Sensory Motor Control

In clinical practice, the upper limb function of hemiplegic post-stroke patients is commonly evaluated using clinical tests and questionnaires. Performing a reliable investigation of compensatory strategies adopted for the upper limb movement may shed light on the basis of motor control and the mechanism of functional recovery. To quantitatively evaluate the compensatory strategies in post-stroke hemiplegic patients, we conducted an observational study in which 36 hemiplegic patients were enrolled and were stratified according to the Fugl-Meyer score. We assessed compensatory strategies in upper limb movements, specifically reaching (RCH) and hand-to-mouth (HTM) movements, using the Kinect V2 device. 11 severe, 8 severe-moderate, 9 moderate-mild, and 8 mild patients and 17 controls participated in the study. Our results showed that severe, severe‑moderate, and moderate‑mild patients can be discriminated from healthy participants in almost all parameters. In particular, patients showed a reduced ROM of the shoulder in RCH, higher shoulder and elbow vertical displacement, and lower wrist vertical displacement in HTM. Interestingly, compensatory parameters also discriminate mild patients from healthy controls, such as head frontal and vertical displacements. Our protocol works effectively and the instrumental assessment of compensatory strategies in post-stroke patients allows to discriminate different levels of impairments even with low-cost devices.

Background: Telerehabilitation is a promising solution to provide continuity of care. Most existing telerehabilitation platforms focus on rehabilitating upper limbs, balance, and cognitive training, but exercises improving cardiovascular fitness are often neglected. Objective: The objective of this study is to evaluate the acceptability and feasibility of a telerehabilitation intervention combining cognitive and aerobic exercises. Methods: A virtual reality-based dual-task exercise exploiting a cycle ergometer was designed, developed, and integrated with a commercially available telerehabilitation platform. Patients with different conditions were enrolled and administered subjective questionnaires investigating attitudes toward technology, usability, technology acceptance, and subjective workload. Their therapists were interviewed, and adherence and performance data were analyzed. Results: In total, 26 patients with neurological or post‑COVID symptoms were included. Their attitude toward technology (range: 0‑5) did not change after the training period (pre: 3.44 [IQR 0.63]; post: 3.50 [IQR 0.48]); the platform was rated usable and acceptable. Frustration and physical and mental workload were present, especially among younger participants. The adherence was moderate, but individual differences were present (0.59 [IQR 0.54]). The therapists highlighted the potential of remote rehabilitation programs but also identified some limitations. Conclusions: This study proved the feasibility and acceptability of a customized virtual reality‑based telerehabilitation program allowing for the safe implementation of aerobic cycling‑based dual‑task training. The solution was judged meaningful for dehospitalized patients, although some environmental and technical barriers should be overcome to implement telerehabilitation more effectively.

Heart Rate Variability (HRV) refers to variation in time intervals between consecutive heartbeats, indicating autonomic nervous system’s control over the heart. Time and frequency analysis of HRV could serve as predictors for severity and functional outcome in stroke. Aim of this study is to verify if HRV, measured during cognitive and sensorimotor upper limb (UL) tasks, can be used as a biomarker of cognitive‑motor interaction in post‑stroke patients. Forty‑six patients with unilateral brain injury following stroke were enrolled: 27 (58.7%) ischemic, 19 hemorrhagic, 24 (52.2%) sub‑acute (<6 months), and 22 chronic. Mean age at evaluation was 61 years. Right side was affected in 16 subjects (34.8%). Each patient underwent HRV recording in the following conditions: (1) Rest (5 minutes); (2) Visuomotor simulation training of the affected upper limb (UL) using Dessintey IVS3 (DE, 5 minutes); (3) Motor Imagery of the affected UL (MI, 5 minutes). UL functional outcome measures were collected for both affected and less affected sides. All patients showed reduced HRV in time and frequency domains and sympathetic tone predominance at rest. During DE and MI, a significant reduction in time domain was observed. In frequency domains, low frequency decreases during DE, with parasympathetic tone predominance. In the subgroup analyses for lesion side, only right hemiparetic patients showed parasympathetic predominance during mental tasks of the upper limb (DE and MI). No correlation was found between HRV parameters and UL functional scales. Different HRV response in time and frequency domains to mental task was observed between right and left hemiparetic subjects. This could be explained by different anatomical‑functional substrates between right and left hemisphere and could reflect different behaviours during UL cognitive‑motor tasks. HRV parameters were not correlated with clinical functional assessment scales, likely meaning that they possible exploring different domains.

Background: Stroke patients often experience alterations in their subjective feeling of ownership for the affected limb, which can hinder motor function and interfere with rehabilitation. In this study, we aimed at disentangling the complex relationship between sensory impairment, body ownership (BO), and motor control in stroke patients. Methods: We recruited 20 stroke patients with unilateral upper limb sensory deficits and 35 age‑matched controls. Participants performed a virtual reality reaching task with a varying displacement between their real unseen hand and a visible virtual hand. We measured reaching errors and subjective ownership ratings as indicators of hand ownership. Reaching errors were modeled using a probabilistic causal inference model, in which ownership for the virtual hand is inferred from the level of congruency between visual and proprioceptive inputs and used to weigh the amount of visual adjustment to reaching movements. Findings: Stroke patients were more likely to experience ownership over an incongruent virtual hand and integrate it into their motor plans. The model explained this tendency in terms of a decreased capability of detecting visuo‑proprioceptive incongruences, proportionally to the amount of proprioceptive deficit. Lesion analysis further revealed that BO alterations, not fully explained by the proprioceptive deficit, are linked to frontoparietal network damage, suggesting a disruption in higher‑level multisensory integration functions. Conclusions: Collectively, our results show that BO alterations in stroke patients can be quantitatively predicted and explained in a computational framework as the result of sensory loss and higher‑level multisensory integration deficits.

Motor cortical high-gamma oscillations (60-90 Hz) occur at movement onset and are spatially focused over the contralateral primary motor cortex. Although high-gamma oscillations are widely recognized for their significance in human motor control, their precise function on a cortical level remains elusive. Importantly, their relevance in human stroke pathophysiology is unknown. Because motor deficits are fundamental determinants of symptom burden after stroke, understanding the neurophysiological processes of motor coding could be an important step in improving stroke rehabilitation. We recorded magnetoencephalography data during a thumb movement rate task in 14 chronic stroke survivors, 15 age-matched control participants and 29 healthy young participants. Motor cortical high-gamma oscillations showed a strong relation with movement rate as trials with higher movement rate were associated with greater high-gamma power. Although stroke survivors showed reduced cortical high-gamma power, this reduction primarily reflected the scaling of high-gamma power with movement rate, yet after matching movement rate in stroke survivors and age-matched controls, the reduction of high-gamma power exceeded the effect of their decreased movement rate alone. Even though motor skill acquisition was evident in all three groups, it was not linked to high-gamma power. Our study quantifies high-gamma oscillations after stroke, revealing a reduction in movement-related high-gamma power. Moreover, we provide strong evidence for a pivotal role of motor cortical high-gamma oscillations in encoding movement rate. KEY POINTS: Neural oscillations in the high-gamma frequency range (60-90 Hz) emerge in the human motor cortex during movement. The precise function of these oscillations in motor control remains unclear, and they have never been characterized in stroke survivors. In a magnetoencephalography study, we demonstrate that high-gamma oscillations in motor cortical areas scale with movement rate, and we further explore their temporal and spatial characteristics. Stroke survivors exhibit lower high-gamma power during movement than age-matched control participants, even after matching for movement rate. The results contribute to the understanding of the role of high-gamma oscillations in motor control and have important implications for neuromodulation in stroke rehabilitation.

Background: Stroke remains a leading cause of disability globally and movement impairment is the most common complication in stroke patients. Resting-state electroencephalography (EEG) microstate analysis is a non-invasive approach of whole-brain imaging based on the spatiotemporal pattern of the entire cerebral cortex. The present study aims to investigate microstate alterations in stroke patients. Methods: Resting-state EEG data collected from 24 stroke patients and 19 healthy controls matched by age and gender were subjected to microstate analysis. For four classic microstates labeled as class A, B, C and D, their temporal characteristics (duration, occurrence and coverage) and transition probabilities (TP) were extracted and compared between the two groups. Furthermore, we explored their correlations with clinical comparisons. Results: Microstate analysis revealed that the stroke group had lower occurrence of microstate A which was regarded as the sensorimotor network (SMN) compared with the control group (p = 0.003, adjusted p = 0.036, t = -2.959). The TP from microstate A to microstate D had a significant positive correlation with the Fugl-Meyer assessment of lower extremity (FMA-LE) scores (p = 0.049, r = 0.406), but this finding did not survive FDR adjustment (adjusted p = 0.432). Additionally, the occurrence and the coverage of microstate B were negatively correlated with the power of delta band in the stroke group, which did not pass adjustment (p = 0.033, adjusted p = 0.790, r = -0.436; p = 0.026, adjusted p = 0.790, r = -0.454, respectively). Conclusions: Our results confirm the abnormal temporal dynamics of brain activity in stroke patients. The study provides further electrophysiological evidence for understanding the mechanism of brain motor functional reorganization after stroke.

Introduction: Upper limb impairment is a common consequence of stroke, significantly affecting the quality of life and independence of survivors. This scoping review assesses the emerging field of muscle synergy analysis in enhancing upper limb rehabilitation, focusing on the comparison of various methodologies and their outcomes. It aims to standardize these approaches to improve the effectiveness of rehabilitation interventions and drive future research in the domain. Evidence acquisition: Studies included in this scoping review focused on the analysis of muscle synergies during longitudinal rehabilitation of stroke survivors’ upper limbs. A systematic literature search was conducted using PubMed, Scopus, and Web of Science databases, until September 2023, and was guided by the PRISMA for scoping review framework. Evidence synthesis: Fourteen studies involving a total of 247 stroke patients were reviewed, featuring varied patient populations and rehabilitative interventions. Protocols differed among studies, with some utilizing robotic assistance and others relying on traditional therapy methods. Muscle synergy extraction was predominantly conducted using Non-Negative Matrix Factorization from electromyography data, focusing on key upper limb muscles essential for shoulder, elbow, and wrist rehabilitation. A notable observation across the studies was the heterogeneity in findings, particularly in the changes observed in the number, weightings, and temporal coefficients of muscle synergies. The studies indicated varied and complex relationships between muscle synergy variations and clinical outcomes. This diversity underscored the complexity involved in interpreting muscle coordination in the stroke population. The variability in results was also influenced by differing methodologies in muscle synergy analysis, highlighting a need for more standardized approaches to improve future research comparability and consistency. Conclusions: The synthesis of evidence presented in this scoping review highlights the promising role of muscle synergy analysis as an indicator of motor control recovery in stroke rehabilitation. By offering a comprehensive overview of the current state of research and advocating for harmonized methodological practices in future longitudinal studies, this scoping review aspires to advance the field of upper limb rehabilitation, ensuring that post-stroke interventions are both scientifically grounded and optimally beneficial for patients.

In the context of neurorehabilitation, there have been rapid and continuous improvements in sensors-based clinical tools to quantify limb performance. As a result of the increasing integration of technologies in the assessment procedure, the need to integrate evidence-based medicine with benchmarking has emerged in the scientific community. In this work, we present the experimental validation of our previously proposed benchmarking scheme for upper limb capabilities in terms of repeatability, reproducibility, and clinical meaningfulness. We performed a prospective multicenter study on neurologically intact young and elderly subjects and post-stroke patients while recording kinematics and electromyography. 60 subjects (30 young healthy, 15 elderly healthy, and 15 post-stroke) completed the benchmarking protocol. The framework was repeatable among different assessors and instrumentation. Age did not significantly impact the performance indicators of the scheme for healthy subjects. In post-stroke subjects, the movements presented decreased smoothness and speed, the movement amplitude was reduced, and the muscular activation showed lower power and lower intra-limb coordination. We revised the original framework reducing it to three motor skills, and we extracted 14 significant performance indicators with a good correlation with the ARAT clinical scale. The applicability of the scheme is wide, and it may be considered a valuable tool for upper limb functional evaluation in the clinical routine.

Background: Following a stroke, patients may suffer from alterations in the perception of their own body due to an acquired deficit in body representations. While such changes may impact their quality of life as well as recovery, they are not systematically assessed in clinical practice. This study aims at providing a better understanding of the rate, evolution, and impact on recovery of upper limb (UL) body perceptions (BPs) alterations following stroke. In addition, we will investigate associations among BPs alterations items, their associations with the sensorimotor functions, UL activity, damages in brain structure and connectivity. Methods: We developed a new tool named ALPQ (for Affected Limb Perception Questionnaire) to address the present study objectives. It assesses subjective alterations in the perception of the affected UL following stroke, by measuring several dimensions, namely: anosognosia for hemiplegia, anosodiaphoria for hemiplegia, hemiasomatognosia, somatoparaphrenia, personification of the affected limb, illusion of modification of physical characteristics (temperature, weight, length), illusory movements, super- or undernumerary limb, UL disconnection, misoplegia, and involuntary movement. This study combines a cross-sectional and longitudinal design. The completed data sample will include a minimum of 60 acute and 100 sub-acute stroke patients. When possible, patients are followed up to the chronic stage. Complementary evaluations are administered to assess patients’ sensorimotor and cognitive functions as well as UL activity, and brain lesions will be analysed. Discussion: This study will provide a better understanding of BPs alterations following stroke: their rate and evolution, as well as their associations with sensorimotor deficit, cognitive profile and UL activity, brain lesions and recovery. Ultimately, the results could support the personalization of rehabilitation strategy according to patients’ UL perception to maximize their recovery. Study registration: The protocol for this study has been pre-registered on the Open Science Framework on July the 7th, 2021: https://osf.io/p6v7f .

