Arm Ability Training Research Articles

Effect of Arm Ability Training on Functional Mobility and Dexterity in Hemiparetic Subjects

Abstract Objective Hemiparesis occurs when a stroke causes paresis on the body, contralateral to the lesioned brain. In poststroke patients, upper limb impairments induce functional restrictions. Arm ability training is a unilateral treatment for mild arm paresis. We evaluated the effectiveness of arm ability training on functional mobility and dexterity in hemiparetic subjects Materials and Methods Forty-two hemiparetic subjects were selected by convenient sampling technique. The subjects were given 40 minutes of arm ability training and 20 minutes of conventional physiotherapy daily, five sessions a week extending for 4 weeks. Functional mobility was assessed through wolf motor function test (WMFT) and dexterity by box and block test (BBT). Results The pre- and post-test scores were evaluated by paired t-test using SPSS software after 4 weeks of training period subjects showed much improvement for the BBT (mean ± standard deviation [SD]: 20.31 ± 4.075 vs. 23.79 ± 4.291), functional ability of WMFT (mean ± SD: 45.38 ± 3.615 vs. 54.07 ± 3.790), time of WMFT (mean ± SD: 479.29 ± 117.79 vs. 434.4 ± 116.455), the strength of WMFT was (mean ± SD: 2.95 ± 0.731 vs. 3.9 ± 0.759), and grip strength of WMFT (mean ± SD: 2.9 ± 1.559 vs. 4.21 ± 1.539), all variables indicating statistical significance (p < 0.05). Conclusion Arm ability training proved effective in improving functional mobility and dexterity in hemiparetic subjects.

Analysis of the therapeutic interaction provided by a humanoid robot serving stroke survivors as a therapeutic assistant for arm rehabilitation.

Objective: To characterize a socially active humanoid robot's therapeutic interaction as a therapeutic assistant when providing arm rehabilitation (i.e., arm basis training (ABT) for moderate-to-severe arm paresis or arm ability training (AAT) for mild arm paresis) to stroke survivors when using the digital therapeutic system Evidence-Based Robot-Assistant in Neurorehabilitation (E-BRAiN) and to compare it to human therapists' interaction. Methods: Participants and therapy: Seventeen stroke survivors receiving arm rehabilitation (i.e., ABT [n = 9] or AAT [n = 8]) using E-BRAiN over a course of nine sessions and twenty-one other stroke survivors receiving arm rehabilitation sessions (i.e., ABT [n = 6] or AAT [n = 15]) in a conventional 1:1 therapist-patient setting. Analysis of therapeutic interaction: Therapy sessions were videotaped, and all therapeutic interactions (information provision, feedback, and bond-related interaction) were documented offline both in terms of their frequency of occurrence and time used for the respective type of interaction using the instrument THER-I-ACT. Statistical analyses: The therapeutic interaction of the humanoid robot, supervising staff/therapists, and helpers on day 1 is reported as mean across subjects for each type of therapy (i.e., ABT and AAT) as descriptive statistics. Effects of time (day 1 vs. day 9) on the humanoid robot interaction were analyzed by repeated-measures analysis of variance (rmANOVA) together with the between-subject factor type of therapy (ABT vs. AAT). The between-subject effect of the agent (humanoid robot vs. human therapist; day 1) was analyzed together with the factor therapy (ABT vs. AAT) by ANOVA. Main results and interpretation: The overall pattern of the therapeutic interaction by the humanoid robot was comprehensive and varied considerably with the type of therapy (as clinically indicated and intended), largely comparable to human therapists' interaction, and adapted according to needs for interaction over time. Even substantially long robot-assisted therapy sessions seemed acceptable to stroke survivors and promoted engaged patients' training behavior. Conclusion: Humanoid robot interaction as implemented in the digital system E-BRAiN matches the human therapeutic interaction and its modification across therapies well and promotes engaged training behavior by patients. These characteristics support its clinical use as a therapeutic assistant and, hence, its application to support specific and intensive restorative training for stroke survivors.

