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Peng RHT, He D, James SA, Williamson JN, Skadden C, Jain S, Hassaneen W, Miranpuri A, Kaur A, Sarol JN, Yang Y. Determining the effects of targeted high-definition transcranial direct current stimulation on reducing post-stroke upper limb motor impairments-a randomized cross-over study. Trials 2024; 25:34. [PMID: 38195605 PMCID: PMC10775560 DOI: 10.1186/s13063-023-07886-w] [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: 10/16/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Stroke is one of the leading causes of death in the USA and is a major cause of serious disability for adults. This randomized crossover study examines the effect of targeted high-definition transcranial direct current transcranial brain stimulation (tDCS) on upper extremity motor recovery in patients in the post-acute phase of stroke recovery. METHODS This randomized double-blinded cross-over study includes four intervention arms: anodal, cathodal, and bilateral brain stimulation, as well as a placebo stimulation. Participants receive each intervention in a randomized order, with a 2-week washout period between each intervention. The primary outcome measure is change in Motor Evoked Potential. Secondary outcome measures include the Fugl-Meyer Upper Extremity (FM-UE) score, a subset of FM-UE (A), related to the muscle synergies, and the Modified Ashworth Scale. DISCUSSION We hypothesize that anodal stimulation to the ipsilesional primary motor cortex will increase the excitability of the damaged cortico-spinal tract, reducing the UE flexion synergy and enhancing UE motor function. We further hypothesize that targeted cathodal stimulation to the contralesional premotor cortex will decrease activation of the cortico-reticulospinal tract (CRST) and the expression of the upper extremity (UE) flexion synergy and spasticity. Finally, we hypothesize bilateral stimulation will achieve both results simultaneously. Results from this study could improve understanding of the mechanism behind motor impairment and recovery in stroke and perfect the targeting of tDCS as a potential stroke intervention. With the use of appropriate screening, we anticipate no ethical or safety concerns. We plan to disseminate these research results to journals related to stroke recovery, engineering, and medicine. TRIAL REGISTRATION ClinicalTrials.gov NCT05479006 . Registered on 26 July 2022.
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Affiliation(s)
- Rita Huan-Ting Peng
- Department of Bioengineering, Grainger College of Engineering, University of Illinois Urbana-Champaign, Urbana, IL, USA
- Carle Foundation Hospital, Urbana, IL, USA
| | - Dorothy He
- The University of Oklahoma College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Shirley A James
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jordan N Williamson
- Department of Bioengineering, Grainger College of Engineering, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | | | - Sanjiv Jain
- Carle Foundation Hospital, Urbana, IL, USA
- Carle Illinois College of Medicine, Urbana, IL, USA
| | - Wael Hassaneen
- Carle Foundation Hospital, Urbana, IL, USA
- Carle Illinois College of Medicine, Urbana, IL, USA
| | - Amrendra Miranpuri
- Carle Foundation Hospital, Urbana, IL, USA
- Carle Illinois College of Medicine, Urbana, IL, USA
| | - Amandeep Kaur
- Interdisciplinary Health Sciences Institute, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | - Jesus N Sarol
- Interdisciplinary Health Sciences Institute, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | - Yuan Yang
- Department of Bioengineering, Grainger College of Engineering, University of Illinois Urbana-Champaign, Urbana, IL, USA.
- Carle Foundation Hospital, Urbana, IL, USA.
- Beckman Institute for Advanced Science and Technology, University of Illinois Urbana-Champaign, Urbana, IL, USA.
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA.
