Relationship of diminished interjoint coordination after stroke to hand path consistency

Three Levels of Neural Control Contributing to Performance-stabilizing Synergies in Multi-finger Tasks

We tested a hypothesis on force-stabilizing synergies during four-finger accurate force production at three levels: (1) The level of the reciprocal and coactivation commands, estimated as the referent coordinate and apparent stiffness of all four fingers combined; (2) The level of individual finger forces; and (3) The level of firing of individual motor units (MU). Young, healthy participants performed accurate four-finger force production at a comfortable, non-fatiguing level under visual feedback on the total force magnitude. Mechanical reflections of the reciprocal and coactivation commands were estimated using small, smooth finger perturbations applied by the "inverse piano" device. Firing frequencies of motor units in the flexor digitorum superficialis (FDS) and extensor digitorum communis (EDC) were estimated using surface recording. Principal component analysis was used to identify robust MU groups (MU-modes) with parallel changes in the firing frequency. The framework of the uncontrolled manifold hypothesis was used to compute synergy indices in the spaces of referent coordinate and apparent stiffness, finger forces, and MU-mode magnitudes. Force-stabilizing synergies were seen at all three levels. They were present in the MU-mode spaces defined for MUs in FDS, in EDC, and pooled over both muscles. No effects of hand dominance were seen. The synergy indices defined at different levels of analysis showed no correlations across the participants. The findings are interpreted within the theory of control with spatial referent coordinates for the effectors. We conclude that force stabilization gets contributions from three levels of neural control, likely associated with cortical, subcortical, and spinal circuitry.

Intra-limb joint coordination measures of upper limb and hand movements: A systematic review

BACKGROUND

People with central nervous system disorders typically have difficulties in coordination of the upper limb and hand movements, which significantly impairs their activities of daily living. Laboratory-based measures can provide quantitative and objective information about intra-limb coordination to aid the rehabilitation process of this population. However, there is currently no comprehensive review of laboratory-based measures.

RESEARCH QUESTIONS

The aim of this review was to identify and summarize laboratory-based intra-limb coordination measures for different upper limb and hand movements.

METHODS

Searches were performed in the CINAHL, Embase, IEEE Xplore, MEDLINE, PubMed and Web of Science databases to identify studies published between 2013 and 2022. Two authors independently performed paper selection, data extraction and quality assessment.

RESULTS

21 papers were identified, and six types of coordination measures were classified. These included principal component analysis, continuous relative phase analysis, correlation analysis, regression analysis, uncontrolled manifold analysis, and uncorrelated surrogate data analysis, in descending order of occurrence. Regarding psychometric properties, all measures demonstrated good discriminative validity. However, only the principal component analysis approach and the continuous relative phase analysis approach were found to have good convergent validity and responsiveness, respectively. In terms of their practicality, these measures were primarily utilized for quantifying coordination in individuals with neurological disorders, with a greater emphasis on the coordination of upper limb movements rather than hand movements.

SIGNIFICANCE

This review summarized and critiqued the characteristics of six types of joint coordination measures. Researchers and clinicians should therefore select appropriate measures based on individual needs. Future research should continue on analysing coordination in individuals with pathological conditions and exploring the application of these measures in quantifying hand movement coordination, to advance current knowledge and inform rehabilitation practices.

Integrating Motor Variability Evaluation Into Movement System Assessment

Common assessment tools for determining therapeutic success in rehabilitation typically focus on task-based outcomes. Task-based outcomes provide some understanding of the individual's functional ability and motor recovery; however, these clinical outcomes may have limited translation to a patient's functional ability in the real world. Limitations arise because (1) the focus on task-based outcome assessment often disregards the complexity of motor behavior, including motor variability, and (2) mobility in highly variable real-world environments requires movement adaptability that is made possible by motor variability. This Perspective argues that incorporating motor variability measures that reflect movement adaptability into routine clinical assessment would enable therapists to better evaluate progress toward optimal and safe real-world mobility. The challenges and opportunities associated with incorporating variability-based assessment of pathological movements are also discussed. This Perspective also indicates that the field of rehabilitation needs to leverage technology to advance the understanding of motor variability and its impact on an individual's ability to optimize movement.

