Side of lesion influences interhemispheric inhibition in subjects with post-stroke hemiparesis

The impact of lesion side on bilateral upper limb coordination after stroke

BACKGROUND

A stroke frequently results in impaired performance of activities of daily life. Many of these are highly dependent on effective coordination between the two arms. In the context of bimanual movements, cyclic rhythmical bilateral arm coordination patterns can be classified into two fundamental modes: in-phase (bilateral homologous muscles contract simultaneously) and anti-phase (bilateral muscles contract alternately) movements. We aimed to investigate how patients with left (LHS) and right (RHS) hemispheric stroke are differentially affected in both individual-limb control and inter-limb coordination during bilateral movements.

METHODS

We used kinematic measurements to assess bilateral coordination abilities of 18 chronic hemiparetic stroke patients (9 LHS; 9 RHS) and 18 age- and sex-matched controls. Using KINARM upper-limb exoskeleton system, we examined individual-limb control by quantifying trajectory variability in each hand and inter-limb coordination by computing the phase synchronization between hands during anti- and in-phase movements.

RESULTS

RHS patients exhibited greater impairment in individual- and inter-limb control during anti-phase movements, whilst LHS patients showed greater impairment in individual-limb control during in-phase movements alone. However, LHS patients further showed a swap in hand dominance during in-phase movements.

CONCLUSIONS

The current study used individual-limb and inter-limb kinematic profiles and showed that bilateral movements are differently impaired in patients with left vs. right hemispheric strokes. Our results demonstrate that both fundamental bilateral coordination modes are differently controlled in both hemispheres using a lesion model approach. From a clinical perspective, we suggest that lesion side should be taken into account for more individually targeted bilateral coordination training strategies.

TRIAL REGISTRATION

the current experiment is not a health care intervention study.

Cortical Stimulation Paired With Volitional Unimanual Movement Affects Interhemispheric Communication

Cortical stimulation (CS) of the motor cortex can cause excitability changes in both hemispheres, showing potential to be a technique for clinical rehabilitation of motor function. However, previous studies that have investigated the effects of delivering CS during movement typically focus on a single hemisphere. On the other hand, studies exploring interhemispheric interactions typically deliver CS at rest. We sought to bridge these two approaches by documenting the consequences of delivering CS to a single motor cortex during different phases of contralateral and ipsilateral limb movement, and simultaneously assessing changes in interactions within and between the hemispheres via local field potential (LFP) recordings. Three macaques were trained in a unimanual reaction time (RT) task and implanted with epidural or intracortical electrodes over bilateral motor cortices. During a given session CS was delivered to one hemisphere with respect to movements of either the contralateral or ipsilateral limb. Stimulation delivered before contralateral limb movement onset shortened the contralateral limb RT. In contrast, stimulation delivered after the end of contralateral movement increased contralateral RT but decreased ipsilateral RT. Stimulation delivered before ipsilateral limb movement decreased ipsilateral RT. All other stimulus conditions as well as random stimulation and periodic stimulation did not have consistently significant effects on either limb. Simultaneous LFP recordings from one animal revealed correlations between changes in interhemispheric alpha band coherence and changes in RT, suggesting that alpha activity may be indicative of interhemispheric communication. These results show that changes caused by CS to the functional coupling within and between precentral cortices is contingent on the timing of CS relative to movement.

Resting motor threshold in the course of hand motor recovery after stroke: a systematic review

Background

Resting motor threshold is an objective measure of cortical excitability. Numerous studies indicate that the success of motor recovery after stroke is significantly determined by the direction and extent of cortical excitability changes. A better understanding of this topic (particularly with regard to the level of motor impairment and the contribution of either cortical hemisphere) may contribute to the development of effective therapeutical strategies in this cohort.

Objectives

This systematic review collects and analyses the available evidence on resting motor threshold and hand motor recovery in stroke patients.

