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Gulde P, Vojta H, Schmidle S, Rieckmann P, Hermsdörfer J. Outside the Laboratory Assessment of Upper Limb Laterality in Patients With Stroke: A Cross-Sectional Study. Stroke 2024; 55:146-155. [PMID: 38037226 DOI: 10.1161/strokeaha.123.043657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/26/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND The rehabilitation of upper limb sensorimotor performance after stroke requires the assessment of daily use, the identification of key levels of impairment, and monitoring the course of recovery. It needs to be answered, how laboratory-based assessments and everyday behavior are connected, which dimension of metrics, that is, volume, intensity, or quality, is most sensitive to reduced function, and what sensor, that is, gyroscope or accelerometer, is best suited to gather such data. METHODS Performance in laboratory-based sensorimotor tests, as well as smartwatch-derived kinematic data of everyday life relative upper limb activity, during 1 day of inpatient neurorehabilitation (Germany, 2022) of 50 patients with stroke, was cross-sectionally assessed and resulting laterality indices (performance ratios) between the limbs were analyzed using ANCOVAs and principal component analysis. RESULTS Laboratory-based tests revealed the strongest laterality indices, followed by smartwatch-based (intensity>quality>volume) metrics. Angular velocity-based metrics revealed higher laterality indices than acceleration-based ones. Laterality indices were overall well associated; however, a principal component analysis suggested upper limb impairments to be unidimensional. CONCLUSIONS Our findings suggest that the use of sensors can deliver valid information of stroke-related laterality. It appeared that commonly used metrics that estimate the volume of use (ie, energy expenditure) are not the most sensitive. Especially reached intensities could be well used for monitoring, because they are more dependent on the performance of the sensorimotor system and less on confounders like age. The unidimensionality of the upper limb laterality suggests that an impaired limb with reduced movement quality and the inability to reach higher intensities will be used less in everyday life, especially when it is the nondominant side.
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Affiliation(s)
- Philipp Gulde
- School of Medicine and Health, Technical University of Munich, Germany (P.G., S.S., J.H.)
| | - Heike Vojta
- Center for Clinical Neuroplasticity, Medical Park Loipl, Bischofswiesen, Germany (H.V., P.R.)
| | - Stephanie Schmidle
- School of Medicine and Health, Technical University of Munich, Germany (P.G., S.S., J.H.)
| | - Peter Rieckmann
- Center for Clinical Neuroplasticity, Medical Park Loipl, Bischofswiesen, Germany (H.V., P.R.)
| | - Joachim Hermsdörfer
- School of Medicine and Health, Technical University of Munich, Germany (P.G., S.S., J.H.)
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Dennler N, Cain A, De Guzman E, Chiu C, Winstein CJ, Nikolaidis S, Matarić MJ. A metric for characterizing the arm nonuse workspace in poststroke individuals using a robot arm. Sci Robot 2023; 8:eadf7723. [PMID: 37967205 DOI: 10.1126/scirobotics.adf7723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 10/19/2023] [Indexed: 11/17/2023]
Abstract
An overreliance on the less-affected limb for functional tasks at the expense of the paretic limb and in spite of recovered capacity is an often-observed phenomenon in survivors of hemispheric stroke. The difference between capacity for use and actual spontaneous use is referred to as arm nonuse. Obtaining an ecologically valid evaluation of arm nonuse is challenging because it requires the observation of spontaneous arm choice for different tasks, which can easily be influenced by instructions, presumed expectations, and awareness that one is being tested. To better quantify arm nonuse, we developed the bimanual arm reaching test with a robot (BARTR) for quantitatively assessing arm nonuse in chronic stroke survivors. The BARTR is an instrument that uses a robot arm as a means of remote and unbiased data collection of nuanced spatial data for clinical evaluations of arm nonuse. This approach shows promise for determining the efficacy of interventions designed to reduce paretic arm nonuse and enhance functional recovery after stroke. We show that the BARTR satisfies the criteria of an appropriate metric for neurorehabilitative contexts: It is valid, reliable, and simple to use.
