Task-specific Movements Research Articles

Augmented Effect of Combined Robotic Assisted Gait Training and Proprioceptive Neuromuscular Facilitation-irradiation Technique on Muscle Activation and Ankle Kinematics in Hemiparetic Gait: A Preliminary Study

Background Proprioceptive neuromuscular facilitation (PNF) alone has limited effectiveness in restoring gait, while robotic-assisted gait training (RAGT) improves motor relearning through repetitive, task-specific movements. Combining PNF with robotic gait training (PRGT) may enhance locomotor recovery by promoting proprioceptive awareness and muscle activation alongside repetitive gait retraining in stroke patients. Objective This study compares the immediate effects of PRGT and RAGT on ankle dorsiflexion and muscle activity in chronic hemiparetic stroke patients and healthy controls. Methods Thirty participants, including 15 stroke patients and 15 healthy controls, were randomly assigned to PRGT or RAGT for a single 30-min session. Muscle activity (pectoralis major, external oblique, internal oblique/transverse abdominis, rectus femoris, tibialis anterior) was measured using electromyography, while ankle dorsiflexion angle was assessed using a dual-axis inclinometer. Results PRGT significantly increased muscle activations compared to RAGT in stroke patients ( p < 0.05). Additionally, there was a significant difference in ankle dorsiflexion between RAGT and PRGT in both groups ( p < 0.05). Conclusion PRGT demonstrated superior immediate effects on muscle activation and ankle movement, suggesting that combining PNF with robotic-assisted gait training is beneficial for chronic stroke rehabilitation.

Current Trends in Effectiveness of Robotic Assisted Gait Training (RAGT) for Gait Recovery in Neuro Rehabilitation - An Evidence-Based Scoping Review

Robotic-assisted gait training plays a pivotal role in the rehabilitation of individuals recovering from post-stroke and post-spinal cord injuries. By employing sophisticated robotics, this therapy facilitates repetitive, task-specific movements essential for relearning walking patterns. The precision and customisation of robotic systems ensure tailored interventions targeting specific impairments. Moreover, these technologies provide real-time feedback, enhancing patient engagement and motivation. In this review, 11 articles were finalized for review, five were for post-stroke rehabilitation and 6 for spinal cord injuries. Results show that there is improvement in Spatiotemporal parameters of gait, functional outcomes and quality of life. In Conclusion, robotic-assisted gait training ultimately accelerates recovery, improves functional outcomes, and restores independence, profoundly impacting rehabilitation effectiveness. KEYWORDS: Assistive technology, Robotics, Gait parameters, Neurorehabilitation, Functional outcome.

Pan-cortical 2-photon mesoscopic imaging and neurobehavioral alignment in awake, behaving mice.

The flow of neural activity across the neocortex during active sensory discrimination is constrained by task-specific cognitive demands, movements, and internal states. During behavior, the brain appears to sample from a broad repertoire of activation motifs. Understanding how these patterns of local and global activity are selected in relation to both spontaneous and task-dependent behavior requires in-depth study of densely sampled activity at single neuron resolution across large regions of cortex. In a significant advance toward this goal, we developed procedures to record mesoscale 2-photon Ca2+ imaging data from two novel in vivo preparations that, between them, allow for simultaneous access to nearly all 0f the mouse dorsal and lateral neocortex. As a proof of principle, we aligned neural activity with both behavioral primitives and high-level motifs to reveal the existence of large populations of neurons that coordinated their activity across cortical areas with spontaneous changes in movement and/or arousal. The methods we detail here facilitate the identification and exploration of widespread, spatially heterogeneous neural ensembles whose activity is related to diverse aspects of behavior.

Pan-cortical 2-photon mesoscopic imaging and neurobehavioral alignment in awake, behaving mice

The flow of neural activity across the neocortex during active sensory discrimination is constrained by task-specific cognitive demands, movements, and internal states. During behavior, the brain appears to sample from a broad repertoire of activation motifs. Understanding how these patterns of local and global activity are selected in relation to both spontaneous and task-dependent behavior requires in-depth study of densely sampled activity at single neuron resolution across large regions of cortex. In a significant advance toward this goal, we developed procedures to record mesoscale 2-photon Ca2+ imaging data from two novel in vivo preparations that, between them, allow for simultaneous access to nearly all 0f the mouse dorsal and lateral neocortex. As a proof of principle, we aligned neural activity with both behavioral primitives and high-level motifs to reveal the existence of large populations of neurons that coordinated their activity across cortical areas with spontaneous changes in movement and/or arousal. The methods we detail here facilitate the identification and exploration of widespread, spatially heterogeneous neural ensembles whose activity is related to diverse aspects of behavior.

