inhibition without changing cortical-spinal-muscle connections. Furthermore, stronger inter-hemispheric inhibition between motor cortices results in more effective reorganization. Thus, this study suggests that bimanual movement is effective for stroke rehabilitation because this movement rotates the encoding PDs of motor cortex neurons.     

Rehabilitation potential of post-stroke patients training for kinesthetic movement imagination: Motor and cognitive aspects

The rehabilitation potential of post-stroke patients was evaluated after a rehabilitation procedure using a hand exoskeleton controlled via a brain–computer interface (BCI). Examples are given for parameters describing the motor and cognitive functions and the capacity for kinesthetic movement imagination. It is emphasized that instrumental quantitative methods are important to use for adequate assessment of both the rehabilitation potential and the effectiveness of the BCI + exoskeleton procedure.     

Skeletal consequences in patients after stroke

Loss of bone mineral density and fractures in patients after stroke are among the most serious health complications. Regarding serious post-stroke impediments, significantly contributing to elevated fracture incidence are falls. An increasing number of subjects after stroke have been observed and better understanding of the nature of skeletal changes might improve the efficacy of their management. The most important issues in post-stroke patients include an evaluation of bone loss magnitude, the occurrence of falls, fracture incidence and prevention procedures. An early start of pharmacological treatment plus exercise are recommended procedures in the early post-stroke stages, in order to diminish as much as possible subsequent bone loss, the direct consequences of which may include hemiosteoporosis, prolonged immobilisation, further falls and fractures.     

Design of a robotic gait trainer using spring over muscle actuators for ankle stroke rehabilitation

Repetitive task training is an effective form of rehabilitation for people suffering from debilitating injuries of stroke. We present the design and working concept of a robotic gait trainer (RGT), an ankle rehabilitation device for assisting stroke patients during gait. Structurally based on a tripod mechanism, the device is a parallel robot that incorporates two pneumatically powered, double-acting, compliant, spring over muscle actuators as actuation links which move the ankle in dorsiflex ion/plantarflexion and inversion/eversion. A unique feature in the tripod design is that the human anatomy is part of the robot, the first fixed link being the patient's leg. The kinematics and workspace of the tripod device have been analyzed determining its range of motion. Experimental gait data from an able-bodied person wearing the working RGT prototype are presented.     

Barrels X-meeting announcement

Abstract

A cerebrovascular accident, otherwise known as stroke, has the potential to damage multiple areas within the brain affecting descending motor control via a multitude of pathways resulting in a wide variety of movement problems. The cortico-reticulospinal system, one of the largest motor systems, is frequently affected, compromising its output, resulting in postural control deficits. The identification of clinically relevant instruments and scales to document and evaluate recovery in post-stroke patients is vital. However, the availability of such measures and scales which take into consideration the role of postural control as an integral component of functional movement performance are scarce. This paper will critically discuss the importance of integrating current neuroscience and motor control knowledge in order to better understand and describe the clinical presentation of persons post-stroke such that the effectiveness of stroke rehabilitation can be appropriately measured.     

Methods in mammalian cell line engineering: from random mutagenesis to sequence-specific approaches

Due to the increasing demand for recombinant proteins, the interest in mammalian cell culture, especially of Chinese hamster ovary cells, grows rapidly. This is accompanied by the desire to improve cell lines in order to achieve higher titers and a better product quality. Until recently, most cell line development procedures were based on random integration and gene amplification, but several methods for targeted genetic modification of cells have been developed. Some of those are homologous recombination, RNA interference and zinc-finger nucleases. Especially the latter two have evolved considerably and will soon become a standard for cell line engineering in research and industrial application. This review presents an overview of established as well as new and promising techniques for targeted genetic modification of mammalian cells.     

Hip circumduction is not a compensation for reduced knee flexion angle during gait

It has long been held that hip abduction compensates for reduced swing-phase knee flexion angle, especially in those after stroke. However, there are other compensatory motions such as pelvic obliquity (hip hiking) that could also be used to facilitate foot clearance with greater energy efficiency. Our previous work suggested that hip abduction may not be a compensation for reduced knee flexion after stroke. Previous study applied robotic knee flexion assistance in people with post-stroke Stiff-Knee Gait (SKG) during pre-swing, finding increased abduction despite improved knee flexion and toe clearance. Thus, our hypothesis was that hip abduction is not a compensation for reduced knee flexion. We simulated the kinematics of post-stroke SKG on unimpaired individuals with three factors: a knee orthosis to reduce knee flexion, an ankle-foot orthosis commonly worn by those post-stroke, and matching gait speeds. We compared spatiotemporal measures and kinematics between experimental factors within healthy controls and with a previously recorded cohort of people with post-stroke SKG. We focused on frontal plane motions of hip and pelvis as possible compensatory mechanisms. We observed that regardless of gait speed, knee flexion restriction increased pelvic obliquity (2.8°, p < 0.01) compared to unrestricted walking (1.5°, p < 0.01), but similar to post-stroke SKG (3.4°). However, those with post-stroke SKG had greater hip abduction (8.2°) compared to unimpaired individuals with restricted knee flexion (4.2°, p < 0.05). These results show that pelvic obliquity, not hip abduction, compensates for reduced knee flexion angle. Thus, other factors, possibly neural, facilitate exaggerated hip abduction observed in post-stroke SKG.     

