'Haste makes waste': The tradeoff between walking speed and target-stepping accuracy.

BACKGROUND: When environmental conditions require accurate foot placement during walking (e.g., on a rough path), we typically walk slower to avoid tripping, slipping or stumbling. Likewise, hurrying too much is a common situational circumstance of walking-related falls. This suggests a tradeoff between walking speed and stepping accuracy in situations that demand precise foot placement. RESEARCH QUESTION: How can this expected tradeoff between walking speed and stepping accuracy best be parameterized? METHODS: In Experiment 1, participants (n = 20) walked at five different speeds over an irregularly spaced sequence of projected stepping targets. Participants were instructed to place their feet accurately onto the targets, while following a constant-speed cue running alongside the walkway. Stepping accuracy was parameterized as overall (RMSE, root mean square error), variable (VE) and constant (CE) stepping errors, quantified over targets as well as per target. In Experiment 2, we determined preferred walking speed and stepping accuracy for regularly and irregularly spaced stepping targets. RESULTS: Repeated-measures ANOVAs revealed that RMSE and VE grew linearly with increasing speeds, both over targets as well as per target. Per target CE varied in magnitude and sign with variations in inter-target spacing: for shorter inter-target spacing targets were overshot (CE > 0), while for longer inter-target spacing targets were undershot (CE < 0). This effect was stronger for faster speeds and for targets preceded by the shortest and longest inter-target spacing. Preferred walking speed and per-target VE did not differ between regularly and irregularly spaced targets. SIGNIFICANCE: Participants stepped less precisely when walking faster. The linear increase in VE with faster speeds was consistent with Schmidt's law regarding the speed-accuracy tradeoff. The systematic comparison of stepping errors over regularly and irregularly spaced stepping-target conditions further provided important clues on how to best parameterize stepping accuracy: per stepping target using VE (i.e., stepping inconsistency), complemented with CE (i.e., stepping bias) in case of irregular inter-target spacing.

A Re-Appraisal of the Effect of Amplitude on the Stability of Interlimb Coordination Based on Tightened Normalization Procedures.

The stability of rhythmic interlimb coordination is governed by the coupling between limb movements. While it is amply documented how coordinative performance depends on movement frequency, theoretical considerations and recent empirical findings suggest that interlimb coupling (and hence coordinative stability) is actually mediated more by movement amplitude. Here, we present the results of a reanalysis of the data of Post, Peper, and Beek (2000), which were collected in an experiment aimed at teasing apart the effects of frequency and amplitude on coordinative stability of both steady-state and perturbed in-phase and antiphase interlimb coordination. The dataset in question was selected because we found indications that the according results were prone to artifacts, which may have obscured the potential effects of amplitude on the post-perturbation stability of interlimb coordination. We therefore redid the same analysis based on movement signals that were normalized each half-cycle for variations in oscillation center and movement frequency. With this refined analysis we found that (1) stability of both steady-state and perturbed coordination indeed seemed to depend more on amplitude than on movement frequency per se, and that (2) whereas steady-state antiphase coordination became less stable with increasing frequency for prescribed amplitudes, in-phase coordination became more stable at higher frequencies. Such effects may have been obscured in previous studies due to (1) unnoticed changes in performed amplitudes, and/or (2) artifacts related to inappropriate data normalization. The results of the present reanalysis therefore give cause for reconsidering the relation between the frequency, amplitude, and stability of interlimb coordination.

Virtual Footprints Can Improve Walking Performance in People With Parkinson's Disease.