Feasibility, coverage, and inter-rater reliability of the assessment of therapeutic interaction by a humanoid robot providing arm rehabilitation to stroke survivors using the instrument THER-I-ACT.

Objective: The instrument THERapy-related InterACTion (THER-I-ACT) was developed to document therapeutic interactions comprehensively in the human therapist-patient setting. Here, we investigate whether the instrument can also reliably be used to characterise therapeutic interactions when a digital system with a humanoid robot as a therapeutic assistant is used. Methods: Participants and therapy: Seventeen stroke survivors receiving arm rehabilitation (i.e., arm basis training (ABT) for moderate-to-severe arm paresis [n = 9] or arm ability training (AAT) for mild arm paresis [n = 8]) using the digital therapy system E-BRAiN over a course of nine sessions. Analysis of the therapeutic interaction: A total of 34 therapy sessions were videotaped. All therapeutic interactions provided by the humanoid robot during the first and the last (9th) session of daily training were documented both in terms of their frequency and time used for that type of interaction using THER-I-ACT. Any additional therapeutic interaction spontaneously given by the supervising staff or a human helper providing physical assistance (ABT only) was also documented. All ratings were performed by two trained independent raters. Statistical analyses: Intraclass correlation coefficients (ICCs) were calculated for the frequency of occurrence and time used for each category of interaction observed. Results: Therapeutic interactions could comprehensively be documented and were observed across the dimensions provision of information, feedback, and bond-related interactions. ICCs for therapeutic interaction category assessments from 34 therapy sessions by two independent raters were high (ICC ≥0.90) for almost all categories of the therapeutic interaction observed, both for the occurrence frequency and time used for categories of therapeutic interactions, and both for the therapeutic interaction performed by the robot and, even though much less frequently observed, additional spontaneous therapeutic interactions by the supervisory staff and a helper being present. The ICC was similarly high for an overall subjective rating of the concentration and engagement of patients (0.87). Conclusion: Therapeutic interactions can comprehensively and reliably be documented by trained raters using the instrument THER-I-ACT not only in the traditional patient-therapist setting, as previously shown, but also in a digital therapy setting with a humanoid robot as the therapeutic agent and for more complex therapeutic settings with more than one therapeutic agent being present.

THERapy-Related InterACTion (THER-I-ACT) in Rehabilitation-Instrument Development and Inter-Rater Reliability.

Objective: To develop an instrument for the observation of therapeutic communication interactions during rehabilitation sessions and test its inter-rater reliability.Methods: The new instrument THER-I-ACT (THERapy–related Inter-ACTion) has been designed to assess both the frequency and timing of therapeutic interactions in the thematic fields information provision, feedback, other motivational interaction, and bonding. For this inter-rater reliability study, a sample of stroke survivors received arm rehabilitation as either arm ability training, arm basis training, or mirror therapy, or neglect training as individually indicated. Therapy sessions were video-recorded (one for each participant) and therapeutic interactions rated by two independent raters using THER-I-ACT.Results: With regard to the instrument's comprehensiveness to document therapeutic interactions with pre-defined categories the data from 29 sessions suggested almost complete coverage. Inter-rater reliability was very high both for individual categories of therapeutic interaction (frequency and time used for interaction) (intraclass correlation coefficient, ICC 0.91–1.00) and summary scores for the thematic fields of interaction (again for frequency and time used for interaction) (ICC 0.98–1.00).The inter-rater reliability for rating engagement and being focussed for both the therapist and patient was substantial (ICC 0.71 and 0.86).Conclusions: The observational study documented that by use of the newly designed THER-I-ACT various types of therapy-related communication interactions performed by therapists can be assessed with a very high inter-rater reliability. In addition, the thematic fields and categories of therapeutic interaction as defined by the instrument comprehensively covered the type of interaction that occurred in the therapeutic sessions observed.

