Extent of damage to descending output from cortex rather than to specific cortical regions drives the emergence of flexor synergy in non-human primates

Obligate flexor synergies are a defining feature of the hemiparetic phenotype following stroke in humans. Although these intrusive synergies can diminish over time, recovery may plateau, leaving some individuals with movements permanently constrained to synergies. Despite their clinical significance, the neural mechanisms underlying the emergence and persistence of abnormal synergies remain poorly understood. To investigate this mechanistically, three macaque monkeys were trained on a reach and grasp task prior to receiving one of three unilateral lesion types: 1) a focal sensorimotor cortical lesion, 2) a combined sensorimotor cortical and magnocellular red nucleus (RNm) lesion, or 3) a lesion of the internal capsule. Upper limb three-dimensional kinematics and EMG cross correlation were used to measure the intrusion of synergies during in synergy vs out of synergy reaching. A combined RNm and cortical lesion produced weakness but no flexor synergy. A similar-sized cortical lesion generated mild synergies which substantially recovered. By contrast, a large internal capsule lesion produced severe, persistent flexor synergy. Collectively, these findings suggest that the emergence of abnormal synergies is determined by the extent of corticofugal disruption, and their persistence depends on the ability of surviving supraspinal motor pathways to regain selective control over muscle contractions.