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Xu D, Kang SH, Lee SJ, Oppizzi G, Zhang LQ. Multi-joint Assessment of Proprioception Impairments Poststroke. Arch Phys Med Rehabil 2024; 105:480-486. [PMID: 37714505 PMCID: PMC10922066 DOI: 10.1016/j.apmr.2023.08.029] [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: 01/21/2023] [Revised: 07/19/2023] [Accepted: 08/21/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVES To investigate shoulder, elbow and wrist proprioception impairment poststroke. DESIGN Proprioceptive acuity in terms of the threshold detection to passive motion at the shoulder, elbow and wrist joints was evaluated using an exoskeleton robot to the individual joints slowly in either inward or outward direction. SETTING A university research laboratory. PARTICIPANTS Seventeen stroke survivors and 17 healthy controls (N=34). Inclusion criteria of stroke survivors were (1) a single stroke; (2) stroke duration <1 year; and (3) cognitive ability to follow simple instructions. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Threshold detection to passive motion and detection error at the shoulder, elbow and wrist. RESULTS There was significant impairment of proprioceptive acuity in stroke survivors as compared to healthy group at all 3 joints and in both the inward (shoulder horizontal adduction, elbow and wrist flexion, P<.01) and outward (P<.01) motion. Furthermore, the distal wrist joint showed more severe impairment in proprioception than the proximal shoulder and elbow joints poststroke (P<.01) in inward motion. Stroke survivors showed significantly larger detection error in identifying the individual joint in motion (P<.01) and the movement direction (P<.01) as compared to the healthy group. There were significant correlations among the proprioception acuity across the shoulder, elbow and wrist joints and 2 movement directions poststroke. CONCLUSIONS There were significant proprioceptive sensory impairments across the shoulder, elbow and wrist joints poststroke, especially at the distal wrist joint. Accurate evaluations of multi-joint proprioception deficit may help guide more focused rehabilitation.
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Affiliation(s)
- Dali Xu
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD
| | - Sang Hoon Kang
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD; Department of Mechanical Engineering, Ulsan National Institute of Science and Technology, Ulsan, South Korea
| | - Song Joo Lee
- Bionics Research Center, Biomedical Research Division, Korea Institute of Science and Technology, Seoul, South Korea
| | - Giovanni Oppizzi
- Department of Bioengineering, University of Maryland, College Park, MD
| | - Li-Qun Zhang
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD; Department of Orthopaedics, University of Maryland, Baltimore, MD; Department of Bioengineering, University of Maryland, College Park, MD.
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2
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Park SH, Dee W, Keefer R, Roth EJ, Rymer WZ, Wu M. Enhanced phasic sensory afferents paired with controlled constraint force improve weight shift toward the paretic side in individuals post-stroke. J Stroke Cerebrovasc Dis 2023; 32:107035. [PMID: 36739709 PMCID: PMC10065899 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107035] [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: 11/24/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The goal of this study was to determine whether enhanced phasic sensory afferent input paired with the application of controlled constraint force during walking would improve weight shift toward the paretic side and enhance use of the paretic leg. METHODS Fourteen stroke survivors participated in two experimental conditions, sessions that consisted of 1 min treadmill walking without force and stimulation (baseline), 7 min walking with either "constraint force and sensory stimulation (constraint+stim)" or "constraint force only (constraint)" (adaptation), and then 2 min walking without force and stimulation (post-adaptation). Kinematics of the pelvis and legs, and muscle activity of the paretic leg were recorded. RESULTS Participants showed greater increases in hip abductor (p < 0.001) and adductor (p = 0.04) muscle activities, weight shift toward the paretic side (p = 0.002), and step length symmetry (p < 0.01) during the late post-adaptation period in the "constraint+stim" condition, compared with the effect of the "constraint" condition. In addition, changes in overground walking speed from baseline to 10 min post treadmill walking was significantly greater for the "constraint force and stimulation" condition than for the "constraint force only" condition (p = 0.04). CONCLUSION Enhanced targeted sensory afferent input during locomotor training may facilitate recruitment of targeted muscles of the paretic leg and facilitate use-dependent motor learning of locomotor tasks, which might retain longer and partially transfer from treadmill to overground walking, in stroke survivors.
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Affiliation(s)
- Seoung Hoon Park
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - Weena Dee
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA
| | - Renee Keefer
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA
| | - Elliot J Roth
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - William Z Rymer
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - Ming Wu
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA; Department of Biomedical Engineering, University of Illinois at Chicago, Chicago, IL, USA.
