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BACKGROUND: Gait deficits and functional disability are persistent problems for many stroke survivors, even after standard neurorehabilitation. There is little quantified information regarding the trajectories of response to a long-dose, 12-month intervention. OBJECTIVE: We quantified treatment response to an intensive neurorehabilitation mobility and fitness program. METHODS: The 12-month neurorehabilitation program targeted impairments in balance, limb coordination, gait coordination, and functional mobility, for five chronic stroke survivors. We obtained measures of those variables every two months. RESULTS: We found statistically and clinically significant group improvement in measures of impairment and function. There was high variation across individuals in terms of the timing and the gains exhibited. CONCLUSIONS: Long-duration neurorehabilitation (12 months) for mobility/fitness produced clinically and/or statistically significant gains in impairment and function. There was unique pattern of change for each individual. Gains exhibited late in the treatment support a 12-month intervention. Some measures for some subjects did not reach a plateau at 12 months, justifying further investigation of a longer program (>12 months) of rehabilitation and/or maintenance care for stroke survivors.

The prevalence of increased muscle tone after stroke is frequently reported as 30% to 40%, and the condition is often concurrent with motor control deficits, manifesting as an inability to isolate paretic-limb joint movements.The objectives of this retrospective analysis were to 1) report the prevalence of increased muscle tone in a convenience sample of 128 chronic stroke survivors with moderate/severe motor deficits and 2) quantify the relation between tone and motor impairment in chronic stroke survivors.Analyses included descriptive statistics and multiple regression modeling, with the modified Ashworth Scale score (MAS; tone) as a predictor of isolated joint movement control (Fugl-Meyer score [FM]; motor impairment).Increased muscle tone was present in 97% of subjects. Increased muscle tone was associated with impaired motor control (FM; upper extremity, P=0.008; lower extremity, P=0.03) after adjusting for age, time since stroke and sex. We found a significant difference between flexor and extensor strength for finger, elbow, hip and knee joints (P0.002). Participants were classified in high and low MAS score groups. With high MAS score and for muscles of finger flexion and forearm pronation, we found a trend toward impaired strength of antagonist muscles (finger extensors and forearm supinators, respectively) as compared with low MAS score for these same muscle pairings.The prevalence of increased tone was higher in this study than in previous reports. Increased muscle tone in chronic stroke survivors with persistent motor dysfunction could be associated with impaired motor control and differential muscle strength of antagonistic muscles.

Background. Effective treatment methods are needed for moderate/severely impairment chronic stroke. Objective. The questions were the following: (1) Is there need for long-dose therapy or is there a mid-treatment plateau? (2) Are the observed gains from the prior-studied protocol retained after treatment? Methods. Single-blind, stratified/randomized design, with 3 applied technology treatment groups, combined with motor learning, for long-duration treatment (300 hours of treatment). Measures were Arm Motor Ability Test time and coordination-function (AMAT-T, AMAT-F, respectively), acquired pre-/posttreatment and 3-month follow-up (3moF/U); Fugl-Meyer (FM), acquired similarly with addition of mid-treatment. Findings. There was no group difference in treatment response ( P ≥ .16), therefore data were combined for remaining analyses (n = 31; except for FM pre/mid/post, n = 36). Pre-to-Mid-treatment and Mid-to-Posttreatment gains of FM were statistically and clinically significant ( P < .0001; 4.7 points and P < .001; 5.1 points, respectively), indicating no plateau at 150 hours and benefit of second half of treatment. From baseline to 3moF/U: (1) FM gains were twice the clinically significant benchmark, (2) AMAT-F gains were greater than clinically significant benchmark, and (3) there was statistically significant improvement in FM ( P < .0001); AMAT-F ( P < .0001); AMAT-T ( P < .0001). These gains indicate retained clinically and statistically significant gains at 3moFU. From posttreatment to 3moF/U, gains on FM were maintained. There were statistically significant gains in AMAT-F ( P = .0379) and AMAT-T P = .003.

Objective Pilot testing of real time functional magnetic resonance imaging (rt-fMRI) and real time functional near infrared spectroscopy (rt-fNIRS) as brain computer interface (BCI) neural feedback systems combined with motor learning for motor recovery in chronic severely impaired stroke survivors. Approach We enrolled a four-case series and administered three sequential rt-fMRI and ten rt-fNIRS neural feedback sessions interleaved with motor learning sessions. Measures were: Arm Motor Assessment Tool, functional domain (AMAT-F; 13 complex functional tasks), Fugl-Meyer arm coordination scale (FM); active wrist extension range of motion (ROM); volume of activation (fMRI); and fNIRS HbO concentration. Performance during neural feedback was assessed, in part, using percent successful brain modulations during rt-fNIRS. Main results Pre-/post-treatment mean clinically significant improvement in AMAT-F (.49 ± 0.22) and FM (10.0 ± 3.3); active wrist ROM improvement ranged from 20° to 50°. Baseline to follow-up change in brain signal was as follows: fMRI volume of activation was reduced in almost all ROIs for three subjects, and for one subject there was an increase or no change; fNIRS HbO was within normal range, except for one subject who increased beyond normal at post-treatment. During rt-fNIRS neural feedback training, there was successful brain signal modulation (42%–78%). Significance Severely impaired stroke survivors successfully engaged in spatially focused BCI systems, rt-fMRI and rt-fNIRS, to clinically significantly improve motor function. At the least, equivalency in motor recovery was demonstrated with prior long-duration motor learning studies (without neural feedback), indicating that no loss of motor improvement resulted from substituting neural feedback sessions for motor learning sessions. Given that the current neural feedback protocol did not prevent the motor improvements observed in other long duration studies, even in the presence of fewer sessions of motor learning in the current work, the results support further study of neural feedback and its potential for recovery of motor function in stroke survivors. In future work, expanding the sophistication of either or both rt-fMRI and rt-fNIRS could hold the potential for further reducing the number of hours of training needed and/or the degree of recovery. ClinicalTrials.gov ID: NCT02856035.

