The Role of Task-Specific Training in Rehabilitation Therapies

Recovery of the lumbopelvic movement and muscle recruitment patterns using motor control exercise program in people with chronic nonspecific low back pain: A prospective study

This study aims to investigate the dysfunction and recovery of the lumbopelvic movement and motor control of people with chronic nonspecific low back pain after a structured rehabilitation which emphasizes on re-education and training of movement and motor control. The lumbopelvic movement and motor control pattern of 30 adults (15 with chronic low back pain, 15 healthy controls) were assessed using 3D motion and electromyographic analysis during the repeated forward bending test, in additional to the clinical outcome measures. Regional kinematics and muscle recruitment pattern of the symptomatic group was analysed before and after the 6-week rehabilitation, and compared to healthy controls. Significant improvement in back pain, functional capacity and self-efficacy of the symptomatic group was found after the rehabilitation. Patients with chronic nonspecific low back pain were capable to recover to a comparable level of the healthy controls in terms of their lumbopelvic movement and motor control pattern upon completion of a 6-week rehabilitation program, despite their dysfunction displayed at baseline. Phase specific motor control reorganization in which more profound and positive changes shown during the flexion phase. Our findings indicate that the recovery of the movement and motor control pattern in patients with chronic low back pain achieved to a comparable level of the healthy able-bodies. The improvement of both the physical outcome measures suggest that specific rehabilitation program which emphasizes on optimizing motor control during movements would help promoting the functional recovery of this specific low back pain subgroup.

Minimal clinically important difference of modified dynamic gait index in people with neurological disorders

BACKGROUND

The minimal clinically important difference (MCID) of modified Dynamic Gait Index (mDGI) has not yet been determined for People with Neurological Disorders (PwND).

RESEARCH QUESTION

To establish the MCID of the mDGI to determine clinically meaningful improvement in balance and gait in PwND.

METHODS

In this longitudinal study from a randomised clinical trial, 55 participants both in and outpatients with neurological disorders, received fifteen 40-minute rehabilitation sessions. Inpatients received daily treatments over a period of three weeks while outpatients received three treatments/week over a period of five weeks. An anchor-based method using percentage rating of improvement in balance (Activities Balance Confidence scale, ABC) was used to determine the MCID of mDGI. The MCID was defined as the minimum change in mDGI total score (post - pre intervention) that was needed to perceive at least a 10 % improvement on the ABC scale. A Receiver Operating Characteristic curve was used to define the cut-off for the optimal MCID of the mDGI discriminating between improved and not improved participants.

RESULTS

The MCID of the mDGI total score was 6 points and Area under the Curve was 0.64. For the mDGI time sub-scores the MCID was 2 points and Area under the Curve was 0.6.

SIGNIFICANCE

The MCID of balance and gait improvement measured by mDGI was prudently establish at ≥7 points, meaning that this is the minimum improvement score PwND need to get to perceive a clinically relevant change in their balance and gait confidence. These reference values can be a tool incorporated into clinicians daily practice to interpret mDGI change scores helping to determine whether the intervention is effective; to develop clinical tailored intervention goals and to establish meaningful perceived change in PwND.

Combination of Stem Cells and Rehabilitation Therapies for Ischemic Stroke

Stem cell transplantation with rehabilitation therapy presents an effective stroke treatment. Here, we discuss current breakthroughs in stem cell research along with rehabilitation strategies that may have a synergistic outcome when combined together after stroke. Indeed, stem cell transplantation offers a promising new approach and may add to current rehabilitation therapies. By reviewing the pathophysiology of stroke and the mechanisms by which stem cells and rehabilitation attenuate this inflammatory process, we hypothesize that a combined therapy will provide better functional outcomes for patients. Using current preclinical data, we explore the prominent types of stem cells, the existing theories for stem cell repair, rehabilitation treatments inside the brain, rehabilitation modalities outside the brain, and evidence pertaining to the benefits of combined therapy. In this review article, we assess the advantages and disadvantages of using stem cell transplantation with rehabilitation to mitigate the devastating effects of stroke.

Effectiveness of a combined transcranial direct current stimulation and virtual reality-based intervention on upper limb function in chronic individuals post-stroke with persistent severe hemiparesis: a randomized controlled trial

BACKGROUND

Functional impairments derived from the non-use of severely affected upper limb after stroke have been proposed to be mitigated by action observation and imagination-based techniques, whose effectiveness is enhanced when combined with transcranial direct current stimulation (tDCS). Preliminary studies in mildly impaired individuals in the acute phase post-stroke show intensified effects when action is facilitated by tDCS and mediated by virtual reality (VR) but the effectiveness in cases of severe impairment and chronic stroke is unknown. This study investigated the effectiveness of a combined tDCS and VR-based intervention in the sensorimotor function of chronic individuals post-stroke with persistent severe hemiparesis compared to conventional physical therapy.

METHODS

Twenty-nine participants were randomized into an experimental group, who received 30 minutes of the combined tDCS and VR-based therapy and 30 minutes of conventional physical therapy, or a control group, who exclusively received conventional physical therapy focusing on passive and active assistive range of motion exercises. The sensorimotor function of all participants was assessed before and after 25 one-hour sessions, administered three to five times a week, using the upper extremity subscale of the Fugl-Meyer Assessment, the time and ability subscales of the Wolf Motor Function Test, and the Nottingham Sensory Assessment.

RESULTS

A clinically meaningful improvement of the upper limb motor function was consistently revealed in all motor measures after the experimental intervention, but not after conventional physical therapy. Similar limited effects were detected in the sensory function in both groups.

CONCLUSION

The combined tDCS and VR-based paradigm provided not only greater but also clinically meaningful improvement in the motor function (and similar sensory effects) in comparison to conventional physical therapy.

Effects of task-oriented training combined with aerobic training on serum BDNF, GDNF, IGF-1, VEGF, TNF-α, and IL-1β levels in people with Parkinson's disease: A randomized controlled study

INTRODUCTION

Parkinson's disease (PD) is a chronic neurodegenerative disease characterized by the death of dopaminergic neurons in the substantia nigra pars compacta. Exercise training, which is incorporated both goal-based training such as task-oriented training (TOT) and aerobic training (AT), has been suggested to induce neuroprotection. However, molecular mechanisms which may underlie exercise-induced neuroprotection are still largely unknown. Thus, the aim of the present study was to investigate the effects of TOT combined with AT (TOT-AT) on serum brain-derived neurotrophic factor (BDNF), glial cell-derived growth factor (GDNF), insulin-like growth factor-1 (IGF-1), vascular endothelial growth factor (VEGF), tumor necrosis factor-α (TNF-α), and interleukin-1β (IL-1β) levels in people with PD (PwPD).

METHODS

Forty PwPD were randomized into 8-week of either exercise group (n = 20) or control group (n = 20). The exercise group received TOT-AT while the control group received only AT. Serum BDNF, GDNF, IGF-1, VEGF, TNF-α, and IL-1β levels determined with ELISA were assessed at baseline and after training.

RESULTS

A total of 29 PwPD completed this study. Our results showed no significant change in the serum BDNF, GDNF, IGF-1, VEGF, TNF-α, and IL-1β levels in both groups. After the intervention period, no significant difference was observed between the groups regarding the serum BDNF, GDNF, IGF-1, VEGF, TNF-α, and IL-1β levels.

CONCLUSION

TOT-AT could not be an effective exercise method for changing serum concentrations of BDNF, GDNF, IGF-1, VEGF, TNF-α, and IL-1β in the rehabilitation of PD.

