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Background Gait deficits are very common after stroke and therefore an important aspect in poststroke rehabilitation. A currently little used method in gait rehabilitation after stroke is the activation of the flexor reflex (FR) by electrical stimulation of the sole of foot while walking. The aim of this study was to investigate the effect of FR stimulation on gait performance and gait parameters in participants with stroke within a single session of flexor reflex stimulation using Incedo™. Methods Twenty-five participants with subacute (n = 14) and chronic (n = 11) stroke were enrolled in the study. Motor functions were tested with a 10-m walk test (10mWT), a 2-min walk test (2minWT), and a gait analysis. These tests were performed with and without Incedo™ within a single session in randomized order. Results In the 10mWT, a significant difference was found between walking with Incedo™ (15.0 ± 8.5 s) versus without Incedo™ (17.0 ± 11.4 s, p = 0.01). Similarly, the 2minWT showed a significant improvement with Incedo™ use (90.0 ± 36.4 m) compared to without Incedo™ (86.3 ± 36.8 m, p = 0.03). These results indicate that while the improvements are statistically significant, they are modest and should be considered in the context of their clinical relevance. The gait parameters remained unchanged except for the step length. A subgroup analysis indicated that participants with subacute and chronic stroke responded similarly to the stimulation. There was a correlation between the degree of response to electrostimulation while walking and degree of improvement in 2minWT ( r  = 0.50, p = 0.01). Conclusions This study is the first to examine FR activation effects in chronic stroke patients and suggests that stimulation effects are independent of the time since stroke. A larger controlled clinical trial is warranted that addresses issues as the necessary number of therapeutical sessions and for how long stimulation-induced improvements outlast the treatment period. Trial registration: The trial was retrospectively registered in German Clinical Trials Register. Clinical trial registration number: DRKS00021457. Date of registration: 29 June 2020.

Clinical gait analysis plays a central role in the rehabilitation of stroke patients. However, practical and technical challenges limit their use in clinical settings. This study aimed to validate SMARTGAIT, a deep learning-based gait analysis system that addresses these limitations. Eight stroke patients took part in the study at the Human Performance Research Centre of the University of Konstanz. Gait measurements were taken using both the marker-based Vicon motion capture system and the single-smartphone-based SMARTGAIT system. We evaluated the agreement for knee, hip, and ankle joint angle kinematics in the frontal and sagittal plane and spatiotemporal gait parameters between the two systems. The results mostly demonstrated high levels of agreement between the two systems, with Pearson correlations of ≥0.79 for all lower body angle kinematics in the sagittal plane and correlations of ≥0.71 in the frontal plane. RMSE values were ≤4.6°. The intraclass correlation coefficients for all derived gait parameters showed good to excellent levels of agreement. SMARTGAIT is a promising tool for gait analysis in stroke, particularly for quantifying gait characteristics in the sagittal plane, which is very relevant for clinical gait analysis. However, further analyses are required to validate the use of SMARTGAIT in larger samples and its transferability to different types of pathological gait. In conclusion, a single smartphone recording (monocular 2D RGB camera) could make gait analysis more accessible in clinical settings, potentially simplifying the process and making it more feasible for therapists and doctors to use in their day-to-day practice.