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Affiliation(s)
- Nathaniel Dennler
- Department of Computer Science, University of Southern California, Los Angeles, CA, USA
| | - Amelia Cain
- Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Erica De Guzman
- Department of Computer Science, University of Southern California, Los Angeles, CA, USA
| | - Claudia Chiu
- Department of Computer Science, University of Southern California, Los Angeles, CA, USA
| | - Carolee J Winstein
- Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Stefanos Nikolaidis
- Department of Computer Science, University of Southern California, Los Angeles, CA, USA
| | - Maja J Matarić
- Department of Computer Science, University of Southern California, Los Angeles, CA, USA
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Bhat SG, Shin AY, Kaufman KR. Upper extremity asymmetry due to nerve injuries or central neurologic conditions: a scoping review. J Neuroeng Rehabil 2023; 20:151. [PMID: 37940959 PMCID: PMC10634143 DOI: 10.1186/s12984-023-01277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/01/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Peripheral nerve injuries and central neurologic conditions can result in extensive disabilities. In cases with unilateral impairment, assessing the asymmetry between the upper extremity has been used to assess outcomes of treatment and severity of injury. A wide variety of validated and novel tests and sensors have been utilized to determine the upper extremity asymmetry. The purpose of this article is to review the literature and define the current state of the art for describing upper extremity asymmetry in patients with peripheral nerve injuries or central neurologic conditions. METHOD An electronic literature search of PubMed, Scopus, Web of Science, OVID was performed for publications between 2000 to 2022. Eligibility criteria were subjects with neurological conditions/injuries who were analyzed for dissimilarities in use between the upper extremities. Data related to study population, target condition/injury, types of tests performed, sensors used, real-world data collection, outcome measures of interest, and results of the study were extracted. Sackett's Level of Evidence was used to judge the quality of the articles. RESULTS Of the 7281 unique articles, 112 articles met the inclusion criteria for the review. Eight target conditions/injuries were identified (Brachial Plexus Injury, Cerebral Palsy, Multiple Sclerosis, Parkinson's Disease, Peripheral Nerve Injury, Spinal Cord Injury, Schizophrenia, and stroke). The tests performed were classified into thirteen categories based on the nature of the test and data collected. The general results related to upper extremity asymmetry were listed for all the reviewed articles. Stroke was the most studied condition, followed by cerebral palsy, with kinematics and strength measurement tests being the most frequently used tests. Studies with a level of evidence level II and III increased between 2000 and 2021. The use of real-world evidence-based data, and objective data collection tests also increased in the same period. CONCLUSION Adequately powered randomized controlled trials should be used to study upper extremity asymmetry. Neurological conditions other than stroke should be studied further. Upper extremity asymmetry should be measured using objective outcome measures like motion tracking and activity monitoring in the patient's daily living environment.
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Affiliation(s)
- Sandesh G Bhat
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kenton R Kaufman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, 55905, USA.
- Motion Analysis Laboratory, Mayo Clinic, DAHLC 4-214A, 200 First Street SW, Rochester, MN, 55905, USA.
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Adaptive control is reversed between hands after left hemisphere stroke and lost following right hemisphere stroke. Proc Natl Acad Sci U S A 2023; 120:e2212726120. [PMID: 36716370 PMCID: PMC9963612 DOI: 10.1073/pnas.2212726120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Human motor adaptability is of utmost utility after neurologic injury such as unilateral stroke. For successful adaptive control of movements, the nervous system must learn to correctly identify the source of a movement error and predictively compensate for this error. The current understanding is that in bimanual tasks, this process is flexible such that errors are assigned to, and compensated for, by the limb that is more likely to produce those errors. Here, we tested the flexibility of the error assignment process in right-handed chronic stroke survivors using a bimanual reaching task in which the hands jointly controlled a single cursor. We predicted that the nondominant left hand in neurotypical adults and the paretic hand in chronic stroke survivors will be more responsible for cursor errors and will compensate more within a trial and learn more from trial to trial. We found that in neurotypical adults, the nondominant left hand does compensate more than the right hand within a trial but learns less trial-to-trial. After a left hemisphere stroke, the paretic right hand compensates more than the nonparetic left hand within-trial but learns less trial-to-trial. After a right hemisphere stroke, the paretic left hand neither corrects more within-trial nor learns more trial-to-trial. Thus, adaptive control of visually guided bimanual reaching movements is reversed between hands after the left hemisphere stroke and lost following the right hemisphere stroke. These results indicate that responsibility assignment is not fully flexible but depends on a central mechanism that is lateralized to the right hemisphere.
