The Role of Task-Specific Training in Rehabilitation Therapies

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.

Combined Transcranial Direct Current Stimulation and Virtual Reality-Based Paradigm for Upper Limb Rehabilitation in Individuals with Restricted Movements. A Feasibility Study with a Chronic Stroke Survivor with Severe Hemiparesis

Impairments of the upper limb function are a major cause of disability and rehabilitation. Most of the available therapeutic options are based on active exercises and on motor and attentional inclusion of the affected arm in task oriented movements. However, active movements may not be possible after severe impairment of the upper limbs. Different techniques, such as mirror therapy, motor imagery, and non-invasive brain stimulation have been shown to elicit cortical activity in absence of movements, which could be used to preserve the available neural circuits and promote motor learning. We present a virtual reality-based paradigm for upper limb rehabilitation that allows for interaction of individuals with restricted movements from active responses triggered when they attempt to perform a movement. The experimental system also provides multisensory stimulation in the visual, auditory, and tactile channels, and transcranial direct current stimulation coherent to the observed movements. A feasibility study with a chronic stroke survivor with severe hemiparesis who seemed to reach a rehabilitation plateau after two years of its inclusion in a physical therapy program showed clinically meaningful improvement of the upper limb function after the experimental intervention and maintenance of gains in both the body function and activity. The experimental intervention also was reported to be usable and motivating. Although very preliminary, these results could highlight the potential of this intervention to promote functional recovery in severe impairments of the upper limb.

Effects of dance-based movement therapy on balance, gait, and psychological functions in severe cerebellar ataxia: A case study

Purpose: Individuals in the later stages of cerebellar ataxia usually experience serious balance and immobility problems. Currently, there is a lack of adequate rehabilitative programs for individuals with severe cerebellar ataxia that can help improve ataxia-related motor impairment. The purpose of the present study was to explore the potential physiotherapeutic benefits of partnered dance on balance, motor functions, and psychological well-being in an individual demonstrating severe cerebellar ataxia symptoms. Methods: The individual was a 39-year-old male diagnosed with cerebellar atrophy. He had the disease for more than 15 years prior to the study. The individual attended 24 intervention sessions over an 8-week period of dance-based movement training that aimed to improve his balance and postural stability by facilitating the perception and control of static and dynamic balance movements and body alignment. Results: The individual demonstrated improvements in independent standing balance, gait characteristics, and functional mobility. In addition, improvements in self-reported depression and quality of life scores were observed after completion of the intervention. Conclusion: Although interpreting the findings of this study is limited to a single participant, partnered dance could be a suitable alternative physiotherapeutic intervention method for people with severely impaired mobility due to cerebellar dysfunction.

Standing Practice In Rehabilitation Early after Stroke (SPIRES): a functional standing frame programme (prolonged standing and repeated sit to stand) to improve function and quality of life and reduce neuromuscular impairment in people with severe sub-acute stroke-a protocol for a feasibility randomised controlled trial

BACKGROUND

The most common physical deficit caused by a stroke is muscle weakness which limits a person's mobility. Mobility encompasses activities necessary for daily functioning: getting in and out bed, on/off toilet, sitting, standing and walking. These activities are significantly affected in people with severe stroke who typically spend most of their time in bed or a chair and are immobile. Immobility is primarily caused by neurological damage but exacerbated by secondary changes in musculoskeletal and cardiorespiratory systems. These secondary changes can theoretically be prevented or minimised by early mobilisation, in this case standing up early post-stroke.Standing up early post-stroke has been identified as an important priority for people who have suffered a severe stroke. However, trials of prolonged passive standing have not demonstrated any functional improvements. Conversely, task-specific training such as repeated sit-to-stand has demonstrated positive functional benefits. This feasibility trial combines prolonged standing and task-specific strength training with the aim of determining whether this novel combination of physiotherapy interventions is feasible for people with severe stroke as well as the overall feasibility of delivering the trial.

