Levin, M. F., Berman, S., Weiss, N., Parmet, Y., Banina, M. C., Frenkel-Toledo, S., et al. (2023). ENHANCE proof-of-concept three-arm randomized trial: effects of reaching training of the hemiparetic upper limb restricted to the spasticity-free elbow range (Vol. 13).
Abstract: Post-stroke motor recovery processes remain unknown. Timescales and patterns of upper-limb (UL) recovery suggest a major impact of biological factors, with modest contributions from rehabilitation. We assessed a novel impairment-based training motivated by motor control theory where reaching occurs within the spasticity-free elbow range. Patients with subacute stroke (</= 6 month; n = 46) and elbow flexor spasticity were randomly allocated to a 10-day UL training protocol, either personalized by restricting reaching to the spasticity-free elbow range defined by the tonic stretch reflex threshold (TSRT) or non-personalized (non-restricted) and with/without anodal transcranial direct current stimulation. Outcomes assessed before, after, and 1 month post-intervention were elbow flexor TSRT angle and reach-to-grasp arm kinematics (primary) and stretch reflex velocity sensitivity, clinical impairment, and activity (secondary). Results were analyzed for 3 groups as well as those of the effects of impairment-based training. Clinical measures improved in both groups. Spasticity-free range training resulted in faster and smoother reaches, smaller (i.e., better) arm-plane path length, and closer-to-normal shoulder/elbow movement patterns. Non-personalized training improved clinical scores without improving arm kinematics, suggesting that clinical measures do not account for movement quality. Impairment-based training within a spasticity-free elbow range is promising since it may improve clinical scores together with arm movement quality.Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique Identifier: NCT02725853; Initial registration date: 01/04/2016.
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Lerner, O., Friedman, J., & Frenkel-Toledo, S. (2021). The effect of high-definition transcranial direct current stimulation intensity on motor performance in healthy adults: a randomized controlled trial. J NeuroEngineering Rehabil, 18, 103.
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Lackritz, H., Parmet, Y., Frenkel-Toledo, S., Banina, M. C., Soroker, N., Solomon, J. M., et al. (2021). Effect of post-stroke spasticity on voluntary movement of the upper limb. J Neuroeng Rehabil, 18(1), 81.
Abstract: BACKGROUND: Hemiparesis following stroke is often accompanied by spasticity. Spasticity is one factor among the multiple components of the upper motor neuron syndrome that contributes to movement impairment. However, the specific contribution of spasticity is difficult to isolate and quantify. We propose a new method of quantification and evaluation of the impact of spasticity on the quality of movement following stroke. METHODS: Spasticity was assessed using the Tonic Stretch Reflex Threshold (TSRT). TSRT was analyzed in relation to stochastic models of motion to quantify the deviation of the hemiparetic upper limb motion from the normal motion patterns during a reaching task. Specifically, we assessed the impact of spasticity in the elbow flexors on reaching motion patterns using two distinct measures of the 'distance' between pathological and normal movement, (a) the bidirectional Kullback-Liebler divergence (BKLD) and (b) Hellinger's distance (HD). These measures differ in their sensitivity to different confounding variables. Motor impairment was assessed clinically by the Fugl-Meyer assessment scale for the upper extremity (FMA-UE). Forty-two first-event stroke patients in the subacute phase and 13 healthy controls of similar age participated in the study. Elbow motion was analyzed in the context of repeated reach-to-grasp movements towards four differently located targets. Log-BKLD and HD along with movement time, final elbow extension angle, mean elbow velocity, peak elbow velocity, and the number of velocity peaks of the elbow motion were computed. RESULTS: Upper limb kinematics in patients with lower FMA-UE scores (greater impairment) showed greater deviation from normality when the distance between impaired and normal elbow motion was analyzed either with the BKLD or HD measures. The severity of spasticity, reflected by the TSRT, was related to the distance between impaired and normal elbow motion analyzed with either distance measure. Mean elbow velocity differed between targets, however HD was not sensitive to target location. This may point at effects of spasticity on motion quality that go beyond effects on velocity. CONCLUSIONS: The two methods for analyzing pathological movement post-stroke provide new options for studying the relationship between spasticity and movement quality under different spatiotemporal constraints.
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Krasovsky, T., Weiss, P. L., Zuckerman, O., Bar, A., Keren-Capelovitch, T., & Friedman, J. (2020). DataSpoon: Validation of an Instrumented Spoon for Assessment of Self-Feeding. Sensors (Basel), 20(7).
Abstract: Clinically feasible assessment of self-feeding is important for adults and children with motor impairments such as stroke or cerebral palsy. However, no validated assessment tool for self-feeding kinematics exists. This work presents an initial validation of an instrumented spoon (DataSpoon) developed as an evaluation tool for self-feeding kinematics. Ten young, healthy adults (three male; age 27.2 +/- 6.6 years) used DataSpoon at three movement speeds (slow, comfortable, fast) and with three different grips: “natural”, power and rotated power grip. Movement kinematics were recorded concurrently using DataSpoon and a magnetic motion capture system (trakSTAR). Eating events were automatically identified for both systems and kinematic measures were extracted from yaw, pitch and roll (YPR) data as well as from acceleration and tangential velocity profiles. Two-way, mixed model Intraclass correlation coefficients (ICC) and 95% limits of agreement (LOA) were computed to determine agreement between the systems for each kinematic variable. Most variables demonstrated fair to excellent agreement. Agreement for measures of duration, pitch and roll exceeded 0.8 (excellent agreement) for >80% of speed and grip conditions, whereas lower agreement (ICC < 0.46) was measured for tangential velocity and acceleration. A bias of 0.01-0.07 s (95% LOA [-0.54, 0.53] to [-0.63, 0.48]) was calculated for measures of duration. DataSpoon enables automatic detection of self-feeding using simple, affordable movement sensors. Using movement kinematics, variables associated with self-feeding can be identified and aid clinical reasoning for adults and children with motor impairments.
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Krasovsky, T., Keren-Capelovitch, T., Friedman, J., & Weiss, P. L. (2021). Self-feeding kinematics in an ecological setting: typically developing children and children with cerebral palsy. IEEE Trans Neural Syst Rehabil Eng, 29, 1462–1469.
Abstract: Assessment of self-feeding kinematics is seldom performed in an ecological setting. In preparation for development of an instrumented spoon for measurement of self-feeding in children with cerebral palsy (CP), the current work aimed to evaluate upper extremity kinematics of self-feeding in young children with typical development (TD) and a small, age-matched group of children with CP in a familiar setting, while eating with a spoon. METHODS: Sixty-five TD participants and six children diagnosed with spastic CP, aged 3-9 years, fed themselves while feeding was measured using miniature three-dimensional motion capture sensors (trakStar). Kinematic variables associated with different phases of self-feeding cycle (movement time, curvature, time to peak velocity and smoothness) were compared across age-groups in the TD sample and between TD children and those with CP. RESULTS: Significant between-age group differences were identified in movement times, time to peak velocity and curvature. Children with CP demonstrated slower, less smooth self-feeding movements, potentially related to activity limitations. CONCLUSIONS: The identified kinematic variables form a basis for implementation of self-feeding performance assessment in children of different ages, including those with CP, which can be deployed via an instrumented spoon.
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