EFFECTIVENESS OF COMBINED USE OF ARM ABILITY TRAINING WITH ARM WEIGHT SUPPORT TO IMPROVE UPPER EXTREMITY FUNCTIONAL SKILLS AND ADL SKILLS IN PARKINSONISM PATIENTS

OBJECTIVE: This study is to determine the effectiveness of combined use of arm ability training with arm weight support to improve upper extremity functional skills and ADL skills in Parkinsonism patients. METHOD: Thirty subjects with parkinsonism ( 5 months to 10 years of Parkinson’s disease) were selected, who fulfilled the inclusion and exclusion criteria and according to the screening measures using UPDRS, Hoehn and Yahr scale and MMSE. Baseline assessment (Pre-test) was done using FMA, UEFI, and Katz index. After baseline assessment arm ability training (AAT) combined with arm weight support (45 minutes) was given to the patients for 12 weeks, 45 minutes in a day for 3 days in a week and post-intervention assessment (Post-test) was taken after 12 weeks by using the same outcome measures. RESULT: Post- training there was a significant improvement in all the outcome measures. The result of the study showed evidence of benefit of the practice of Arm ability training with Arm weight support in Parkinsonism; enhance improvement as a result of Arm ability training along with Arm weight support were found in FMA-UE is x= 97.00 (volitional movement), UEFI is x= 46.20 ( Hand functionality), Katz Index is x= 5.20 (Autonomy of ADL). The post-test has showed a greater improvement than from the pre-test in all the outcome measure (FMA-UE-P=0.001, UEFI-P=0.001 and Katz Index- P=0.001). The Pre and Post score comparison of outcome variables shown improvement in upper extremity functional skills and in Activities of Daily living skills following the intervention programme. CONCLUSION: The Arm ability training techniques with Arm weight support was found to be effective in improving upper extremity functional skills as well as ADL skills among the Parkinsonism patients. The Arm ability training combined with Arm weight support can be used with other occupational therapy intervention to provide additional benefits to the Parkinsonism patients. KEYWORDS: upper extremity functional skills, Activities of Daily Living, Arm ability training, Arm weight support, Parkinson’s disease.

Arm Ability Training (AAT) Promotes Dexterity Recovery After a Stroke-a Review of Its Design, Clinical Effectiveness, and the Neurobiology of the Actions.

Arm Ability Training (AAT) has been specifically designed to promote manual dexterity recovery for stroke patients who have mild to moderate arm paresis. The motor control problems that these patients suffer from relate to a lack of efficiency in terms of the sensorimotor integration needed for dexterity. Various sensorimotor arm and hand abilities such as speed of selective movements, the capacity to make precise goal-directed arm movements, coordinated visually guided movements, steadiness, and finger dexterity all contribute to our “dexterity” in daily life. All these abilities are deficient in stroke patients who have mild to moderate paresis causing focal disability. The AAT explicitly and repetitively trains all these sensorimotor abilities at the individual's performance limit with eight different tasks; it further implements various task difficulty levels and integrates augmented feedback in the form of intermittent knowledge of results. The evidence from two randomized controlled trials indicates the clinical effectiveness of the AAT with regard to the promotion of “dexterity” recovery and the reduction of focal disability in stroke patients with mild to moderate arm paresis. In addition, the effects have been shown to be superior to time-equivalent “best conventional therapy.” Further, studies in healthy subjects showed that the AAT induced substantial sensorimotor learning. The observed learning dynamics indicate that different underlying sensorimotor arm and hand abilities are trained. Capacities strengthened by the training can, in part, be used by both arms. Non-invasive brain stimulation experiments and functional magnetic resonance imaging data documented that at an early stage in the training cortical sensorimotor network areas are involved in learning induced by the AAT, yet differentially for the tasks trained. With prolonged training over 2 to 3 weeks, subcortical structures seem to take over. While behavioral similarities in training responses have been observed in healthy volunteers and patients, training-induced functional re-organization in survivors of a subcortical stroke uniquely involved the ipsilesional premotor cortex as an adaptive recruitment of this secondary motor area. Thus, training-induced plasticity in healthy and brain-damaged subjects are not necessarily the same.

Predicting Training Gain for a 3 Week Period of Arm Ability Training in the Subacute Stage After Stroke.

