Derek G. Kamper

IMPAIRMENT OF VOLUNTARY CONTROL OF FINGER MOTION FOLLOWING STROKE: ROLE OF INAPPROPRIATE MUSCLE COACTIVATION

Subjects with chronic hemiplegia following stroke attempted to perform voluntary isometric, isokinetic, and free contractions of the extensor muscles of the metacarpophalangeal (MCP) joints. We recorded torque, metacarpophalangeal joint angle and velocity, and electromyographic (EMG) activity of the extrinsic extensors and flexors and the first dorsal interosseous (FDI). We found that voluntary MCP joint extension in hemiparetic subjects was greatly impaired in comparison with control subjects: only two of the 11 stroke subjects were able to generate even 0.21 N‐m of isometric extension torque, only two could produce positive finger extension with no load, and none could develop an isokinetic concentric extension. Deficits seemed to result from a combination of coactivation of the finger flexor and extensor muscles and decreased voluntary excitation of the extensors, as normalized flexor and FDI EMG activity were greater for stroke than for control subjects (P < 0.001), but normalized extensor activity was reduced (P < 0.001).

Hand Rehabilitation Following Stroke: A Pilot Study of Assisted Finger Extension Training in a Virtual Environment

Abstract Background and Purpose: The purpose of this pilot study was to investigate the impact of assisted motor training in a virtual environment on hand function in stroke survivors. Participants: Fifteen volunteer stroke survivors (32–88 years old) with chronic upper extremity hemiparesis (1–38 years post incident) took part. Method: Participants had 6 weeks of training in reach-to-grasp of virtual and actual objects. They were randomized to one of three groups: assistance of digit extension provided by a novel cable orthosis, assistance provided by a novel pneumatic orthosis, or no assistance provided. Hand performance was evaluated at baseline, immediately following training, and 1 month after completion of training. Clinical assessments included the Wolf Motor Function Test (WMFT), Box and Blocks Test (BB), Upper Extremity Fugl-Meyer Test (FM), and Rancho Los Amigos Functional Test of the Hemiparetic Upper Extremity (RLA). Biomechanical assessments included grip strength, extension range of motion and velocity, spasticity, and isometric strength. Results: Participants demonstrated a significant decrease in time to perform functional tasks for the WMFT (p = .02), an increase in the number of blocks successfully grasped and released during the BB (p = .09), and an increase for the FM score (p = .08). There were no statistically significant changes in time to complete tasks on the RLA or any of the biomechanical measures. Assistance of extension did not have a significant effect. Discussion and Conclusion: After the training period, participants in all 3 groups demonstrated a decrease in time to perform some of the functional tasks. Although the overall gains were slight, the general acceptance of the novel rehabilitation tools by a population with substantial impairment suggests that a larger randomized controlled trial, potentially in a subacute population, may be warranted.

Relative contributions of neural mechanisms versus muscle mechanics in promoting finger extension deficits following stroke.

The origins of impaired finger and hand function were examined in 10 stroke survivors with chronic spastic hemiparesis, with the intent of assessing whether mechanical restraint or altered neurophysiological control mechanisms are responsible for the well‐known impairment of finger extension. Simultaneous extension of all four metacarpophalangeal (MCP) joints of the impaired hand was either externally imposed using a rotary actuator or attempted voluntarily by the subject. Trials were conducted both before and after administration of a local anesthetic, blocking the median and ulnar nerves at the elbow. The anesthetic was administered to reduce the activity of the muscles flexing the MCP joints, in order to distinguish mechanical from neuronal resistance to imposed MCP rotation. We found that the nerve blockade resulted in a reduction in velocity‐dependent torque (P = 0.01), thereby indicating significant joint impedance due to spasticity. Blockade also produced a posture‐dependent reduction in static torque in declaratively relaxed subjects (P = 0.04), suggesting some tonic flexor activity for specific hand postures. No change in either extensor isometric (P = 0.33) or isokinetic (0.53) torque was apparent, but 3 of the 10 subjects did exhibit substantial (>10°) improvement in voluntary MCP extension following the blockade. This improvement seemed largely due to a decrease in inappropriate flexor activity during the movement, rather than an increase in extensor activity. We argue that persistent and inappropriate flexor activation plays a role in limiting voluntary finger extension, and that this activation is potentially a reflection of altered supraspinal control of key spinal pathways. In all cases, this inappropriate activation was compounded by weakness, apparent in both the extensor and flexor muscles. Muscle Nerve 28: 309–318, 2003