The Disability Rate of 5-Year Post-Stroke and Its Correlation Factors: A National Survey in China

Few studies on long-term functional outcome have been conducted in post-stroke patients in China. The objective of this study was to conduct a nationwide survey in China to investigate the 5-year prevalence of post-stroke disability and its correlation factors. A total of 893 patients with ischemic stroke were included. Demographic, clinical and neuro-imaging information were collected with standardized instruments that assessed stroke severity, depression, cognitive impairment, stroke recurrence and physical disability. Disability was assessed with the modified Ranking Score (mRS), of which a cutoff score ≥2 indicates disability. Statistical analysis included chi-square tests, two independent samples t-tests, Mann-Whitney U test and multiple logistic regression analysis. The frequency of disability in this study population was 45%. Multivariate analyses revealed that older age, lower education level, previous history of stroke, stroke severity at admission, depression, cognitive impairment at 3 months, and stroke recurrence within 5 years follow up were all significantly associated with post-stroke disability. The disability rate in 5-year post-stroke was high in Chinese patients. Treatment of depression, secondary prevention of stroke and rehabilitation may benefit disabled patients with stroke in China.     

Robotic artificial chordal replacement for repair of mitral valve prolapse

Artificial chordal replacement (ACR) has emerged as a superior method of mitral valve repair with excellent early and late efficacy. It is also ideal to combine with robotic techniques for correction of mitral prolapse, and this article presents a current method of robotic Gore-Tex ACR. Patients with isolated posterior leaflet prolapse are approached with the fourth-generation DaVinci robotic system and endoaortic balloon occlusion. A pledgetted anchor stitch is placed in a papillary muscle, and a 2-o Gore-Tex suture is passed through the anchor pledget. After full annuloplasty ring placement, the Gore-Tex suture is woven into the prolapsing segment and positioned temporarily with robotic forceps. Chordal length is then "adjusted" by lengthening or shortening the temporary knot over 1-cm increments as the valve is tested by injection of cold saline into the ventricle. After achieving good leaflet position and valve competence, the chord is tied permanently. The "adjustable" ACR procedure preserves leaflet surface area and produces a competent valve in the majority of patients. Postoperative transesophageal echo shows a large surface area of coaptation. Patient recovery is facilitated by the minimally invasive approach, while long-term stability of similar open ACR techniques have been excellent with a 2% to 3% failure rate over 10 years of follow-up. Robotic Gore-Tex ACR without leaflet resection is a reproducible procedure that simplifies mitral repair for prolapse. The outcomes observed in early robotic applications have been excellent. It is suggested that most patients with simple prolapse might validly be approached in this manner.     

Hand Preference for a Novel Bimanual Coordinated Task During Termite Feeding in Wild Western Gorillas (<Emphasis Type="Italic">Gorilla gorilla gorilla</Emphasis>)

Although the level of handedness in humans varies cross-culturally, humans are generally described as right-handed, which has been considered a uniquely human trait. Recently, captive chimpanzees (Pan troglodytes) have been shown to exhibit right-hand preference when performing bimanual but not unimanual tasks. Less clear is whether this pattern also occurs in wild chimpanzees and other African apes. Using videos (N = 49) of six wild western gorillas (Gorilla gorilla gorilla) feeding on termites at the Mondika Research Center (Republic of Congo), we tested whether they exhibit hand preference when performing unimanual, i.e., reaching for termite mound pieces; bimanual, i.e., “termite tapping”: rhythmically shaking a piece of termite mound with the dominant hand and collecting the termites in the other hand tasks; or hand transfer prior to bimanual tasks, i.e., transferring a piece of termite mound from one hand to the other. All individuals exhibited exclusive hand preference when performing the bimanual tasks, with five of six gorillas preferring the right hand. Conversely, most individuals did not show any manual preference during the unimanual task. In addition, hand preference during hand transfer revealed clear hand dominance of similar strength and direction of those shown for the bimanual task, suggesting that this measure is as sensitive as the bimanual task itself. Thus, we propose “termite feeding” as a novel task to be considered in future hand-preference studies in wild western gorillas. Our results are in concordance with those for chimpanzees and captive gorillas showing hemispheric specialization for bimanual actions in apes.     