IMPACT

This Perspective contends that traditional therapeutic assessments do not adequately evaluate the ability of individuals to adapt their movements to the challenges faced when negotiating the dynamic environments encountered during daily life. Assessment of motor variability derived during movement execution can address this issue and provide better insight into a patient's movement stability and maneuverability in the real world. Creating such a shift in motor system assessment would advance understanding of rehabilitative approaches to motor system recovery and intervention.

Abnormal coordination of upper extremity during target reaching in persons post stroke

Understanding abnormal synergy of the upper extremity (UE) in stroke survivors is critical for better identification of motor impairment. Here, we investigated to what extent stroke survivors retain the ability to coordinate multiple joints of the arm during a reaching task. Using an exoskeleton robot, 37 stroke survivors' arm joint angles (θ) and torques (τ) during hand reaching in the horizontal plane was compared to that of 13 healthy controls. Kinematic and kinetic coordination patterns were quantified as variances of the multiple-joint angles and multiple-joint torques across trials, respectively, that were partitioned into task-irrelevant variance (TIVθ and TIVτ) and task-relevant variance (TRVθ and TRVτ). TIVθ and TRVθ (or TIVτ and TRVτ) led to consistent and inconsistent hand position (or force), respectively. The index of synergy (ISθ and ISτ) was determined as [Formula: see text] and [Formula: see text] for kinematic and kinetic coordination patterns, respectively. Both kinematic ISθ and kinetic ISτ in the stroke group were significantly lower than that of the control group, indicating stroke survivors had impaired reaching abilities in utilizing the multiple joints of the UE for successful completion of a reaching task. The reduction of kinematic ISθ in the stroke group was mainly attributed to the lower TIVθ as compared to the control group, while the reduction of kinetic ISτ was mainly due to the higher [Formula: see text] as well as lower TIVτ. Our results also indicated that stroke may lead to motor deficits in formation of abnormal kinetic synergistic movement of UE, especially during outward movement. The findings in abnormal synergy patterns provides a better understanding of motor impairment, suggesting that impairment-specific treatment could be identified to help improve UE synergies, focusing on outward movements.

Synergic control in asymptomatic welders during multi-finger force exertion and load releasing while standing

Motor synergies, i.e., neural mechanisms that organize multiple motor elements to ensure stability of actions, are affected by several neurological condition. Asymptomatic welders showed impaired synergy controlling the stability of multi-finger action compared to non-welders and this impairment was associated with microstructural damage in the globus pallidus. We further explored the effect of welding-related metal exposure on multi-finger synergy and extended our investigation to posture-stabilizing synergy during a standing task. Occupational, MRI, and performance-stabilizing synergies during multi-finger accurate force production and load releasing while standing were obtained from 29 welders and 19 age- and sex-matched controls. R2* and R1 relaxation rate values were used to estimate brain iron and manganese content, respectively, and diffusion tensor imaging was used to reflect brain microstructural integrity. Associations of brain MRI (caudate, putamen, globus pallidus, and red nucleus), and motor synergy were explored by group status. The results revealed that welders had higher R2* values in the caudate (p = 0.03), putamen (p = 0.01), and red nucleus (p = 0.08, trend) than controls. No group effect was revealed on multi-finger synergy index during steady-state phase of action (ΔVZss). Compared to controls, welders exhibited lower ΔVZss (-0.106 ± 0.084 vs. 0.160 ± 0.092, p = 0.04) and variance that did not affect the performance variable (VUCM, 0.022 ± 0.003 vs. 0.038 ± 0.007, p = 0.03) in the load releasing, postural task. The postural synergy index, ΔVZss, was associated negatively with higher R2* in the red nucleus in welders (r = -0.44, p = 0.03), but not in controls. These results suggest that the synergy index in the load releasing during a standing task may reflect welding-related neurotoxicity in workers with chronic metals exposure. This finding may have important clinical and occupational health implications.