Background and Objective: A new direction in the study of motor control was opened about two decades ago with the introduction of a model for the generation of motor commands as combination of muscle synergies. Muscle synergies provide a simple yet quantitative framework for analyzing the hierarchical and modular architecture of the human motor system. However, to gain insights on the functional role of muscle synergies, they should be related to the task space. The recently introduced mixed-matrix factorization (MMF) algorithm extends the standard approach for synergy extraction based on non‑negative matrix factorization (NMF) allowing to factorize data constituted by a mixture of non‑negative variables (e.g. EMGs) and unconstrained variables (e.g. kinematics, naturally including both positive and negative values). The kinematic‑muscular synergies identified by MMF provide a direct link between muscle synergies and the task space. In this contribution, we support the adoption of MMF through a Matlab toolbox for the extraction of kinematic‑muscular synergies and a set of practical guidelines to allow biomedical researchers and clinicians to exploit the potential of this novel approach. Methods: MMF is implemented in the SynergyAnalyzer toolbox using an object‑oriented approach. In addition to the MMF algorithm, the toolbox includes standard methods for synergy extraction (NMF and PCA), as well as methods for pre‑processing EMG and kinematic data, and for plotting data and synergies. Results: As an example of MMF application, kinematic‑muscular synergies were extracted from EMG and kinematic data collected during reaching movements towards 8 targets on the sagittal plane. Instructions and command lines to achieve such results are illustrated in detail. The toolbox has been released as an open‑source software on GitHub under the GNU General Public License. Conclusions: Thanks to its ease of use and adaptability to a variety of datasets, SynergyAnalyzer will facilitate the adoption of MMF to extract kinematic‑muscular synergies from mixed EMG and kinematic data, a useful approach in biomedical research to better understand and characterize the functional role of muscle synergies.

Despite human’s praxis abilities are unique among primates, comparative observations suggest that these cognitive motor skills could have emerged from exploitation and adaptation of phylogenetically older building blocks, namely the parieto-frontal networks subserving prehension and manipulation. Within this framework, investigating to which extent praxis and prehension-manipulation overlap and diverge within parieto-frontal circuits could help in understanding how human cognition shapes hand actions. This issue has never been investigated by combining lesion mapping and direct electrophysiological approaches in neurosurgical patients. To this purpose, 79 right-handed left-brain tumour patient candidates for awake neurosurgery were selected based on inclusion criteria. First, a lesion mapping was performed in the early postoperative phase to localize the regions associated with an impairment in praxis (imitation of meaningless and meaningful intransitive gestures) and visuo-guided prehension (reaching-to-grasping) abilities. Then, lesion results were anatomically matched with intraoperatively identified cortical and white matter regions, whose direct electrical stimulation impaired the Hand Manipulation Task. The lesion mapping analysis showed that prehension and praxis impairments occurring in the early postoperative phase were associated with specific parietal sectors. Dorso-mesial parietal resections, including the superior parietal lobe and precuneus, affected prehension performance, while resections involving rostral intraparietal and inferior parietal areas affected praxis abilities (covariate clusters, 5000 permutations, cluster-level family-wise error correction P < 0.05). The dorsal bank of the rostral intraparietal sulcus was associated with both prehension and praxis (overlap of non-covariate clusters). Within praxis results, while resection involving inferior parietal areas affected mainly the imitation of meaningful gestures, resection involving intraparietal areas affected both meaningless and meaningful gesture imitation. In parallel, the intraoperative electrical stimulation of the rostral intraparietal and the adjacent inferior parietal lobe with their surrounding white matter during the hand manipulation task evoked different motor impairments, i.e. the arrest and clumsy patterns, respectively. When integrating lesion mapping and intraoperative stimulation results, it emerges that imitation of praxis gestures first depends on the integrity of parietal areas within the dorso-ventral stream. Among these areas, the rostral intraparietal and the inferior parietal area play distinct roles in praxis and sensorimotor process controlling manipulation. Due to its visuo-motor ‘attitude’, the rostral intraparietal sulcus, putative human homologue of monkey anterior intraparietal, might enable the visuo-motor conversion of the observed gesture (direct pathway). Moreover, its functional interaction with the adjacent, phylogenetic more recent, inferior parietal areas might contribute to integrate the semantic-conceptual knowledge (indirect pathway) within the sensorimotor workflow, contributing to the cognitive upgrade of hand actions.

Skill training aims to improve the performance of the task at hand and aims to transfer the acquired skill to related tasks. Both skill training and skill transfer are part of our everyday lives, and essential for survival, and their importance is reflected in years of research. Theoretically, the five training tasks and the three transfer tasks varied approximately linearly from each other. Empirical data, however, suggested merely the presence of three statistically different training tasks and two significantly different transfer tasks, indicating a nonlinear relationship. Against our expectation, Bayesian statistics suggested that the type of skill training was not related to the type of skill transfer. However, the amount of skill training was positively related to the amount of skill transfer. Together, we showed that motor learning studies can be conducted online. Further, our results shed light on the complex relationship between skill training and skill transfer. Understanding this relationship has wide‐ranging practical implications for the general population, particularly for musicians, athletes and patients recovering from injury.

In clinical scenarios, the use of biomedical sensors, devices and multi-parameter assessments is fundamental to provide a comprehensive portrait of patients’ state, in order to adapt and personalize rehabilitation interventions and support clinical decision-making. However, there is a huge gap between the potential of the multidomain techniques available and the limited practical use that is made in the clinical scenario. This paper reviews the current state-of-the-art and provides insights into future directions of multi-domain instrumental approaches in the clinical assessment of patients involved in neuromotor rehabilitation. We also summarize the main achievements and challenges of using multi-domain approaches in the assessment of rehabilitation for various neurological disorders affecting motor functions. Our results showed that multi-domain approaches combine information and measurements from different tools and biological signals, such as kinematics, electromyography (EMG), electroencephalography (EEG), near-infrared spectroscopy (NIRS), and clinical scales, to provide a comprehensive and objective evaluation of patients’ state and recovery. This multi-domain approach permits the progress of research in clinical and rehabilitative practice and the understanding of the pathophysiological changes occurring during and after rehabilitation. We discuss the potential benefits and limitations of multi-domain approaches for clinical decision-making, personalized therapy, and prognosis. We conclude by highlighting the need for more standardized methods, validation studies, and the integration of multi-domain approaches in clinical practice and research.

Objective: Human figure drawings are widely used in clinical practice as a qualitative indication of Body Representations (BRs) alterations in stroke patients. The objective of this study is to present and validate the use of a new app called QDraw for the quantitative analysis of drawings and to investigate whether this analysis can reveal distortions of BRs in chronic stroke patients. Results: QDraw has proven to generate reliable data as compared to manual scoring and in terms of inter-rater reliability, as shown by the high correlation coefficients. Moreover, human figure drawings from chronic stroke patients demonstrated a distortion of upper limb perception, as shown by a significantly higher arm length asymmetry compared to legs, whereas no difference was found in healthy controls. Conclusions: The present study supports the use of quantitative, digital methods (the QDraw app) to analyze human figure drawings as a tool to evaluate BRs distortions in stroke patients.

In humans, motor learning is underpinned by changes in sensorimotor network functional connectivity (FC). Unilateral contractions increase FC in the ipsilateral primary motor cortex (M1) and supplementary motor area (SMA); areas involved in motor planning and execution of the contralateral hand. Therefore, unilateral contractions are a promising approach to augment motor performance in the contralateral hand. In a within‑participant, randomized, cross‑over design, 15 right‑handed adults had two magnetic resonance imaging (MRI) sessions, where functional‑MRI and MR‑Spectroscopic Imaging were acquired before and after repeated right‑hand contractions at either 5% or 50% maximum voluntary contraction (MVC). Before and after scanning, response times (RTs) were determined in both hands. Nine minutes of 50% MVC contractions resulted in decreased handgrip force in the contracting hand, and decreased RTs and increased handgrip force in the contralateral hand. This improved motor performance in the contralateral hand was supported by significant neural changes: increased FC between SMA‑SMA and increased FC between right M1 and right Orbitofrontal Cortex. At a neurochemical level, the degree of GABA decline in left M1, left and right SMA correlated with subsequent behavioural improvements in the left‑hand. These results support the use of repeated handgrip contractions as a potential modality for improving motor performance in the contralateral hand.

Because of the biophysical relation between muscle fibre diameter and the propagation velocity of action potentials along the muscle fibres, motor unit conduction velocity could be a non‑invasive index of muscle fibre size in humans. However, the relation between motor unit conduction velocity and fibre size has been only assessed indirectly in animal models and in human patients with invasive intramuscular EMG recordings, or it has been mathematically derived from computer simulations. By combining advanced non‑invasive techniques to record motor unit activity in vivo, i.e. high‑density surface EMG, with the gold standard technique for muscle tissue sampling, i.e. muscle biopsy, here we investigated the relation between the conduction velocity of populations of motor units identified from the biceps brachii muscle, and muscle fibre diameter. We demonstrate the possibility of predicting muscle fibre diameter (R² = 0.66) and cross‑sectional area (R² = 0.65) from conduction velocity estimates with low systematic bias (~2 % and ~4 % respectively) and a relatively low margin of individual error (~8 % and ~16 %, respectively). The proposed neuromuscular interface opens new perspectives in the use of high‑density EMG as a non‑invasive tool to estimate muscle fibre size without the need of surgical biopsy sampling. The non‑invasive nature of high‑density surface EMG for the assessment of muscle fibre size may be useful in studies monitoring child development, ageing, space and exercise physiology, although the applicability and validity of the proposed methodology need to be more directly assessed in these specific populations by future studies.

We present a normative computational theory of how the brain may support visually-guided goal-directed actions in dynamically changing environments. It extends the Active Inference theory of cortical processing according to which the brain maintains beliefs over the environmental state, and motor control signals try to fulfill the corresponding sensory predictions. We propose that the neural circuitry in the Posterior Parietal Cortex (PPC) compute flexible intentions—or motor plans from a belief over targets—to dynamically generate goal-directed actions, and we develop a computational formalization of this process. A proof-of-concept agent embodying visual and proprioceptive sensors and an actuated upper limb was tested on target-reaching tasks. The agent behaved correctly under various conditions, including static and dynamic targets, different sensory feedbacks, sensory precisions, intention gains, and movement policies; limit conditions were individuated, too. Active Inference driven by dynamic and flexible intentions can thus support goal-directed behavior in constantly changing environments, and the PPC might putatively host its core intention mechanism. More broadly, the study provides a normative computational basis for research on goal-directed behavior in end-to-end settings and further advances mechanistic theories of active biological systems.

Despite the tight coupling between sensory and motor processing for fine manipulation in humans, it is not yet totally clear which specific properties of the fingers are mapped in the precentral and postcentral gyrus. We used fMRI to compare the morphology, connectivity, and encoding of the motor and tactile finger representations (FRs) in the precentral and postcentral gyrus of 25 5-fingered participants (8 females). Multivoxel pattern and structural and functional connectivity analyses demonstrated the existence of distinct motor and tactile FRs within both the precentral and postcentral gyrus, integrating finger-specific motor and tactile information. Using representational similarity analysis, we found that the motor and tactile FRs in the sensorimotor cortex were described by the perceived structure of the hand better than by the actual hand anatomy or other functional models (finger kinematics, muscles synergies). We then studied a polydactyly individual (i.e., with a congenital 6-fingered hand) showing superior manipulation abilities and divergent anatomic-functional hand properties. The perceived hand model was still the best model for tactile representations in the precentral and postcentral gyrus, while finger kinematics better described motor representations in the precentral gyrus. We suggest that, under normal conditions (i.e., in subjects with a standard hand anatomy), the sensorimotor representations of the 5 fingers in humans converge toward a model of perceived hand anatomy, deviating from the real hand structure, as the best synthesis between functional and structural features of the hand. SIGNIFICANCE STATEMENT Distinct motor and tactile finger representations exist in both the precentral and postcentral gyrus, supported by a finger-specific pattern of anatomic and functional connectivity across modalities. At the representational level, finger representations reflect the perceived structure of the hand, which might result from an adapting process harmonizing (i.e., uniformizing) the encoding of hand function and structure in the precentral and postcentral gyrus. The same analyses performed in an extremely rare polydactyly subject showed that the emergence of such representational geometry is also found in neuromechanical variants with different hand anatomy and function. However, the harmonization process across the precentral and postcentral gyrus might not be possible because of divergent functional-structural properties of the hand and associated superior manipulation abilities.

