Intrusion of pathological synergies does not explain impaired 3D arm movements in subacute stroke

It has long been of interest to characterize the components that generate the motor control abnormalities in the arm after stroke. One approach has been to decompose the hemiparesis phenotype into negative signs, such as weakness, and positive signs, such as intrusion of synergies. Here, we sought to identify the contributions of weakness and the flexor synergy to motor function and impairment, as defined by kinematic and clinical scales, respectively, in sub-acute stroke using two 3D arm tasks that differed in their requirement for elbow extension. Thirty-three sub-acute post-stroke participants and sixteen healthy controls performed a cup-to-mouth task, requiring shoulder and elbow flexion (within flexor synergy), and a reaching task, requiring shoulder flexion and elbow extension (out of flexor synergy). Using markerless 3D pose-estimation, we analyzed upper limb kinematics to assess overall task performance and intrusion of pathological synergies. Weakness was measured using a grip dynamometer. Performance in both tasks was impaired to a similar degree in the stroke participants compared to controls. Subsequent analysis of coordination patterns between the elbow and the shoulder joints revealed intrusion of synergies in the reaching task based on the time spent within a flexion-flexion pattern (flexor synergy proportion) and the correlation between shoulder and elbow angles when the shoulder was flexing (flexion synergy strength). Regression analysis indicated that the significant predictors of poor task performance were weakness and flexor synergy intrusion. Notably, the Fugl-Meyer Assessment was abnormal even when just weakness caused the impairment, which means that caution is required when using this scale to quantify synergies. We conclude that both weakness and synergy intrusion contribute to impaired coordination of the elbow and shoulder joints in the sub-acute post-stroke period. This study shows that careful kinematic analysis of naturalistic movements is required to better characterize the components of upper limb impairment after stroke.