Background: Biomarkers for gains of evidence based interventions for upper limb motor training in the subacute stage following stroke have rarely been described. Information about these parameters might help to identify patients who benefit from specific interventions and to determine individually expected behavioral gains for a certain period of therapy.Objective: To evaluate predictors for hand motor outcome after arm ability training in the subacute stage after stroke selected from known potentially relevant parameters (initial motor strength, structural integrity of the pyramidal tract and functional motor cortex integrity).Methods: We applied the arm ability training (AAT) over 3 weeks to a subpopulation of stroke patients with mild arm paresis, i.e., in 14 patients on average 4 weeks after stroke. The following biomarkers were measured before therapy onset: grip strength on the affected hand, transcranial magnetic stimulation recruitment curve steepness over the primary motor hand area [slope ratio between the ipsilesional hemisphere (IH) and contralesional hemisphere (CH)], and diffusion weighted MRI fractional anisotropy (FA) in the posterior limb of the internal capsule (PLIC; determined as a lateralization index between IH and CH). Outcome was assessed as the AATgain (percentage improvement over training). The “Test d'Evaluation des Membres Supérieurs de Personnes Âgées” (TEMPA) was assessed before and after training to test for possible associations of AAT with activity of daily living.Results: A stepwise linear regression identified the lateralization index of PLIC FA as the only significant predictor for AAT-gain (R2 = 0.519; P = 0.029). AAT-gain was positively associated (r = 0.59; P = 0.028) with improvement in arm function during daily activities (TEMPA).Conclusions: While all mildly affected patients achieved a clinically relevant therapeutic effect, pyramidal tract integrity nevertheless had a modifying role for clinical benefit.

Enhancement of motor learning by focal intermittent theta burst stimulation (iTBS) of either the primary motor (M1) or somatosensory area (S1) in healthy human subjects.

Motor rehabilitation after brain damage relies on motor re-learning as induced by specific training. Non-invasive brain stimulation (NIBS) can alter cortical excitability and thereby has a potential to enhance subsequent training-induced learning. Knowledge about any priming effects of NIBS on motor learning in healthy subjects can help to design targeted therapeutic applications in brain-damaged subjects. To examine whether complex motor learning in healthy subjects can be enhanced by intermittent theta burst stimulation (iTBS) to primary motor or sensory cortical areas. Eighteen young healthy subjects trained eight different arm motor tasks (arm ability training, AAT) once a day for 5 days using their left non-dominant arm. Except for day 1 (baseline), training was performed after applying an excitatory form of repetitive transcranial magnetic stimulation (iTBS) to either (I) right M1 or (II) S1, or (III) sham stimulation to the right M1. Subjects were randomly assigned to conditions I, II, or III. A principal component analysis of the motor behaviour data suggested eight independent motor abilities corresponding to the 8 trained tasks. AAT induced substantial motor learning across abilities with generalisation to a non-trained test of finger dexterity (Nine-Hole-Peg-Test, NHPT). Participants receiving iTBS (to either M1 or S1) showed better performance with the AAT tasks over the period of training compared to sham stimulation as well as a bigger improvement with the generalisation task (NHPT) for the trained left hand after training completion. Priming with an excitatory repetitive transcranial magnetic stimulation as iTBS of either M1 or S1 can enhance motor learning across different sensorimotor abilities.

Changes in motor cortex excitability for the trained and non-trained hand after long-term unilateral motor training

Repetitive unilateral upper limb motor training does not only affect behavior but also increases excitability of the contralateral primary motor cortex (M1). The behavioral gain is partially transferred to the non-trained side. Changes in M1 intracortical facilitation (ICF) might as well be observed for both hand sides. We measured ICF of both left and right abductor pollicis brevis muscles (APB) before and after a two-week period of arm ability training (AAT) of the left hand in 13 strongly right handed healthy volunteers. Performance with AAT-tasks improved for both the left trained and right untrained hand. ICF for the untrained hand decreased over training while it remained unchanged for the left trained hand. Decrease of ICF for the right hand was moderately associated with an increase of AAT-performance for the untrained right hand. We conclude that ICF-imbalance between dominant and non-dominant hand is sensitive to long-term motor training: training of the non-dominant hand results in a decrease of ICF of the dominant hand. The ICF-decrease is associated with a transfer of training-induced improvement of performance from the non-dominant to the dominant hand.