Objective. Somatosensory function is critical to normal motor control. After stroke, dysfunction of the sensory systems prevents normal motor function and degrades quality of life. Structural neuroplasticity underpinnings of sensory recovery after stroke are not fully understood. The objective of this study was to identify changes in bilateral cortical thickness (CT) that may drive recovery of sensory acuity. Methods. Chronic stroke survivors (n = 20) were treated with 12 weeks of rehabilitation. Measures were sensory acuity (monofilament), Fugl-Meyer upper limb and CT change. Permutation-based general linear regression modeling identified cortical regions in which change in CT was associated with change in sensory acuity. Results. For the ipsilesional hemisphere in response to treatment, CT increase was significantly associated with sensory improvement in the area encompassing the occipital pole, lateral occipital cortex (inferior and superior divisions), intracalcarine cortex, cuneal cortex, precuneus cortex, inferior temporal gyrus, occipital fusiform gyrus, supracalcarine cortex, and temporal occipital fusiform cortex. For the contralesional hemisphere, increased CT was associated with improved sensory acuity within the posterior parietal cortex that included supramarginal and angular gyri. Following upper limb therapy, monofilament test score changed from 45.0 ± 13.3 to 42.6 ± 12.9 mm ( P = .063) and Fugl-Meyer score changed from 22.1 ± 7.8 to 32.3 ± 10.1 ( P < .001). Conclusions. Rehabilitation in the chronic stage after stroke produced structural brain changes that were strongly associated with enhanced sensory acuity. Improved sensory perception was associated with increased CT in bilateral high-order association sensory cortices reflecting the complex nature of sensory function and recovery in response to rehabilitation.

(1) Objective: The objective was two-fold: (a) test a protocol of combined interventions, (b) administer this combined protocol within the framework of a six-month, intensive, long-duration program. The array of interventions was designed to target the treatment-resistant impairments underlying persistent mobility dysfunction: weakness, balance deficit, limb movement dyscoordination, and gait dyscoordination. (2) Methods: A convenience sample of eight chronic stroke survivors (&gt, 4 months post stroke) was enrolled. Treatment was 5 days/week, 1&ndash, 2.5 h/day for 6 months, as follows: strengthening exercise, balance training, limb/gait coordination training, and aerobic exercise. Outcome measures: Berg Balance Scale (BBS), Fugl-Meyer Lower Limb Coordination (FM), gait speed, 6 Minute Walk Test (6MWT), Timed up and Go (TUG), Functional Independence Measure (FIM), Craig Handicap Assessment Rating Tool (CHART), and personal milestones. Pre-/post-treatment comparisons were conducted using the Permutation Test, suitable for ordinal measures and small sample size. (3) Results: For the group, there was a statistically (p &le, 0.04) significant improvement in balance, limb movement coordination (FM), gait speed, functional mobility (TUG), and functional activities (FIM). There were measurable differences (minimum detectible change: MDC) in BBS, FM, gait speed, 6MWT, and TUG. There were clinically significant milestones achieved for selected subjects according to clinical benchmarks for the BBS, 6MWT, gait speed, and TUG, as well as achievement of personal milestones of life role participation. Effect sizes (Cohen&rsquo, s D) ranged from 0.5 to 1.0 (with the exception of the (6MWT)). After six months of treatment, the above array of gains were beyond that reported by other published studies of chronic stroke survivor interventions. Personal milestones included: walking to mailbox, gardening/yardwork, walking a distance to neighbors, return to driving, membership at a fitness center, vacation trip to the beach, swimming at local pool, returning to work, housework, cooking meals. (4) Conclusions: Stroke survivors with mobility dysfunction were able to participate in the long-duration, intensive program, with the intervention array targeted to address impairments underlying mobility dysfunction. There were either clinically or statistically significant improvements in an array of measures of impairment, functional mobility, and personal milestone achievements.

Background and purpose Poststroke hemiparesis increases the perceived challenge of walking. Perceived challenge is commonly measured by self-report, which is susceptible to measurement bias. A promising approach to objectively assess perceived challenge is measuring sympathetic nervous system (SNS) activity with skin conductance to detect the physiological stress response. We investigated the feasibility of using skin conductance measurements to detect task-related differences in the challenge posed by complex walking tasks in adults poststroke. Methods Adults poststroke (n = 31) and healthy young adults (n = 8) performed walking tasks including typical walking, walking in dim lighting, walking over obstacles, and dual-task walking. Measures of skin conductance and spatiotemporal gait parameters were recorded. Continuous decomposition analysis was conducted to assess changes in skin conductance level (ΔSCL) and skin conductance response (ΔSCR). A subset of participants poststroke also underwent a 12-week rehabilitation intervention. Results SNS activity measured by skin conductance (both ΔSCL and ΔSCR) was significantly greater for the obstacles task and dual-task walking than for typical walking in the stroke group. Participants also exhibited "cautious" gait behaviors of slower speed, shorter step length, and wider step width during the challenging tasks. Following the rehabilitation intervention, SNS activity decreased significantly for the obstacles task and dual-task walking. Discussion and conclusions SNS activity measured by skin conductance is a feasible approach for quantifying task-related differences in the perceived challenge of walking tasks in people poststroke. Furthermore, reduced SNS activity during walking following a rehabilitation intervention suggests a beneficial reduction in the physiological stress response evoked by complex walking tasks.Video Abstract available for more insights from the authors (See Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A234).

