Control of double-joint arm posture in adults with unilateral brain damage

Does the Finger-to-Nose Test measure upper limb coordination in chronic stroke?

BACKGROUND

We aimed to kinematically validate that the time to perform the Finger-to-Nose Test (FNT) assesses coordination by determining its construct, convergent and discriminant validity.

METHODS

Experimental, criterion standard study. Both clinical and experimental evaluations were done at a research facility in a rehabilitation hospital. Forty individuals (20 individuals with chronic stroke and 20 healthy, age- and gender-matched individuals) participated.. Both groups performed two blocks of 10 to-and-fro pointing movements (non-dominant/affected arm) between a sagittal target and the nose (ReachIn, ReachOut) at a self-paced speed. Time to perform the test was the main outcome. Kinematics (Optotrak, 100Hz) and clinical impairment/activity levels were evaluated. Spatiotemporal coordination was assessed with slope (IJC) and cross-correlation (LAG) between elbow and shoulder movements.

RESULTS

Compared to controls, individuals with stroke (Fugl-Meyer Assessment, FMA-UE: 51.9 ± 13.2; Box & Blocks, BBT: 72.1 ± 26.9%) made more curved endpoint trajectories using less shoulder horizontal-abduction. For construct validity, shoulder range (β = 0.127), LAG (β = 0.855) and IJC (β = -0.191) explained 82% of FNT-time variance for ReachIn and LAG (β = 0.971) explained 94% for ReachOut in patients with stroke. In contrast, only LAG explained 62% (β = 0.790) and 79% (β = 0.889) of variance for ReachIn and ReachOut respectively in controls. For convergent validity, FNT-time correlated with FMA-UE (r = -0.67, p < 0.01), FMA-Arm (r = -0.60, p = 0.005), biceps spasticity (r = 0.39, p < 0.05) and BBT (r = -0.56, p < 0.01). A cut-off time of 10.6 s discriminated between mild and moderate-to-severe impairment (discriminant validity). Each additional second represented 42% odds increase of greater impairment.

CONCLUSIONS

For this version of the FNT, the time to perform the test showed construct, convergent and discriminant validity to measure UL coordination in stroke.

Spatial control of reflexes, posture and movement in normal conditions and after neurological lesions

Control of reflexes is usually associated with central modulation of their sensitivity (gain) or phase-dependent inhibition and facilitation of their influences on motoneurons (reflex gating). Accumulated empirical findings show that the gain modulation and reflex gating are secondary, emergent properties of central control of spatial thresholds at which reflexes become functional. In this way, the system pre-determines, in a feedforward and task-specific way, where, in a spatial domain or a frame of reference, muscles are allowed to work without directly prescribing EMG activity and forces. This control strategy is illustrated by considering reflex adaptation to repeated muscle stretches in healthy subjects, a process associated with implicit learning and generalization. It has also been shown that spasticity, rigidity, weakness and other neurological motor deficits may have a common source - limitations in the range of spatial threshold control elicited by neural lesions.

Compensatory Versus Noncompensatory Shoulder Movements Used for Reaching in Stroke

Background The extent to which the upper-limb flexor synergy constrains or compensates for arm motor impairment during reaching is controversial. This synergy can be quantified with a minimal marker set describing movements of the arm-plane. Objectives To determine whether and how (a) upper-limb flexor synergy in patients with chronic stroke contributes to reaching movements to different arm workspace locations and (b) reaching deficits can be characterized by arm-plane motion. Methods Sixteen post-stroke and 8 healthy control subjects made unrestrained reaching movements to targets located in ipsilateral, central, and contralateral arm workspaces. Arm-plane, arm, and trunk motion, and their temporal and spatial linkages were analyzed. Results Individuals with moderate/severe stroke used greater arm-plane movement and compensatory trunk movement compared to those with mild stroke and control subjects. Arm-plane and trunk movements were more temporally coupled in stroke compared with controls. Reaching accuracy was related to different segment and joint combinations for each target and group: arm-plane movement in controls and mild stroke subjects, and trunk and elbow movements in moderate/severe stroke subjects. Arm-plane movement increased with time since stroke and when combined with trunk rotation, discriminated between different subject groups for reaching the central and contralateral targets. Trunk movement and arm-plane angle during target reaches predicted the subject group. Conclusions The upper-limb flexor synergy was used adaptively for reaching accuracy by patients with mild, but not moderate/severe stroke. The flexor synergy, as parameterized by the amount of arm-plane motion, can be used by clinicians to identify levels of motor recovery in patients with stroke.