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Lee KW, Kang SH, Lim SC. Simple and Reliable Position Sense Assessment under Different External Torques: Toward Developing a Post-stroke Proprioception Evaluation Device. IEEE Trans Neural Syst Rehabil Eng 2022; 30:823-832. [PMID: 35324443 DOI: 10.1109/tnsre.2022.3161948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Evaluation of position sense post-stroke is essential for rehabilitation. Position sense may be an output of a process needing position information, external torque, and the sense of effort. Even for healthy individuals, it is unclear whether external torque affects position sense. Thus, evaluation of position sense under different external torques in clinical settings is strongly needed. However, simple devices for measuring position sense under different external torques in clinical settings are lacking. Technologically advanced devices that may evaluate the elbow position sense under different torques were reported to be infeasible clinically because of device complexity and the need for technical experts when analyzing data. To address the unmet need, in this study, a simple and light elbow position sense measurement device was developed that allows clinicians to measure elbow position sense under different external torques in the form of position matching error objectively without any technical difficulties. The feasibility of the device, including intra-session intra-rater reliability and test-retest reliability over two consecutive days, was verified to be clinically applicable using tests with 25 healthy subjects. Thanks to its ease of use, high reliability, and ease of data analysis, it is expected that the device can help to evaluate the position sense post-stroke comprehensively.
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Francis JT, Rozenboym A, von Kraus L, Xu S, Chhatbar P, Semework M, Hawley E, Chapin J. Similarities Between Somatosensory Cortical Responses Induced via Natural Touch and Microstimulation in the Ventral Posterior Lateral Thalamus in Macaques. Front Neurosci 2022; 16:812837. [PMID: 35250454 PMCID: PMC8888535 DOI: 10.3389/fnins.2022.812837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/24/2022] [Indexed: 11/30/2022] Open
Abstract
Lost sensations, such as touch, could be restored by microstimulation (MiSt) along the sensory neural substrate. Such neuroprosthetic sensory information can be used as feedback from an invasive brain-machine interface (BMI) to control a robotic arm/hand, such that tactile and proprioceptive feedback from the sensorized robotic arm/hand is directly given to the BMI user. Microstimulation in the human somatosensory thalamus (Vc) has been shown to produce somatosensory perceptions. However, until recently, systematic methods for using thalamic stimulation to evoke naturalistic touch perceptions were lacking. We have recently presented rigorous methods for determining a mapping between ventral posterior lateral thalamus (VPL) MiSt, and neural responses in the somatosensory cortex (S1), in a rodent model (Choi et al., 2016; Choi and Francis, 2018). Our technique minimizes the difference between S1 neural responses induced by natural sensory stimuli and those generated via VPL MiSt. Our goal is to develop systems that know what neural response a given MiSt will produce and possibly allow the development of natural “sensation.” To date, our optimization has been conducted in the rodent model and simulations. Here, we present data from simple non-optimized thalamic MiSt during peri-operative experiments, where we used MiSt in the VPL of macaques, which have a somatosensory system more like humans, as compared to our previous rat work (Li et al., 2014; Choi et al., 2016). We implanted arrays of microelectrodes across the hand area of the macaque S1 cortex as well as in the VPL. Multi and single-unit recordings were used to compare cortical responses to natural touch and thalamic MiSt in the anesthetized state. Post-stimulus time histograms were highly correlated between the VPL MiSt and natural touch modalities, adding support to the use of VPL MiSt toward producing a somatosensory neuroprosthesis in humans.
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Affiliation(s)
- Joseph Thachil Francis
- Cullen College of Engineering, Department of Biomedical Engineering and Electrical and Computer Engineering, University of Houston, Houston, TX, United States
- Department of Physiology and Pharmacology, State of New York Downstate Medical School, Brooklyn, NY, United States
- *Correspondence: Joseph Thachil Francis,
| | - Anna Rozenboym
- Department of Physiology and Pharmacology, State of New York Downstate Medical School, Brooklyn, NY, United States
- Department of Biological Sciences, Kingsborough Community College-CUNY, Brooklyn, NY, United States
| | - Lee von Kraus
- Department of Physiology and Pharmacology, State of New York Downstate Medical School, Brooklyn, NY, United States
| | - Shaohua Xu
- Department of Physiology and Pharmacology, State of New York Downstate Medical School, Brooklyn, NY, United States
| | - Pratik Chhatbar
- Department of Physiology and Pharmacology, State of New York Downstate Medical School, Brooklyn, NY, United States
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Mulugeta Semework
- Department of Physiology and Pharmacology, State of New York Downstate Medical School, Brooklyn, NY, United States
| | - Emerson Hawley
- Department of Physiology and Pharmacology, State of New York Downstate Medical School, Brooklyn, NY, United States
| | - John Chapin
- Department of Physiology and Pharmacology, State of New York Downstate Medical School, Brooklyn, NY, United States
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Fossataro C, Bruno V, Gindri P, Garbarini F. Defending the Body Without Sensing the Body Position: Physiological Evidence in a Brain-Damaged Patient With a Proprioceptive Deficit. Front Psychol 2018; 9:2458. [PMID: 30564182 PMCID: PMC6288365 DOI: 10.3389/fpsyg.2018.02458] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 11/20/2018] [Indexed: 01/10/2023] Open
Abstract
The ability to know where our body parts are located in space (proprioception) is fundamental for both successfully interacting with the external world and monitoring potential threats. In this case-control study, we investigated whether the absence of proprioceptive signals may affect physiological defensive responses. To this aim, a right brain-damaged patient with a left upper-limb proprioceptive deficit (P+ patient) and age-matched healthy controls, underwent the recording of the Hand-Blink Reflex (HBR). This defensive response, elicited by electrical stimulation of the median nerve and recorded from the orbicularis oculi, is modulated by the hand position: it is enhanced when the threatened hand is near to the face, inside the defensive peripersonal-space (DPPS). According to the classical neuropsychological perspective, we used P+ patient as a model to investigate the role of proprioception in HBR modulation, by manipulating the congruity/incongruity between the intended and actual positions of the stimulated hand. P+ patient, with his eyes closed, had to voluntarily place his left hand either far from or near to his face and to relieve the arm's weight over a supporting device. Then, in congruent conditions, the hand was stimulated in the actual (intended) position. In incongruent conditions, the patient's hand was moved by the examiner from the intended to the opposite (not-intended) position and then stimulated. We observed an inverse response pattern between congruent and incongruent conditions. In congruent conditions, P+ patient showed an HBR enhancement in near compared to far position, comparable to that found in healthy controls. This suggests that, even in absence of proprioceptive and visual information, the HBR modulation was still present. Conversely, in incongruent conditions, P+ patient showed a greater HBR magnitude for far position (when the hand was actually far, but the patient intended it to be near) than for near position (when the hand was actually near, but the patient intended it to be far). This result suggests that proprioceptive signals are not necessary for HBR modulation to occur. It relies more on the intended than on the actual position of the hand. The role of motor intention and planning in shaping the DPPS is discussed.
