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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.

Introduction In clinical practice, observational scales are the most common approach used to assess gait pattern in people with neurological disorders. The Gait Assessment and Intervention Tool (GAIT) is an observational gait scale, and it has proved to be the most comprehensive, homogeneous, and objective of all the observational gait scales studied in people with neurological conditions. Objective To study the construct validity of the GAIT in people with multiple sclerosis (MS). Design An observational study was conducted. Setting Multiple Sclerosis Foundation in Madrid (Spain). Patients Thirty-five patients with MS were assessed. Main outcome measure(s) GAIT construct validity was assessed using the following scales: Rivermead Visual Gait Assessment (RVGA), Tinetti Gait Scale (TGS), 10-Meter Walking Test (10MWT), Timed Up&Go (TUG), Hauser Ambulatory Index (HAI), Multiple Sclerosis Walking Scale-12 (MSWS-12), Functional Gait Assessment (FGA), Modified Ashworth Scale (MAS), and Rivermead Mobility Index (RMI). Results A total of 35 subjects with MS were assessed. The correlations between the GAIT and the RVGA were excellent (r > .90) and moderate with TGS (values between -.62 and -.59). Correlations with HAI, FGA, MSWS-12, and RMI were moderate (with values between .57 and .67). Correlations were lower for the velocity scales TUG and MAS. Conclusions The construct validity of the GAIT is high, as a measure of gait coordination in people with MS. Specifically, there was excellent correlation with the RVGA. There was a moderate correlation for the GAIT with measures of functional mobility, but a lesser correlation of the GAIT with measures restricted to temporal gait characteristics (speed measures) or measurements of impairments underlying gait patterns such as balance or muscle tone.

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.

Background The Gait Assessment and Intervention Tool (G.A.I.T.) has been shown to be a comprehensive and objectively scored tool to assess gait in people with neurologic disease. However, there is only an English version of the scale, the language in which it was developed. Objective To carry out a cross-cultural adaptation of the Gait Assessment and Intervention Tool (G.A.I.T.) scale for its use in the Spanish-speaking population, and to study the content validity of the Spanish version. Design A cross-cultural adaptation and validation study of the G.A.I.T. Setting University Laboratory (Alcorcon, Madrid, Spain). Participants Not applicable. Methods or interventions Cross-cultural adaptation of a scale. Main outcome measurements The Spanish version of the G.A.I.T. was obtained using the double-translation and back-translation method, and a subsequent Expert Committee revision. The Expert Committee studied the content validity of the Spanish G.A.I.T. using the content validity index (CVI). Results The final version of the G.A.I.T. in Spanish was obtained after the cross-cultural process. The CVI was found to be excellent for the overall G.A.I.T. (0.94), and excellent for 87% of its 31 items (≥0.78). CVI was good for 10% of the items (arm swing and toes, CVI ≥0.72). Although 3% of items (shoulder and elbow position) showed CVI = 0.28, these items were retained for completeness. Conclusions The Spanish version of the G.A.I.T. was developed through a cross-cultural adaptation process from its original version in English, and according to an Expert Committee it has an excellent overall content validity.

Objective In stroke survivors, a treatment-resistant problem is inability to volitionally differentiate upper limb wrist extension versus flexion. When one intends to extend the wrist, the opposite occurs, wrist flexion, rendering the limb non-functional. Conventional therapeutic approaches have had limited success in achieving functional recovery of patients with chronic and severe upper extremity impairments. Functional magnetic resonance imaging (fMRI) neurofeedback is an emerging strategy that has shown potential for stroke rehabilitation. There is a lack of information regarding unique blood-oxygenation-level dependent (BOLD) cortical activations uniquely controlling execution of wrist extension versus uniquely controlling wrist flexion. Therefore, a first step in providing accurate neural feedback and training to the stroke survivor is to determine the feasibility of classifying (or differentiating) brain activity uniquely associated with wrist extension from that of wrist flexion, first in healthy adults. Approach We studied brain signal of 10 healthy adults, who performed wrist extension and wrist flexion during fMRI data acquisition. We selected four types of analyses to study the feasibility of differentiating brain signal driving wrist extension versus wrist flexion, as follows: 1) general linear model (GLM) analysis; 2) support vector machine (SVM) classification; 3) ‘Winner Take All’; and 4) Relative Dominance. Results With these four methods and our data, we found that few voxels were uniquely active during either wrist extension or wrist flexion. SVM resulted in only minimal classification accuracies. There was no significant difference in activation magnitude between wrist extension versus flexion; however, clusters of voxels showed extension signal > flexion signal and other clusters vice versa. Spatial patterns of activation differed among subjects. Significance We encountered a number of obstacles to obtaining clear group results in healthy adults. These obstacles included the following: high variability across healthy adults in all measures studied; close proximity of uniquely active voxels to voxels that were common to both the extension and flexion movements; in general, higher magnitude of signal for the voxels common to both movements versus the magnitude of any given uniquely active voxel for one type of movement. Our results indicate that greater precision in imaging will be required to develop a truly effective method for differentiating wrist extension versus wrist flexion from fMRI data.

