Separating the control of moving and holding in post-stroke arm paresis

Abstract

Moving and holding-still (holding) have been posited to be under separate control regimes for both eye and arm movements. The paretic arm after stroke exhibits different abnormalities during rest vs. movement, providing an opportunity to ask whether control of these behaviors is independently affected in stroke. Here, we quantified resting postural abnormalities in stroke patients by measuring their biases in force production as they held their hand still in various locations in a planar workspace, and then assessed the influence of these resting force biases on reaching in the same workspace. We found that patients had marked resting force biases at each location, even when the arm was supported. However, these biases did not transfer to arm-supported planar reaching movements: not during initial acceleration, not in response to mid-trajectory perturbations, and not during deceleration to a stop. Rather, the abnormal resting forces only appeared to switch on after a movement had fully stopped. These findings suggest that moving and holding are functionally separable modes of control. At the same time, we found that the resting biases mirrored characteristics of abnormal synergies during movement: they markedly decreased when arm support was provided; they were higher in more distant positions that require breaking out of flexion; and they scaled with the Fugl-Meyer score for the upper extremity (a measure of intrusion of abnormal synergies during active movement). These three shared features suggest a common mechanism for resting biases and abnormal synergies, which appears to be a contradiction given the functional separation of moving and holding observed in the same patients. To resolve this paradox, we propose a conceptual model that predicts a breakdown in the functional separation between reaching and holding when patients move in the absence of weight support. This conceptual model posits that synergies are the behavioral manifestation of a spillover of posture into movement. Mapping these functional systems onto anatomical and physiological details of lesioned substrate after stroke may provide implementation-level insight into how normal arm motor control is assembled.