Objective To compare response to upper-limb treatment using robotics plus motor learning (ML) versus functional electrical stimulation (FES) plus ML versus ML alone, according to a measure of complex functional everyday tasks for chronic, severely impaired stroke survivors. Design Single-blind, randomized trial. Setting Medical center. Participants Enrolled subjects (N=39) were >1 year postsingle stroke (attrition rate=10%; 35 completed the study). Interventions All groups received treatment 5d/wk for 5h/d (60 sessions), with unique treatment as follows: ML alone (n=11) (5h/d partial- and whole-task practice of complex functional tasks), robotics plus ML (n=12) (3.5h/d of ML and 1.5h/d of shoulder/elbow robotics), and FES plus ML (n=12) (3.5h/d of ML and 1.5h/d of FES wrist/hand coordination training). Main Outcome Measures Primary measure: Arm Motor Ability Test (AMAT), with 13 complex functional tasks; secondary measure: upper-limb Fugl-Meyer coordination scale (FM). Results There was no significant difference found in treatment response across groups (AMAT: P≥.584; FM coordination: P≥.590). All 3 treatment groups demonstrated clinically and statistically significant improvement in response to treatment (AMAT and FM coordination: P≤.009). A group treatment paradigm of 1:3 (therapist/patient) ratio proved feasible for provision of the intensive treatment. No adverse effects. Conclusions Severely impaired stroke survivors with persistent (>1y) upper-extremity dysfunction can make clinically and statistically significant gains in coordination and functional task performance in response to robotics plus ML, FES plus ML, and ML alone in an intensive and long-duration intervention; no group differences were found. Additional studies are warranted to determine the effectiveness of these methods in the clinical setting.

Background Weakening and dyscoordination of expiratory muscles in multiple sclerosis (MS) can impair respiratory and swallow function. Objective The objective of this paper is to test a novel expiratory muscle strength training (EMST) device on expiratory pressure, swallow function, and swallow-related quality-of-life (SWAL-QOL) in individuals with MS. Methods Participants with MS were randomized to a five-week breathing practice of either positive pressure load (EMST) or near-zero pressure (sham). We compared baseline to post-treatment data according to maximum expiratory pressure (MEP), abnormal airway penetration and aspiration (PAS), and SWAL-QOL. Results Both groups improved in MEP ( p Conclusion Results suggest that strengthening of expiratory muscles can occur with repetition of focused breathing practice in the absence of high resistance. Conversely, results from the PAS and SWAL-QOL domains suggest that the high resistance of the EMST was required in order to improve the functional safety (reduced penetration/aspiration) and coordination of swallowing, specifically pharyngeal function and saliva management.

Veterans with blast-related mild traumatic brain injury (TBI) experience cognitive deficits that interfere with functional activities. Goal Management Training (GMT), which is a metacognitive intervention, offers an executive function rehabilitation approach that draws upon theories concerning goal processing and sustained attention. GMT has received empirical support in studies of patients with TBI but has not been tested in Veterans with blast-related mild TBI. GMT was modified from 7 weekly to 10 biweekly sessions. Participants included six combat Veterans that reported multiple blast exposures resulting in symptoms consistent with mild TBI. Group analysis showed a significant improvement in measures of executive function derived from performance on the computerized Tower of London. There were no significant changes on self/informant questionnaires of executive function, indicating a lack of generalization of improvement from the clinic to everyday activities. Overall, while the data indicate efficacy of GMT in the rehabilitation of combat Veterans with executive function deficits because of blast-related mild TBI, enhancement of generalization is needed.

Purpose: Recovery of the most basic shoulder-flexion/elbow-extension components of functional reach is critical for effective arm function following stroke. In order to understand the mechanisms of motor recovery, it is important to characterize the pattern of brain activation during the reach task. Methods: We evaluated 11 controls and 23 moderately to severely impaired chronic stroke survivors (>6 months), with impaired shoulder flexion and elbow extension. Measures were acquired for Arm Motor Ability Test (AMAT) and functional Magnetic Resonance Imaging (fMRI) during the basic shoulder/elbow reach. Results: First, in controls, lateralization of fMRI signal during the reach task was less pronounced in comparison to other tasks, and even further diminished after stroke (p < 0.05). Second, for the stroke group, centroid locations, for specific ipsilesional (contralateral to working limb) motor-sensory regions and for contralesional (ipsilateral to working arm) somatosensory and SMA regions, were significantly more distant from the centroid location of average healthy controls (p < 0.05). Third, both greater activation volume and greater degree of signal intensity were correlated with better motor function in stroke survivors. Conclusions: These findings can be useful in guiding the development of more targeted brain training methods for recovery of impaired reach coordination.

Introduction: White matter changes in response to rehabilitation of chronic motor deficits after stroke has not been well understood. Our hypothesis is that there is a relationship between gains in motor function and changes in structure of white matter tracts. Methods: Fugl-Meyer upper limb (FM) score and Diffusion Tensor Imaging (DTI) were collected before and after a 12-week upper limb motor learning therapy. DTI data was processed using the longitudinal Freesurfer Tracula stream where white matter tracts are reconstructed using global probabilistic tractography. The average fractional anisotropy (FA), as well as axial diffusivity (Da) and radial diffusivity (Dr) were computed for 14 major white matter tracts. General linear models were fit where pre-to-post change in FA for a given tract were dependent variables and pre-to-post change in FM was a predictor. The relationship was adjusted for baseline FM score. Spearman correlations were determined between FA, Da and Dr. Wilcoxon test was used for pre-to-post comparisons. Results: We evaluated and treated 21 stroke survivors; they were 1.9±1.2 (mean±std.dev) years post stroke, 55.1±12.9 yrs old and 42% female. FM improved from 23±8.75 to 34.1±10.5 (p Conclusion: Improvement in function of chronic motor deficits in the upper extremity is related to structural changes in temporal-occipital and transcallosal occipital tracts that connect visual-spatial processing regions. Furthermore, our results suggest that changes in neuronal activity of the identified tracts may be associated with microstructural changes that increase radial diffusivity.