The nervous system is sensitive to statistical regularities of the external world and forms internal models of these regularities to predict environmental dynamics. Given the inherently social nature of human behavior, being capable of building reliable predictive models of others’ actions may be essential for successful interaction. While social prediction might seem to be a daunting task, the study of human motor control has accumulated ample evidence that our movements follow a series of kinematic invariants, which can be used by observers to reduce their uncertainty during social exchanges. Here, we provide an overview of the most salient regularities that shape biological motion, examine the role of these invariants in recognizing others’ actions, and speculate that anchoring socially-relevant perceptual decisions to such kinematic invariants provides a key computational advantage for inferring conspecifics’ goals and intentions.

Objective: To develop and validate a quick observational clinical tool, the Functional ASsessment Test for Upper Limb (FAST-UL), for the evaluation of upper limb impairment in goal-directed functional-oriented motor tasks after stroke. Design: Observational, cross-sectional, psychometric study. Setting: Inpatient and outpatient rehabilitation clinic. Participants: A total of 188 post-stroke survivors (mean age 65.2±17.7 years, 61% men, 48% with ischemic stroke and 66% in the sub-acute phase; N=188). Interventions: Not applicable. Main outcome measures: Principal component analysis and Rasch analysis through a Partial Credit Model were used to assess the structure and psychometric properties of the 5 items of the FAST-UL (Hand to Mouth [HtM], Reach to Target, Prono-Supination, Grasp and Release, and Pinch and Release [PaR]). Results: The Cronbach’s α equal to 0.96 was indicative of an acceptable internal consistency; the reliability, as measured through the Person Separation Reliability equal to 0.87, was good. The FAST-UL tool was unidimensional. All the FAST-UL items were found to fit well the Rasch measurement model. The easiest to perform FAST-UL item was the HtM movement while the most difficult was the PaR movement. Conclusions: The FAST-UL is a quick, easy-to-administer observational assessment tool of upper limb motor impairment in post-stroke survivors with good item-level psychometric properties.

Current clinical practice does not leverage electroencephalography (EEG) measurements in stroke patients, despite its potential to contribute to post-stroke recovery predictions. We review the literature on the effectiveness of various quantitative and qualitative EEG-based measures after stroke as a tool to predict upper limb motor outcome, in relation to stroke timeframe and applied experimental tasks. Moreover, we aim to provide guidance on the use of EEG in the assessment of upper limb motor recovery after stroke, suggesting a high potential for some metrics in the appropriate context. We identified relevant papers (N = 16) from databases ScienceDirect, Web of Science and MEDLINE, and assessed their methodological quality with the Joanna Briggs Institute (JBI) Critical Appraisal. We applied the Preferred Reporting Systems for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) Framework. Identified works used EEG to identify properties including event-related activation, spectral power in physiologically relevant bands, symmetry in brain dynamics, functional connectivity, cortico-muscular coherence and rhythmic coordination. EEG was acquired in resting state or in relation to behavioural conditions. Motor outcome was mainly evaluated with the Upper Limb Fugl-Meyer Assessment. Despite great variability in the literature, data suggests that the most promising EEG quantifiers for predicting post-stroke motor outcome are event-related measures. Measures of spectral power in physiologically relevant bands and measures of brain symmetry also show promise. We suggest that EEG measures may improve our understanding of stroke brain dynamics during recovery, and contribute to establishing a functional prognosis and choosing the rehabilitation approach.

The continuous stream of multisensory information between the brain and the body during body-environment interactions is crucial to maintain the updated representation of the perceived dimensions of body parts (metric body representation) and the space around the body (the peripersonal space). Such flow of multisensory signals is often limited by upper limb sensorimotor deficits after stroke. This would suggest the presence of systematic distortions of metric body representation and peripersonal space in chronic patients with persistent sensorimotor deficits. We assessed metric body representation and peripersonal space representation in 60 chronic stroke patients with unilateral upper limb motor deficits, in comparison with age-matched healthy controls. We also administered a questionnaire capturing explicit feelings towards the affected limb. These novel measures were analysed with respect to patients’ clinical profiles and brain lesions to investigate the neural and functional origin of putative deficits. Stroke patients showed distortions in metric body representation of the affected limb, characterized by an underestimation of the arm length and an alteration of the arm global shape. A descriptive lesion analysis (subtraction analysis) suggests that these distortions may be more frequently associated with lesions involving the superior corona radiata and the superior frontal gyrus. Peripersonal space representation was also altered, with reduced multisensory facilitation for stimuli presented around the affected limb. These deficits were more common in patients reporting pain during motion. Explorative lesion analyses (subtraction analysis, disconnection maps) suggest that the peripersonal space distortions would be more frequently associated with lesions involving the parietal operculum and white matter frontoparietal connections. Moreover, patients reported altered feelings towards the affected limb, which were associated with right brain damage, proprioceptive deficits and a lower cognitive profile. These results reveal implicit and explicit distortions involving metric body representation, peripersonal space representation and the perception of the affected limb in chronic stroke patients. These findings might have important clinical implications for the longitudinal monitoring and the treatments of often-neglected deficits in body perception and representation.

In hemiplegic patients with stroke, investigating the ipsilesional limb may shed light on the upper limb motor control, impairments and mechanisms of functional recovery. Usually investigation of motor impairment and rehabilitative interventions in patients are performed only based on the contralesional limb. Previous studies found that also the ipsilesional limb presents motor deficits, mostly evaluated with clinical scales which could lack of sensibility. To quantitatively evaluate the performance of the ipsilesional limb in patient with stroke, we conducted an observational study in which 49 hemiplegic patients were enrolled, divided in subgroups based on the severity of impairment of the contralesional limb, and assessed with a kinematic, dynamic and motor control evaluation protocol on their ipsilesional upper limb during reaching movements. Measurements were repeated in the acute and subacute phases and compared to healthy controls. Our results showed that the ipsilesional limb presented lower kinematic and dynamic performances with respect to the healthy controls. Patients performed the movements slower and with a reduced range of motion, indicating a difficulty in controlling the motion of the arm. The energy and the power outputs were lower in both shoulder and elbow joint with a high significance level, confirming the limitation found in kinematics. Moreover, we showed that motor deficits were higher in the acute phase with respect to the subacute one and we found higher significant differences in the group with a more severe contralesional limb impairment. Ipsilesional upper limb biomechanics adds significant and more sensible measures for assessments based on multi-joints dynamics, providing a better insight on the upper limb motor control after stroke. These results could have clinical implications while evaluating and treating ipsilesional and contralesional upper limb impairments and dysfunctions in patients with stroke.

Studies with experimental animals have revealed a mood‑regulating neural pathway linking intrinsically photosensitive retinal ganglion cells (ipRGCs) and the prefrontal cortex (PFC), involved in the pathophysiology of mood disorders. Since humans also have light‑intensity–encoding ipRGCs, we asked whether a similar pathway exists in humans. Here, functional MRI was used to identify PFC regions and other areas exhibiting light‑intensity–dependent signals. We report 26 human brain regions having activation that either monotonically decreases or monotonically increases with light intensity. Luxotonic‑related activation occurred across the cerebral cortex, in diverse subcortical structures, and in the cerebellum, encompassing regions with functions related to visual image formation, motor control, cognition, and emotion. Light suppressed PFC activation, which monotonically decreased with increasing light intensity. The sustained time course of light‑evoked PFC responses and their susceptibility to prior light exposure resembled those of ipRGCs. These findings offer a functional link between light exposure and PFC‑mediated cognitive and affective phenomena.

A detailed comprehension of the central and peripheral processes underlying walking is essential to develop effective therapeutic interventions to slow down gait decline with age, and rehabilitation strategies to maximize motor recovery for patients with damages at the central nervous system. The combined use of electromyography (EMG) and electroencephalography (EEG), in the framework of coherence analysis, has recently established for neuromotor integrity/impairment assessment. In this study, we propose corticomuscular (EEG-EMG) and inter/intramuscular (EMG-EMG) coherences as measures of the cognitive reserve, i.e., the process whereby a wider repertoire of cognitive strategies, as well as more flexible and efficient strategies, can moderate the manifestation of brain disease/damage. We recorded EEG signals from the main brain source locations and superficial EMG signals from the main leg muscles involved in gait in 16 healthy young adults (age ≤ 30 years) and 13 healthy elderly (age ≥ 65 years) during three different overground walking conditions (i.e., spontaneous walking, walking with cognitive dual-task, and walking with targets drawn on the floor). In all conditions, we calculated corticomuscular and inter/intramuscular coherences. We observed higher corticomuscular and inter/intramuscular coherences during targeted walking compared to spontaneous walking in both groups, even if the increase was greater in young people. Considering dual-task walking compared to spontaneous walking, only corticomuscular coherence in the elderly increased. These results suggest age-related differences in cognitive reserve that reflect different abilities to perform complex cognitive or motor tasks during gait. This study demonstrates the feasibility, repeatability, and effectiveness of the proposed method to investigate brain-to-muscle connectivity during different gait conditions, to study the related changes with age, and to quantify the cognitive reserve.

Background: A conventional treatment outcome is suboptimal for sensory impairments in stroke patients. Novel approaches based on electrical stimulation or robotics are proposed as an adjuvant for rehabilitation, though their efficacy for motor, sensory, and body representation recovery have not been tested. Methods: Sixty chronic stroke patients with unilateral motor deficits were included in a pseudo‑randomized open‑label multi‑arm control trial (ClinicalTrials.gov: NCT03349138). We tested the effects of a robotic glove (GloReha [GR]) and a new neuromuscular electrical stimulation system (Helping Hand [HH]) and compared them with conventional treatment (CT) in restoring motor and sensory functions and the affected limb perception. HH was designed to concurrently deliver peripheral motor activation and enhanced cutaneous sensation. Patients were split in four dose‑matched groups: CT, GR, HH, and GRHH (receiving 50% GR and 50% HH). Assessments were performed at inclusion, halfway, end of treatment (week 9), and follow‑up (week 13). Findings: HH provided an earlier benefit, quantified by the Motricity Index (MI), than GR. At the end of the treatment, the amelioration was higher in groups GRHH and HH and extended to somatosensory functions. These benefits persisted at the follow‑up. GRHH and HH also improved the perceived dimensions and altered feeling toward the affected limb. Interestingly, the reduction of altered feelings correlated with MI improvements and depended on the amount of HH. Conclusions: We suggest that HH concurrently stimulates sensory and motor systems by generating an enhanced cutaneous sensation, coherent in location with the elicited motor recruitment, leading to ameliorated sensorimotor functions and bodily perceptions in stroke patients. Funding: This work was supported by a Foundation advised by CARIGEST, by Fondazione CARIPLO, by the SNSF NCCR Robotics, and by the Bertarelli Foundation.

A key problem for biological motor control is to establish a link between an idea of a movement and the generation of a set of muscle‑stimulating signals that lead to the movement execution. The number of signals to generate is thereby larger than the body’s mechanical degrees of freedom in which the idea of the movement may be easily expressed, as the movement is actually executed in this space. A mathematical formulation that provides a solving link is presented in this paper in the form of a layered, hierarchical control architecture. It is meant to synthesise a wide range of complex three-dimensional muscle‑driven movements. The control architecture consists of a ‘conceptual layer’, where the movement is planned, a ‘structural layer’, where the muscles are stimulated, and between both an additional ‘transformational layer’, where the muscle‑joint redundancy is resolved. We demonstrate the operativeness by simulating human stance and squatting in a three-dimensional digital human model (DHM). The DHM considers 20 angular DoFs and 36 Hill‑type muscle–tendon units (MTUs) and is exposed to gravity, while its feet contact the ground via reversible stick–slip interactions. The control architecture continuously stimulates all MTUs (‘structural layer’) based on a high‑level, torque‑based task formulation within its ‘conceptual layer’. Desired states of joint angles (postural plan) are fed to two mid‑level joint controllers in the ‘transformational layer’. The ‘transformational layer’ communicates with the biophysical structures in the ‘structural layer’ by providing direct MTU stimulation contributions and further input signals for low‑level MTU controllers. Thereby, the redundancy of the MTU stimulations with respect to the joint angles is resolved, i.e. a link between plan and execution is established, by exploiting some properties of the biophysical structures modelled. The resulting joint torques generated by the MTUs via their moment arms are fed back to the conceptual layer, closing the high‑level control loop. Within our mathematical formulations of the Jacobian matrix‑based layer transformations, we identify the crucial information for the redundancy solution to be the muscle moment arms, the stiffness relations of muscle and tendon tissue within the muscle model, and the length–stimulation relation of the muscle activation dynamics. The present control architecture allows the straightforward feeding of conceptual movement task formulations to MTUs. With this approach, the problem of movement planning is eased, as solely the mechanical system has to be considered in the conceptual plan.