METHODS/DESIGN

This is a pragmatic multi-centre parallel single-blinded two-armed feasibility randomised controlled trial. Fifty people with a diagnosis of severe stroke will be randomly allocated to either the functional standing frame programme or usual physiotherapy. All patient participants will be assessed at baseline and followed up at 3 weeks, then 3, 6 and 12 months post-randomisation. Trial objectives are to determine the feasibility according to the following indicators:: (i) Process: recruitment and retention rate, ability to consent, eligibility criteria, willingness/ability of physiotherapists to recruit, willingness of patients to be randomised, and acceptability of the intervention; (ii) Resource: burden and potential costs; (iii) Management: treatment fidelity, participant adherence, acceptability and completeness of outcome measures, impact and management or orthostatic hypotension; and (iv) Safety: number and nature of adverse and serious adverse events.

DISCUSSION

The functional standing frame programme addresses a key concern for people who have suffered a severe stroke. However, several uncertainties exist which need to be understood prior to progressing to a full-scale trial, including acceptability and tolerance of the functional standing frame programme intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN15412695. Registration on 19 December 2016.

Instrumental or Physical-Exercise Rehabilitation of Balance Improves Both Balance and Gait in Parkinson's Disease

We hypothesised that rehabilitation specifically addressing balance in Parkinson's disease patients might improve not only balance but locomotion as well. Two balance-training protocols (standing on a moving platform and traditional balance exercises) were assessed by assigning patients to two groups (Platform, n = 15, and Exercises, n = 17). The platform moved periodically in the anteroposterior, laterolateral, and oblique direction, with and without vision in different trials. Balance exercises were based on the Otago Exercise Program. Both platform and exercise sessions were administered from easy to difficult. Outcome measures were (a) balancing behaviour, assessed by both Index of Stability (IS) on platform and Mini-BESTest, and (b) gait, assessed by both baropodometry and Timed Up and Go (TUG) test. Falls Efficacy Scale-International (FES-I) and Parkinson's Disease Questionnaire (PDQ-8) were administered. Both groups exhibited better balance control, as assessed both by IS and by Mini-BESTest. Gait speed at baropodometry also improved in both groups, while TUG was less sensitive to improvement. Scores of FES-I and PDQ-8 showed a marginal improvement. A four-week treatment featuring no gait training but focused on challenging balance tasks produces considerable gait enhancement in mildly to moderately affected patients. Walking problems in PD depend on postural instability and are successfully relieved by appropriate balance rehabilitation. This trial is registered with ClinicalTrials.gov NCT03314597.

Stroke

Stroke, or cerebrovascular accident, involves injury to the central nervous system as a result of a vascular cause, and is a leading cause of disability worldwide. People with stroke often experience sensory, cognitive, and motor sequelae that can lead to difficulty walking, controlling balance in standing and voluntary tasks, and reacting to prevent a fall following an unexpected postural perturbation. This chapter discusses the interrelationships between stroke-related impairments, problems with control of balance and gait, fall risk, fear of falling, and participation in daily physical activity. Rehabilitation can improve balance and walking function, and consequently independence and quality of life, for those with stroke. This chapter also describes effective interventions for improving balance and walking function poststroke, and identifies some areas for further research in poststroke rehabilitation.

Arm rehabilitation in post stroke subjects: A randomized controlled trial on the efficacy of myoelectrically driven FES applied in a task-oriented approach

Purpose

Motor recovery of persons after stroke may be enhanced by a novel approach where residual muscle activity is facilitated by patient-controlled electrical muscle activation. Myoelectric activity from hemiparetic muscles is then used for continuous control of functional electrical stimulation (MeCFES) of same or synergic muscles to promote restoration of movements during task-oriented therapy (TOT). Use of MeCFES during TOT may help to obtain a larger functional and neurological recovery than otherwise possible.

Study design

Multicenter randomized controlled trial.