Methods

PubMed was searched from its inception through to 31/10/2020 on studies investigating resting motor threshold of the affected and/or the non-affected hemisphere and motor function of the affected hand in stroke cohorts.

Results

Overall, 92 appropriate studies (including 1978 stroke patients and 377 healthy controls) were identified. The analysis of the data indicates that severe hand impairment is associated with suppressed cortical excitability within both hemispheres and with great between-hemispheric imbalance of cortical excitability. Favorable motor recovery is associated with an increase of ipsilesional motor cortex excitability and reduction of between-hemispheric imbalance. The direction of change of contralesional motor cortex excitability depends on the amount of hand motor impairment. Severely disabled patients show an increase of contralesional motor cortex excitability during motor recovery. In contrast, recovery of moderate to mild hand motor impairment is associated with a decrease of contralesional motor cortex excitability.

Conclusions

This data encourages a differential use of rehabilitation strategies to modulate cortical excitability. Facilitation of the ipsilesional hemisphere may support recovery in general, whereas facilitation and inhibition of the contralesional hemisphere may enhance recovery in severe and less severely impaired patients, respectively.

Modulation of Functional Connectivity in Response to Mirror Visual Feedback in Stroke Survivors: An MEG Study

Background. Several brain regions are activated in response to mirror visual feedback (MVF). However, less is known about how these brain areas and their connectivity are modulated in stroke patients. This study aimed to explore the effects of MVF on brain functional connectivity in stroke patients. Materials and Methods. We enrolled 15 stroke patients who executed Bilateral-No mirror, Bilateral-Mirror, and Unilateral-Mirror conditions. The coherence values among five brain regions of interest in four different frequency bands were calculated from magnetoencephalographic signals. We examined the differences in functional connectivity of each two brain areas between the Bilateral-No mirror and Bilateral-Mirror conditions and between the Bilateral-Mirror and Unilateral-Mirror conditions. Results. The functional connectivity analyses revealed significantly stronger connectivity between the posterior cingulate cortex and primary motor cortex in the beta band (adjusted p = 0.04) and possibly stronger connectivity between the precuneus and primary visual cortex in the theta band (adjusted p = 0.08) in the Bilateral-Mirror condition than those in the Bilateral-No mirror condition. However, the comparisons between the Bilateral-Mirror and Unilateral-Mirror conditions revealed no significant differences in cortical coherence in all frequency bands. Conclusions. Providing MVF to stroke patients may modulate the lesioned primary motor cortex through visuospatial and attentional cortical networks.

Baseline Motor Impairment Predicts Transcranial Direct Current Stimulation Combined with Physical Therapy-Induced Improvement in Individuals with Chronic Stroke

Transcranial direct current stimulation (tDCS) can enhance the effect of conventional therapies in post-stroke neurorehabilitation. The ability to predict an individual's potential for tDCS-induced recovery may permit rehabilitation providers to make rational decisions about who will be a good candidate for tDCS therapy. We investigated the clinical and biological characteristics which might predict tDCS plus physical therapy effects on upper limb motor recovery in chronic stroke patients. A cohort of 80 chronic stroke individuals underwent ten to fifteen sessions of tDCS plus physical therapy. The sensorimotor function of the upper limb was assessed by means of the upper extremity section of the Fugl-Meyer scale (UE-FM), before and after treatment. A backward stepwise regression was used to assess the effect of age, sex, time since stroke, brain lesion side, and basal level of motor function on UE-FM improvement after treatment. Following the intervention, UE-FM significantly improved (p < 0.05), and the magnitude of the change was clinically important (mean 6.2 points, 95% CI: 5.2-7.4). The baseline level of UE-FM was the only significant predictor (R 2 = 0.90, F (1, 76) = 682.80, p < 0.001) of tDCS response. These findings may help to guide clinical decisions according to the profile of each patient. Future studies should investigate whether stroke severity affects the effectiveness of tDCS combined with physical therapy.