The present study investigated the relationship between psychophysiological state and clutch or choking performance during golf putting under pressure. Ten males and 13 females who were high-level competitive amateur golfers performed 25 putts under control and pressure conditions. State-Trait Anxiety Inventory Y1 (STAI-Y1), heart rate variability (HRV), and putting scores were measured. Participants whose performance improved under the pressure condition compared to the control condition were defined as clutch performers and all others were defined as choking performers. Change ratios between the pressure and control conditions for each variable were calculated and compared between clutch and choking performers. There was a significant difference in the change ratio of the low frequency (LF) component of HRV such that LF HRV decreased under the pressure condition compared with the control condition only in choking performers. Thus, LF HRV may be associated with improved fine motor control, such as golf putting, under pressure circumstances.

Objectives: Gait impairment dramatically affects stroke patients’ functional independence. The Ekso™ is a wearable powered exoskeleton able to improve over-ground gait abilities, but the relationship between the cortical gait control mechanisms and lower limbs kinematics is still unclear. Our aims are: to assess whether the Ekso™ induces an attention-demanding process with prefrontal cortex activation during a gait task; to describe the relationship between the gait-induced muscle activation pattern and the prefrontal cortex activity. Methods: We enrolled 22 chronic stroke patients and 15 matched controls. We registered prefrontal cortex (PFC) activity with functional Near-Infrared Spectroscopy (fNIRS) and muscle activation with surface-electromyography (sEMG) during an over-ground gait task, performed with and without the Ekso™. Results: We observed prefrontal cortex activation during normal gait and a higher activation during Ekso-assisted walking among stroke patients. Furthermore, we found that muscle hypo-activation and co-activation of non-paretic limb are associated to a high prefrontal metabolism. Conclusions: Among stroke patients, over-ground gait is an attention-demanding task. Prefrontal activity is modulated both by Ekso-assisted tasks and muscle activation patterns of non-paretic lower limb. Further studies are needed to elucidate if other Ekso™ settings induce different cortical and peripheral effects. Significance: This is the first study exploring the relationship between central and peripheral mechanisms during an Ekso-assisted gait task.

Monitoring the real‑life mobility of stroke patients could be extremely useful for clinicians. Step counters are a widely accessible, portable, and cheap technology that can be used to monitor patients in different environments. The aim of this study was to validate a low‑cost commercial tri‑axial accelerometer‑based step counter for stroke patients and to determine the best positioning of the step counter (wrists, ankles, and waist). Ten healthy subjects and 43 post‑stroke patients were enrolled and performed four validated clinical tests (10 m, 50 m, and 6 min walking tests and timed up and go tests) while wearing five step counters in different positions while a trained operator counted the number of steps executed in each test manually. Data from step counters and those collected manually were compared using the intraclass coefficient correlation and mean average percentage error. The Bland–Altman plot was also used to describe agreement between the two quantitative measurements (step counter vs. manual counting). During walking tests in healthy subjects, the best reliability was found for lower limbs and waist placement (intraclass coefficient correlations (ICCs) from 0.46 to 0.99), and weak reliability was observed for upper limb placement in every test (ICCs from 0.06 to 0.38). On the contrary, in post‑stroke patients, moderate reliability was found only for the lower limbs in the 6 min walking test (healthy ankle ICC: 0.69; pathological ankle ICC: 0.70). Furthermore, the Bland–Altman plot highlighted large average discrepancies between methods for the pathological group. However, while the step counter was not able to reliably determine steps for slow patients, when applied to the healthy ankle of patients who walked faster than 0.8 m/s, it counted steps with excellent precision, similar to that seen in the healthy subjects (ICCs from 0.36 to 0.99). These findings show that a low‑cost accelerometer‑based step counter could be useful for measuring mobility in select high‑performance patients and could be used in clinical and real‑world settings.

Objective: Spontaneous recovery is an important determinant of upper extremity recovery after stroke and has been described by the 70% proportional recovery rule for the Fugl–Meyer motor upper extremity (FM-UE) scale. However, this rule is criticized for overestimating the predictability of FM-UE recovery. Our objectives were to develop a longitudinal mixture model of FM-UE recovery, identify FM-UE recovery subgroups, and internally validate the model predictions. Methods: We developed an exponential recovery function with the following parameters: subgroup assignment probability, proportional recovery coefficient r_k, time constant in weeks τ_k, and distribution of the initial FM-UE scores. We fitted the model to FM-UE measurements of 412 first‑ever ischemic stroke patients and cross‑validated endpoint predictions and FM-UE recovery cluster assignment. Results: The model distinguished 5 subgroups with different recovery parameters (r₁ = 0.09, τ₁ = 5.3, r₂ = 0.46, τ₂ = 10.1, r₃ = 0.86, τ₃ = 9.8, r₄ = 0.89, τ₄ = 2.7, r₅ = 0.93, τ₅ = 1.2). Endpoint FM‑UE was predicted with a median absolute error of 4.8 (interquartile range [IQR] = 1.3–12.8) at 1 week poststroke and 4.2 (IQR = 1.3–9.8) at 2 weeks. Overall accuracy of assignment to the poor (subgroup 1), moderate (subgroups 2 and 3), and good (subgroups 4 and 5) FM‑UE recovery clusters was 0.79 (95% equal‑tailed interval [ETI] = 0.78–0.80) at 1 week poststroke and 0.81 (95% ETI = 0.80–0.82) at 2 weeks. Interpretation: FM‑UE recovery reflects different subgroups, each with its own recovery profile. Cross‑validation indicates that FM‑UE endpoints and FM‑UE recovery clusters can be well predicted. Results will contribute to the understanding of upper limb recovery patterns in the first 6 months after stroke.

The frontoparietal networks underlying grasping movements have been extensively studied, especially using fMRI. Accordingly, whereas much is known about their cortical locus much less is known about the temporal dynamics of visuomotor transformations. Here, we show that multivariate EEG analysis allows for detailed insights into the time course of visual and visuomotor computations of precision grasps. Male and female human participants first previewed one of several objects and, upon its reappearance, reached to grasp it with the thumb and index finger along one of its two symmetry axes. Object shape classifiers reached transient accuracies of 70% at ~105 ms, especially based on scalp sites over visual cortex, dropping to lower levels thereafter. Grasp orientation classifiers relied on a system of occipital-to-frontal electrodes. Their accuracy rose concurrently with shape classification but ramped up more gradually, and the slope of the classification curve predicted individual reaction times. Further, cross-temporal generalization revealed that dynamic shape representation involved early and late neural generators that reactivated one another. In contrast, grasp computations involved a chain of generators attaining a sustained state about 100 ms before movement onset. Our results reveal the progression of visual and visuomotor representations over the course of planning and executing grasp movements.

The stability of coordinated rhythmic movement is primarily affected by the required mean relative phase. In general, symmetrical coordination is more stable than asymmetrical coordination; however, there are two ways to define relative phase and the associated symmetries. The first is in an egocentric frame of reference, with symmetry defined relative to the sagittal plane down the midline of the body. The second is in an allocentric frame of reference, with symmetry defined in terms of the relative direction of motion. Experiments designed to separate these constraints have shown that both egocentric and allocentric constraints contribute to overall coordination stability, with the former typically showing larger effects. However, separating these constraints has meant comparing movements made either in different planes of motion, or by limbs in different postures. In addition, allocentric information about the coordination is either in the form of the actual limb motion, or a transformed, Lissajous feedback display. These factors limit both the comparisons that can be made and the interpretations of these comparisons. The current study examined the effects of egocentric relative phase, allocentric relative phase, and allocentric feedback format on coordination stability in a single task. We found that while all three independently contributed to stability, the egocentric constraint dominated. This supports previous work. We examine the evidence underpinning theoretical explanations for the egocentric constraint, and describe how it may reflect the haptic perception of relative phase.

Automated procedures for the assessment of motor performance to be used in clinical environments, such as clinics, in surgeries and domestic environment. In this study, 20 post-stroke patients performed reaching movements with their more affected limb, and a physician administered the Reaching Performance Scale (RPS) to assess motor functionality. At the same time, patients’ kinematics were recorded with the Kinect V2 sensor. An automated algorithm was developed to compute the RPS from Kinect V2 tracking data, and visual and Kinect V2 RPS scores were compared. Results showed a high statistical correlation between the automated procedure and the visual administration (Pearson correlation Coefficient: R=0.90, p<0.001). While the number of patients is limited, the automated RPS seems to be successfully applicable to different levels of impairment, from mild to severe.

Mobile Brain/Body Imaging (MoBI) is rapidly gaining traction as a new imaging modality to study how cognitive processes support locomotion. Electroencephalogram (EEG) and electromyogram (EMG), due to their time resolution, non-invasiveness and portability are the techniques of choice for MoBI, but synchronization requirements among others restrict its use to high-end research facilities. Here we test the effectiveness of a technique that enables us to achieve MoBI‑grade synchronization of EEG and EMG, even when other strategies (such as Lab Streaming Layer (LSL)) cannot be used e.g., due to the unavailability of proprietary Application Programming Interfaces (APIs), which is often the case in clinical settings. The proposed strategy is that of aligning several spikes at the beginning and end of the session. We delivered a train of spikes to the EEG amplifier and EMG electrodes every 2 s over a 10‑min time period. We selected a variable number of spikes (from 1 to 10) both at the beginning and end of the time series and linearly resampled the data so as to align them. We then compared the misalignment of the “middle” spikes over the whole recording to test for jitter and synchronization drifts, highlighting possible nonlinearities (due to hardware filters) and estimated the maximum length of the recording to achieve a [-5 to 5] ms misalignment range. We demonstrate that MoBI‑grade synchronization can be achieved within 10‑min recordings with a 1.7 ms jitter and [-5 5] ms misalignment range. We show that repeated spike delivery can be used to test online synchronization options and to troubleshoot synchronization issues over EEG and EMG. We also show that synchronization cannot rely only on the equipment sampling rate advertised by manufacturers. The synchronization strategy described can be used virtually in every clinical environment, and may increase the interest among a broader spectrum of clinicians and researchers in the MoBI framework, ultimately leading to a better understanding of the brain processes underlying locomotion control and the development of more effective rehabilitation approaches.

Elaboration of appropriate responses to behavioral situations rests on the ability of selecting appropriate motor outcomes in accordance to specific environmental inputs. To this end, the primary motor cortex (M1) is a key structure for the control of voluntary movements and motor skills learning. Subcortical loops regulate the activity of the motor cortex and thus contribute to the selection of appropriate motor plans. Monoamines are key mediators of arousal, attention and motivation. Their firing pattern enables a direct encoding of different states thus promoting or repressing the selection of actions adapted to the behavioral context. Monoaminergic modulation of motor systems has been extensively studied in subcortical circuits. Despite evidence of converging projections of multiple neurotransmitters systems in the motor cortex pointing to a direct modulation of local circuits, their contribution to the execution and learning of motor skills is still poorly understood. Monoaminergic dysregulation leads to impaired plasticity and motor function in several neurological and psychiatric conditions, thus it is critical to better understand how monoamines modulate neural activity in the motor cortex. This review aims to provide an update of our current understanding on the monoaminergic modulation of the motor cortex with an emphasis on motor skill learning and execution under physiological conditions.

Understanding both the organization of the human cortex and its relation to the performance of distinct functions is fundamental in neuroscience. The primary sensory cortices display topographic organization, whereby receptive fields follow a characteristic pattern, from tonotopy to retinotopy to somatotopy [1]. GABAergic signaling is vital to the maintenance of cortical receptive fields [2]; however, it is unclear how this fine‑grain inhibition relates to measurable patterns of perception [3, 4]. Based on perceptual changes following perturbation of the GABAergic system, it is conceivable that the resting level of cortical GABAergic tone directly relates to the spatial specificity of activation in response to a given input [5–7]. The specificity of cortical activation can be considered in terms of cortical tuning: greater cortical tuning yields more localized recruitment of cortical territory in response to a given input. We applied a combination of fMRI, MR spectroscopy, and psychophysics to substantiate the link between the cortical neurochemical milieu, the tuning of cortical activity, and variability in perceptual acuity, using human somatosensory cortex as a model. We provide data that explain human perceptual acuity in terms of both the underlying cellular and metabolic processes. Specifically, higher concentrations of sensorimotor GABA are associated with more selective cortical tuning, which in turn is associated with enhanced perception. These results show anatomical and neurochemical specificity and are replicated in an independent cohort. The mechanistic link from neurochemistry to perception provides a vital step in understanding population variability in sensory behaviour, informing metabolic therapeutic interventions to restore perceptual abilities clinically.

Perceiving the external spatial location of touch requires that tactile information about the stimulus location on the skin be integrated with proprioceptive information about the location of the body in external space, a process called tactile spatial remapping. Recent results have suggested that this process relies on a distorted representation of the hand. Here, I investigated whether similar distortions are also found on the forearm and how they are affected by the presence of the wrist joint, which forms a categorical, segmental boundary between the hand and the arm. Participants used a baton to judge the perceived location of touches applied to their left hand or forearm. Similar distortions were apparent on both body parts, with overestimation of distances in the medio‑lateral axis compared to the proximo‑distal axis. There was no perceptual expansion of distances that crossed the wrist boundary. However, there was increased overestimation of distances near the wrist in the medio‑lateral orientation. These results replicate recent findings of a distorted representation of the hand underlying tactile spatial remapping, and show that this effect is not idiosyncratic to the hand, but also affects the forearm. These distortions may be a general characteristic of the mental representation of the arms.