Methods

Eighty two acute and chronic stroke victims were recruited through the collaborating facilities and after signing an informed consent were randomized to receive either the experimental (MeCFES assisted TOT (M-TOT) or conventional rehabilitation care including TOT (C-TOT). Both groups received 45 minutes of rehabilitation over 25 sessions. Outcomes were Action Research Arm Test (ARAT), Upper Extremity Fugl-Meyer Assessment (FMA-UE) scores and Disability of the Arm Shoulder and Hand questionnaire.

Results

Sixty eight subjects completed the protocol (Mean age 66.2, range 36.5–88.7, onset months 12.7, range 0.8–19.1) of which 45 were seen at follow up 5 weeks later. There were significant improvements in both groups on ARAT (median improvement: MeCFES TOT group 3.0; C-TOT group 2.0) and FMA-UE (median improvement: M-TOT 4.5; C-TOT 3.5). Considering subacute subjects (time since stroke < 6 months), there was a trend for a larger proportion of improved patients in the M-TOT group following rehabilitation (57.9%) than in the C-TOT group (33.2%) (difference in proportion improved 24.7%; 95% CI -4.0; 48.6), though the study did not meet the planned sample size.

Conclusion

This is the first large multicentre RCT to compare MeCFES assisted TOT with conventional care TOT for the upper extremity. No adverse events or negative outcomes were encountered, thus we conclude that MeCFES can be a safe adjunct to rehabilitation that could promote recovery of upper limb function in persons after stroke, particularly when applied in the subacute phase.

How a diverse research ecosystem has generated new rehabilitation technologies: Review of NIDILRR's Rehabilitation Engineering Research Centers

Over 50 million United States citizens (1 in 6 people in the US) have a developmental, acquired, or degenerative disability. The average US citizen can expect to live 20% of his or her life with a disability. Rehabilitation technologies play a major role in improving the quality of life for people with a disability, yet widespread and highly challenging needs remain. Within the US, a major effort aimed at the creation and evaluation of rehabilitation technology has been the Rehabilitation Engineering Research Centers (RERCs) sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. As envisioned at their conception by a panel of the National Academy of Science in 1970, these centers were intended to take a "total approach to rehabilitation", combining medicine, engineering, and related science, to improve the quality of life of individuals with a disability. Here, we review the scope, achievements, and ongoing projects of an unbiased sample of 19 currently active or recently terminated RERCs. Specifically, for each center, we briefly explain the needs it targets, summarize key historical advances, identify emerging innovations, and consider future directions. Our assessment from this review is that the RERC program indeed involves a multidisciplinary approach, with 36 professional fields involved, although 70% of research and development staff are in engineering fields, 23% in clinical fields, and only 7% in basic science fields; significantly, 11% of the professional staff have a disability related to their research. We observe that the RERC program has substantially diversified the scope of its work since the 1970's, addressing more types of disabilities using more technologies, and, in particular, often now focusing on information technologies. RERC work also now often views users as integrated into an interdependent society through technologies that both people with and without disabilities co-use (such as the internet, wireless communication, and architecture). In addition, RERC research has evolved to view users as able at improving outcomes through learning, exercise, and plasticity (rather than being static), which can be optimally timed. We provide examples of rehabilitation technology innovation produced by the RERCs that illustrate this increasingly diversifying scope and evolving perspective. We conclude by discussing growth opportunities and possible future directions of the RERC program.

Different effects of running wheel exercise and skilled reaching training on corticofugal tract plasticity in hypertensive rats with cortical infarctions

