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Objective: To improve recovery of gait after stroke, we need to attain better understanding of lower extremity motor control. Transcranial magnetic stimulation (TMS) allows for evaluation of corticomotor input (CMI) integrity. Our objective was to explore the relationship between CMI to the dorsi-/plantarflexors and measures of motor impairment and gait speed. Methods: Fugl-Meyer for Lower Extremity (FM), gait speed and TMS Motor Evoked Potentials (MEP) were collected for 27 ambulatory chronic stroke survivors. Maximum MEPs (MEP max ) were collected for paretic and non-paretic tibialis anterior (TA) and lateral gastrocnemius muscles (Gastroc) using a cone-shaped TMS coil targeting primary motor cortices. We collected MEPs while seated participants activated their tested muscles to 20% of maximum effort. MEPs were normalized by the maximum compound muscle action potentials obtained by stimulation of the peripheral motor nerves. Symmetry of the corticospinal motor output was calculated as ratio of the normalized paretic and non-paretic MEP max . Analysis included descriptive statistics, paired t-test and Pearson correlation. Non-normally distributed data was log-transformed. Results: Study participants were 65.7±7.5 years old, 5.3±4.4 years after stroke and 81% male. Their mean±SD FM was 24.6±3.7 and gait speed was 0.74±0.38 m/s. For both TA and Gastroc, paretic MEP max were significantly smaller than non-paretic (p=3.8e -18 ). For Gastroc, higher ratio of paretic/non-paretic MEP max correlated with lesser impairment measured with FM (r=0.42, p=0.027). For TA, the correlation was lower and did not reach statistical significance (r=0.33, p=0.088). Gait speed did not have a significant correlation with MEP max . FM moderately correlated with gait speed (r=0.44, p=0.02). Conclusion: Gastroc MEP might be a better biomarker of motor impairment than TA. Thus, CMI to TA and Gastroc may provide different information in elucidating the mechanism of lower limb motor control. Gait speed does not correlate with CMI for dorsi-/plantarflexors which suggests that motor control of ambulation (gait speed) may differ from that of isolated joint movement (FM).

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 Somatosensory deficits are prevalent after stroke, but effective interventions are limited. Brain stimulation of the contralesional primary somatosensory cortex (S1) is a promising adjunct to peripherally administered rehabilitation therapies. Objective To assess short-term effects of repetitive transcranial magnetic stimulation (rTMS) targeting contralesional (S1) of the upper extremity. Methods Using a single-session randomized crossover design, stroke survivors with upper extremity somatosensory loss participated in 3 rTMS treatments targeting contralesional S1: Sham, 5 Hz, and 1 Hz. rTMS was delivered concurrently with peripheral of sensory electrical stimulation and vibration of the affected hand. Outcomes included 2-point discrimination (2PD), proprioception, vibration perception threshold, monofilament threshold (size), and somatosensory evoked potential (SEP). Measures were collected before, immediately after treatment, and 1 hour after treatment. Mixed models were fit to analyze the effects of the 3 interventions. Results Subjects were 59.8 ± 8.1 years old and 45 ± 39 months poststroke. There was improvement in 2PD after 5-Hz rTMS for the stroke-affected ( F(2, 76.163) = 3.5, P = .035) and unaffected arm ( F(2, 192.786) = 10.6, P < .0001). Peak-to-peak SEP amplitudes were greater after 5-Hz rTMS for N33-P45 ( F(2, 133.027) = 3.518, P = .032) and N45-P60 ( F(2, 67.353) = 3.212, P = .047). Latencies shortened after 5-Hz rTMS for N20 ( F(2, 69.64) = 3.37, P = .04), N60 ( F(2, 47.343) = 4.375, P = .018), and P100 ( F(2, 37.608) = 3.537, P = .039) peaks. There were no differences between changes immediately after the intervention and an hour later. Conclusions Short-term application of facilitatory high-frequency rTMS (5Hz) to contralesional S1 combined with peripheral somatosensory stimulation may promote somatosensory function. This intervention may serve as a useful adjunct in somatosensory rehabilitation after stroke.