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Affiliation(s)
- Carlotta Fossataro
- MANIBUS Laboratory, Psychology Department, University of Turin, Turin, Italy
| | - Valentina Bruno
- MANIBUS Laboratory, Psychology Department, University of Turin, Turin, Italy
| | - Patrizia Gindri
- MANIBUS Laboratory, Psychology Department, University of Turin, Turin, Italy
- San Camillo Hospital of Turin, Turin, Italy
| | - Francesca Garbarini
- MANIBUS Laboratory, Psychology Department, University of Turin, Turin, Italy
- San Camillo Hospital of Turin, Turin, Italy
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Ghai S, Schmitz G, Hwang TH, Effenberg AO. Auditory Proprioceptive Integration: Effects of Real-Time Kinematic Auditory Feedback on Knee Proprioception. Front Neurosci 2018; 12:142. [PMID: 29568259 PMCID: PMC5852112 DOI: 10.3389/fnins.2018.00142] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 02/22/2018] [Indexed: 01/23/2023] Open
Abstract
The purpose of the study was to assess the influence of real-time auditory feedback on knee proprioception. Thirty healthy participants were randomly allocated to control (n = 15), and experimental group I (15). The participants performed an active knee-repositioning task using their dominant leg, with/without additional real-time auditory feedback where the frequency was mapped in a convergent manner to two different target angles (40 and 75°). Statistical analysis revealed significant enhancement in knee re-positioning accuracy for the constant and absolute error with real-time auditory feedback, within and across the groups. Besides this convergent condition, we established a second divergent condition. Here, a step-wise transposition of frequency was performed to explore whether a systematic tuning between auditory-proprioceptive repositioning exists. No significant effects were identified in this divergent auditory feedback condition. An additional experimental group II (n = 20) was further included. Here, we investigated the influence of a larger magnitude and directional change of step-wise transposition of the frequency. In a first step, results confirm the findings of experiment I. Moreover, significant effects on knee auditory-proprioception repositioning were evident when divergent auditory feedback was applied. During the step-wise transposition participants showed systematic modulation of knee movements in the opposite direction of transposition. We confirm that knee re-positioning accuracy can be enhanced with concurrent application of real-time auditory feedback and that knee re-positioning can modulated in a goal-directed manner with step-wise transposition of frequency. Clinical implications are discussed with respect to joint position sense in rehabilitation settings.
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Affiliation(s)
- Shashank Ghai
- Institute of Sports Science, Leibniz University Hannover, Hannover, Germany
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7
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Hemispheric Dominance for Stereognosis in a Patient With an Infarct of the Left Postcentral Sensory Hand Area. Cogn Behav Neurol 2017; 30:102-115. [PMID: 28926418 DOI: 10.1097/wnn.0000000000000135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The concept of left hemispheric dominance for praxis, speech, and language has been one of the pillars of neurology since the mid-19th century. In 1906, Hermann Oppenheim reported a patient with bilateral stereoagnosia (astereognosis) caused by a left parietal lobe tumor and proposed that the left hemisphere was also dominant for stereognosis. Surprisingly, few cases of bilateral stereoagnosia caused by a unilateral cerebral lesion have been documented in the literature since then. Here we report a 75-year-old right-handed man who developed bilateral stereoagnosia after suffering a small infarct in the crown of the left postcentral gyrus. He could not recognize objects with either hand, but retained the ability to localize stimuli applied to the palm of his left (ipsilesional) hand. He was severely disabled in ordinary activities requiring the use of his hands. The lesion corresponded to Brodmann area 1, where probabilistic anatomic, functional, and electrophysiologic studies have located one of the multiple somatosensory representations of the hand. The lesion was in a strategic position to interrupt both the processing of afferent tactile information issuing from the primary somatosensory cortex (areas 3a and 3b) and the forward higher-order processing in area 2, the secondary sensory cortex, and the contralateral area 1. The lesion also deprived the motor hand area of its afferent regulation from the sensory hand area (grasping), while leaving intact the visuomotor projections from the occipital cortex (reaching). Our patient supports Oppenheim's proposal that the left postcentral gyrus of some individuals is dominant for stereognosis.
