Research at PTRS

Investigator: Sandy McCombe Waller, PhD, PT SOM Faculty Profile GPILS Faculty Profile SIMDAR Lab

 

Overview

Stroke is the leading cause of disability in the United States and remains a major health care issue. Too often in rehabilitation we seek to find the “best” training approach for our patients after stroke. However, it is clear there is no one best approach that meets the needs of every patient and in fact, it may be combinations of training that will prove to be the best in promoting recovery of meaningful function.

Upper extremity dysfunction after stroke can be debilitating with fewer than 20% of stroke survivors regaining independence in arm and hand function. Clearly there is a need to generate scientific evidence to guide the development and implementation of more effective rehabilitation interventions. In our lab we have been developing and testing training approaches that target patients with severe motor impairment after stroke.

Grant Support

2008- 2010
Combining Proximal and Distal Arm Training for Patients with Chronic Hemiparesis
Principal Investigator: Sandy McCombe Waller
Co Investigator: Jill Whitall, Dan Hanley, Rich Macko, Michael Terrin
NIH/ NCMRR: 1R21HD052125-01A2

2008-2009
Development of BATRAC Training Device in Subacute Care Population Post-Stroke
Principal Investigator: Sandy McCombe Waller
Subcontract on SBIR, Lead Company: Newregen Inc.
Co Investigator: Jill Whitall, Leslie Glickman
NIH/NINDS: 1R43NS062454 - 01

2007-2009
Biological prediction and correlation of response to robotic therapy
PI: George Wittenberg
Consultant: Sandy McCombe Waller
Veterans Administration Cooperative Study

2006-2009
Combining bilateral and distal arm training to promote arm and hand recovery in patients with chronic hemiparesis.
Principal Investigator: Sandy McCombe Waller
Co Investigator: Jill Whitall and Dan Hanley
Core Development Project in Claude D. Pepper Center Grant
Center Grant PI: Andrew Goldberg
National Institute on Aging

2006-2009
Funded Junior Faculty: Sandy McCombe Waller
Claude D. Pepper Center Grant:
Center Grant PI: Andrew Goldberg
National Institute on Aging

2006 – 2009
Bilateral vs. unilateral arm training in chronic stroke
Principal Investigator: Jill Whitall
Co-Investigator: Sandy McCombe Waller
National Center for Neuromuscular Rehabilitation Research

Current Projects

Studies of Functional and Neural Outcomes of Novel Interventions after Stroke

• BATRAC Training: Bilateral Arm Training with Rhythmic Auditory Cueing - We have been studying the effects of Bilateral Arm training with Rhythmic Auditory Cueing (BATRAC) – (pronounced Bah-track) using a Device developed and patented by Jill Whitall and Sandy McCombe Waller. We are studying the effects this training has on function of the arm and hand as well as the impact training has on brain plasticity after stroke, using both functional magnetic resonance imaging and transcranial magnetic stimulation.
   
        
• Bilateral Arm Training with Subacute Hemiparesis of the Arm - Working together with Newregen a local small business and Good Samaritan Hospital we are also conducting a study looking at developing the BATRAC for use in the inpatient, outpatient and home setting. This newer light weight BATRAC will have additional features that provide motivational cues to patients during training and will have the capability to provide quantitative measures of performance to therapists in the clinic. This collaborative study is supported by a NIH grant from the National Institute for Neurological Disease and Stroke.
   
     
• Combining BATRAC and Training with the Saebo flex Orthosis - Recognizing that any one treatment may not be sufficient to improve function in patients post stroke, especially those with severe motor impairment, we have been studying a combination of training approaches. We have two funded projects, on supported by the Claude D. Pepper Center and the other supported by a NIH grant from the National Center for Medical Rehabilitation Research. In these projects we are investigating the functional benefits of combining BATRAC training with a set of whole arm training exercises (in the standing position) using Saeboflex Orthosis. We are collecting data using functional magnetic resonance imaging and transcranial magnetic stimulation to provide information about brain plasticity associated with combination training.
   