A Cable-Driven Three-DOF Wrist Rehabilitation Exoskeleton With Improved Performance

This paper developed a cable-driven three-degree-of-freedom (DOF) wrist rehabilitation exoskeleton actuated by the distributed active semi-active (DASA) system. Compared with the conventional cable-driven robots, the workspace of this robot is increased greatly by adding the rotating compensation mechanism and by optimizing the distribution of the cable attachment points. In the meanwhile, the efficiency of the cable tension is improved, and the parasitic force (the force acting on the joint along the limb) is reduced. Besides, in order to reduce the effects of compliant elements (e.g., cables or Bowden cables) between the actuators and output, and to improve the force bandwidth, we designed the DASA system composed of one geared DC motor and four magnetorheological (MR) clutches, which has low output inertia. A fast unbinding strategy is presented to ensure safety in abnormal conditions. A passive training algorithm and an assist-as-needed (AAN) algorithm were implemented to control the exoskeleton. Several experiments were conducted on both healthy and impaired subjects to test the performance and effectiveness of the proposed system for rehabilitation. The results show that the system can meet the needs of rehabilitation training for workspace and force-feedback, and provide efficient active and passive training.

Compensatory Trunk Movements in Naturalistic Reaching and Manipulation Tasks in Chronic Stroke Survivors

Impairment of arm movements poststroke often results in the use of compensatory trunk movements to complete motor tasks. These compensatory movements have been mostly observed in tightly controlled conditions, with very few studies examining them in more naturalistic settings. In this study, the authors quantified the presence of compensatory movements during a set of continuous reaching and manipulation tasks performed with both the paretic and nonparetic arm (in 9 chronic stroke survivors) or the dominant arm (in 20 neurologically unimpaired control participants). Kinematic data were collected using motion capture to assess trunk and elbow movement. The authors found that trunk displacement and rotation were significantly higher when using the paretic versus nonparetic arm (P = .03). In contrast, elbow angular displacement was significantly lower in the paretic versus nonparetic arm (P = .01). The reaching tasks required significantly higher trunk compensation and elbow movement than the manipulation tasks. These results reflect increased reliance on compensatory trunk movements poststroke, even in everyday functional tasks, which may be a target for home rehabilitation programs. This study provides a novel contribution to the rehabilitation literature by examining the presence of compensatory movements in naturalistic reaching and manipulation tasks.

A comparison of standard occupational therapy versus early enhanced occupation-based therapy in a medical/surgical intensive care unit: study protocol for a single site feasibility trial (EFFORT-ICU)

BACKGROUND

Admissions to intensive care units (ICUs) are increasing due to an ageing population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care.

METHODS

This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60-min sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed.

DISCUSSION

This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268 ; prospectively registered on 13 March 2018/ https://www.anzctr.org.au Trial funding: Metro South Health Research Support Scheme Postgraduate Scholarship.

Novel velocity estimation for symmetric and asymmetric self-paced treadmill training

Background

Self-paced treadmills (SPT) can provide an engaging setting for gait rehabilitation by responding directly to the user’s intent to modulate the external environment and internal effort. They also can improve gait analyses by allowing scientists and clinicians to directly measure the effect of an intervention on walking velocity. Unfortunately, many common SPT algorithms are not suitable for individuals with gait impairment because they are designed for symmetric gait patterns. When the user’s gait is asymmetric due to paresis or if it contains large accelerations, the performance is diminished. Creating and validating an SPT that is suitable for asymmetric gait will improve our ability to study rehabilitation interventions in populations with gait impairment. The objective of this study was to test and validate a novel self-paced treadmill on both symmetric and asymmetric gait patterns and evaluate differences in gait kinematics, kinetics, and muscle activity between fixed-speed and self-paced treadmill walking.

Methods

We collected motion capture, ground reaction force data, and muscle activity from 6 muscles in the dominant leg during walking from 8 unimpaired subjects. In the baseline condition, the subjects walked at 3 fixed-speeds normalized to their leg length as Froude numbers. We developed a novel kinematic method for increasing the accuracy of the user’s estimated walking velocity and compared our method against other published algorithms at each speed. Afterward, subjects walked on the SPT while matching their walking speed to a given target velocity using visual feedback of the treadmill speed. We evaluated the SPT by measuring steady-state error and the number of steps to reach the desired speed. We split the gait cycle into 7 phases and compared the kinematic, kinetic, and muscle activity between the fixed speed and self-paced mode in each phase. Then, we validated the performance of the SPT for asymmetric gait by having subjects walk on the SPT while wearing a locked-knee brace set to 0° on the non-dominant leg.

Results

Our SPT enabled controlled walking for both symmetric and asymmetric gait patterns. Starting from rest, subjects were able to control the SPT to reach the targeted speeds using visual feedback in 13–21 steps. With the locked knee brace, subjects controlled the treadmill with substantial step length and step velocity asymmetry. One subject was able to execute a step-to gait and halt the treadmill on heel-strikes with the braced leg. Our kinematic correction for step-length outperformed the competing algorithms by significantly reducing the velocity estimation error at the tested velocities. The joint kinematics, joint torques, and muscle activity were generally similar between fixed-speed and self-paced walking. Statistically significant differences were found in 5 of 63 tests for joint kinematics, 2 of 63 tests for joint torques, and 9 of 126 tests for muscle activity. The differences that were statistically significant were not found across all speeds and were generally small enough to be of limited clinical relevance.

Conclusions

We present a validated method for implementing a self-paced treadmill for asymmetric and symmetric gaits. As a result of the increased accuracy of our estimation algorithm, our SPT produced controlled walking without including a position feedback controller, thereby reducing the influence of the controller on measurements of the user’s true walking speed. Our method relies only on a kinematic correction to step length and step time which can support transfer to systems outside of the laboratory for symmetric and asymmetric gaits in clinical populations.

Dynamic Surface Exercise Training in Improving Trunk Control and Gross Motor Functions among Children with Quadriplegic Cerebral Palsy: A Single Center, Randomized Controlled Trial

Background:

Dynamic surface provides proprioceptive and vestibular feedback with optimal level of arousal. The activities on unstable environment have greater sensorimotor experiences. There is a lack of evidence examining the benefits of dynamic surface exercise training (DSET) among the children with spastic quadriplegic cerebral palsy (CP).

Aim:

The aim of the study was to analyze the effect of dynamic surface exercises on trunk control and gross motor functions in children with quadriplegic CP.

Materials and Methods:

A total of 30 children with spastic quadriplegic CP with Gross Motor Function Classification System of levels III and IV were recruited by the simple random sampling method (random number generator) to participate in this randomized controlled study. Recruited children were randomly divided into two groups, DSET group and standard physiotherapy training group. Both the groups received active training program lasting for 60 min, 4 days/week for 6 weeks. Gross Motor Function Measure (GMFM)-88 and Pediatric Balance Scale (PBS) scores were recorded at baseline, and at the end of 6-week post-intervention.

Results:

Total 30 children with quadriplegic CP with mean age 6.64 ± 2.15 years in experimental group and 6.50 ±1.59 years in control group participated in the study. Experimental group showed a significant difference for GMFM and PBS scores between pre- and post-intervention with P < 0.005. A significant difference was observed in GMFM scores between experimental and control group with P < 0.005.

Conclusion:

Six-week dynamic surface exercise therapy along with standard physiotherapy was effective in improving trunk control and gross motor function performance among children with spastic quadriplegic CP aged 6–12 years.

Effects of a Perturbation-Based Balance Training on Compensatory Postural Responses to Backward Loss of Balance in Patients with Cerebellar Disease: A Case Study

OBJECTIVES The damage to the cerebellum primarily results in balance-related abnormalities that may affect performance of locomotion and postural adjustments, eventually contributing to an increased risk of fall and fear of falling in patients with cerebellar disease. The purpose of the present study was to investigate the effect of a perturbation-based training that induced backward loss of balance on compensatory postural responses in patients with cerebellar disease.METHODS The participant was a 51-year-old female diagnosed with spinocerebellar ataxia and had the disease for 19 years. The perturbation-based backward balance training was performed over 8 weeks (a total of 24 training sessions) in order to facilitate the perception of postural perturbation onset and execution of rapid compensatory responses.RESULTS The patient demonstrated a noticeable reduction in the number of steps required to recover body balance after postural disturbances. The reduction of multi-step reactions in recovering balance could be attributed to improvements in the body center-of-mass displacement and trunk control during the landing of step. Besides, there were also improvements in subjective measures of functional mobility and psychological well-being after the balance training.CONCLUSION Although current research evidence of balance rehabilitation for cerebellar patients is lacking, this study offers the feasibility of adaptive training to improve postural stability through task-specific training intervention.

