Jill Campbell Stewart

Intervention to enhance skilled arm and hand movements after stroke: A feasibility study using a new virtual reality system

BackgroundRehabilitation programs designed to develop skill in upper extremity (UE) function after stroke require progressive practice that engage and challenge the learner. Virtual realty (VR) provides a unique environment where the presentation of stimuli can be controlled systematically for optimal challenge by adapting task difficulty as performance improves. We describe four VR tasks that were developed and tested to improve arm and hand movement skills for individuals with hemiparesis.MethodsTwo participants with chronic post-stroke paresis and different levels of motor severity attended 12 training sessions lasting 1 to 2 hours each over a 3-week period. Behavior measures and questionnaires were administered pre-, mid-, and post-training.ResultsBoth participants improved VR task performance across sessions. The less impaired participant averaged more time on task, practiced a greater number of blocks per session, and progressed at a faster rate over sessions than the more impaired participant. Impairment level did not change but both participants improved functional ability after training. The less impaired participant increased the number of blocks moved on the Box & Blocks test while the more impaired participant achieved 4 more items on the Functional Test of the Hemiparetic UE.ConclusionTwo participants with differing motor severity were able to engage in VR based practice and improve performance over 12 training sessions. We were able to successfully provide individualized, progressive practice based on each participants level of movement ability and rate of performance improvement.

Patient-Reported Measures Provide Unique Insights Into Motor Function After Stroke

Background and Purpose— Patient-reported outcome measures have been found useful in many disciplines but have received limited evaluation after stroke. The current study investigated the relationship that patient-reported measures have with standard impairment and disability scales after stroke. Methods— Patients with motor deficits after stroke were scored on standard assessments including the National Institutes of Health Stroke Scale, modified Rankin Scale, and Fugl-Meyer motor scale, and on 2 patient-reported measures, the hand function domain of the Stroke Impact Scale, which documents difficulty of hand motor usage, and the amount of use portion of the Motor Activity Log, which records amount of arm motor usage. Results— The 43 participants had mild disability (median modified Rankin Scale=2), moderate motor deficits (Fugl-Meyer motor scale=46±22), and mild cognitive/language deficits. The 2 patient-reported outcome measures, Stroke Impact Scale and Motor Activity Log, were sensitive to the presence of arm motor deficits. Of 21 patients classified as having minimal or no impairment or disability by the National Institutes of Health Stroke Scale or modified Rankin Scale (score of 0–1), 15 (71%) reported difficulty with hand movements by the Stroke Impact Scale score or reduced arm use by the Motor Activity Log score. Furthermore, of 14 patients with a normal examination, 10 (71%) reported difficulty with hand movements or reduction in arm use. Conclusions— Patient-reported measures were a unique source of insight into clinical status in the current population. Motor deficits were revealed in a majority of patients classified by standard scales as having minimal or no disability, and in a majority of patients classified as having no deficits.

An integrated system: virtual reality, haptics and modern sensing technique (VHS) for post-stroke rehabilitation

In this paper, we introduce an interdisciplinary project, involving researchers from the fields of Physical Therapy, Computer Science, Psychology, Communication and Cell Neurobiology, to develop an integrated virtual reality, haptics and modern sensing technique system for post-stroke rehabilitation. The methodology to develop the system includes identification of movement pattern, development of simulated task and diagnostics. Each part of the methodology can be achieved through several sub-steps that are described in detail in this paper. The system is designed from Physical Therapy perspective that can address the motor rehabilitation needs of stroke patients. The system is implemented through stereoscopic displays, force feedback devices and modern sensing techniques that have game-like features and can capture accurate data for further analysis. Diagnostics and evaluation can be made through an Artificial Intelligence based model using collected data and clinical tests have been conducted.

Age-related variability in performance of a motor action selection task is related to differences in brain function and structure among older adults.