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Varghese R, Chang B, Kim B, Liew SL, Schweighofer N, Winstein CJ. Corpus Callosal Microstructure Predicts Bimanual Motor Performance in Chronic Stroke Survivors: a Preliminary Cross-Sectional Study. Top Stroke Rehabil 2022:1-9. [PMID: 35856402 PMCID: PMC9852360 DOI: 10.1080/10749357.2022.2095085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Microstructural changes in the corpus callosum (CC) are associated with more severe motor impairment in the paretic hand, poor recovery, and general disability. The purpose of this study was to determine if CC microstructure predicts bimanual motor performance in chronic stroke survivors. METHODS We examined the relationship between the fractional anisotropy (FA) across the CC, in both the sensorimotor and non-sensorimotor regions, and movement times for two self-initiated and self-paced bimanual tasks in 41 chronic stroke survivors. Using publicly available control datasets (n = 52), matched closely for imaging acquisition parameters, we also explored the effect of stroke and age on callosal microstructure. RESULTS In mild-to-moderate chronic stroke survivors with relatively localized lesions to the motor areas, lower callosal FA values, suggestive of a more disorganized microstructure, were associated with slower bimanual performance. Associations were strongest for the primary motor fibers (b = -2.19 ± 1.03, p = .035), followed closely by premotor/supplementary motor (b = -2.07 ± 1.07, p = .041) and prefrontal (b = -1.92 ± 0.97, p = .05) fibers of the callosum. Secondary analysis revealed that compared to neurologically age-similar adults, chronic stroke survivors exhibited significantly lower mean FA in all regions of the CC, except the splenium. CONCLUSION Remote widespread changes in the callosal genu and body are associated with slower performance on cooperative bimanual tasks that require precise and interdependent coordination of the hands. Measures of callosal microstructure may prove to be a useful predictor of real-world bimanual performance in chronic stroke survivors.
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Affiliation(s)
- Rini Varghese
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA 90089
| | - Brianna Chang
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA 90089
| | - Bokkyu Kim
- SUNY Upstate Medical University, Department of Physical Therapy, Syracuse, NY 13210
| | - Sook-Lei Liew
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA 90089.,Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA 90089
| | - Nicolas Schweighofer
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA 90089
| | - Carolee J. Winstein
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA 90089.,Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033
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Ballester BR, Winstein C, Schweighofer N. Virtuous and Vicious Cycles of Arm Use and Function Post-stroke. Front Neurol 2022; 13:804211. [PMID: 35422752 PMCID: PMC9004626 DOI: 10.3389/fneur.2022.804211] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/03/2022] [Indexed: 12/22/2022] Open
Abstract
Large doses of movement practice have been shown to restore upper extremities' motor function in a significant subset of individuals post-stroke. However, such large doses are both difficult to implement in the clinic and highly inefficient. In addition, an important reduction in upper extremity function and use is commonly seen following rehabilitation-induced gains, resulting in "rehabilitation in vain". For those with mild to moderate sensorimotor impairment, the limited spontaneous use of the more affected limb during activities of daily living has been previously proposed to cause a decline of motor function, initiating a vicious cycle of recovery, in which non-use and poor performance reinforce each other. Here, we review computational, experimental, and clinical studies that support the view that if arm use is raised above an effective threshold, one enters a virtuous cycle in which arm use and function can reinforce each other via self-practice in the wild. If not, one enters a vicious cycle of declining arm use and function. In turn, and in line with best practice therapy recommendations, this virtuous/vicious cycle model advocates for a paradigm shift in neurorehabilitation whereby rehabilitation be embedded in activities of daily living such that self-practice with the aid of wearable technology that reminds and motivates can enhance paretic limb use of those who possess adequate residual sensorimotor capacity. Altogether, this model points to a user-centered approach to recovery post-stroke that is tailored to the participant's level of arm use and designed to motivate and engage in self-practice through progressive success in accomplishing meaningful activities in the wild.
