Long-Term Plasticity in Reflex Excitability Induced by Five Weeks of Arm and Leg Cycling Training after Stroke.

Neural connections remain partially viable after stroke, and access to these residual connections provides a substrate for training-induced plasticity. The objective of this project was to test if reflex excitability could be modified with arm and leg (A & L) cycling training. Nineteen individuals with chronic stroke (more than six months postlesion) performed 30 min of A & L cycling training three times a week for five weeks. Changes in reflex excitability were inferred from modulation of cutaneous and stretch reflexes. A multiple baseline (three pretests) within-subject control design was used. Plasticity in reflex excitability was determined as an increase in the conditioning effect of arm cycling on soleus stretch reflex amplitude on the more affected side, by the index of modulation, and by the modulation ratio between sides for cutaneous reflexes. In general, A & L cycling training induces plasticity and modifies reflex excitability after stroke.

Exploiting Interlimb Arm and Leg Connections for Walking Rehabilitation: A Training Intervention in Stroke.

Rhythmic arm and leg (A&L) movements share common elements of neural control. The extent to which A&L cycling training can lead to training adaptations which transfer to improved walking function remains untested. The purpose of this study was to test the efficacy of A&L cycling training as a modality to improve locomotor function after stroke. Nineteen chronic stroke (>six months) participants were recruited and performed 30 minutes of A&L cycling training three times a week for five weeks. Changes in walking function were assessed with (1) clinical tests; (2) strength during isometric contractions; and (3) treadmill walking performance and cutaneous reflex modulation. A multiple baseline (3 pretests) within-subject control design was used. Data show that A&L cycling training improved clinical walking status increased strength by ~25%, improved modulation of muscle activity by ~25%, increased range of motion by ~20%, decreased stride duration, increased frequency, and improved modulation of cutaneous reflexes during treadmill walking. On most variables, the majority of participants showed a significant improvement in walking ability. These results suggest that exploiting arm and leg connections with A&L cycling training, an accessible and cost-effective training modality, could be used to improve walking ability after stroke.

Neuromechanical interactions between the limbs during human locomotion: an evolutionary perspective with translation to rehabilitation.

During bipedal locomotor activities, humans use elements of quadrupedal neuronal limb control. Evolutionary constraints can help inform the historical ancestry for preservation of these core control elements support transfer of the huge body of quadrupedal non-human animal literature to human rehabilitation. In particular, this has translational applications for neurological rehabilitation after neurotrauma where interlimb coordination is lost or compromised. The present state of the field supports including arm activity in addition to leg activity as a component of gait retraining after neurotrauma.

Neural control of rhythmic arm cycling after stroke.

Disordered reflex activity and alterations in the neural control of walking have been observed after stroke. In addition to impairments in leg movement that affect locomotor ability after stroke, significant impairments are also seen in the arms. Altered neural control in the upper limb can often lead to altered tone and spasticity resulting in impaired coordination and flexion contractures. We sought to address the extent to which the neural control of movement is disordered after stroke by examining the modulation pattern of cutaneous reflexes in arm muscles during arm cycling. Twenty-five stroke participants who were at least 6 mo postinfarction and clinically stable, performed rhythmic arm cycling while cutaneous reflexes were evoked with trains (5 × 1.0-ms pulses at 300 Hz) of constant-current electrical stimulation to the superficial radial (SR) nerve at the wrist. Both the more (MA) and less affected (LA) arms were stimulated in separate trials. Bilateral electromyography (EMG) activity was recorded from muscles acting at the shoulder, elbow, and wrist. Analysis was conducted on averaged reflexes in 12 equidistant phases of the movement cycle. Phase-modulated cutaneous reflexes were present, but altered, in both MA and LA arms after stroke. Notably, the pattern was "blunted" in the MA arm in stroke compared with control participants. Differences between stroke and control were progressively more evident moving from shoulder to wrist. The results suggest that a reduced pattern of cutaneous reflex modulation persists during rhythmic arm movement after stroke. The overall implication of this result is that the putative spinal contributions to rhythmic human arm movement remain accessible after stroke, which has translational implications for rehabilitation.

Persistence of locomotor-related interlimb reflex networks during walking after stroke.