Does Exercise-Based Conventional Training Improve Reactive Balance Control among People with Chronic Stroke?

Background: Exercise-based conventional training has predominantly benefited fall-associated volitional balance control domain; however, the effect on reactive balance control is under-examined. Therefore, the purpose of this study was to examine the effect of exercise-based conventional training on reactive balance control. Methods: Eleven people with chronic stroke (PwCS) underwent multi-component training for six weeks (20 sessions) in a tapering manner. Training focused on four constructs-stretching, functional strengthening, balance, and endurance. Volitional balance was measured via movement velocity on the Limits of Stability (LOS) test and reactive balance via center of mass (COM) state stability on the Stance Perturbation Test (SPT). Additionally, behavioral outcomes (fall incidence and/or number of steps taken) were recorded. Results: Movement velocity significantly increased on the LOS test (p < 0.05) post-intervention with a significant decrease in fall incidence (p < 0.05). However, no significant changes were observed in the COM state stability, fall incidence and number of recovery steps on the SPT post-intervention. Conclusion: Although volitional and reactive balance control may share some neurophysiological and biomechanical components, training based on volitional movements might not significantly improve reactive balance control for recovery from large-magnitude perturbations due to its task-specificity.

Functional Resistance Training to Improve Knee Strength and Function After Acute Anterior Cruciate Ligament Reconstruction: A Case Study

BACKGROUND

Thigh muscle weakness after anterior cruciate ligament reconstruction (ACLR) can persist after returning to activity. While resistance training can improve muscle function, "nonfunctional" training methods are not optimal for inducing transfer of benefits to activities such as walking. Here, we tested the feasibility of a novel functional resistance training (FRT) approach to restore strength and function in an individual with ACLR.

HYPOTHESIS

FRT would improve knee strength and function after ACLR.

STUDY DESIGN

Case report.

LEVEL OF EVIDENCE

Level 5.

METHODS

A 15-year-old male patient volunteered for an 8-week intervention where he performed 30 minutes of treadmill walking, 3 times per week, while wearing a custom-designed knee brace that provided resistance to the thigh muscles of his ACLR leg. Thigh strength, gait mechanics, and corticospinal and spinal excitability were assessed before and immediately after the 8-week intervention. Voluntary muscle activation was evaluated immediately after the intervention.

RESULTS

Knee extensor and flexor strength increased in the ACLR leg from pre- to posttraining (130 to 225 N·m [+74%] and 44 to 88 N·m [+99%], respectively) and increases in between-limb extensor and flexor strength symmetry (45% to 92% [+74%] and 47% to 72% [+65%], respectively) were also noted. After the intervention, voluntary muscle activation in the ACLR leg was 72%, compared with the non-ACLR leg at 75%. Knee angle and moment during late stance phase decreased (ie, improved) in the ACLR leg and appeared more similar to the non-ACLR leg after FRT training (18° to 14° [-23.4] and 0.07 to -0.02 N·m·kg^-1·m^-1 [-122.8%], respectively). Corticospinal and spinal excitability in the ACLR leg decreased (3511 to 2511 [-28.5%] and 0.42 to 0.24 [-43.7%], respectively) from pre- to posttraining.

CONCLUSION

A full 8 weeks of FRT that targeted both quadriceps and hamstring muscles lead to improvements in strength and gait, suggesting that FRT may constitute a promising and practical alternative to traditional methods of resistance training.

CLINICAL RELEVANCE

FRT may serve as a viable approach to improve knee strength and function after ACL reconstruction.

A Comparative Study on the Effect of Task Specific Training on Right Versus Left Chronic Stroke Patients

Functional impairment of the upper limb (UL) after stroke is a great problem. Finding methods that can improve UL function after stroke is a major concern to all medical service providers. This study was intended to compare the effect of upper limb task specific training (TST) on brain excitability of the affected hemisphere and motor function improvements in patients with left and right stroke. Forty male patients with mild impairment of UL functions were divided into two equal groups; G1 consisted of patients with left hemisphere affection (right side stroke) while G2 consisted of patients with right hemisphere affection (left side stroke). All patients received TST for the affected UL for one hour, three sessions per week for six consecutive weeks. Evaluation was performed twice, pre-, and post-treatment. Outcome measures used were Wolf Motor Function Test (WMFT) and Box and Block Test (BBT) as measures of UL motor function and Quantitative Electroencephalogram (QEEG) of motor and sensory areas of the affected hemisphere as a measure of brain reorganization post-stroke. Both groups showed improvement in motor function of the affected UL measured by WMFT and BBT with reported significant difference between them. G1 showed greater improvement in motor function of the affected UL post-treatment compared to G2. Additionally, there was a significant increase in peak frequency of motor and sensory areas with higher and significant excitability in G1 only. These findings imply that brain reorganization in the left hemisphere responded more to TST compared to the right hemisphere. Based on findings of the current study, we can recommend adding TST to the physical therapy program in stroke patients with left hemisphere lesions.

Importance of Wrist Movement Direction in Performing Activities of Daily Living Efficiently

The wrist is an essential component in performing the activities of daily living (ADLs) associated with a high quality of life. After a neurological disorder, motor function of the hand and wrist can be affected, reducing quality of life. Many experiments have illustrated that more wrist flexion/extension is required than radial/ulnar deviation when performing ADLs; however, how this result translates to efficiency in performing ADLs has not been investigated. Motivated by clinical assessment during neurorehabilitation, in this paper we investigate with able-bodied participants how performing tasks representative of the Jebsen-Taylor Hand Function Test are impacted when a splint constrains the user to a single rotational degree of freedom of the wrist. Twenty participants enrolled in the study, performing five tasks under five conditions, including constraint to pure flexion/extension and radial/ulnar deviation. The importance of wrist movement direction in performing ADLs efficiently found in this study could shape clinical wrist rehabilitation paradigms and wrist rehabilitation robot designs.

Validation of a Novel Wearable Electromyography Patch for Monitoring Submental Muscle Activity During Swallowing: A Randomized Crossover Trial

Purpose Surface electromyography (sEMG) is often used for biofeedback during swallowing rehabilitation. However, commercially available sEMG electrodes are not optimized for the head and neck area, have rigid form, and are mostly available in large medical centers. We developed an ultrathin, soft, and flexible sEMG patch, specifically designed to conform to the submental anatomy and which will be ultimately incorporated into a telehealth system. To validate this first-generation sEMG patch, we compared its safety, efficiency, and signal quality in monitoring submental muscle activity with that of widely used conventional sEMG electrodes. Method A randomized crossover design was used to compare the experimental sEMG patch with conventional (snap-on) sEMG electrodes. Participants completed the same experimental protocol with both electrodes in counterbalanced order. Swallow trials included five trials of 5- and 10-ml water. Comparisons were made on (a) signal-related factors: signal-to-noise ratio (SNR), baseline amplitude, normalized mean amplitude, and sEMG burst duration and (b) safety/preclinical factors: safety/adverse effects, efficiency of electrode placement, and satisfaction/comfort. Noninferiority and equivalence tests were used to examine signal-related factors. Paired t tests and descriptive statistics were used to examine safety/preclinical factors. Results Forty healthy adults participated (24 women, M _age = 67.5 years). Signal-related factors: SNR of the experimental patch was not inferior to the SNR of the conventional electrodes (p < .0056). Similarly, baseline amplitude obtained with the experimental patch was not inferior to that obtained with conventional electrodes (p < .0001). Finally, normalized amplitude values were equivalent across swallows (5 ml: p < .025; 10 ml: p < .0012), and sEMG burst duration was also equivalent (5 ml: p < .0001; 10 ml: p < .0001). Safety/preclinical factors: The experimental patch resulted in fewer mild adverse effects. Participant satisfaction was higher with the experimental patch (p = .0476, d = 0.226). Conclusions Our new wearable sEMG patch is equivalent with widely used conventional sEMG electrodes in terms of technical performance. In addition, our patch is safe, and healthy older adults are satisfied with it. With lessons learned from the current COVID-19 pandemic, efforts to develop optimal swallowing telerehabilitation devices are more urgent than ever. Upon further validation, this new technology has the potential to improve rehabilitation and telerehabilitation efforts for patients with dysphagia. Supplemental Material https://doi.org/10.23641/asha.12915509.