In Parkinson's disease (PD) self-directed movement, such as walking, is often found to be impaired while goal directed movement, such as catching a ball, stays relatively unaltered. This dichotomy is most clearly observed when sensory cueing techniques are used to deliver patterns of sound and/or light which in turn act as an external guide that improves gait performance. In this study we developed visual cues that could be presented in an immersive, interactive virtual reality (VR) environment. By controlling how the visual cues (black footprints) were presented, we created different forms of spatial and temporal information. By presenting the black footprints at a pre-specified distance apart we could recreate different step lengths (spatial cues) and by controlling when the black footprints changed color to red, we could convey information about the timing of the foot placement (temporal cues). A group of healthy controls (HC; N = 10) and a group of idiopathic PD patients (PD, N = 12) were asked to walk using visual cues that were tailored to their own gait performance [two spatial conditions (115% [N] and 130% [L] of an individual's baseline step length) and three different temporal conditions (spatial only condition [NT], 100 and 125% baseline step cadence)]. Both groups were found to be able to match their gait performance (step length and step cadence) to the information presented in all the visual cue conditions apart from the 125% step cadence conditions. In all conditions the PD group showed reduced levels of gait variability (p < 0.05) while the HC group did not decrease. For step velocity there was a significant increase in the temporal conditions, the spatial conditions and of the interaction between the two for both groups of participants (p < 0.05). The coefficient of variation of step length, cadence, and velocity were all significantly reduced for the PD group compared to the HC group. In conclusion, our results show how virtual footsteps presented in an immersive, interactive VR environment can significantly improve gait performance in participants with Parkinson's disease.

Crossing Virtual Doors: A New Method to Study Gait Impairments and Freezing of Gait in Parkinson's Disease.

Studying freezing of gait (FOG) in the lab has proven problematic. This has primarily been due to the difficulty in designing experimental setups that maintain high levels of ecological validity whilst also permitting sufficient levels of experimental control. To help overcome these challenges, we have developed a virtual reality (VR) environment with virtual doorways, a situation known to illicit FOG in real life. To examine the validity of this VR environment, an experiment was conducted, and the results were compared to a previous "real-world" experiment. A group of healthy controls (N = 10) and a group of idiopathic Parkinson disease (PD) patients without any FOG episodes (N = 6) and with a history of freezing (PD-f, N = 4) walked under three different virtual conditions (no door, narrow doorway (100% of shoulder width) and standard doorway (125% of shoulder width)). The results were similar to those obtained in the real-world setting. Virtual doorways reduced step length and velocity while increasing general gait variability. The PD-f group always walked slower, with a smaller step length, and showed the largest increases in gait variability. The narrow doorway induced FOG in 66% of the trials, while the standard doorway caused FOG in 29% of the trials. Our results closely mirrored those obtained with real doors. In short, this methodology provides a safe, personalized yet adequately controlled means to examine FOG in Parkinson's patients, along with possible interventions.

Autism in Action: Reduced Bodily Connectedness during Social Interactions?

Autism is a lifelong disorder, defined by deficits in social interactions and flexibility. To date, diagnostic markers for autism primarily include limitations in social behavior and cognition. However, such tests have often shown to be inadequate for individuals with autism who are either more cognitively able or intellectually disabled. The assessment of the social limitations of autism would benefit from new tests that capture the dynamics of social initiative and reciprocity in interaction processes, and that are not dependent on intellectual or verbal skills. New entry points for the development of such assessments may be found in 'bodily connectedness', the attunement of bodily movement between two individuals. In typical development, bodily connectedness is related to psychological connectedness, including social skills and relation quality. Limitations in bodily connectedness could be a central mechanism underlying the social impairment in autism. While bodily connectedness can be minutely assessed with advanced techniques, our understanding of these skills in autism is limited. This Perspective provides examples of how the potential relation between bodily connectedness and specific characteristics of autism can be examined using methods from the coordination dynamics approach. Uncovering this relation is particularly important for developing sensitive tools to assess the tendency to initiate social interactions and the dynamics of mutual adjustments during social interactions, as current assessments are not suited to grasp ongoing dynamics and reciprocity in behavior. The outcomes of such research may yield valuable openings for the development of diagnostic markers for autism that can be applied across the lifespan.

Attentional costs of walking are not affected by variations in lateral balance demands in young and older adults.

