New model of how brain functions are organized may revolutionize stroke rehab

A new model of brain lateralization for movement could dramatically improve the future of rehabilitation for stroke patients, according to Penn State researcher Robert Sainburg, who proposed and confirmed the model through novel virtual reality and brain lesion experiments.

Since the 1860s, neuroscientists have known that the human brain is organized into two hemispheres, each of which is responsible for different functions. Known as neural lateralization, this functional division has significant implications for the control of movement and is familiar in the phenomenon of handedness.

Understanding the connections between neural lateralization and motor control is crucial to many applications, including the rehabilitation of stroke patients. While most people intuitively understand handedness, the neural foundations underlying motor asymmetry have until recently remained elusive, according to Sainburg, professor of kinesiology and neurology and participant in the neuroscience and physiology graduate programs at the University’s Huck Institutes of the Life Sciences.

Research by Sainburg and his colleagues in the Center for Motor Control and published in the journal Brain has revealed a new model of motor lateralization that accounts for the neural foundations of handedness. The discovery could fundamentally change the way post-stroke rehabilitation is designed.

"Each hemisphere of the brain is specialized for different aspects of motor control, and thus each arm is ‘dominant’ for different features of movement," said Sainburg. "The dominant arm is used for applying specific force sequences — such as when slicing a loaf of bread with a knife — and the other arm is used for impeding forces to maintain stable posture, such as holding the loaf of bread. Together these specialized control mechanisms are seamlessly integrated into every day activities.

"Our research has shown that this integration breaks down in neural disorders such as stroke, which produces different motor deficits depending on whether the right or left hemisphere has been damaged," Sainburg continued. "Traditionally, physical rehabilitation professionals have used the same protocols to practice movements of the paretic arm, regardless of the hemisphere that has been damaged. Our research shows that each arm should be treated for different control deficits, and it also indicates that therapists should directly retrain patients in how to use the two arms together in order to recover function."

In preparing to test their model, Sainburg and his team selected study participants from the New Mexico Veterans Administration Hospital and Penn State Milton S. Hershey Medical Center based on specific criteria in order to accurately distinguish the motor control mechanisms specific to each brain hemisphere. Participants were then asked to perform a series of tasks on a virtual reality interface, programmed and designed by Sainburg, which allowed the researchers to record detailed 3D position and motion data. The data for all the participants’ hand trajectories and final positions were then aggregated to compare the effects of left versus right hemisphere damage on different aspects of control.

"Our results indicated that while both groups of patients showed similar clinical impairment in the contralesional arm, this was produced by different motor control deficits," Sainburg said. "Right hemisphere damaged patients were able to make straight movements that were directed toward the targets, but were unable to stabilize their arms in the targets at the end of motion. In contrast, left hemisphere damaged patients were unable to make straight and efficient movements, but had no difficulty stabilizing their arms at the end of motion. These results confirmed that each hemisphere contributes unique control to its contralesional arm, verifying why our arms seem different when we use them for the same tasks."

Results mirror those of Sainburg’s prior studies of motor deficits in unilateral stroke patients, focused on the ipsilesional arm, which formed the basis for his model of lateralization.

"Because both arms in stroke patients show motor deficits that are specific to the hemisphere that was damaged, we have concluded that the left arm is not simply controlled with the right hemisphere and vice versa," Sainburg said. "This is a revolutionarily new perspective on sensorimotor control: each hemisphere contributes different control mechanisms to the coordination of both arms, regardless of which arm is considered dominant."

Sainburg and his colleagues are currently designing follow-up studies that will aid the development of new rehabilitation protocols addressing the specific motor deficits associated with each hemisphere.

Shift of Language Function to Right Hemisphere Impedes Post-Stroke Aphasia Recovery

In a study designed to differentiate why some stroke patients recover from aphasia and others do not, investigators have found that a compensatory reorganization of language function to right hemispheric brain regions bodes poorly for language recovery. Patients who recovered from aphasia showed a return to normal left-hemispheric language activation patterns. These results, which may open up new rehabilitation strategies, are available in the current issue of Restorative Neurology and Neuroscience.