A Dynamical Approach to the Uncontrolled Manifold: Predicting Performance Error During Steady-State Isometric Force Production

The uncontrolled manifold (UCM) approach quantifies the presence of compensatory variability between musculoskeletal elements involved in a motor task. This approach has proved useful for identifying synergistic control strategies for a variety of everyday motor tasks and for investigating how control strategies are affected by motor pathology. However, the UCM approach is limited in its ability to relate compensatory motor variance directly to task performance because variability along the UCM is mathematically agnostic to performance. We present a new approach to UCM analysis that quantifies patterns of irregularity in the compensatory variability between motor elements over time. In a bimanual isometric force stabilization task, irregular patterns of compensation between index fingers predicted greater performance error associated with difficult task conditions, in particular for individuals who exploited a larger set of compensatory strategies (i.e., a larger subspace of the UCM). This relationship between the amount and structure of compensatory motor variance might be an expression of underlying processes supporting performance resilience.

Intramuscle Synergies: Their Place in the Neural Control Hierarchy

We accept a definition of synergy introduced by Nikolai Bernstein and develop it for various actions, from those involving the whole body to those involving a single muscle. Furthermore, we use two major theoretical developments in the field of motor control—the idea of hierarchical control with spatial referent coordinates and the uncontrolled manifold hypothesis—to discuss recent studies of synergies within spaces of individual motor units (MUs) recorded within a single muscle. During the accurate finger force production tasks, MUs within hand extrinsic muscles form robust groups, with parallel scaling of the firing frequencies. The loading factors at individual MUs within each of the two main groups link them to the reciprocal and coactivation commands. Furthermore, groups are recruited in a task-specific way with gains that covary to stabilize muscle force. Such force-stabilizing synergies are seen in MUs recorded in the agonist and antagonist muscles but not in the spaces of MUs combined over the two muscles. These observations reflect inherent trade-offs between synergies at different levels of a control hierarchy. MU-based synergies do not show effects of hand dominance, whereas such effects are seen in multifinger synergies. Involuntary, reflex-based, force changes are stabilized by intramuscle synergies but not by multifinger synergies. These observations suggest that multifinger (multimuscle synergies) are based primarily on supraspinal circuitry, whereas intramuscle synergies reflect spinal circuitry. Studies of intra- and multimuscle synergies promise a powerful tool for exploring changes in spinal and supraspinal circuitry across patient populations.

Ipsilesional arm reaching movements are not affected by the postural configuration adopted by individuals with stroke

Individuals with stroke present several impairments in the ipsilesional arm reaching movements that can limit the execution of daily living activities. These impairments depend on the side of the brain lesion. The present study aimed to compare the arm reaching movements performed in sitting and standing positions and to examine whether the effects of the adopted posture configuration depend on the side of the brain lesion. Twenty right-handed individuals with stroke (half with right hemiparesis and a half with left hemiparesis) and twenty healthy adults (half used the left arm) reached toward a target displayed on a monitor screen placed in one of three heights (i.e., upper, central, or lower targets). Participants performed the reaches in sitting and standing positions under conditions where the target location was either well-known in advance (certainty condition) or unknown until the movement onset (uncertainty condition). The values of movement onset time, movement time, and constant error were compared across conditions (posture configuration and uncertainty) and groups for each target height. Individuals with stroke were slower and spent more time to start to move than healthy participants, mainly when they reached the superior target in the upright position and under the uncertainty condition. Individuals who have suffered a right stroke were more affected by the task conditions and those who suffered a left stroke showed less accurate reaches. Overall, these results were observed regardless of the adopted posture. The current findings suggested that ipsilesional arm reaching movements are not affected by the postural configuration adopted by individuals with stroke. The central nervous system modulates the reaching movements according to the target position, adopted posture, and the uncertainty in the final target position to be reached.

