Optimal use of limb mechanics distributes control during bimanual tasks

Upper extremity asymmetry due to nerve injuries or central neurologic conditions: a scoping review

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.

Impact of unilateral and bilateral impairments on bimanual force production following stroke

Large bilateral asymmetry and task deficits are typically observed during bimanual actions of stroke survivors. Do these abnormalities originate from unilateral impairments affecting their more-impaired limb, such as weakness and abnormal synergy, or from bilateral impairments such as incoordination of two limbs? To answer this question, 23 subjects including 10 chronic stroke survivors and 13 neurologically intact subjects participated in an experiment where they produced bimanual forces at different hand locations. The force magnitude and directional deviation of the more-impaired arm were measured for unilateral impairments and bimanual coordination across locations for bilateral impairments. Force asymmetry and task error were used to define task performance. Significant unilateral impairments were observed in subjects with stroke; the maximal force capacity of their more-impaired arm was significantly lower than that of their less-impaired arm, with a higher degree of force deviation. However, its force contribution during submaximal tasks was greater than its relative force capacity. Significant bilateral impairments were also observed, as stroke survivors modulated two forces to a larger degree across hand locations but in a less coordinated manner than control subjects did. But only unilateral, not bilateral, impairments explained a significant amount of between-subject variability in force asymmetry across subjects with stroke. Task error, in contrast, was correlated with neither unilateral nor bilateral impairments. Our results suggest that unilateral impairments of the more-impaired arm of stroke survivors mainly contribute to its reduced recruitment, but that the degree of its participation in bimanual task may be greater than their capacity as they attempt to achieve symmetry.NEW & NOTEWORTHY We studied how unilateral and bilateral impairments in stroke survivors affect their bimanual task performance. Unilateral impairments of the more-impaired limb, both weakness and loss of directional control, mainly contribute to bimanual asymmetry, but stroke survivors generally produce higher force with their more-impaired limb than their relative capacity. Bilateral force coordination was significantly impaired in stroke survivors, but its degree of impairment was not related to their unilateral impairments.

Redundancy Resolution in Trimanual vs. Bimanual Tracking Tasks

Supernumerary limbs promise to allow users to perform complex tasks that would otherwise require the actions of teams. However, how the user's capability for multimanual coordination compares to bimanual coordination, and how the motor system decides to configure its limb contributions given task redundancy is unclear. We conducted bimanual and trimanual (with the foot as a third-hand controller) virtual reality visuomotor tracking experiments to study how 32 healthy participants changed their limb coordination in response to uninstructed cursor mapping changes. This used a shared cursor mapped to the average limbs' position for different limb combinations. The results show that most participants correctly identified the different mappings during bimanual tracking, and accordingly minimized task-irrelevant motion. Instead during trimanual coordination, participants consistently moved all three limbs concurrently, showing weaker ipsilateral hand-foot coordination. These findings show how redundancy resolution and the resulting coordination patterns differ between similar bimanual and trimanual tasks. Further research is needed to consider the effect of learning on coordination behaviour.

How virtual and mechanical coupling impact bimanual tracking

Bilateral training systems look to promote the paretic hand's use in individuals with hemiplegia. Although this is normally achieved using mechanical coupling (i.e., a physical connection between the hands), a virtual reality system relying on virtual coupling (i.e., through a shared virtual object) would be simpler to use and prevent slacking. However, it is not clear whether different coupling modes differently impact task performance and effort distribution between the hands. We explored how 18 healthy right-handed participants changed their motor behaviors in response to the uninstructed addition of mechanical coupling, and virtual coupling using a shared cursor mapped to the average hands' position. In a second experiment, we then studied the impact of connection stiffness on performance, perception, and effort imbalance. The results indicated that both coupling types can induce the hands to actively contribute to the task. However, the task asymmetry introduced by using a cursor mapped to either the left or right hand only modulated the hands' contribution when not mechanically coupled. The tracking performance was similar for all coupling types, independent of the connection stiffness, although the mechanical coupling was preferred and induced the hands to move with greater correlation. These findings suggest that virtual coupling can induce the hands to actively contribute to a task in healthy participants without hindering their performance. Further investigation on the coupling types' impact on the performance and hands' effort distribution in patients with hemiplegia could allow for the design of simpler training systems that promote the affected hand's use.NEW & NOTEWORTHY We showed that the uninstructed addition of a virtual and/or a mechanical coupling can induce both hands to actively contribute in a continuous redundant bimanual tracking task without impacting performance. In addition, we showed that the task asymmetry can only alter the effort distribution when the hands are not connected, independent of the connection stiffness. Our findings suggest that virtual coupling could be used in the development of simpler VR-based training devices.

Bilateral Asymmetry of Hand Force Production in Dynamic Physically-Coupled Tasks

Physically-coupled bimanual tasks (activities where a force effect occurs between two human limbs) involve the coordination and cooperation of bilateral arms. Such uncertain contribution of two arms is often studied under static configuration, which is not sufficient to typify all activities of daily life (ADLs). This study aims to investigate peoples bilateral force production and control in dynamic tasks. Experiments were conducted with a customized robotic system that is characterized with two handles and programmable force fields between them. Fourteen healthy right-handed human volunteers were instructed to generate force with each hand when performing predefined trajectory tracking tasks, in which the sum of forces contributed by the left and the right hand is required to equal a target force. Significant asymmetry was found in the force output between bilateral hands. With the homologous muscles activated synchronously, the contribution of the left hand was larger, while when the non-homogenous muscles were activated synchronously, the laterality was subject to the moving direction. In addition, when considering the force difference between two hands in terms of direction and magnitude, the former decreased with the increase of the target force, but the latter was more sensitive to moving directions. The results reveal the unique characteristics of non-isometric force control tasks compared with isometric ones.