How Commercially Available Virtual Reality-Based Interventions Are Delivered and Reported in Gait, Posture, and Balance Rehabilitation: A Systematic Review

OBJECTIVE

Virtual reality (VR) technologies are increasingly used in physical rehabilitation; however, it is unclear how VR interventions are being delivered, and, in particular, the role of the therapist remains unknown. The purpose of this study was to systematically evaluate how commercially available VR technologies are being implemented in gait, posture, and balance rehabilitation, including justification, content, procedures, and dosage of the intervention and details of the therapist role.

METHODS

Five databases were searched between 2008 and 2018. Supervised interventional trials with >10 adult participants using commercially available VR technologies to address mobility limitations were independently selected by 2 authors. One author extracted reported intervention characteristics into a predesigned table and assessed methodological quality, which was independently verified by a second author. A total of 29 studies were included.

RESULTS

Generally, minimal clinical reasoning was provided to justify technology or activity selection, with recreational systems and games used most commonly (n = 25). All but 1 study used a single interventional technology. When explicitly described, the intervention was delivered by a physical therapist (n = 14), a therapist assistant (n = 2), both (n = 1), or an occupational therapist (n = 1). Most studies reported supervision (n = 12) and safeguarding (n = 8) as key therapist roles, with detail of therapist feedback less frequently reported (n = 4). Therapist involvement in program selection, tailoring, and progression was poorly described.

CONCLUSION

Intervention protocols of VR rehabilitation studies are incompletely described and generally lack detail on clinical rationale for technology and activity selection and on the therapist role in intervention design and delivery, hindering replication and translation of research into clinical practice. Future studies utilizing commercially available VR technologies should report all aspects of intervention design and delivery and consider protocols that allow therapists to exercise clinical autonomy in intervention delivery.

IMPACT STATEMENT

The findings of this systematic review have highlighted that VR rehabilitation interventions targeting gait, posture, and balance are primarily delivered by physical therapists, whose most reported role was supervision and safeguarding. There was an absence of detail regarding complex clinical skills, such as tailoring of the intervention and reasoning for the choice of technology and activity. This uncertainty around the role of the therapist as an active ingredient in VR-based rehabilitation hinders the development of implementation guidelines. To inform the optimal involvement of therapists in VR rehabilitation, it is essential that future studies report on all aspects of VR intervention design and delivery.

The use of augmented reality for rehabilitation after stroke: a narrative review

PURPOSE

To explore research relating to the use of Augmented Reality (AR) technology for rehabilitation after stroke in order to better understand the current, and potential future application of this technology to enhance stroke rehabilitation.

METHODS

Database searches and reference list screening were conducted to identify studies relating to the use of AR for stroke rehabilitation. These studies were then reviewed and summarised.

RESULTS

Eighteen studies were identified where AR was used for upper or lower limb rehabilitation following stroke. The findings of these studies indicate the technology is in the early stages of development and application. No clear definition of AR was established, with some confusion between virtual and augmented reality identified. Most AR systems engaged users in rote exercises which lacked an occupational focus and contextual relevance. User experience was mostly positive, however the poor quality of the studies limits generalisability of these findings to the greater stroke survivor population.

CONCLUSION

AR systems are currently being used for stroke rehabilitation in a variety of ways however the technology is in its infancy and warrants further investigation. A consistent definition of AR must be developed and further research is required to determine the possibilities of using AR to promote practice of occupations in a more contextually relevant environment to enhance motor learning and generalisation to other tasks. This could include using AR to bring the home environment into the hospital setting to enhance practice of prioritised occupations before returning home.IMPLICATIONS FOR REHABILITATIONThere is a developing body of evidence evaluating the use of various forms of AR technology for stroke rehabilitation.User motivation and engagement in rehabilitation may improve with the use of AR.A clear and consistent definition for AR must be developed.Ongoing work could explore how AR systems support engagement in, and promote motor learning that links to, meaningful occupations.

Motor Learning, Neuroplasticity, and Strength and Skill Training: Moving From Compensation to Retraining in Behavioral Management of Dysphagia

Purpose Learning a motor skill and regaining a motor skill after it is lost are key tenets to the field of speech-language pathology. Motor learning and relearning have many theoretical underpinnings that serve as a foundation for our clinical practice. This review article applies selective motor learning theories and principles to feeding and swallowing across the life span. Conclusion In reviewing these theoretical fundamentals, clinical exemplars surrounding the roles of strength, skill, experience, compensation, and retraining, and their influence on motor learning and plasticity in regard to swallowing/feeding skills throughout the life span are discussed.

Feasibility Randomized Trial for an Intensive Memory-Focused Training Program for School-Aged Children with Acquired Brain Injury

(1) Background: Memory deficits are common sequelae of pediatric Acquired Brain Injury (ABI). Only methods for non-focused cognitive remediation are available to the pediatric field. The aims of this feasibility trial are the description, implementation, and test of an intensive program specific to the training and re-adaptation of memory function in children, called Intensive Memory-Focused Training Program (IM-FTP); (2) Methods: Eleven children and adolescents with ABI (mean age at injury = 12.2 years, brain tumor survivors excluded) were clinically assessed and rehabilitated over 1-month through IM-FTP, including physio-kinesis/occupational, speech, and neuropsychology treatments. Each patient received a psychometric evaluation and a brain functional MRI at enrollment and at discharge. Ten pediatric controls with ABI (mean age at injury = 13.8 years) were clinically assessed, and rehabilitated through a standard program; (3) Results: After treatment, both groups had marked improvement in both immediate and delayed recall. IM-FTP was associated with better learning of semantically related and unrelated words, and larger improvement in immediate recall in prose memory. Imaging showed functional modification in the left frontal inferior cortex; (4) Conclusions: We described an age-independent reproducible multidisciplinary memory-focused rehabilitation protocol, which can be adapted to single patients while preserving inter-subject comparability, and is applicable up to a few months after injury. IM-FTP will now be employed in a powered clinical trial.

A Randomized Controlled Study Assessing the Effects of a Shoe Lift Under the Nonparetic Leg on Balance Performance in Individuals With Chronic Stroke

BACKGROUND AND PURPOSE

Improvement of balance and postural stability is an important goal in stroke rehabilitation. The purpose of this study was to investigate the effects of a shoe lift under the nonparetic leg on balance function and balance confidence in persons with chronic stroke.

METHODS

Thirty-six individuals with chronic stroke (21 males and 15 females), who were able to walk independently and showed stance asymmetry, were randomized to a shoe insert and a control group. The interventions included a 6-week balance training program, in conjunction with a shoe lift under the nonaffected leg (shoe insert group, n = 18), or balance training alone (control group, n = 18). The outcome measures were weight-bearing asymmetry (WBA), root mean square (RMS) of anterior-posterior (AP) and medial-lateral (ML) center-of-pressure (COP) velocity asymmetry, Berg Balance Scale (BBS), and Activities-specific Balance Confidence (ABC) Scale. These were measured in both groups at baseline, after the intervention, and at a 3-month follow-up. A repeated-measure multivariate analysis of variance was conducted to evaluate the impact of 2 different interventions on balance measures, across the 3 periods.

RESULTS AND DISCUSSION

No significant between-group differences were found for demographics and stroke-related characteristics of participants (P > .05). The outcome measures between the 2 groups were not significantly different at baseline (P > .05). There were between-group differences for WBA and the RMS of AP COP velocity asymmetry after the intervention and at the 3-month follow-up (P < .05). No significant difference in the RMS of ML COP velocity asymmetry, BBS, and ABC was identified between the 2 groups after the intervention and at the 3-month follow-up (P > .05).

CONCLUSION

The results indicated that the use of a shoe lift under the nonaffected leg in the context of a balance training program could result in a greater improvement in static standing balance as compared with balance training alone in an individual with chronic stroke.

