Bimanual Motor Skill Learning With Robotics in Chronic Stroke

Background. Most activities of daily life (ADL) require cooperative bimanual movements. A unilateral stroke may severely impair bimanual ADL. How patients with stroke (re)learn to coordinate their upper limbs (ULs) is largely unknown.The objectives are to determine whether patients with chronic supratentorial stroke could achieve bimanual motor skill learning (bim-MSkL). To compare bim-MSkL between patients and healthy individuals (HIs).Methods. Twenty-four patients and ten HIs trained over 3 consecutive days on an asymmetrical bimanual coordination task (CIRCUIT) implemented as a serious game in the REAplan® robot. With a common cursor controlled by coordinated movements of the ULs through robotic handles, they performed as many laps as possible (speed constraint) on the CIRCUIT while keeping the cursor within the track (accuracy constraint). The primary outcome was a bimanual speed/accuracy trade-off (biSAT), we used a bimanual coordination factor (biCO) and bimanual forces (biFOP) for the secondary outcomes. Several clinical scales were used to evaluate motor and cognitive functions.Results. Overall, the patients showed improvements on biSAT and biCO. Based on biSAT progression, the HI achieved a larger bim-MSkL than the patients with mild to moderate impairment (Fugl-Meyer Assessment Upper Extremity (FMA-UE): 28-55, n=15) but not significantly different from those with minimal motor impairment (FMA-UE: 66, n=9). There was a significant positive correlation between biSAT evolution and the FMA-UE and Stroke Impact Scale.Conclusions. Both HI and patients with chronic stroke training on a robotic device achieved bim-MSkL, although the more impaired patients were less efficient. Bim-MSkL with REAplan® may be interesting for neurorehabilitation after stroke.Trial registration. ClinicalTrial.gov identifier: NCT03974750. Registered 05 June 2019.https://clinicaltrials.gov/ct2/show/NCT03974750?cond=NCT03974750&draw=2&rank=1

Bimanual Movements and Chronic Stroke Rehabilitation: Looking Back and Looking Forward

Executing voluntary motor actions in the upper extremities after a stroke is frequently challenging and frustrating. Although spontaneous motor recovery can occur, reorganizing the activation of the primary motor cortex and supplementary motor area takes a considerable amount of time involving effective rehabilitation interventions. Based on motor control theory and experience-dependent neural plasticity, stroke protocols centered on bimanual movement coordination are generating considerable evidence in overcoming dysfunctional movements. Looking backward and forward in this comprehensive review, we discuss noteworthy upper extremity improvements reported in bimanual movement coordination studies including force generation. Importantly, the effectiveness of chronic stroke rehabilitation approaches that involve voluntary interlimb coordination principles look promising.

Neuromuscular Fatigue in Unimanual Handgrip Does Not Completely Affect Simultaneous Bimanual Handgrip

Simultaneous bimanual movements are not merely the sum of two unimanual movements. Here, we considered the unimanual/bimanual motor system as comprising three components: unimanual-specific, bimanual-specific, and overlapping (mobilized during both unimanual and bimanual movements). If the force-generating system controlling the same limb differs between unimanual and bimanual movements, unimanual exercise would be expected to fatigue the unimanual-specific and overlapping parts in the force-generating system but not the bimanual-specific part. Therefore, we predicted that the decrease in bimanual force generation induced by unimanual neuromuscular fatigue would be smaller than the decrease in unimanual force generation. Sixteen healthy right-handed adults performed unimanual and bimanual maximal handgrip measurements before and after a submaximal fatiguing handgrip task. In the fatigue task, participants were instructed to maintain unimanual handgrip force at 50% of their maximal handgrip force until the time to task failure. Each participant performed this task in a left-hand fatigue (LF) condition and a right-hand fatigue (RF) condition, in a random order. Although the degree of neuromuscular fatigue was comparable in both conditions, as expected, the decrease in bimanual right handgrip force was significantly smaller than those during unimanual right performance in the RF condition, but not in the LF condition. These results indicate that for the right-hand, neuromuscular fatigue in unimanual handgrip does not completely affect simultaneous bimanual handgrip. Regarding the underlying mechanisms, we propose that although neuromuscular fatigue caused by unimanual handgrip reduces the motor output of unimanual-specific and overlapping parts in the force-generating system, when simultaneous bimanual handgrip is performed, the overlapping part (which is partially fatigued) and the bimanual-specific part (which is not yet fatigued) generate motor output, thus decreasing the force reduction.