P251 Effect of long term comprehensive training of the left hand in strongly right handed participants: Reduction of interhemispheric asymmetry in intracortical facilitation (ICF)

Introduction The effect of intracortical facilititation (ICF) is independent from hemispheric dominance and handedness (Baumer et al., 2007). Short term training selectively increases excitability over the contralateral primary motor cortex (M1c) of the trained hand (e.g. Lotze et al., 2003). M1-excitability measurements after long-term training (several weeks) are rare but – to our knowledge – are even absent for ICF-parameters. Objectives To evaluate effects of ICF during a two week comprehensive period of training of the left hand in strongly right handed healthy participants. Materials and ethods Thirteen strongly right-handed healthy participants (23 ± 3.5 years; 6 women) underwent a two-week arm ability training (AAT) for their left, nondominant hand for one hour per day (Platz, 2004). Performance increase was expressed as percentual changes over time and averaged over all eight AAT-tasks. Focal TMS was delivered to the optimal scalp position for activation of the musculus abductor policis brevis (APB) of each hand using a figure-of-eight coil. Resting motor threshold (rMT) and intracortical facilitation (ICF; test stimulus intensity 120% rMT; conditioning stimulus 80% rMT; interstimulus interval 10 ms) were used as measures of corticomotor excitability. Results Training resulted in considerable improvement of the trained left (30 ± 3.5%) hand, but – to a lesser extent – also the non-trained right hand (18 ± 5.4%) performance. RMT was not altered over time. For ICF we found a strong time effect in ANOVA; but post hoc t-tests showed only a relevant decrease over time for the untrained side (T(12) = 3.33; p = 0.006; Fig. 1). Conclusion Our study showed no significant changes in ICF for the trained hand side, but a decrease for the non trained hand’s motor cortex. It has been demonstrated that the interaction between an increase of unilateral movement and 10 h unilateral immobilization of the other hand is critical for excitability effects over M1c (Avanzino et al., 2011). We argue that interhemispheric changes induced by unilateral limb training of the non-dominant hand might be multifactorial; here we observed an increased interhemispheric balance in ICF after training the less experienced, and presumably in spontaneous behavior less intensively used hand. Download : Download high-res image (410KB) Download : Download full-size image

Priming Hand Motor Training with Repetitive Stimulation of the Fingertips; Performance Gain and Functional Imaging of Training Effects.

Application of repetitive electrical stimulation (rES) of the fingers has been shown to improve tactile perception and sensorimotor performance in healthy individuals. To increase motor performance by priming the effects of active motor training (arm ability training; AAT) using rES. We compared the performance gain for the training increase of the averaged AAT tasks of both hands in two groups of strongly right-handed healthy volunteers. Functional Magnetic Resonance Imaging (fMRI) before and after AAT was assessed using three tasks for each hand separately: finger sequence tapping, visually guided grip force modulation, and writing. Performance during fMRI was controlled for preciseness and frequency. A total of 30 participants underwent a two-week unilateral left hand AAT, 15 participants with 20 minutes of rES priming of all fingertips of the trained hand, and 15 participants without rES priming. rES-primed AAT improved the trained left-hand performance across all training tasks on average by 32.9%, non-primed AAT improved by 29.5%. This gain in AAT performance with rES priming was predominantly driven by an increased finger tapping velocity. Functional imaging showed comparable changes for both training groups over time. Across all participants, improved AAT performance was associated with a higher contralateral primary somatosensory cortex (S1) fMRI activation magnitude during the grip force modulation task. This study highlights the importance of S1 for hand motor training gain. In addition, it suggests the usage of rES of the fingertips for priming active hand motor training.