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Findlater SE, Dukelow SP. Upper Extremity Proprioception After Stroke: Bridging the Gap Between Neuroscience and Rehabilitation. J Mot Behav 2016; 49:27-34. [PMID: 27726645 DOI: 10.1080/00222895.2016.1219303] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Proprioception is an important aspect of function that is often impaired in the upper extremity following stroke. Unfortunately, neurorehabilitation has few evidence based treatment options for those with proprioceptive deficits. The authors consider potential reasons for this disparity. In doing so, typical assessments and proprioceptive intervention studies are discussed. Relevant evidence from the field of neuroscience is examined. Such evidence may be used to guide the development of targeted interventions for upper extremity proprioceptive deficits after stroke. As researchers become more aware of the impact of proprioceptive deficits on upper extremity motor performance after stroke, it is imperative to find successful rehabilitation interventions to target these deficits and ultimately improve daily function.
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Affiliation(s)
- Sonja E Findlater
- a Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences , Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary , Calgary, Alberta , Canada
| | - Sean P Dukelow
- a Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences , Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary , Calgary, Alberta , Canada
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Scholz DS, Rohde S, Nikmaram N, Brückner HP, Großbach M, Rollnik JD, Altenmüller EO. Sonification of Arm Movements in Stroke Rehabilitation - A Novel Approach in Neurologic Music Therapy. Front Neurol 2016; 7:106. [PMID: 27445970 PMCID: PMC4928599 DOI: 10.3389/fneur.2016.00106] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 06/20/2016] [Indexed: 01/17/2023] Open
Abstract
Gross motor impairments are common after stroke, but efficient and motivating therapies for these impairments are scarce. We present an innovative musical sonification therapy, especially designed to retrain patients’ gross motor functions. Sonification should motivate patients and provide additional sensory input informing about relative limb position. Twenty-five stroke patients were included in a clinical pre–post study and took part in the sonification training. The patients’ upper extremity functions, their psychological states, and their arm movement smoothness were assessed pre and post training. Patients were randomly assigned to either of two groups. Both groups received an average of 10 days (M = 9.88; SD = 2.03; 30 min/day) of musical sonification therapy [music group (MG)] or a sham sonification movement training [control group (CG)], respectively. The only difference between the two protocols was that in the CG no sound was played back during training. In the beginning, patients explored the acoustic effects of their arm movements in space. At the end of the training, the patients played simple melodies by coordinated arm movements. The 15 patients in the MG showed significantly reduced joint pain (F = 19.96, p < 0.001) in the Fugl–Meyer assessment after training. They also reported a trend to have improved hand function in the stroke impact scale as compared to the CG. Movement smoothness at day 1, day 5, and the last day of the intervention was compared in MG patients and found to be significantly better after the therapy. Taken together, musical sonification may be a promising therapy for motor impairments after stroke, but further research is required since estimated effect sizes point to moderate treatment outcomes.
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Affiliation(s)
- Daniel S Scholz
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media , Hannover , Germany
| | - Sönke Rohde
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media , Hannover , Germany
| | - Nikou Nikmaram
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media , Hannover , Germany
| | - Hans-Peter Brückner
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media , Hannover , Germany
| | - Michael Großbach
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media , Hannover , Germany
| | - Jens D Rollnik
- Institute for Neurorehabilitational Research (InFo), BDH-Clinic Hessisch Oldendorf, Teaching Hospital of Hannover Medical School (MHH) , Hessisch Oldendorf , Germany
| | - Eckart O Altenmüller
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media , Hannover , Germany
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Ben-Shabat E, Matyas TA, Pell GS, Brodtmann A, Carey LM. The Right Supramarginal Gyrus Is Important for Proprioception in Healthy and Stroke-Affected Participants: A Functional MRI Study. Front Neurol 2015; 6:248. [PMID: 26696951 PMCID: PMC4668288 DOI: 10.3389/fneur.2015.00248] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 11/12/2015] [Indexed: 01/15/2023] Open
Abstract
Human proprioception is essential for motor control, yet its central processing is still debated. Previous studies of passive movements and illusory vibration have reported inconsistent activation patterns related to proprioception, particularly in high-order sensorimotor cortices. We investigated brain activation specific to proprioception, its laterality, and changes following stroke. Twelve healthy and three stroke-affected individuals with proprioceptive deficits participated. Proprioception was assessed clinically with the Wrist Position Sense Test, and participants underwent functional magnetic resonance imaging scanning. An event-related study design was used, where each proprioceptive stimulus of passive wrist movement was followed by a motor response of mirror -copying with the other wrist. Left (LWP) and right (RWP) wrist proprioception were tested separately. Laterality indices (LIs) were calculated for the main cortical regions activated during proprioception. We found proprioception-related brain activation in high-order sensorimotor cortices in healthy participants especially in the supramarginal gyrus (SMG LWP z = 4.51, RWP z = 4.24) and the dorsal premotor cortex (PMd LWP z = 4.10, RWP z = 3.93). Right hemispheric dominance was observed in the SMG (LI LWP mean 0.41, SD 0.22; RWP 0.29, SD 0.20), and to a lesser degree in the PMd (LI LWP 0.34, SD 0.17; RWP 0.13, SD 0.25). In stroke-affected participants, the main difference in proprioception-related brain activation was reduced laterality in the right SMG. Our findings indicate that the SMG and PMd play a key role in proprioception probably due to their role in spatial processing and motor control, respectively. The findings from stroke--affected individuals suggest that decreased right SMG function may be associated with decreased proprioception. We recommend that clinicians pay particular attention to the assessment and rehabilitation of proprioception following right hemispheric lesions.