OBJECTIVE: Cutaneous nerve stimulation evokes coordinated and phase-modulated reflex output widely distributed to muscles of all four limbs during walking. Accessibility to this distributed network after stroke offers insight into the pathological changes and suggests utility for therapeutic applications. Here we examined muscles in both the more (MA) and less affected (LA) legs evoked by stimulation at the ankle and wrist during walking in chronic (>6 months post CVA) stroke. METHODS: Stroke and control participants walked on a treadmill with a harness support system. Reflexes were evoked with trains of electrical stimuli delivered separately to the cutaneous superficial peroneal (SP; at the ankle) and superficial radial (SR; at the wrist) nerves. Background locomotor and reflex EMG were phase-averaged across the gait cycle and analyzed off line. RESULTS: Locomotor background muscle activation patterns were altered bilaterally in stroke, as compared with control. Phase-dependent modulation of interlimb cutaneous reflexes was found in both stroke and control subjects with stimulation of each nerve, but responses were blunted in stroke. Reflex reversal in tibialis anterior (TA) at heel strike with SP nerve stimulation was present in both groups. Notably, SR nerve stimulation produced facilitation during the swing-to-stance transition in the TA and suppression of MG in the MA leg during stance. CONCLUSIONS: Interlimb cutaneous inputs may access coordinated reflex pathways in the MA limb during walking after stroke. Importantly activation in these pathways could provoke responses to counter foot drop during swing phase of walking. Additionally, our data support the perspective that there is no "unaffected" side after stroke and that caution should be used when interpreting the LA side as "control" after stroke. SIGNIFICANCE: The presence of functionally-relevant interlimb cutaneous reflexes in the MA leg presents a substrate that may be strengthened by rehabilitation.

Context-dependent modulation of cutaneous reflex amplitudes during forward and backward leg cycling.

We used amplitude modulation of cutaneous reflexes during leg cycling as a paradigm to investigate neural control mechanisms regulating forward (FWD) and backward (BWD) rhythmic limb movement. Our prediction was a simple reversal of reflex modulation during BWD leg cycling and context-dependent reflex modulation. Cutaneous reflexes were evoked by electrical stimulation delivered to the superficial peroneal (SP) and distal tibial (TIB) nerves at the ankle. EMG recordings were collected from muscles acting at the hip, knee, and ankle. Kinematic data were also collected at these joints. Cutaneous reflexes were analyzed according to the phase of movement in which they were evoked. When functional phases (i.e., flexion or extension) of cycling were matched between FWD and BWD, background EMG and reflex modulation patterns were generally similar. The reflex patterns when compared at similar functional phases presented as a simple reversal suggesting FWD and BWD cycling are regulated by similar neural mechanisms. The general reflex regulation of limb trajectory was maintained between cycling directions in accordance with the task requirements of the movement direction.

Neural regulation of rhythmic arm and leg movement is conserved across human locomotor tasks.

It has been proposed that different forms of rhythmic human limb movement have a common central neural control ('common core hypothesis'), just as in other animals. We compared the modulation patterns of background EMG and cutaneous reflexes during walking, arm and leg cycling, and arm-assisted recumbent stepping. We hypothesized that patterns of EMG and reflex modulation during cycling and stepping (deduced from mathematical principal components analysis) would be comparable to those during walking because they rely on similar neural substrates. Differences between the tasks were assessed by evoking cutaneous reflexes via stimulation of nerves in the foot and hand in separate trials. The EMG was recorded from flexor and extensor muscles of the arms and legs. Angular positions of the hip, knee and elbow joints were also recorded. Factor analysis revealed that across the three tasks, four principal components explained more than 93% of the variance in the background EMG and middle-latency reflex amplitude. Phase modulation of reflex amplitude was observed in most muscles across all tasks, suggesting activity in similar control networks. Significant correlations between EMG level and reflex amplitude were frequently observed only during static voluntary muscle activation and not during rhythmic movement. Results from a control experiment showed that strong correlation between EMG and reflex amplitudes was observed during discrete, voluntary leg extension but not during walking. There were task-dependent differences in reflex modulation between the three tasks which probably arise owing to specific constraints during each task. Overall, the results show strong correlation across tasks and support common neural patterning as the regulator of arm and leg movement during various rhythmic human movements.

Rhythmic arm cycling produces a non-specific signal that suppresses Soleus H-reflex amplitude in stationary legs.

Rhythmic arm cycling significantly suppresses Hoffmann (H-) reflex amplitude in Soleus muscles of stationary legs. The specific parameters of arm cycling contributing to this suppression, however, are unknown. Between the arms or legs, movement results in suppression of the H-reflex that is specifically related to the phase of movement and the locus of limb movement. We speculated that the effects of arm movement features on H-reflexes in the leg would be similar and hypothesized that the Soleus H-reflex suppression evoked by arm movement would therefore be specifically related to: (1) phase of the movement; (2) the locus of the movement (i.e., ipsilateral or contralateral arm); (3) range of arm motion; and (4) frequency of arm cycling. Participants performed bilateral arm cycling at 1 and 2 Hz with short and long-crank lengths. Ipsilateral and contralateral arm cycling was also performed at 1 Hz with a long-crank length. Soleus H-reflexes were evoked at four equidistant phases and comparisons were made while maintaining similar evoked motor waves and Soleus activation. Our results show that comparable suppressive effects were seen at all phases of the arm movement: there was no phase-dependence. Further, bilateral or unilateral (whether ipsi- or contralateral arm) cycling yielded equivalent suppression of the H-reflex amplitude. Cycling at 2 Hz resulted in a significantly larger suppression than with 1 Hz cycling. We conclude that a general, rather than a specific, signal related to the command to produce rhythmic arm muscle activity mediates the suppression of Soleus H-reflex during arm cycling.