Background Neurological injuries such as stroke often differentially impair hand motor and somatosensory function, as well as the interplay between the two, which leads to limitations in performing activities of daily living. However, it is challenging to identify which specific aspects of sensorimotor function are impaired based on conventional clinical assessments that are often insensitive and subjective. In this work we propose and validate a set of robot-assisted assessments aiming at disentangling hand proprioceptive from motor impairments, and capturing their interrelation (sensorimotor impairments). Methods A battery of five complementary assessment tasks was implemented on a one degree-of-freedom end-effector robotic platform acting on the index finger metacarpophalangeal joint. Specifically, proprioceptive impairments were assessed using a position matching paradigm. Fast target reaching, range of motion and maximum fingertip force tasks characterized motor function deficits. Finally, sensorimotor impairments were assessed using a dexterous trajectory following task. Clinical feasibility (duration), reliability (intra-class correlation coefficient ICC, smallest real difference SRD) and validity (Kruskal-Wallis test, Spearman correlations ρ with Fugl-Meyer Upper Limb Motor Assessment, kinesthetic Up-Down Test, Box & Block Test) of robotic tasks were evaluated with 36 sub-acute stroke subjects and 31 age-matched neurologically intact controls. Results Eighty-three percent of stroke survivors with varied impairment severity (mild to severe) could complete all robotic tasks (duration: <15 min per tested hand). Further, the study demonstrated good to excellent reliability of the robotic tasks in the stroke population (ICC>0.7, SRD<30%), as well as discriminant validity, as indicated by significant differences ( p -value<0.001) between stroke and control subjects. Concurrent validity was shown through moderate to strong correlations ( ρ =0.4-0.8) between robotic outcome measures and clinical scales. Finally, robotic tasks targeting different deficits (motor, sensory) were not strongly correlated with each other ( ρ ≤ 0.32, p -value>0.1), thereby presenting complementary information about a patient’s impairment profile. Conclusions The proposed robot-assisted assessments provide a clinically feasible, reliable, and valid approach to distinctly characterize impairments in hand proprioceptive and motor function, along with the interaction between the two. This opens new avenues to help unravel the contributions of unique aspects of sensorimotor function in post-stroke recovery, as well as to contribute to future developments towards personalized, assessment-driven therapies.

To explore the effects of motor imagery (MI) and action observation (AO) of foot movements on motor excitability. Fifteen healthy subjects were studied at rest, during MI of foot dorsiflexions and during watching a video of foot dorsiflexions. Transcranial magnetic stimulation was used to explore corticospinal and intracortical excitability by comparing amplitudes of motor-evoked potentials during the different conditions. F waves were recorded to test the spinal motoneuronal excitability. MI and AO increased corticospinal excitability, but MI was more effective than AO. During MI, intracortical inhibition was reduced. Intracortical facilitation and spinal motoneuronal excitability remained unchanged. Excitability increases were similar for the right and the left leg when recording from the side the subjects had focused their MI on. However, MI of left foot dorsiflexions did not increase excitability in the right tibial anterior muscle. MI and AO of foot dorsiflexions enhance motor excitability. MI induced a disinhibition in the motor cortex. The lack of excitability increase during MI of contralateral foot movements might be related to the alternating movement pattern during walking. MI and AO effects could support the restitution of motor deficits in neurological diseases with impaired motor excitability.

Whenever we are confronted with action opportunities in everyday life, e.g., when passing an opening, we rely on our ability to precisely estimate our own bodily capabilities in relation to the environmental conditions. So-called affordance judgments can be affected after brain damage. Previous studies with healthy adults showed that such judgments appeared to be trainable within one session. In the current study, we examined whether stroke patients with either right brain damage ( n = 30) or left brain damage ( n = 30) may similarly profit from training in an aperture task. Further, the role of neuropsychological deficits in trainability was investigated. In the administered task, stroke patients decided whether their hand would fit into a presented opening with varying horizontal width (Aperture Task). During one training session, patients were asked to try to fit their hand into the opening and received feedback on their decisions. We analyzed accuracy and the detection theory parameters perceptual sensitivity and judgment tendency. Both patients with right brain damage and patients with left brain damage showed improved performance during training as well as post training. High variability with differential profiles of trainability was revealed in these patients. Patients with impaired performance in a visuo-spatial or motor-cognitive task appeared to profit considerably from the target-driven action phase with feedback, but the performance increase in judgments did not last when the action was withdrawn. Future studies applying lesion analysis with a larger sample may shed further light on the dissociation in the trainability of affordance judgments observed in patients with versus without visuo-spatial or motor-cognitive deficits.