The approaches that facilitate white matter plasticity may prompt functional recovery after a stroke. The effects of different exercise methods on motor recovery in stroke rats have been investigated. However, it is not clear whether their effects on axonal plasticity different. The aim of this study was to compare the effects of the forced running wheel exercise (RWE) and skilled reaching training (SRT) on axonal plasticity and motor recovery. Cortical infarctions were generated in stroke-prone renovascular hypertensive rats. The rats were randomly divided into the following three groups: the control (Con) group, the RWE group, and the SRT group. A sham group was also included. The mNSS and forelimb grip strength tests were performed on days 3, 7, 14, 21, 28, 35, and 42 after ischemia. The anterograde tract tracer biotinylated dextran amine (BDA) was injected into the rats to trace the axonal plasticity of the contralesional corticofugal tracts. Compared with the Con group, the mNSS scores in the SRT and RWE groups decreased on day 28 (P<0.05) and on days 35 and 42 (P<0.01). The grip strength in the SRT group increased relative to that in the RWE group at 42day post-ischemia (P<0.01). Both the RWE and SRT groups exhibited enhanced plasticity of the contralesional corticofugal tract axons at the level of the red nucleus (P<0.01) and the cervical enlargement (P<0.01). More contralateral corticorubral tract remodeling was observed at the red nucleus level in the SRT group than in the RWE group (P<0.001). Taken together, these results suggest that SRT may enhance axon plasticity in the corticorubral tract more effectively than the forced RWE and is associated with better motor recovery after cerebral ischemia.

AExaCTT - Aerobic Exercise and Consecutive Task-specific Training for the upper limb after stroke: Protocol for a randomised controlled pilot study

Motor function may be enhanced if aerobic exercise is paired with motor training. One potential mechanism is that aerobic exercise increases levels of brain-derived neurotrophic factor (BDNF), which is important in neuroplasticity and involved in motor learning and motor memory consolidation. This study will examine the feasibility of a parallel-group assessor-blinded randomised controlled trial investigating whether task-specific training preceded by aerobic exercise improves upper limb function more than task-specific training alone, and determine the effect size of changes in primary outcome measures. People with upper limb motor dysfunction after stroke will be allocated to either task-specific training or aerobic exercise and consecutive task-specific training. Both groups will perform 60 hours of task-specific training over 10 weeks, comprised of 3 × 1 hour sessions per week with a therapist and 3 × 1 hours of home-based self-practice per week. The combined intervention group will also perform 30 minutes of aerobic exercise (70-85%HRmax) immediately prior to the 1 hour of task-specific training with the therapist. Recruitment, adherence, retention, participant acceptability, and adverse events will be recorded. Clinical outcome measures will be performed pre-randomisation at baseline, at completion of the training program, and at 1 and 6 months follow-up. Primary clinical outcome measures will be the Action Research Arm Test (ARAT) and the Wolf Motor Function Test (WMFT). If aerobic exercise prior to task-specific training is acceptable, and a future phase 3 randomised controlled trial seems feasible, it should be pursued to determine the efficacy of this combined intervention for people after stroke.

Combining Dopaminergic Facilitation with Robot-Assisted Upper Limb Therapy in Stroke Survivors: A Focused Review

Despite aggressive conventional therapy, lasting hemiplegia persists in a large percentage of stroke survivors. The aim of this article is to critically review the rationale behind targeting multiple sites along the motor learning network by combining robotic therapy with pharmacotherapy and virtual reality–based reward learning to alleviate upper extremity impairment in stroke survivors. Methods for personalizing pharmacologic facilitation to each individual’s unique biology are also reviewed. At the molecular level, treatment with levodopa was shown to induce long-term potentiation-like and practice-dependent plasticity. Clinically, trials combining conventional therapy with levodopa in stroke survivors yielded statistically significant but clinically unconvincing outcomes because of limited personalization, standardization, and reproducibility. Robotic therapy can induce neuroplasticity by delivering intensive, reproducible, and functionally meaningful interventions that are objective enough for the rigors of research. Robotic therapy also provides an apt platform for virtual reality, which boosts learning by engaging reward circuits. The future of stroke rehabilitation should target distinct molecular, synaptic, and cortical sites through personalized multimodal treatments to maximize motor recovery.