The Reaching Phase of Feeding and Self-Care Actions Optimizes Action Observation Effects in Chronic Stroke Subjects

Background The Action Observation Therapy (AOT) is a well-established post-stroke rehabilitation treatment based on the theoretical framework of the Mirror Neuron System (MNS) activation. However, AOT protocols are still heterogeneous in terms of video contents of observed actions. Objective The aim of this study was to analyze electroencephalographic (EEG) recordings in stroke patients during the observation of different videos of task-specific upper limb movements, and to define which category of actions can elicit a stronger cortical activation in the observer’s brain. Methods Signals were analyzed from 19 chronic stroke subjects observing customized videos that represented 3 different categories of upper limb actions: Finalized Actions, Non-Finalized Actions, and Control Videos. The Event-Related Desynchronization in the µ and β bands was chosen to identify the involvement of the cerebral cortex: the area of the normalized power spectral density was calculated for each category and, deepening, for the reaching and completion sub-phases of Finalized Actions. For descriptive purposes, the time course of averaged signal power was described. The Kruskal–Wallis test (P < .05) was applied. Results The analysis showed a greater desynchronization when subjects observed Finalized Actions with respect to Non-Finalized in all recorded areas; Control videos provoked a synchronization in the same areas and frequency bands. The reaching phase of feeding and self-care actions evoked a greater suppression both in µ and β bands. Conclusions The observation of finalized arm movements seems to elicit the strongest activation of the MNS in chronic stroke patients. This finding may help the clinicians to design future AOT-based stroke rehabilitation protocols. Clinical Trial Registration: Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT04047134.

Comparison of Integrated Task Oriented Bodyweight Supported Overground Training with Body-Weight Supported Treadmill Training to Improve Functional Mobility in Children with Spastic Diplegic Cerebral Palsy - A Single Blinded Randomized Control Trial

Functional gait training in cerebral palsy can involve over ground gait training or treadmill-based gait training which incorporates partial body weight support (PBWS) system. Insufficient clinical evidence prevails to recommend the superiority over the other intervention. ICF model has created a paradigm shift in understanding motor learning mechanisms, with the use of repetitive, task-specific movements beneficial to restructuring motor pathways. The primary aim of the study was to compare the effect of integrated task oriented Body Weight Supported overground Training (BWSOGT) against the Body Weight Supported Treadmill Training (BWSTT) and the conventional gait training protocols to improve the functional mobility in Cerebral Palsy. Methods: A Single-blinded, randomised control design. Sixty-children with GMFCS Level of III, IV were recruited in the study with an age ranges between 4 to 14 years (mean age = 9). Participants were randomly assigned into three groups using simple randomisation method with 20 subjects in each group for 8 weeks. The training programme consists of Group A with 40% of body weight supported walker with overhead pulley system which allows multiple degrees of freedom. Body weight- supported treadmill training (Group B) in a closed environment and conventional gait protocol using standard walkers (Group C). Outcome measures: Gross Motor Function Measure dimension-88 (GMFM-88) score. Gait kinematics (Stride length, Step length, Cadence) and 10 meter walk test. Tukey’s Post Hoc for group and time interactions, Krushkal Wallis test for overall significance and Mann Whitney’s U test to compare the significance between the groups. BWSOGT group showed significance over the BWSTT and Control group in GMFM score with p = 0.000 p = 0.002, respectively. Step length of gait parameter remained unchanged in all the three groups. Integrated task oriented BWSOGT might be an effective intervention to improve functional ambulation in children with spastic cerebral palsy due to the usage of a context specific environment and the training protocol.

Benefits of task-specific movement program on en bloc turning in Parkinson's disease: A randomized controlled trial.

