Neuromechanical measurement of motor impairments in relation to upper limb activity limitations after stroke

Loss of upper-limb function is a problem following stroke. Recent research has led to the emergence of new treatments but progress is hampered by lack of reliable objective measures of impairment, and understanding of the underlying impairment mechanisms associated with loss and recovery of functional activity. The aim of this research was to identify, using neuromechanical measurement methods, inter-relationships between motor impairments, and correlates of motor impairments with functional activity limitation in the upper limb of acute and chronic stroke survivors.An instrumented rig has been developed to measure impairments: muscle weakness, active range of movement, motor control accuracy in rhythmic and discrete tracking tasks, spasticity, coactivation, contracture and non-neural stiffness. In pilot studies, signal processing and data analysis techniques have been used to generate novel, clinically and physiologically relevant indices to quantify impairments. In a Main Study, 13 older impaired participants in the acute phase post-stroke, 13 in the chronic phase 14 age-matched unimpaired participants underwent rig assessments and performed a test of upper limb activity. A sub-group of impaired participants were tested on two days for test-retest reliability evaluation.Statistical tests have confirmed the validity of the impairments to distinguish between acute and chronic patients and unimpaired individuals, except coactivation during discrete movements and non-neural stiffness. Repeatability coefficients for the active test indices have been presented as benchmark values for use in future trials. The muscle activation indices showed lower repeatability which highlights the challenge of using these to measure change over time. The impairments that contributed to lower motor control accuracy were reduced extensor weakness, delayed extensor onset timing, coactivation and smaller extension AROM and PROM; coactivation was more strongly associated with motor control accuracy than with spasticity or stiffness.The most important contributors to functional activity in the acute group was extensor weakness, and in the chronic group was motor control accuracy and coactivation (rhythmic task). Contracture was important contributor in both groups, and was associated with weakness and loss of active range of movement rather than spasticity. The findings support the notion that rehabilitation strategies should focus on increasing muscle strength and prevention of contracture. However, assessment of more complex impairments like motor control accuracy and coactivation may be crucial to better target therapy, especially in the later phases post-stroke

Implementing physiologically-based approaches to improve Brain-Computer Interfaces usability in post-stroke motor rehabilitation

Stroke is one of the leading causes of long-term motor disability and, as such, directly impacts on daily living activities. Identifying new strategies to recover motor function is a central goal of clinical research. In the last years the approach to the post-stroke function restore has moved from the physical rehabilitation to the evidence-based neurological rehabilitation. Brain-Computer Interface (BCI) technology offers the possibility to detect, monitor and eventually modulate brain activity. The potential of guiding altered brain activity back to a physiological condition through BCI and the assumption that this recovery of brain activity leads to the restoration of behaviour is the key element for the use of BCI systems for therapeutic purposes. To bridge the gap between research-oriented methodology in BCI design and the usability of a system in the clinical realm requires efforts towards BCI signal processing procedures that would optimize the balance between system accuracy and usability. The thesis focused on this issue and aimed to propose new algorithms and signal processing procedures that, by combining physiological and engineering approaches, would provide the basis for designing more usable BCI systems to support post-stroke motor recovery. Results showed that introduce new physiologically-driven approaches to the pre-processing of BCI data, methods to support professional end-users in the BCI control parameter selection according to evidence-based rehabilitation principles and algorithms for the parameter adaptation in time make the BCI technology more affordable, more efficient, and more usable and, therefore, transferable to the clinical realm

Functional Relevance of Resistance Training-Induced Neuroplasticity in Health and Disease

[Abstract] Repetitive, monotonic, and effortful voluntary muscle contractions performed for just a few weeks, i.e., resistance training, can substantially increase maximal voluntary force in the practiced task and can also increase gross motor performance. The increase in motor performance is often accompanied by neuroplastic adaptations in the central nervous system. While historical data assigned functional relevance to such adaptations induced by resistance training, this claim has not yet been systematically and critically examined in the context of motor performance across the lifespan in health and disease. A review of muscle activation, brain and peripheral nerve stimulation, and imaging data revealed that increases in motor performance and neuroplasticity tend to be uncoupled, making a mechanistic link between neuroplasticity and motor performance inconclusive. We recommend new approaches, including causal mediation analytical and hypothesis-driven models to substantiate the functional relevance of resistance training-induced neuroplasticity in the improvements of gross motor function across the lifespan in health and disease