     
• Postural Control Benefits of Arm Training in Standing - An exciting addition to this work includes the study of the benefits to postural stability and balance from arm training in the standing position. Most activities of daily living require ambulatory skills, postural control, reaching, grasping and manipulation of objects in the standing position. However as previously indicated, most rehabilitation interventions treat each of these physical limitations in isolation. In daily living, reaching is more likely to be performed in a standing position however, the majority of arm training approaches are conducted in the seated position. There is evidence of an interaction between reaching and postural stability. When reaching for an object in standing, there are many components that contribute to the performance of the whole task, including anticipatory postural responses to stabilize posture, weight shift to move the body center of mass (COM) to the object, visual fixation on the object, and the voluntary grasp, reach and release of the object. In pilot work conducted in our lab we have found that training the upper extremity in the standing position has a positive impact on postural control. Future studies will investigate the control of motor planning and preparation associated with arm training in the upright position.

Collaborations

University of Maryland School of Medicine
Larry W. Forrester, PhD
Andrew Goldberg, MD
Rau Gullapalli, PhD
Richard Macko, MD
Alan McMillan, PhD
Michelle G. Prettyman, PT, MS, DPT
Mark Rogers, PhD, PT
Michael Terrin, PhD
Jill Whitall, PhD
George Wittenberg, MD, PhD

University of Zurich
Andreas Luft, MD

Johns Hopkins University
Dan Hanley, MD

University of Maryland Baltimore County
Appa Anjanappa, PhD

University of Maryland College Park
Gemstone Project / Pamela Abshire, PhD

Good Samaritan Hospital
Charlene Foote, OT, Program Manager Outpatient Rehab
Anneliese Massey, MPT
Dave Federline, OT

Lab Personnel

Bobby Asbury BS, Research Assistant
Toye Jenkins MS, PT, Research Specialist
Melissa Mulcahy BS, Research Assistant

Publications

Peer Reviewed Journal Articles

• Luft AR, McCombe Waller S, Forrester L, Whitall J, Macko RF, Smith GV, Goldberg AP, Hanley DF (2004) Lesion location alters brain activation in chronically impaired stroke survivors. Neuroimage Mar; 21(3):924-35.
• Luft, A., McCombe Waller, S., Whitall, J, Smith, G., Forrester, L, Macko, R., Hauser, T., Goldberg, A., Hanley, D. (2004) Interhemispheric Reorganization of Motor Activity is Necessary for Successful Rehabilitation. JAMA Oct 20; 292(15):1853-61.
• McCombe Waller, S., & Whitall, J (2004). “Fine motor function in adults with chronic hemiparesis: Baseline comparison to non-disabled adults and effects of bilateral arm training. Archives of Physical Medicine and Rehabilitation Jul; 85(7):1076-83
• McCombe Waller, S. and Jill Whitall (2005) Hand Dominance and Side of Stroke Affect Rehabilitation in Chronic Stroke. Clinical Rehabilitation Aug; 19(5):544-51
• Luft, A., Forrester, L., Macko, R., McCombe Waller, S., Whitall, J., Villagra, F., and Hanley, D. (2005) Brain activation of lower extremity movement in chronically impaired stroke survivors. Neuroimage. May 15; 26(1):184-94.
• Harris-Love, McCombe Waller, S., Whitall, J. (2005) Exploiting interlimb coupling to improve paretic arm reaching performance in people with chronic stroke. Arch Phys Med Rehabil. Nov;86(11):2131-7.
• McCombe Waller, S., Harris-Love, M., Wei, L., and Whitall J. (2006) Temporal Coordination of the Arms During Bilateral and Sequential Movements in Patients with Chronic Hemiparesis, Experimental Brain Research 168,450-454.
• Whitall, J. Savin Jr., D., Harris-Love, M., McCombe Waller, S. (2006) Extending the applicability of the Wolf Motor Function Test. Archives of Physical Medicine and Rehabilitation 87, 656-660.
• Whitall, J., McCombe Waller, S., Luft, A., Hanley, D. (2006). Motor function improvement is associated with brain re-organization after bilateral arm training in chronic stroke – Case report. Physioscience, 2, 93-98.
• McCombe Waller, S., Wei, L., Whitall, J. (2008) Temporal and Spatial Control following Bilateral versus Unilateral Training, Human Movement Science. Jul 16. [Epub ahead of print] PMID: 18639360 [PubMed - as supplied by publisher
• McCombe Waller, S. & Whitall, J (2008) “Bilateral Arm Training: Why and Who Benefits? Journal of Neurorehabilitation. 23(1):29-41. Review
• McCombe Waller, S., Forrester, L., Villagra, F., Whitall, J. (2008) Intracortical inhibition and facilitation with unilateral dominant, unilateral nondominant and bilateral movement tasks in left and right handed adults. Journal of the Neurological Sciences, 269, 96-104.