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van der Velden LL, Onneweer B, Haarman CJW, Benner JL, Roebroeck ME, Ribbers GM, Selles RW. Development of a single device to quantify motor impairments of the elbow: proof of concept. J Neuroeng Rehabil 2022; 19:77. [PMID: 35864498 PMCID: PMC9306071 DOI: 10.1186/s12984-022-01050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 07/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background For patients with post-stroke upper limb impairments, the currently available clinical measurement instruments are inadequate for reliable quantification of multiple impairments, such as muscle weakness, abnormal synergy, changes in elastic joint properties and spasticity. Robotic devices to date have successfully achieved precise and accurate quantification but are often limited to the measurement of one or two impairments. Our primary aim is to develop a robotic device that can effectively quantify four main motor impairments of the elbow. Methods The robotic device, Shoulder Elbow Perturbator, is a one-degree-of-freedom device that can simultaneously manipulate the elbow joint and support the (partial) weight of the human arm. Upper limb impairments of the elbow were quantified based on four experiments on the paretic arm in ten stroke patients (mean age 65 ± 10 yrs, 9 males, post-stroke) and the non-dominant arm in 20 healthy controls (mean age 65 ± 14 yrs, 6 males). The maximum strength of elbow flexor and elbow extensor muscles was measured isometrically at 90-degree elbow flexion. The maximal active extension angle of the elbow was measured under different arm weight support levels to assess abnormal synergy. Torque resistance was analyzed during a slow (6°/s) passive elbow rotation, where the elbow moved from the maximal flexion to maximal extension angle and back, to assess elastic joint properties. The torque profile was evaluated during fast (100°/s) passive extension rotation of the elbow to estimate spasticity. Results The ten chronic stroke patients successfully completed the measurement protocol. The results showed impairment values outside the 10th and 90th percentile reference intervals of healthy controls. Individual patient profiles were determined and illustrated in a radar figure, to support clinicians in developing targeted treatment plans. Conclusion The Shoulder Elbow Perturbator can effectively quantify the four most important impairments of the elbow in stroke patients and distinguish impairment scores of patients from healthy controls. These results are promising for objective and complete quantification of motor impairments of the elbow and monitoring patient prognosis. Our newly developed Shoulder Elbow Perturbator can therefore in the future be employed to evaluate treatment effects by comparing pre- and post-treatment assessments. Supplementary Information The online version contains supplementary material available at 10.1186/s12984-022-01050-2.
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Affiliation(s)
- Levinia Lara van der Velden
- Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands. .,Rijndam Rehabilitation, Westersingel 300, 3015 LJ, Rotterdam, The Netherlands.
| | - Bram Onneweer
- Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.,Rijndam Rehabilitation, Westersingel 300, 3015 LJ, Rotterdam, The Netherlands
| | | | - Joyce Lisanne Benner
- Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Marij Eugenie Roebroeck
- Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.,Rijndam Rehabilitation, Westersingel 300, 3015 LJ, Rotterdam, The Netherlands
| | - Gerard Maria Ribbers
- Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.,Rijndam Rehabilitation, Westersingel 300, 3015 LJ, Rotterdam, The Netherlands
| | - Ruud Willem Selles
- Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.,Rijndam Rehabilitation, Westersingel 300, 3015 LJ, Rotterdam, The Netherlands
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PARK CHANHEE, YOU SUNGJOSHUAH. VALIDITY AND TEST–RETEST RELIABILITY OF AN INTELLIGENT ROBOTIC SHOULDER JOINT KINEMATICS SYSTEM FOR REHABILITATION. J MECH MED BIOL 2021. [DOI: 10.1142/s0219519421400650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The presence of normal upper limb arm swing movement is considered an important gait movement that affects the selective coordinated locomotor control of the shoulder, elbow, and wrist joint movements. However, in patients with neurological disorders, flexor synergy is characterized by decreased selective neuromuscular control and reciprocal disinhibition of the wrist flexor muscles associated with spasticity or shortness. This research aimed to demonstrate the reliability, validity, and feasibility of the progressive exoskeletal robotic shoulder joint kinematics system. The robotic shoulder joint kinematics system comprises a gait function-retraining robot designed to provide arm swing. The changes in the shoulder joint angle between ImageJ motion analysis software and robotic shoulder joint kinematics system were compared in this research to investigate the reliability and validity of the latter. The linear regression analysis revealed good correlation between the measured angles and the shoulder angle data ([Formula: see text]). Furthermore, the test–retest reliability test demonstrated excellent reliability ([Formula: see text]). The robotic shoulder joint kinematics system generated successful arm swing during the locomotion and range of motion training of the shoulder.
