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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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Banina, M. C., Molad, R., Solomon, J. S., Berman, S., Soroker, N., Frenkel-Toledo, S., et al. (2020). Exercise intensity of the upper limb can be enhanced using a virtual rehabilitation system. Disabil Rehabil Assist Technol, , 1–7.
Abstract: Purpose: Motor recovery of the upper limb (UL) is related to exercise intensity, defined as movement repetitions divided by minutes in active therapy, and task difficulty. However, the degree to which UL training in virtual reality (VR) applications deliver intense and challenging exercise and whether these factors are considered in different centres for people with different sensorimotor impairment levels is not evidenced. We determined if (1) a VR programme can deliver high UL exercise intensity in people with sub-acute stroke across different environments and (2) exercise intensity and difficulty differed among patients with different levels of UL sensorimotor impairment.Methods: Participants with sub-acute stroke (<6 months) with Fugl-Meyer scores ranging from 14 to 57, completed 10 approximately 50-min UL training sessions using three unilateral and one bilateral VR activity over 2 weeks in centres located in three countries. Training time, number of movement repetitions, and success rates were extracted from game activity logs. Exercise intensity was calculated for each participant, related to UL impairment, and compared between centres.Results: Exercise intensity was high and was progressed similarly in all centres. Participants had most difficulty with bilateral and lateral reaching activities. Exercise intensity was not, while success rate of only one unilateral activity was related to UL severity.Conclusion: The level of intensity attained with this VR exercise programme was higher than that reported in current stroke therapy practice. Although progression through different activity levels was similar between centres, clearer guidelines for exercise progression should be provided by the VR application.Implications for rehabilitationVR rehabilitation systems can be used to deliver intensive exercise programmes.VR rehabilitation systems need to be designed with measurable progressions through difficulty levels.
Keywords: Stroke; difficulty; exercise therapy; intensity; personalized exercise; upper limb; virtual reality
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Liebermann, D. G., Berman, S., Weingarden H., Levin, M. F., & Weiss, P. L. (2009). Kinematic features of arm and trunk movements in stroke patients and age-matched healthy controls during reaching in virtual and physical environments. In Virtual Rehabilitation International Conference (pp. 179–184).
Abstract: Motor performance of stroke patients and healthy individuals was compared in terms of selected kinematic features of arm and trunk movements while subjects reached for visual targets in virtual (VR) and physical (PH) environments. In PH, the targets were placed at an extended arm distance, while in VR comparably placed virtual targets were presented via GestureTek's IREX system. Our goal was to obtain further insights into research methods related to VR-based rehabilitation. Eight right-hemiparetic stroke patients (age =46-87 years) and 8 healthy adults (age =51-73 years) completed 84 reaching movements in VR and PH environments while seated. The results showed that arm and trunk movements differed in the two environments in patients and to a lesser extent in healthy individuals. Arm motion of patients became jerkier in VR, with larger paths and longer movement durations, and presented greater arm torsion (i.e., larger elbow rotations around the hand-shoulder axis). Interestingly, patients also showed a significant reduction of compensatory trunk movements during VR reaching. The findings indicate that when targets were perceived to be beyond hand reach, stroke patients may be less able to estimate 3D virtual target locations obtained from the 2D TV planar displays. This was not the case for healthy participants.
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Krasovsky, T., Berman, S., & Liebermann, D. G. (2010). Kinematic features of continuous hand reaching movements under simple and complex rhythmical constraints. J Electromyogr Kinesiol, 20(4), 636–641.
Abstract: BACKGROUND: Auditory cues are known to alter movement kinematics in healthy people as well as in people with neurological conditions (e.g., Parkinson's disease or stroke). Pacing movement to rhythmical constraints is known to change both the spatial and temporal features of movement. However, the effect of complexity of pacing on the spatial and temporal kinematic properties is still poorly understood. The current study investigated spatial and temporal aspects of movement (path and speed, respectively) and their integration while subjects followed simple isochronous or complex non-isochronous rhythmical constraints. Spatiotemporal decoupling was expected under the latter constraint. METHODS: Ten subjects performed point-to-point hand movements towards visual targets on the surface of a hemisphere, while following continuous auditory cues of different pace and meter. The spatial and temporal properties of movement were compared to geodesic paths and unimodal bell-shaped speed profiles, respectively. Multiple two-way RM-ANOVAs (pace [1-2 Hz] x meter [duple-triple]) were performed on the different kinematic variables calculated to assess hand deviations from the model data (p< or = 0.05). RESULTS: As expected, increasing pace resulted in straighter hand paths and smoother speed profiles. Meter, however, affected only the path (shorter and straighter under triple) without significantly changing speed. Such an effect was observed at the slow pace only. CONCLUSIONS: Under simple rhythmic cues, an increase in pace causes spontaneous adjustments in spatial features (straighter hand paths) while preserving temporal ones (maximally-smoothed hand speeds). Complex rhythmical cues in contrast perturb spatiotemporal coupling and challenge movement control. These results may have important practical implications in motor rehabilitation.
Keywords: *Acoustic Stimulation; Adult; Biomechanics; *Cues; Female; Hand/*physiology; Humans; Male; Movement/*physiology
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Liebermann, D. G., Berman, S., Weiss, P. L. T., & Levin, M. F. (2012). Kinematics of reaching movements in a 2-d virtual environment in adults with and without stroke. IEEE Trans Neural Syst Rehabil Eng, 20(6), 778–787.
Abstract: Virtual reality environments are increasingly being used for upper limb rehabilitation in poststroke patients. Our goal was to determine if arm reaching movements made in a 2-D video-capture virtual reality environment are similar to those made in a comparable physical environment. We compared arm and trunk kinematics for reaches made with the right, dominant arm to three targets (14 trials per target) in both environments by 16 adults with right poststroke hemiparesis and by eight healthy age-matched controls. Movement kinematics were recorded with a three-camera optoelectronic system at 100 samples/s. Reaching movements made by both control and stroke subjects were affected by viewing the targets in the video-capture 2-D virtual environment. Movements were slower, shorter, less straight, less accurate and involved smaller ranges of shoulder and elbow joint excursions for target reaches in the virtual environment compared to the physical environment in all subjects. Thus, there was a decrease in the overall movement quality for movements made in the 2-D virtual environment. This suggests that 2-D video-capture virtual reality environments should be used with caution when the goal of the rehabilitation program is to improve the quality of movement patterns of the upper limb.
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