Carolee Winstein

University of Southern California | USC · Division of Biokinesiology and Physical Therapy

Background Walking patterns in stroke survivors are highly heterogeneous, which poses a challenge in systematizing treatment prescriptions for walking rehabilitation interventions. Objectives We used bilateral spatiotemporal and force data during walking to create a multi-site research sample to: (1) identify clusters of walking behaviors in peopl...

An overreliance on the less-affected limb for functional tasks at the expense of the paretic limb and in spite of recovered capacity is an often-observed phenomenon in survivors of hemispheric stroke. The difference between capacity for use and actual spontaneous use is referred to as arm nonuse. Obtaining an ecologically valid evaluation of arm no...

Background In stroke rehabilitation, wearable technology can be used as an intervention modality by providing timely, meaningful feedback on motor performance. Stroke survivors’ preferences may offer a unique perspective on what metrics are intuitive, actionable, and meaningful to change behavior. However, few studies have identified feedback prefe...

Chronic motor impairments are a leading cause of disability after stroke. Previous studies have predicted motor outcomes based on the degree of damage to predefined structures in the motor system, such as the corticospinal tract. However, such theory-based approaches may not take full advantage of the information contained in clinical imaging data....

Background: Walking patterns in stroke survivors are highly heterogeneous, which poses a challenge in systematizing treatment prescriptions for walking rehabilitation interventions. Objective: We used bilateral spatiotemporal and force data during walking to create a multi-site research sample to: 1) identify clusters of walking behaviors in people...

Background In stroke rehabilitation, wearable technology can be used as an intervention modality by providing timely, meaningful feedback on motor performance. Stroke survivors’ preferences may offer a unique perspective on what metrics are intuitive, actionable, and meaningful to change behavior. However, few studies have identified feedback prefe...

Background and objectives: Functional outcomes after stroke are strongly related to focal injury measures. However, the role of global brain health is less clear. Here, we examined the impact of brain age, a measure of neurobiological aging derived from whole brain structural neuroimaging, on post-stroke outcomes, with a focus on sensorimotor perf...

Human motor adaptability is of utmost utility after neurologic injury such as unilateral stroke. For successful adaptive control of movements, the nervous system must learn to correctly identify the source of a movement error and predictively compensate for this error. The current understanding is that in bimanual tasks, this process is flexible su...

Background: Microstructural changes in the corpus callosum (CC) are associated with more severe motor impairment in the paretic hand, poor recovery, and general disability. The purpose of this study was to determine if CC microstructure predicts bimanual motor performance in chronic stroke survivors. Methods: We examined the relationship between...

Accurate lesion segmentation is critical in stroke rehabilitation research for the quantification of lesion burden and accurate image processing. Current automated lesion segmentation methods for T1-weighted (T1w) MRIs, commonly used in stroke research, lack accuracy and reliability. Manual segmentation remains the gold standard, but it is time-con...

Objective Patients show substantial differences in response to rehabilitation therapy after stroke. We hypothesized that specific genetic profiles might explain some of this variance and, secondarily, that genetic factors are related to cerebral atrophy post-stroke. Methods The phase 3 ICARE study examined response to motor rehabilitation therapie...

Accurate lesion segmentation is critical in stroke rehabilitation research for the quantification of lesion burden and accurate image processing. Current automated lesion segmentation methods for T1-weighted (T1w) MRIs, commonly used in rehabilitation research, lack accuracy and reliability. Manual segmentation remains the gold standard, but it is...

In neurotypical individuals, arm choice in reaching movements depends on expected biomechanical effort, expected success, and a handedness bias. Following a stroke, does arm choice change to account for the decreased motor performance, or does it follow a pre-injury habitual preference pattern? Participants with mild to moderate chronic stroke who...

Up to two-thirds of stroke survivors experience persistent sensorimotor impairments. Recovery relies on the integrity of spared brain areas to compensate for damaged tissue. Deep grey matter structures play a critical role in the control and regulation of sensorimotor circuits. The goal of this work is to identify associations between volumes of sp...