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Affiliation(s)
- Ettie Ben-Shabat
- Neurorehabilitation and Recovery, Stroke, Florey Institute of Neuroscience and Mental Health , Melbourne, VIC , Australia ; Occupational Therapy, School of Allied Health, College of Science, Health and Engineering, La Trobe University , Melbourne, VIC , Australia
| | - Thomas A Matyas
- Neurorehabilitation and Recovery, Stroke, Florey Institute of Neuroscience and Mental Health , Melbourne, VIC , Australia ; Occupational Therapy, School of Allied Health, College of Science, Health and Engineering, La Trobe University , Melbourne, VIC , Australia
| | - Gaby S Pell
- Neurorehabilitation and Recovery, Stroke, Florey Institute of Neuroscience and Mental Health , Melbourne, VIC , Australia
| | - Amy Brodtmann
- Neurorehabilitation and Recovery, Stroke, Florey Institute of Neuroscience and Mental Health , Melbourne, VIC , Australia
| | - Leeanne M Carey
- Neurorehabilitation and Recovery, Stroke, Florey Institute of Neuroscience and Mental Health , Melbourne, VIC , Australia ; Occupational Therapy, School of Allied Health, College of Science, Health and Engineering, La Trobe University , Melbourne, VIC , Australia
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Scholz DS, Rhode S, Großbach M, Rollnik J, Altenmüller E. Moving with music for stroke rehabilitation: a sonification feasibility study. Ann N Y Acad Sci 2015; 1337:69-76. [PMID: 25773619 DOI: 10.1111/nyas.12691] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Gross-motor impairments are common after stroke, but efficacious and motivating therapies for these impairments are scarce. We present a novel musical sonification therapy especially designed to retrain gross-motor functions. Four stroke patients were included in a clinical pre-post feasibility study and were trained with our sonification training. Patients' upper-extremity functions and their psychological states were assessed before and after training. The four patients were subdivided into two groups, with both groups receiving 9 days of musical sonification therapy (music group, MG) or a sham sonification training (control group, CG). The only difference between these training protocols was that, in the CG, no sound was played back. During the training the patients initially explored the acoustic effects of their arm movements, and at the end of the training the patients played simple melodies by moving their arms. The two patients in the MG improved in nearly all motor function tests after the training. They also reported in the stroke impact scale, which assesses well-being, memory, thinking, and social participation, to be less impaired by the stroke. The two patients in the CG did benefit less from the movement training. Taken together, musical sonification may be a promising therapy for impairments after stroke.
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Affiliation(s)
- Daniel S Scholz
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama, and Media, Hannover, Germany
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Hughes CML, Tommasino P, Budhota A, Campolo D. Upper extremity proprioception in healthy aging and stroke populations, and the effects of therapist- and robot-based rehabilitation therapies on proprioceptive function. Front Hum Neurosci 2015; 9:120. [PMID: 25784872 PMCID: PMC4345814 DOI: 10.3389/fnhum.2015.00120] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 02/17/2015] [Indexed: 12/31/2022] Open
Abstract
The world’s population is aging, with the number of people ages 65 or older expected to surpass 1.5 billion people, or 16% of the global total. As people age, there are notable declines in proprioception due to changes in the central and peripheral nervous systems. Moreover, the risk of stroke increases with age, with approximately two-thirds of stroke-related hospitalizations occurring in people over the age of 65. In this literature review, we first summarize behavioral studies investigating proprioceptive deficits in normally aging older adults and stroke patients, and discuss the differences in proprioceptive function between these populations. We then provide a state of the art review the literature regarding therapist- and robot-based rehabilitation of the upper extremity proprioceptive dysfunction in stroke populations and discuss avenues of future research.