Maintained Representations of the Ipsilateral and Contralateral Limbs during Bimanual Control in Primary Motor Cortex

Primary motor cortex (M1) almost exclusively controls the contralateral side of the body. However, M1 activity is also modulated during ipsilateral body movements. Previous work has shown that M1 activity related to the ipsilateral arm is independent of the M1 activity related to the contralateral arm. How do these patterns of activity interact when both arms move simultaneously? We explored this problem by training 2 monkeys (male, Macaca mulatta) in a postural perturbation task while recording from M1. Loads were applied to one arm at a time (unimanual) or both arms simultaneously (bimanual). We found 83% of neurons (n = 236) were responsive to both the unimanual and bimanual loads. We also observed a small reduction in activity magnitude during the bimanual loads for both limbs (25%). Across the unimanual and bimanual loads, neurons largely maintained their preferred load directions. However, there was a larger change in the preferred loads for the ipsilateral limb (∼25%) than the contralateral limb (∼9%). Lastly, we identified the contralateral and ipsilateral subspaces during the unimanual loads and found they captured a significant amount of the variance during the bimanual loads. However, the subspace captured more of the bimanual variance related to the contralateral limb (97%) than the ipsilateral limb (66%). Our results highlight that, even during bimanual motor actions, M1 largely retains its representations of the contralateral and ipsilateral limbs.SIGNIFICANCE STATEMENT Previous work has shown that primary motor cortex (M1) represents information related to the contralateral limb, its downstream target, but also reflects information related to the ipsilateral limb. Can M1 still represent both sources of information when performing simultaneous movements of the limbs? Here we record from M1 during a postural perturbation task. We show that activity related to the contralateral limb is maintained between unimanual and bimanual motor actions, whereas the activity related to the ipsilateral limb undergoes a small change between unimanual and bimanual motor actions. Our results indicate that two independent representations can be maintained and expressed simultaneously in M1.

How optimal is bimanual tracking? The key role of hand coordination in space

When coordinating two hands to achieve a common goal, the nervous system has to assign responsibility to each hand. Optimal control theory suggests that this problem is solved by minimizing costs such as the variability of movement and effort. However, the natural tendency to produce similar movements during bimanual tasks has been somewhat ignored by this approach. We consider a task in which participants were asked to track a moving target by means of a single cursor controlled simultaneously by the two hands. Two types of hand-cursor mappings were tested: one in which the cursor position resulted from the average location of two hands (Mean) and one in which horizontal and vertical positions of the cursor were driven separately by each hand (Split). As expected, unimanual tracking performance was better with the dominant hand than with the more variable nondominant hand. More interestingly, instead of exploiting this effect by increasing the use of the dominant hand, the contributions from both hands remained symmetrical during bimanual cooperative tasks. Indeed, for both mappings, and even after 6min of practice, the right and left hands remained strongly correlated, performing similar movements in extrinsic space. Persistence of this bimanual coupling demonstrates that participants prefer to maintain similar movements at the expense of unnecessary movements (in the Split task) and of increased noise from the nondominant hand (in the Mean task). Altogether, the findings suggest that bimanual tracking exploits hand coordination in space rather than minimizing motor costs associated with variability and effort.NEW & NOTEWORTHY When two hands are coordinated to achieve a common goal, optimal control theory proposes that the brain assigns responsibility to each hand by minimizing movement variability and effort. Nevertheless, we show that participants perform bimanual tracking using similar contributions from the dominant and nondominant hands, despite unnecessary movements and a less accurate nondominant hand. Our findings suggest that bimanual tracking exploits hand coordination in space rather than minimizing motor costs associated with variability and effort.

Independent representations of ipsilateral and contralateral limbs in primary motor cortex

Several lines of research demonstrate that primary motor cortex (M1) is principally involved in controlling the contralateral side of the body. However, M1 activity has been correlated with both contralateral and ipsilateral limb movements. Why does ipsilaterally-related activity not cause contralateral motor output? To address this question, we trained monkeys to counter mechanical loads applied to their right and left limbs. We found >50% of M1 neurons had load-related activity for both limbs. Contralateral loads evoked changes in activity ~10ms sooner than ipsilateral loads. We also found corresponding population activities were distinct, with contralateral activity residing in a subspace that was orthogonal to the ipsilateral activity. Thus, neural responses for the contralateral limb can be extracted without interference from the activity for the ipsilateral limb, and vice versa. Our results show that M1 activity unrelated to downstream motor targets can be segregated from activity related to the downstream motor output.

Long-latency reflexes for inter-effector coordination reflect a continuous state feedback controller

Successful performance in many everyday tasks requires compensating unexpected mechanical disturbance to our limbs and body. The long-latency reflex plays an important role in this process because it is the fastest response to integrate sensory information across several effectors, like when linking the elbow and shoulder or the arm and body. Despite the dozens of studies on inter-effector long-latency reflexes, there has not been a comprehensive treatment of how these reveal the basic control organization that sets constraints on any candidate model of neural feedback control such as optimal feedback control. We considered three contrasting ways that controllers can be organized: multiple independent controllers vs. a multiple-input multiple-output (MIMO) controller, a continuous feedback controller vs. an intermittent feedback controller, and a direct MIMO controller vs. a state feedback controller. Following a primer on control theory and review of the relevant evidence, we conclude that continuous state feedback control best describes the organization of inter-effector coordination by the long-latency reflex.