Effect of light on the activity of motor cortex neurons during locomotion

The motor cortex plays a critical role in accurate visually guided movements such as reaching and target stepping. However, the manner in which vision influences the movement-related activity of neurons in the motor cortex is not well understood. In this study we have investigated how the locomotion-related activity of neurons in the motor cortex is modified when subjects switch between walking in the darkness and in light. Three adult cats were trained to walk through corridors of an experimental chamber for a food reward. On randomly selected trials, lights were extinguished for approximately 4s when the cat was in a straight portion of the chamber's corridor. Discharges of 146 neurons from layer V of the motor cortex, including 51 pyramidal tract cells (PTNs), were recorded and compared between light and dark conditions. It was found that while cats' movements during locomotion in light and darkness were similar (as judged from the analysis of three-dimensional limb kinematics and the activity of limb muscles), the firing behavior of 49% (71/146) of neurons was different between the two walking conditions. This included differences in the mean discharge rate (19%, 28/146 of neurons), depth of stride-related frequency modulation (24%, 32/131), duration of the period of elevated firing ([PEF], 19%, 25/131), and number of PEFs among stride-related neurons (26%, 34/131). 20% of responding neurons exhibited more than one type of change. We conclude that visual input plays a very significant role in determining neuronal activity in the motor cortex during locomotion by altering one, or occasionally multiple, parameters of locomotion-related discharges of its neurons.

Differential responses of fast- and slow-conducting pyramidal tract neurons to changes in accuracy demands during locomotion

Most movements need to be accurate. The neuronal mechanisms controlling accuracy during movements are poorly understood. In this study we compare the activity of fast- and slow-conducting pyramidal tract neurons (PTNs) of the motor cortex in cats as they walk over both a flat surface, a task that does not require accurate stepping and can be accomplished without the motor cortex, as well as along a horizontal ladder, a task that requires accuracy and the activity of the motor cortex to be successful. Fast- and slow-conducting PTNs are known to have distinct biophysical properties as well as different afferent and efferent connections. We found that while the activity of all PTNs changes substantially upon transition from simple locomotion to accurate stepping on the ladder, slow-conducting PTNs respond in a much more concerted manner than fast-conducting ones. As a group, slow-conducting PTNs increase discharge rate, especially during the late stance and early swing phases, decrease discharge variability, have a tendency to shift their preferred phase of the discharge into the swing phase, and almost always produce a single peak of activity per stride during ladder locomotion. In contrast, the fast-conducting PTNs do not display such concerted changes to their activity. In addition, upon transfer from simple locomotion to accurate stepping on the ladder slow-conducting PTNs more profoundly increase the magnitude of their stride-related frequency modulation compared with fast-conducting PTNs. We suggest that slow-conducting PTNs are involved in control of accuracy of locomotor movements to a greater degree than fast-conducting PTNs.

Descending corticospinal control of intersegmental dynamics

To make an accurate movement, the CNS has to overcome the inherent complexities of the multijoint limb. For example, interaction torques arise when motion of individual arm segments propagates to adjacent segments causing their movement without any muscle contractions. Since these passive joint torques significantly add to the overall torques generated by active muscular contractions, they must be taken into account during planning or execution of goal-directed movements. We investigated the role of the corticospinal tract in compensating for the interaction torques during arm movements in humans. Twelve subjects reached to visual targets with their arm supported by a robotic exoskeleton. Reaching to one target was accompanied by interaction torques that assisted the movement, while reaching to the other target was accompanied by interaction torques that resisted the movement. Corticospinal excitability was assessed at different times during movement using single-pulse transcranial magnetic stimulation (TMS) over the upper-arm region of M1 (primary motor cortex). We found that TMS responses in shoulder monoarticular and elbow-shoulder biarticular muscles changed together with the interaction torques during movements in which the interaction torques were resistive. In contrast, TMS responses did not correlate with assistive interaction torques or with co-contraction. This suggests that the descending motor command includes compensation for passive limb dynamics. Furthermore, our results suggest that compensation for interaction torques involves the biarticular muscles, which span both shoulder and elbow joints and are in a biomechanically advantageous position to provide such compensation.