Background Proprioceptive function can be affected after neurological injuries such as stroke. Severe and persistent proprioceptive impairments may be associated with a poor functional recovery after stroke. To better understand their role in the recovery process, and to improve diagnostics, prognostics, and the design of therapeutic interventions, it is essential to quantify proprioceptive deficits accurately and sensitively. However, current clinical assessments lack sensitivity due to ordinal scales and suffer from poor reliability and ceiling effects. Robotic technology offers new possibilities to address some of these limitations. Nevertheless, it is important to investigate the psychometric and clinimetric properties of technology-assisted assessments. Methods We present an automated robot-assisted assessment of proprioception at the level of the metacarpophalangeal joint, and evaluate its reliability, validity, and clinical feasibility in a study with 23 participants with stroke and an age-matched group of 29 neurologically intact controls. The assessment uses a two-alternative forced choice paradigm and an adaptive sampling procedure to identify objectively the difference threshold of angular joint position. Results Results revealed a good reliability (ICC(2,1) = 0.73) for assessing proprioception of the impaired hand of participants with stroke. Assessments showed similar task execution characteristics (e.g., number of trials and duration per trial) between participants with stroke and controls and a short administration time of approximately 12 min. A difference in proprioceptive function could be found between participants with a right hemisphere stroke and control subjects ( p <0.001). Furthermore, we observed larger proprioceptive deficits in participants with a right hemisphere stroke compared to a left hemisphere stroke ( p =0.028), despite the exclusion of participants with neglect. No meaningful correlation could be established with clinical scales for different modalities of somatosensation. We hypothesize that this is due to their low resolution and ceiling effects. Conclusions This study has demonstrated the assessment’s applicability in the impaired population and promising integration into clinical routine. In conclusion, the proposed assessment has the potential to become a powerful tool to investigate proprioceptive deficits in longitudinal studies as well as to inform and adjust sensorimotor rehabilitation to the patient’s deficits.

Somatosensory deficits after stroke correlate with functional disabilities and impact everyday-life. In particular, the interaction of proprioception and motor dysfunctions affects the recovery. While corticospinal tract (CST) damage is linked to poor motor outcome, much less is known on proprioceptive recovery. Identifying a predictor for such a recovery could help to gain insights in the complex functional recovery processes thereby reshaping rehabilitation strategies. Methods 50 patients with subacute stroke were tested before and after neurological rehabilitation. Proprioceptive and motor impairments were quantified with three clinical assessments and four hand movement and proprioception measures using a robotic device. Somatosensory evoked potentials (SSEP) to median nerve stimulation and structural imaging data (MRI) were also collected. Voxel-based lesion-symptom mapping (VLSM) along with a region of interest (ROI) analysis were performed for the corticospinal tract (CST) and for cortical areas.Before rehabilitation, the VLSM revealed lesion correlates for all clinical and three robotic measures. The identified voxels were located in the white matter within or near the CST. These regions associated with proprioception were located posterior compared to those associated with motor performance. After rehabilitation the patients showed an improvement of all clinical and three robotic assessments. Improvement in the box and block test was associated with an area in anterior CST. Poor recovery of proprioception was correlated with a high lesion load in fibers towards primary sensorymotor cortex (S1 and M1 tract). Patients with loss of SSEP showed higher lesion loads in these tracts and somewhat poorer recovery of proprioception. The VSLM analysis for SSEP loss revealed a region within and dorsal of internal capsule next to the posterior part of CST, the posterior part of insula and the rolandic operculum.Lesions dorsal to internal capsule next to the posterior CST were associated with proprioceptive deficits and may have predictive value. Higher lesion load was correlated with poorer restoration of proprioceptive function. Furthermore, patients with SSEP loss trended towards poor recovery of proprioception, the corresponding lesions were also located in the same location. These findings suggest that structural imaging of the internal capsule and CST could serve as a recovery predictor of proprioceptive function.

In neurological patients, a lack of insight into their impairments can lead to possibly dangerous situations and non-compliance in rehabilitation therapy with worse rehabilitation outcomes as a result. This so called anosognosia is a multifaceted syndrome that can occur after brain damage affecting different neurological or cognitive functions. To our knowledge no study has investigated anosognosia for apraxia of common tool-use (CTU) so far. CTU-apraxia is a disorder frequently occurring after stroke that affects the use of familiar objects. Here, we introduce a new questionnaire to diagnose anosognosia for CTU-apraxia, the Visual Analogue Test assessing Anosognosia for Naturalistic Action Tasks (VATA-NAT). This assessment is adapted from a series of VATA-questionnaires that evaluate insight into motor (VATA-M) or language (VATA-L) impairment and take known challenges such as aphasia into account. Fifty one subacute stroke patients with left (LBD) or right (RBD) brain damage were investigated including patients with and without CTU-apraxia. Patients were assessed with the VATA-L, -M and -NAT before and after applying a diagnostics session for each function. Interrater reliability, composite reliability as well as convergent and divergent validity were evaluated for the VATA-NAT. Seven percent of the LBD patients with CTU-apraxia demonstrated anosognosia. After tool-use diagnostics this number increased to 20 percent. For the VATA-NAT, psychometric data revealed high interrater-reliability ( ≥ 0.828), composite reliability (CR ≥ 0.809) and convergent validity ( = -0.626). When assessing patients with severe aphasia, the possible influence of language comprehension difficulties needs to be taken into account for interpretation. Overall, close monitoring of anosognosia over the course of rehabilitation is recommended. With the VATA-NAT we hereby provide a novel assessment for anosognosia in patients with CTU-apraxia. For diagnosing anosognosia we recommend to combine this new tool with the existing VATA-M and -L subtests, particularly in patients who demonstrate severe functional deficits.