One more time about motor (and non-motor) synergies

We revisit the concept of synergy based on the recently translated classical book by Nikolai Bernstein (On the construction of movements, Medgiz, Moscow 1947; Latash, Bernstein's Construction of Movements, Routledge, Abingdon 2020b) and progress in understanding the physics and neurophysiology of biological action. Two aspects of synergies are described: organizing elements into stable groups (modes) and ensuring dynamical stability of salient performance variables. The ability of the central nervous system to attenuate synergies in preparation for a quick action-anticipatory synergy adjustments-is emphasized. Recent studies have demonstrated synergies at the level of hypothetical control variables associated with spatial referent coordinates for effectors. Overall, the concept of synergies fits naturally the hierarchical scheme of control with referent coordinates with an important role played by back-coupling loops within the central nervous system and from peripheral sensory endings. Further, we review studies showing non-trivial changes in synergies with development, aging, fatigue, practice, and a variety of neurological disorders. Two aspects of impaired synergic control-impaired stability and impaired agility-are introduced. The recent generalization of the concept of synergies for non-motor domains, including perception, is discussed. We end the review with a list of unresolved and troubling issues.

Quantifying Pathological Synergies in the Upper Extremity of Stroke Subjects With the Use of Inertial Measurement Units: A Pilot Study

BACKGROUND

Stroke is one of the main causes of disability in the world, causing loss of motor function on mainly one side of the body. A proper assessment of motor function is required to help to direct and evaluate therapy. Assessment is currently performed by therapists using observer-based standardized clinical assessment protocols. Sensor-based technologies can be used to objectively quantify the presence and severity of motor impairments in stroke patients.

METHODS

In this work, a minimally obstructive distributed inertial sensing system, intended to measure kinematics of the upper extremity, was developed and tested in a pilot study, where 10 chronic stroke subjects performed the arm-related tasks from the Fugl-Meyer Assessment protocol with the affected and non-affected side.

RESULTS

The pilot study showed that the developed distributed measurement system was adequately sensitive to show significant differences in stroke subjects' arm postures between the affected and non-affected side. The presence of pathological synergies can be analysed using the measured joint angles of the upper limb segments, that describe the movement patterns of the subject.

CONCLUSION

Features measured by the system vary from the assessed FMA-UE sub-score showing its potential to provide more detailed clinical information.

Stability of reaching during standing in stroke

Reaching from standing requires simultaneous adjustments of focal and postural task elements. We investigated the ability of people with stroke to stabilize the endpoint trajectory while maintaining balance during standing reaches. Nineteen stroke and 11 age-equivalent healthy subjects reached toward a target (n = 30 trials) located beyond arm length from standing. Endpoint and center-of-mass (COM) trajectories were analyzed using the uncontrolled manifold (UCM) approach, with segment angles as elemental variables. A synergy index (SI) represented the normalized difference between segment angle combinations, leading to endpoint or COM trajectory stabilization (V_UCM) and lack of stabilization (in an orthogonal space; V_ORT). A higher SI reflects greater stability. In both groups, the endpoint SI (SI_END) decreased in parallel with endpoint velocity and returned close to baseline at the end of the movement. The range of SI_END was significantly greater in stroke (median: 0.87; QR:0.54) compared with healthy subjects (median: 0.58; QR: 0.33; P = 0.009). In both groups, the lowest SI_END occurred at the endpoint peak velocity, whereas the minimal SI_END of the stroke group (median: 0.51; QR:0.41) was lower than the healthy group (median: 0.25; QR: 0.50; P = 0.033). The COM SI (SI_COM) remained stable in both groups (~0.8). The maintenance of a high SI_COM despite a large reduction of SI_END in stroke subjects suggests that kinematic redundancy was effectively used to stabilize the COM position, but less so for endpoint position stabilization. Both focal and postural task elements should be considered when analyzing whole body reaching deficits in patients with stroke.NEW & NOTEWORTHY Reaching from standing requires simultaneous adjustments of endpoint and center-of-mass (COM) positions. We used uncontrolled manifold analysis to investigate the impact of stroke on the ability to use kinematic redundancy in this task. Our results showed that COM position was stabilized, whereas endpoint trajectory was more variable in stroke than healthy subjects. Enhancing the capacity to meet multiple task goals may be beneficial for motor recovery after stroke.