Absence of equifinality of hand position in a double-step unloading task

Equifinality, during arm reaching movements, relates to the capacity of the neuromuscular system to attain the same final position in the presence or absence of transient perturbations. There have been several controversies regarding equifinality in the literature. A brief elastic perturbation, applied during a fast arm movement or just before its initiation, typically does not affect final arm position. On the other hand, several experiments have shown that velocity-dependent perturbations, such as Coriolis force or negative damping, while transient in nature, have a significant effect on final arm position when compared to unperturbed movements. In this study, an unloading paradigm was used to study the role of reflexes with respect to equifinality. The effects on final arm position of suddenly decreasing a static load maintained by fourteen subjects were analyzed. Subjects maintained an initial load produced by a double-joint manipulandum moving in the horizontal plane. The load was suddenly decreased, either in one or in two successive steps with different time intervals, resulting in a rapid reflex-mediated change in arm position. Unloading led to short-latency changes in the activity of shoulder and elbow muscles and significant variations in tonic activity. It was found that the final hand position was shorter for double- versus single-step unloading if the time between two successive changes in load was greater than 100 ms. With a shorter time interval, the final hand positions were the same. This difference in final hand positions was inversely proportional to the hand velocity at the time of the second change in load. Further, agonist/antagonist co-activation increased in double-step unloading. Thus, the change in both the load and the movement velocity may influence the magnitude of the unloading reflex. This may be indicative of a dependence of stretch reflexes on velocity. Perturbation may cause a reflex-mediated increase in joint stiffness, which could explain why equifinality is not preserved after some perturbations, such as velocity-dependant external forces.

Control of wrist position and muscle relaxation by shifting spatial frames of reference for motoneuronal recruitment: possible involvement of corticospinal pathways

It has previously been established that muscles become active in response to deviations from a threshold (referent) position of the body or its segments, and that intentional motor actions result from central shifts in the referent position. We tested the hypothesis that corticospinal pathways are involved in threshold position control during intentional changes in the wrist position in humans. Subjects moved the wrist from an initial extended to a final flexed position (and vice versa). Passive wrist muscle forces were compensated with a torque motor such that wrist muscle activity was equalized at the two positions. It appeared that motoneuronal excitability tested by brief muscle stretches was also similar at these positions. Responses to mechanical perturbations before and after movement showed that the wrist threshold position was reset when voluntary changes in the joint angle were made. Although the excitability of motoneurons was similar at the two positions, the same transcranial magnetic stimulus (TMS) elicited a wrist extensor jerk in the extension position and a flexor jerk in the flexion position. Extensor motor-evoked potentials (MEPs) elicited by TMS at the wrist extension position were substantially bigger compared to those at the flexion position and vice versa for flexor MEPs. MEPs were substantially reduced when subjects fully relaxed wrist muscles and the wrist was held passively in each position. Results suggest that the corticospinal pathway, possibly with other descending pathways, participates in threshold position control, a process that pre-determines the spatial frame of reference in which the neuromuscular periphery is constrained to work. This control strategy would underlie not only intentional changes in the joint position, but also muscle relaxation. The notion that the motor cortex may control motor actions by shifting spatial frames of reference opens a new avenue in the analysis and understanding of brain function.

Differences in movement mechanics, electromyographic, and motor cortex activity between accurate and nonaccurate stepping

What are the differences in mechanics, muscle, and motor cortex activity between accurate and nonaccurate movements? We addressed this question in relation to walking. We assessed full-body mechanics (229 variables), activity of 8 limb muscles, and activity of 63 neurons from the motor cortex forelimb representation during well-trained locomotion with different demands on the accuracy of paw placement in cats: during locomotion on a continuous surface and along horizontal ladders with crosspieces of different widths. We found that with increasing accuracy demands, cats assumed a more bent-forward posture (by lowering the center of mass, rotating the neck and head down, and by increasing flexion of the distal joints) and stepped on the support surface with less spatial variability. On the ladder, the wrist flexion moment was lower throughout stance, whereas ankle and knee extension moments were higher and hip moment was lower during early stance compared with unconstrained locomotion. The horizontal velocity time histories of paws were symmetric and smooth and did not differ among the tasks. Most of the other mechanical variables also did not depend on accuracy demands. Selected distal muscles slightly enhanced their activity with increasing accuracy demands. However, in a majority of motor cortex cells, discharge rate means, peaks, and depths of stride-related frequency modulation changed dramatically during accurate stepping as compared with simple walking. In addition, in 30% of neurons periods of stride-related elevation in firing became shorter and in 20-25% of neurons activity or depth of frequency modulation increased, albeit not linearly, with increasing accuracy demands. Considering the relatively small changes in locomotor mechanics and substantial changes in motor cortex activity with increasing accuracy demands, we conclude that during practiced accurate stepping the activity of motor cortex reflects other processes, likely those that involve integration of visual information with ongoing locomotion.