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Affiliation(s)
- CHANHEE PARK
- Department of Physical Therapy, Yonsei University, Wonju 26493, Republic of Korea
| | - SUNG JOSHUA H. YOU
- Department of Physical Therapy, Yonsei University, Wonju 26493, Republic of Korea
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McPherson JG, Stienen AHA, Schmit BD, Dewald JPA. Biomechanical parameters of the elbow stretch reflex in chronic hemiparetic stroke. Exp Brain Res 2018; 237:121-135. [PMID: 30353212 DOI: 10.1007/s00221-018-5389-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 10/01/2018] [Indexed: 11/30/2022]
Abstract
We sought to determine the relative velocity sensitivity of stretch reflex threshold angle and reflex stiffness during stretches of the paretic elbow joint in individuals with chronic hemiparetic stroke, and to provide guidelines to streamline spasticity assessments. We applied ramp-and-hold elbow extension perturbations ranging from 15 to 150°/s over the full range of motion in 13 individuals with hemiparesis. After accounting for the effects of passive mechanical resistance, we modeled velocity-dependent reflex threshold angle and torque-angle slope to determine their correlation with overall resistance to movement. Reflex stiffness exhibited substantially greater velocity sensitivity than threshold angle, accounting for ~ 74% (vs. ~ 15%) of the overall velocity-dependent increases in movement resistance. Reflex stiffness is a sensitive descriptor of the overall velocity-dependence of movement resistance in spasticity. Clinical spasticity assessments can be streamlined using torque-angle slope, a measure of reflex stiffness, as their primary outcome measure, particularly at stretch velocities greater than 100°/s.
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Affiliation(s)
- Jacob G McPherson
- Department of Biomedical Engineering, Florida International University, 10555 W. Flagler St., EC #3171, Miami, FL, 33176, USA
| | - Arno H A Stienen
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, 645 N Michigan Ave, Suite 1100, Chicago, IL, 60611, USA
| | - Brian D Schmit
- Department of Biomedical Engineering, Marquette University, P.O. Box 1881, Milwaukee, WI, 53201, USA
| | - Julius P A Dewald
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, 645 N Michigan Ave, Suite 1100, Chicago, IL, 60611, USA.
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McPherson JG, McPherson LM, Thompson CK, Ellis MD, Heckman CJ, Dewald JPA. Altered Neuromodulatory Drive May Contribute to Exaggerated Tonic Vibration Reflexes in Chronic Hemiparetic Stroke. Front Hum Neurosci 2018; 12:131. [PMID: 29686611 PMCID: PMC5900019 DOI: 10.3389/fnhum.2018.00131] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 03/22/2018] [Indexed: 12/05/2022] Open
Abstract
Exaggerated stretch-sensitive reflexes are a common finding in elbow flexors of the contralesional arm in chronic hemiparetic stroke, particularly when muscles are not voluntarily activated prior to stretch. Previous investigations have suggested that this exaggeration could arise either from an abnormal tonic ionotropic drive to motoneuron pools innervating the paretic limbs, which could bring additional motor units near firing threshold, or from an increased influence of descending monoaminergic neuromodulatory pathways, which could depolarize motoneurons and amplify their responses to synaptic inputs. However, previous investigations have been unable to differentiate between these explanations, leaving the source(s) of this excitability increase unclear. Here, we used tonic vibration reflexes (TVRs) during voluntary muscle contractions of increasing magnitude to infer the sources of spinal motor excitability in individuals with chronic hemiparetic stroke. We show that when the paretic and non-paretic elbow flexors are preactivated to the same percentage of maximum prior to vibration, TVRs remain significantly elevated in the paretic arm. We also show that the rate of vibration-induced torque development increases as a function of increasing preactivation in the paretic limb, even though the amplitude of vibration-induced torque remains conspicuously unchanged as preactivation increases. It is highly unlikely that these findings could be explained by a source that is either purely ionotropic or purely neuromodulatory, because matching preactivation should control for the effects of a potential ionotropic drive (and lead to comparable tonic vibration reflex responses between limbs), while a purely monoaminergic mechanism would increase reflex magnitude as a function of preactivation. Thus, our results suggest that increased excitability of motor pools innervating the paretic limb post-stroke is likely to arise from both ionotropic and neuromodulatory mechanisms.