TRIAL REGISTRATION

The study was retrospectively registered in the Iranian Registry of Clinical Trials (IRCT20190603043808N1).

Neuromuscular Control Training Does Not Improve Gait Biomechanics in Those With Chronic Ankle Instability: A Critically Appraised Topic

Introduction/Clinical Scenario: Ankle sprains are highly common within the population and can lead to chronic ankle instability (CAI). Individuals with CAI have both functional and mechanical impairments, which are thought to contribute to maladaptive gait biomechanics. Neuromuscular control and balance training are frequently incorporated into rehabilitation programs, however the effect of balance training on gait biomechanics remains unknown. Focused Clinical Question: Does balance or neuromuscular training improve gait biomechanics in individuals with CAI? Summary of Key Findings: Three studies assessed 4–6 weeks of progressive neuromuscular control training and found no improvements in gait biomechanics. One study found a worsening of eversion position at midstance upon program completion. However, when training was augmented with destabilizing shoes, improvements in dorsiflexion were noted. Clinical Bottom Line: Cumulative findings suggest that neuromuscular control training does not improve gait biomechanics in those with CAI. However, augmentation of programs may be beneficial. Strength of Recommendation: There is high-quality evidence(Grade B) that balance training does not alter gait biomechanics in patients with CAI.

Effect of Adding Motor Imagery to Task Specific Training on Facilitation of Sit to Stand in Hemiparetic Patients

Background: Motor imagery training is a cognitive process in which an internal representation of a movement is activated in working memory. The movement is mentally rehearsed, without any physical activity. Task-specific training emphasizes the repetitive practice of skilled movement to enhance functional abilities in hemiparesis. Objectives: To investigate whether task specific training preceded by motor imagery or task specific training alone was more effective for facilitating sit to stand in patients with stroke. Methods: Thirty male patients with stroke were selected from the Cairo University Outpatient Clinic; the median age of participants was 54.5 ± 3.51 years and they were divided equally into two groups. Patients in study group A (n = 15) received motor imagery training for 15 minutes followed by task specific training for 45 minutes, as well as a selected physical therapy program 3 times per week for 6 weeks. The control group B (n = 15) received task specific training for 45 minutes, as well as a selected physical therapy program 3 times per week for 6 weeks. The Fugl-Meyer section of the lower extremity (FMA-LE), Timed up and go test (TUG), and Biodex Balance system were assessed before and after treatment. Results: The results were highly significant for all variables including FMA-LE, TUG and Biodex Balance system in favor of the study group, post treatment. (P = 0.0004, P = 0.0001 and P = 0.0001, respectively). Conclusions: Motor imagery training results in greater improvement in sit to stand ability when used in conjunction with task specific training, rather than task specific training alone.

A Comparison of the Armeo to Tabletop-assisted Therapy Exercises as Supplemental Interventions in Acute Stroke Rehabilitation: A Randomized Single Blind Study

OBJECTIVES

To evaluate the feasibility of an additional therapeutic upper limb exercise (ULE) intervention in early phase post-stroke rehabilitation and to assess outcomes of therapy using the Armeo Spring (ARMEO) versus Therapist-assisted Table Top (TAT) interventions.

DESIGN

Randomized, single-blind trial.

SETTING

Stroke acute inpatient rehabilitation unit.

PARTICIPANTS

Forty-five participants early after first stroke, Fugl-Meyer Assessment (FMA) score >8, Modified Ashworth score (MAS) of <3.

INTERVENTIONS

Participants were randomized to TAT or ARMEO ULE in addition to the required 3 hours of 1:1 standard of care provided in an inpatient rehabilitation facility (IRF).

MAIN OUTCOME MEASURES

Completed number of treatments; withdrawals; serious/adverse events; Functional Independence Measure (FIM) motor; FIM efficiency; FMA; MAS; elbow active (A) and passive (P) range of motion (ROM); and therapist effort measured by the Modified Borg Rating of Perceived Exertion Scale (RPE).

RESULTS

Post-intervention FIM and FMA scores increased but did not demonstrate any statistically significant differences between the intervention groups (P = .585, .962, partial n² = .001, .001, respectively). There were no statistically significant differences in post-intervention MAS elbow flexion and extension (P = .332, .252, partial n² = .009, .007, respectively) and A/P ROM elbow extension between training groups (P = .841, .731, partial n² = .001, .003, respectively). There was a statistically significant difference in post-intervention A/P ROM elbow flexion between groups (P = .031, .018, partial n² = .123, .146). Post-intervention RPE did not show any statistically significant differences between the training groups (P = .128, partial n² = .063). Total elbow range showed larger adjusted mean gains for the ARMEO. No serious adverse events were reported.

CONCLUSIONS

This study demonstrates that additional therapeutic ULE in the early phase of post-stroke inpatient rehabilitation is feasible and that both interventions showed positive changes in selected outcomes.

A pilot study on the design and validation of a hybrid exoskeleton robotic device for hand rehabilitation

STUDY DESIGN

An iterative design process was used to obtain design parameters that satisfy both kinematic and dynamic requirements for the hand exoskeleton. This design was validated through experimental studies.

INTRODUCTION

The success of hand rehabilitation after impairments depends on the timing, intensity, repetition, and frequency, as well as task-specific training. Considering the continuing constraints placed on therapist-led rehabilitation and need for better outcomes, robot-assisted rehabilitation has been explored. Soft robotic approaches have been implemented for a hand rehabilitation exoskeleton as they have more tolerance for alignment with biological joints than those of hard exoskeletons.

PURPOSE OF THE STUDY

The purpose of the study was to design, develop, and validate a soft robotic exoskeleton for hand rehabilitation.

METHODS

A motion capture system validated the kinematics of the soft robotic digit attached on top of a human index finger. A pneumatic control system and algorithms were developed to operate the exoskeleton based on three therapeutic modes: continuous passive, active assistive, and active resistive motion. Pilot studies were carried out on one healthy and one poststroke participant using continuous passive motion and bilateral/bimanual therapy modes.

RESULTS

The soft robotic digits were able to produce required range of motion and accommodate for dorsal lengthening, with trajectories of the center of rotation of the soft robotic joints in close agreement with the center of rotation of the human finger joints.

DISCUSSION

The exoskeleton showed the robust performance of the robot in applying continuous passive motion and bilateral/bimanual therapy.

CONCLUSIONS

This soft robotic exoskeleton is promising for assisting in the rehabilitation of the hand.

Comparisons between end-effector and exoskeleton rehabilitation robots regarding upper extremity function among chronic stroke patients with moderate-to-severe upper limb impairment

End-effector (EE) and exoskeleton (Exo) robots have not been directly compared previously. The present study aimed to directly compare EE and Exo robots in chronic stroke patients with moderate-to-severe upper limb impairment. This single-blinded, randomised controlled trial included 38 patients with stroke who were admitted to the rehabilitation hospital. The patients were equally divided into EE and Exo groups. Baseline characteristics, including sex, age, stroke type, brain lesion side (left/right), stroke duration, Fugl–Meyer Assessment (FMA)–Upper Extremity score, and Wolf Motor Function Test (WMFT) score, were assessed. Additionally, impairment level (FMA, motor status score), activity (WMFT), and participation (stroke impact scale [SIS]) were evaluated. There were no significant differences in baseline characteristics between the groups. After the intervention, improvements were significantly better in the EE group with regard to activity and participation (WMFT–Functional ability rating scale, WMFT–Time, and SIS–Participation). There was no intervention-related adverse event. The EE robot intervention is better than the Exo robot intervention with regard to activity and participation among chronic stroke patients with moderate-to-severe upper limb impairment. Further research is needed to confirm this novel finding.