En bloc turning highlights a lack of rotational intersegmental coordination, which commonly impacts turning ability in people with Parkinson's disease (PD). Whilst this turning deficit responds fairly well to medical treatment, it may be further mitigated by performing specific exercise training. Thus, the present study aimed to examine the effects of a 4-week exercise program, which focused on task-specific movements (TSM program) on turning ability and clinical outcomes in people with PD. Twenty-two adults (67±6years) with early-to-mid-stage idiopathic PD were randomly assigned to an experimental group (EG; n=11) or a control group (CG; n=11). The exercise group (EG) group received a 60-min per session TSM program for 4weeks (a total of 15 sessions), while the CG group performed their routine rehabilitation program (a total of 12 sessions). Inertial measurement units were used to measure turning kinematics including; onset latency of body segments and stepping characteristics. Clinical outcomes included the Unified Parkinson's Disease Rating Scale (UPDRS), functional reach test (FRT), and fall efficacy scale international (FES-I). Assessments were conducted at baseline and after 4weeks. In the EG, turning kinematics, UPDRS scores, FRT, and FES-I scale, were improved at the end of the 4-week program compared with the CG (all p<0.05). A 4-week TSM program could be a promising alternative rehabilitation program for improving "en bloc" turns and clinical outcomes in PD patients.

Botulinum Toxin Therapy in Writer's Cramp and Musician's Dystonia.

Task-specific focal dystonia is characterized by muscle contraction(s) during a specific task, resulting in abnormal postures or movements. Specifically, writer’s cramp involves the upper extremity during the act of writing. Musician’s dystonia has a highly variable presentation, and thus makes therapeutic options more limited. Treatments include oral pharmacologic agents, neuromodulation, surgery and, most often, botulinum toxin (BoNT) injection. Selection of target muscles for toxin injection continues to be an area of active research for these task-specific movements. We present a review of the literature selected from a predefined search of the MEDLINE and ClinicalTrials.gov databases. We include six controlled studies of botulinum toxin for the management of writer’s cramp and focal task-specific dystonia (FTSD), including musician’s dystonia. Overall, 139 patients were included across all studies, with 99 individuals injected for writer’s cramp and the remaining 40 individuals with FTSD. The age range of all patients was 18–80 years old. We included studies that utilized only the BoNT-A serotype. These studies utilized various severity scales to quantify response to toxin injection, with ratings of instrument or pen control included as subjective ratings. Of the included 139 patients in this review, pooled data for toxin response show that 73% of patients who received the drug demonstrated improvement. Specific techniques for muscle localization and targeting were difficult to study as variable methods were employed. This remains an area of ongoing exploration.

California sea lions employ task-specific strategies for active touch sensing.

ABSTRACTActive sensing is the process of moving sensors to extract task-specific information. Whisker touch is often referred to as an active sensory system as whiskers are moved with purposeful control. Even though whisker movements are found in many species, it is unknown whether any animal can make task-specific movements with their whiskers. California sea lions (Zalophus californianus) make large, purposeful whisker movements and are capable of performing many whisker-related discrimination tasks. Therefore, California sea lions are an ideal species to explore the active nature of whisker touch sensing. Here, we show that California sea lions can make task-specific whisker movements. California sea lions move their whiskers with large amplitudes around object edges to judge size, make smaller, lateral stroking movements to judge texture and make very small whisker movements during a visual task. These findings, combined with the ease of training mammals and measuring whisker movements, makes whiskers an ideal system for studying mammalian perception, cognition and motor control.

Impact of virtual reality game therapy and task-specific neurodevelopmental treatment on motor recovery in survivors of stroke

Background/AimsThis study aimed to compare the impact of virtual reality game therapy and task-specific neurodevelopmental training on the motor recovery of upper limb and trunk control, as well as physical function, in people who have had a stroke.MethodsThis randomised, assessor-blinded clinical trial was conducted with 34 patients with post-stroke duration of 135 ± 23 days. Patients with first-onset cortical stroke aged 40–60 years, Mini-Mental State Examination score &gt;20, ability to complete a nine-hole peg test within 120 seconds, ability to lift the affected arm at shoulder level and independent standing were included. Patients were excluded if they had unilateral neglect and musculoskeletal injuries of the affected limb in the past 2 months. Outcome measures used were the Fugl-Meyer Upper Extremity Scale, Action Research Arm Test, Trunk Impairment Scale and Stroke Impact Scale-16. The virtual reality game therapy group performed interactive table tennis, boxing and discus throwing games. The neurodevelopmental treatment group underwent task-specific movements of the upper limb in sitting and standing. All patients performed 45 minutes of treatment, 5 days a week for 4 weeks.ResultsBoth groups showed improvements in all measures after training (P&lt;0.05). There was a between-group difference of 3.47 points in Fugl-Meyer Upper Extremity Scale in favour of the virtual reality game therapy.ConclusionsBoth treatment regimens resulted in equal improvements in hand dexterity and trunk control after stroke. Virtual reality game therapy improved the upper limb motor recovery of stroke survivors to a greater extent than neurodevelopmental treatment.