Coordination in adults with neurological impairment - A systematic review of uncontrolled manifold studies

BACKGROUND

Analysis of sensorimotor synergies has been greatly advanced by the Uncontrolled Manifold (UCM) approach. The UCM method is based on partitioning inter-trial variance displayed by elemental variables into 'good' (V_UCM) and 'bad' (V_ORT) variability that, respectively, indicate maintenance or loss of task stability. In clinical populations, these indices can be used to investigate the strength, flexibility, stereotypy and agility of synergistic control.

RESEARCH QUESTION

How are synergies affected by neurological impairment in adults? Specifically, this study aimed to determine i) the impact of pathology on V_UCM, V_ORT, and their ratio (synergy index); ii) the relationship between synergy indices and functional performance; iii) changes in anticipatory synergy adjustments (ASAs); and iv) the effects of interventions on synergies.

METHODS

Systematic review of UCM studies on adults with neurological impairment.

RESULTS

Most of the 17 studies had moderate to high quality scores in the adapted Critical Review Form and the UCM reporting quality checklist developed for this review. i) Most of the studies found reduced synergy indices for patients with Parkinson's disease (PD), olivo-ponto-cerebellar atrophy, multiple sclerosis and spinocerebellar degeneration, with variable levels of change in V_UCM and V_ORT. Reduction in synergy indices was not as consistent for stroke, in three out of six studies it was unchanged. ii) Five of seven studies found no significant correlations between scores on motor function scales and UCM indices. iii) Seven studies consistently reported ASAs that are smaller in magnitude, delayed, or both, for patients compared to healthy controls. iv) Two studies reported increased synergy indices, either via increase in V_UCM or decrease in V_ORT, after dopaminergic drugs for patients with PD. There were similar synergy indices but improved ASAs after deep brain stimulation for patients with PD.

SIGNIFICANCE

UCM can provide reliable and sensitive indicators of altered synergistic control in adults with neurological impairment.

Post-stroke kinematic analysis in rats reveals similar reaching abnormalities as humans

A coordinated pattern of multi-muscle activation is essential to produce efficient reaching trajectories. Disruption of these coordinated activation patterns, termed synergies, is evident following stroke and results in reaching deficits; however, preclinical investigation of this phenomenon has been largely ignored. Furthermore, traditional outcome measures of post-stroke performance seldom distinguish between impairment restitution and compensatory movement strategies. We sought to address this by using kinematic analysis to characterize reaching movements and kinematic synergies of rats performing the Montoya staircase task, before and after ischemic stroke. Synergy was defined as the simultaneous movement of the wrist and other proximal forelimb joints (i.e. shoulder, elbow) during reaching. Following stroke, rats exhibited less individuation between joints, moving the affected limb more as a unit. Moreover, abnormal flexor synergy characterized by concurrent elbow flexion, shoulder adduction, and external rotation was evident. These abnormalities ultimately led to inefficient and unstable reaching trajectories, and decreased reaching performance (pellets retrieved). The observed reaching abnormalities in this preclinical stroke model are similar to those classically observed in humans. This highlights the potential of kinematic analysis to better align preclinical and clinical outcome measures, which is essential for developing future rehabilitation strategies following stroke.

Stability of steady hand force production explored across spaces and methods of analysis