Arm rehabilitation : Current concepts and therapeutic options

Arm paralysis after a stroke is a major cause of impairment. Presentation of therapeutic options and the efficacy in arm rehabilitation after stroke. Based on a systematic critical appraisal of randomized controlled trials (RCT) the therapeutic procedures for arm paralysis after stroke in the context of their effectiveness are introduced, including robotic therapy, mirror therapy, constraint-induced movement therapy (CIMT), arm basis training, arm ability training, neuromuscular electrical stimulation, bilateral and task-specific training, mental training and transcranial stimulation techniques, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). Several therapeutic procedures with proven efficacy are currently available for arm rehabilitation after stroke. Their differential indications are presented and associated with conclusions for clinical practice.

EP 4. Recruitment of premotor cortices in subacute stroke patients – A longitudinal fMRI study

Objective In order to investigate changes in functional representation of hand movement after stroke we used functional magnetic resonance imaging (fMRI) during an active motor task of the affected hand before and after a three week comprehensive motor training. Methods 12 patients in the subacute phase after mild to moderate motor stroke (4.8 ± 2.1 weeks after stroke; age 58.5 ± 12.5 years, NIHSS: 2.4 ± 1.6) underwent a three week (1 hour daily) arm ability training (AAT; Platz et al., 2009 ). Before and after training active hand grip of both hand sides was measured with fMRI while controlling for frequency and force. Accuracy was calculated as deviation from mean amplitude and frequency. In order to compare brain activation with that of healthy controls (HC) representation maps of age-matched subjects were made. To evaluate the correlates of recovery processes we subtracted representation maps of pre- and post-measurement. Correlations of amplitude accuracy with fMRI activation maps were restricted to areas known to be involved in recovery ( Rehme et al., 2012 ). Results Before training performance of patients in the scanner was not as accurate as of controls. These differences decreased after training. Patients not only improved in trained tasks (t(13) = 20.315, p Conclusion Our data underline the importance of the premotor areas for recovered motor performance after stroke. However, the theoretically helpful support of premotor cortices may reach its maximum and performance levels do not attain those of healthy controls although more motor regions are recruited. It has to be evaluated if these recruitments are ineffective – comparable to the fMRI-activations of elder individuals compared to younger subjects ( Loibl et al., 2011 ).

EP 2. Pyramidal tract FA predicts motor outcome in subacute stroke patients after a three week period of arm ability training for ADL-relevant hand motor tests

Objective Outcome prediction after motor stroke for the acute to subacute phase can be consulted for individual therapy modification. For the outcome of severely impaired patients the intactness of the pyramidal tract descending from the lesioned hemisphere (ipsilesional; i ) has been described as an important parameter for upper limb strength as a measure of motor outcome ( Stinear et al., 2012 ). In addition, in chronic stroke fractional anisotrophy (FA) of the pyramidal tract is predictive for hand motor impairment in strength ( Lindenberg et al., 2010 ). In this study we tested whether this does also holds true for the subacute phase and for activity of daily living (ADL) relevant testing of arm activities, i.e. finger and hand dexterity. Methods Thirteen patients after first time stroke (4.7 ± 1.9 weeks after stroke; 9 with left hemispheric lesion; age 60 ± 12.6 years, NIHSS: 2.69±1.8; Edinburg handedness 81.35 ± 34.7) were recruited at the BDH-hospital of Greifswald. They had small lesions (predominantly subcortical; volume: 7.17±15.8 ccl) and mini mental status revealed no severe cognitive impairments (average score 27). Patients underwent a three week course of arm ability training (1 hour per day, 5 days a week) ( Platz et al., 2009 ) in addition to the standard inpatient rehabilitation therapy. MRI and motor performance (Box and Block test; Nine Hole Peg test) were measured before and after training. MRI comprised of high resolution T1-weighted imaging (MPrage-sequence) and a diffusion weighted imaging (64 directions; MDDW-sequence) using a 32 channel head coil with a 3 Tesla MRI scanner (Siemens, Erlangen). The average FA was evaluated for the pyramidal tract between the affected hand area of the primary motor cortex (M1 i ) to the internal capsule and M1i crossing to the contralesional ( c ) pons. FSL was used for calculating average FA over tract. Results Motor tests for the affected hand significantly improved during training (NHP: t = 3.87; p t = 4.58; p i to internal capsule: t = 4.83; p i to pons c : t = 4.83; p i to internal capsule: r = −0.57; p = 0.04; M1 i to pons c : r = −0.87 p = 0.02) and BB (M1 i to internal capsule: r = 0.68; p = 0.01; M1 i to pons c : r = 0.84 p = 0.04). Conclusion Intactness of pyramidal tract is capable for predicting activity of daily living relevant hand motor outcome after comprehensive and specific arm motor training in subacute stroke patients.