Background: Evidence supports cortical reorganization in sensorimotor areas induced by constraint-induced movement therapy (CIMT). However, only a few studies examined the neural plastic changes as a function of task specificity. This provoked us to retrospectively analyze a previously unpublished imaging dataset from chronic stroke survivors befor...

Background and purpose: The corticospinal tract (CST) is a crucial brain pathway for distal arm and hand motor control. We aimed to determine whether a diffusion tensor imaging (DTI)-derived CST metric predicts distal upper extremity (UE) motor improvements in chronic stroke survivors. Methods: We analyzed clinical and neuroimaging data from a r...

Pain influences both attention and motor behavior. We used a dual-task interference paradigm to investigate (1) alterations in attentional performance, (2) the ability to switch task prioritization, and (3) the effect of attentional demand on trunk coordination during narrow-based walking in and out of a painful episode in individuals with recurren...

A bstract Microstructural changes in the corpus callosum are associated with more severe motor impairment in the paretic hand, poor recovery, and general disability. Considering its role in bimanual coordination, we suspected that these microstructural changes across the callosum may also be reflected in the performance of ecologically valid routin...

Chronic stroke survivors with severe contralesional arm paresis face numerous challenges to performing activities of daily living, which largely rely on the use of the less-affected ipsilesional arm. While use of the ipsilesional arm is often encouraged as a compensatory strategy in rehabilitation, substantial evidence indicates that motor control...

Objective To identify associations between atrophy of spared subcortical nuclei and sensorimotor behavior at different timepoints after stroke. Methods We pooled high-resolution T1-weighted MRI brain scans and behavioral data in 828 individuals with unilateral stroke from 28 cohorts worldwide. Cross-sectional analyses using linear mixed-effects mo...

A goal of rehabilitation after stroke is to promote pre-stroke levels of arm use for every day, frequently bimanual, functional activities. We reasoned that, after a stroke, the choice to use one or both hands for bimanual tasks might depend not only on residual motor capacity, but also the specialized demands imposed by the task on the paretic han...

Pain influences both attention and motor behavior. We used a dual-task interference paradigm to investigate 1) alterations in attentional performance, 2) the ability to switch task prioritization, and 3) the effect of attentional demand on trunk coordination during narrow-based walking in and out of a painful episode in individuals with recurrent l...

Objective: Determine the extent to which estimates of sample and effect size in stroke rehabilitation trials can be affected by simple summation of ordinal Upper Extremity Fugl-Meyer (UEFM) items compared to a Rasch-rescaled UEFM. Design: Rasch analysis of ICARE Phase III trial data, comparing three upper extremity (UE) motor treatments in stroke...

Background. Nonuse (NU) after stroke is characterized by failure to use the contralesional arm despite adequate capacity. It has been suggested that NU is a consequence of the greater effort and/or attention required to use the affected limb, but such accounts have not been directly tested, and we have poor understanding of the predictors of NU. Ob...

A goal of rehabilitation after stroke is to promote pre-stroke levels of arm use for everyday, frequently bimanual, functional activities. We reasoned that, after a stroke, the choice to use one or both hands for bimanual tasks might depend not only on residual motor capacity but also the specialized demands imposed by the task on the paretic hand....

Objective To adapt the Reaching Performance Scale for Stroke (RPSS) for the Wolf Motor Function Test (WMFT) “Lift Can” (Can) and “Hand to Box” (Box) items. Design Retrospective analysis of video-recorded WMFT assessment performed by three raters on two occasions; Setting N/A; Participants 29 participants with mild to moderate upper extremity imp...

This study investigated effects of cognitive dual-task interference and task prioritization instructions on task performance and trunk control during a dynamic balance task in persons with and without recurrent low back pain (rLBP). First, we tested the hypothesis that those with rLBP rely more on cognitive resources than back-healthy controls, and...

Neurorehabilitation relies on core principles of neuroplasticity to activate and engage latent neural connections, promote detour circuits, and reverse impairments. Clinical interventions incorporating these principles have been shown to promote recovery while demoting compensation. However, many clinicians struggle to find evidence for these princ...

