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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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Markstrom, J. L., Liebermann, D. G., Schelin, L., & Hager, C. K. (2022). Atypical Lower Limb Mechanics During Weight Acceptance of Stair Descent at Different Time Frames After Anterior Cruciate Ligament Reconstruction. Am J Sports Med, , 1–9.
Abstract: BACKGROUND: An anterior cruciate ligament (ACL) rupture may result in poor sensorimotor knee control and, consequentially, adapted movement strategies to help maintain knee stability. Whether patients display atypical lower limb mechanics during weight acceptance of stair descent at different time frames after ACL reconstruction (ACLR) is unknown. PURPOSE: To compare the presence of atypical lower limb mechanics during the weight acceptance phase of stair descent among athletes at early, middle, and late time frames after unilateral ACLR. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 49 athletes with ACLR were classified into 3 groups according to time after ACLR-early (<6 months; n = 17), middle (6-18 months; n = 16), and late (>18 months; n = 16)-and compared with asymptomatic athletes (control; n = 18). Sagittal plane hip, knee, and ankle angles; angular velocities; moments; and powers were compared between the ACLR groups' injured and noninjured legs and the control group as well as between legs within groups using functional data analysis methods. RESULTS: All 3 ACLR groups showed greater knee flexion angles and moments than the control group for injured and noninjured legs. For the other outcomes, the early group had, compared with the control group, less hip power absorption, more knee power absorption, lower ankle plantarflexion angle, lower ankle dorsiflexion moment, and less ankle power absorption for the injured leg and more knee power absorption and higher vertical ground reaction force for the noninjured leg. In addition, the late group showed differences from the control group for the injured leg revealing more knee power absorption and lower ankle plantarflexion angle. Only the early group took a longer time than the control group to complete weight acceptance and demonstrated asymmetry for multiple outcomes. CONCLUSION: Athletes with different time frames after ACLR revealed atypically large knee angles and moments during weight acceptance of stair descent for both the injured and the noninjured legs. These findings may express a chronically adapted strategy to increase knee control. In contrast, atypical hip and ankle mechanics seem restricted to an early time frame after ACLR. CLINICAL RELEVANCE: Rehabilitation after ACLR should include early training in controlling weight acceptance. Including a control group is essential when evaluating movement patterns after ACLR because both legs may be affected.
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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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Issurin, V. B., Liebermann, D. G., & Tenenbaum, G. (1994). Effect of vibratory stimulation training on maximal force and flexibility (Vol. 12).
Abstract: In this study, we investigated a new method of training for maximal strength and flexibility, which included exertion with superimposed vibration (vibratory stimulation, VS) on target muscles. Twenty-eight male athletes were divided into three groups, and trained three times a week for 3 weeks in one of the following conditions: (A) conventional exercises for strength of the arms and VS stretching exercises for the legs; (B) VS strength exercises for the arms and conventional stretching exercises for the legs; (C) irrelevant training (control group). The vibration was applied at 44 Hz while its amplitude was 3 mm. The effect of training was evaluated by means of isotonic maximal force, heel-to-heel length in the two-leg split across, and flex-and-reach test for body flexion. The VS strength training yielded an average increase in isotonic maximal strength of 49.8%, compared with an average gain of 16% with conventional training, while no gain was observed for the control group. The VS flexibility training resulted in an average gain in the legs split of 14.5 cm compared with 4.1 cm for the conventional training and 2 cm for the control groups, respectively. The ANOVA revealed significant pre-post training effects and an interaction between pre-post training and 'treatment' effects (P < 0.001) for the isotonic maximal force and both flexibility tests. It was concluded that superimposed vibrations applied for short periods allow for increased gains in maximal strength and flexibility.
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Hoffman, J. R., Liebermann, D., & Gusis, A. (1997). Relationship of leg strength and power to ground reaction forces in both experienced and novice jump trained personnel. Aviat Space Environ Med, 68(8), 710–714.
Abstract: METHODS: There were 14 male soldiers who participated in this study examining the relationship of leg strength and power on landing performance. Subjects were separated into two groups. The first group (E, n = 7) were parachute training instructors and highly experienced in parachute jumping. The second group of subjects (N, n = 7) had no prior parachute training experience and were considered novice jumpers. All subjects were tested for one-repetition maximum (1 RM) squat strength and maximal jump power. Ground reaction forces (GRF) and the time to peak force (TPF) at landing were measured from jumps at four different heights (95 cm, 120 cm, 145 cm, and 170 cm). All jumps were performed from a customized jump platform onto a force plate. RESULTS: No differences were seen between E and N in either IRM squat strength or in MJP. In addition, no differences were seen between the groups for time to peak force at any jump height. However, significantly greater GRF were observed in E compared to N. Moderate to high correlations between maximal jump power and GRF (r values ranging from 0.62-0.93) were observed in E. Although maximal jump power and the TPF was significantly correlated (r = -0.89) at only 120 cm for E, it was interesting to note that the correlations between MJP and the time to peak force in E were all negative and that the correlations between these variables in N were all positive. CONCLUSIONS: These results suggest that experienced parachutists may use a different landing strategy than novice jumpers. This difference may be reflected by differences in GRF generated during impact and a more efficient utilization of muscle power during the impact phase of the landing.
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