EMG Signs of Motor Units’ Enlargement in Stroke Survivors

The degeneration of lower motoneurons has often been reported in stroke survivors, with possible collateral reinnervation from the surviving motoneurons to the denervated muscle fibers. Under this assumption, a stroke would be expected to increase the size of motor units in paretic muscles. We indirectly address this issue with electrical stimulation and surface electromyography, asking whether stroke leads to greater variations in the amplitude of M waves elicited in paretic muscles than in contralateral, non-paretic muscles. Current pulses at progressively greater intensities were applied to the musculocutaneous nerve, stimulating motoneurons supplying the biceps brachii of eight stroke patients. The size of increases in the amplitude of M waves elicited consecutively, hereafter defined as increments, was considered to evaluate changes in the innervation ratio of biceps brachii motor units following stroke. Our findings showed that patients presented significantly (p = 0.016) greater increments in muscles of paretic than in non-paretic limbs. This result corroborates the notion that collateral reinnervation takes place after stroke, enlarging motor units’ size and the magnitude of the muscle responses. Therefore, the non-invasive analysis proposed here may be useful for health professionals to assess disease progression by tracking for neuromuscular changes likely associated with clinical outcomes in stroke survivors, such as in the muscles’ strength

Motor Unit Properties of the First Dorsal Interosseous in Chronic Stroke Subjects: Concentric Needle and Single Fiber EMG Analysis

The purpose of this study was to better understand changes in motor unit electrophysiological properties in people with chronic stroke based on concentric needle electromyography (EMG) and single fiber EMG recordings. The first dorsal interosseous (FDI) muscle was studied bilaterally in eleven hemiparetic stroke subjects. A significant increase in mean fiber density (FD) was found in the paretic muscle compared with the contralateral side based on single fiber EMG (1.6 ± 0.2 vs. 1.3 ± 0.1, respectively, P = 0.003). There was no statistically significant difference between the paretic and contralateral sides in most concentric needle motor unit action potential (MUAP) parameters, such as amplitude (768.7 ± 441.7 vs. 855.0 ± 289.9 μV), duration (8.9 ± 1.8 vs. 8.68 ± 0.9 ms) and size index (1.2 ± 0.5 vs. 1.1 ± 0.3) (P > 0.18), nor was there a significant difference in single fiber EMG recorded jitter (37.0 ± 9.6 vs. 39.9 ± 10.6 μs, P = 0.45). The increase in FD suggests motor units of the paretic FDI have enlarged due to collateral reinnervation. However, sprouting might be insufficient to result in a statistically significant change in the concentric needle MUAP parameters. Single fiber EMG appears more sensitive than concentric needle EMG to reflect electrophysiological changes in motor units after stroke. Both single fiber and concentric needle EMG recordings may be necessary to better understand muscle changes after stroke, which is important for development of appropriate rehabilitation strategies. The results provide further evidence that motor units are remodeled after stroke, possibly in response to a loss of motoneurons

Motor patterns evaluation of people with neuromuscular disorders for biomechanical risk management and job integration/reintegration

Neurological diseases are now the most common pathological condition and the leading cause of disability, progressively worsening the quality of life of those affected. Because of their high prevalence, they are also a social issue, burdening both the national health service and the working environment. It is therefore crucial to be able to characterize altered motor patterns in order to develop appropriate rehabilitation treatments with the primary goal of restoring patients' daily lives and optimizing their working abilities. In this thesis, I present a collection of published scientific articles I co-authored as well as two in progress in which we looked for appropriate indices for characterizing motor patterns of people with neuromuscular disorders that could be used to plan rehabilitation and job accommodation programs. We used instrumentation for motion analysis and wearable inertial sensors to compute kinematic, kinetic and electromyographic indices. These indices proved to be a useful tool for not only developing and validating a clinical and ergonomic rehabilitation pathway, but also for designing more ergonomic prosthetic and orthotic devices and controlling collaborative robots

Analysis of the Interlimb similarity of motor patterns for improving stroke assessment and neurorehabilitation