Psychological states can influence motor performance and learning. In Parkinson's disease (PD), placebo effects or expectancies for pharmacological treatment benefits are not uncommon, but little is known about whether self‐efficacy, beliefs about personal performance capabilities, may play a role in this population. To address this question, we in...

In motor skill learning, the greater the dose of training, the greater the efficacy of training, the lower the efficiency of training, and the better the long-term retention. Whether such principles apply to motor training after stroke is unclear. Here, we developed novel mixed-effects models of the change in the quality of arm movements during and...

There is growing evidence that after a stroke, sensorimotor deficits in the ipsilesional hand are related to the degree of impairment in the contralesional upper extremity. Here, we asked if the relationship between the motor capacities of the two hands differs based on the side of stroke. Forty-two pre-morbidly right-handed chronic stroke survivor...

The goal of the Enhancing Neuroimaging Genetics through Meta-Analysis (ENIGMA) Stroke Recovery working group is to understand brain and behavior relationships using well-powered meta- and mega-analytic approaches. ENIGMA Stroke Recovery has data from over 1,800 stroke patients collected across 32 research sites and 10 countries around the world, co...

The second Stroke Recovery and Rehabilitation Roundtable “metrics” task force developed consensus around the recognized need to add kinematic and kinetic movement quantification to its core recommendations for standardized measurements of sensorimotor recovery in stroke trials. Specifically, we focused on measurement of the quality of upper limb mo...

Successful bimanual coordination is accomplished by overcoming a variety of cognitive, perceptual and neuromotor constraints, e.g. higher-order representation of task goals, visual perceptual demands, attention demands, task demands (i.e., speed, accuracy) and sensorimotor integration. Sensorimotor interference in planning, executing and correcting...

Background. Previous research has detailed the hemisphere dependence and specific kinematic deficits observed for the less-affected arm of patients with unilateral stroke. Objective. We now examine whether functional motor deficits in the less-affected arm, measured by standardized clinical measures of motor function, also depend on the hemisphere...

The second Stroke Recovery and Rehabilitation Roundtable “metrics” task force developed consensus around the recognized need to add kinematic and kinetic movement quantification to its core recommendations for standardized measurements of sensorimotor recovery in stroke trials. Specifically, we focused on measurement of the quality of upper limb mo...

Background The phenomenon of non-use after stroke is characterized by failure to use the contralesional arm despite adequate capacity. It has been suggested that non-use is a consequence of the greater effort and/or attention required to use the affected limb, but such accounts have not been tested, and we have poor understanding of the characteris...

Abstract Background Spinal cord injury (SCI) can lead to severe and permanent functional deficits. In humans, peri-auricular muscles (PAMs) do not serve any physiological function, though their innervation is preserved in even high level SCI. Auricular control systems provide a good example of leveraging contemporary technologies (e.g., sEMG contro...

Background and Purpose- For stroke rehabilitation, task-specific training in animal models and human rehabilitation trials is considered important to modulate neuroplasticity, promote motor learning, and functional recovery. Little is known about what constitutes an effective dosage of therapy. Methods- This is a parallel group, 4 arms, single-blin...

There is considerable evidence that after a stroke, ipsilesional deficits increase as contralesional impairment increases. However, it is unclear whether this relationship differs based on the side of stroke. Here, we tested the hypothesis that the ipsilesional hand motor capacity co-varies with contralesional hand impairment only in individuals wi...

Background: Research imaging costs limit lesion-based analyses in already expensive large stroke rehabilitation trials. Despite the belief that lesion characteristics influence recovery and treatment response, prior studies have not sufficiently addressed whether lesion features are an important consideration in motor rehabilitation trial design. O...

Background: Persistent deficits in arm function are common after stroke. An improved understanding of the factors that contribute to the performance of skilled arm movements is needed. One such factor may be self-efficacy (SE). Objective: To determine the level of SE for skilled, goal-directed reach actions in individuals with mild motor impairm...

Functional reorganization in musician’s brain has been considered strong evidence of experience-dependent neuroplasticity. However, it is unclear whether musician’s motor performance was driven by, or independent of auditory process. Highly coordinated bimanual movements stem from intensive instrument training require abundant communication between...