Physical activity, both exercise and non-exercise, has far-reaching benefits to physical health. Although exercise has also been linked to psychological health (e.g., happiness), little research has examined physical activity more broadly, taking into account non-exercise activity as well as exercise. We examined the relationship between physical activity (measured broadly) and happiness using a smartphone application. This app has collected self-reports of happiness and physical activity from over ten thousand participants, while passively gathering information about physical activity from the accelerometers on users’ phones. The findings reveal that individuals who are more physically active are happier. Further, individuals are happier in the moments when they are more physically active. These results emerged when assessing activity subjectively, via self-report, or objectively, via participants’ smartphone accelerometers. Overall, this research suggests that not only exercise but also non-exercise physical activity is related to happiness. This research further demonstrates how smartphones can be used to collect large-scale data to examine psychological, behavioral, and health-related phenomena as they naturally occur in everyday life.

Both tactile distance perception and position sense are believed to require that immediate afferent signals be referenced to a stored representation of body size and shape (the body model). For both of these abilities, recent studies have reported that the stored body representations involved are highly distorted, at least in the case of the hand, with the hand dorsum represented as wider and squatter than it actually is. Here, we investigated whether individual differences in the magnitude of these distortions are shared between tactile distance perception and position sense, as would be predicted by the hypothesis that a single distorted body model underlies both tasks. We used established tasks to measure distortions of the represented shape of the hand dorsum. Consistent with previous results, in both cases there were clear biases to overestimate distances oriented along the medio-lateral axis of the hand compared to the proximo-distal axis. Moreover, within each task there were clear split-half correlations, demonstrating that both tasks show consistent individual differences. Critically, however, there was no correlation between the magnitudes of distortion in the two tasks. This casts doubt on the proposal that a common body model underlies both tactile distance perception and position sense.

The various neurocognitive processes contributing to the sense of body ownership have been investigated extensively in healthy participants, but studies in neurological patients can shed unique light into such phenomena. Here, we aimed to investigate whether visual capture by a fake hand (without any synchronous or asynchronous tactile stimulation) affects body ownership in a group of hemiplegic patients with or without disturbed sensation of limb ownership (DSO) following damage to the right hemisphere. We recruited 31 consecutive patients, including seven patients with DSO. The majority of our patients (64.5% overall and up to 86% of the patients with DSO) experienced strong feelings of ownership over a rubber hand within 15 sec following mere visual exposure, which correlated with the degree of proprioceptive deficits across groups and in the DSO group. Using voxel-based lesion-symptom mapping analysis, we were able to identify lesions associated with this pathological visual capture effect in a selective fronto‑parietal network, including significant voxels (p < .05) in the frontal operculum and the inferior frontal gyrus. By contrast, lesions associated with DSO involved more posterior lesions, including the right temporoparietal junction and a large area of the supramarginal gyrus, and to a lesser degree the middle frontal gyrus. Thus, this study suggests that our sense of ownership includes dissociable mechanisms of multisensory integration.

Objective To design and implement an electromyography (EMG)-based controller for a hand robotic assistive device, which is able to classify the user’s motion intention before the effective kinematic movement execution. Methods Multiple degrees-of-freedom hand grasp movements (i.e. pinching, grasp an object, grasping) were predicted by means of surface EMG signals, recorded from 10 bipolar EMG electrodes arranged in a circular configuration around the forearm 2-3 cm from the elbow. Two cascaded artificial neural networks were then exploited to detect the patient’s motion intention from the EMG signal window starting from the electrical activity onset to movement onset (i.e. electromechanical delay). Results The proposed approach was tested on eight healthy control subjects (4 females; age range 25-26 years) and it demonstrated a mean ± SD testing performance of 76% ± 14% for correctly predicting healthy users’ motion intention. Two post-stroke patients tested the controller and obtained 79% and 100% of correctly classified movements under testing conditions. Conclusion A task-selection controller was developed to estimate the intended movement from the EMG measured during the electromechanical delay.

Knowledge of the body is filtered by perceptual information, recalibrated through predominantly innate stored information, and neurally mediated by direct sensory motor information. Despite multiple sources, the immediate prediction, construction, and evaluation of one’s body are distorted. The origins of such distortions are unclear. In this review, we consider three possible sources of awareness that inform body distortion. First, the precision in the body metric may be based on the sight and positioning sense of a particular body segment. This view provides information on the dual nature of body representation, the reliability of a conscious body image, and implicit alterations in the metrics and positional correspondence of body parts. Second, body awareness may reflect an innate organizational experience of unity and continuity in the brain, with no strong isomorphism to body morphology. Third, body awareness may be based on efferent/afferent neural signals, suggesting that major body distortions may result from changes in neural sensorimotor experiences. All these views can be supported empirically, suggesting that body awareness is synthesized from multimodal integration and the temporal constancy of multiple body representations. For each of these views, we briefly discuss abnormalities and therapeutic strategies for correcting the bodily distortions in various clinical disorders.

Introduction Moving the arm towards an object is a complex task. Movements of the arm joints must be well coordinated in order to obtain a smooth and accurate hand trajectory. Most studies regarding reaching movements address young subjects. Coordination differences in the neural mechanism underlying motor control throughout the life stages is yet unknown. The understanding of these changes can lead to a better comprehension of neuromotor pathologies and therefore to more suitable therapies. Methods Our purpose was to investigate interjoint coordination in three different aging groups (children, young, elderly). Kinematics and kinetics specific variables were analyzed focusing on defined parameters to get insight into arm coordination. Intersegmental dynamics was used to calculate shoulder and elbow torques assuming a 2-link segment model of the upper extremity (upper arm and forearm) with two friction-less joints (shoulder and elbow). A virtual reality environment was used to examine multidirectional planar reaching in three different directions (randomly presented). Results Seven measures were computed to investigate group interlimb differences: shoulder and elbow muscle torques (peak and impulse), work performed by shoulder and elbow joints, maximum velocity, movement distance, distance error at final position, movement duration and acceleration duration. Our data analysis showed differences between movement performances for all analyzed variables, at all ages. Conclusion We found that the intersegmental dynamics for the interlimb (left/right) comparisons were similar for the elderly and children groups as compared to the young. In addition, the coordination and control of motor tasks changes during life, becoming less effective in old age.

My thesis investigated the effect of four psychosocial factors (physical attractiveness, emotion, likability, and morphological similarity) on interpersonal motor coordination. By adopting the dynamical system approach, we have found that how we behaviorally coordinate with other people was influenced by these four factors. Underlying mechanisms were also explored in the experiments to see whether attention or eye tracking mediated the relation between these psychosocial properties and interpersonal motor coordination. We discussed how these four factors could be viewed as social affordances that afford different coordinated behaviors depending on psychosocial stimuli. Our results are supportive of the embodied concept that cognition is embodied in such a way that our overt behavior manifests inner cognitive processes. In this vein, it is argued that interpersonal motor coordination could be used as behavioral markers to assess psychosocial processes during social interaction.

Upper-limb movement analysis is important to monitor objectively rehabilitation interventions, contributing to improving the overall treatments outcomes. Simple, fast, easy-to-use, and applicable methods are required to allow routinely functional evaluation of patients with different pathologies and clinical conditions. This paper describes the Reaching and Hand-to-Mouth Evaluation Method, a fast procedure to assess the upper-limb motor control and functional ability, providing a set of normative data from 42 healthy subjects of different ages, evaluated for both the dominant and the nondominant limb motor performance. Sixteen of them were reevaluated after two weeks to perform test-retest reliability analysis. Data were clustered into three subgroups of different ages to test the method sensitivity to motor control differences. Experimental data show notable test-retest reliability in all tasks. Data from older and younger subjects show significant differences in the measures related to the ability for coordination thus showing the high sensitivity of the method to motor control differences. The presented method, provided with control data from healthy subjects, appears to be a suitable and reliable tool for the upper-limb functional assessment in the clinical environment.

Heartbeat detection tasks are often used to measure cardiac interoceptive sensitivity—the ability to detect sensations from one’s heart. However, there is little work to guide decisions on the optimum number of trials to use, which should balance reliability and power against task duration and participant burden. Here, 174 participants completed 100 trials of a widely used heartbeat detection task where participants attempt to detect whether presented tones occurred synchronously or asynchronously with their heartbeats. First, we quantified measurement reliability of the participant’s accuracy derived from differing numbers of trials of the task using a correlation metric; we found that at least 40–60 trials were required to yield sufficient reliability. Next, we quantified power by simulating how the number of trials influenced the ability to detect a correlation between cardiac interoceptive sensitivity and other variables that differ across participants, including a variable measured from our sample (body mass index) as well as simulated variables of varying effect sizes. Using these simulations, we quantified the trade-offs between sample size, effect size, and number of trials in the heartbeat detection task such that a researcher can easily determine any one of these variables at given values of the other two variables. We conclude that using fewer than 40 trials is typically insufficient due to poor reliability and low power in estimating an effect size, although the optimal number of trials can differ by study.

Background: Glenohumeral subluxation (GHS) is a common symptom following stroke. Many therapists postulate that GHS may be reduced if the base of support (BOS) is reduced and the centre of mass (COM) is raised as this requires greater postural muscle activity. However, there is little empirical evidence to support this practice. Objective: The aim of this preliminary study was to investigate if the amount of GHS alters from sitting to standing. Study design: A cross sectional, within-subject design in a convenience sample of 15 stroke patients with GHS was utilised. Methods: A prospective design was used with a single blinded tester who assessed GHS using the calliper method in sitting, standing and on return to sitting. Friedman and post hoc Wilcoxon tests showed that GHS was significantly reduced in standing compared to sitting (p <0.05) but this reduction was not maintained on return to sitting (p = 0.25). Conclusions: The results of this study are limited by its small size. However, these results indicate that reducing BOS during rehabilitation may improve GHS after stroke. Whilst the maintenance of benefit is not established, these findings suggest that reducing BOS as part of treatment may help patients with GHS. Further research is now required to replicate these results in a larger sample and to directly examine shoulder muscle activity to investigate which muscles may influence GHS in response to changing BOS. Future work could also aim to determine whether the reduction in GHS was directly attributable to a reduced BOS or the effort associated with moving from sitting to standing.

Anxiety and anxiety sensitivity are positively related to accuracy in the perception of bodily sensations. At the same time, research consistently reports that these traits are positively related to bias, resulting in the report of more and more intense symptoms that poorly correspond with physiological dysfunction. The aim of this study was to test the relationship of accuracy and bias in interoception. Furthermore, we tested the impact of individual differences in negative affect and symptom report in daily life on interoceptive accuracy and bias. Individuals higher in symptom report in daily life and negative affect were marginally more accurate in an interoceptive classification task in which participants were asked to identify different respiratory stimuli (inducing breathing effort) as belonging to a high or low intensity category. At the same time, bias in overestimating intensity of stimuli was significantly increased in participants higher in symptom report and negative affect, but only for more ambiguous stimuli. Results illustrate that interoceptive accuracy and bias need to be considered independently to understand their interaction with psychological factors and to disentangle (mis)perception of bodily sensations from liberal or conservative perceptual decision strategies.

Interoception is the moment-to-moment sensing of the physiological condition of the body. The multimodal sources of interoception can be classified into two different streams of afferents: an internal pathway of signals arising from core structures (i.e., heart, blood vessels, and bronchi) and an external pathway of body-mapped sensations (i.e., chemosensation and pain) arising from peripersonal space. This study examines differential processing along these streams within the insular cortex (IC) and their subcortical tracts connecting frontotemporal networks. Two rare patients presenting focal lesions of the IC (insular lesion, IL) or its subcortical tracts (subcortical lesion, SL) were tested. Internally generated interoceptive streams were assessed through a heartbeat detection (HBD) task, while those externally triggered were tapped via taste, smell, and pain recognition tasks. A differential pattern was observed. The IC patient showed impaired internal signal processing while the SL patient exhibited external perception deficits. Such selective deficits remained even when comparing each patient with a group of healthy controls and a group of brain-damaged patients. These outcomes suggest the existence of distinguishable interoceptive streams. Results are discussed in relation with neuroanatomical substrates, involving a fronto-insulo-temporal network for interoceptive and cognitive contextual integration.

Study evaluating specialized kinesitherapeutic methodology on static and functional balance in chronic ischemic stroke patients, showing significant improvement after 10 days and gradual gains over 3 months using the Berg Balance Scale.