Intensive gait training can produce improvements in gait and function (6 months after stroke); findings are mixed for enhanced life role participation. Therefore, it is unclear if improved gait and function translate into life role participation gain. Our objective was to evaluate whether intensive gait therapy can produce significant improvements in life role participation for chronic stroke survivors.In conjunction with a clinical gait training trial, we conducted a secondary analysis for a 44-member cohort with stroke (6 months). Gait training interventions included exercise, body weight supported treadmill training (BWSTT), over-ground gait training, and functional electrical stimulation (FES) for 1.5 h/day, 4 days/wk for 12 weeks. Study measures included Tinetti Gait (TG) (gait impairment), Functional Independence Measure (FIM, function), Stroke Impact Scale Subscale of Life Role Participation (SISpart), and Craig Handicap AssessmentReporting Technique (CHART, life-role participation). Analyses included Wilcoxon Signed Rank Test and PLUM Regression Model.Gait interventions produced significant improvement in CHART (p = 0.020), SISpart (p = 0.011), FIM (p0.0001), and Tinetti Gait (p0.0001). Age, gender and time since stroke did not predict response to treatment.Intensive, multi-modal, long-duration gait therapy resulted in significant gain in life-role participation, according to a relatively comprehensive, homogeneous measure.

Background. No single intervention restores the coordinated components of gait after stroke. Objective. The authors tested the multimodal Gait Training Protocol, with or without functional electrical stimulation (FES), to improve volitional walking (without FES) in patients with persistent (>6 months) dyscoordinated gait. Methods. A total of 53 subjects were stratified and randomly allocated to either FES with intramuscular (IM) electrodes (FES-IM) or No-FES. Both groups received 1.5-hour training sessions 4 times a week for 12 weeks of coordination exercises, body weight–supported treadmill training (BWSTT), and over-ground walking, provided with FES-IM or No-FES. The primary outcome was the Gait Assessment and Intervention Tool (G.A.I.T.) of coordinated movement components, with secondary measures, including manual muscle testing, isolated leg movements (Fugl-Meyer scale), 6-Minute Walk Test, and Locomotion/Mobility subscale of the Functional Independence Measure (FIM). Results. No baseline differences in subject characteristics and measures were found. The G.A.I.T. showed an additive advantage with FES-IM versus No-FES (parameter statistic 1.10; P = .045, 95% CI = 0.023-2.179) at the end of training. For both FES-IM and No-FES, a within-group, pre/posttreatment gain was present for all measures ( P < .05), and a continued benefit from mid- to posttreatment ( P < .05) was present. For FES-IM, recovered coordinated gait persisted at 6-month follow-up but not for No-FES. Conclusion. Improved gait coordination and function were produced by the multimodal Gait Training Protocol. FES-IM added significant gains that were maintained for 6 months after the completion of training.

Background. After hemiparetic stroke, coordination of the shoulder flexor and elbow extensor muscles during a reaching movement is impaired and contributes to poor performance. Objective. The aim was to determine whether functional coupling between electromyographic signals of synergist muscles during reaching was weakened in stroke patients who had poor motor coordination. Methods. Surface electromyography (EMG) from the anterior deltoid, triceps brachii, biceps brachii, pectoralis major, supraspinatus, and latissimus dorsi of the affected upper limb in 11 stroke patients (mean Fugl-Meyer upper extremity score 27 ± 8) and in the dominant arm of 8 healthy controls were measured. Results. Coherence between the EMG of the anterior deltoid and triceps brachii, 2 synergists for reaching, was lower in patients compared with controls, in the 0- to 11-Hz range. Detailed segmented frequency-range analysis indicated significant differences in the coherence between groups in 0- to 3.9-Hz and 4- to 7.9-Hz ranges. Conclusions. This weakened functional coupling may contribute to poor reaching performance and could be a consequence of a loss of common drive at the frequency bands as a result of interruption of information flow in the corticospinal pathway.

BACKGROUND/PURPOSE A large proportion of individuals with stroke have persistent deficits for which current interventions have not restored normal motor behavior. Noninvasive brain computer interfaces (BCIs) have potential advantages for restoration of function. There are also potential advantages for combining BCI with functional electrical stimulation (FES). We tested the feasibility of combined BCI + FES for motor learning after stroke. CASE DESCRIPTION The participant was a 43-year-old woman who was 10 months post-stroke. She was unable to produce isolated movement of any of the digits of her involved hand. With effort she exhibited simultaneous mass hyperextension of metacarpal phalangeal joints of all four fingers and thumb with simultaneous flexion of proximal interphalangeal and distal interphalangeal joints of all fingers. INTERVENTION Brain signals from the lesioned hemisphere were used to trigger FES for movement practice. The BCI + FES intervention consisted of trials of either attempted finger movement and relax conditions or imagined finger movement and relax conditions. The training was performed three times per week for three weeks (nine sessions total). OUTCOME : The participant exhibited highly accurate control of brain signal in the first session for attempted movement (97%), imagined movement (83%), and some difficulties with attempted relaxation (65%). By session 6, control of relaxation (deactivation of brain signal) improved to >80%. After nine sessions (three per week) of BCI + FES intervention, the participant demonstrated recovery of volitional isolated index finger extension. DISCUSSION BCI + FES training for motor learning after stroke was feasible. A highly accurate brain signal control was achieved, and this signal could be reliably used to trigger the FES device for isolated index finger extension. With training, volitional control of isolated finger extension was attained in a small number of sessions. The source of motor recovery could be attributable to BCI, FES, combined BCI + FES, or whole arm or hand motor task practice.