A Pneumatic Glove and Immersive Virtual Reality Environment for Hand Rehabilitative Training After Stroke

While a number of devices have recently been developed to facilitate hand rehabilitation after stroke, most place some restrictions on movement of the digits or arm. Thus, a novel glove was developed which can provide independent extension assistance to each digit while still allowing full arm movement. This pneumatic glove, the PneuGlove, can be used for training grasp-and-release movements either with real objects or with virtual objects in a virtual reality environment. Two groups of stroke survivors, with seven subjects in each group, completed a six-week rehabilitation training protocol, consisting of three 1-h sessions held each week. One group wore the PneuGlove during training, performed both within a novel virtual reality environment and outside of it with physical objects, while the other group completed the same training without the device. Across subjects, significant improvements were observed in the Fugl-Meyer Assessment for the upper extremity ( p<;;0.001), the hand/wrist portion of the Fugl-Meyer Assessment ( p<;;0.001), the Box and Blocks test ( p<;;0.05), and palmar pinch strength ( p<;;0.05). While changes in the two groups were not statistically different, the group using the PneuGlove did show greater mean improvement on each of these measures, such as gains of 3.7 versus 2.4 points on the hand/wrist portion of the Fugl-Meyer Assessment and 14 N versus 5 N in palmar pinch.

An Actuated Finger Exoskeleton for Hand Rehabilitation Following Stroke

Chronic hand impairment is common following stroke. While mass practice of movement has shown promise for rehabilitation, initial impairment of the hand may be too severe to permit even approximations of the desired movement. To facilitate movement, especially of pinch, we are building an exoskeleton to permit independent actuation of each of the three joints of the index finger. Separate actuators are used for flexion and extension, with closed-loop control of either force or position. In the future, a companion thumb exoskeleton will be developed to permit coordinated performance of pinch. This system will be used to assess strategies for optimizing rehabilitation of pinch and reach-to-pinch following stroke. The design of the actuated index finger exoskeleton is presented here.

Quantitative features of the stretch response of extrinsic finger muscles in hemiparetic stroke

Despite its potential importance in hand dysfunction, spasticity in the finger muscles following stroke has not been well described. To explore this area, we assessed the role of finger flexor spasticity, along with that of passive mechanical forces, in resisting finger movement in 13 chronic stroke subjects. Subjects were tested with a device that stretched the extrinsic finger muscles through imposed rotation of the metacarpophalangeal (MCP) joints. Both maintained and constant‐velocity stretches were imposed. For the constant‐velocity stretches, eight of the 13 stroke subjects exhibited strong stretch reflexes, as determined by electromyography and net work. The net work of this reflex response, calculated from the integral of the torque‐angle plots, increased proportionally with increasing velocity, indicating a contribution from flexor muscle spasticity. Conversely, nine of the 13 stroke subjects did not possess distinctly greater passive, mechanical resistance to MCP rotation than control subjects. While extensor spasticity was not observed, stretch of the extrinsic finger flexors also produced some reflex activity in the finger extensors concomitant with reflex excitation of the flexors. These findings suggest that resistance to muscle stretching following stoke is mediated primarily by neurological rather than biomechanical disturbances, although changes in muscle fiber length may exaggerate the resistance.

A low cost instrumented glove for extended monitoring and functional hand assessment

A wearable finger flexion monitor developed to measure hand function in individuals with hand dysfunction was evaluated for feasibility, measurement repeatability and reliability, fidelity of wireless transmission, and user acceptance. Configuration of the monitor allows use in situations when a traditional measurement glove cannot be worn. Five healthy individuals participated in the study of repeatability, while 10 healthy individuals and 10 individuals with acquired brain injury participated in trials to assess feasibility and user comfort. Repeatability results showed an overall error of 3.4 degrees , compared to 5.5 degrees and 5.7 degrees reported with other sensor gloves, and to manual measurements (5-8 degrees). Intraclass coefficient of reliability (using coefficient alpha) averaged 0.95. User feedback regarding comfort of the monitor was very high. Loss of data during wireless transmission was no greater than 1.2%. Results demonstrate that the monitor has a strong potential to be used as a tool for objective hand function evaluation in the home and community for both short- and long-term monitoring.