Background: New models of care delivery are necessary to meet workforce needs while delivering expert care in neurorehabilitation. Therefore, we sought to develop and assess the implementation of a new model of care for neurorehabilitation using a 5-member team of therapists (5-Team Model) for the treatment of individuals with chronic stroke, rather than a conventional single-therapist model. Methods: A mixed methods approach was employed; continuous quality improvement methods and quasi-experimental pre-test/post-test methods were used to assess the effectiveness of the new model. Six chronic stroke patients participated in an upper limb neurorehabilitation motor learning protocol 5 days/week, 5 hours/day (60 sessions; 300 hours); treatment was administered using the 5-Team Model approach to treatment. Results: Mean improvement on the Fugl Meyer (FM) was 11.5 points. All six participants demonstrated improvement on Fugl Meyer that was within or beyond the minimal clinically important difference (MCID) range of 4.25-7.25 points for chronic stroke. Results indicated that the 5-Team Model was effective in implementing care. Conclusions: The 5-Team Model for neurorehabilitation was successfully implemented, with patient hand-off every day to a different therapist; it produced clinically significant improvement on a measure of coordination (FM) which is comparable to or better than prior reports from a standard care model. This new model of care met the needs of the research team workforce for flexibility, while maintaining the level of quality of care. Successful implementation required addressing a series of hindering factors in an iterative manner and enhancing promoting factors. These elements included the context within which the change was implemented, the methods used in implementing the change, the evidence that the change was successful, and communication that the change was successful. The context requirements included existing framework and participating model members who were willing to exert the required effort for success, model champions. This high level of enthusiastic participation along with strong leadership contributed to long-term success, sustainability.

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.

BACKGROUND: Control of walking by the central nervous system includes contributions from executive control mechanisms, such as attention and motor planning resources. Executive control of walking can be estimated objectively by recording prefrontal cortical activity using functional near infrared spectroscopy (fNIRS). OBJECTIVE: The primary objective of this study was to investigate group differences in prefrontal/executive control of walking among young adults, older adults, and adults post-stroke. Also assessed was the extent to which walking-related prefrontal activity fits existing cognitive frameworks of prefrontal over-activation. METHODS: Participants included 24 adults post-stroke with moderate to severe walking deficits, 15 older adults with mild gait deficits, and 9 young healthy adults. Executive control of walking was quantified as oxygenated hemoglobin concentration in the prefrontal cortex measured by fNIRS. Three walking tasks were assessed: typical walking, walking over obstacles, and walking while performing a verbal fluency task. Walking performance was assessed by walking speed. RESULTS: There was a significant effect of group for prefrontal activity (p