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Affiliation(s)
- Charmayne Mary Lee Hughes
- Robotics Research Centre, School of Mechanical and Aerospace Engineering, Nanyang Technological University , Singapore
| | - Paolo Tommasino
- Robotics Research Centre, School of Mechanical and Aerospace Engineering, Nanyang Technological University , Singapore
| | - Aamani Budhota
- Robotics Research Centre, School of Mechanical and Aerospace Engineering, Nanyang Technological University , Singapore ; Interdisciplinary Graduate School, Nanyang Technological University , Singapore
| | - Domenico Campolo
- Robotics Research Centre, School of Mechanical and Aerospace Engineering, Nanyang Technological University , Singapore
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Scholz DS, Wu L, Pirzer J, Schneider J, Rollnik JD, Großbach M, Altenmüller EO. Sonification as a possible stroke rehabilitation strategy. Front Neurosci 2014; 8:332. [PMID: 25368548 PMCID: PMC4202805 DOI: 10.3389/fnins.2014.00332] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 10/01/2014] [Indexed: 11/24/2022] Open
Abstract
Despite cerebral stroke being one of the main causes of acquired impairments of motor skills worldwide, well-established therapies to improve motor functions are sparse. Recently, attempts have been made to improve gross motor rehabilitation by mapping patient movements to sound, termed sonification. Sonification provides additional sensory input, supplementing impaired proprioception. However, to date no established sonification-supported rehabilitation protocol strategy exists. In order to examine and validate the effectiveness of sonification in stroke rehabilitation, we developed a computer program, termed “SonicPointer”: Participants' computer mouse movements were sonified in real-time with complex tones. Tone characteristics were derived from an invisible parameter mapping, overlaid on the computer screen. The parameters were: tone pitch and tone brightness. One parameter varied along the x, the other along the y axis. The order of parameter assignment to axes was balanced in two blocks between subjects so that each participant performed under both conditions. Subjects were naive to the overlaid parameter mappings and its change between blocks. In each trial a target tone was presented and subjects were instructed to indicate its origin with respect to the overlaid parameter mappings on the screen as quickly and accurately as possible with a mouse click. Twenty-six elderly healthy participants were tested. Required time and two-dimensional accuracy were recorded. Trial duration times and learning curves were derived. We hypothesized that subjects performed in one of the two parameter-to-axis–mappings better, indicating the most natural sonification. Generally, subjects' localizing performance was better on the pitch axis as compared to the brightness axis. Furthermore, the learning curves were steepest when pitch was mapped onto the vertical and brightness onto the horizontal axis. This seems to be the optimal constellation for this two-dimensional sonification.
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Affiliation(s)
- Daniel S Scholz
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media Hannover, Germany
| | - Liming Wu
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media Hannover, Germany
| | - Jonas Pirzer
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media Hannover, Germany
| | - Johann Schneider
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media Hannover, Germany
| | - Jens D Rollnik
- Institute for Neurorehabilitational Research (InFo), BDH-Clinic Hessisch Oldendorf, Teaching Hospital of Hannover Medical School (MHH) Hessisch Oldendorf, Germany
| | - Michael Großbach
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media Hannover, Germany
| | - Eckart O Altenmüller
- Institute of Music Physiology and Musicians' Medicine, University of Music, Drama and Media Hannover, Germany
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Kenzie JM, Semrau JA, Findlater SE, Herter TM, Hill MD, Scott SH, Dukelow SP. Anatomical correlates of proprioceptive impairments following acute stroke: a case series. J Neurol Sci 2014; 342:52-61. [PMID: 24819922 DOI: 10.1016/j.jns.2014.04.025] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/31/2014] [Accepted: 04/21/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Proprioception is the sensation of position and movement of our limbs and body in space. This sense is important for performing smooth coordinated movements and is impaired in approximately 50% of stroke survivors. In the present case series we wanted to determine how discrete stroke lesions to areas of the brain thought to be critical for somatosensation (thalamus, posterior limb of internal capsule, primary somatosensory cortex and posterior parietal cortex) would affect position sense and kinesthesia in the acute stages post-stroke. Given the known issues with standard clinical measures of proprioception (i.e. poor sensitivity and reliability) we used more modern quantitative robotic assessments to measure proprioception. METHODS Neuroimaging (MRI, n=10 or CT, n=2) was performed on 12 subjects 2-10 days post-stroke. Proprioception was assessed using a KINARM robot within the same time frame. Visually guided reaching was also assessed to allow us to compare and contrast proprioception with visuomotor performance. RESULTS AND CONCLUSIONS Proprioceptive impairments were observed in 7 of 12 subjects. Thalamic lesions (n=4) were associated with position sense (n=1) or position sense and kinesthesia (n=1) impairments. Posterior limb of the internal capsule lesions (n=4) were associated with primarily position sense (n=1) or kinesthesia (n=2) impairments. Lesions affecting primary somatosensory cortex and posterior parietal cortex (n=2) were associated with significant position sense and kinesthesia impairments. All subjects with damage to hypothesized structures displayed impairments with performance on the visually guided reaching task. Across the proprioceptive tasks, we saw that position sense and kinesthesia were impaired to differing degrees, suggesting a potential dissociation between these two components of proprioception.