Control-Oriented Finger Kinematic Model: Geometry-Based Approach

Abstract This paper proposes a novel finger kinematic model for human hand configurations, which applies to the realization of a naturalistic human finger motion for robotic finger systems and artificial hands. The proposed finger model is derived based on the geometry of a hand shape grasping a virtual cylindrical object. The model is capable of describing the natural rotation configuration of the joints of a long finger with three degrees of freedom by a single parameter, i.e., the radius of a cylindrical object. Experimental validation of the model shows that it can simulate closely naturalistic human finger movements. With the use of the proposed model, discussions were made on how to achieve multifinger coordination that makes task-specific hand movements or a posture for specific hand actions. Due to the simplicity of the model to define joints angle configuration in a long finger by a single parameter, the combination of the proposed model and the multifinger coordination concept discussed can be seen as an inclusive framework in human-like hand systems design and control. This paper is the first step toward exploring future novel combined design–control strategies for the development of under-actuated prosthetic and powered orthotic devices for the naturalistic motion that are based on both Cartesian space trajectory tracking and joint angle coordination.

Reviewing Complex Static-Dynamic Concepts of Spine Stability: Does the Spine Care Only to Be Stiff to Be Stable?

Background Changes in the load-displacement relationship in spine segments suggesting alterations in biomechanical stiffness may not yield significant clinical information. Changes in Spine stiffness may arise secondary to neuro-muscular adjustments in the para-spinal muscles and may not be associated with physical anatomical laxity or motion restrictions at segmental articulations. Segmental stiffness may vary dynamically at different zones within the range-of-motion, suggesting a non-linear load-displacement relationship during motion. There is no linear, mechanistic relationship between spine pain and biomechanical markers of spine instability. Objective To review diagnostic assessment approaches of spine instability based on palpatory techniques, end-of-range radiography and imaging in light of our current understanding of biomechanical spine stability. Method The Medline and PubMed databases were screened for primary medical and engineering research articles and reviews on spine stability. Information related to bio-mechanical concepts and clinical decision-making were extracted and synthesized. Spine stability was described in two classical forms, the structural (anatomical) and the functional (physiological), the implications of static and dynamic instability was described in terms of biomechanical and mathematical models used to understand etiology of non-specific back pain. Results Evidence supports the view that dynamic adaptations in the load-displacement relationship of the spine may be resistive or assistive, depending on task-specific movements. Diagnosis of instability is based on structural and functional integrity of the segments in a static or dynamic context. Conclusion Development of specific criteria to define clinical spine stability, compatible with system-based biomechanical concept of spine stiffness, is an ongoing topic in clinical and basic science research.

Using gaze behavior to parcellate the explicit and implicit contributions to visuomotor learning.

Successful motor performance relies on our ability to adapt to changes in the environment by learning novel mappings between motor commands and sensory outcomes. Such adaptation is thought to involve two distinct mechanisms: an implicit, error-based component linked to slow learning and an explicit, strategic component linked to fast learning and savings (i.e., faster relearning). Because behavior, at any given moment, is the resultant combination of these two processes, it has remained a challenge to parcellate their relative contributions to performance. The explicit component to visuomotor rotation (VMR) learning has recently been measured by having participants verbally report their aiming strategy used to counteract the rotation. However, this procedure has been shown to magnify the explicit component. Here we tested whether task-specific eye movements, a natural component of reach planning, but poorly studied in motor learning tasks, can provide a direct readout of the state of the explicit component during VMR learning. We show, by placing targets on a visible ring and including a delay between target presentation and reach onset, that individual differences in gaze patterns during sensorimotor learning are linked to participants' rates of learning and their expression of savings. Specifically, we find that participants who, during reach planning, naturally fixate an aimpoint rotated away from the target location, show faster initial adaptation and readaptation 24 h later. Our results demonstrate that gaze behavior cannot only uniquely identify individuals who implement cognitive strategies during learning but also how their implementation is linked to differences in learning. NEW & NOTEWORTHY Although it is increasingly well appreciated that sensorimotor learning is driven by two separate components, an error-based process and a strategic process, it has remained a challenge to identify their relative contributions to performance. Here we demonstrate that task-specific eye movements provide a direct read-out of explicit strategies during sensorimotor learning in the presence of visual landmarks. We further show that individual differences in gaze behavior are linked to learning rate and savings.