Background/Problem: Standard neurorehabilitation and gait training has not proved effective in restoring normal gait coordination for many stroke survivors. Rather, persistent gait dyscoordination occurs, with associated poor function, and progressively deteriorating quality of life. One difficulty is the array of symptoms exhibited by stroke survivors with gait deficits. Some researchers have addressed lower limb weakness following stroke with exercises designed to strengthen muscles, with the expectation of improving gait. However, gait dyscoordination in many stroke survivors appears to result from more than straightforward muscle weakness. Purpose: Thus, the purpose of this case study is to report results of long-duration gait coordination training in an individual with initial good strength, but poor gait swing phase hip/knee and ankle coordination. Methods: Mr. X was enrolled at >6 months after a left hemisphere ischemic stroke. Gait deficits included a ‘stiff-legged gait’ characterized by the absence of hip and knee flexion during right mid-swing, despite the fact that he showed good initial strength in right lower limb quadriceps, hamstrings, and ankle dorsiflexors. Treatment was provided 4 times/week for 1.5 h, for 12 weeks. The combined treatment included the following: motor learning exercises designed for coordination training of the lower limb; functional electrical stimulation (FES) assisted practice; weight-supported coordination practice; and over-ground and treadmill walking. The FES was used as an adjunct to enhance muscle response during motor learning and prior to volitional recovery of motor control. Weight-supported treadmill training was administered to titrate weight and pressure applied at the joints and to the plantar foot surface during stance phase and pre-swing phase of the involved limb. Later in the protocol, treadmill training was administered to improve speed of movement during the gait cycle. Response to treatment was assessed through an array of impairment, functional mobility, and life role participation measures. Results: At post-treatment, Mr. X exhibited some recovery of hip, knee, and ankle coordination during swing phase according to kinematic measures, and the stiff-legged gait was resolved. Muscle strength measures remained essentially constant throughout the study. The modified Ashworth scale showed improved knee extensor tone from baseline of 1 to normal (0) at post-treatment. Gait coordination overall improved by 12 points according to the Gait Assessment and Intervention Tool, Six Minute Walk Test improved by 532′, and the Stroke Impact Scale improved by 12 points, including changes in daily activities; mobility; and meaningful activities. Discussion: Through the combined use of motor learning exercises, FES, weight-support, and treadmill training, coordination of the right lower limb improved sufficiently to exhibit a more normal swing phase, reducing the probability of falls, and subsequent downwardly spiraling dysfunction. The recovery of lower limb coordination during swing phase illustrates what is possible when strength is sufficient and when coordination training is targeted in a carefully titrated, highly incrementalized manner. Conclusions/Contribution to the Field: This case study contributes to the literature in several ways: (1) illustrates combined interventions for gait training and response to treatment; (2) provides supporting case evidence of relationships among knee flexion coordination, swing phase coordination, functional mobility, and quality of life; (3) illustrates that strength is necessary, but not sufficient to restore coordinated gait swing phase after stroke in some stroke survivors; and (4) provides details regarding coordination training and progression of gait training treatment for stroke survivors.

Background After stroke, wrist extension dyscoordination precludes functional arm/hand. We developed a more spatially precise brain signal for use in brain computer interface (BCI's) for stroke survivors. New method Combination BCI protocol of real-time functional magnetic resonance imaging (rt-fMRI) sequentially followed by functional near infrared spectroscopy (rt-fNIRS) neurofeedback, interleaved with motor learning sessions without neural feedback. Custom Matlab and Python code was developed to provide rt-fNIRS-based feedback to the chronic stroke survivor, system user. Results The user achieved a maximum of 71 % brain signal accuracy during rt-fNIRS neural training; progressive focus of brain activation across rt-fMRI neural training; increasing trend of brain signal amplitude during wrist extension across rt-fNIRS training; and clinically significant recovery of arm coordination and active wrist extension. Comparison with existing methods Neurorehabilitation, peripherally directed, shows limited efficacy, as do EEG-based BCIs, for motor recovery of moderate/severely impaired stroke survivors. EEG-based BCIs are based on electrophysiological signal; whereas, rt-fMRI and rt-fNIRS are based on neurovascular signal. Conclusion The system functioned well during user testing. Methods are detailed for others' use. The system user successfully engaged rt-fMRI and rt-fNIRS neurofeedback systems, modulated brain signal during rt-fMRI and rt-fNIRS training, according to volume of brain activation and intensity of signal, respectively, and clinically significantly improved limb coordination and active wrist extension. fNIRS use in this case demonstrates a feasible/practical BCI system for further study with regard to use in chronic stroke rehab, and fMRI worked in concept, but cost and some patient-use issues make it less feasible for clinical practice.

Background Gait impairment is one of the main causes of disability in people with multiple sclerosis. The Gait Assessment and Intervention Tool is an observational gait scale that assesses kinematic parameters using video recordings. Objective To study intra- and interrater reliability and the minimal detectable change of the Gait Assessment and Intervention Tool in individuals with multiple sclerosis. Design Observational study. Setting Multiple Sclerosis Foundation. Participants Thirty-five participants with multiple sclerosis were assessed (12 men, 23 women; 47.7 ± 11 y; Expanded Disability Status Scale = 4.32 ± 1.4). Interventions Not applicable. Main outcome measurements Intra- and interrater reliability of the Gait Assessment and Intervention Tool was assessed for each limb using the Intraclass Correlation Coefficient. In addition, the minimal detectable change was calculated. Results The Intraclass Correlation Coefficient for the intrarater reliability was found to be excellent for the total score both for the right side (.91; 95% confidence interval 95% CI .85-.95) and the left side (.93; 95% CI .88-.96). The intraclass correlation coefficient for the interrater reliability was .91 (95% CI .85-.95) for the right side, and .93 (95% CI .88-.96) for the left side. The minimal detectable change for the intrarater reliability was 1.19 points for the right side and .77 for the left side. Conclusions The Gait Assessment and Intervention Tool exhibits excellent intra- and interrater reliability and a small minimal detectable change for people with multiple sclerosis.