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Affiliation(s)
- Jacob G McPherson
- Department of Biomedical Engineering, Florida International University, Miami, FL, United States.,Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Laura M McPherson
- Department of Biomedical Engineering, Florida International University, Miami, FL, United States.,Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Physical Therapy, Florida International University, Miami, FL, United States
| | - Christopher K Thompson
- Department of Physical Therapy, Temple University, Philadelphia, PA, United States.,Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Michael D Ellis
- Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Charles J Heckman
- Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Julius P A Dewald
- Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Department of Biomedical Engineering, Northwestern University, Evanston, IL, United States
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McPherson JG, Stienen AH, Drogos JM, Dewald JP. Modification of Spastic Stretch Reflexes at the Elbow by Flexion Synergy Expression in Individuals With Chronic Hemiparetic Stroke. Arch Phys Med Rehabil 2017; 99:491-500. [PMID: 28751255 DOI: 10.1016/j.apmr.2017.06.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/15/2017] [Accepted: 06/19/2017] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To systematically characterize the effect of flexion synergy expression on the manifestation of elbow flexor stretch reflexes poststroke, and to relate these findings to elbow flexor stretch reflexes in individuals without neurologic injury. DESIGN Controlled cohort study. SETTING Academic medical center. PARTICIPANTS Participants (N=20) included individuals with chronic hemiparetic stroke (n=10) and a convenience sample of individuals without neurologic or musculoskeletal injury (n=10). INTERVENTIONS Participants with stroke were interfaced with a robotic device that precisely manipulated flexion synergy expression (by regulating shoulder abduction loading) while delivering controlled elbow extension perturbations over a wide range of velocities. This device was also used to elicit elbow flexor stretch reflexes during volitional elbow flexor activation, both in the cohort of individuals with stroke and in a control cohort. In both cases, the amplitude of volitional elbow flexor preactivation was matched to that generated involuntarily during flexion synergy expression. MAIN OUTCOME MEASURES The amplitude of short- and long-latency stretch reflexes in the biceps brachii, assessed by electromyography, and expressed as a function of background muscle activation and stretch velocity. RESULTS Increased shoulder abduction loading potentiated elbow flexor stretch reflexes via flexion synergy expression in the paretic arm. Compared with stretch reflexes in individuals without neurologic injury, paretic reflexes were larger at rest but were approximately equal to control muscles at matched levels of preactivation. CONCLUSIONS Because flexion synergy expression modifies stretch reflexes in involved muscles, interventions that reduce flexion synergy expression may confer the added benefit of reducing spasticity during functional use of the arm.
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Affiliation(s)
- Jacob G McPherson
- Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Arno H Stienen
- Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Justin M Drogos
- Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Julius P Dewald
- Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Biomedical Engineering, Northwestern University McCormick School of Engineering, Chicago, IL.
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Rhythmic affects on stroke-induced joint synergies across a range of speeds. Exp Brain Res 2013; 229:517-24. [DOI: 10.1007/s00221-013-3613-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 06/09/2013] [Indexed: 10/26/2022]
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Stienen AHA, McPherson JG, Schouten AC, Dewald JPA. The ACT-4D: a novel rehabilitation robot for the quantification of upper limb motor impairments following brain injury. IEEE Int Conf Rehabil Robot 2011; 2011:5975460. [PMID: 22275658 DOI: 10.1109/icorr.2011.5975460] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Rehabilitation robots and other controlled diagnostic devices are useful tools to objectively quantify debilitating, post-stroke impairments. The goal of this paper is to describe the design of the ACT-4D rehabilitation robot which can quantify arm impairments during functional movement. The robot can instantly switch between a compliant mode that minimizes impedance of voluntary movement, and a stiff mode that applies controlled position/speed perturbations to the elbow (up to 75 Nm or 450 deg/s at 4500 deg/s(2)). It has a limited range of movement of the shoulder and elbow, which is further reduced when a damper is needed to enhance the positional stiffness of the base robot. In recent experiments, the ACT-4D has been used successfully for the quantification of elbow impairments.
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Affiliation(s)
- Arno H A Stienen
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA.
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