Objective To investigate the functional connection between motor cortex and muscles, we measured electroencephalogram–electromyogram (EEG–EMG) coherence of stroke patients and controls. Methods Eight healthy controls and 21 patients with shoulder and elbow coordination deficits were enrolled. All subjects performed a reaching task involving shoulder flexion and elbow extension. EMG of the anterior deltoid (AD) and brachii muscles (BB, TB) and 64-channel scalp EEG were recorded during the task. Time-frequency coherence was calculated using the bivariate autoregressive model. Results Stroke patients had significantly lower corticomuscular coherence compared with healthy controls for the AD and BB muscles at both the beta (20–30 Hz) and lower gamma (30–40 Hz) bands during the movement. BH procedure (FDR) identified a reduced corticomuscular coherence for stroke patients in 11 of 15 scalp area–muscle combinations. There was no statistically significant difference between stroke patients and control subjects according to coherence in other frequency bands. Conclusion Poorly recovered stroke survivors with persistent upper-limb motor deficits exhibited significantly lower gamma-band corticomuscular coherence in performing a reaching task. Significance The study suggests poor brain-muscle communication or poor integration of the EEG and EMG signals in higher frequency band during reaching task may reflect an underlying mechanism producing movement deficits post-stroke.

Summary Recent advances in analysis of brain signals, training patients to control these signals, and improved computing capabilities have enabled people with severe motor disabilities to use their brain signals for communication and control of objects in their environment, thereby bypassing their impaired neuromuscular system. Non-invasive, electroencephalogram (EEG)-based brain–computer interface (BCI) technologies can be used to control a computer cursor or a limb orthosis, for word processing and accessing the internet, and for other functions such as environmental control or entertainment. By re-establishing some independence, BCI technologies can substantially improve the lives of people with devastating neurological disorders such as advanced amyotrophic lateral sclerosis. BCI technology might also restore more effective motor control to people after stroke or other traumatic brain disorders by helping to guide activity-dependent brain plasticity by use of EEG brain signals to indicate to the patient the current state of brain activity and to enable the user to subsequently lower abnormal activity. Alternatively, by use of brain signals to supplement impaired muscle control, BCIs might increase the efficacy of a rehabilitation protocol and thus improve muscle control for the patient.

fMRI has been used to characterize the abnormal brain activity after stroke during attempted motor tasks, the change in brain activity accompanying spontaneous motor recovery, and response to interventions. However, many patients after stroke exhibit abnormally high effort during attempted movements, including undesired movements of the supposed quiescent, uninvolved limb, which could confound fMRI measures. We developed a method of identifying the potentially confounded scans, using EMG measures of muscle activity in the supposed quiescent limb. We found that there was no interference in the MRI signal from the EMG data acquisition system, during simultaneous use of both MRI and EMG. For EMG signal acquisition, as expected, we were able to identify EMG signal free of MRI noise contamination during the inter-scan interval between any given scan and its subsequent scan. We tested movement of the involved limb. We determined that when undesired muscle activation was present in the uninvolved, supposed quiescent limb, there was an over-estimation of the number of active voxels ranging from 10 to 11, depending upon the ROI.

Introduction: Loss of somatosensory function after stroke weakens the ability to adequately relate to our environment, thus significantly reduces quality of life. Neuroplastic processes of sensory recovery are poorly understood. The objective of this study was to identify cortical regions that undergo structural changes (measured by change in cortical thickness (CT)) during sensory recovery. The hypothesis was that for subjects who improve sensory acuity, CT change in regions of the bilateral sensory network correlates with change in sensory acuity. Methods: Chronic stroke survivors were treated with 12-weeks rehabilitation. Outcome measures were sensory acuity (monofilament), Fugl-Meyer upper limb coordination and CT (T1 Magnetic Resonance Imaging). CT change was calculated based on T1 images using Freesurfer longitudinal processing stream. General linear regression modeling identified cortical regions where change in CT was associated with change in sensory acuity after controlling for baseline sensory impairment and change in motor function. Cluster-wise correction for multiple comparisons was conducted using Monte-Carlo simulation at p Results: Subjects, who improved in sensory acuity (n=18), were 55.8±13.7 year old; 10% female; 1.8±0.9 years after first ever stroke. Acuity improved from 43.9±14mm to 40.53±13mm (p=0.004). FM improved from 22.4±8 to 34.5±10 (p Conclusion: Rehabilitation produces modality-specific structural brain changes that can be measured by changes in cortical thickness. Improved sensation correlates with increased thickness in bilateral high-order association sensory cortices reflecting a complex nature of sensory rehabilitation.

More than 3 million stroke survivors live with residual disabilities and mobility deficits even after rehabilitation. Therefore, it is important to develop new, more effective, gait training methods. The purpose of this study was twofold: (1) testing the feasibility of combining multi-channel functional neuromuscular stimulation (FNS) using intramuscular (IM) electrodes and body weight supported treadmill training (BWSTT) for gait training; and (2) documenting the potential gait practice advantages afforded by combining FNS-IM and BWSTT. Eight subjects with gait deficits in the chronic phase (>12 months) were enrolled. Intramuscular electrodes were placed in the paretic hip abductors, knee flexors and extensors, and ankle dorsiflexors, plantarflexors, and evertors. Subjects were treated with exercise and gait training using the combined technologies 1 1/2 h/week, four times/week, for 12 weeks. Feasibility was tested according to performance of the technologies, clinician skill factors, and subject satisfaction. Impairment, function, and quality of life were measured. Provision of practice for eight gait characteristics was catalogued. We found the following results for the combined technologies: (1) the combined technologies were safe and feasible; (2) clinicians required five training sessions to reach proficiency; (3) subjects were satisfied; (4) there were significant gains in impairment and functional measures; (5) a greater number of gait practice characteristics were provided with the combined technologies than with either alone.