Book Chapters / Proceedings/ Reviews (invited or peer-reviewed)

• Whitall, J. & McCombe Waller, S. Bilateral arm training based on motor control/learning principles improves motor control and function in patients with chronic hemiparetic stroke. In N. Gantchev (Ed.) From Basic Motor Control to Functional Recovery II; (pp.435-444), Sofia, Bulgaria: Drinov Academic Publishing House. (2001)
• McCombe Waller, S. Hand dominance and side of stroke affect rehabilitation in chronic stroke. In Monduzzi (Ed.) Neurological Rehabilitation Proceedings of the 3rd World Congress ;( pp235 –240), Bologna, Italy: Monduzzi Editore. (2002)

Abstract/ Proffered Communications

• McCombe Waller, S., and Whitall, J.(2004) “The Effect of Bilateral Rhythmic Arm Training on Motor Coordination and Function in Patients with Moderate Severity Chronic Stroke, presented at the Combined Sections Meeting, Nashville, Tennessee.
• McCombe Waller, S., & Whitall, J. (2004) “Cortical Inhibition and Facilitation in Unilateral versus Bilateral Movement Tasks and Adaptability to Training in Nondisabled Adults” presented at the International Conference on Motor Control, Barcelona, Spain.
• McCombe Waller, S., Whitall, J., Harris-Love, M., Rose, D and Winstein, C (2004) “Does focused bilateral arm training enhance recovery of upper limb hemiparesis?” ,presented as part of a symposium at the Annual Conference for the American Physical Therapy Association, Chicago.
• Whitall, J. McCombe Waller, S., Harris-Love, M., Luft, A., Hanley, D.(2004). Repetitive Bilateral Upper Extremity Training for Patients with Chronic Hemiparesis: Theory and Practice. Paper presented in a symposium at the joint annual conference of the American Congress of Rehabilitation/American Society of Neural Rehabilitation, Ponta Verde, FL.
• McCombe Waller, S. (2005).”Combining bilateral and distal arm training to promote arm and hand recovery in patients with chronic hemiparesis: A Case Report”, presented at the 5th World Congress for Neurological Rehabilitation, Hong Kong.
• Whitall, J., Savin, D., Harris-Love, M. & McCombe Waller, S. (2005) Psychometric Properties of a Modified Wolf Motor Function Test for Persons with Mild and Moderate Upper Extremity Hemiparesis, presented at the 5th World Congress for Neurological Rehabilitation, Hong Kong.
• McCombe Waller, S., & Whitall, J. (2005) “Cortical Inhibition and Facilitation in Unilateral versus Bilateral Movement Tasks and Adaptability to Training in Nondisabled Adults”, presented at the Society for Neuroscience Meeting, Washington DC.
• McCombe Waller, S. (2006) “Combining Proximal and Distal Arm Training for Patients with Chronic Hemiparesis” presented at the Second Neuroplasticity and Rehabilitation Science Conference, Teubingen Germany
• McCombe Waller, S. (2007) “Temporal and Spatial Control in Bilateral versus Unilateral Training “ presented at the Annual Pepper Center Meeting in Bethesda, MD.