Stroke is the leading cause of adult disability, with upper limb hemiparesis being one of the most common consequences. Regaining voluntary arm movement is one of the major goals of rehabilitation. However, even with intensive rehabilitation, approximately 30% of patients remain permanently disabled and only 5 to 20% of them recover full independence. Hence, there is an increasing interest in incorporating the latest advances in neuroscience, medicine and engineering to improve the efficacy of conventional therapies. In the last years, a variety of promising targets have been identified to improve rehabilitation. However, there is no consensus on which measure should be applied as a gold standard to study functional recovery. This fact dramatically hinders the development of new interventions since it turns difficult to compare different clinical trials and draw consistent conclusions about therapeutic efficiency. In addition, available scales are subjective, qualitative and often lead to incongruent outcomes. Indeed, there is increasing suspicion that the lack of optimal assessment measures hampers the detection of benefits of new therapies. Moreover, existing scales totally ignore the neuromuscular state of the patient masking the ongoing recovery processes. In consequence, making appropriate clinical decisions in such environment is almost impossible. In light of all these facts, the need for new objective biomarkers to develop effective therapies is undeniable. To give response to these demands we have organized this thesis into two main branches. On the one hand, we have developed an innovative physiological scale that reveals the neuromuscular state of the patient and is able to discriminate between motor impairment levels. The innovation here resides in the concept of interlimb similarity (ILS). Based on the latest findings about the modular organization of the motor system and taking into account that stroke provokes unilateral motor damage, we propose comparing the control structure of the unaffected arm with the control structure of the paretic arm to quantify motor impairment. We have defined the control structure as the set of muscle synergies and activation coefficients needed to complete a task. The advantage of this approach is not only its capacity to provide neuromuscular information about the patient, but also that the ILS is personalized to each patient and can purposely guide rehabilitation based on the patient¿s own physiological patterns. This supposes a huge advance taking into account the heterogeneity of stroke pathogenesis. On other hand, we have characterized the therapeutic potential of Visual Feedback (VF) as a tool to purposely induce neuroplastic changes. We have chosen VF among the various interventions proven to improve motor performance, because VF is a cheap strategy that can be implemented in almost any rehabilitation center. We demonstrate that VF is able to modulate the human control structure. In healthy subjects, it seems that VF makes accessible the refined dominant motor programs for the nondominant hemisphere giving rise to an increased interlimb similarity of the control structure. Interestingly, in stroke patients VF is able to manipulate the ILS of upper-limb kinematics in favor of finer motor control but a single training session seems not to be enough to fix those changes in the neuromuscular system of a damaged brain. Overall, these findings offer a new promising framework to develop and assess an effective intervention to guide the restoration of the original neuromuscular patterns and avoid unwanted maladaptive neuroplasticity. In conclusion, this thesis seeks moving forward in the understanding of human motor recovery processes and their relationship with neuroplasticity. In this sense, it provides important advances in the design of a new biomarker of motor impairment and tests the power of VF to modulate the neuromuscular control of patients with stroke.L'ictus és la principal causa de discapacitat en adults, essent l'hemiparèsia del membre superior una de les conseqüències més comunes. Els programes de rehabilitació tenen com a objectiu fonamental restituir la mobilitat del braç afectat. No obstant això, es calcula que només entre el 5 i el 20% dels pacients aconsegueixen recuperar la seva independència mentre que el 30% queden incapacitats permanentment. En front d'aquest escenari es fa necessari incorporar els últims avenços de la neurociència, la medicina i l'enginyeria en aquesta àrea. En els darrers anys s'han identificat diversos aspectes clau per intentar millorar la rehabilitació. El problema, però, és que no hi ha consens per definir una mesura com a "gold estàndard" per avaluar la recuperació funcional, motiu pel qual, el desenvolupament de noves teràpies queda profundament afectat, ja que esdevé impossible poder comparar diferents assajos clínics i extreure conclusions consistents sobre la seva eficiència terapèutica. A més, les diverses mesures que s'utilitzen són subjectives, qualitatives i sovint donen resultats incongruents. De fet, se sospita que la manca de mesures d'avaluació òptimes dificulta la detecció dels beneficis de noves teràpies. A tot això se li ha d'afegir que les mesures actuals no consideren l'estat neuromuscular del pacient, emmascarant els processos reparadors subjacents. Així doncs, prendre les decisions clíniques adequades sota aquestes condicions esdevé pràcticament impossible. En aquestes circumstàncies, no es pot ignorar el requeriment de nous biomarcadors que proporcionin dades objectives per catalitzar el disseny de teràpies efectives. Per donar resposta a aquesta situació, la tesi s'ha estructurat en dues parts. Per una banda, s'ha desenvolupat una innovadora escala fisiològica que revela l'estat neuromuscular del pacient i és capaç de discriminar entre diferents nivells d'incapacitat motora. La innovació rau en el concepte de similitud entre membres (ILS, en anglès). Així, basant-nos en els darrers descobriments sobre l'organització modular del sistema motor, i en el fet que l'ictus provoca dany unilateral, proposem comparar l'estructura de control del braç no-afectat amb l'estructura de control del braç parètic per quantificar la incapacitat motora. L'estructura de control l'hem definida com el conjunt de sinergies musculars i coeficients d'activació que es necessiten per a dur a terme una tasca. L'avantatge d'aquesta proposta és doble, ja que proporciona informació sobre l'estat neuromuscular del pacient i en ser personalitzable, pot guiar la rehabilitació d'acord amb els patrons fisiològics propis de cada pacient. Això suposa un enorme avenç en aquesta àrea, donada la immensa heterogeneïtat de la patogènesi d'aquest trastorn. D'altra banda, s'ha caracteritzat el potencial terapèutic del feedback visual (VF) per induir canvis neuroplàstics. Aquesta és una eina molt interessant perquè a més de millorar el control motor, és assequible per gairebé qualsevol centre de rehabilitació. S'ha demostrat que el VF és capaç de modular l'estructura de control. Concretament, el VF sembla transferir els programes motors de l'hemisferi dominant al costat no dominant augmentant així el ILS dels subjectes sans. En pacients amb ictus, el VF és capaç d'augmentar el ILS cinemàtic afavorint patrons de control més fins. En conclusió, l'objectiu d'aquesta tesi és aprofundir en la comprensió dels processos de recuperació motora i la seva relació amb la neuroplasticitat. La tesi ofereix un nou i prometedor marc per desenvolupar i avaluar procediments efectius per guiar la restauració dels patrons neuromusculars originals i evitar que el cervell pateixi canvis neuroplàstics indesitjables. Així, la tesi proporciona avanços importants en el disseny d'un biomarcador per quantificar la incapacitat motora i avaluar el potencial del VF per modular el control neuromuscular de pacients amb ictus.Postprint (published version