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Affiliation(s)
- Belen R. Ballester
- Synthetic, Perceptive, Emotive and Cognitive Systems Laboratory, Institute for Bioengineering in Catalonia, Barcelona, Spain
| | - Carolee Winstein
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, United States
| | - Nicolas Schweighofer
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, United States
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Pollet AK, Patel P, Lodha N. Does the contribution of the paretic hand to bimanual tasks change with grip strength capacity following stroke? Neuropsychologia 2022; 168:108186. [PMID: 35189182 PMCID: PMC9007327 DOI: 10.1016/j.neuropsychologia.2022.108186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 02/14/2022] [Accepted: 02/17/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The majority of tasks we perform every day require coordinated use of both hands. Following a stroke, the paretic hand contribution to bimanual tasks is often impaired, leading to asymmetric hand use. Grip strength is a commonly used clinical indicator of progress towards stroke motor recovery. The extent to which the paretic hand's contribution to bimanual tasks improves with increasing grip strength is not known. The purpose of this study is to determine how grip strength capacity of the paretic hand influences its contribution to bimanual tasks. METHODS Twenty-one chronic stroke participants and ten older control participants volunteered to take part in this study. The individuals with stroke were recruited in two distinct groups based on the grip strength capacity of paretic hand, i.e., paretic hand strength/non-paretic hand strength, expressed as a percentage. The low strength-capacity group was identified as individuals with grip strength capacity less than 60% and the high strength-capacity group was individuals with grip strength capacity greater than or equal to 60%. All groups performed isometric, grip force contractions in two bimanual tasks - a maximum force production (MVC) task and a submaximal force control task. We quantified the magnitude of force contributed by the paretic and non-paretic hands during both tasks. Additionally, in the force control task we quantified the amount and structure of force variability using coefficient of variation (CV) and approximate entropy (ApEn) for both hands. RESULTS The amount of force contributed by the paretic hand increased in bimanual tasks with an increase in its grip strength capacity, (maximal force production: r = 0.85, p < 0.01; submaximal force control: r = 0.62, p < 0.01). In the bimanual MVC task and bimanual force control task, both hands contributed equal magnitudes of force in the high strength-capacity group but unequal forces in low strength-capacity group. Surprisingly, the amount and structure of force variability in bimanual force control tasks did not change with the increase in grip strength capacity, (CV of force: r = - 0.07, p = 0.77; ApEn: r = - 0.23, p = 0.31). Both low and high strength-capacity stroke groups showed significantly higher CV of force and heightened ApEn compared with the control group. CONCLUSION With the increase in grip strength capacity, the paretic hand contributes greater magnitude of force but continues to show persistent deficits in force modulation in bimanual tasks. Therefore, stroke rehabilitation should emphasize retraining of the paretic hand for force modulation to maximize its use in bimanual tasks.
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Affiliation(s)
- Aviva K Pollet
- Department of Health and Exercise Science, Colorado State University, Fort Collins, USA
| | - Prakruti Patel
- Department of Health and Exercise Science, Colorado State University, Fort Collins, USA
| | - Neha Lodha
- Department of Health and Exercise Science, Colorado State University, Fort Collins, USA.
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Lundquist CB, Nielsen JF, Brunner IC. Prediction of Upper Limb use Three Months after Stroke: A Prospective Longitudinal Study. J Stroke Cerebrovasc Dis 2021; 30:106025. [PMID: 34464925 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/16/2021] [Accepted: 07/25/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND A major goal of upper limb (UL) rehabilitation after stroke is to facilitate the use of the paretic arm in daily life activities. PURPOSE To examine if UL impairment two weeks after stroke can predict real-life UL use at three months. Furthermore, to identify additional factors which contribute to future UL use, and characteristics of patients who do not achieve normal UL use. METHODS This study included patients with stroke ≥ 18 years. UL impairment was assessed by Fugl-Meyer upper extremity motor assessment (FM). Use ratio between affected and unaffected UL was assessed with accelerometers at three months after stroke. The association between FM score and UL use ratio was investigated with linear regression models and adjusted for secondary variables. Non-normal use was examined by a logistic regression. RESULTS Eighty-seven patients were included. FM score two weeks after stroke predicted 38% of the variance in UL use ratio three months after stroke. A multivariate regression model predicted 55%, and the significant predictors were FM, motor-evoked potential (MEP) status, and neglect. Non-normal use could be predicted with a high accuracy based on MEP and/or neglect. In a logistic regression sensitivity for prediction of non-normal use was 0.93 and specificity was 0.75. CONCLUSION Better baseline capacity of the paretic UL predicted increased use of the arm and hand in daily life. Non-normal UL use could be predicted reliably based on the absence of MEPs and/or presence of neglect.
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Affiliation(s)
- Camilla Biering Lundquist
- Research Department, Hammel Neurorehabilitation Centre and University Research Clinic, Hammel, Denmark.
| | - Jørgen Feldbæk Nielsen
- Research Department, Hammel Neurorehabilitation Centre and University Research Clinic, Hammel, Denmark.
| | - Iris Charlotte Brunner
- Research Department, Hammel Neurorehabilitation Centre and University Research Clinic, Hammel, Denmark; Aarhus University, Department of Clinical Medicine, Denmark.
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