Relationship between stretch reflex thresholds and voluntary arm muscle activation in patients with spasticity

Previous studies have shown that deficits in agonist-antagonist muscle activation in the single-joint elbow system in patients with spastic hemiparesis are directly related to limitations in the range of regulation of the thresholds of muscle activation. We extended these findings to the double-joint, shoulder-elbow system in these patients. Ten non-disabled individuals and 11 stroke survivors with spasticity in upper limb muscles participated. Stroke survivors had sustained a single unilateral stroke 6-36 months previously, had full pain-free passive range of motion of the affected shoulder and elbow and had some voluntary control of the arm. EMG activity from four elbow and two shoulder muscles was recorded during quasi-static (<5 degrees /s) stretching of elbow flexors/extensors and during slow voluntary elbow flexion/extension movement through full range. Stretches and active movements were initiated from full elbow flexion or extension with the shoulder in three different initial positions (60 degrees , 90 degrees , 145 degrees horizontal abduction). SRTs were defined as the elbow angle at which EMG signals began to exceed 2SD of background noise. SRT angles obtained by passive muscle stretch were compared with the angles at which the respective muscles became activated during voluntary elbow movements. SRTs in elbow flexors were correlated with clinical spasticity scores. SRTs of elbow flexors and extensors were within the biomechanical range of the joint and varied with changes in the shoulder angle in all subjects with hemiparesis but could not be reached in this range in all healthy subjects when muscles were initially relaxed. In patients, limitations in the regulation of SRTs resulted in a subdivision of all-possible shoulder-elbow arm configurations into two areas, one in which spasticity was present ("spatial spasticity zone") and another in which it was absent. Spatial spasticity zones were different for different muscles in different patients but, taken together, for all elbow muscles, the zones occupied a large part of elbow-shoulder joint space in each patient. The shape of the boundary between the spasticity and no-spasticity zones depended on the state of reflex inter-joint interaction. SRTs in single- and double-joint flexor muscles correlated with the positions at which muscles were activated during voluntary movements, for all shoulder angles, and this effect was greater in elbow flexor muscles (brachioradialis, biceps brachii). Flexor SRTs correlated with clinical spasticity in elbow flexors only when elbow muscles were at mid-length (90 degrees ). These findings support the notion that motor impairments after CNS damage are related to deficits in the specification and regulation of SRTs, resulting in the occurrence of spasticity zones in the space of elbow-shoulder configurations. It is suggested that the presence of spatial spasticity zones might be a major cause of motor impairments in general and deficits in inter-joint coordination in particular in patients with spasticity.

Threshold position control and the principle of minimal interaction in motor actions

The answer to the question of how the nervous system controls multiple muscles and body segments while solving the redundancy problem in choosing a unique action from the set of many possible actions is still a matter of controversy. In an attempt to clarify the answer, we review data showing that motor actions emerge from central resetting of the threshold position of appropriate body segments, i.e. the virtual position at which muscles are silent but deviations from it will elicit activity and resistive forces (threshold position control). The difference between the centrally-set threshold position and the sensory-signaled actual position is responsible for the activation of neuromuscular elements and interactions between them and the environment. These elements tend to diminish the evoked activity and interactions by minimizing the gap between the actual position and the threshold position (the principle of minimal interaction). Threshold control per se does not solve the redundancy problem: it only limits the set of possible actions. The principle of minimal interaction implies that the system relies on the natural capacity of neuromuscular elements to interact between themselves and with the environment to reduce this already restricted set to a unique action, thus solving the redundancy problem in motor control. This theoretical framework appears to be helpful in the explanation of the control and production of a variety of actions (reaching movements, specification of different hand configurations, grip force generation, and whole-body movements such as sit-to-stand or walking). Experimental tests of this theory are provided. The prediction that several types of neurons specify referent control variables for motor actions may be tested in future studies. The theory may also be advanced by applying the notion of threshold control to perception and cognition.