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Affiliation(s)
- Jeffrey M Kenzie
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Faculties of Medicine and Kinesiology, University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4, Canada
| | - Jennifer A Semrau
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Faculties of Medicine and Kinesiology, University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4, Canada
| | - Sonja E Findlater
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Faculties of Medicine and Kinesiology, University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4, Canada
| | - Troy M Herter
- Department of Exercise Science, University of South Carolina, 1300 Wheat St, Columbia, SC 29208, USA
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4, Canada
| | - Stephen H Scott
- Department of Anatomy and Cell Biology, Queen's University, Botterell Hall, Room 219, Kingston, ON K7L 3N6, Canada; Providence Care, St. Mary's of the Lake Hospital, 340 Union St, Kingston, ON K7L 5A2, Canada
| | - Sean P Dukelow
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Faculties of Medicine and Kinesiology, University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4, Canada; Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4, Canada.
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15
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Pseudocortical and dissociate discriminative sensory dysfunction in a thalamic stroke. Cortex 2013; 49:336-9. [DOI: 10.1016/j.cortex.2012.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 12/06/2011] [Accepted: 07/20/2012] [Indexed: 11/20/2022]
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16
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Thumb, forefinger, and lip numbness: a distinctive thalamic lacunar syndrome. Neurol Sci 2012; 34:253-4. [PMID: 22367225 DOI: 10.1007/s10072-012-0992-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 02/17/2012] [Indexed: 10/28/2022]
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17
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Classification of Ischemic Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10020-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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18
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Davis AS, Mazur-Mosiewicz A, Dean RS. The Presence and Predictive Value of Astereognosis and Agraphesthesia in Patients with Alzheimer's Disease. ACTA ACUST UNITED AC 2010; 17:262-6. [DOI: 10.1080/09084282.2010.525102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Andrew S. Davis
- a Department of Educational Psychology , Ball State University , Muncie, Indiana
| | - Anna Mazur-Mosiewicz
- a Department of Educational Psychology , Ball State University , Muncie, Indiana
| | - Raymond S. Dean
- a Department of Educational Psychology , Ball State University , Muncie, Indiana
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19
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Kumar KR, Kiley M. Essential thrombocythaemia presenting with subclavian artery thrombosis and multiple embolic events. BMJ Case Rep 2009; 2009:bcr11.2008.1240. [PMID: 21686395 DOI: 10.1136/bcr.11.2008.1240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The present report describes a case of in situ thrombosis of the left subclavian artery complicated by posterior circulation stroke, left arm ischaemia and possibly ischaemic pancreatitis. Essential thrombocythaemia was found to be the underlying cause.
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Affiliation(s)
- Kishore Raj Kumar
- Royal Adelaide Hospital, Neurology, North Terrace, Adelaide, South Australia, 5006, Australia
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20
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Affiliation(s)
- Geoffrey A Donnan
- National Stroke Research Institute, Heidelberg, Victoria, Australia.
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21
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22
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Classification of Ischemic Stroke. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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23
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Kumral E, Evyapan D, Kutluhan S. Pure thalamic infarctions: Clinical findings. J Stroke Cerebrovasc Dis 2000. [DOI: 10.1053/jscd.2000.18741] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Timmermann L, Ploner M, Freund HJ, Schnitzler A. Separate representations of static and dynamic touch in human somatosensory thalamus. Neurology 2000; 54:2024-6. [PMID: 10822455 DOI: 10.1212/wnl.54.10.2024-a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- L Timmermann
- Department of Neurology, Heinrich-Heine-University, Düsseldorf, Germany
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25
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de Oliveira-Souza R, Martins ME, Andreiuolo PA, Rotmeister A. [Virtual dystonia due to posterior ventrolateral thalamic infarct: case report]. ARQUIVOS DE NEURO-PSIQUIATRIA 1996; 54:484-9. [PMID: 9109996 DOI: 10.1590/s0004-282x1996000300020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Behaviors, actions and movements may take place as purely mental events, as in the obsessions of obsessive-compulsive disorder, phantom limbs or sensory tics. In the present paper we report on the case of a 43-year-old diabetic hypertensive man who developed an incomplete form of the Dejerine-Roussy syndrome. Whenever he lay down or withdrew the leg from the ground, he experienced the illusion that the left intermediate toes painfully twisted and mounted each other. Conversely, as he stood up or firm pressure was artificially exerted against the sole, there was a dramatic relief from the "cramp" whose illusory character could he be certain of only by looking down at the foot. By passively moving his toes into the referred position we realized that the experienced deformity conformed to the pattern of a fixed dystonia not outwardly expressed through the motor system. There was severe proprioceptive loss in the same toes that harbored the cramp. MRI showed the appropriate lesion in the posteroventrolateral thalamus (VPL) and wallerian degeneration of thalamo-cortical projections. SPECT showed hypoperfusion of the overlying ipsilateral parietal cortex as well as of the basal nuclei bilaterally, besides the expected image of thalamic exclusion. We hypothesize that the infarct disconnected the somatic sensory cortex (S-1) from critical proprioceptive input with relative sparing of superficial sensibility. Lifting the foot deprived S-1 of tonic inputs conveyed by undamaged contact-pressure pathways, a functional effect promptly reversed by placing the foot back against the ground. The case illustrates how a capricious deafferentation of S-1 by a discrete VPL thalamic infarct might facilitate the emergence of autochthonous activity.