Increased attentional costs of walking in older adults have been attributed to age-related changes in visuomotor and/or balance control of walking. The present experiment was conducted to examine the hypothesis that attentional costs of walking vary with lateral balance demands during walking in young and older adults. Twenty young and twenty older adults walked on a treadmill at their preferred walking speed under five conditions: unconstrained normal walking, walking on projected visual lines corresponding to either the participant's preferred step width or 50% thereof (i.e. increased balance demand), and walking within low- and high-stiffness lateral stabilization frames (i.e. lower balance demands). Attentional costs were assessed using a probe reaction-time task during these five walking conditions, normalized to baseline performance as obtained during sitting. Both imposed step-width conditions were more attentionally demanding than the three other conditions, in the absence of any other significant differences between conditions. These effects were similar in the two groups. The results indicate that the attentional costs of walking were, in contrast to what has been postulated previously, not influenced by lateral balance demands. The observed difference in attentional costs between normal walking and both visual lines conditions suggests that visuomotor control processes, rather than balance control, strongly affect the attentional costs of walking. A tentative explanation of these results may be that visuomotor control processes are mainly governed by attention-demanding cortical processes, whereas balance is regulated predominantly subcortically.

Does interpersonal movement synchronization differ from synchronization with a moving object?

We examined whether movement synchronization is different during coordination with another person than during coordination with a moving object. In addition, the influence of belief in the other person's agency was assessed. Participants synchronized their lower-arm movements with a computer-controlled rhythmic reference movement. The reference movements were pre-recorded, biological movements and were identical in all conditions. They were presented either by means of a confederate's arm in a motor-driven manipulandum or by means of movements of the manipulandum alone. To assess the influence of the belief in the confederate's agency, participants either were or were not informed that the confederate's movements were motor driven. The strength of coupling between the participant's movements and the reference movements was assessed in terms of the standard deviation of relative phase and the time needed to re-establish the coordination pattern after an unexpected perturbation of the reference signal. Mean relative phase indicated whether the participant was leading or lagging the reference movements. Coupling strength was not affected by the presence of another person in the coordination task, nor by the belief in this person's agency. However, participants had a stronger tendency to lead while synchronizing with the manipulandum, indicating that they responded differently to the observed kinematics of this moving object than to the kinematics of the confederate's arm movements, at least when the confederate's agency was assumed. Hence, although neither the involvement of another person nor the participant's belief in this person's agency affected coupling strength, the form of the coupling seemed to be influenced by the former factor, suggesting a different attunement to the reference movements during a joint-action situation. Future research is required to determine whether these interpretations extend to unintentional and bidirectional coordination, in which agency is not only assumed but actually effectuated.

Attuning one's steps to visual targets reduces comfortable walking speed in both young and older adults.

Comfortable walking speed (CWS) is indicative of clinically relevant factors in the elderly, such as fall risk and mortality. Standard CWS tests involve walking on a straight, unobstructed surface, while in reality surfaces are uneven and cluttered and so walkers rely on visually guided adaptations to avoid trips or slips. Hence, the predictive value of CWS may be expected to increase when assessed for walking in more realistic (visually guided) conditions. We examined CWS in young (n=18) and older (n=18) adults for both overground and treadmill walking. Overground CWS was assessed using the 10-meter walk test with and without visual stepping targets. For treadmill walking, four conditions were examined: (i) uncued walking, and (ii-iv) cued walking with visual stepping targets where the inter-stepping target distance varied by 0%, 20%, or 40%. Pre-experimental measures were taken so that the average inter-stepping target distance could be adjusted for each belt speed based on each participant's self-selected gait characteristics. Results showed that CWS was significantly slower when stepping targets were present in both overground (p<.001) and treadmill walking (p<.001). Thus, attuning steps to visual targets significantly affected CWS, even when the patterning of these targets matched the participant's own gait pattern (viz. 0%-treadmill-walking condition). Results from the treadmill-walking task showed that the amount of variation in inter-stepping target distance did not differentially affect CWS. Our results suggest that it may be worthwhile in clinical assessments to not only determine walking speed using standard conditions but also in situations that require visually guided stepping.