Threshold control of arm posture and movement adaptation to load

We addressed the fundamental questions of which variables underlie the control of arm movement and how they are stored in motor memory, reproduced and modified in the process of adaptation to changing load conditions. Such variables are defined differently in two major theories of motor control (internal models and threshold control). To resolve the controversy, these theories were tested (experiment 1) based on their ability to explain why active movement away from a stable posture is not opposed by stabilizing mechanisms (the posture-movement problem). The internal model theory suggests that the system counteracts the opposing forces by increasing the muscle activity in proportion to the distance from the initial posture (position-dependent EMG control). In contrast, threshold control fully excludes these opposing forces by shifting muscle activation thresholds and thus resetting the stabilizing mechanisms to a new posture. Subjects were sitting, holding the vertical handle of a double-joint manipulandum with their right hand and were facing a computer screen on which the handle and target to be reached were displayed. In response to an auditory signal, subjects quickly moved the handle from an initial position to one of two (frontal and sagittal) targets. No load was applied during the movement but in separate trials, a brief perturbation was applied to the handle by torque motors controlling the manipulandum. Perturbations were applied prior to or 3 s after movement offset, in the latter case in one of eight directions. The EMG activity of the majority of the seven recorded muscles was at zero level before movement onset and returned to zero level after movement offset. Those muscles that remained active before or after the movement could be made silent whereas previously silent muscles could be activated after a small passive displacement (several millimeters) elicited by perturbations in appropriate directions. Results showed that the activation thresholds of motoneurons of arm muscles were reset from the initial to a final position and that EMG activity was not position-dependent. These results were inconsistent with the internal model theory but confirmed the threshold control theory. Then the ability of threshold control theory to explain rapid movement adaptation to a position-dependent load was investigated (experiment 2 and 3). Subjects produced fast movement to the frontal target with and without a position-dependent load applied to the handle. Trials were organized in blocks alternating between the load and no-load condition (20 blocks in total, with randomly chosen number of five to ten trials in each). Subjects were instructed "do not correct" in experiment 2 and "correct" movement errors during the trial in experiment 3. Five threshold arm configurations underlying the movement production and adaptation were identified. When instructed "do not correct", movement precision was fully restored on average after two trials. No significant improvement was observed as the experiment progressed despite the fact that the same load condition was repeated after one block of trials. Thus, in each block, the adaptation was made anew, implying that subjects relied on short-term memory and could not recall the threshold arm configurations they specified to accurately reach the same target in the same load condition in previous blocks. When instructed to "correct" within each trial, precision was restored faster, on average after one trial. Major aspects of the production and adaptation of arm movement (including the kinematics, movement errors, instruction-dependent behavior, and absence of position-related EMG activity) are explained in terms of threshold control.

Disruption of bilateral temporal coordination during arm swinging in patients with hemiparesis

Persistent motor deficits in the paretic arm present a major barrier to the recovery of the ability to perform bimanual tasks even in individuals who have recovered well after a stroke. Impaired performance may be related to deficits in bimanual temporal coordination due to stroke-related damage of specific brain motor structures as well as changed biomechanics of the paretic arm. To determine the extent of the deficit in bilateral temporal coordination after the stroke, we investigated how bilateral reciprocal coordination was regained after external perturbations of the arm in individuals with hemiparesis due to stroke. We used a bilateral task that would be minimally affected by the unilateral arm motor deficit. Nine non-disabled control subjects and 12 individuals with chronic hemiparesis performed reciprocal (anti-phase) arm swinging in the standing position for 15 s per trial. In each trial, movement of one arm was unexpectedly and transiently (approximately 150-350 ms) arrested at the level of the wrist once in the forward and once in the backward phase of swinging. Perturbation was applied to the left and right arms in control subjects and to the paretic and non-paretic arms of individuals with hemiparesis. Kinematic data from endpoint markers on both hands and electromyographic activity of anterior and posterior deltoid muscles from both arms were recorded. The oscillatory period, the phase differences between arms and the mean EMG activity before, during and after perturbation were analyzed. In both groups the perturbation altered the period of the perturbed cycle in both the arrested and non-arrested arms and resulted in a change from anti-phase to in-phase coordination, following which anti-phase coordination was regained. Recovery of anti-phase swinging took significantly longer in patients with hemiparesis compared to control subjects. Stable pre-perturbed (anti-phase) reciprocal coordination was regained within one cycle following perturbation for the control subjects and within two cycles following perturbation for the patients with hemiparesis. Analysis of EMG activation levels showed that, compared to control subjects, there was significantly less activation of the shoulder muscles in response to perturbation in the patient group and the pattern of muscle activation in the paretic arm was opposite to that in the non-paretic and control arms. The finding that patients had a reduced capacity for maintaining and restoring the required reciprocal coordination when perturbation occurred suggests that stroke-related brain damage in our patients led to instability of bilateral temporal coordination for this rhythmical task.