Following stroke, many patients do not regain a normal, safe gait pattern even after receiving conventional physical therapy. One promising technique is functional neuromuscular stimulation (FNS) with intramuscular (IM) electrodes (FNS-IM). Five subjects were admitted into the study at 3 weeks to 3 months following the stroke. For each subject, electrodes were placed intramuscularly at the motor point of up to seven lower extremity paretic muscles. Subjects were treated for 6 months, twice weekly with FNS-IM for exercise and gait training. The stimulator and software provided individualized stimulation patterns, with flexible stimulus parameters and activation timings of multiple muscles. Outcome measures were active joint movement, coordination (Fugl-Meyer scale), balance (Tinetti scale), gait (Tinetti scale), activities of daily living (functional independence measure), and therapist and subject satisfaction (survey instrument). Subjects tolerated well the placement of IM electrodes with no adverse effects, and subjects lost no conventional rehabilitation time. Therapists and subjects were satisfied with the FNS-IM system as a rehabilitation tool. Post treatment, subjects demonstrated improvements in impairment and disability in active joint movement, coordination, balance, gait and activities of daily living. Considered together with prior research for chronic stroke subjects, this research suggests that FNS-IM can be successfully and efficaciously utilized for gait training for those with acute stroke.

Objective To compare the gains for chronic stroke patients in volitional gait pattern attained from treatment with functional neuromuscular stimulation (FNS) and intramuscular electrodes (IM) with gains attained using conventional therapy, including treatment with FNS using surface electrodes (surface-stim). Design This single-subject research design consisted of a series of two subjects. Three months of conventional therapy and surface-stim were followed by treatment using the FNS-IM system. Two stroke patients had cerebrovascular accident 1 or 4 yr before the study and ambulated with a cane. Interventions consisted of 3 months of conventional exercise and gait training including surface-stim, followed by 7-14 months of treatment with the FNS-IM system. Treatments occurred up to 3 times/wk for 1-hr sessions and a home program. Outcome measures consisted of six kinematic gait components, as measured by a six-camera video-based data-acquisition system. Coordination of isolated joint movement was measured according to the Fugl-Meyer scale. Results Both subjects improved during conventional therapy to some degree. During FNS-IM treatment, gains were made beyond those attained during conventional therapy. Statistically significant differences were found between conventional and FNS-IM therapy. Conclusions For these two subjects, gains in volitional control of gait were made during conventional treatment (including surface-stim); for these two subjects during FNS-IM treatment, additional gains were made in volitional gait pattern, beyond those attained during conventional therapy.

Purpose : The purpose of this study was to investigate the response of muscles with prolonged flaccid paralysis (a year after stroke) to two types of treatment: (1) functional neuromuscular stimulation (FNS) with surface electrodes; and (2) FNS with intramuscular (IM) electrodes (FNS-IM). A second purpose was to compare FNS-gait versus volitional gait (no FNS activation). Method : We used a single case study design; our patient was age 72, with flaccid paralysis of knee flexors and ankle dorsiflexors. Results : Following four months of treatment with surfacestimulation, there was no change in muscle function or gait. Following treatment with FNS-IM, the patient regained partial volitional control of knee flexors and dorsiflexors; untreated muscles did not change. Conclusion : FNS-gait provided more normal knee and ankle dorsiflexion during swing phase versus volitional gait swing phase (no FNS activation).

Zimbelman J, Daly JJ, Roenigk KL, Butler K, Burdsall R, Holcomb JP. Capability of 2 gait measures for detecting response to gait training in stroke survivors: Gait Assessment and Intervention Tool and the Tinetti Gait Scale. Objective To characterize the performance of 2 observational gait measures, the Tinetti Gait Scale (TGS) and the Gait Assessment and Intervention Tool (G.A.I.T.), in identifying improvement in gait in response to gait training. Design In secondary analysis from a larger study of multimodal gait training for stroke survivors, we measured gait at pre-, mid-, and posttreatment according to G.A.I.T. and TGS, assessing their capability to capture recovery of coordinated gait components. Setting Large medical center. Participants Cohort of stroke survivors (N=44) greater than 6 months after stroke. Interventions All subjects received 48 sessions of a multimodal gait-training protocol. Treatment consisted of 1.5 hours per session, 4 sessions per week for 12 weeks, receiving these 3 treatment aspects: (1) coordination exercise, (2) body weight–supported treadmill training, and (3) overground gait training, with 46% of subjects receiving functional electrical stimulation. Main Outcome Measures All subjects were evaluated with the G.A.I.T. and TGS before and after completing the 48-session intervention. An additional evaluation was performed at midtreatment (after session 24). Results For the total subject sample, there were significant pre-/post-, pre-/mid-, and mid-/posttreatment gains for both the G.A.I.T. and the TGS. According to the G.A.I.T., 40 subjects (91%) showed improved scores, 2 (4%) no change, and 2 (4%) a worsening score. According to the TGS, only 26 subjects (59%) showed improved scores, 16 (36%) no change, and 1 (2%) a worsening score. For 1 treatment group of chronic stroke survivors, the TGS failed to identify a significant treatment response to gait training, whereas the G.A.I.T. measure was successful. Conclusions The G.A.I.T. is more sensitive than the TGS for individual patients and group treatment response in identifying recovery of volitional control of gait components in response to gait training.

