Both the American Heart Association and the VA/DoD endorse upper-extremity robot-mediated rehabilitation therapy for stroke care. However, we do not know yet how to optimize therapy for a particular patient’s needs. Here, we explore whether we must train patients for each functional task that they must perform during their activities of daily living or alternatively capacitate patients to perform a class of tasks and have therapists assist them later in translating the observed gains into activities of daily living. The former implies that motor adaptation is a better model for motor recovery. The latter implies that motor learning (which allows for generalization) is a better model for motor recovery. We quantified trained and untrained movements performed by 158 recovering stroke patients via 13 metrics, including movement smoothness and submovements. Improvements were observed both in trained and untrained movements suggesting that generalization occurred. Our findings suggest that, as motor recovery progresses, an internal representation of the task is rebuilt by the brain in a process that better resembles motor learning than motor adaptation. Our findings highlight possible improvements for therapeutic algorithms design, suggesting sparse-activity-set training should suffice over exhaustive sets of task specific training.

General-purpose computers have become ubiquitous and important for everyday life, but they are difficult for people with paralysis to use. Specialized software and personalized input devices can improve access, but often provide only limited functionality. In this study, three research participants with tetraplegia who had multielectrode arrays implanted in motor cortex as part of the BrainGate2 clinical trial used an intracortical brain-computer interface (iBCI) to control an unmodified commercial tablet computer. Neural activity was decoded in real time as a point-and-click wireless Bluetooth mouse, allowing participants to use common and recreational applications (web browsing, email, chatting, playing music on a piano application, sending text messages, etc.). Two of the participants also used the iBCI to “chat” with each other in real time. This study demonstrates, for the first time, high-performance iBCI control of an unmodified, commercially available, general-purpose mobile computing device by people with tetraplegia.

Objective: To compare the outcome of training the functional movement of transport of the arm and grasping an object with the alternative of training the transport of the arm in isolation. Design: Pretest-posttest comparison. Setting: Rehabilitation hospitals, outpatient care. Participants: Volunteer sample of forty-seven persons with persistent hemiparesis from a single, unilateral stroke within the past one to five years. Intervention: Robotic therapy 3x/week for 6 weeks for the paretic upper limb consisted of either a) sensorimotor, active-assistive impairment-based exercise during repetitive planar reaching tasks, or b) a "free-hand" approach, in which the robot assisted subjects employing the sensorimotor active-assistive exercise to transport the hand to a series of targets, where it stopped to allow the person to interact with actual objects (functional approach 1), or c) transport and manipulation, in which the robot assisted subjects employing active-assistive exercise during repetitive planar reaching tasks while grasping a simulated object and releasing it at the target or followed by grasp and release of a simulated object (functional approach 2). Primary Outcome Measure: Fugl-Meyer Assessment. Results: All three groups improved from pre-to post-treatment with the sensorimotor impairment based approach demonstrating the best outcome of the three approaches. Conclusions: Short-term, goal-directed robotic therapy can significantly improve motor abilities of the exercised limb segments in persons with chronic stroke, but contrary to expectation, training both the transport of the arm and manipulation of an object (functionally-based approaches) did not confer any advantage over training solely transport of the arm (impairment-based approach).

Efficacious smoking cessation interventions for smokers with MS should be developed to address a critical health need for a population of highly nicotine-dependent smokers who face numerous obstacles to quitting.

Current assessments do not provide reliable factors predictive of outcome from stroke for stroke survivors of intermediate age and severity of deficit. We sought to investigate whether early rate of functional improvement can facilitate prediction of functional outcome, length of stay, and disposition beyond that afforded by age and initial severity of deficit. Prospective study of consecutive admissions to acute rehabilitation (N = 244) with diagnosis of ischemic or hemorrhagic stroke. Independent measures were age, marital status, living situation, social situation, lag from symptom onset to rehabilitation, stroke type, admission score on the Functional Independence Measure (FIM), rate of FIM change (ROFC) as assessed by the best weekly FIM change in the first 3 weeks of rehabilitation. Dependent measures were functional status on discharge as assessed by a modification of Steinman's method, length of stay, and discharge disposition. Logistic regression analyses on each of the dependent measures identified significant factors, and interactions of significant factors were assessed by analysis of variance on continuous dependent variables. Cross-tabulations using significant factors from the logistic regression analyses were performed to identify groups with homogeneous outcomes. Groups with >80% homogeneity were considered likely to have predictive value. Discharge functional status: Admission FIM (AFIM) again fractionated the population into groups with poor outcome (AFIM <50 remained dependent), good outcome (AFIM >70 achieved nondependence), and an intermediate group with unpredictable outcome. In this intermediate group, ROFC had significant effect only for a small number of patients (n = 9) with rapid improvement (ROFC >25) who achieved nondependence. LOS: AFIM >70 had less than average LOS, ROFC = 10-15 FIM/week had longer than average LOS. LOS was significantly prolonged in patients with poor outcomes. Disposition: AFIM >70 and age <60 were strongly associated with home discharge. Patients not living at home before admission were not discharged home. Married patients had a greater tendency to home discharge than did those not married. ROFC had no bearing on disposition. ROFC has an independent influence on outcome but was sufficiently powerful in our sample to identify reliably only a very small subset of patients with otherwise indeterminate prognosis. LOS seems inordinately prolonged in patients with poor outcomes. Both of these results can guide efficient rehabilitation management.

Background and Objectives:Brain computer interfaces (BCIs) are being developed to restore mobility, communication, and functional independence to people with paralysis. Though supported by decades of preclinical data, the safety of chronically implanted microelectrode array BCIs in humans is unknown. We report safety results from the prospective, open-label, non-randomized BrainGate feasibility study (NCT00912041), the largest and longest-running clinical trial of an implanted BCI.Methods:Adults aged 18-75 with quadriparesis from spinal cord injury, brainstem stroke, or motor neuron disease were enrolled through seven clinical sites in the United States. Participants underwent surgical implantation of one or two microelectrode arrays in the motor cortex of the dominant cerebral hemisphere. The primary safety outcome was device-related serious adverse events requiring device explanation or resulting in death or permanently increased disability during the one-year post-implant evaluation period. Secondary outcomes include the type and frequency of other adverse events as well as the feasibility of the BrainGate system for controlling a computer or other assistive technologies.Results:From 2004 – 2021, fourteen adults enrolled in the BrainGate trial had devices surgically implanted. The average duration of device implantation was 872 days, yielding 12,203 days of safety experience. There were 68 device-related adverse events, including 6 device-related serious adverse events. The most common device-related adverse event was skin irritation around the percutaneous pedestal. There were no safety events that required device explantation, no unanticipated adverse device events, no intracranial infections, and no participant deaths or adverse events resulting in permanently increased disability related to the investigational device.Discussion:The BrainGate Neural Interface system has a safety record comparable to other chronically implanted medical devices. Given rapid recent advances in this technology and continued performance gains, these data suggest a favorable risk/benefit ratio in appropriately selected individuals to support ongoing research and development.Trial Registration Information:ClinicalTrials.gov Identifier:NCT00912041.Classification of Evidence:This study provides Class IV evidence that the neurosurgically placed BrainGate Neural Interface system is associated with a low rate of SAEs defined as those requiring device explanation, resulting in death, or resulting in permanently increased disability during the one-year post implant period.

Interventions that have successfully increased adoption by the two other clinician groups should be utilized to increase tobacco dependence treatment provision by rehabilitation clinicians. Additional research is warranted to determine how to overcome obstacles to adoption.

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