Background Motor deficits are the most common symptoms after stroke. There is some evidence that intensity and amount of exercises influence the degree of improvement of functions within the first 6 months after the injury. The purpose of this pilot study was to evaluate the feasibility and acceptance of semi-autonomous exercises with an upper extremity exoskeleton in addition to an inpatient rehabilitation program. In addition, changes of motor functions were examined. Methods Ten stroke patients with a severe upper extremity paresis were included. They were offered to perform a semi-autonomous training with a gravity-supported, computer-enhanced device (Armeo®Spring, Hocoma AG) six times per week for 4 weeks. Feasibility was evaluated by weekly structured interviews with patients and supervisors. Motor functions were assessed before and after the training period using the Wolf Motor Function Test (WMFT). The Wilcoxon Signed Rank Test was used for assessing pre-post differences. The Pearson correlation co-efficient was used for correlating the number of completed sessions with the change in motor function. Acceptance of the device and the level of satisfaction with the training were determined by a questionnaire based on visual analogue scales. Results Neither patients nor supervisors reported side effects. However, one patient had to be excluded from analysis because of transportation difficulties from the ward to the treatment facility. Therefore, analysis was based on nine patients. On average, 13.2 (55%) sessions were realized. WMFT results showed significant improvements of proximal arm functions. The number of sessions correlated with the degree of shoulder force improvement. Patients rated the exercises to be motivating, and enjoyable and would continue using the Armeo®Spring at home if they had the opportunity. Conclusion Using an upper extremity exoskeleton for semi-autonomous training in an inpatient setting is feasible without side effects and is positively rated by the patients. It might further support the recovery of upper extremity function. Trial registration The trial was retrospectively registered. Registration number ISRCTN42633681 .

Background Physical training is able to induce changes at neurophysiological and behavioral level associated with performance changes for the trained movements. The current study explores the effects of an additional intense robot-assisted upper extremity training on functional outcome and motor excitability in subacute stroke patients. Methods Thirty moderately to severely affected patients < 3 months after stroke received a conventional inpatient rehabilitation. Based on a case–control principle 15 patients were assigned to receive additional 45 min of robot-assisted therapy (Armeo ® Spring) 5 times per week (n = 15, intervention group, IG). The Fugl-Meyer Assessment for the Upper Extremity (FMA-UE) was chosen as primary outcome parameter. Patients were tested before and after a 3-week treatment period as well as after a follow-up period of 2 weeks. Using transcranial magnetic stimulation motor evoked potentials (MEPs) and cortical silent periods were recorded from the deltoid muscle on both sides before and after the intervention period to study effects at neurophysiological level. Statistical analysis was performed with non-parametric tests. Correlation analysis was done with Spearman´s rank correlation co-efficient. Results Both groups showed a significant improvement in FMA-UE from pre to post (IG: + 10.6 points, control group (CG): + 7.3 points) and from post to follow-up (IG: + 3.9 points, CG: + 3.3 points) without a significant difference between them. However, at neurophysiological level post-intervention MEP amplitudes were significantly larger in the IG but not in the CG. The observed MEP amplitudes changes were positively correlated with FMA-UE changes and with the total amount of robot-assisted therapy . Conclusion The additional robot-assisted therapy induced stronger excitability increases in the intervention group. However, this effect did not transduce to motor performance improvements at behavioral level. Trial registration The trial was registered in German Clinical Trials Register. Clinical trial registration number: DRKS00015083. Registration date: September 4th, 2018. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015083 . Registration was done retrospectively