The Role of Robotic Path Assistance and Weight Support in Facilitating 3D Movements in Individuals With Poststroke Hemiparesis

Background. High-intensity repetitive training is challenging to provide poststroke. Robotic approaches can facilitate such training by unweighting the limb and/or by improving trajectory control, but the extent to which these types of assistance are necessary is not known. Objective. The purpose of this study was to examine the extent to which robotic path assistance and/or weight support facilitate repetitive 3D movements in high functioning and low functioning subjects with poststroke arm motor impairment relative to healthy controls. Methods. Seven healthy controls and 18 subjects with chronic poststroke right-sided hemiparesis performed 300 repetitions of a 3D circle-drawing task using a 3D Cable-driven Arm Exoskeleton (CAREX) robot. Subjects performed 100 repetitions each with path assistance alone, weight support alone, and path assistance plus weight support in a random order over a single session. Kinematic data from the task were used to compute the normalized error and speed as well as the speed-error relationship. Results. Low functioning stroke subjects (Fugl-Meyer Scale score = 16.6 ± 6.5) showed the lowest error with path assistance plus weight support, whereas high functioning stroke subjects (Fugl-Meyer Scale score = 59.6 ± 6.8) moved faster with path assistance alone. When both speed and error were considered together, low functioning subjects significantly reduced their error and increased their speed but showed no difference across the robotic conditions. Conclusions. Robotic assistance can facilitate repetitive task performance in individuals with severe arm motor impairment, but path assistance provides little advantage over weight support alone. Future studies focusing on antigravity arm movement control are warranted poststroke.

The impact of a patient-directed activity program on functional outcomes and activity participation after stroke during inpatient rehabilitation—a randomized controlled trial

Objective:

Individuals post stroke are inactive, even during rehabilitation, contributing to ongoing disability and risk of secondary health conditions. Our aims were to (1) conduct a randomized controlled trial to examine the efficacy of a “Patient-Directed Activity Program” on functional outcomes in people post stroke during inpatient rehabilitation and (2) examine differences three months post inpatient rehabilitation discharge.

Design:

Randomized control trial.

Setting:

Inpatient rehabilitation facility.

Subjects:

Patients admitted to inpatient rehabilitation post stroke.

Interventions:

Patient-Directed Activity Program (PDAP) or control (usual care only). Both groups underwent control (three hours of therapy/day), while PDAP participants were prescribed two additional 30-minute activity sessions/day.

Main measures:

Outcomes (Stroke Rehabilitation Assessment of Movement Measure, Functional Independence Measure, balance, physical activity, Stroke Impact Scale) were collected at admission and discharge from inpatient rehabilitation and three-month follow-up.

Results:

Seventy-three patients (PDAP ( n = 37); control ( n = 36)) were included in the primary analysis. Patients in PDAP completed a total of 23.1 ± 16.5 sessions (10.7 ± 8.5 upper extremity; 12.4 ± 8.6 lower extremity) during inpatient rehabilitation. No differences were observed between groups at discharge in functional measures. PDAP completed significantly more steps/day (PDAP = 657.70 ± 655.82, control = 396.17 ± 419.65; P = 0.022). The Stroke Impact Scale showed significantly better memory and thinking (PDAP = 86.2 ± 11.4, control = 80.8 ± 16.7; P = 0.049), communication (PDAP = 93.6 ± 8.3, control = 89.6 ± 12.4; P = 0.042), mobility (PDAP = 62.2 ± 22.5, control = 53.8 ± 21.8; P = 0.038), and overall recovery from stroke (PDAP = 62.1 ± 19.1, control = 52.2 ± 18.7; P = 0.038) for PDAP compared to control. At three months post discharge, PDAP ( n = 11) completed significantly greater physical activity ( P = 0.014; 3586.5 ± 3468.5 steps/day) compared to control ( n = 10; 1760.9 ± 2346.3 steps/day).

Conclusion:

Functional outcome improvement was comparable between groups; however, PDAP participants completed more steps and perceived greater recovery.

Novel Activity Detection Algorithm to Characterize Spontaneous Stepping During Multimodal Spinal Neuromodulation After Mid-Thoracic Spinal Cord Injury in Rats

A mid-thoracic spinal cord injury (SCI) severely impairs activation of the lower limb sensorimotor spinal networks, leading to paralysis. Various neuromodulatory techniques including electrical and pharmacological activation of the spinal networks have been successful in restoring locomotor function after SCI. We hypothesized that the combination of self-training in a natural environment with epidural stimulation (ES), quipazine (Quip), and strychnine (Strych) would result in greater activity in a cage environment after paralysis compared to either intervention alone. To assess this, we developed a method measuring and characterizing the chronic EMG recordings from tibialis anterior (TA) and soleus (Sol) muscles while rats were freely moving in their home cages. We then assessed the relationship between the change in recorded activity over time and motor-evoked potentials (MEPs) in animals receiving treatments. We found that the combination of ES, Quip, and Strych (sqES) generated the greatest level of recovery followed by ES + Quip (qES) while ES + Strych (sES) and ES alone showed least improvement in recorded activity. Further, we observed an exponential relationship between late response (LR) component of the MEPs and spontaneously generated step-like activity. Our data demonstrate the feasibility and potential importance of quantitatively monitoring mechanistic factors linked to activity-dependence in response to combinatorial interventions compared to individual therapies after SCI.

Effect of Group-Task-Oriented Training on Gross and Fine Motor Function, and Activities of Daily Living in Children with Spastic Cerebral Palsy

Aims: To determine the effects of group-task-oriented training (group-TOT) on gross and fine motor function, activities of daily living (ADL) and social function of children with spastic cerebral palsy (CP).Methods: Eighteen children with spastic CP (4-7.5 years, gross motor function classification system level I-III) were randomly assigned to the Group-TOT (9 children received group-TOT for 1 hour, twice a week for 8 weeks) or the comparison group (9 children received individualized traditional physical and occupational therapy). The Gross Motor Function Measure (GMFM)-88, the Bruininks-Oseretsky Test of Motor Proficiency 2^nd edition (BOT-2), and the Pediatric Evaluation of Disability Inventory (PEDI) were administered before and after the intervention, and in the Group-TOT, 16 weeks after the intervention.Results: Children in the Group-TOT showed significant improvements in the GMFM-88 standing and walking/running/jumping subscales, the BOT-2 manual dexterity subscale, and the PEDI social function subscale (p < 0.05); changes were maintained 16 weeks after the intervention ended. In contrast, the comparison group improved in only the BOT-2 fine motor integration subscale (p < 0.05).Conclusions: The findings provide evidence of effectiveness of group-TOT in improving gross and fine motor function, and social function in children with CP.

Robotic body weight support enables safe stair negotiation in compliance with basic locomotor principles

BACKGROUND

After a neurological injury, mobility focused rehabilitation programs intensively train walking on treadmills or overground. However, after discharge, quite a few patients are not able to independently negotiate stairs, a real-world task with high physical and psychological demands and a high injury risk. To decrease fall risk and improve patients' capacity to navigate typical environments, early stair negotiation training can help restore competence and confidence in safe stair negotiation. One way to enable early training in a safe and permissive environment is to unload the patient with a body weight support system. We here investigated if unloaded stair negotiation complies with basic locomotor principles, in terms of enabling performance of a physiological movement pattern with minimal compensation.

METHODS

Seventeen able-bodied participants were unloaded with 0-50% bodyweight during self-paced ascent and descent of a 4-tread staircase. Spatio-temporal parameters, joint ranges of motion, ground reaction forces and myoelectric activity in the main lower limb muscles of participants were compared between unloading levels. Likelihood ratio tests of separated linear mixed models of the investigated outcomes assessed if unloading affects the parameters in general. Subsequent post-hoc testing revealed which levels of unloading differed from unsupported stair negotiation.

RESULTS

Unloading affected walking velocity, joint ranges of motion, vertical ground reaction force parameters and myoelectric activity in all investigated muscles for stair ascent and descent while step width and single support duration were only affected during ascent. A reduction with increasing levels of body weight support was seen in walking velocity (0.07-0.12 m/s), ranges of motion of the knee and hip (2-10°), vertical ground reaction force peaks (10-70%) and myoelectric activity (17-70%). An increase with unloading was only seen during ascent for ankle range of motion and tibialis anterior activity at substantial unloading.