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: Structural changes related to recovery of sensory function are not well understood. Previously, we demonstrated a relationship between improved sensory function and increased cortical thickness in ipsilesional occipitoparietal and contralesional temporoparietal areas following rehabilitation of patients with chronic stroke(Pundik et al, 2018). The objective of the current work was to evaluate changes in white matter (WM) tracts originating in these cortical regions where thickness changes were related to enhanced sensory function after rehabilitation in chronic stroke. Methods: Chronic stroke survivors (n=18) received 12 weeks of upper limb sensory-motor rehabilitation. Outcome measures were sensory acuity (monofilament test, a sum over 9 locations on the hand; best score 25.47) and DTI measures of diffusivity [mean (MD), radial (RD), axial (AD)] and fractional anisotropy (FA). DTI analysis included: probabilistic tractography from seeds where cortical thickness changes correlated with sensory recovery, creation of a group-based tract by combining individual tracts, tract-based analysis using Spearman correlation, significance at p Results: Subjects were 53.9±12.1 years old, 1.9±1.2 years after stroke and 27.8% female. Monofilament score improved from 46.6±13.1 to 43.9±12.9. Improved sensory acuity correlated with increased AD (rho=0.69, p=0.002), RD (rho=0.59, p=0.0093) and MD (rho=0.63, p=0.005) in the tract originating in the ipsilesional occipital pole. Voxel-based analysis between changes in MD and in monofilament identified a statistically significant cluster (family-wise error corrected p=0.03) within a subcortical region of the tract originating in the ipsilesional occipital pole. Conclusion: Improved sensory acuity after rehabilitation was related to DTI-measured microstructural changes in WM tracts. These findings further support the notion of structural plasticity associated with sensory function improvement during rehabilitation in chronic stroke.

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/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 Upper limb motor deficits following traumatic brain injury are prevalent and effective therapies are needed. The purpose of this case report was to illustrate response to a novel therapy using a myoelectric orthosis in a person with TBI. Case description: A 42-year-old female, 29.5 years post-traumatic brain injury with diminished motor control/coordination, and learned nonuse of the right arm. She also had cognitive deficits and did not spontaneously use her right arm functionally. Intervention Study included three phases: baseline data collection/device fabrication (five weeks); in-clinic training (2×/week for nine weeks); and home-use phase (nine weeks). The orthosis was incorporated into motor learning-based therapy. Outcomes: During in-clinic training, active range of motion, tone, muscle power, Fugl-Meyer, box and blocks test, and Chedoke assessment score improved. During the home-use phase, decrease in tone was maintained and all other outcomes declined but were still better upon study completion than baseline. The participant trained with the orthosis 70.12 h, logging over 13,000 repetitions of elbow flexion/extension and hand open/close. Discussion Despite long-standing traumatic brain injury, meaningful improvements in motor function were observed and were likely the results of high repetition practice of functional movement delivered over a long duration. Further assessment in a larger cohort is warranted.