Task performance for behaviors that engage motor cognitive processes may be particularly sensitive to age-related changes. One well-studied model of cognitive motor function involves engagement of action selection (AS) processes. In young adults, task conditions that add AS demands result in increased preparation times and greater engagement of bilateral dorsal premotor (PMd) and parietal cortices. The current study investigated the behavioral and neural response to a change in motor cognitive demands in older adults through the addition of AS to a movement task. Sixteen older adults made a joystick movement under two conditions during functional magnetic resonance imaging. In the AS condition, participants moved right or left based on an abstract rule; in the execution only (EO) condition, participants moved in the same direction on every trial. Across participants, the AS condition, as compared to the EO condition, was associated with longer reaction time and increased activation of left inferior parietal lobule. Variability in behavioral response to the AS task between participants related to differences in brain function and structure. Overall, individuals with poorer AS task performance showed greater activation in left PMd and dorsolateral prefrontal cortex and decreased structural integrity of white matter tracts that connect sensorimotor, frontal, and parietal regions-key regions for AS task performance. Additionally, two distinct patterns of functional connectivity were found. Participants with a pattern of decreased primary motor-PMd connectivity in response to the AS condition, compared to those with a pattern of increased connectivity, were older and had poorer behavioral performance. These neural changes in response to increased motor cognitive demands may be a marker for age-related changes in the motor system and have an impact on the learning of novel, complex motor skills in older adults.

Textbook of Neural Repair and Rehabilitation: Conditions of task practice for individuals with neurologic impairments

This chapter provides a scientific rationale for choosing the conditions of practice that best promote skill learning in the context of task-specific training for diminished functional ability in the neurologically impaired patient. It defines skill and motor learning within the context of neurorehabilitation. Motor learning is a set of processes associated with practice or experience leading to relatively permanent changes in the capability for responding. The chapter discusses the differences between use and skill as these terms apply to upper extremity (UE) and manual actions. It argues that this distinction becomes important for choosing the appropriate conditions of practice for individuals post-stroke. The chapter reviews the literature pertaining to two important conditions of practice known to be critical for motor skill learning: augmented feedback and explicit information and task scheduling. Finally, it outlines how these conditions might be manipulated to promote recovery of functional skills in the neurologically impaired patient.

Pilot Trial Results from a Virtual Reality System Designed to Enhance Recovery of Skilled Arm and Hand Movements after Stroke

Rehabilitation programs designed to develop skill in upper extremity (UE) function after stroke require learner-centered opportunities for active problem solving. Virtual realty (VR) provides a unique environment where the presentation of stimuli can be systematically controlled to enable an optimal level of challenge by progressing task difficulty as performance improves. We describe four VR tasks that were developed and tested to improve skilled arm and hand movements in individuals with hemiparesis. Two participants post-stroke with different levels of motor severity attended 12 training sessions lasting 1 to 2 hours each over a 3-week period. Behavioral measures and questionnaires were administered pre-, mid-, and post-training. The less impaired participant averaged more time on task, practiced a greater number of blocks per session, and progressed at a faster rate over sessions than the more impaired participant. Differences in functional outcomes for these two cases can be explained in part by which tasks were practiced, the level of task difficulty applied during practice, and the amount of repetition included in practice

Dorsal premotor activity and connectivity relate to action selection performance after stroke.

Compensatory activation in dorsal premotor cortex (PMd) during movement execution has often been reported after stroke. However, the role of PMd in the planning of skilled movement after stroke has not been well studied. The current study investigated the behavioral and neural response to the addition of action selection (AS) demands, a motor planning process that engages PMd in controls, to movement after stroke. Ten individuals with chronic, left hemisphere stroke and 16 age‐matched controls made a joystick movement with the right hand under two conditions. In the AS condition, participants moved right or left based on an abstract, visual rule; in the execution only condition, participants moved in the same direction on every trial. Despite a similar behavioral response to the AS condition (increase in reaction time), brain activation differed between the two groups: the control group showed increased activation in left inferior parietal lobule (IPL) while the stroke group showed increased activation in several right/contralesional regions including right IPL. Variability in behavioral performance between participants was significantly related to variability in brain activation. Individuals post‐stroke with relatively poorer AS task performance showed greater magnitude of activation in left PMd and dorsolateral prefrontal cortex (DLPFC), increased left primary motor cortex‐PMd connectivity, and decreased left PMd‐DLPFC connectivity. Changes in the premotor‐prefrontal component of the motor network during complex movement conditions may negatively impact the performance and learning of skilled movement and may be a prime target for rehabilitation protocols aimed at improving the function of residual brain circuits after stroke. Hum Brain Mapp 37:1816–1830, 2016.

