Functional Muscle Networks as Biomarkers of Post-Stroke Motor Impairment and Therapeutic Responsiveness
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eLife Assessment
This important work employed a recent, functional muscle network analysis for evaluating rehabilitation outcomes in post-stroke patients. While the research direction is relevant and suggests the need for further investigation, the strength of evidence supporting the claims is incomplete. Muscle interactions can serve as biomarkers, but improvements in function are not directly demonstrated, and the method's robustness is not benchmarked against existing approaches.
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Abstract
Standardised assessment of post-stroke motor impairment and treatment responsiveness remains a major clinical challenge. In this study, we tackle this challenge by applying a novel muscle network analysis framework to stroke survivors undergoing intensive upper-limb motor training. Our approach revealed distinct patterns of redundant and synergistic muscle interactions, collectively reflecting the diverse biomechanical roles of flexor- and extensor-driven networks. From these patterns, we derived new biomarkers that stratified patients by impairment severity and therapeutic responsiveness, each associated with unique physiological signatures. Notably, we identified a shift from redundancy to synergy in muscle coordination as a hallmark of effective rehabilitation—a transformation supported by a more precise quantification of treatment outcomes. These findings offer an in-depth functional characterisation of post-stroke motor recovery and establish a robust, independent tool for evaluating rehabilitation efficacy.
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eLife Assessment
This important work employed a recent, functional muscle network analysis for evaluating rehabilitation outcomes in post-stroke patients. While the research direction is relevant and suggests the need for further investigation, the strength of evidence supporting the claims is incomplete. Muscle interactions can serve as biomarkers, but improvements in function are not directly demonstrated, and the method's robustness is not benchmarked against existing approaches.
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Reviewer #1 (Public review):
Summary:
This study addresses an important clinical challenge by proposing muscle network analysis as a tool to evaluate rehabilitation outcomes. The research direction is relevant, and the findings suggest further research. The strength of evidence supporting the claims is, however, limited: the improvements in function are not directly demonstrated, the robustness of the method is not benchmarked against already published approaches, and key terminology is not clearly defined, which reduces the clarity and impact of the work.
Comments:
There are several aspects of the current work that require clarification and improvement, both from a methodological and a conceptual standpoint.
First, the actual improvements associated with the rehabilitation protocol remain unclear. While the authors report certain …
Reviewer #1 (Public review):
Summary:
This study addresses an important clinical challenge by proposing muscle network analysis as a tool to evaluate rehabilitation outcomes. The research direction is relevant, and the findings suggest further research. The strength of evidence supporting the claims is, however, limited: the improvements in function are not directly demonstrated, the robustness of the method is not benchmarked against already published approaches, and key terminology is not clearly defined, which reduces the clarity and impact of the work.
Comments:
There are several aspects of the current work that require clarification and improvement, both from a methodological and a conceptual standpoint.
First, the actual improvements associated with the rehabilitation protocol remain unclear. While the authors report certain quantitative metrics, the study lacks more direct evidence of functional gains. Typically, rehabilitation interventions are strengthened by complementary material (e.g., videos or case examples) that clearly demonstrate improvements in activities of daily living. Including such evidence would make the findings more compelling.
Second, the claim that the proposed muscle network analysis is robust is not sufficiently substantiated. The method is introduced without adequate reference to, or comparison with, the extensive literature that has proposed alternative metrics. It is also not evident whether a simpler analysis (e.g., EMG amplitude) might produce similar results. To highlight the added value of the proposed method, it would be important to benchmark it against established approaches. This would help clarify its specific advantages and potential applications. Moreover, several studies have shown very good outcomes when using AI and latent manifold analyses in patients with neural lesions. Interpreting the latent space appears even easier than interpreting muscle networks, as the manifolds provide a simple encoding-decoding representation of what the patient can still perform and what they can no longer do.