Cortical neural activity evoked by bilateral and unilateral mirror therapy after stroke

OBJECTIVE

This study aimed to investigate the differential effects of bilateral and unilateral mirror therapy (MT) on motor cortical activations in stroke patients by magnetoencephalography (MEG).

METHODS

Sixteen stroke patients and 16 right-handed healthy volunteers were recruited. All participants were required to perform 4 conditions: resting, no mirror with bilateral hand movements (Bilateral-No mirror), mirror with bilateral hand movements (Bilateral-Mirror) and mirror with unilateral hand movements (Unilateral-Mirror). Beta oscillatory activities in the primary motor cortex (M1) were collected during each condition using MEG. The percentage change of beta oscillatory activity was calculated for each condition to correct the baseline differences.

RESULTS

In the stroke group, the percentage change of M1 beta oscillatory activity significantly decreased more in the Bilateral-Mirror condition than in the Bilateral-No mirror and Unilateral-Mirror conditions. In the healthy group, no significant differences in the percentage change of beta oscillatory activity were found among the 3 conditions. Further, a significant difference in the percentage change of beta oscillatory activity only in the Bilateral-Mirror condition was found between the 2 groups.

CONCLUSIONS

This study provides new information on the differential cortical activations modulated by bilateral and unilateral MT.

SIGNIFICANCE

Bilateral MT led to greater M1 neural activities than unilateral MT and bilateral movements without a mirror in stroke patients.

Are ipsilateral motor evoked potentials subject to intracortical inhibition?

Paired-pulse transcranial magnetic stimulation (TMS) can be used to examine intracortical inhibition in primary motor cortex (M1), termed short-interval intracortical inhibition (SICI). To our knowledge, SICI has only been demonstrated in contralateral motor evoked potentials (MEPs). Ipsilateral MEPs (iMEPs) are assumed to reflect excitability of an uncrossed oligosynaptic pathway, and can sometimes be evoked in proximal upper-limb muscles using high-intensity TMS. We examined whether iMEPs in the biceps brachii (BB) would be suppressed by subthreshold conditioning, therefore demonstrating SICI of iMEPs. TMS was delivered to the dominant M1 to evoke conditioned (C) and nonconditioned (NC) iMEPs in the nondominant BB of healthy participants during weak bilateral elbow flexion. The conditioning stimulus intensities tested were 85%, 100%, and 115% of active motor threshold (AMT), at 2 ms and 4 ms interstimulus intervals (ISI). The iMEP ratio (C/NC) was calculated for each condition to assess the amount of inhibition. Inhibition of iMEPs was present at 2 ms ISI with 100% and 115% AMT (bothP< 0.03), mediated by a reduction in persistence and size (allP< 0.05). To our knowledge, this is the first demonstration of SICI of iMEPs. This technique may be useful as a tool to better understand the role of ipsilateral M1 during functional motor tasks.

Recovery Potential After Acute Stroke

In acute stroke, the major factor for recovery is the early use of thrombolysis aimed at arterial recanalization and reperfusion of ischemic brain tissue. Subsequently, neurorehabilitative training critically improves clinical recovery due to augmention of postlesional plasticity. Neuroimaging and electrophysiology studies have revealed that the location and volume of the stroke lesion, the affection of nerve fiber tracts, as well as functional and structural changes in the perilesional tissue and in large-scale bihemispheric networks are relevant biomarkers of post-stroke recovery. However, associated disorders, such as mood disorders, epilepsy, and neurodegenerative diseases, may induce secondary cerebral changes or aggravate the functional deficits and, thereby, compromise the potential for recovery.