Background: Spontaneous use of the more-affected arm is a meaningful indicator of stroke recovery. The Bilateral Arm Reaching Test (BART) was previously developed to quantify arm use by measuring arm choice to targets projected over a horizontal hemi-workspace. In order to improve clinical validity, we constrained the available movement time, there...

Background and Purpose: For stroke rehabilitation, task-specific training in animal models and human rehabilitation trials is considered important to trigger inherent neuroplasticity, promote motor learning, and functional recovery. Little is known, however, about what constitutes an effective dosage of therapy. Methods: This is a parallel group, f...

Substantial evidence supports the beneficial effect of an external (vs. internal) focus of attention on task performance during goal-directed movements. Counter-intuitively, an external focus has also been shown to increase joint-level movement variability. Objective: To determine whether shifting attentional focus can alter the structure of movem...

The purpose of this Special Communication is to summarize guidelines and recommendations stemming from an expert panel convened by the National Institutes of Health (NIH), National Center for Medical Rehabilitation Research (NCMRR) for a workshop entitled, The Future of Medical Rehabilitation Clinical Trials, held 29-30 September 2016 at the NCMRR...

Background: The extraordinary advances in technology such as body-worn sensors, health information technologies, technological advances in neuroimaging, and computational approaches to predictive modelling using biomarkers offers considerable promise to literally transform our thinking, our approach to the problem, and the design of future clinica...

Background Increased activity in the lesioned hemisphere has been related to improved poststroke motor recovery. However, the role of the dominant hemisphere—and its relationship to activity in the lesioned hemisphere—has not been widely explored. Objective Here, we examined whether the dominant hemisphere drives the lateralization of brain activi...

Figure S1: Example from video stimuli during fMRI. Figure S2: Whole brain activity contrasted between right and left action observation compared between stroke and control groups at a more lenient threshold. Figure S3: Lesion overlap heat map (whole group). Figure S4: Lesion overlap heat map for cortical left hemisphere strokes (n = 6). Figure S5:...

Background: Different diffusion tensor imaging (DTI) has been used to estimate corticospinal tract (CST) structure in the context of stroke rehabilitation research. However, there is no gold standard for the estimate of CST structure in chronic stroke survivors. This study aims to determine the most accurate DTI-derived CST estimate that is associ...

Stroke is the leading cause of adult disability worldwide, with up to two-thirds of individuals experiencing long-term disabilities. Large-scale neuroimaging studies have shown promise in identifying robust biomarkers (e.g., measures of brain structure) of long-term stroke recovery following rehabilitation. However, analyzing large rehabilitation-r...

The last decade has witnessed an increase in the number of moderate to large-scale nonpharmacologic stroke recovery trials. While a majority, having tested the superiority of a particular evidence-based intervention, returned negative findings, the rehabilitation research community has gained an important perspective for future efforts. We offer ou...

Background. Task-oriented therapies have been developed to address significant upper extremity disability that persists after stroke. Yet, the extent of and approach to rehabilitation and recovery remains unsatisfactory to many. Objective. To compare a skill-directed investigational intervention with usual care treatment for body functions and stru...

The observational study presented in this conference abstract describes bimanual behavior, specifically spontaneous bimanual arm use, in chronic stroke and explores clinico-behavioral predictors of use. A manuscript report of these findings is now under preparation. Link to published abstract: http://stroke.ahajournals.org/content/49/Suppl_1/AWP1...

Associations between subcortical gray matter volume and motor performance post-stroke are unclear, partly because many stroke MRI studies are underpowered. Potential influences of the severity of motor impairment, lesion laterality, and time since stroke on these associations is also unknown. Here, we addressed these questions using a large dataset...

After a stroke, returning to activities of daily living requires the use of the two hands together for bimanual tasks, such as cutting bread, buttoning a shirt etc. Here, we sought to first, identify spontaneous volitional arm use patterns adopted for two distinct bimanual tasks, and, next, determine if and to what extent the degree of impairment,...

Background: Genetic factors may be useful to understand differences in outcomes post-stroke. We studied an imaging measure of brain atrophy in relation to two genotypes that may be associated with differences in stroke recovery, the val ⁶⁶ met genotype for brain-derived neurotrophic factor (BDNF) and the ApoE e4 genotype. Each genotype has been ass...