(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).

Brain-computer interface (BCI) technology can restore communication and control to people who are severely paralyzed. There has been speculation that this technology might also be useful for a variety of diverse therapeutic applications. This survey considers possible ways that BCI technology can be applied to motor rehabilitation following stroke, Parkinson’s disease, and psychiatric disorders. We consider potential neural signals as well as the design and goals of BCI-based therapeutic applications. These diverse applications all share a reliance on neuroimaging and signal-processing technologies. At the same time, each of these potential applications presents a series of unique challenges.

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.

A formal definition of brain-computer interface (BCI) is as follows: a system that acquires brain signal activity and translates it into an output that can replace, restore, enhance, supplement, or improve the existing brain signal, which can, in turn, modify or change ongoing interactions between the brain and its internal or external environment. More simply, a BCI can be defined as a system that translates "brain signals into new kinds of outputs." After brain signal acquisition, the BCI evaluates the brain signal and extracts signal features that have proven useful for task performance. There are 2 broad categories of BCIs: implantable and noninvasive, distinguished by invasively and noninvasively acquired brain signals, respectively. For this supplement, we will focus on BCIs that use noninvasively acquired brain signals.

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.

Purpose: Anatomical localization of brain networks controlling post-stroke spasticity are not fully understood. The purpose of this study was to determine the relationship between the integrity of white matter tracts and severity of spasticity and how this relationship changes with mitigation of spasticity in response to motor learning therapy. Methods: Eleven stroke survivors (>6 months post-stroke) with arm sensorimotor deficits had 12-week (5 d/week, 5 hr/day) motor learning therapy. Outcome measures included modified Ashworth Scale (mAS), Fugl-Meyer Upper limb (FM) and Diffusion Tensor Imaging (DTI). mAS was scored for 9 arm muscles and summated. Using Freesurfer software, DTI was analyzed via longitudinal processing stream and white matter tracts were reconstructed according to a global probabilistic tractography algorithm. Fractional anisotropy (FA), axial diffusivity (AD), and radial diffusivity (RD) were averaged along the center of the 8 bilateral and 2 interhemispheric white matter tracts. We performed partial Spearman correlation (Bonferonni correction for multiple comparisons) to evaluate the relationship between mAS and DTI measures while controlling for change in Fugl-Meyer. Wilcoxon paired sign rank test was used to compare pre vs post rehab scores for mAS and FM. Results: Subjects were 59±8.3 years old, 46±30 months after stroke and 54% were female. mAS improved from 5.95±3 to 3.95±2.6 (p=0.002, paired sign rank test) and FM improved from 25.9±12.4 to 37.6±13.9 (p=0.00097). At baseline, lower spasticity correlated with higher AD in the ipsilesional cingulum angular bundle (rho=.86; p=0.0007). Greater improvement in spasticity correlated with lower AD in the contralesional uncinate fasciculus (rho=.79;p=0.004) at baseline. Both tracts are part of limbic system. Furthermore, lower spasticity at baseline correlated with lower FA in the contralesional corticospinal tract (rho=.81; p=0.004) at baseline. Conclusion: The results show the complex nature of anatomical localization for spasticity and its mitigation. Structural integrity of the contralesional corticospinal tract as well as bi-hemispheric limbic system tracts may be involved in post-stroke spasticity.

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.

In this study functional Magnetic Resonance Imaging (fMRI) was used to evaluate cortical motor network adaptation after a rehabilitation program for upper extremity motor function in chronic stroke patients. Patients and healthy controls were imaged when they attempted to perform shoulder–elbow and wrist–hand movements in a 1.5 T Siemens scanner. We perform fMRI analysis at both single- and group-subject levels. Activated voxel counts are calculated to quantify brain activation in regions of interest. We discuss several candidate regression models for making inference on the count data, and propose an application of a generalized negative-binomial model (GNBM) with structured dispersion in the study. The effects of inappropriate statistical models that ignore the nature of data are addressed through Monte Carlo simulations. Based on the GNBM, significant activation differences are observed in a number of cortical regions for stroke versus control and as a result of treatment; notably, these differences are not detected when the data are analyzed using a conventional linear regression model. Our findings provide an improved functional neuroimaging data analysis protocol, specifically for pixel/voxel counts.

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.