Analysis of forearm muscles activity by means of new protocols of multichannel EMG signal recording and processing

Los movimientos voluntarios del cuerpo son controlados por el sistema nervioso central y periférico a través de la contracción de los músculos esqueléticos. La contracción se inicia al liberarse un neurotransmisor sobre la unión neuromuscular, iniciando la propagación de un biopotencial sobre la membrana de las fibras musculares que se desplaza hacia los tendones: el Potencial de Acción de la Unidad Motora (MUAP). La señal electromiográfica de superficie registra la activación continua de dichos potenciales sobre la superficie de la piel y constituye una valiosa herramienta para la investigación, diagnóstico y seguimiento clínico de trastornos musculares, así como para la identificación de la intención movimiento tanto en términos de dirección como de potencia. En el estudio de las enfermedades del sistema neuromuscular es necesario analizar el nivel de actividad, la capacidad de producción de fuerza, la activación muscular conjunta y la predisposición a la fatiga muscular, todos ellos asociados con factores fisiológicos que determinan la resultante contracción mioeléctrica. Además, el uso de matrices de electrodos facilita la investigación de las propiedades periféricas de las unidades motoras activas, las características anatómicas del músculo y los cambios espaciales en su activación, ocasionados por el tipo de tarea motora o la potencia de la misma. El objetivo principal de esta tesis es el diseño e implementación de protocolos experimentales y algoritmos de procesado para extraer información fiable de señales sEMG multicanal en 1 y 2 dimensiones del espacio. Dicha información ha sido interpretada y relacionada con dos patologías específicas de la extremidad superior: Epicondilitis Lateral y Lesión de Esfuerzo Repetitivo. También fue utilizada para identificar la dirección de movimiento y la fuerza asociada a la contracción muscular, cuyos patrones podrían ser de utilidad en aplicaciones donde la señal electromiográfica se utilice para controlar interfaces hombre-máquina como es el caso de terapia física basada en robots, entornos virtuales de rehabilitación o realimentación de la actividad muscular. En resumen, las aportaciones más relevantes de esta tesis son: * La definición de protocolos experimentales orientados al registro de señales sEMG en una región óptima del músculo. * Definición de índices asociados a la co-activación de diferentes músculos * Identificación de señales artefactuadas en registros multicanal * Selección de los canales mas relevantes para el análisis Extracción de un conjunto de características que permita una alta exactitud en la identificación de tareas motoras Los protocolos experimentales y los índices propuestos permitieron establecer que diversos desequilibrios entre músculos extrínsecos del antebrazo podrían desempeñar un papel clave en la fisiopatología de la epicondilitis lateral. Los resultados fueron consistentes en diferentes ejercicios y pueden definir un marco de evaluación para el seguimiento y evaluación de pacientes en programas de rehabilitación motora. Por otra parte, se encontró que las características asociadas con la distribución espacial de los MUAPs mejoran la exactitud en la identificación de la intención de movimiento. Lo que es más, las características extraídas de registros sEMG de alta densidad son más robustas que las extraídas de señales bipolares simples, no sólo por la redundancia de contacto implicada en HD-EMG, sino también porque permite monitorizar las regiones del músculo donde la amplitud de la señal es máxima y que varían con el tipo de ejercicio, permitiendo así una mejor estimación de la activación muscular mediante el análisis de los canales mas relevantes.Voluntary movements are achieved by the contraction of skeletal muscles controlled by the Central and Peripheral Nervous system. The contraction is initiated by the release of a neurotransmitter that promotes a reaction in the walls of the muscular fiber, producing a biopotential known as Motor Unit Action Potential (MUAP) that travels from the neuromuscular junction to the tendons. The surface electromyographic signal records the continuous activation of such potentials over the surface of the skin and constitutes a valuable tool for the diagnosis, monitoring and clinical research of muscular disorders as well as to infer motion intention not only regarding the direction of the