A framework is presented of how theoretical predictions can be tested across the expert athlete to disabled patient skill continuum. Common-coding theory is used as the exemplar to discuss sensory and motor system contributions to perceptual-motor behavior. Behavioral and neural studies investigating expert athletes and patients recovering from cer...

Over the past decade, ATTEND is one of only a handful of moderate to large-scale nonpharmacologic stroke recovery trials with a focus on rehabilitation. While unique in some respects, its test of superiority for the experimental intervention returned negative/neutral results, with no differences in outcome between the experimental intervention and...

Introduction. Non-use, an acquired, transiently reversible behavioral response to suppress movement of the paretic limb, is a persistent problem in stroke survivors, but it is unclear whether level of sensorimotor impairment, cognitive, and/or or psychological factors may influence its presence. We reasoned that paretic arm use may be modulated by...

Over 50 million United States citizens (1 in 6 people in the US) have a developmental, acquired, or degenerative disability. The average US citizen can expect to live 20% of his or her life with a disability. Rehabilitation technologies play a major role in improving the quality of life for people with a disability, yet widespread and highly challe...

Finding, testing and demonstrating efficacy of new treatments for stroke recovery is a multifaceted challenge. We believe that to advance the field, neurorehabilitation trials need a conceptually rigorous starting framework. An essential first step is to agree on definitions of sensorimotor recovery and on measures consistent with these definitions...

Purposes: To present the history and aims of the STEP conferences; describe the interdependence of prevention, prediction, plasticity, and participation; reflect on where we stand today regarding those 4 Ps; and discuss how future neurorehabilitation should look for individuals with movement disorders. Key points: Physical therapists have focuse...

Purposes: To present the history and aims of the STEP conferences; describe the interdependence of prevention, prediction, plasticity, and participation; reflect on where we stand today regarding those 4 Ps; and discuss how future neurorehabilitation should look for individuals with movement disorders. Key points: Physical therapists have focuse...

Finding, testing and demonstrating efficacy of new treatments for stroke recovery is a multifaceted challenge. We believe that to advance the field, neurorehabilitation trials need a conceptually rigorous starting framework. An essential first step is to agree on definitions of sensorimotor recovery and on measures consistent with these definitions...

Date Presented 4/1/2017 This poster presents an fMRI study on the role of the action observation network in stroke recovery by examining brain activity differences after left hemisphere stroke and right hemisphere stroke. Our findings suggest that the side of stroke may impact responsiveness to treatment. Primary Author and Speaker: Kaori L. Ito Co...

Background: Recovery of arm function after stroke is often incomplete. An improved understanding of brain structure-motor behavior relationships is needed for the development of novel and targeted rehabilitation interventions. Objective: To examine the relationship between skilled reach performance and the integrity of two putative white matter...

Background: Stroke patients with mild-moderate upper extremity motor impairments and minimal sensory and cognitive deficits provide a useful model to study recovery and improve rehabilitation. Laboratory-based investigators use lesioning techniques for similar goals. Objective: To determine whether stroke lesions in an upper extremity rehabilita...

Objective: To investigate the measurement properties of the Functional Test of the Hemiparetic Upper Extremity (FTHUE) and examine how its score may or may not inform design of a rehabilitation program. Design: The FTHUE was recently used in the Interdisciplinary Comprehensive Arm Rehabilitation Evaluation Stroke (ICARE) Randomized Clinical Tria...

The laterality of the lesioned hemisphere is often overlooked in stroke recovery research due to small sample sizes. Here, we used a well-powered dataset from ENIGMA Stroke Recovery (a consortium that harmonizes post-stroke MRIs and behavioral data worldwide; http://enigma.usc.edu) to analyze the effects of left (LHL) versus right (RHL) hemisphere...

Background. There is growing interest to establish recovery biomarkers, especially neurological biomarkers, in order to develop new therapies and prediction models for the promotion of stroke rehabilitation and recovery. However, there is no consensus among the neurorehabilitation community about which biomarker(s) have the highest predictive value...