The purpose was to determine timing characteristics of leg muscle latencies for patients following stroke (>12 months) who had persistent coordination and gait deficits, and to determine the relationships among abnormal latencies, dyscoordination, and gait deficits. We compared nine healthy controls and 27 stroke survivors. Surface electromyography measured activation and deactivation latencies of knee flexor and extensor muscles during a ballistic knee flexion task, consistency of latencies across repetitions, and close coupling between agonist and antagonist muscle latencies. We measured Fugl-Meyer (FM) coordination and the functional gait measure, six minute walk test (6MWT). For stroke subjects, there were significant delays of muscle activation and deactivation, abnormal inconsistency, and abnormal decoupled agonist and antagonist activations. There was good correlation between activation latencies and FM and 6MWT. Results suggest abnormal timing characteristics underlie coordination impairment and dysfunctional gait. These abnormal muscle activation and deactivation timing characteristics are important targets for rehabilitation.

After stroke rehabilitation, many survivors of stroke exhibit persistent gait deficits. In previous work, we demonstrated significant gains in gait kinematics for survivors of chronic stroke using multichannel functional electrical stimulation with intramuscular electrodes (FES-IM). For this study, we tested the feasibility of combining FES-IM and gait robot technologies for treating persistent gait deficits after stroke. Six subjects, >or= 6 months after stroke, received 30-minute intervention sessions of combined FES-IM and gait robotics 4 days a week for 12 weeks. Feasibility was assessed according to three factors: (1) performance of the interface of the two technologies during intervention sessions, (2) clinicians' success in using two technologies simultaneously, and (3) subject satisfaction. FES-IM system hardware and software design features combined with the gait robot technology proved feasible to use. Each technology alone provided unique advantages and disadvantages of gait practice characteristics. Because of the unique advantages and disadvantages of each technology, gait deficits need to be accurately identified and a judicious treatment plan properly targeted before FES-IM, a gait robot, or both combined are selected.

Brain injury resulting from stroke often causes upper-extremity motor deficits that limit activities of daily living. Several therapies being developed for motor rehabilitation after stroke focus on increasing time spent using the extremity to promote motor relearning. Providing a novel system for user-worn therapy may increase the amount and rate of functional motor recovery. A user-worn system comprising accelerometers, gyroscopes, and electromyography amplifiers was used to wirelessly transmit motion and muscle activity from normal and stroke subjects to a computer as they completed five upper-extremity rehabilitation tasks. An algorithm was developed to automatically detect the therapy task a subject performed based on the gyroscope and electromyography data. The system classified which task a subject was attempting to perform with greater than 80% accuracy despite the fact that those with severe impairment produced movements that did not resemble the goal tasks and were visually indistinguishable from different tasks. This developed system could potentially be used for home-therapy compliance monitoring, real-time patient feedback and to control therapy interventions.

Persistent gait deficits after stroke can cause falls, elevated energy cost and poor endurance. Coordination impairment is an underlying cause of gait deficits. Few efficacious interventions have been described that have targeted and measured restoration of coordinated gait components. Neuromuscular electrical stimulation can provide the critical gait practice characteristic of close-to-normal movements, by electrically inducing muscle contractions and coordinated movements that are not possible under volitional effort. Two-channel, surface neuromuscular electrical stimulation can be synchronized with phases of gait and can provide faster, more symmetrical neuromuscular electrical stimulation-assisted gait than gait with no neuromuscular electrical stimulation. Difficulties encountered during the use of surface neuromuscular electrical stimulation for gait training led to the development of neuromuscular electrical stimulation with implanted technologies. Implanted electrodes and/or stimulators proved to be feasible for gait training in stroke survivors. Gait training with a multichannel neuromuscular electrical stimulation system with implanted electrodes proved more advantageous than gait training without neuromuscular electrical stimulation, according to measures of volitional coordinated gait components (neuromuscular electrical stimulation deactivated).

Purpose Cortical function is not well understood in stroke survivors with persistent dyscoordination. The study purpose was two-fold: 1) characterize cognitive planning time and cognitive effort level for a circle-drawing motor task in stroke survivors using shoulder/elbow muscles and 2) identify the relationship between cognitive effort level and movement smoothness. Methods Twelve stroke survivors with shoulder/elbow coordination deficits (> 12 mo) and eight controls were enrolled. The motor task was to draw a circle on a horizontal surface using only shoulder/elbow muscles. Outcome measures were: EEG-derived cognitive planning time, cognitive effort level, and movement smoothness. Comparisons between stroke and controls were made using t -tests. The Pearson's correlation model was analyzed to determine the relationship between movement smoothness and cognitive effort level. Results Stroke subjects showed a statistically significant prolonged motor planning time versus controls for both lesion and non-lesion sides ( p = 0.013 and 0.049, respectively). They also showed a statistically significant elevated effort level versus controls for both sides ( p = 0.016 and 0.013). The patients exhibited statistically significant poor movement smoothness in the medial/lateral and forward/backward movement directions versus controls ( p = 0.035 and 0.037, respectively). For stroke, there was a significant correlation between cognitive effort level on the non-lesion side and smoothness of movement in the medial/lateral and forward/backward directions ( r = 0.54, p = 0.036 and r = 0.76, p = 0.002, respectively). On the lesion side, results were mixed ( r = 0.268, p = 0.2 r = 0.59, p = 0.023, respectively). Conclusions Stroke survivors with upper limb motor deficits exhibit a longer cognitive planning time and elevated cognitive effort for performance of a complex shoulder/elbow motor coordination task. The elevated cognitive effort level was associated with poor (jerky) motor performance, suggesting a potential role of the CNS in controlling movement smoothness of the arm.