Effects of Bilateral Transcranial Direct Current Stimulation on Simultaneous Bimanual Handgrip Strength

Although the effects of transcranial direct current stimulation (tDCS) on contralateral unimanual movement have been well reported, its effects on coordinated multi-limb movements remain unclear. Because multi-limb coordination is often performed in daily activities and sports, clarifying the effects of tDCS on multi-limb coordination may have valuable implications. However, considering the neural crosstalk involved in bimanual movements, including the transcallosal pathway and ipsilateral motor pathway, the extent of tDCS-induced improvement may differ between unimanual and bimanual movement. We examined how tDCS affects simultaneous bimanual maximal voluntary contraction (MVC) by testing the effects of tDCS of the bilateral primary motor cortex (M1) on unimanual and bimanual handgrip strength. Twenty-one right-handed healthy adults underwent three bilateral tDCS protocols (“RaLc,” with an anode on right M1 and a cathode on left M1, “RcLa,” with an anode on left M1 and a cathode on right M1, and “Sham”) in a randomized order. A 1.5 mA current was applied for 15 min during tDCS. Participants then performed maximal unimanual and bimanual handgrip tests. Bimanual handgrip force was higher in both hands in the RcLa condition than in the Sham condition. Similarly, unimanual handgrip force was higher in the RcLa condition than in the Sham condition. Stimulus responses were asymmetrical and were not observed in the RaLc condition. Our findings demonstrate that RcLa tDCS leads to neuromodulation that can produce greater unimanual and bimanual handgrip strength. This result provides basic evidence that tDCS may be useful in sports, particularly those involving bilateral coordination of upper limb movement.

Amplitude setting and dopamine response of finger tapping and gait are related in Parkinson's disease

Objective: Movement amplitude setting is affected early in Parkinson's disease (PD), clinically manifesting as bradykinesia. Our objective was to determine if amplitude setting of upper limb bimanual movements and bipedal gait are similarly modulated in PD. Methods: 27 PD and 24 control participants were enrolled. Participants performed a bimanual anti-phase finger tapping task wearing gloves with joint angular sensors, and an instrumented gait assessment. Motor load was varied by asking participants to perform movements at a normal and fast pace. PD participants were evaluated OFF (PD-OFF) and ON (PD-ON) levodopa. Results: PD-OFF participants had shorter tap interval, smaller tap amplitude, and greater tap amplitude variability than controls in the more affected hands (all p<0.05). Tap amplitude and stride length (p=0.030), and tap frequency and gait cadence (p=0.011) were correlated in PD-OFF. Tap frequency and amplitude were also correlated with motor UPDRS (p<0.005) and bradykinesia motor (p<0.05) and ADL (p<0.005) UPDRS subscales. Levodopa improved mean tap amplitude and stride length during fast tapping in PD participants. Conclusion: In PD-OFF, mean finger tapping amplitude and gait stride length were correlated and showed similar dopaminergic response. Significance: Future studies manipulating upper limb amplitude could help provide greater understanding of the networks responsible for amplitude setting in PD.

Local field potentials in the parietal reach region reveal mechanisms of bimanual coordination

Primates use their arms in complex ways that frequently require coordination between the two arms. Yet the planning of bimanual movements has not been well-studied. We recorded spikes and local field potentials (LFP) from the parietal reach region (PRR) in both hemispheres simultaneously while monkeys planned and executed unimanual and bimanual reaches. From analyses of interhemispheric LFP-LFP and spike-LFP coherence, we found that task-specific information is shared across hemispheres in a frequency-specific manner. This shared information could arise from common input or from direct communication. The population average unit activity in PRR, representing PRR output, encodes only planned contralateral arm movements while beta-band LFP power, a putative PRR input, reflects the pattern of planned bimanual movement. A parsimonious interpretation of these data is that PRR integrates information about the movement of the left and right limbs, perhaps in service of bimanual coordination.

Visuomotor information drives interference between the hands more than dynamic motor information during bimanual reaching

During complex bimanual movements, interference can occur in the form of one hand influencing the action of the contralateral hand. Interference likely results from conflicting sensorimotor information shared between brain regions controlling hand movements via neural crosstalk. However, how visual and force-related feedback processes interact with each other during bimanual reaching is not well understood. In this study, four groups experienced either a visuomotor perturbation, dynamic perturbation, combined visuomotor and dynamic perturbation, or no perturbation in their right hand during bimanual reaches, with each hand controlling its own cursor. The left hand was examined for interference as a consequence of the right-hand perturbation. The results indicated that the visuomotor and combined perturbations showed greater interference in the left hand than the dynamic perturbation, but that the combined and visuomotor perturbations were equivalent. This suggests that dynamic sensorimotor and visuomotor processes do not interact between hemisphere-hand systems, and that primarily visuomotor processes lead to interference between the hands.