Counting Grasping Action Using Force Myography: An Exploratory Study With Healthy Individuals

Background

Functional arm movements generally require grasping an object. The possibility of detecting and counting the action of grasping is believed to be of importance for individual with motor function deficits of the arm, as it could be an indication of the number of the functional arm movements performed by the individuals during rehabilitation. In this exploratory work, the feasibility of using armbands recording radial displacements of forearm muscles and tendons (ie, force myography, FMG) to estimate hand grasping with healthy individuals was investigated. In contrast to previous studies, this exploratory study investigates the feasibility of (1) detecting grasping when the participants move their arms, which could introduce large artifacts to the point of potentially preventing the practical use of the proposed technology, and (2) counting grasping during arm-reaching tasks.

Objective

The aim of this study was to determine the usefulness of FMG in the detection of functional arm movements. The use of FMG straps placed on the forearm is proposed for counting the number of grasping actions in the presence of arm movements.

Methods

Ten healthy volunteers participated in this study to perform a pick-and-place exercise after providing informed consent. FMG signals were simultaneously collected using 2 FMG straps worn on their wrist and at the midposition of their forearm, respectively. Raw FMG signals and 3 additional FMG features (ie, root mean square, wavelength, and window symmetry) were extracted and fed into a linear discriminant analysis classifier to predict grasping states. The transition from nongrasping to grasping states was detected during the process of counting the number of grasping actions.

Results

The median accuracy for detecting grasping events using FMG recorded from the wrist was 95%, and the corresponding interquartile range (IQR) was 5%. For forearm FMG classification, the median accuracy was 92%, and the corresponding IQR was 3%. The difference between the 2 median accuracies was statistically significant (P<.001) when using a paired 2-tailed sign test. The median percentage error for counting grasping events when FMG was recorded from the wrist was 1%, and the corresponding IQR was 2%. The median percentage error for FMG recorded from the forearm was 2%, and the corresponding IQR was also 2%. While the median percentage error for the wrist was lower than that of the forearm, the difference between the 2 was not statistically significant based on a paired 2-tailed sign test (P=.29).

Conclusions

This study reports that grasping can reliably be counted using an unobtrusive and simple FMG strap even in the presence of arm movements. Such a result supports the foundation for future research evaluating the feasibility of monitoring hand grasping during unsupervised ADL, leading to further investigations with individuals with motor function deficits of the arm.

Robot-assisted gait training for stroke patients: current state of the art and perspectives of robotics

In this review, we give a brief outline of robot-mediated gait training for stroke patients, as an important emerging field in rehabilitation. Technological innovations are allowing rehabilitation to move toward more integrated processes, with improved efficiency and less long-term impairments. In particular, robot-mediated neurorehabilitation is a rapidly advancing field, which uses robotic systems to define new methods for treating neurological injuries, especially stroke. The use of robots in gait training can enhance rehabilitation, but it needs to be used according to well-defined neuroscientific principles. The field of robot-mediated neurorehabilitation brings challenges to both bioengineering and clinical practice. This article reviews the state of the art (including commercially available systems) and perspectives of robotics in poststroke rehabilitation for walking recovery. A critical revision, including the problems at stake regarding robotic clinical use, is also presented.

Effects of skilled reach training with affected forelimb and treadmill exercise on the expression of neurotrophic factor following ischemia-induced brain injury in rats

[Purpose] The aim of the present study was to investigate effects of skilled reach training with affected forelimb and treadmill exercise on the expression of neurotrophic factor following ischemia-induced brain injury in rats. [Subjects and Methods] Thirty male Sprague-Dawley rats were divided into 3 groups randomly: namely, the control sacrified 2 weeks after surgery, skilled reach training with forepaw contralateral to brain injury for 2 weeks, and treadmill exercise for 2 weeks. Transient focal cerebral ischemia was induced by intraluminal occlusion of the left middle cerebral artery. After that, skilled reach training and treadmill exercise were conducted. Western blot analysis was performed to investigate expressions of neurotrophic factors. [Results] There were significant differences in brain-derived neurotrophic factor and nerve growth factor expression between the control group and the experimental group. There were no significant differences in brain-derived neurotrophic factor and nerve growth factor expression between the skilled reach training group and the treadmill exercise group. [Conclusion] Skilled reach training and treadmill exercise can affect the expression of neurotrophic factors.