Purpose: Sensory deficits are prevalent after stroke but effective interventions are limited. Non-invasive brain stimulation is a promising adjunct to peripherally administered rehabilitation therapies. However, the utility of brain stimulation in sensory re-education after stroke has not been tested. The purpose of this study was to assess immediate response to repetitive Transcranial Magnetic Stimulation (rTMS) of the contralesional primary sensory cortex (S1). Methods: Stroke survivors (>6 mo post; n=16) with arm sensory deficits participated in 3 different rTMS treatments targeting contralesional S1 as follows: 1) Sham, 2) 5 Hz and 3) 1 Hz. rTMS was paired with peripherally directed modalities (electrical stimulation via mesh glove followed by hand vibration). rTMS paradigms were administered in random order 1 week apart. Outcomes included 2-point discrimination, vibration, monofilament discrimination and proprioception. Measures were collected before and 1 hour after treatment and responses were calculated as post minus pre for each session. Data did not appear to be normally distributed, nor were responses correlated between the 3 treatments. Kruskal-Wallis tests were employed. Results: Subjects were 59.8±8.3 years old, 43±38 months after stroke, 88% were male and 59% had subcortical stroke. Baseline sensory impairment for the stroke Affected (A) and Unaffected (U) arms were as follows: 2-point discrimination threshold 12.47±4.73mm (A) and 2.86±1.01mm (U), monofilament 4.98±1.69mm (A) and 3.55±0.55mm (U), proprioception % accuracy at index 71.67±24.6%(A) and 99.37±1.81% (U), vibration amplitude threshold in relative units 9.7±8.6(A) and 4.75±1.8(U). There was an improvement in 2-point discrimination after 5 Hz rTMS in the affected arm; a reduced threshold of 1.68±3.5mm following 5Hz intervention vs reduction of 0.333±1.18mm after 1 Hz and increase of 0.13±2.06mm after sham (p=0.009). The unaffected arm also had improvement in 2-point discrimination of 0.38±0.8mm following 5Hz rTMS compared with increased threshold after both 1Hz (0.6±0.73mm) and sham (0.2±0.77mm) (p=0.009). Conclusion: High frequency rTMS targeting contralesional S1 cortex is a potential adjunct intervention for sensory re-education after stroke.

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.

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.

Individuals with stroke are often left with persistent upper limb dysfunction, even after treatment with traditional rehabilitation methods. The purpose of this retrospective study is to demonstrate feasibility of the implementation of an upper limb myoelectric orthosis for the treatment of persistent moderate upper limb impairment following stroke (>6 months). Methods: Nine patients (>6 months post stroke) participated in treatment at an outpatient Occupational Therapy department utilizing the MyoPro myoelectric orthotic device. Group therapy was provided at a frequency of 1–2 sessions per week (60–90 minutes per session). Patients were instructed to perform training with the device at home on non-therapy days and to continue with use of the device after completion of the group training period. Outcome measures included Fugl-Meyer Upper Limb Assessment (FM) and modified Ashworth Scale (MAS). Results: Patients demonstrated clinically important and statistically significant improvement of 9.0±4.8 points (p = 0.0005) on a measure of motor control impairment (FM) during participation in group training. It was feasible to administer the training in a group setting with the MyoPro, using a 1:4 ratio (therapist to patients). Muscle tone improved for muscles with MAS >1.5 at baseline. Discussion: Myoelectric orthosis use is feasible in a group clinic setting and in home-use structure for chronic stroke survivors. Clinically important motor control gains were observed on FM in 7 of 9 patients who participated in training.

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.

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.

Background.Arm spasticity is a challenge in the care of chronic stroke survivors with motor deficits. In order to advance spasticity treatments, a better understanding of the mechanism of spasticity-related neuroplasticity is needed.Objective.To investigate brain function correlates of spasticity in chronic stroke and to identify specific regional functional brain changes related to rehabilitation-induced mitigation of spasticity.Methods.23 stroke survivors (>6 months) were treated with an arm motor learning and spasticity therapy (5 d/wk for 12 weeks). Outcome measures included Modified Ashworth scale, sensory tests, and functional magnetic resonance imaging (fMRI) for wrist and hand movement.Results.First, at baseline, greater spasticity correlated with poorer motor function (P=0.001) and greater sensory deficits (P=0.003). Second, rehabilitation produced improvement in upper limb spasticity and motor function (P<0.0001). Third, at baseline, greater spasticity correlated with higher fMRI activation in the ipsilesional thalamus (rho=0.49,P=0.03). Fourth, following rehabilitation, greater mitigation of spasticity correlated with enhanced fMRI activation in the contralesional primary motor (r=-0.755,P=0.003), premotor (r=−0.565,P=0.04), primary sensory (r=−0.614,P=0.03), and associative sensory (r=−0.597,P=0.03) regions while controlling for changes in motor function.Conclusions.Contralesional motor regions may contribute to restoring control of muscle tone in chronic stroke.