“Overall, approximately 30% of patients with stroke suffer from various types of aphasia, with this deficit most common in stroke with left middle cerebral artery territory damage. Some of the affected patients recover to a certain degree in the months and years following the stroke. The recovery process is modulated by several known factors, but the degree of the contribution of brain areas unaffected by stroke to the recovery process is less clear,” says lead investigator Jerzy P. Szaflarski, MD, PhD, of the Departments of Neurology at the University of Alabama and University of Cincinnati Academic Health Center.

For the study, 27 right-handed adults who suffered from a left middle cerebral artery infarction at least one year prior to study enrollment were recruited. After language testing, 9 subjects were considered to have normal language ability while 18 were considered aphasic. Patients underwent a battery of language tests as well as a semantic decision/tone decision cognitive task during functional MRI (fMRI) in order to map language function. MRI scans were used to determine stroke volume.

The authors found that linguistic performance was better in those who had stronger left-hemispheric fMRI signals while performance was worse in those who had stronger signal-shifts to the right hemisphere. As expected, they also found a negative association between the size of the stroke and performance on some linguistic tests. Right cerebellar activation was also linked to better post-stroke language ability.

The authors say that while a shift to the non-dominant right hemisphere can restore language function in children who have experienced left-hemispheric injury or stroke, for adults such a shift may impede recovery. For adults, it is the left hemisphere that is necessary for language function preservation and/or recovery.

The split brain: A tale of two halves

In the first months after her surgery, shopping for groceries was infuriating. Standing in the supermarket aisle, Vicki would look at an item on the shelf and know that she wanted to place it in her trolley — but she couldn’t. “I’d reach with my right for the thing I wanted, but the left would come in and they’d kind of fight,” she says. “Almost like repelling magnets.” Picking out food for the week was a two-, sometimes three-hour ordeal. Getting dressed posed a similar challenge: Vicki couldn’t reconcile what she wanted to put on with what her hands were doing. Sometimes she ended up wearing three outfits at once. “I’d have to dump all the clothes on the bed, catch my breath and start again.”

In one crucial way, however, Vicki was better than her pre-surgery self. She was no longer racked by epileptic seizures that were so severe they had made her life close to unbearable. She once collapsed onto the bar of an old-fashioned oven, burning and scarring her back. “I really just couldn’t function,” she says. When, in 1978, her neurologist told her about a radical but dangerous surgery that might help, she barely hesitated. If the worst were to happen, she knew that her parents would take care of her young daughter. “But of course I worried,” she says. “When you get your brain split, it doesn’t grow back together.”

In June 1979, in a procedure that lasted nearly 10 hours, doctors created a firebreak to contain Vicki’s seizures by slicing through her corpus callosum, the bundle of neuronal fibres connecting the two sides of her brain. This drastic procedure, called a corpus callosotomy, disconnects the two sides of the neocortex, the home of language, conscious thought and movement control. Vicki’s supermarket predicament was the consequence of a brain that behaved in some ways as if it were two separate minds.

After about a year, Vicki’s difficulties abated. “I could get things together,” she says. For the most part she was herself: slicing vegetables, tying her shoe laces, playing cards, even waterskiing.

But what Vicki could never have known was that her surgery would turn her into an accidental superstar of neuroscience. She is one of fewer than a dozen ‘split-brain’ patients, whose brains and behaviours have been subject to countless hours of experiments, hundreds of scientific papers, and references in just about every psychology textbook of the past generation. And now their numbers are dwindling.

Through studies of this group, neuroscientists now know that the healthy brain can look like two markedly different machines, cabled together and exchanging a torrent of data. But when the primary cable is severed, information — a word, an object, a picture — presented to one hemisphere goes unnoticed in the other. Michael Gazzaniga, a cognitive neuroscientist at the University of California, Santa Barbara, and the godfather of modern split-brain science, says that even after working with these patients for five decades, he still finds it thrilling to observe the disconnection effects first-hand. “You see a split-brain patient just doing a standard thing — you show him an image and he can’t say what it is. But he can pull that same object out of a grab-bag,” Gazzaniga says. “Your heart just races!”

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