Unilateral and bilateral upper-limb training interventions after stroke have similar effects on bimanual coupling strength.

BACKGROUND: Bilateral training in poststroke upper-limb rehabilitation is based on the premise that simultaneous movements of the nonparetic upper limb facilitate performance and recovery of paretic upper-limb function through neural coupling effects. OBJECTIVE: To determine whether the degree of coupling between both hands is higher after bilateral than after unilateral training and control treatment. METHODS: In a single-blinded randomized controlled trial, we investigated rhythmic interlimb coordination after unilateral (mCIMT) and bilateral (mBATRAC) upper-limb training and a dose-matched control treatment (DMCT) in 60 patients suffering from stroke. To this end, we used a series of tasks to discern intended and unintended coupling effects between the hands. In addition, we investigated the control over the paretic hand as reflected by movement harmonicity and amplitude. All tasks were performed before and after a 6-week intervention period and at follow-up 6 weeks later. RESULTS: There were no significant between-group differences in change scores from baseline to postintervention and from postintervention to follow-up with regard to interlimb coupling. However, the mBATRAC group showed greater movement harmonicity and larger amplitudes with the paretic hand after training than the mCIMT and DMCT groups. CONCLUSIONS: The degree of coupling between both hands was not significantly higher after bilateral than after unilateral training and control treatment. Although improvements in movement harmonicity and amplitude following mBATRAC may indicate a beneficial influence of the interlimb coupling, those effects were more likely due to the particular type of limb movements employed during this training protocol.

Attentional costs of visually guided walking: effects of age, executive function and stepping-task demands.

During walking, attention needs to be flexibly allocated to deal with varying environmental constraints. This ability may be affected by aging and lower overall executive function. The present study examined the influence of aging and executive function on the attentional costs of visually guided walking under different task demands. Three groups, young adults (n=15) and elderly adults with higher (n=16) and lower (n=10) executive function, walked on a treadmill in three conditions: uncued walking and walking with regular and irregular patterns of visual stepping targets projected onto the belt. Attentional costs were assessed using a secondary probe reaction time task and corrected by subtracting baseline single-task reaction time, yielding an estimate of the additional attentional costs of each walking condition. We found that uncued walking was more attentionally demanding for elderly than for young participants. In young participants, the attentional costs increased significantly from uncued to regularly cued to irregularly cued walking, whereas for the higher executive function group, attentional costs only increased significantly from regularly cued to irregularly cued walking. For the group with lower executive function, no significant differences were observed. The observed decreased flexibility of elderly, especially those with lower executive function, to allocate additional attentional resources to more challenging walking conditions may be attributed to the already increased attentional costs of uncued walking, presumably required for visuomotor and/or balance control of walking.

Evaluation of mirrored muscle activity in patients with Complex Regional Pain Syndrome.

OBJECTIVE: Motor dysfunction in Complex Regional Pain Syndrome (CRPS) has been associated with bilateral changes in central motor processing, suggesting abnormal coupling between the affected and unaffected limb. We evaluated the occurrence of involuntary muscle activity in a limb during voluntary movements of the contralateral limb (i.e., mirror activity) in unilaterally affected patients to examine disinhibition of contralateral motor activity in CRPS. METHODS: Mirror activity was examined during unimanual rhythmic flexion-extension movements of the wrist through in-depth analysis of electromyography recordings from the passive arm in 20 CRPS patients and 40 controls. RESULTS: The number of mirror-epochs was comparable for both arms in both CRPS patients and controls. Mirror-epochs in the affected arm of patients were comparable to those in controls. Mirror-epochs in the unaffected arm were shorter and showed less resemblance (in terms of rhythm and timing) to activity of the homologous muscle in the moving arm compared to mirror-epochs in controls. CONCLUSIONS: No evidence for disinhibition of contralateral motor activity was found during unimanual movement. SIGNIFICANCE: Although motor dysfunction in CRPS has been associated with bilateral changes in cortical motor processing, the present findings argue against disinhibition of interhemispheric projections to homologous muscles in the contralateral limb during unimanual movement.