Control of reach extent with the paretic and nonparetic arms after unilateral sensorimotor stroke: kinematic differences based on side of brain damage

Scaling of reach kinematics to targets that vary in distance is indicative of the use of planning and feedback-based adjustments. The control of reach extent, however, has not been reported for the paretic arm after stroke. The purpose of this study was to determine whether individuals post-stroke utilized planning (scaling acceleration magnitude) and feedback-based adjustments (scaling acceleration duration) to reach to targets that varied in distance. Individuals with mild-to-moderate motor impairment after stroke and nondisabled adults reached with both arms to targets presented at three distances (8, 16, 24 cm). Kinematic data were used to determine scaling of peak acceleration magnitude and duration to target distance and compared between arms (control, nonparetic, paretic). Despite differences in the magnitude of movement variables, individuals post-stroke utilized both planning and feedback-based adjustments to meet the demands of the task with the nonparetic and paretic arms in a similar manner as controls. However, there was variability in the use of planning with the paretic arm, some individuals utilized planning while others did not. After right brain damage, differences in reach control related to the specialized role this hemisphere plays in endpoint control were found in both arms; no hemisphere-specific changes were found after left brain damage (LBD). The appearance of hemispheric-specific effects after right but not LBD were not due to age, degree of motor impairment, or time post-stroke, but, instead, may be related to relative differences in visual-motor processing ability, lesion characteristics, or interhemispheric inhibition changes between groups.

Age and hemispheric differences in transcallosal inhibition between motor cortices: an ispsilateral silent period study

Background

In this study, we investigated age and hemispheric differences in transcallosal inhibition (TCI) in the context of active contraction using the ipsilateral silent period (iSP). We also examined whether age-related changes in TCI would be related to corresponding changes in manual performance with age. Participants consisted of right-handed individuals from two age groups (young adults, n=13; seniors, n=17). The iSP was measured for each hemisphere using suprathreshold TMS pulses delivered over the primary motor cortex ipsilateral to the maximally contracting hand while the homologue muscles of the opposite hand were lightly contracting (~15% of the maximum). Manual performance was assessed bilaterally for both grip strength and fine dexterity.

Results

Our results yielded two main findings. First, TCI measures derived from iSP were strongly influenced by age, whereas differences between hemispheres were only minor. Second, correlation analyses revealed that age-related variations in TCI measures were related to changes in manual performance, so that left-to-right TCI correlated with right hand performance and vice-versa for the opposite hand/hemisphere.

Conclusion

Overall, these results concur with other recent reports indicating that mutual inhibition between motor cortices tends to decline with age. In this respect, our observations are in line with the notion that the balance of normally predominantly inhibitory interactions between motor cortices is shifted toward excitatory processes with age.

Motor impairment of the ipsilesional body side in poststroke subjects

BACKGROUND

In poststroke hemiparetic patients, motor weakness usually occurs on the contralesional body side to the brain. Impairment on the ipsilateral body side also occurs, but less than the contralateral side. The level and type of deficits on the less-affected side is still unclear. Clinicians usually do not consider the less-affected side for assessment and management.

OBJECTIVE

The main purpose is to explore the motor weakness (coordination, gross and fine motor dexterity, and muscle strength) of the less-affected side. The secondary aim is to determine the relationship between the impairments of both body sides (affected and less-affected).

METHOD

A prospective, cross-sectional, and nonexperimental study was conducted at an outpatient occupational therapy unit of a rehabilitation institute. A convenient sample of 27 poststroke (19.0 ± 14.28 months) subjects (21 males and 6 females, 22 right-sided and 5 left-sided hemiparesis) was recruited. Outcome measures for the less-affected side were Minnesota Manual Dexterity Test (MMDT), Purdue PegBoard Test (PPBT) and Manual Muscle Testing (MMT). Brunnstrom Recovery Stage (BRS) and Fugl-Meyer Assessment (FMA) were applied for the affected side. The less-affected side of the poststroke subjects was compared with the side-, age-, and gender-matched controls.

RESULT

The results showed highly significant (p < 0.001) difference between the scores of the ipsilesional body side of the poststroke subjects (MMDT = 105.21 ± 22.70 s, PPBT = 9.30 ± 2.47, and median MMT grade range from 3 to 4) and the matched side of the controls (MMDT = 72.41 ± 11.69 s, PPBT = 13.78 ± 1.76, and median MMT grade 5). The findings also suggested no significant relation between the motor deficits of the less-affected and affected sides.