CONCLUSIONS

Body weight support facilitates stair negotiation by providing safety and support against gravity. Although unloading effects are present in most parameters, up to 30% body weight support these changes are small, and no dysfunctional patterns are introduced. Body weight support therefore fulfills all the necessary requirements for early stair negotiation training.

Effect of task-oriented training on balance and motor function of ambulant children with cerebral palsy

INTRODUCTION AND OBJECTIVES

The study evaluated the effect of task-oriented training (TOT) on the motor function (MF) and balance of ambulant children with cerebral palsy (CP).

MATERIALS AND METHODS

A total of 46 children were randomised into TOT group (n=23) and Control Group (CG [n=23]), but 39 children complete the study. Balance and MF were assessed at baseline, 6th and 12th weeks and 6 weeks post-intervention. Data were analysed with repeated measures ANOVA, Friedman's, Mann-Whitney U, Student's-t and post hoc tests at α≤0.05.

RESULTS

The two groups were comparable in all baseline scores (P>0.05). At the 6th week, significant between-group difference was observed in MF only [TOT=81.9 (18.5); CG=72.8 (19.4)] (P<0.05). There were significant between-group differences in MF [TOT=88.8 (9.4); CG=75.5 (18.5); P<0.05] and balance (TOT=9.4±4.5; CG=13.6±6.9; P<0.05) at the 12th week (P<0.05) and 6 weeks post-intervention (P<0.05).

CONCLUSION

TOT improved the balance and MF of ambulant children with CP.

Design Requirements of Generic Hand Exoskeletons and Survey of Hand Exoskeletons for Rehabilitation, Assistive, or Haptic Use

Most current hand exoskeletons have been designed specifically for rehabilitation, assistive, or haptic applications to simplify the design requirements. Clinical studies on poststroke rehabilitation have shown that adapting assistive or haptic applications into physical therapy sessions significantly improves the motor learning and treatment process. The recent technology can lead to the creation of generic hand exoskeletons that are application-agnostic. In this paper, our motivation is to create guidelines and best practices for generic exoskeletons by reviewing the literature of current devices. First, we describe each application and briefly explain their design requirements, and then list the design selections to achieve these requirements. Then, we detail each selection by investigating the existing exoskeletons based on their design choices, and by highlighting their impact on application types. With the motivation of creating efficient generic exoskeletons in the future, we finally summarize the best practices in the literature.

Usability Assessment of a Cable-Driven Exoskeletal Robot for Hand Rehabilitation

Study design: Case series.

Background: Robot-assisted rehabilitation mediated by exoskeletal devices is a popular topic of research. The biggest difficulty in the development of rehabilitation robots is the consideration of the clinical needs. This study investigated the usability of a novel cable-driven exoskeletal robot specifically designed for hand rehabilitation.

Methods: The study consists of three steps, including prototype development, spasticity observation, and usability evaluation. First, we developed the prototype robot DexoHand to manipulate the patient's fingers based on the clinical needs and the cable-driven concept established in our previous work. Second, we applied DexoHand to patients with different levels of spasticity. Finally, we obtained the system usability scale (SUS) and assessed its usability.

Results: Two healthy subjects were recruited in the pre-test, and 18 patients with stroke and four healthy subjects were recruited in the formal test for usability. The total SUS score obtained from the patients and healthy subjects was 94.77 ± 2.98 (n = 22), indicating an excellent level of usability. The satisfaction score was 4.74 ± 0.29 (n = 22), revealing high satisfaction with DexoHand. The tension profile measured by the cables showed the instantaneous force used to manipulate fingers among different muscle tone groups.

Conclusions:DexoHand meets the clinical needs with excellent usability, satisfaction, and reliable tension force monitoring, yielding a feasible platform for robot-assisted hand rehabilitation.

Analysis of the Factors Related to the Effectiveness of Transcranial Current Stimulation in Upper Limb Motor Function Recovery after Stroke: a Systematic Review

Transcranial direct current stimulation is one of the non-invasive techniques whose main mechanism of action is based on its modulation of cortical excitability. The objective of this study is to analyze the variables (i.e, demographics, clinicals, stimulation parameters) that could influence into the responses during rehabilitation of the upper extremity in patients with stroke. Our systematic review has been performed by searching full-text articles published from January 2008 to December 2018 in Embase, Medline, PubMed and Cochrane Library databases. Studies with adult patients with ischemic or hemorrhagic stroke at any stage of evolution were included. We compared interventions with any type of transcranial direct current stimulation (anodal, cathodal or bihemispheric, also known as dual) regarding improvement of upper extremity motor function. We included 14 studies with 368 patients, of whom almost 89% have ischemic etiology and more than half are males. Most patients were considered subacute or chronic, while only two studies were selected with patients in the acute phase. Different methods of using transcranial direct current stimulation with several complementary therapies were identified, such as virtual reality, robot therapy, Occupational Therapy, Physiotherapy, Constraint Induced Movement Therapy or Peripheral Nerve Stimulation. In conclusion, there is not significant evidence due to heterogeneity of clinical data and therapies. Clinical studies with greater number of participants and protocols standardized could outline this assessment in future studies.

Effects of task-oriented training on upper extremity functional performance in patients with sub-acute stroke: a randomized controlled trial

[Purpose] The present study aimed to determine the effects of a task-oriented training on paretic upper extremity functional performance in patients with subacute stroke. [Participants and Methods] Twenty-eight subacute stroke sufferers (mean age: 50.07, standard deviation 9.31 years; mean time since stroke 11.11, standard deviation 6.73 weeks) were randomly allocated to task-oriented training (n=14) or conventional exercise program (n=14) group. They were trained as a hospital-based, individualized training 1 hour a session, 5 sessions a week for 4 weeks. Wolf Motor Function Test (primary outcome), motor portion of Fugl-Meyer assessment upper extremity, and hand function domain of Stroke Impact Scale were assessed at baseline, after 2 and 4 weeks of training. [Results] All participants completed their training programs. At all post-training assessments, the task-oriented training group showed significantly more improvements in all outcomes than the conventional exercise program group. No serious adverse effects were observed during or after the training. [Conclusion] Task-oriented training produced statistically significant and clinically meaningful improvements of paretic upper extremity functional performance in patients with subacute stroke. These beneficial effects were observed after 2 weeks (10 hours) of training. Future investigation is warranted to confirm and expand these findings.

Challenges in developing a magnetic resonance-compatible haptic hand-controller for neurosurgical training

A haptic device is an actuated human-machine interface utilized by an operator to dynamically interact with a remote environment. This interaction could be virtual (virtual reality) or physical such as using a robotic arm. To date, different mechanisms have been considered to actuate the haptic device to reflect force feedback from the remote environment. In a low-force environment or limited working envelope, the control of some actuation mechanisms such as hydraulic and pneumatic may be problematic. In the development of a haptic device, challenges include limited space, high accuracy or resolution, limitations in kinematic and dynamic solutions, points of singularity, dexterity as well as control system development/design. Furthermore, the haptic interface designed to operate in a magnetic resonance imaging environment adds additional challenges related to electromagnetic interference, static/variable magnetic fields, and the use of magnetic resonance-compatible materials. Such a device would allow functional magnetic resonance imaging to obtain information on the subject's brain activity while performing a task. When used for surgical trainees, functional magnetic resonance imaging could provide an assessment of surgical skills. In this application, the trainee, located supine within the magnet bore while observing the task environment on a graphical user interface, uses a low-force magnetic resonance-compatible haptic device to perform virtual surgical tasks in a limited space. In the quest to develop such a device, this review reports the multiple challenges faced and their potential solutions. The review also investigates efforts toward prototyping such devices and classifies the main components of a magnetic resonance-compatible device including actuation and sensory systems and materials used.