Individual contributions to (re-)stabilizing interpersonal movement coordination.

Interpersonal movement coordination is characterized by stable coordination patterns. We examined the extent to which the two individuals within a dyad contributed to the stabilization of a shared coordination pattern. Within each dyad, the two participants coordinated rhythmic movements of their right lower arms in either in-phase or antiphase. We analyzed the responses to precisely controlled mechanical perturbations to one of the arms that disrupted the coordination pattern. Return to the original coordination pattern did not only involve phase adaptations in the perturbed arm, but in the unperturbed arm as well. Hence, the coupling between the companions was bidirectional and subserved the coordinative stability. Moreover, for both coordination patterns the interpersonal coupling was near symmetrical, with both actors (perturbed and unperturbed) contributing to the same extents to the restabilization of the coordination between them. The applied methodology provides a new entry point to examine asymmetries in interpersonal coupling, due to, for instance, social impairments, differences in social competence, or particular task setting.

Motor dysfunction of complex regional pain syndrome is related to impaired central processing of proprioceptive information.

UNLABELLED: Our understanding of proprioceptive deficits in complex regional pain syndrome (CRPS) and its potential contribution to impaired motor function is still limited. To gain more insight into these issues, we evaluated accuracy and precision of joint position sense over a range of flexion-extension angles of the wrist of the affected and unaffected sides in 25 chronic CRPS patients and in 50 healthy controls. The results revealed proprioceptive impairment at both the patients' affected and unaffected sides, characterized predominantly by overestimation of wrist extension angles. Precision of the position estimates was more prominently reduced at the affected side. Importantly, group differences in proprioceptive performance were observed not only for tests at identical percentages of each individual's range of wrist motion but also when controls were tested at wrist angles that corresponded to those of the patient's affected side. More severe motor impairment of the affected side was associated with poorer proprioceptive performance. Based on additional sensory tests, variations in proprioceptive performance over the range of wrist angles, and comparisons between active and passive displacements, the disturbances of proprioceptive performance most likely resulted from altered processing of afferent (and not efferent) information and its subsequent interpretation in the context of a distorted "body schema." PERSPECTIVE: The present results point at a significant role for impaired central processing of proprioceptive information in the motor dysfunction of CRPS and suggest that therapeutic strategies aimed at identification of proprioceptive impairments and their restoration may promote the recovery of motor function in CRPS patients.

Unilateral versus bilateral upper limb training after stroke: the Upper Limb Training After Stroke clinical trial.

BACKGROUND AND PURPOSE: Unilateral and bilateral training protocols for upper limb rehabilitation after stroke represent conceptually contrasting approaches with the same ultimate goal. In a randomized controlled trial, we compared the merits of modified constraint-induced movement therapy, modified bilateral arm training with rhythmic auditory cueing, and a dose-matched conventional treatment. Modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing targeted wrist and finger extensors, given their importance for functional recovery. We hypothesized that modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing are superior to dose-matched conventional treatment. METHODS: Sixty patients, between 1 to 6 months after stroke, were randomized over 3 intervention groups. The primary outcome measure was the Action Research Arm test, which was conducted before, directly after, and 6 weeks after intervention. RESULTS: Although all groups demonstrated significant improvement on the Action Research Arm test after intervention, which persisted at 6 weeks follow-up, no significant differences in change scores on the Action Research Arm test were found between groups postintervention and at follow-up. CONCLUSIONS: Modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing are not superior to dose-matched conventional treatment or each other in improving upper limb motor function 1 to 6 months after stroke. CLINICAL TRIAL REGISTRATION URL: http://www.trialregister.nl. Unique identifier: NTR1665.