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Affiliation(s)
- R de Oliveira-Souza
- Clínica Médica III, Hospital Universitário Gaffrée Guinle (HUGG, UNI-RIO), Brasil
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26
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Bastian AJ, Thach WT. Cerebellar outflow lesions: a comparison of movement deficits resulting from lesions at the levels of the cerebellum and thalamus. Ann Neurol 1995; 38:881-92. [PMID: 8526460 DOI: 10.1002/ana.410380608] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Previous work has shown that lesions in the lateral cerebellum involving the dentate nucleus impair both reaching and pinching movements in humans and monkeys. This study addressed the question of whether disruption of the cerebellar-thalamo-cortical pathway at the level of the thalamus would produce behavioral deficits similar to those seen after dentate damage. We compared the performance of both reaching and pinching movements in patients with lateral cerebellar lesions and in patients with discrete lesions of the ventrolateral thalamus. The patients with thalamic lesions had minimal or no sensory loss and no corticospinal signs, suggesting that the abnormal movements were due to disruption of the cerebellar projection to the thalamus. We found that lesions of the ventrolateral thalamus resulted in impaired pinching movements, but remarkably normal reaching movements with the exception of a slight tremor. This is in contrast to the profound pinching and reaching impairments of patients with lateral cerebellar lesions involving the dentate nucleus. Implications about the functional organization of cerebellar output are discussed.
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Affiliation(s)
- A J Bastian
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO 63110, USA
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27
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Dibert SW, Asconapé J. Embolic pontine infarction in a nonhypertensive patient following coronary angioplasty. J Neuroimaging 1995; 5:194-5. [PMID: 7626830 DOI: 10.1111/jon199553194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
A 63-year-old woman was found to have decreased vibration, light touch, and proprioception sensations in the right hemi-body, following cardiac angioplasty. The patient was not hypertensive although she had a history of hypercholesterolemia and was a smoker. Magnetic resonance images of the brain demonstrated abnormal signal intensity in the left paramedian basis pons anterior to the fourth ventricle. The lesion was believed to be consistent with a lacunar infarction. Unlike this woman, the majority of patients who have a small-vessel stroke are usually diabetic or hypertensive. The interesting features here were that the stroke was a complication of coronary angioplasty, was cardioembolic to the pons, and was falsely localized to the thalamus. In addition, rarely does an embolic stroke involve a single brainstem tract.
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Affiliation(s)
- S W Dibert
- Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC, USA
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28
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Gutrecht JA, Zamani AA, Pandya DN. Lacunar thalamic stroke with pure cerebellar and proprioceptive deficits. J Neurol Neurosurg Psychiatry 1992; 55:854-6. [PMID: 1402983 PMCID: PMC1015118 DOI: 10.1136/jnnp.55.9.854] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Case reports of two patients with cerebellar ataxia and proprioceptive sensory loss are presented. MRI of the brain revealed lesions of the ventroposterior part of the thalamus. These patients illustrate clinically the anatomical independence of cerebellar and sensory pathways in the thalamus. We suggest that the ataxic deficit is caused by interruption of cerebellar outflow pathways in the thalamus and not secondary to sensory deafferentation.
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Affiliation(s)
- J A Gutrecht
- Department of Neurology, Lahey Clinic Medical Center, Burlington, Massachusetts 01805
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29
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Ross RT. Dissociated loss of vibration, joint position and discriminatory tactile senses in disease of spinal cord and brain. Neurol Sci 1991; 18:312-20. [PMID: 1913366 DOI: 10.1017/s0317167100031875] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The clinical functions of the posterior columns of the spinal cord and the signs of disease of these structures have been debated for years. Todd in 1847 and Schiff in 1858 knew the functions of the posterior columns and 10 years later Brown-Séquard knew as well. Reynolds, Romberg, and Duchenne, each described a posterior column syndrome based on a disease in which the primary lesion was not in the posterior columns. In the last 150 years almost every white matter structure of the cord has been credited with serving the sensations that we now know are a function of the posterior columns. Vibration, joint position and movement as well as discriminatory touch each seem to be served by separate fibres of the posterior columns and medial lemniscus. There is evidence of this in cat and man. These sensations may be lost individually, totally, or in certain stereotyped combinations. Vibration or joint sense is commonly lost alone. When a discriminatory touch sensation is lost with one other sense, it is almost inevitably joint position sense. Absent discriminatory touch and vibration sense with normal joint position sense appears to be unknown. This functional separation continues into the thalamus. At the highest level there is no evidence that vibration sense has any conscious somatosensory cortical affiliation, while joint position and discriminatory touch senses definitely do.
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Affiliation(s)
- R T Ross
- Department of Medicine, University of Manitoba, Winnipeg, Canada
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