Electrically Assisted Movement Therapy in Chronic Stroke Patients With Severe Upper Limb Paresis: A Pilot, Single-Blind, Randomized Crossover Study

To evaluate the effects of electrically assisted movement therapy (EAMT) in which patients use functional electrical stimulation, modulated by a custom device controlled through the patient's unaffected hand, to produce or assist task-specific upper limb movements, which enables them to engage in intensive goal-oriented training. Randomized, crossover, assessor-blinded, 5-week trial with follow-up at 18 weeks. Rehabilitation university hospital. Patients with chronic, severe stroke (N=11; mean age, 47.9y) more than 6 months poststroke (mean time since event, 46.3mo). Both EAMT and the control intervention (dose-matched, goal-oriented standard care) consisted of 10 sessions of 90 minutes per day, 5 sessions per week, for 2 weeks. After the first 10 sessions, group allocation was crossed over, and patients received a 1-week therapy break before receiving the new treatment. Fugl-Meyer Motor Assessment for the Upper Extremity, Wolf Motor Function Test, spasticity, and 28-item Motor Activity Log. Forty-four individuals were recruited, of whom 11 were eligible and participated. Five patients received the experimental treatment before standard care, and 6 received standard care before the experimental treatment. EAMT produced higher improvements in the Fugl-Meyer scale than standard care (P<.05). Median improvements were 6.5 Fugl-Meyer points and 1 Fugl-Meyer point after the experimental treatment and standard care, respectively. The improvement was also significant in subjective reports of quality of movement and amount of use of the affected limb during activities of daily living (P<.05). EAMT produces a clinically important impairment reduction in stroke patients with chronic, severe upper limb paresis.

Training the equidistant principle of number line spacing.

The characteristics of effective numerical trainings are still under scientific debate. Given the importance of number line estimation due to the strong relation between task performance and arithmetic abilities, the current study aimed at training one important number line characteristic: the equidistant spacing of adjacent numbers. Following an embodied training approach, second-graders were trained using a randomized crossover design to divide a presented line into different numbers of equal segments by walking the line with equally spaced steps. Performance was recorded, and feedback as to the correct equidistant spacing was provided using the Kinect sensor system. Training effects were compared to a control training with no involvement of task-specific whole-body movements. Results indicated more pronounced specific training effects after the embodied training. Moreover, transfer effects to number line estimation and arithmetic performance were partially observed. In particular, differential training effects for bounded versus unbounded number line estimation corroborate the assumption that not only bodily experiences but also the need for a flexible adaption of the perspective on the training material might influence training success. Hence, more pronounced training effects of the embodied training might stem from different cognitive processes involved.

Intuitive Work Assistance by Reciprocal Human-robot Interaction in the Subject Area of Direct Human-robot Collaboration

Abstract The paper focuses on the interaction in human-robot collaboration. On the one hand, the robot assistance system individually aligns itself to the employee and on the other hand, the employee gets an interface which enables him to influence certain robot positions. The aim is to support the employee in assembly tasks. The employee's personal anthropometric data and age-related as well as temporary restrictions in movements are considered by being recorded individually via motion capturing before the workplace is built in a virtual and real environment. Based on the data, task specific movements of the employee are simulated using digital human models for the virtual representation of the employee, combined with an ergonomic analysis within the work environment. The impact of the employee on the assistance robot system is provided by the design of intuitive user interfaces. The positioning of the components in the assembly is done user-specifically by the robot. In addition, the employee gets a graphical user interface and can additionally adjust the position or turn the components. In this paper, preliminary results of this ongoing research project are presented as well as two reference processes from the field of assembly technologies as application examples.

Differential effects of type of keyboard playing task and tempo on surface EMG amplitudes of forearm muscles.