Design considerations for a wearable monitor to measure finger posture

BackgroundObjective measures of hand function as individuals participate in home and community activities are needed in order to better plan and evaluate rehabilitation treatments. Traditional measures collected in the clinical setting are often not reflective of actual functional performance. Recent advances in technology, however, enable the development of a lightweight, comfortable data collection monitor to measure hand kinematics.MethodsThis paper presents the design analysis of a wearable sensor glove with a specific focus on the sensors selected to measure bend. The most important requirement for the glove is easy donning and removal for individuals with significantly reduced range of motion in the hands and fingers. Additional requirements include comfort and durability, cost effectiveness, and measurement repeatability. These requirements eliminate existing measurement gloves from consideration. Glove construction is introduced, and the sensor selection and glove evaluation process are presented.ResultsEvaluation of commercial bend sensors shows that although most are not appropriate for repeatable measurements of finger flexion, one has been successfully identified. A case study for sensor glove repeatability using the final glove configuration and sensors does show a high degree of repeatability in both the gripped and flat hand positions (average coefficient of variability = 2.96% and 0.10%, respectively).ConclusionMeasuring functional outcomes in a portable manner can provide a wealth of information important to clinicians for the evaluation and treatment of movement disorders in the hand and fingers. This device is an important step in that direction as both a research and an evaluation method.

The Effect of Motor Imagery on Spinal Segmental Excitability

The purpose of this study was to investigate the effect of motor imagery on spinal segmental excitability by recording the reflex responses to externally applied stretch of the extrinsic finger flexors and extensors during the performance of an imaginary task. Nine young healthy subjects performed a series of imagined flexion-extension movements of the fingers. Muscle stretch was imposed concurrently by applying rotations of the metacarpophalangeal joints at 100, 300, or 500°/sec. Three of the nine tested subjects also generated 0.2 Newton meter voluntary flexion torque in preloading tasks before stretch. At 300°/sec stretch, electromyogram (EMG) and torque reflex responses, which were observed in the finger flexors in four of nine subjects during motor imagery, were activated at a short latency (38.6 ± 10.6 msec). This latency was similar to that recorded during a stretch of preactivated flexor muscles (34.4 ± 3.6 msec), in which motoneurons are already suprathreshold and in which monosynaptic effects of muscle afferents are likely to be discernable. In a similar manner, for stretches imposed at 500°/sec, responses to stretch of the flexors were observed in all five tested subjects in imaginary flexion tasks at very short latencies (26.4 ± 3.7 msec), again similar to those induced by tendon taps (22.8 ± 1.2 msec). No EMG response was observed at rest during stretches. These observations support the view that effects must have been mediated by imagery-related subthreshold activation of spinal motoneurons and/or interneurons, rather than by long-latency transcortical reflex responses. We conclude that motor imagery has a potent effect on the excitability of spinal reflex pathways.

Subject-Specific Myoelectric Pattern Classification of Functional Hand Movements for Stroke Survivors

In this study, we developed a robust subject-specific electromyography (EMG) pattern classification technique to discriminate intended manual tasks from muscle activation patterns of stroke survivors. These classifications will enable volitional control of assistive devices, thereby improving their functionality. Twenty subjects with chronic hemiparesis participated in the study. Subjects were instructed to perform six functional tasks while their muscle activation patterns were recorded by ten surface electrodes placed on the forearm and hand of the impaired limb. In order to identify intended functional tasks, a pattern classifier using linear discriminant analysis was applied to the EMG feature vectors. The classification accuracy was mainly affected by the impairment level of the subject. Mean classification accuracy was 71.3% for moderately impaired subjects (Chedoke Stage of Hand 4 and 5), and 37.9% for severely impaired subjects (Chedoke Stage of Hand 2 and 3). Most misclassification occurred between grip tasks of similar nature, for example, among pinch, key, and three-fingered grips, or between cylindrical and spherical grips. EMG signals from the intrinsic hand muscles significantly contributed to the inter-task variability of the feature vectors, as assessed by the inter-task squared Euclidean distance, thereby indicating the importance of intrinsic hand muscles in functional manual tasks. This study demonstrated the feasibility of the EMG pattern classification technique to discern the intent of stroke survivors. Future work should concentrate on the construction of a subject-specific EMG classification paradigm that carefully considers both functional and physiological impairment characteristics of each subject in the target task selection and electrode placement procedures.