A training approach to improve stepping automaticity while dual-tasking in Parkinson's disease: A prospective pilot study

BACKGROUND

Deficits in motor movement automaticity in Parkinson's disease (PD), especially during multitasking, are early and consistent hallmarks of cognitive function decline, which increases fall risk and reduces quality of life. This study aimed to test the feasibility and potential efficacy of a wearable sensor-enabled technological platform designed for an in-home music-contingent stepping-in-place (SIP) training program to improve step automaticity during dual-tasking (DT).

METHODS

This was a 4-week prospective intervention pilot study. The intervention uses a sensor system and algorithm that runs off the iPod Touch which calculates step height (SH) in real-time. These measurements were then used to trigger auditory (treatment group, music; control group, radio podcast) playback in real-time through wireless headphones upon maintenance of repeated large amplitude stepping. With small steps or shuffling, auditory playback stops, thus allowing participants to use anticipatory motor control to regain positive feedback. Eleven participants were recruited from an ongoing trial (Trial Number: ISRCTN06023392). Fear of falling (FES-I), general cognitive functioning (MoCA), self-reported freezing of gait (FOG-Q), and DT step automaticity were evaluated.

RESULTS

While we found no significant effect of training on FES-I, MoCA, or FOG-Q, we did observe a significant group (music vs podcast) by training interaction in DT step automaticity (P<0.01).

CONCLUSION

Wearable device technology can be used to enable musically-contingent SIP training to increase motor automaticity for people living with PD. The training approach described here can be implemented at home to meet the growing demand for self-management of symptoms by patients.

Effect of task-specific training on Eph/ephrin expression after stroke

Recent evidence indicates that the ephrin receptors and ephrin ligands (Eph/ephrin) expression modulate axonal reorganization and synaptic plasticity in stroke recovery. To investigate the effect of task-specific training (TST) on Eph/ephrin expression in the corticospinal tract (CST) after stroke, we compared Eph/ephrin expression in the peri-infarct cortex, pyramid, and spinal cord of a photothrombotic stroke model of rat brains treated with or without TST. The TST treatment showed significantly better recovery in the behavioral tests compared with no treatment. The significant upregulation of ephrin-A1 and ephrin-A5 observed in activated astrocytes of the CST at 2 weeks’ post-stroke was decreased by TST. At 5 weeks, post-stroke, the elevated ephrin-A5 levels were decreased in the ipsilateral pyramid and spinal cord by TST. Glial fibrillary acidic protein was upregulated concomitantly with the altered ephrin expression after stroke, and the expression of these proteins was attenuated by TST. These data suggest that TST alters the expression of ephrin ligands in the CST after stroke.

Effect of task-oriented training and high-variability practice on gross motor performance and activities of daily living in children with spastic diplegia

[Purpose] This study investigates how a task-oriented training and high-variability practice program can affect the gross motor performance and activities of daily living for children with spastic diplegia and provides an effective and reliable clinical database for future improvement of motor performances skills. [Subjects and Methods] This study randomly assigned seven children with spastic diplegia to each intervention group including that of a control group, task-oriented training group, and a high-variability practice group. The control group only received neurodevelopmental treatment for 40 minutes, while the other two intervention groups additionally implemented a task-oriented training and high-variability practice program for 8 weeks (twice a week, 60 min per session). To compare intra and inter-relationships of the three intervention groups, this study measured gross motor performance measure (GMPM) and functional independence measure for children (WeeFIM) before and after 8 weeks of training. [Results] There were statistically significant differences in the amount of change before and after the training among the three intervention groups for the gross motor performance measure and functional independence measure. [Conclusion] Applying high-variability practice in a task-oriented training course may be considered an efficient intervention method to improve motor performance skills that can tune to movement necessary for daily livelihood through motor experience and learning of new skills as well as change of tasks learned in a complex environment or similar situations to high-variability practice.