CONCLUSION

The ipsilesional body side of poststroke subjects had impaired coordination, gross and fine motor dexterity, and the upper and lower limb muscle strength. The side must be assessed and managed accordingly. Management would promote motor and functional recovery on both the sides.

Motor planning in chronic upper-limb hemiparesis: evidence from movement-related potentials

Background

Chronic hemiplegia is a common long-term consequence of stroke, and subsequent motor recovery is often incomplete. Neurophysiological studies have focused on motor execution deficits in relatively high functioning patients. Much less is known about the influence exerted by processes related to motor preparation, particularly in patients with poor motor recovery.

Methodology/Principal Findings

The current study investigates motor preparation using a modified response-priming experiment in a large sample of patients (n = 50) with moderate-to-severe chronic hemiparesis. The behavioural results revealed that hemiparetic patients had an increased response-priming effect compared to controls, but that their response times were markedly slower for both hands. Patients also demonstrated significantly enhanced midline late contingent negative variation (CNV) during paretic hand preparation, despite the absence of overall group differences when compared to controls. Furthermore, increased amplitude of the midline CNV correlated with a greater response-priming effect. We propose that these changes might reflect greater anticipated effort to respond in patients, and consequently that advance cueing of motor responses may be of benefit in these individuals. We further observed significantly reduced CNV amplitudes over the lesioned hemisphere in hemiparetic patients compared to controls during non-paretic hand preparation, preparation of both hands and no hand preparation. Two potential explanations for these CNV reductions are discussed: alterations in anticipatory attention or state changes in motor processing, for example an imbalance in inter-hemispheric inhibition.

Conclusions/Significance

Overall, this study provides evidence that movement preparation could play a crucial role in hemiparetic motor deficits, and that advance motor cueing may be of benefit in future therapeutic interventions. In addition, it demonstrates the importance of monitoring both the non-paretic and paretic hand after stroke and during therapeutic intervention.

Multisensory stimulation in stroke rehabilitation

The brain has a large capacity for automatic simultaneous processing and integration of sensory information. Combining information from different sensory modalities facilitates our ability to detect, discriminate, and recognize sensory stimuli, and learning is often optimal in a multisensory environment. Currently used multisensory stimulation methods in stroke rehabilitation include motor imagery, action observation, training with a mirror or in a virtual environment, and various kinds of music therapy. Non-invasive brain stimulation has showed promising preliminary results in aphasia and neglect. Patient heterogeneity and the interaction of age, gender, genes, and environment are discussed. Randomized controlled longitudinal trials starting earlier post-stroke are needed. The advance in brain network science and neuroimaging enabling longitudinal studies of structural and functional networks are likely to have an important impact on patient selection for specific interventions in future stroke rehabilitation. It is proposed that we should pay more attention to age, gender, and laterality in clinical studies.

Volumetric effects of motor cortex injury on recovery of ipsilesional dexterous movements

Damage to the motor cortex of one hemisphere has classically been associated with contralateral upper limb paresis, but recent patient studies have identified deficits in both upper limbs. In non-human primates, we tested the hypothesis that the severity of ipsilesional upper limb motor impairment in the early post-injury phase depends on the volume of gray and white matter damage of the motor areas of the frontal lobe. We also postulated that substantial recovery would accompany minimal task practice and that ipsilesional limb recovery would be correlated with recovery of the contralesional limb. Gross (reaching) and fine hand motor functions were assessed for 3-12 months post-injury using two motor tests. Volumes of white and gray matter lesions were assessed using quantitative histology. Early changes in post-lesion motor performance were inversely correlated with white matter lesion volume indicating that larger lesions produced greater decreases in ipsilesional hand movement control. All monkeys showed improvements in ipsilesional hand motor skill during the post-lesion period, with reaching skill improvements being positively correlated with total lesion volume indicating that larger lesions were associated with greater ipsilesional motor skill recovery. We suggest that reduced trans-callosal inhibition from the lesioned hemisphere may play a role in the observed skill improvements. Our findings show that significant ipsilesional hand motor recovery is likely to accompany injury limited to frontal motor areas. In humans, more pronounced ipsilesional motor deficits that invariably develop after stroke may, in part, be a consequence of more extensive subcortical white and gray matter damage.