Increased ventral premotor cortex recruitment after arm training in an fMRI study with subacute stroke patients

To investigate therapy associated changes in the cerebral representation of movement after stroke, we used functional magnetic resonance imaging (fMRI) during an active and a passive motor task for the affected and unaffected hand before and after a three week comprehensive hand motor training.Twelve patients in the subacute phase from 2 to 9 weeks after mild to moderate motor stroke were recruited. During fMRI, the active task comprised fist clenching, which was precisely controlled for motor performance by visual feedback of force and frequency. The passive task consisted of wrist flexion-extension of 1Hz frequency by means of a pneumatic driven splint. Arm Ability Training (AAT) was conducted one hour per day over 3 weeks in addition to inward rehabilitative therapy. Performance gain was tested using movements trained with AAT, but also with conventional hand motor tests (Nine-Hole-Peg Test, Box-and-Block Test).Rehabilitation therapy and AAT resulted in considerable improvement of performance in trained tasks and other hand motor functions (e.g., Nine-Hole-Peg Test). FMRI activation in the ventral premotor cortex (vPMC) of the lesioned hemisphere increased over time for the active task only for the affected hand. No such change was present for the passive wrist extension task or the active task with the unaffected hand. In addition, only for the post measurement of the active task performed with the affected hand, bilateral vPMC shows a more pronounced activation than in healthy controls. This finding contradicts the simple “near to normal is good recovery” opinion.

Arm basis training and arm ability training: two impairment-oriented exercise training techniques for improving arm function after stroke

Arm basis training and arm ability training: two impairment-oriented exercise training techniques for improving arm function after stroke

Changes in cortical, cerebellar and basal ganglia representation after comprehensive long term unilateral hand motor training

We were interested in motor performance gain after unilateral hand motor training and associated changes of cerebral and cerebellar movement representation tested with functional magnetic resonance imaging (fMRI) before and after training. Therefore, we trained the left hand of strongly right-handed healthy participants with a comprehensive training (arm ability training, AAT) over two weeks. Motor performance was tested for the trained and non-trained hand before and after the training period. Functional imaging was performed for the trained and the non-trained hand separately and comprised force modulation with the fist, sequential finger movements and a fast writing task. After the training period the performance gain of tapping movements was comparable for both hand sides, whereas the motor performance for writing showed a higher training effect for the trained hand. fMRI showed a reduction of activation in supplementary motor, dorsolateral prefrontal cortex, parietal cortical areas and lateral cerebellar areas during sequential finger movements over time. During left hand writing lateral cerebellar hemisphere also showed reduced activation, while activation of the anterior cerebellar hemisphere was increased. An initially high anterior cerebellar activation magnitude was a predictive value for high training outcome of finger tapping and visual guided movements. During the force modulation task we found increased activation in the striate.Overall, a comprehensive long-term training of the less skillful hand in healthy participants resulted in relevant motor performance improvements, as well as an intermanual learning transfer differently pronounced for the type of movement tested. Whereas cortical motor area activation decreased over time, cerebellar anterior hemisphere and striatum activity seem to represent increasing resources after long-term motor training.