Exercise Guidelines for Gait Function in Parkinson’s Disease: A Systematic Review and Meta-analysis

This systematic review and meta-analysis is to provide comprehensive evidence-based exercise recommendations targeting walking function for adults with Parkinson’s disease. Methods. Fixed- or random-effect meta-analyses estimated standardized effect sizes (Hedge’s g), comparing treatment effects from exercise with nonexercise and another form of exercise (non-EXE control and EXE control). Cuing and exercise duration were used as moderators for subanalyses. Results. The 40 included randomized controlled trials comprised 1656 patients. The exercise group showed significantly superior performance in timed up-and-go ( g = −0.458; g = −0.390) compared with non-EXE control and EXE control; significantly greater improvement in comfortable walking speed ( g = 0.449), fast walking speed ( g = 0.430), and stride or step length ( g = 0.379) compared with non-EXE control; and significantly greater cadence ( g = 0.282) compared with EXE controls. No significant differences between intervention and control groups were observed for double-leg support time (DLST), dynamic gait index (DGI), 6-minute walk test, or freezing of gait questionnaire (FOG-Q). Notably, treatment effect from the exercise of interest compared with a standard exercise was greater than for nonexercise for cadence and FOG-Q. Moreover, EXE control was favored for DLST and DGI. Cuing had a significantly positive effect on stride length alone. Exercise duration significantly, but negatively, influenced the treatment effect on comfortable walking speed. Conclusion. Gait-specific training, rather than a general exercise program, should be emphasized if gait is the outcome of interest. Further investigation is needed on exercise dosage and its selective effect on more challenging walking tasks, endurance, and freezing of gait.

External biomechanical constraints impair maximal voluntary grip force stability post-stroke

BACKGROUND

Grip strength is frequently measured as a global indicator of motor function. In clinical populations, such as hemiparesis post-stroke, grip strength is associated with upper-extremity motor impairment, function, and ability to execute activities of daily living. However, biomechanical configuration of the distal arm and hand may influence the magnitude and stability of maximal voluntary grip force and varies across studies. The influence of distal arm/hand biomechanical configuration on grip force remains unclear. Here we investigated how biomechanical configuration of the distal arm/hand influence the magnitude and trial-to-trial variability of maximal grip force performed in similar positions with variations in external constraint.

METHODS

We studied three groups of 20 individuals: healthy young, healthy older, and individuals post-stroke. We tested maximal voluntary grip force in 4 conditions: 1: self-determined/"free"; 2: standard; 3: fixed arm-rest; 4: gripper fixed to arm-rest, using an instrumented grip dynamometer in both dominant/non-dominant and non-paretic/paretic hands.

FINDINGS

Regardless of hand or group, maximal voluntary grip force was highest when the distal limb was most constrained (i.e., Condition 4), followed by the least constrained (i.e., Condition 1) (Cohen's f = 0.52, P's < 0.001). Coefficient of variation among three trials was greater in the paretic hand compared with healthy individuals, particularly in more (Conditions 3 and 4) compared to less (Conditions 1 and 2) constrained conditions (Cohen's f = 0.29, P's < 0.05).

INTERPRETATION

These findings have important implications for design of rehabilitation interventions and devices. Particularly in individuals post-stroke, external biomechanical constraints increase maximal voluntary grip force variability while fewer biomechanical constraints yield more stable performance.

Agreed Definitions and a Shared Vision for New Standards in Stroke Recovery Research: The Stroke Recovery and Rehabilitation Roundtable Taskforce

The first Stroke Recovery and Rehabilitation Roundtable established a game changing set of new standards for stroke recovery research. Common language and definitions were required to develop an agreed framework spanning the four working groups: translation of basic science, biomarkers of stroke recovery, measurement in clinical trials and intervention development and reporting. This paper outlines the working definitions established by our group and an agreed vision for accelerating progress in stroke recovery research.

Synergistic Effects of Enriched Environment and Task-Specific Reach Training on Poststroke Recovery of Motor Function

BACKGROUND AND PURPOSE

Reach training in concert with environmental enrichment provides functional benefits after experimental stroke in rats. The present study extended these findings by assessing whether intensive task-specific reach training or enrichment initiated alone would provide similar functional benefit. Additionally, we investigated whether the 70% recovery rule, or a combined model of initial poststroke impairment, cortical infarct volume, and rehabilitation intensity, could predict recovery in the single-pellet task, as previously found for the Montoya staircase.

METHODS

Rats were trained on single-pellet reaching before middle cerebral artery occlusion via intracerebral injection of ET-1 (endothelin-1). There were 4 experimental groups: stroke+enrichment, stroke+reaching, stroke+enrichment+reaching, and sham+enrichment+reaching. Reaching rehabilitation utilized a modified Whishaw box that encouraged impaired forelimb reaching for 6 hours per day, 5 days per week, for 4 weeks. All treatment paradigms began 7 days after ischemia with weekly assessment on the single-pellet task during rehabilitation and again 4 weeks after rehabilitation concluded.

RESULTS

Rats exposed to the combination of enrichment and reaching showed the greatest improvement in pellet retrieval and comparable performance to shams after 3 weeks of treatment, whereas those groups that received a monotherapy remained significantly impaired at all time points. Initial impairment alone did not significantly predict recovery in single-pellet as the 70% rule would suggest; however, a combined model of cortical infarct volume and rehabilitation intensity predicted change in pellet retrieval on the single-pellet task with the same accuracy as previously shown with the staircase, demonstrating the generalizability of this model across reaching tasks.

CONCLUSIONS

Task-specific reach training and environmental enrichment have synergistic effects in rats that persist long after rehabilitation ends, and this recovery is predicted by infarct volume and rehabilitation intensity.

A narrative review of gait training after stroke and a proposal for developing a novel gait training device that provides minimal assistance

BACKGROUND

Gait impairment is common in stroke survivors. Recovery of walking ability is one of the most pressing objectives in stroke rehabilitation.

OBJECTIVES

Of this report are to briefly review recent progress in gait training after stroke including the use of partial body weight-supported treadmill training (PBWSTT) and robot-assisted step training (RAST), and propose a minimal assistance strategy that may overcome some of limitations of current RAST.

METHODS

The literature review emphasizes a dilemma that recent randomized clinical trials did not support the use of RAST. The unsatisfactory results of current RAST clinical trials may be partially due to a lack of careful analysis of movement deficiencies and their relevance to gait training task specificity after stroke. Normal movement pattern is implied to be part of task specificity in the current RAST. Limitations of such task specificity are analyzed.

RESULTS

Based on the review, we redefine an alternative set of gait training task specificity that represents a minimal assistance strategy in terms of assisted body movements and amount of assistance. Specifically, assistances are applied only to hip flexion and ankle dorsiflexion of the affected lower limb during swing phase. Furthermore, we propose a conceptual design of a novel device that may overcome limitations of current RAST in gait training after stroke. The novel device uses a pulling cable, either manually operated by a therapist or automated by a servomotor, to provide assistive forces to help hip flexion and ankle dorsiflexion of the affected lower limb during gait training.

CONCLUSION

The proposed minimal assistance strategy may help to design better devices for gait or other motor training.

Activity training on the ground in children with cerebral palsy: Systematic review and meta-analysis

Purpose: To systematically review the evidence about whether activity training on the ground is effective on activity or participation in children with cerebral palsy. Methods: Randomized controlled trials (RCTs) were searched in databases using relevant keywords. RCTs were included with children (≤18 years) with cerebral palsy who received activity training on the ground only or activity training on the ground combined with another type of physiotherapy. Outcome measures classified as measures of activity or participation according to the International Classification of Functioning, Disability, and Health were analyzed. Results: Nine RCTs (257 participants) were included in this review. Individual studies resulted in conflicting results when activity training on the ground was compared to no intervention. Based on meta-analysis, activity training on the ground was not more effective than no intervention (standardized mean difference [SMD]: 0.18; confidence interval [CI]: -1.49 to 1.86) or other therapies (SMD: -0.09; CI: -0.86 to 0.69) (I² > 75%) on improving activity or participation. Results from a single study demonstrated that activity training on the ground combined with other physiotherapy intervention was not more effective than no intervention (SMD: -0.18 CI: -0.89 to 0.54). Conclusions: The available evidence shows little effect of activity training on the ground on activity or participation in children with cerebral palsy, suggesting that rigorous trials with larger samples and larger "dosage" of activity training on the ground are needed in the future.