movement but also its power. In the study of diseases of the neuromuscular system it is necessary to analyze the level of activity, the capacity of production of strength, the load-sharing between muscles and the probably predisposition to muscular fatigue, all of them associated with physiological factors determining the resultant muscular contraction. Moreover, the use of electrode arrays facilitate the investigation of the peripheral properties of the active Motor Units, the anatomical characteristics of the muscle and the spatial changes induced in their activation of as product of type of movement or power of the contraction.The main objective of this thesis was the design and implementation of experimental protocols, and algorithms to extract information from multichannel sEMG signals in 1 and 2 dimensions of the space. Such information was interpreted and related to pathological events associated to two upper-limb conditions: Lateral Epicondylitis and Repetitive Strain Injury. It was also used to identify the direction of movement and contraction strength which could be useful in applications concerning the use of biofeedback from EMG like in robotic- aided therapies and computer-based rehabilitation training.In summary, the most relevant contributions are:§The definition of experimental protocols intended to find optimal regions for the recording of sEMG signals. §The definition of indices associated to the co- activation of different muscles. §The detection of low-quality signals in multichannel sEMG recordings.§ The selection of the most relevant EMG channels for the analysis§The extraction of a set of features that led to high classification accuracy in the identification of tasks.The experimental protocols and the proposed indices allowed establishing that imbalances between extrinsic muscles of the forearm could play a key role in the pathophysiology of lateral epicondylalgia. Results were consistent in different types of motor task and may define an assessment framework for the monitoring and evaluation of patients during rehabilitation programs.On the other hand, it was found that features associated with the spatial distribution of the MUAPs improve the accuracy of the identification of motion intention. What is more, features extracted from high density EMG recordings are more robust not only because it implies contact redundancy but also because it allows the tracking of (task changing) skin surface areas where EMG amplitude is maximal and a better estimation of muscle activity by the proper selection of the most significant channels

Variation of Finger Activation Patterns Post-stroke Through Non-invasive Nerve Stimulation

Purpose: A transcutaneous proximal nerve stimulation technique utilizing an electrode grid along the nerve bundles has previously shown flexible activation of multiple fingers. This case study aimed to further demonstrate the ability of this novel stimulation technique to induce various finger grasp patterns in a stroke survivor.Methods: An individual with chronic hemiplegia and severe hand impairment was recruited. Electrical stimulation was delivered to different pairs of an electrode grid along the ulnar and median nerves to selectively activate different finger flexor muscles, with an automated electrode switching method. The resultant individual isometric flexion forces and forearm flexor high-density electromyography (HDEMG) were acquired to evaluate the finger activation patterns. A medium and low level of overall activation were chosen to gauge the available finger patterns for both the contralateral and paretic hands. All the flexion forces were then clustered to categorize the different types of grasp patterns.Results: Both the contralateral and paretic sides demonstrated various force clusters including single and multi-finger activation patterns. The contralateral hand showed finger activation patterns mainly centered on median nerve activation of the index, middle, and ring fingers. The paretic hand exhibited fewer total activation patterns, but still showed activation of all four fingers in some combination.Conclusion: Our results show that electrical stimulation at multiple positions along the proximal nerve bundles can elicit a select variety of finger activation patterns even in a stroke survivor with minimal hand function. This system could be further implemented for better rehabilitative training to help induce functional grasp patterns or to help regain muscle mass