Intensive cycle ergometer training improves gait speed and endurance in patients with Parkinson's disease: A comparison with treadmill training

PURPOSE

Cycle ergometer training improves gait in the elderly, but its effect in patients with Parkinson's disease (PD) is not completely known.

METHODS

Twenty-nine PD inpatients were randomized to treadmill (n = 13, PD-T) or cycle ergometer (n = 16, PD-C) training for 3 weeks, 1 hour/day. Outcome measures were distance travelled during the 6-min walking test (6MWT), spatio-temporal variables of gait assessed by baropodometry, the Timed Up and Go (TUG) duration, the balance score through the Mini-BESTest, and the score of the Unified Parkinson's Disease Rating Scale (UPDRS).

RESULTS

Sex, age, body mass index, disease duration, Hoehn-Yahr staging, comorbidity and medication did not differ between groups. At end of training, ANCOVA showed significant improvement, of similar degree, in both groups for 6MWT, speed, step length and cadence of gait, TUG, Mini-BESTest and UPDRS.

CONCLUSIONS

This pilot study shows that cycle ergometer training improves walking parameters and reduces clinical signs of PD, as much as treadmill training does. Gait velocity is accompanied by step lengthening, making the gait pattern close to that of healthy subjects. Cycle ergometer is a valid alternative to treadmill for improving gait in short term in patients with PD.

Home Exercise Programs for Adults With Neurological Injuries: A Survey

OBJECTIVE

The purpose of this study was to describe current occupational therapy practices in the usage and prescription of and clinical reasoning process supporting home exercise programs (HEPs) for clients with neurological injuries (CWNIs).

METHOD

A survey was distributed via mail to 2,000 members of the American Occupational Therapy Association. The survey questions concerned basic demographics, current HEP practices, and attitudes toward using HEPs with CWNIs.

RESULTS

In the 360 returned surveys, occupational therapists reported numerous benefits of using HEPs and were able to clearly articulate their clinical reasoning. Commonly reported HEP activities were preparatory in nature, and the most frequently prescribed dosage was 16-30 min daily. Most therapists relied on the same clinical reasoning process but varied in implementation methods.

CONCLUSION

This study's results highlight the gaps between evidence and practice. The active ingredients in HEPs for CWNIs need to be more clearly defined and described.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Towards compliant and wearable robotic orthoses: A review of current and emerging actuator technologies

Robotic orthoses, or exoskeletons, have the potential to provide effective rehabilitation while overcoming the availability and cost constraints of therapists. However, current orthosis actuation systems use components designed for industrial applications, not specifically for interacting with humans. This can limit orthoses' capabilities and, if their users' needs are not adequately considered, contribute to their abandonment. Here, a user centered review is presented on: requirements for orthosis actuators; the electric, hydraulic, and pneumatic actuators currently used in orthoses and their advantages and limitations; the potential of new actuator technologies, including smart materials, to actuate orthoses; and the future of orthosis actuator research.

Assistive Control System for Upper Limb Rehabilitation Robot

This paper presents an assistive control system with a special kinematic structure of an upper limb rehabilitation robot embedded with force/torque sensors. A dynamic human model integrated with sensing torque is used to simulate human interaction under three rehabilitation modes: active mode, assistive mode, and passive mode. The hereby proposed rehabilitation robot, called NTUH-ARM, provides 7 degree-of- freedom (DOF) motion and runs subject to an inherent mapping between the 7 DOFs of the robot arm and the 4 DOFs of the human arm. The Lyapunov theory is used to analyze the stability of the proposed controller design. Clinical trials have been conducted with six patients, one of which acts as a control. The results of these experiments are positive and STREAM assessment by physical therapists also reveals promising results.

