Biomechanical and neural aspects of eccentric and concentric muscle performance in stroke subjects : Implications for resistance training

Abstract: Muscle weakness is one of the major causes of post-stroke disability. Stroke rehabilitation programs now often incorporate the same type of resistance training that is used for healthy subjects; however, the training effects induced from these training strategies are often limited for stroke patients. An important resistance training principle is that an optimal level of stress is exerted on the neuromuscular system, both during concentric (shortening) and eccentric (lengthening) contractions. One potential problem for post-stroke patients might be difficulties achieving sufficient levels of stress on the neuromuscular system. This problem may be associated with altered muscular function after stroke. In healthy subjects, maximum strength during eccentric contractions is higher than during concentric contractions. In individuals with stroke, this difference in strength is often increased. Moreover, it has also been shown that individuals with stroke exhibit alteration with respect to how the strength varies throughout the range of motion. For example, healthy subjects exhibit a joint specific torque-angle relationship that normally is the same irrespective of contraction mode and contraction velocity. In contrast, individuals with stroke exhibit an overall change of the torque-angle relationship. This change, as described in the literature, consists of a more pronounced strength loss at short muscle length. In individuals with stroke, torque-angle relationships are only partially investigated and so far these relationships have not been analysed using testing protocols that include eccentric, isometric, and concentric modes of contraction. This thesis investigates the torque-angle relationship of elbow flexors in subjects with stroke during all three modes of contractions – isometric, concentric, and eccentric ­– and the relative loading throughout the range of movement during a resistance exercise. In addition, this thesis studies possible central nervous system mechanisms involved in the control of muscle activation during eccentric and concentric contractions. The torque-angle relationship during maximum voluntary elbow flexion was examined in stroke subjects (n=11), age-matched healthy subjects (n=11), and young subjects (n=11) during different contraction modes and velocities. In stroke subjects, maximum torque as well as the torque angle relationship was better preserved during eccentric contractions compared to concentric contractions. Furthermore, the relative loading during a resistance exercise at an intensity of 10RM (repetition maximum) was examined. Relative loading throughout the concentric phase of the resistance exercise, expressed as percentage of concentric torque, was found to be similar in all groups. However, relative loading during the eccentric contraction phase, expressed as the percentage of eccentric isokinetic torque, was significantly lower for the stroke group. In addition, when related to isometric maximum voluntary contraction, the loading for the stroke group was significantly lower than for the control groups during both the concentric and eccentric contraction phases.Functional magnetic resonance imaging was used to examine differences between recruited brain regions during the concentric and the eccentric phase of imagined maximum resistance exercise of the elbow flexors (motor imagery) in young healthy subjects (n=18) and in a selected sample of individuals with stroke (n=4). The motor and premotor cortex was less activated during imagined maximum eccentric contractions compared to imagined maximum concentric contraction of elbow flexors. Moreover, BA44 in the ventrolateral prefrontal cortex, a brain area that has been shown to be involved in inhibitory control of motor activity, was additionally recruited during eccentric compared to concentric conditions. This pattern was evident only on the contralesional (the intact hemisphere) in some of the stroke subjects. On the ipsilesional hemisphere, the recruitment in ventrolateral prefrontal cortex was similar for both modes of contractions.  Compared to healthy subjects, the stroke subjects exhibited altered muscular function comprising a specific reduction of torque producing capacity and deviant torque-angle relationship during concentric contractions. Therefore, the relative training load during the resistance exercise at a training intensity of 10RM was lower for subjects with stroke. Furthermore, neuroimaging data indicates that the ventrolateral prefrontal cortex may be involved in a mechanism that modulates cortical motor drive differently depending on mode of the contractions. This might partly be responsible for why it is impossible to fully activate a muscle during eccentric contractions. Moreover, among individuals with stroke, a disturbance of this system could also lie behind the lack of contraction mode-specific modulation of muscle activation that has been found in this population. The altered neuromuscular function evident after a stroke means that stroke victims may find it difficult to supply a sufficient level of stress during traditional resistance exercises to promote adaptation by the neuromuscular system. This insufficiency may partially explain why the increase in strength, in response to conventional resistance training, often has been found to be low among subjects with stroke.