Prolonged motor skill learning – a combined behavioural training and theta burst TMS study

To assess the behavioural effects of prolonged motor practice in healthy volunteers, and the specific impact of inhibiting different motor-related brain regions in the late phase of motor learning using continuous theta burst transcranial magnetic stimulation (cTBS). Twelve subjects trained their non-dominant arm in eight arm motor tasks (Arm Ability Training, AAT) once a day for three weeks (16 sessions). During the last four days, training was performed before and after applying cTBS to either M1, S1, SMA, or PMC. The AAT induced substantial and robust motor learning for the trained arm with variations across tasks. Considerable motor learning was also observed in the non-trained dominant arm with remarkably similar variations across tasks, suggesting that practise improved common underlying sensorimotor capacities (abilities) in addition to effector-specific effects. When applied after prolonged training, inhibitory cTBS showed no detrimental effects on motor performance/learning; M1 cTBS even improved performance in a labyrinth task. Prolonged training with the non-dominant arm led to profound motor learning across abilities with transfer to the non-trained dominant arm. Unlike during early stages of motor learning, no detrimental effect of cTBS over M1, S1, PMC, or SMA could be substantiated after prolonged motor practice.

Early stages of motor skill learning and the specific relevance of the cortical motor system – a combined behavioural training and theta burst TMS study

To examine whether motor performance and motor learning in healthy subjects can be segregated into a number of distinct motor abilities which are linked to intact processing in different motor-related brain regions (M1, S1, SMA, PMC) early during learning. Seven young healthy subjects trained in eight motor arm tasks (Arm Ability Training, AAT) once a day for 5 days using their left non-dominant arm. Except for day 1 (baseline), training was performed before and after applying an inhibitory form of repetitive transcranial magnetic stimulation (cTBS, continuous theta burst) to either M1, S1, SMA, or PMC. A principal component analysis of the motor behaviour data suggested four independent motor abilities: aiming, speed, steadiness, and visuomotor tracking. AAT induced substantial motor learning across abilities. Within session effects of cTBS revealed that activity in primary somatosensory cortex (S1) was relevant for motor performance and learning across all tasks whereas M1 was specifically involved in rapid tapping movements, PMC in ballistic arm navigation in extra-personal space; performance on a non-trained motor tasks was not affected by cTBS. Cortical sensory and motor areas including S1, M1, and PMC functionally contribute to early motor learning in a differential manner across motor abilities.

Best Conventional Therapy Versus Modular Impairment-Oriented Training for Arm Paresis After Stroke: A Single-Blind, Multicenter Randomized Controlled Trial

Background. The study investigated whether passive splinting or active motor training as either individualized best conventional therapy or as standardized impairment-oriented training (IOT) would be superior in promoting motor recovery in subacute stroke patients with mildly or severely paretic arms. Methods. A total of 148 anterior circulation ischemic stroke patients were randomly assigned to 45 minutes of additional daily arm therapy over 3 to 4 weeks as either ( a) passive therapy with inflatable splints or active arm motor therapy as either (b) individualized best conventional therapy (CONV) or ( c) standardized IOT, that is Arm BASIS training for severe paresis or Arm Ability training for mild paresis. Main outcome measures included the following: Fugl-Meyer arm motor score (severely paretic arms) and the TEMPA time scores (mildly affected arms). Pre—post (immediate effects) and pre—4 weeks follow-up analyses (long-term effects) were performed. Results. Overall improvements were documented (mean baseline and change scores efficacy: Fugl-Meyer, arm motor scores, 24.4, +9.1 points; TEMPA, 119, −26.6 seconds; P < .0001), but with no differential effects between splint therapy and the combined active motor rehabilitation groups. Both efficacy and effectiveness analyses indicated, however, bigger immediate motor improvements after IOT as compared with best conventional therapy (Fugl-Meyer, arm motor scores: IOT +12.3, CONV +9.2 points; TEMPA: IOT −31.1 seconds, CONV −20.5 seconds; P = .0363); for mildly affected patients long-term effects could also be substantiated. Conclusions. Specificity of active training seemed more important for motor recovery than intensity (therapy time). The comprehensive modular IOT approach promoted motor recovery in patients with either severe or mild arm paresis.