Biases in rhythmic sensorimotor coordination: effects of modality and intentionality.

Sensorimotor biases were examined for intentional (tracking task) and unintentional (distractor task) rhythmic coordination. The tracking task involved unimanual tracking of either an oscillating visual signal or the passive movements of the contralateral hand (proprioceptive signal). In both conditions the required coordination patterns (isodirectional and mirror-symmetric) were defined relative to the body midline and the hands were not visible. For proprioceptive tracking the two patterns did not differ in stability, whereas for visual tracking the isodirectional pattern was performed more stably than the mirror-symmetric pattern. However, when visual feedback about the unimanual hand movements was provided during visual tracking, the isodirectional pattern ceased to be dominant. Together these results indicated that the stability of the coordination patterns did not depend on the modality of the target signal per se, but on the combination of sensory signals that needed to be processed (unimodal vs. cross-modal). The distractor task entailed rhythmic unimanual movements during which a rhythmic visual or proprioceptive distractor signal had to be ignored. The observed biases were similar as for intentional coordination, suggesting that intentionality did not affect the underlying sensorimotor processes qualitatively. Intentional tracking was characterized by active sensory pursuit, through muscle activity in the passively moved arm (proprioceptive tracking task) and rhythmic eye movements (visual tracking task). Presumably this pursuit afforded predictive information serving the coordination process.

Deficient muscle activation in patients with Complex Regional Pain Syndrome and abnormal hand postures: an electromyographic evaluation.

OBJECTIVE: Motor abnormalities in Complex Regional Pain Syndrome (CRPS) are common and often characterized by a restricted active range of motion (AROM) and an increased resistance to passive movements, whereby the affected body part preferably adopts an abnormal posture. The objective of the present study was to obtain a better understanding of the factors that are associated with these abnormal postures and limitations of the AROM, and to investigate whether these motor impairments reflect dystonia. METHODS: We evaluated characteristics of surface EMG of the flexor carpi radialis and extensor carpi radialis muscles during active maintenance of various flexion-extension postures of the wrist of the affected and unaffected side in 15 chronic CRPS patients, and in 15 healthy controls. RESULTS: Deviant joint postures in chronic CRPS - at least in those patients with some range of active movement - were not characterized by sustained muscle contractions, and limitations of the AROM were not attributable to excessive co-contraction. Rather, the agonistic muscle and its antagonist were activated in normal proportions, albeit over a limited range. CONCLUSIONS: The AROM limitations and abnormal postures that are often observed in chronic CRPS patients are not associated with excessive muscle activity and hence do not exhibit the characteristics typical of dystonia. SIGNIFICANCE: We hypothesize that structural alterations in skeletal muscle tissue and pain-induced adaptations of motor function may contribute to the observed motor impairments. Our findings may have important clinical implications, since commonly prescribed treatments are aimed at reducing excessive muscle contraction.

Match and mismatch between objective and subjective improvements in upper limb function after stroke.

PURPOSE: To identify stroke patients showing a match between an objectively meaningful improvement in upper-limb motor capacity and subjectively meaningful improvement in upper-limb performance after stroke, as well as determinants of matching and non-matching. METHODS: Changes in upper-limb capacity in 39 stroke patients were measured over 17 weeks using the Action Research Arm Test (ARAT). Subjective change was measured with the Stroke Impact Scale Hand domain (SIS-Hand) and the Motor Activity Log (MAL). Patients showing a match between objective and subjective improvements (matchers) and patients showing a mismatch (non-matchers) were identified. Subsequently, determinants for the matchers were modeled using a logistic regression analysis. RESULTS: A significant association was found between improvements on the ARAT and MAL (p = 0.011), but not for improvements on the ARAT and SIS-Hand. For the ARAT and SIS-Hand level of education and mood significantly improved the model. The probability of a match between objective and subjective outcomes in lower-educated patients with a positive mood was estimated to be 0.83, whereas in higher-educated patients with a negative mood it was estimated to be 0.07. CONCLUSIONS: Mismatches between objective and subjective outcomes are relevant for practitioners evaluating rehabilitation goals, and for defining outcome variables in future upper limb rehabilitation trials. Implications for Rehabilitation In upper limb rehabilitation after stroke, a match between capacity and self-perception outcome measures is not self-evident. Regarding these potential mismatches, practitioners and patients should consider carefully which goals to set, and how to evaluate upper limb rehabilitation after stroke; preferably with capacity measures and self-perception measures combined.