Coastal terrorism: using tabletop discussions to enhance coastal community infrastructure through relationship building.

The unique vulnerability of the nations ports to terrorist attacks and other major disasters requires development of specialized training approaches that integrate and connect critical stakeholders. In 2003, the University of South Carolina Center for Public Health Preparedness developed and held its first Coastal Terrorism workshop in conjunction with the National Oceanic and Atmospheric Administration. Key federal, regional, state, and coastal agency leaders were invited to the 2-day event to explore, in a no-risk environment, the crucial role that public health agencies would play in a covert biological agent incident aboard a cruise ship. The incident began as a possible outbreak of a Norwalk-like viral agent; however, as the scenario unfolded, evidence of a terrorist plot emerged. This immediately shifted the scenario from a public health-dominated incident to one directed by law enforcement. Communication and coordination issues surfaced illustrating potential conflicts between disciplines and jurisdictions in terms of roles and responsibilities of responding agencies. The goals of the workshop were to facilitate communication and interagency networking among coastal stakeholders while assessing their training and research needs and increasing their familiarity with resources and protocols regarding a bioterrorist coastal event. Positive systems changes were observed.

Role of corpus callosum integrity in arm function differs based on motor severity after stroke

While the corpus callosum (CC) is important to normal sensorimotor function, its role in motor function after stroke is less well understood. This study examined the relationship between structural integrity of the motor and sensory sections of the CC, as reflected by fractional anisotropy (FA), and motor function in individuals with a range of motor impairment level due to stroke. Fifty-five individuals with chronic stroke (Fugl-Meyer motor score range 14 to 61) and 18 healthy controls underwent diffusion tensor imaging and a set of motor behavior tests. Mean FA from the motor and sensory regions of the CC and from corticospinal tract (CST) were extracted and relationships with behavioral measures evaluated. Across all participants, FA in both CC regions was significantly decreased after stroke (p < 0.001) and showed a significant, positive correlation with level of motor function. However, these relationships varied based on degree of motor impairment: in individuals with relatively less motor impairment (Fugl-Meyer motor score > 39), motor status correlated with FA in the CC but not the CST, while in individuals with relatively greater motor impairment (Fugl-Meyer motor score ≤ 39), motor status correlated with FA in the CST but not the CC. The role interhemispheric motor connections play in motor function after stroke may differ based on level of motor impairment. These findings emphasize the heterogeneity of stroke, and suggest that biomarkers and treatment approaches targeting separate subgroups may be warranted.

MotoR IMAgER y duRIng MovEMEnt ActIv AtES tHE bRAIn MoRE tHAn MovEMEnt AlonE AftER StRokE: A pIlot Study

OBJECTIVE To examine the neural correlates of motor imagery performed in conjunction with movement of the paretic arm after stroke. DESIGN Cross-sectional, cohort study. SUBJECTS Seven individuals in the chronic phase of stroke recovery (median (range): age: 58 years (37-73); time post-stroke: 9 months (4-42); upper extremity Fugl-Meyer motor score: 48 (36-64)). METHODS Participants actively moved the paretic/right arm under two conditions while undergoing functional magnetic resonance imaging. In the motor condition, pronation/supination movements were made in response to a visual cue. In the motor + imagery condition, the same movements were performed in response to a visual cue but the participants were instructed to imagine opening and closing a doorknob during performance of the movement. RESULTS For the motor condition, the anticipated motor network was activated and included left sensorimotor cortex and right cerebellum. For performance of the same movements during the motor + imagery condition, additional brain regions were significantly engaged including the left inferior parietal lobule and right dorsolateral prefrontal cortex. CONCLUSIONS The addition of motor imagery to movement may provide a practical, accessible way to modulate activity in both the planning and execution components of the motor network after stroke.