This study aimed to investigate whether interindividual differences in autonomic inhibitory control predict safety learning and fear extinction in an interoceptive fear conditioning paradigm. Data from a previously reported study (N=40) were extended (N=17) and re-analyzed to test whether healthy participants’ resting heart rate variability (HRV) – a proxy of cardiac vagal tone – predicts learning performance. The conditioned stimulus (CS) was a slight sensation of breathlessness induced by a flow resistor, the unconditioned stimulus (US) was an aversive short‑lasting suffocation experience induced by a complete occlusion of the breathing circuitry. During acquisition, the paired group received 6 paired CS‑US presentations; the control group received 6 explicitly unpaired CS‑US presentations. In the extinction phase, both groups were exposed to 6 CS‑only presentations. Measures included startle blink EMG, skin conductance responses (SCR) and US‑expectancy ratings. Resting HRV significantly predicted the startle blink EMG learning curves both during acquisition and extinction. In the unpaired group, higher levels of HRV at rest predicted safety learning to the CS during acquisition. In the paired group, higher levels of HRV were associated with better extinction. Our findings suggest that the strength or integrity of prefrontal inhibitory mechanisms involved in safety‑and extinction learning can be indexed by HRV at rest.

This review focuses on a novel rehabilitation approach known as action observation treatment (AOT). It is now a well‑accepted notion in neurophysiology that the observation of actions performed by others activates in the perceiver the same neural structures responsible for the actual execution of those same actions. Areas endowed with this action observation–action execution matching mechanism are defined as the mirror neuron system. AOT exploits this neurophysiological mechanism for the recovery of motor impairment. During one typical session, patients observe a daily action and afterwards execute it in context. So far, this approach has been successfully applied in the rehabilitation of upper limb motor functions in chronic stroke patients, in motor recovery of Parkinson’s disease patients, including those presenting with freezing of gait, and in children with cerebral palsy. Interestingly, this approach also improved lower limb motor functions in post‑surgical orthopaedic patients. AOT is well grounded in basic neuroscience, thus representing a valid model of translational medicine in the field of neurorehabilitation. Moreover, the results concerning its effectiveness have been collected in randomized controlled studies, thus being an example of evidence‑based clinical practice.

Background. Poststroke impairment may lead to fall and unsafe functional performance. The underlying mechanism for the balance dysfunction is unclear. Objective. To analyze the relation between the motor level of the affected limbs and balance in poststroke subjects. Method. A prospective, cross-sectional, and nonexperimental design was conducted in a rehabilitation institute. A convenience sample of 44 patients was assessed for motor level using Brunnstrom recovery stage (BRS) and Fugl-Meyer Assessment: upper (FMA-UE) and lower extremities (FMA-LE). The balance was measured by Berg Balance Scale (BBS), Postural Assessment Scale for Stroke Patients (PASS), and Functional Reach Test (FRT). Results. BRS showed moderate correlation with BBS (ρ = 0.54 to 0.60; P < 0.001), PASS (r = 0.48 to 0.64; P < 0.001) and FRT (ρ = 0.48 to 0.59; P < 0.001). FMA-UE also exhibited moderate correlation with BBS (ρ = 0.59; P < 0.001) and PASS (ρ = 0.60; P < 0.001). FMA-LE showed fair correlation with BBS (ρ = 0.50; P = 0.001) and PASS (ρ = 0.50; P = 0.001). Conclusion. Motor control of the affected limbs plays an important role in balance. There is a moderate relation between the motor level of the upper and lower extremities and balance. The findings of the present study may be applied in poststroke rehabilitation.

The standard account of motor control considers descending outputs from primary motor cortex (M1) as motor commands and efference copy. This account has been challenged recently by an alternative formulation in terms of active inference: M1 is considered as part of a sensorimotor hierarchy providing top‑down proprioceptive predictions. The key difference between these accounts is that predictions are sensitive to the current proprioceptive context, whereas efference copy is not. Using functional electric stimulation to experimentally manipulate proprioception during voluntary movement in healthy human subjects, we assessed the evidence for context sensitive output from M1. Dynamic causal modeling of functional magnetic resonance imaging responses showed that FES altered proprioception increased the influence of M1 on primary somatosensory cortex (S1). These results disambiguate competing accounts of motor control, provide some insight into the synaptic mechanisms of sensory attenuation and may speak to potential mechanisms of action of FES in promoting motor learning in neurorehabilitation.

Laterality is an important feature of motor behavior. Several studies have shown that lateralization in right-handed young adults (i.e., right versus left arm superiority) emerges also during imagined actions, that is when an action is internally simulated without any motor output. Such information, however, is lacking for elderly people and it could be valuable to further comprehend the evolution of mental states of action in normal aging. Here, we evaluated the influence of age on motor laterality during mental actions. Twenty-four young (mean age: 24.7 ± 4.4 years) and 24 elderly (mean age: 72.4 ± 3.6 years) participants mentally simulated and actually executed pointing movements with either their dominant-right or non-dominant-left arm in the horizontal plane. We recorded and analyzed the time of actual and mental movements and looked for differences between groups and arms. In addition, electromyographic activity from arm muscle was recorded to quantify any enhancement in muscle activation during mental actions. Our findings indicated that both groups mentally simulated arm movements without activating the muscles of the right or the left arm above the baseline level. This finding suggests that young and, notably, elderly adults are able to generate covert actions without any motor output. We found that manual asymmetries (i.e., faster movements with the right arm) were preserved in young adults for both actual and mental movements. In elderly adults, manual asymmetries were observed for actual but not for mental movements (i.e., equal movement times for both arms). These findings clearly indicate an age-related reduction of motor laterality during mental actions.

Accurate perception of bodily sensations is essential to protect health. However, misperception and misinterpretation of signals from within the body are common and can be fatal, for example in asthma or cardiovascular disease. We suggest that placing interoceptive stimuli into interoceptive categories (e.g., symptoms vs. benign sensations) leads to perceptual generalization effects which may underlie misinterpretation. In two studies, we presented stimuli inducing respiratory effort (respiratory loads) organized into categories vs. located on a continuous dimension. We found pervasive effects of categorization on magnitude estimations, on measures of affective stimulus evaluation, on stimulus recognition, and on breathing behavior. Results advocate for opening a new perspective in interoception which includes basal cognitive processes of stimulus organization to understand interoceptive bias. They are relevant to a wide range of interoception-related phenomena ranging from emotion to symptom perception.

The Motor Assessment Scale (MAS) and the Functional Independence Measure (FIM) are commonly used in Australian rehabilitation centres but there have been few systematic studies using them to measure recovery after stroke, especially with regard to upper limb function. The aims of this study were to provide a profile of upper limb recovery in a non-surgical stroke population using measures of impairment and disability. The records of 153 subjects were audited for upper limb MAS sub-scores, the FIM sub-score for upper body dressing, and the total FIM score at admission and discharge from rehabilitation. Significant improvement occurred for all outcome measures. There was no relationship between the MAS scores and the functional task of upper body dressing. The results emphasize the importance of using outcome measures that assess both impairment and disability, and indicate that substantial improvements in upper limb function frequently occur after stroke. Although the MAS has limitations, it is a valuable tool for measuring upper limb outcome after stroke because it provides a more accurate profile of true upper limb recovery than the FIM.

Sensory tricks are various maneuvers that can ameliorate dystonia. Common characteristics are well known, but their variety is wide, sensory stimulation is not necessarily the critical feature, and their physiology is unknown. To enumerate the various forms of sensory tricks and describe their nature, research findings and theories that may elucidate their neurophysiologic mechanism, we reviewed the literature pertaining to sensory tricks, including variants like motor tricks, imaginary tricks, forcible tricks and reverse sensory tricks. On the basis of this information, we propose a new classification of sensory tricks to include its variants. We highlight neurophysiologic evidence suggesting that sensory tricks work by decreasing abnormal facilitation. We tie this with established dystonia pathogenesis and postulate that sensory tricks decrease abnormally increased facilitation-to-inhibition ratios in the dystonic brain. It appears worthwhile for patients to search for possible sensory tricks.

Objective: To analyze the relation between contralesional and ipsilesional limbs in subjects with stroke during step-to-step transition of walking. Design: Observational, transversal, analytical study with a convenience sample. Setting: Physical medicine and rehabilitation clinic. Participants: Subjects (n = 16) with poststroke hemiparesis with the ability to walk independently and healthy controls (n = 22). Interventions: Not applicable. Main Outcome Measures: Bilateral lower limbs electromyographic activity of the soleus (SOL), gastrocnemius medialis, tibialis anterior, biceps femoris, rectus femoris, and vastus medialis (VM) muscles and the ground reaction force were analyzed during double-support and terminal stance phases of gait. Results: The propulsive impulse of the contralesional trailing limb was negatively correlated with the braking impulse of the leading limb during double support (r = -.639, P = .01). A moderate functional relation was observed between thigh muscles (r = -.529, P = .035), and a strong and moderate dysfunctional relation was found between the plantar flexors of the ipsilesional limb and the vastus medialis of the contralesional limb, respectively (SOL-VM, r = -.80, P < .001; gastrocnemius medialis-VM, r = -.655, P = .002). Also, a functional moderate negative correlation was found between the SOL and rectus femoris muscles of the ipsilesional limb during terminal stance and between the SOL (r = -.506, P = .046) and VM (r = -.518, P = .04) muscles of the contralesional limb during loading response, respectively. The trailing limb relative impulse contribution of the contralesional limb was lower than the ipsilesional limb of subjects with stroke (P = .02) and lower than the relative impulse contribution of the healthy limb (P = .008) during double support. Conclusions: The findings obtained suggest that the lower performance of the contralesional limb in forward propulsion during gait is related not only to contralateral supraspinal damage but also to a dysfunctional influence of the ipsilesional limb.

Background: MUNDUS is an assistive framework for recovering direct interaction capability of severely motor impaired people based on arm reaching and hand functions. It aims at achieving personalization, modularity and maximization of the user’s direct involvement in assistive systems. To this, MUNDUS exploits any residual control of the end-user and can be adapted to the level of severity or to the progression of the disease allowing the user to voluntarily interact with the environment. MUNDUS target pathologies are high-level spinal cord injury (SCI) and neurodegenerative and genetic neuromuscular diseases, such as amyotrophic lateral sclerosis, Friedreich ataxia, and multiple sclerosis (MS). The system can be alternatively driven by residual voluntary muscular activation, head/eye motion, and brain signals. MUNDUS modularly combines an antigravity lightweight and non-cumbersome exoskeleton, closed-loop controlled Neuromuscular Electrical Stimulation for arm and hand motion, and potentially a motorized hand orthosis, for grasping interactive objects. Methods: The definition of the requirements and of the interaction tasks were designed by a focus group with experts and a questionnaire with 36 potential end-users. Results: The functionality of all modules has been successfully demonstrated. User’s intention was detected with a 100% success. Averaging all subjects and tasks, the minimum evaluation score obtained was 1.13 ± 0.99 for the release of the handle during the drinking task, whilst all the other sub-actions achieved a mean value above 1.6. All users, but one, subjectively perceived the usefulness of the assistance and could easily control the system. Donning time ranged from 6 to 65 minutes, scaled on the configuration complexity. Conclusions: The MUNDUS platform provides functional assistance to daily life activities; the modules integration depends on the user’s need, the functionality of the system have been demonstrated for all the possible configurations, and preliminary assessment of usability and acceptance is promising.

An important issue in motor control is understanding the basic principles underlying the accomplishment of natural movements. According to optimal control theory, the problem can be stated in these terms: what cost function do we optimize to coordinate the many more degrees of freedom than necessary to fulfill a specific motor goal? This question has not received a final answer yet, since what is optimized partly depends on the requirements of the task. Many cost functions were proposed in the past, and most of them were found to be in agreement with experimental data. Therefore, the actual principles on which the brain relies to achieve a certain motor behavior are still unclear. Existing results might suggest that movements are not the results of the minimization of single but rather of composite cost functions. In order to better clarify this last point, we consider an innovative experimental paradigm characterized by arm reaching with target redundancy. Within this framework, we make use of an inverse optimal control technique to automatically infer the (combination of) optimality criteria that best fit the experimental data. Results show that the subjects exhibited a consistent behavior during each experimental condition, even though the target point was not prescribed in advance. Inverse and direct optimal control together reveal that the average arm trajectories were best replicated when optimizing the combination of two cost functions, nominally a mix between the absolute work of torques and the integrated squared joint acceleration. Our results thus support the cost combination hypothesis and demonstrate that the recorded movements were closely linked to the combination of two complementary functions related to mechanical energy expenditure and joint-level smoothness.