Bimanual training for children with cerebral palsy: exploring the effects of Lissajous-based computer gaming.

OBJECTIVE: Hemiplegic cerebral palsy often results in impaired bimanual coordination, partly due to strong coupling between the arms. We aimed at inducing more flexibility in this coupling, to improve bimanual coordination. METHODS: We designed computer games involving simple perceptual goals, based on Lissajous feedback. Such feedback implicitly facilitates the performance of complex rhythmic bimanual coordination patterns. A sample of six children received 9 h of computer training over a 6 weeks period. The effects of this training on functional bimanual performance were explored using the Assisting Hand Assessment (AHA). RESULTS: Gaming performance and bimanual rhythmic antiphase coordination improved after training. The AHA results were mixed. Two children improved significantly, but at a group level no significant effects were found. CONCLUSIONS: The results were evaluated in relation to the specificity of the AHA and the potential benefit of combining the proposed training with dedicated bimanual functional training programs.

Learning a new bimanual coordination pattern: interlimb interactions, attentional focus, and transfer.

Because bimanual coordinative stability is governed by interlimb coupling, we examined how learning a new pattern (90°) was reflected in changes in the underlying interlimb interactions. Three interlimb interaction sources were distinguished: integrated timing of feedforward control signals, error corrections based on perceived relative phase, and phase entrainment by contralateral afference. By comparing 4 tasks that involve these interactions to a different extent, changes in the stabilizing contributions of these coupling sources could be studied. Furthermore, we studied how the learning process and changes in the underlying interactions were influenced by attentional focus (internal vs. external), and we examined retention of the learned pattern and transfer to the mirror-symmetrical pattern (270°). Results showed that stability and accuracy of the new pattern increased significantly with learning, due to improved integrated timing and error correction. Integrated timing improved first, possibly providing a reference frame for the error corrections that subsequently became more effective. Despite some qualitative differences in the learning process, neither performance of the learned pattern nor the underlying interlimb interactions was influenced by attentional focus. Whereas the learned pattern improved directly after practice, transfer followed later, suggesting that a more general representation was formed at a slower rate after practice.

A systematic review of bilateral upper limb training devices for poststroke rehabilitation.

Introduction. In stroke rehabilitation, bilateral upper limb training is gaining ground. As a result, a growing number of mechanical and robotic bilateral upper limb training devices have been proposed. Objective. To provide an overview and qualitative evaluation of the clinical applicability of bilateral upper limb training devices. Methods. Potentially relevant literature was searched in the PubMed, Web of Science, and Google Scholar databases from 1990 onwards. Devices were categorized as mechanical or robotic (according to the PubMed MeSH term of robotics). Results. In total, 6 mechanical and 14 robotic bilateral upper limb training devices were evaluated in terms of mechanical and electromechanical characteristics, supported movement patterns, targeted part and active involvement of the upper limb, training protocols, outcomes of clinical trials, and commercial availability. Conclusion. Initial clinical results are not yet of such caliber that the devices in question and the concepts on which they are based are firmly established. However, the clinical outcomes do not rule out the possibility that the concept of bilateral training and the accompanied devices may provide a useful extension of currently available forms of therapy. To actually demonstrate their (surplus) value, more research with adequate experimental, dose-matched designs, and sufficient statistical power are required.