Despite increasing interest in keyboard playing as a strategy for repetitive finger exercises in fine motor skill development and hand rehabilitation, comparative analysis of task-specific finger movements relevant to keyboard playing has been less extensive. This study examined, whether there were differences in surface EMG activity levels of forearm muscles associated with different keyboard playing tasks. Results demonstrated higher muscle activity with sequential keyboard playing in a random pattern compared to individuated playing or sequential playing in a successive pattern. Also, the speed of finger movements was found as a factor that affect muscle activity levels, demonstrating that faster tempo elicited significantly greater muscle activity than self-paced tempo. The results inform our understanding of the type of finger movements involved in different types of keyboard playing at different tempi. This helps to consider the efficacy and fatigue level of keyboard playing tasks when being used as an intervention for amateur pianists or individuals with impaired fine motor skills.

Effectiveness of interventions to improve occupational performance of people with motor impairments after stroke: an evidence-based review.

We conducted a review to determine the effectiveness of interventions to improve occupational performance in people with motor impairments after stroke as part of the American Occupational Therapy Association's Evidence-Based Practice Project. One hundred forty-nine studies met inclusion criteria. Findings related to key outcomes from select interventions are presented. Results suggest that a variety of effective interventions are available to improve occupational performance after stroke. Evidence suggests that repetitive task practice, constraint-induced or modified constraint-induced movement therapy, strengthening and exercise, mental practice, virtual reality, mirror therapy, and action observation can improve upper-extremity function, balance and mobility, and/or activity and participation. Commonalities among several of the effective interventions include the use of goal-directed, individualized tasks that promote frequent repetitions of task-related or task-specific movements.

Sex differences in task distribution and task exposures among Danish house painters: an observational study combining questionnaire data with biomechanical measurements.

ObjectivesSex differences in occupational biomechanical exposures may be part of the explanation why musculoskeletal complaints and disorders tend to be more common among women than among men. We aimed to determine possible sex differences in task distribution and task-specific postures and movements of the upper extremities among Danish house painters, and to establish sex-specific task exposure matrices.MethodsTo obtain task distributions, we sent out a questionnaire to all members of the Painters' Union in Denmark (N = 9364), of whom 53% responded. Respondents reported their task distributions in a typical week. To obtain task exposures, postures and movements were measured in 25 male and 25 female house painters for one whole working day per person. We used goniometers on the wrists, and inclinometers on the forehead and the upper arms. Participants filled in a logbook allowing task-specific exposures to be identified. Percentiles and % time with non-neutral postures were used to characterise postures. Velocity, range of motion, repetitiveness, and variation were used as measures of movement. Cochran-Mantel-Haenszel statistics and unpaired double-sided t-tests with post-hoc Bonferroni correction were used to evaluate sex differences.ResultsStatistically significant (p<0.05) sex differences were revealed in task proportions, but the proportions differed by less than 4%. For task exposures, no statistically significant sex differences were found.ConclusionsOnly minor sex differences were found in task distribution and task exposures regarding postures and movements among Danish house painters. Sex-specific task exposure matrices were established.

Effect of Intensive Functional Electrical Stimulation Therapy on Upper-Limb Motor Recovery after Stroke: Case Study of a Patient with Chronic Stroke

Motivated by a prior successful randomized controlled trial showing that functional electrical stimulation (FES) therapy can restore voluntary arm and hand function in people with severe stroke, this study was designed to examine neuromuscular changes in the upper limb following intensive FES therapy, consisting of task-specific upper-limb movements with a combination of preprogrammed FES and manual assisted motion. The patient was a 22-year-old woman who had suffered a haemorrhagic stroke 2 years earlier. FES therapy was administered for 1 hour twice daily for 12 weeks, for a total of 108 treatment sessions. While maximal voluntary contraction level of the upper-limb muscles did not show significant improvement, the ability to initiate and stop the muscle contraction voluntarily was regained in several upper-limb muscles (approx. 5%-15% of the maximum voluntary contraction of the same muscle in the less-affected arm). A reduction in arm spasticity was also observed, as indicated by the reduction of H-reflex in the wrist flexor muscle (82.1% to 45.0% in Hmax/Mmax) and decreased Modified Ashworth Scale scores (from 3 to 2 for the hand and 4 to 3 for the arm). Coordination between shoulder and elbow joints during the circle-drawing test improved considerably over the course of FES therapy: the patient was unable to draw a circle at all at baseline but was able to do so proficiently at discharge. Improvements in upper-limb function observed in people with severe stroke following intensive FES therapy can be attributed to (a) regained ability to voluntarily contract muscles of the affected arm, (b) reduced spasticity and improved muscle tone in the same muscles, and (c) increased range of motion of all joints.