Cathodal transcranial direct current stimulation of the primary motor cortex improves selective muscle activation in the ipsilateral arm

Proximal upper limb muscles are represented bilaterally in primary motor cortex. Goal-directed upper limb movement requires precise control of proximal and distal agonist and antagonist muscles. Failure to suppress antagonist muscles can lead to abnormal movement patterns, such as those commonly experienced in the proximal upper limb after stroke. We examined whether noninvasive brain stimulation of primary motor cortex could be used to improve selective control of the ipsilateral proximal upper limb. Thirteen healthy participants performed isometric left elbow flexion by contracting biceps brachii (BB; agonist) and left forearm pronation (BB antagonist) before and after 20 min of cathodal transcranial direct current stimulation (c-tDCS) or sham tDCS of left M1. During the tasks, motor evoked potentials (MEPs) in left BB were acquired using single-pulse transcranial magnetic stimulation of right M1 150-270 ms before muscle contraction. As expected, left BB MEPs were facilitated before flexion and suppressed before pronation. After c-tDCS, left BB MEP amplitudes were reduced compared with sham stimulation, before pronation but not flexion, indicating that c-tDCS enhanced selective muscle activation of the ipsilateral BB in a task-specific manner. The potential for c-tDCS to improve BB antagonist control correlated with BB MEP amplitude for pronation relative to flexion, expressed as a selectivity ratio. This is the first demonstration that selective muscle activation in the proximal upper limb can be improved after c-tDCS of ipsilateral M1 and that the benefits of c-tDCS for selective muscle activation may be most effective in cases where activation strategies are already suboptimal. These findings may have relevance for the use of tDCS in rehabilitation after stroke.

Interhemispheric interactions between the human primary somatosensory cortices

In the somatosensory domain it is still unclear at which processing stage information reaches the opposite hemispheres. Due to dense transcallosal connections, the secondary somatosensory cortex (S2) has been proposed to be the key candidate for interhemispheric information transfer. However, recent animal studies showed that the primary somatosensory cortex (S1) might as well account for interhemispheric information transfer. Using paired median nerve somatosensory evoked potential recordings in humans we tested the hypothesis that interhemispheric inhibitory interactions in the somatosensory system occur already in an early cortical processing stage such as S1. Conditioning right S1 by electrical median nerve (MN) stimulation of the left MN (CS) resulted in a significant reduction of the N20 response in the target (left) S1 relative to a test stimulus (TS) to the right MN alone when the interstimulus interval between CS and TS was between 20 and 25 ms. No such changes were observed for later cortical components such as the N20/P25, N30, P40 and N60 amplitude. Additionally, the subcortically generated P14 response in left S1 was also not affected. These results document the existence of interhemispheric inhibitory interactions between S1 in human subjects in the critical time interval of 20–25 ms after median nerve stimulation.

The corticospinal system and transcranial magnetic stimulation in stroke

During the last decades, transcranial magnetic stimulation (TMS) has been used as a noninvasive method to investigate motor cortical reorganization and neuroplasticity in humans after stroke. An increasing number of studies in the field of motor control have used TMS to gain an understanding of the different aspects of stroke cortical physiology and motor recovery. This review addresses the effects of corticospinal tract (CST) lesions in humans and nonhuman primates on the functional organization of the motor system. We review information on the physiological mechanisms by which the CST contributes to normal motor control and to central nervous system reorganization following stroke when the CST is injured as measured using TMS. Insight into these physiological mechanisms has led to the development of scientifically sound interventional proposals in the field of neurorehabilitation.