Background: The restoration of walking ability is the main goal of post-stroke lower limb rehabilitation and different studies suggest that pedaling may have a positive effect on locomotion. The aim of this study was to explore the feasibility of a biofeedback pedaling treatment and its effects on cycling and walking ability in chronic stroke patients. A case series study was designed and participants were recruited based on a gait pattern classification of a population of 153 chronic stroke patients. Methods: In order to optimize participants selection, a k-means cluster analysis was performed to subgroup homogenous gait patterns in terms of gait speed and symmetry. The training consisted of a 2-week treatment of 6 sessions. A visual biofeedback helped the subjects in maintaining a symmetrical contribution of the two legs during pedaling. Participants were assessed before, after training and at follow-up visits (one week after treatment). Outcome measures were the unbalance during a pedaling test, and the temporal, spatial, and symmetry parameters during gait analysis. Results and discussion: Three clusters, mainly differing in terms of gait speed, were identified and participants, representative of each cluster, were selected. An intra-subject statistical analysis (ANOVA) showed that all patients significantly decreased the pedaling unbalance after treatment and maintained significant improvements with respect to baseline at follow-up. The 2-week treatment induced some modifications in the gait pattern of two patients: one, the most impaired, significantly improved mean velocity and increased gait symmetry; the other one reduced significantly the over-compensation of the healthy limb. No benefits were produced in the gait of the last subject who maintained her slow but almost symmetrical pattern. Thus, this study might suggest that the treatment can be beneficial for patients having a very asymmetrical and inefficient gait and for those that overuse the healthy leg. Conclusion: The results demonstrated that the treatment is feasible and it might be effective in translating progresses from pedaling to locomotion. If these results are confirmed on a larger and controlled scale, the intervention, thanks to its safety and low price, could have a significant impact as a home- rehabilitation treatment for chronic stroke patients.

The restoration of walking ability is crucial for maximizing independent mobility among patients with stroke. Leg cycling is becoming an established intervention to supplement ambulation training for stroke patients with problems of unbalance and weakness. The aim of the study was to explore the feasibility of a biofeedback pedaling treatment and its effects on cycling and walking ability in chronic stroke patients. Three patients were included in the study. The training consisted of a 2-week treatment of 6 sessions, during which a visual biofeedback helped the participants in maintaining a symmetrical pedaling. Participants were assessed before, after training and at follow-up, by means of a pedaling test and gait analysis. Outcome measurements were the unbalance during pedaling, the temporal, spatial and symmetry parameters during walking. An intra-subject statistical analysis (ANOVA, p<0.05) showed that all patients significantly decreased pedaling unbalance after treatment and maintained the improvements at follow-up. The training induced some gait pattern modifications in two patients: one significantly improved mean velocity and gait symmetry, while the other one reduced the compensation strategy of the healthy leg. The results demonstrated the feasibility of the treatment. If further trials on a larger and controlled scale confirmed the same results, this treatment, thanks to its safety and low price, could have a significant impact as a home-rehabilitation treatment.

We describe several influential hypotheses in the field of motor control including the equilibrium-point (referent configuration) hypothesis, the uncontrolled manifold hypothesis, and the idea of synergies based on the principle of motor abundance. The equilibrium-point hypothesis is based on the idea of control with thresholds for activation of neuronal pools; it provides a framework for analysis of both voluntary and involuntary movements. In particular, control of a single muscle can be adequately described with changes in the threshold of motor unit recruitment during slow muscle stretch (threshold of the tonic stretch reflex). Unlike the ideas of internal models, the equilibrium-point hypothesis does not assume neural computations of mechanical variables. The uncontrolled manifold hypothesis is based on the dynamic system approach to movements; it offers a toolbox to analyze synergic changes within redundant sets of elements related to stabilization of potentially important performance variables. The referent configuration hypothesis and the principle of abundance can be naturally combined into a single coherent scheme of control of multi-element systems. A body of experimental data on healthy persons and patients with movement disorders are reviewed in support of the mentioned hypotheses. In particular, movement disorders associated with spasticity are considered as consequences of an impaired ability to shift threshold of the tonic stretch reflex within the whole normal range. Technical details and applications of the mentioned hypotheses to studies of motor learning are described. We view the mentioned hypotheses as the most promising ones in the field of motor control, based on a solid physical and neurophysiological foundation.

Physiological bodily states play an important role in affective experiences. This study investigated whether the neural processing of internal body state (interoception) is associated with empathy, the understanding of the affective states of others. We used the ‘heartbeat-evoked potential’ (HEP), a surface electroencephalography (EEG) pattern, as a neural index of interoceptive processing. The HEP is contingent on the most prominent peak (R-wave) of the electrocardiogram (ECG) and is thought to reflect cortical processing of cardiac afferent input. Twenty-one healthy adults performed empathy and control tasks while EEG and ECG were recorded, where they made judgments based on either the affective or physical aspects of images of human eyes. HEP, ECG and heart rate in each task block were calculated and compared. Results showed that cardiac activity was not significantly different between tasks. In contrast, HEP showed a significant task difference, exhibited as an increased negativity during the empathy task over frontocentral sites at a latency of approximately 250-430 ms. Furthermore, a self-reported measure of empathy was associated with mean HEP amplitude during the period of task-related differentiation. These results suggest that afferent feedback from visceral activity may contribute to inferences about the affective state of others.

Knowing the body’s location in external space is a fundamental perceptual task. Perceiving the location of body parts through proprioception requires that information about the angles of each joint (i.e., body posture) be combined with information about the size and shape of the body segments between joints. Although information about body posture is specified by on-line afferent signals, no sensory signals are directly informative about body size and shape. Thus, human position sense must refer to a stored body model of the body’s metric properties, such as body part size and shape. The need for such a model has long been recognized; however, the properties of this model have never been systematically investigated. We developed a technique to isolate and measure this body model. Participants judged the location in external space of 10 landmarks on the hand. By analyzing the internal configuration of the locations of these points, we produced implicit maps of the mental representation of hand size and shape. We show that this part of the body model is massively distorted, in a reliable and characteristic fashion, featuring shortened fingers and broadened hands. Intriguingly, these distortions appear to retain several characteristics of primary somatosensory representations, such as the Penfield homunculus.

Optimal control theory and its more recent extension, optimal feedback control theory, provide valuable insights into the flexible and task-dependent control of movements. Here, we focus on the problem of coordination, defined as movements that involve multiple effectors (muscles, joints or limbs). Optimal control theory makes quantitative predictions concerning the distribution of work across multiple effectors. Optimal feedback control theory further predicts variation in feedback control with changes in task demands and the correlation structure between different effectors. We highlight two crucial areas of research, hierarchical control and the problem of movement initiation, that need to be developed for an optimal feedback control theory framework to characterise movement coordination more fully and to serve as a basis for studying the neural mechanisms involved in voluntary motor control.

Many stroke survivors have residual sensorimotor deficits that impact negatively on balance and quality of life. The purpose of this review is to provide an overview of the impairments in motor control following stroke and the impact of those impairments on muscle activation patterns during postural control in stroke. Motor control impairments following stroke result in force production that is slow, weak and lacking in precision making it difficult to produce a fast rate of force development with sufficient magnitude to be effective for postural responses. Whether postural perturbations require feedback or feedforward responses, there is impairment to the timing, magnitude and sequencing of muscle activation following stroke. The impairment in muscle activation is dependent on the extent of the motor control impairments and strategies used by the individuals following stroke to compensate for the impairments. The central nervous system uses a variety of mechanisms to improve the muscle activation patterns needed for the recovery of postural responses following stroke.

Background Inflammation is associated with psychological, emotional, and behavioral disturbance, known as sickness behavior. Inflammatory cytokines are implicated in coordinating this central motivational reorientation accompanying peripheral immunologic responses to pathogens. Studies in rodents suggest an afferent interoceptive neural mechanism, although comparable data in humans are lacking. Methods In a double-blind, randomized crossover study, 16 healthy male volunteers received typhoid vaccination or saline (placebo) injection in two experimental sessions. Profile of Mood State questionnaires were completed at baseline and at 2 and 3 hours. Two hours after injection, participants performed a high-demand color word Stroop task during functional magnetic resonance imaging. Blood samples were performed at baseline and immediately after scanning. Results Typhoid but not placebo injection produced a robust inflammatory response indexed by increased circulating interleukin-6 accompanied by a significant increase in fatigue, confusion, and impaired concentration at 3 hours. Performance of the Stroop task under inflammation activated brain regions encoding representations of internal bodily state. Spatial and temporal characteristics of this response are consistent with interoceptive information flow via afferent autonomic fibers. During performance of this task, activity within interoceptive brain regions also predicted individual differences in inflammation-associated but not placebo-associated fatigue and confusion. Maintenance of cognitive performance, despite inflammation-associated fatigue, led to recruitment of additional prefrontal cortical regions. Conclusions These findings suggest that peripheral infection selectively influences central nervous system function to generate core symptoms of sickness and reorient basic motivational states.

Purpose: To investigate the relationship between upper limb impairments and activity limitation. Method: A cross sectional, single assessment observational study in which people with hemiplegia as a result of a stroke underwent a testing procedure in an instrumented wrist rig in which the following measures of impairment were recorded: Spasticity; motor control (ability to track a moving target); muscle activation patterns during tracking; stiffness; range of active movement and isometric muscle strength. Participants also performed clinical tests of upper limb activity (Action Research Arm Test) and hyper-tonicity (Modified Ashworth Scale). Results: Seventeen people with hemiplegia whose mean age was 57 (SD 13.4) took part. Their mean upper limb activity, measured by the Action Research Arm Test, was 19.3 (SD 11.2). Statistically significant positive relationships between level of activity and the negative features of the upper motor neuron syndrome such as motor control r = 0.710 (p = 0.003), active range of movement r = 0.540 (p = 0.025) and strength into flexion r = 0.515 (p = 0.034) and extension r = 0.575 (p = 0.016) were identified, but not with the positive features, such as spasticity or the secondary features such as stiffness. Conclusions: The negative features of the upper motor neuron syndrome appear more likely to affect upper limb activity than the positive or secondary features, but findings need confirming in different study populations, preferably with larger samples.

Quadrupedal limb coordination during human walking was recently shown to be upregulated during obstacle stepping. An anticipatory activity of coupled cervico-thoraco-lumbar interneuronal circuits is followed by an appropriate executory activation of leg and arm muscles during task performance. This mechanism was studied in subjects with Parkinson’s disease and age-matched controls walking on a treadmill with a randomly approaching obstacle. Spinal reflex (SR) responses, evoked by tibial nerve stimulation during mid-stance, were present in all arm and leg muscles investigated. They were larger before execution of obstacle avoidance compared with normal steps in both subject groups. The performance of obstacle stepping was slightly worse in Parkinson’s disease than in control subjects. The anticipatory SR in the arm muscles prior to normal and obstacle steps was larger in Parkinson’s disease compared with age-matched subjects, but smaller in the tibialis anterior. The arm and leg muscle activation was stronger during obstacle compared with normal swing but did not differ between Parkinson’s disease and age-matched subjects. These observations indicate that quadrupedal limb coordination is basically preserved in Parkinson’s disease subjects. Our data are consistent with the proposal that in Parkinson’s disease subjects the enhanced anticipatory spinal neuronal activity (reflected in the SR) in the arm muscles is required to achieve an appropriate muscle activation for the automatic control of body equilibrium during the performance of the task. In the tibialis anterior the SR is attenuated presumably because of a stronger voluntary (i.e. cortical) control of leg movements.

Involvement of the right inferior parietal area in action awareness was investigated while taking into account differences in the conscious experiences of one’s own actions; especially, the awareness that an intended action is consistent with movement consequences and the awareness of the authorship of the action (i.e., the sense of agency). We hypothesized that these experiences are both associated with processes implemented in inferior parietal cortex, specifically, right angular gyrus (Ag). Two blood-oxygenation-level-dependent functional magnetic resonance imaging studies employed a novel delayed visual feedback technique to distinguish the neural correlates of these 2 forms of action awareness. We showed that right Ag is associated with both awareness of discrepancy between intended and movement consequences and awareness of action authorship. We propose that this region is involved in higher-order aspects of motor control that allows one to consciously access different aspects of one’s own actions. Specifically, this region processes discrepancies between intended action and movement consequences in such a way that these will be consciously detected by the subject. This joint processing is at the core of the various experiences one uses to interpret an action.

Pain naturally draws one’s attention. However, humans are capable of engaging in cognitive tasks while in pain, although it is not known how the brain represents these processes concurrently. There is some evidence for a cortical interaction between pain- and cognitive-related brain activity, but the outcome of this interaction may depend on the relative load imposed by the pain versus the task. Therefore, we used 3 levels of cognitive load (multisource interference task) and 2 levels of pain intensity (median nerve stimulation) to examine how functional magnetic resonance imaging activity in regions identified as pain-related or cognitive-related responds to different combinations of pain intensity and cognitive load. Overall, most pain-related or cognitive-related brain areas showed robust responses with little modulation. However, during the more intense pain, activity in primary sensorimotor cortex, secondary somatosensory cortex/posterior insula, anterior insula, paracentral lobule, caudal anterior cingulate cortex, cerebellum, and supplementary motor area was modestly attenuated by the easy task and in some cases the difficult task. Conversely, cognitive-related activity was not modulated by pain, except when cognitive load was minimal during the control task. These findings support the notion that brain networks supporting pain perception and cognition can be simultaneously active.

Recent findings on motor lateralization have revealed consistent differences in the control strategies of the dominant and nondominant hemisphere/limb systems that could have implications for hemiplegic stroke patients. Studies in stroke patients have demonstrated deficiencies in the ipsilesional arm that reflect these distinctions; patients with right-hemisphere damage tend to show deficits in positional accuracy, and patients with left-hemisphere damage show deficits in trajectory control. Such deficits have been shown to impede functional performance; yet patients with severe dominant-side hemiplegia must often use the nondominant arm as the primary manipulator for activities of daily living. Nevertheless, the nondominant arm may not spontaneously become efficient as a dominant manipulator, as indicated by the persistence of deficits in chronic stroke patients. More research is necessary to determine whether motor therapy can facilitate a more effective transition of this arm from a nondominant to a dominant controller.