Third, the terminology used throughout the manuscript is sometimes ambiguous. A key example is the distinction made between "functional" and "redundant" synergies. The abstract states: "Notably, we identified a shift from redundancy to synergy in muscle coordination as a hallmark of effective rehabilitation-a transformation supported by a more precise quantification of treatment outcomes."
However, in motor control research, redundancy is not typically seen as maladaptive. Rather, it is a fundamental property of the CNS, allowing the same motor task to be achieved through different patterns of muscle activity (e.g., alternative motor unit recruitment strategies). This redundancy provides flexibility and robustness, particularly under fatiguing conditions, where new synergies often emerge. Several studies have emphasized this adaptive role of redundancy. Thus, if the authors intend to use "redundancy" differently, it is essential to define the term explicitly and justify its use to avoid misinterpretation.
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Reviewer #2 (Public review):
Summary:
This study analyzes muscle interactions in post-stroke patients undergoing rehabilitation, using information-theoretic and network analysis tools applied to sEMG signals with task performance measurements. The authors identified patterns of muscle interaction that correlate well with therapeutic measures and could potentially be used to stratify patients and better evaluate the effectiveness of rehabilitation.
However, I found that the Methods and Materials section, as it stands, lacks sufficient detail and clarity for me to fully understand and evaluate the quality of the method. Below, I outline my main points of concern, which I hope the authors will address in a revision to improve the quality of the Methods section. I would also like to note that the methods appear to be largely based on a …
Reviewer #2 (Public review):
Summary:
This study analyzes muscle interactions in post-stroke patients undergoing rehabilitation, using information-theoretic and network analysis tools applied to sEMG signals with task performance measurements. The authors identified patterns of muscle interaction that correlate well with therapeutic measures and could potentially be used to stratify patients and better evaluate the effectiveness of rehabilitation.
However, I found that the Methods and Materials section, as it stands, lacks sufficient detail and clarity for me to fully understand and evaluate the quality of the method. Below, I outline my main points of concern, which I hope the authors will address in a revision to improve the quality of the Methods section. I would also like to note that the methods appear to be largely based on a previous paper by the authors (O'Reilly & Delis, 2024), but I was unable to resolve my questions after consulting that work.
I understand the general procedure of the method to be: (1) defining a connectivity matrix, (2) refining that matrix using network analysis methods, and (3) applying a lower-dimensional decomposition to the refined matrix, which defines the sub-component of muscle interaction. However, there are a few steps not fully explained in the text.
(1) The muscle network is defined as the connectivity matrix A. Is each entry in A defined by the co-information? Is this quantity estimated for each time point of the sEMG signal and task variable? Given that there are only 10 repetitions of the measurement for each task, I do not fully understand how this is sufficient for estimating a quantity involving mutual information.
In the previous paper (O'Reilly & Delis, 2024), the authors initially defined the co-information (Equation 1.3) but then referred to mutual information (MI) in the subsequent text, which I found confusing. In addition, while the matrix A is symmetrical, it should not be orthogonal (the authors wrote AᵀA = I) unless some additional constraint was imposed?
(2) The authors should clarify what the following statement means: "Where a muscle interaction was determined to be net redundant/synergistic, their corresponding network edge in the other muscle network was set to zero."
(3) It should be clarified what the 'm' values are in Equation 1.1. Are these the co-information values after the sparsification and applying the Louvain algorithm to the matrix 'A'? Furthermore, since each task will yield a different co-information value, how is the information from different tasks (r) being combined here?
(4) In general, I recommend improving the clarity of the Methods section, particularly by being more precise in defining the quantities that are being calculated. For example, the adjacency matrix should be defined clearly using co-information at the beginning, and explain how it is changed/used throughout the rest of the section.
(5) In the previous paper (O'Reilly & Delis, 2024), the authors applied a tensor decomposition to the interaction matrix and extracted both the spatial and temporal factors. In the current work, the authors simply concatenated the temporal signals and only chose to extract the spatial mode instead. The authors should clarify this choice.
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