Background: In chronic stroke, recovery of coordinated reaching is critical to arm function and quality of life. Improvement of motor function can be achieved with intensive rehabilitation even years after stroke, but current methods fall short of restoring normal movement for many stroke survivors. Little is known regarding the change in brain function that is required to improve shoulder/elbow reach function. Therefore, the aim of this study was to characterize the change in brain activity of bilateral motor-sensory brain regions, which may drive recovery of functional reach. Methods: 22 stroke subjects (>6 months post-stroke) with arm motor deficits were enrolled and treated with intensive arm rehabilitation (5 hours/day, 5 days/week for 12 weeks). Outcome measures were: 1) functional magnetic resonance imaging (fMRI) during a shoulder/elbow reach task (paretic arm), 2) skilled motor function (Arm Motor Assessment Test (AMAT)). fMRI activation (voxel count) was calculated for bilateral sensory-motor control regions. Multiple linear regression analysis was conducted to determine the relationship between the change in brain function and recovery of functional reach. Co-variates included pre-treatment AMAT, age and time-since-stroke. Results: Subject characteristics were: age, 56.3 (±12.8years); 41%, female; and 1.8 (±1.1) years post-stroke. AMAT improved from 1636.63 (±668.41) to 1213.67 (±6643.79) seconds (p Conclusions: In chronic stroke, important gain in functional reach is associated with increased activation, not only in the ipsilesional primary motor region, but also in the contralesional motor-sensory regions, which occurred in response to intensive neurorehabilitation. Arm neurorehabilitation methods should be based on principles that engage this brain plasticity, which may drive recovery of arm function.

Intensive gait training can produce improvements in gait and function (6 months after stroke); however, 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 improvements in life-role participation for chronic-stroke survivors, according to a comprehensive measure dedicated to life-role participation.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 functional neuromuscular stimulation, body-weight supported treadmill training, over-ground gait training and exercise for 1.5 hours/day, 4 days/week for 12 weeks. Study measures included Tinetti Gait (gait impairment), Functional Independence Measure (FIM, function), Stroke Impact Scale subscale of life-role participation (SIS part) and Craig Handicap Assessment and Reporting Technique (CHART, life-role participation). Analysis included Wilcoxon signed rank test and polytomous universal regression model.Gait interventions produced significant improvement in CHART (p = 0.020), SIS part (p = 0.011), FIM (p0.0001), and Tinetti Gait (p0.0001). Age, gender and time since stroke did not predict response to treatment.Intensive gait therapy resulted in significant gain in life-role participation, according to a comprehensive measure, so dedicated.