Method for Qualitative and Quantitative Assessment of Proprioceptive Perception of Single-joint Arm Movements

The phenomenon of reproduction of the series of passive single-joint movements in the tested arm by the contralateral arm just in the course of passive movements with no visual control was studied in 35 healthy subjects and 13 post-stroke patients in order to develop a new method for objective assessment of sense of the arm motion for the detection of proprioceptive deficit and for monitoring of the changes in proprioception during rehabilitation. We examined the reproduction of flexion–extension at the elbow and wrist joints, abduction–adduction at the wrist joint and the forearm pronation–supination in both right and left arms in healthy subjects and in the affected arm in post-stroke patients. Displacements of the angles in the tested joint and a homonymous joint of the other arm were acquired by means of video recording system, goniometers, or 9-DoF inertional-magnetometric sensors. Qualitative and quantitative indicators were evaluated to assess the similarity of the passive and active movements. It has been found that the healthy subjects are able to actively reproduce the repeated passive movements at different joints of either the left or right tested arm almost simultaneously and with quite accurate reproduction of an amplitude and shape of movement. At the same time, most of post-stroke patients reproduce movements either with qualitative errors demonstrating incorrect location or wrong estimation of direction or number of repeated test movements, or with significant reduction of accuracy (increased latency or shape distortion). We proposed a method for the assessment of movement proprioception at individual joints. The procedure is easy and convenient for both physicians and patients. It does not require special heavy equipment and can easily be performed under different conditions in a wide range of patients.     

Dynamic balance during walking adaptability tasks in individuals post-stroke

Maintaining dynamic balance during community ambulation is a major challenge post-stroke. Community ambulation requires performance of steady-state level walking as well as tasks that require walking adaptability. Prior studies on balance control post-stroke have mainly focused on steady-state walking, but walking adaptability tasks have received little attention. The purpose of this study was to quantify and compare dynamic balance requirements during common walking adaptability tasks post-stroke and in healthy adults and identify differences in underlying mechanisms used for maintaining dynamic balance. Kinematic data were collected from fifteen individuals with post-stroke hemiparesis during steady-state forward and backward walking, obstacle negotiation, and step-up tasks. In addition, data from ten healthy adults provided the basis for comparison. Dynamic balance was quantified using the peak-to-peak range of whole-body angular-momentum in each anatomical plane during the paretic, nonparetic and healthy control single-leg-stance phase of the gait cycle. To understand differences in some of the key underlying mechanisms for maintaining dynamic balance, foot placement and plantarflexor muscle activation were examined. Individuals post-stroke had significant dynamic balance deficits in the frontal plane across most tasks, particularly during the paretic single-leg-stance. Frontal plane balance deficits were associated with wider paretic foot placement, elevated body center-of-mass, and lower soleus activity. Further, the obstacle negotiation task imposed a higher balance requirement, particularly during the trailing leg single-stance. Thus, improving paretic foot placement and ankle plantarflexor activity, particularly during obstacle negotiation, may be important rehabilitation targets to enhance dynamic balance during post-stroke community ambulation.     

Beneficial effects of footbaths in controlling spasticity after stroke

Footbaths are considered to provide beneficial thermal therapy for post-stroke patients with spasticity, but their anti-spastic effects have not been investigated comprehensively. The present study aimed to evaluate alterations in motor-neuron excitability using F-wave parameters in post-stroke patients with spastic hemiplegia. Subjects’ legs below the knee joint were immersed in water at 41°C and F-wave recordings were made over the abductor hallucis muscle before, immediately after, and 30 min after thermal treatment. Antidromic stimulation was performed on the tibial nerve at the ankle. Measurements included F-wave amplitude, F-wave/M-response ratio, changes in modified Ashworth scale (MAS), body temperature and surface-skin temperature. The mean values of both F-wave parameters were higher on the affected side before footbath treatment. In post-stroke patients, the mean values of F-wave parameters were significantly reduced after footbath treatment (P < 0.01). The anti-spastic effects of footbath treatment were indicated by decreased F-wave parameters, in parallel with decreases in MAS. Body temperature was significantly increased both immediately after, and 30 min following footbath treatment in both groups, which appeared to play an important role in decreased spasticity. Surface-skin temperature increased immediately after footbath treatment in both groups and returned to baseline 30 min later. These findings demonstrate that the use of footbaths is an effective nonpharmacological anti-spastic treatment that might facilitate stroke rehabilitation.     

Effects of Neurofeedback Training on Performing Bimanual Coordination In-phase and Anti-phase Patterns in Children with ADHD

It is generally accepted that children with attention-deficit/hyperactivity disorder (ADHD) have poor motor control, especially in bimanual coordination tasks. Such children characteristically have impaired fine motor ability, problems with force control, and poor motor coordination. They are at particular risk of loss of motor control and reduced bimanual coordination. We tested whether, compared to a control condition, neurofeedback training (NFT) could improve bimanual coordination among children with ADHD. 20 Children with ADHD (mean age 7.9 years; SD 2.11) were randomly assigned either to NFT or to a control condition. All participants completed a bimanual coordination test at the following time points: baseline, assessment 1, assessment 2, assessment 3, and again 12 session later at posttest. NFT consisted of Sensory Motor Rhythm (SMR) training to achieve increased SMR in C3 and C4, while participants in the control condition were under mock NFT conditions. Bimanual coordination accuracy and consistency improved from baseline to completion of the intervention (significant Time effect), but in the NFT condition (significant time?×?group interaction). Compared to the control condition, the NFT group had fewer errors in both patterns of bimanual coordination (significant Group effect). Among children with ADHD, SMR neurofeedback training (NFT) led to significant improvements in a bimanual coordination task. The SMR NFT thus appears to have the potential to improve and enhance the motor control of ADHD patients.