Young and elderly participants performed concurrent ipsilateral hand-foot movements either isodirectionally or nonisodirectionally. We determined performance by measuring the maximal cycling frequency at which the coordination pattern could be performed successfully (CFmax). We also determined attentional costs by means of a dual-task paradigm. Findings revealed that CFmax was significantly lower in the elderly than in the young participants for the nonisodirectional mode, whereas we observed no differences for the isodirectional mode. Under dual-task conditions, coordination deteriorated in the elderly group only. However, when we equated levels of task difficulty, differences between the groups disappeared. Furthermore, attentional costs did not differ between isodirectional and nonisodirectional movements. This indicates that age-related coordination deficits were not primarily evoked by reduced attentional resources or control in elderly persons.

In a recent study we demonstrated that otolith input modifies the torsional angular vestibulo-ocular reflex (torVOR) of healthy human subjects: Compared to turntable oscillations in supine position, oscillations in upright position increased the gain of torVOR by 0.1 and cancelled the phase lead originating from low-frequency semicircular canal signals. We asked whether these otolith-related changes of torVOR are still present in patients after vestibular neuritis. Eight patients were sinusoidally oscillated about their naso-occipital axis in supine (canal-only stimulation) and upright (canal-and-otolith stimulation) position. Three-dimensional eye movements were recorded with dual search coils. The patients showed similar otolith-related gain and phase changes of the torVOR as healthy subjects: the gain increased by about 0.1 (p < 0.05) and the low-frequency phase lead from semicircular canal signals was abolished. These results indicate that otolith function after VN is still sufficient to interact with semicircular canal signals to optimize torsional gaze stabilization when the head is upright.

Garland SJ, Willems DA, Ivanova TD, Miller KJ. Recovery of standing balance and functional mobility after stroke. Arch Phys Med Rehabil 2003;84:1753-9. Objective: To examine the extent to which recovery of functional balance and mobility is accompanied by change in a few specific physiologic measures of postural control. Design: Longitudinal prospective study. Setting: Laboratory setting in Ontario. Participants: Twenty-seven volunteers (age, 64.2±13.7y) undergoing 4 weeks of rehabilitation after stroke participated. At initial testing, patients were 32.7±18.4 days poststroke and exhibited a moderate level of motor recovery (lower-extremity and postural control, stages 3–4 on the Chedoke-McMaster Stroke Assessment Impairment Inventory). Interventions: Not applicable. Main Outcome Measures: Three functional measures (Berg Balance Scale, Clinical Outcome Variables Scale, gait speed) were assessed. Three physiologic measures (electromyographic data of hamstrings and soleus muscles bilaterally, postural sway, arm acceleration) were taken while subjects stood quietly on a force platform and while they performed a rapid shoulder flexion movement of the nonparetic upper extremity. Results: After 1 month of rehabilitation, there was an overall significant improvement in all outcome measures (functional, physiologic). However, 10 patients failed to show any improvement in the electromyographic activation of hamstrings muscle on the paretic side in response to the rapid arm movement. These patients compensated by increasing the anticipatory activation of the nonparetic hamstrings. Conclusion: After stroke, patients showed improvement in both physiologic and functional measures of balance and mobility over a 1-month period. We have identified some patients who may be using compensatory strategies to increase function. The factors that may predict those patients who are likely to use compensatory strategies awaits further study.

Bimanual coordination, a prototype of a complex motor skill, has recently become the subject of intensive investigation. Whereas past research focused mainly on the identification of the elementary coordination constraints that limit performance, the focus is now shifting towards overcoming these coordination constraints by means of task symbolization or perceptual transformation rules that promote the integration of the task components into a meaningful ‘gestalt’. The study of these cognitive penetrations into action will narrow the brain–mind gap and will facilitate the development of a cognitive neuroscience perspective on bimanual movement control.

Converging evidence indicates that primates have a distinct cortical image of homeostatic afferent activity that reflects all aspects of the physiological condition of all tissues of the body. This interoceptive system, associated with autonomic motor control, is distinct from the exteroceptive system (cutaneous mechanoreception and proprioception) that guides somatic motor activity. The primary interoceptive representation in the dorsal posterior insula engenders distinct highly resolved feelings from the body that include pain, temperature, itch, sensual touch, muscular and visceral sensations, vasomotor activity, hunger, thirst, and ‘air hunger’. In humans, a meta-representation of the primary interoceptive activity is engendered in the right anterior insula, which seems to provide the basis for the subjective image of the material self as a feeling (sentient) entity, that is, emotional awareness.

To determine whether other digits move when normal humans attempt to move just one digit, we asked 10 right‑handed subjects to move one finger at a time while we recorded the motion of all five digits simultaneously with both a video motion analysis system and an instrumented glove. We quantified the independence of the digits to compare (1) the different digits, (2) the right versus the left hand, and (3) movements at a self‑paced frequency versus externally paced movements at 3 Hz. We also quantified the degree to which motion occurred at the proximal, middle, or distal joint of each digit. Even when asked to move just one finger, normal human subjects produced motion in other digits. Movements of the thumb, index finger, and little finger typically were more highly individuated than were movements of the middle or ring fingers. Fingers of the dominant hand were not more independent than were those of the nondominant hand. Self‑paced movements made at ~2 Hz were more highly individuated than were externally paced movements at 3 Hz. Angular motion tended to be greatest at the middle joint of each digit, with increased angular motion at the proximal and distal joints during 3 Hz movements. Simultaneous motion of noninstructed digits may result in part from passive mechanical connections between the digits, in part from the organization of multitendonated finger muscles, and in part from distributed neural control of the hand.

Recent studies in humans and nonhuman primates have shown that the functional organization of the human sensorimotor cortex changes following sensory stimulation or following the acquisition of motor skills. It is unknown whether functional plasticity in response to the acquisition of new motor skills and the continued performance of complicated bimanual movements for years is associated with structural changes in the organization of the motor cortex. Professional musicians, especially keyboard and string players, are a prototypical group for investigating these changes in the human brain. Using magnetic resonance images, we measured the length of the posterior wall of the precentral gyrus bordering the central sulcus (intrasulcal length of the precentral gyrus, ILPG) in horizontal sections through both hemispheres of right-handed keyboard players and of an age- and handedness-matched control group. Lacking a direct in vivo measurement of the primary motor cortex in humans, we assumed that the ILPG is a measure of the size of the primary motor cortex. Left-right asymmetry in the ILPG was analyzed and compared between both groups. Whereas controls exhibited a pronounced left-larger-than-right asymmetry, keyboard players had more symmetrical ILPG. The most pronounced differences in ILPG between keyboard players and controls were seen in the most dorsal part of the presumed cortical hand representation of both hemispheres. This was especially true in the nondominant right hemispheres. The size of the ILPG was negatively correlated with age of commencement of musical training in keyboard players, supporting our hypothesis that the human motor cortex can exhibit functionally induced and long-lasting structural adaptations.

The role of intrinsic and extrinsic information feedback in learning a new bimanual coordination pattern was investigated. The pattern required continuous flexion-extension movements of the upper limbs with a 90° phase offset. Separate groups practiced the task under one of the following visual feedback conditions: (a) blindfolded (reduced FB group), (b) with normal vision (normal FB group), or (c) with concurrent relative motion information (enhanced FB group). All groups were subjected to three different transfer test conditions at regular intervals during practice. These tests included reduced, normal vision, and enhanced vision conditions. Experiment 1 showed that the group receiving augmented information feedback about its relative motions in real-time produced the required coordination pattern more successfully than the remaining two groups, irrespective of the transfer conditions under which performance was evaluated. Experiment 2 replicated and extended the superiority of the enhanced feedback group during acquisition and retention. Experiment 3 demonstrated that successful transfer to various transfer test conditions was not a result of test-trial effects. Overall, the data suggest that the conditions that optimized performance of the coordination pattern during acquisition also optimized transfer performance.

The basal ganglia comprise several nuclei in the forebrain, diencephalon, and midbrain thought to play a significant role in the control of posture and movement. It is well recognized that people with degenerative diseases of the basal ganglia suffer from rigidly held abnormal body postures, slowing of movement, involuntary movements, or a combination of these abnormalities. However, it has not been agreed just what the basal ganglia contribute to normal movement. Recent advances in knowledge of the basal ganglia circuitry, activity of basal ganglia neurons during movement, and the effect of basal ganglia lesions have led to a new hypothesis of basal ganglia function. The hypothesis states that the basal ganglia do not generate movements. Instead, when voluntary movement is generated by cerebral cortical and cerebellar mechanisms, the basal ganglia act broadly to inhibit competing motor mechanisms that would otherwise interfere with the desired movement. Simultaneously, inhibition is removed focally from the desired motor mechanisms to allow that movement to proceed. Inability to inhibit competing motor programs results in slow movements, abnormal postures and involuntary muscle activity.

The common denominator in the assessment of human balance and posture is the inverted pendulum model. If we focus on appropriate versions of the model we can use it to identify the gravitational and acceleration perturbations and pinpoint the motor mechanisms that can defend against any perturbation. We saw that in quiet standing an ankle strategy applies only in the direction and that a separate hip load/unload strategy by the hip abd/adductors is the totally dominant defence in the direction when standing with feet side by side. In other standing positions (tandem, or intermediate) the two mechanisms still work separately, but their roles reverse. In the tandem position balance is an ankle mechanism (invertors/evertors) while in the direction a hip load/unloading mechanism dominates. During initiation and termination of gait these two separate mechanisms control the trajectory of the COP to ensure the desired acceleration and deceleration of the COM. During initiation the initial acceleration of the COM forward towards the stance limb is achieved by a posterior and lateral movement of the COP towards the swing limb. After this release phase there is a sudden loading of the stance limb which shifts the COP to the stance limb. The COM is now accelerated forward and laterally towards the future position of the swinging foot. Also shifts of the COP were controlled by the hip abductors/adductors and all shifts were under the control of the ankle plantar/dorsiflexors. During termination the trajectory of both COM and COP reverse. As the final weight-bearing on the stance foot takes place the COM is passing forward along the medial border of that foot. Hyperactivity of that foot’s plantarflexors takes the COP forward and when the final foot begins to bear weight the COP moves rapidly across and suddenly stops at a position ahead of the future position of the COM. Then the plantarflexors of both feet release and allow the COP to move posteriorly and approach the COM and meet it as quiet stance is achieved. The inverted pendulum model permitted us to understand the separate roles of the two mechanisms during these critical unbalancing and rebalancing periods. During walking the inverted pendulum model explained the dynamics of the balance of HAT in both the and directions. Here the model includes the couple due to the acceleration of the weight-bearing hip as well as gravitational perturbations. The exclusive control of balance and posture are the hip extensors and flexors, while in the direction the dominant control is with the hip abductors with very minor adductor involvement. At the ankle the inverted pendulum model sees the COM passing forward along the medial border to the weight-bearing foot. The model predicts that during single support the body is falling forward and being accelerated medially towards the future position of the swing foot. The model predicts an insignificant role of the ankle invertors/evertors in the control. Rather, the future position of the swing foot is the critical variable or more specifically the lateral displacement from the COM at the start of single support. The position is actually under the control of the hip abd/adductors during the previous early swing phase. The critical importance of the hip abductors/adductors in balance during all phases of standing and walking is now evident. This separate mechanism is important from a neural control perspective and clinically it focuses major attention on therapy and potential problems with some surgical procedures. On the other hand the minuscule role of the ankle invertors/evertors is important to note. Except for the tandem standing position these muscles have negligible involvement in balance control.

Tele-rehabilitation systems have been increasingly studied, becoming an important complement to traditional therapy as they can provide high‑intensity, repetitive and interactive treatments of the injured extremities. Several systems have been developed in research projects and some of these have become products mainly for being used at hospitals and care centers. After the initial rehabilitation performed at rehabilitation centers, patients are obliged to go to the centers, with many consequences, as costs, loss of time, discomfort and demotivation. However, it has been demonstrated that patients recovering at home heal faster because surrounded by the love of their relatives and with the community support. So, there is a strong need for rehabilitation systems to use at home. There are already some devices available on the market for home care: their main weakness is the limited strategy for motor learning. The ambition of the HEAD (Human Empowerment Aging and Disability) project is to combine assistance with appropriate feedback to close the loop in motor learning strategy for the home. HEAD platform challenging objective is to develop a novel tele‑rehabilitation system and related provision services for a holistic rehabilitation aiming at restoring limb motor functional abilities, and at launching both system and services at home. The tele‑rehabilitation system is based on the use of low cost sensors, connected with a gaming module for cognitive‑motor rehabilitation, and integrated with an infrastructure connecting the patient at home with therapists at hospitals who monitor the rehabilitation exercises.