Background: Spasticity can prevent productive practice of skilled movement that should occur during neurorehabilitation of coordinated arm movements after stroke. Studies showed that spasticity could be reduced following an intervention that inhibited activation of the contralesional primary motor region (M1) using non-invasive transcranial magnetic or electric stimulation. However, there is little understanding of how the mitigation of spasticity might be controlled by the multiple sensorimotor control brain regions. Therefore, the aim of this study was to evaluate the change in activation patterns of multiple sensorimotor regions that predict the mitigation of spasticity, in response to intensive upper limb neurrehabiltiation. Methods: Twenty three stroke subjects (>6 months after stroke) with persistent arm motor deficits were treated with intensive upper extremity rehabilitation (5 hours/day, 5 days/week for 12 weeks). Baseline and post-rehab evaluation consisted of three measures: 1) functional magnetic resonance imaging (fMRI) during a shoulder/elbow reach task for the paretic arm, 2) a skilled motor function (Arm Motor Assessment test (AMAT)), and 3) spasticity (Modified Ashworth Scale(MAS)). Volume of brain activation (voxel count) during the reach task was calculated for sensory and motor control regions using SPM05 (London, UK) and in-house software in MATLAB (Natick, MA). Paired t-test analysis was conducted for pre- vs post-treatment comparisons. Multiple linear regression analysis was conducted, where post-rehab AMAT was the dependent variable, the co-variate was pre-rehab score, and the predictors were change from pre- to post-rehab in voxel count in bilateral M1, somatosensory (SS), posterior parietal (PP), lateral premotor (LPM) and supplementary motor (SMA) areas. Results: Subject characteristics were as follows: mean age, 56.3 ±12.8years; 41%, female; and 1.8±1.1 years after first ever stroke. Change in the activation pattern in a number of regions significantly predicted mitigated spasticity (R2=.86). Specifically, in response to treatment, increased activation, in ipsilesional SMA (p=.002) and contralesional M1 (p=.002), predicted mitigated spasticity. Reduction in activation volume, in ipsilesional PP region (p=.0009), contralesional SS (p=.008) and SMA (p=.006), predicted mitigated spasticity. AMAT score improved from 1636.63±668.41 to 1213.67±6643.79 seconds (p Conclusions: A specific pattern of functional brain change across multiple regions predicted mitigation of spasticity following neurorehabilitation; skill functional recovery occurred, as well. This information could be used in constructing study design for future research that would investigate brain training to mitigate spasticity and improve skilled functional task performance.

Background/Objectives: Gait coordination is not well-studied nor well-described in chronic stroke. Gait coordination can be defined as the simultaneous consideration of spatial and temporal movement characteristics. One aspect of gait coordination is the consistency of relative movements of hip/knee, hip/ankle, and knee/ankle across the gait cycle. Without consistency of relative joint movement from step to step, safety of gait is compromised and function is reduced. Therefore, the hypothesis of this study was that in chronic stroke survivors with persistent gait deficits, consistency of gait coordination is impaired, according to a measure of inter-joint coordination consistency (hip/knee; hip/ankle; and knee/ankle) of movement excursion and timing across the gait cycle from step to step. Methods: Ten healthy adults and thirty-eight subjects with persistnet gait deficits were enrolled (>6mos after stroke). In terms of gait speed, stroke subjects were either household ambulators (HA; Conclusions: Inconsistent relative joint movement between hip, knee, and ankle across the gait cycle, could be a source of falls, poor walking endurance, and dysfunction. The presence of this impairment should be noted in assessment and targeted during treatment.

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.

Recent neuroscience methods have provided the basis upon which to develop effective gait training methods for recovery of the coordinated components of gait after neural injury. We determined that there was not an existing observational measure that was, at once, adequately comprehensive, scored in an objectively-based manner, and capable of assessing incremental improvements in the coordinated components of gait. Therefore, the purpose of this work was to use content valid procedures in order to develop a relatively inexpensive, more comprehensive measure, scored with an objectively-based system, capable of incrementally scoring improvements in given items, and that was both reliable and capable of discriminating treatment response for those who had a stroke. Eight neurorehabilitation specialists developed criteria for the gait measure, item content, and scoring method. In subjects following stroke (>12 months), the new measure was tested for intra- and inter-rater reliability using the Intraclass Correlation Coefficient; capability to detect treatment response using Wilcoxon Signed Ranks Test; and discrimination between treatment groups, using the Plum Ordinal Regression. The Gait Assessment and Intervention Tool (G.A.I.T.) is a 31-item measure of the coordinated movement components of gait and associated gait deficits. It exhibited the following advantages: comprehensive, objective-based scoring method, incremental measurement of improvement within given items. The G.A.I.T. had good intra- and inter-rater reliability (ICC=.98, p=.0001, 95% CI=.95, .99; ICC=.83, p=.007, 95% CI=.32, .96, respectively. The inexperienced clinician who had training, had an inter-rater reliability with an experienced rater of ICC=.99 (p=.0001, CI=.97, .999). The G.A.I.T. detected improvement in response to gait training for two types of interventions: comprehensive gait training (z=-2.93, p=.003); and comprehensive gait training plus functional electrical stimulation (FES; z=-3.3, p=.001). The G.A.I.T. was capable of discriminating between two gait training interventions, showing an additive advantage of FES to otherwise comparable comprehensive gait training (parameter estimate=1.72, p=.021; CI, .25, 3.1).