It is unknown whether electroencephalography (EEG) signal characteristics in stroke survivors with motor deficits register enough activity for use with brain-computer interfaces (BCIs). This research studied pre-movement EEG from shoulder-elbow movement in stroke survivors to identify signal characteristics potentially useful for robot-assisted stroke rehabilitation. Pre-movement event-related desynchronization (ERD) was examined in the alpha band mu rhythm for control (n = 7) and stroke subjects (n = 11). Subjects were all right-hand dominant; stroke subjects used their impaired arm and controls were assigned a side to match stroke subjects. Both non-dominant-arm-tested stroke and control subjects exhibited greater ERD intensity vs. those using their dominant arm (p < 0.05). Also, pre-movement ERD was detected in stroke survivors, which suggests at the possibility of using ERD as a BCI system control signal. However, the peak ERD of stroke survivors was significantly lower than that of healthy subjects (p < 0.05), which brings doubt to whether the intensity of ERD in stroke survivors is large enough to be used as a BCI system control signal

Understanding cortical function can provide accurately targeted interventions after stroke. Initially, stroke survivors had prolonged cognitive planning time and elevated cognitive effort, highly correlated with motor control impairments. Exploratory results suggest that neurorehabilitation, accurately targeted to dyscoordination, weakness, and dysfunctional task component execution, can improve cognitive processes controlling motor function.

Purpose Purpose one was to characterize the consistency of intra-limb hip/knee (H/K) coordination according to a measure of average coefficient of correspondence (ACC) across strides. Purpose two was to investigate H/K ACC validity and ability to discriminate pre-/post-treatment change in stroke survivors. Methods Five healthy controls and 32 chronic (>12 mos) stroke survivors were enrolled, and H/K ACC was calculated for both groups. Comparison between controls and stroke was made using the Mann–Whitney Test. Convergent validity of H/K ACC was tested using the Pearson Correlation model with gait speed and the 6 min Walk Test (6MWT). Stroke survivors were randomized to either: (1) gait training with functional neuromuscular stimulation (FNS) using intramuscular (IM) electrodes or (2) gait training without FNS. Both groups had treatment 1.5 h/day, 5 days/week, for 12weeks, including .5 h coordination exercise, .5 h body weight supported treadmill training (BWSTT), and .5 h over ground gait training. The FNS-IM group used FNS-IM for all treatment components; the No-FNS group did not. Pre-/post-treatment comparisons were made using ANOVA. Results H/K ACC detected a significant difference between controls versus stroke involved limb (p = .0001) and controls versus stroke uninvolved limb (p = .042). The H/K ACC measure was well-correlated with gait speed (r = .70) and 6MWT (r = .69). H/K ACC showed a significant treatment response to FNS-IM (p = .003), but not No-FNS (p = .747). Conclusions H/K ACC sensitively discriminated between controls versus stroke involved or uninvolved limbs. H/K ACC was valid, with significant correlations with both walking speed and 6MWT. FNS-IM produced a significant gain in H/K ACC, and No-FNS did not.

Background and Purpose— Conventional therapies fail to restore normal gait to many patients after stroke. The study purpose was to test response to coordination exercise, overground gait training, and weight-supported treadmill training, both with and without functional neuromuscular stimulation (FNS) using intramuscular (IM) electrodes (FNS-IM). Methods— In a randomized controlled trial, 32 subjects (>1 year after stroke) were assigned to 1 of 2 groups: FNS-IM or No-FNS. Inclusion criteria included ability to walk independently but inability to execute a normal swing or stance phase. All subjects were treated 4 times per week for 12 weeks. The primary outcome measure, obtained by a blinded evaluator, was gait component execution, according to the Tinetti gait scale. Secondary measures were coordination, balance, and 6-minute walking distance. Results— Before treatment, there were no significant differences between the 2 groups for age, time since stroke, stroke severity, and each study measure. FNS-IM produced a statistically significant greater gain versus No-FNS for gait component execution ( P =0.003; parameter estimate 2.9; 95% CI, 1.2 to 4.6) and knee flexion coordination ( P =0.049). Conclusion— FNS-IM can have a significant advantage versus No-FNS in improving gait components and knee flexion coordination after stroke.

After stroke, persistent gait deficits cause debilitating falls and poor functional mobility. Gait restoration can preclude these outcomes. Sixteen subjects (>12 months poststroke) were randomized to two gait training groups. Group 1 received 12 weeks of treatment, 4 times a week, 90 min per session, including 30 min strengthening and coordination, 30 min over-ground gait training, and 30 min weight-supported treadmill training. Group 2 received the same treatment, but also used functional neuromuscular stimulation (FNS) with intramuscular (IM) electrodes (FNS-IM) for each aspect of treatment. Outcome measures were kinematics of gait swing phase. Both groups showed no significant pre-/posttreatment gains in peak swing hip flexion. Group 1 (no FNS) had no significant gains in other gait components at posttreatment or at follow-up. Group 2 (FNS-IM) had significant gains in peak swing knee flexion and mid-swing ankle dorsiflexion (p < 0.05) that were maintained for 6 months.

Twelve moderately to severely involved chronic stroke survivors (>12 mo) were randomized to one of two treatments: robotics and motor learning (ROB-ML) or functional neuromuscular stimulation and motor learning (FNS-ML). Treatment was 5 h/d, 5 d/wk for 12 wk. ROB-ML group had 1.5 h per session devoted to robotics shoulder and elbow (S/E) training. FNS-ML had 1.5 h per session devoted to functional neuromuscular stimulation (surface electrodes) for wrist and hand (W/H) flexors/extensors. The primary outcome measure was the functional measure Arm Motor Ability Test (AMAT). Secondary measures were AMAT-S/E and AMAT-W/H, Fugl-Meyer (FM) upper-limb coordination, and the motor control measures of target accuracy (TA) and smoothness of movement (SM). ROB-ML produced significant gains in AMAT, AMAT-S/E, FM upper-limb coordination, TA, and SM. FNS-ML produced significant gains in AMAT-W/H and FM upper-limb coordination.