Abstract: BACKGROUND: Recovery of voluntary movement is a main rehabilitation goal. Efforts to identify effective upper limb (UL) interventions after stroke have been unsatisfactory. This study includes personalized impairment-based UL reaching training in virtual reality (VR) combined with non-invasive brain stimulation to enhance motor learning. The approach is guided by limiting reaching training to the angular zone in which active control is preserved (“active control zone”) after identification of a “spasticity zone”. Anodal transcranial direct current stimulation (a-tDCS) is used to facilitate activation of the affected hemisphere and enhance inter-hemispheric balance. The purpose of the study is to investigate the effectiveness of personalized reaching training, with and without a-tDCS, to increase the range of active elbow control and improve UL function. METHODS: This single-blind randomized controlled trial will take place at four academic rehabilitation centers in Canada, India and Israel. The intervention involves 10 days of personalized VR reaching training with both groups receiving the same intensity of treatment. Participants with sub-acute stroke aged 25 to 80 years with elbow spasticity will be randomized to one of three groups: personalized training (reaching within individually determined active control zones) with a-tDCS (group 1) or sham-tDCS (group 2), or non-personalized training (reaching regardless of active control zones) with a-tDCS (group 3). A baseline assessment will be performed at randomization and two follow-up assessments will occur at the end of the intervention and at 1 month post intervention. Main outcomes are elbow-flexor spatial threshold and ratio of spasticity zone to full elbow-extension range. Secondary outcomes include the Modified Ashworth Scale, Fugl-Meyer Assessment, Streamlined Wolf Motor Function Test and UL kinematics during a standardized reach-to-grasp task. DISCUSSION: This study will provide evidence on the effectiveness of personalized treatment on spasticity and UL motor ability and feasibility of using low-cost interventions in low-to-middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02725853 . Initially registered on 12 January 2016.

Abstract: The present study examined the effect of continuous vision and its occlusion in timing of pre-landing actions during free falls. When vision is occluded, muscle activation is hypothesized to start relative to onset of the fall. However, when continuous vision is available onset of action is hypothesized to be relative to the moment of touchdown. Six subjects performed 6 randomized sets of 6 trials after becoming familiar with the task. The 36 trials were divided in 2 visual conditions (vision and blindfold) and 3 heights of fall (15, 45 and 75 cm). EMG activity was recorded from the gastrocnemius and rectus femoris muscles during the falls. The latency of onset (L(o)) and the lapse from EMG onset to touchdown (T(c)) were obtained from these muscles. Vertical forces were recorded to assess the effects of pre-landing activity on the impacts at collision with and without continuous vision. Peak amplitude (F(max)), time to peak (T(max)) and peak impulse normalized to momentum (I(norm)) were used as outcome measures. Within flight time ranges of approximately 50-400 ms, the results showed that L(o) and T(c) follow a similar linear trend whether continuous vision was available or occluded. However, the variability of T(c) for each of the muscles was larger in the vision occluded condition. Analyses of variance showed that the rectus femoris muscle started consistently earlier in no vision trials. Finally, impact forces were not different in vision or blindfold conditions, and thus, they were not affected by minor differences in the timing of muscles prior to landing. Thus, it appears that knowing the surroundings before falling may help to reduce the need for a continuous visual input. The relevance of such input cannot be ruled out for falls from high landing heights, but cognitive factors (e.g., attention to specific cues and anticipation of a fall) may play a dominant role in timing actions during short duration falls encountered daily.

Abstract: We examined how the digit forces adjust when a load force acting on a hand-held object continuously varies. The subjects were required to hold the handle still while a linearly increasing and then decreasing force was applied to the handle. The handle was constrained, such that it could only move up and down, and rotate about a horizontal axis. In addition, the moment arm of the thumb tangential force was 1.5 times the moment arm of the virtual finger (VF, an imagined finger with the mechanical action equal to that of the four fingers) force. Unlike the situation when there are equal moment arms, the experimental setup forced the subjects to choose between (a) sharing equally the increase in load force between the thumb and VF but generating a moment of tangential force, which had to be compensated by negatively co-varying the moment due to normal forces, or (b) sharing unequally the load force increase between the thumb and VF but preventing generation of a moment of tangential forces. We found that different subjects tended to use one of these two strategies. These findings suggest that the selection by the CNS of prehension synergies at the VF-thumb level with respect to the moment of force is non-obligatory and reflects individual subject preferences. This unequal sharing of the load by the tangential forces, in contrast to the previously observed equal sharing, suggests that the invariant feature of prehension may be a correlated increase in tangential forces rather than an equal increase.