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.

INTRODUCTION The Gait Coordination Protocol (GCP) was successful in producing clinically and statistically significant gains in impairment, function, and life-role participation for those in the chronic phase after stroke who had exhibited persistent moderate to severe gait deficits [1-3]. The GCP was initially developed to test response to functional electrical stimulation (FES); notably, the GCP produced enhanced coordinated gait regardless of whether FES was used [1]. (The Video shows gait recovery in response to the GCP for a participant from the "No-FES group.") In response to national and state presentations, there was a strong call for description of the details of the GCP and its clinical implementation. Therefore, the purpose here is to detail the implementation of this treatment protocol. We constructed the GCP based on the phenomenon of brain plasticity and associated motor learning principles that included task-specific practice (practice as close-to-normal movement as possible [4-7] with continual progression toward normal), high repetition of the desired movement pattern [8-10], focused attention on the part of the learner [11], training specificity [9,12-14], and awareness and feedback [15]. The GCP, described subsequently, was provided 1.5 h/d, 4 d/wk, and for at least 48 visits (12 weeks) [1-2]. Before treatment, the initial assessment included muscle strength, coordination, muscle tone, balance, gait coordination, gait speed, function, and quality of life. Critical aspects of the assessment included the ability to generate normal movement at the hip, knee, and ankle for the motor tasks listed in Figure 1: A-J. For those movements that were impaired, assessment included not only the ability to volitionally generate each of these movements, but also the ability to move in conjunction with an array of assistive movement devices (body-weight support [BWS], bodyweight supported treadmill training [BWSTT], FES) and gait support devices (parallel bars, walker, cane). Each motor task (Figure 1) was assessed for the following characteristics: * Percentage of the normal range of movement that could be executed, volitionally and independently. * Percentage of the motor task that could be executed with the support of verbal or tactile facilitation. * Percentage of the normal range of movement that could be executed along with an assistive movement device. * Normality of effort level during the task (e.g., holding breath, abnormal co-contraction of muscles distant from the targeted task joints or antagonist muscle contractions). * Compensatory strategies employed during execution of the motor task. * Percentage of the task for which compensatory strategies were employed. * Number of repetitions of the motor task that could be performed with only a "beat" between repetitions before the motor task was performed in an abnormal fashion. In this manner, the assessment was used to identify the initial training level in the hierarchy schema of difficulty (Figure 1). For those motor tasks that could not be volitionally performed, an array of motor learning tools were employed (Figure 2). The GCP utilized an array of tools to optimally apply the principles of motor learning. These tools included selective body positioning (Figure 2: B.1-B.1.1), awareness training (Figure 2: B.2), and practice-assist devices (Figure 2: B.3). The position for motor task practice was selected to satisfy practice of both the most normal movement possible and also the most challenging body position, both of which are required for motor skill acquisition [16-19] (Figure 2: B.1). Practice included the standing position (Figure 2: B.1.1) and dynamic walking, of course, to satisfy the learning principle of task specificity (Figure 2: B.1.2). [FIGURE 2 OMITTED] Awareness training (Figure 2: B.2) consisted of learning to identify and differentiate between normal coordinated movement and the abnormal movement, learning to monitor oneself during practice, assessing how close one's movement was to the normal movement pattern, and assessing the frequency of execution of the more normal movement pattern during a series of practice trials [15]. …