We used the framework of the uncontrolled manifold (UCM) hypothesis and explored the reliability of several outcome variables across different spaces of analysis during a very simple four-finger accurate force production task. Fourteen healthy, young adults performed the accurate force production task with each hand on 3 days. Small spatial finger perturbations were generated by the "inverse piano" device three times per trial (lifting the fingers 1 cm/0.5 s and lowering them). The data were analyzed using the following main methods: (1) computation of indices of the structure of inter-trial variance and motor equivalence in the space of finger forces and finger modes, and (2) analysis of referent coordinates and apparent stiffness values for the hand. Maximal voluntary force and the index of enslaving (unintentional finger force production) showed good to excellent reliability. Strong synergies stabilizing total force were reflected in both structure of variance and motor equivalence indices. Variance within the UCM and the index of motor equivalent motion dropped over the trial duration and showed good to excellent reliability. Variance orthogonal to the UCM and the index of non-motor equivalent motion dropped over the 3 days and showed poor to moderate reliability. Referent coordinate and apparent stiffness indices co-varied strongly and both showed good reliability. In contrast, the computed index of force stabilization showed poor reliability. The findings are interpreted within the scheme of neural control with referent coordinates involving the hierarchy of two basic commands, the r-command and c-command. The data suggest natural drifts in the finger force space, particularly within the UCM. We interpret these drifts as reflections of a trade-off between stability and optimization of action. The implications of these findings for the UCM framework and future clinical applications are explored in the discussion. Indices of the structure of variance and motor equivalence show good reliability and can be recommended for applied studies.

Learning alternative movement coordination patterns using reinforcement feedback

One of the characteristic features of the human motor system is redundancy-i.e., the ability to achieve a given task outcome using multiple coordination patterns. However, once participants settle on using a specific coordination pattern, the process of learning to use a new alternative coordination pattern to perform the same task is still poorly understood. Here, using two experiments, we examined this process of how participants shift from one coordination pattern to another using different reinforcement schedules. Participants performed a virtual reaching task, where they moved a cursor to different targets positioned on the screen. Our goal was to make participants use a coordination pattern with greater trunk motion, and to this end, we provided reinforcement by making the cursor disappear if the trunk motion during the reach did not cross a specified threshold value. In Experiment 1, we compared two reinforcement schedules in two groups of participants-an abrupt group, where the threshold was introduced immediately at the beginning of practice; and a gradual group, where the threshold was introduced gradually with practice. Results showed that both abrupt and gradual groups were effective in shifting their coordination patterns to involve greater trunk motion, but the abrupt group showed greater retention when the reinforcement was removed. In Experiment 2, we examined the basis of this advantage in the abrupt group using two additional control groups. Results showed that the advantage of the abrupt group was because of a greater number of practice trials with the desired coordination pattern. Overall, these results show that reinforcement can be successfully used to shift coordination patterns, which has potential in the rehabilitation of movement disorders.

Spasticity may obscure motor learning ability after stroke

Previous motor learning studies based on adapting movements of the hemiparetic arm in stroke subjects have not accounted for spasticity occurring in specific joint ranges (spasticity zones), resulting in equivocal conclusions about learning capacity. We compared the ability of participants with stroke to rapidly adapt elbow extension movements to changing external load conditions outside and inside spasticity zones. Participants with stroke ( n = 12, aged 57.8 ± 9.6 yr) and healthy age-matched controls ( n = 8, 63.5 ± 9.1 yr) made rapid 40°-50° horizontal elbow extension movements from an initial (3°) to a final (6°) target. Sixteen blocks (6-10 trials/block) consisting of alternating loaded (30% maximal voluntary contraction) and nonloaded trials were made in one (controls) or two sessions (stroke; 1 wk apart). For the stroke group, the tonic stretch reflex threshold angle at which elbow flexors began to be activated during passive elbow extension was used to identify the beginning of the spasticity zone. The task was repeated in joint ranges that did or did not include the spasticity zone. Error correction strategies were identified by the angular positions before correction and compared between groups and sessions. Changes in load condition from no load to load and vice versa resulted in undershoot and overshoot errors, respectively. Stroke subjects corrected errors in 1-4 trials compared with 1-2 trials in controls. When movements did not include the spasticity zone, there was an immediate decrease in the number of trials needed to restore accuracy, suggesting that the capacity to learn may be preserved after stroke but masked by the presence of spasticity. NEW & NOTEWORTHY When arm movements were made outside, instead of inside, the range affected by spasticity, there was an immediate decrease in the number of trials needed to restore accuracy in response to a change in the external load. This suggests that motor learning processes may be preserved in patients with stroke but masked by the presence of spasticity in specific joint ranges. This has important implications for designing rehabilitation interventions predicated on motor learning principles.