Functional strength training and movement performance therapy produce analogous improvement in sit-to-stand early after stroke: early-phase randomised controlled trial

OBJECTIVES

Restoring independence in the sit-to-stand (STS) task is an important objective for stroke rehabilitation. It is not known if a particular intervention, strength training or therapy focused on movement performance is more likely to improve STS recovery. This study aimed to compare STS outcomes from functional strength training, movement performance therapy and conventional therapy.

DESIGN

Randomised controlled trial.

SETTING

Acute stroke units.

PARTICIPANTS

Medically well patients (n=93) with recent (<42 days) stroke. The mean age of patients was 68.8 years, mean time post ictus was 33.5 days, 54 (58%) were male, 20 showed neglect (22%) and 37 (40%) had a left-sided brain lesion.

INTERVENTIONS

Six weeks of either conventional therapy, functional strength training or movement performance therapy. Subjects were allocated to groups on a random basis.

MAIN OUTCOME MEASURES

STS ability, timing, symmetry, co-ordination, smoothness and knee velocity were measured at baseline, outcome (after 6 weeks of intervention) and follow-up (3 months after outcome).

RESULTS

No significant differences were found between the groups. All three groups improved their STS ability, with 88% able to STS at follow-up compared with 56% at baseline. Few differences were noted in quality of movement, with only symmetry when rising showing significantly greater improvement in the movement performance therapy group; this benefit was not evident at follow-up.

CONCLUSIONS

Recovery of the STS movement is consistently good during stroke rehabilitation, irrespective of the type of therapy experienced. Changes in quality of movement did not differ according to group allocation, indicating that the type of therapy is less important. Clinical trial registration number NCT00322192.

Partial body weight support treadmill training speed influences paretic and non-paretic leg muscle activation, stride characteristics, and ratings of perceived exertion during acute stroke rehabilitation

BACKGROUND

Intensive task-specific training is promoted as one approach for facilitating neural plastic brain changes and associated motor behavior gains following neurologic injury. Partial body weight support treadmill training (PBWSTT), is one task-specific approach frequently used to improve walking during the acute period of stroke recovery (<1month post infarct). However, only limited data have been published regarding the relationship between training parameters and physiologic demands during this early recovery phase.

OBJECTIVE

To examine the impact of four walking speeds on stride characteristics, lower extremity muscle demands (both paretic and non-paretic), Borg ratings of perceived exertion (RPE), and blood pressure.

DESIGN

A prospective, repeated measures design was used.

METHODS

Ten inpatients post unilateral stroke participated. Following three familiarization sessions, participants engaged in PBWSTT at four predetermined speeds (0.5, 1.0, 1.5 and 2.0mph) while bilateral electromyographic and stride characteristic data were recorded. RPE was evaluated immediately following each trial.

RESULTS

Stride length, cadence, and paretic single limb support increased with faster walking speeds (p⩽0.001), while non-paretic single limb support remained nearly constant. Faster walking resulted in greater peak and mean muscle activation in the paretic medial hamstrings, vastus lateralis and medial gastrocnemius, and non-paretic medial gastrocnemius (p⩽0.001). RPE also was greatest at the fastest compared to two slowest speeds (p<0.05).

CONCLUSIONS

During the acute phase of stroke recovery, PBWSTT at the fastest speed (2.0mph) promoted practice of a more optimal gait pattern with greater intensity of effort as evidenced by the longer stride length, increased between-limb symmetry, greater muscle activation, and higher RPE compared to training at the slowest speeds.

Neurologic Music Therapy Training for Mobility and Stability Rehabilitation with Parkinson's Disease - A Pilot Study

Idiopathic Parkinson's Disease (PD) is a progressive condition with gait disturbance and balance disorder as the main symptoms. Previous research studies focused on the application of Rhythmic Auditory Stimulation (RAS) in PD gait rehabilitation. The key hypothesis of this pilot study, however, assumes the major role of the combination of all three Neurologic Music Therapy (NMT) sensorimotor techniques in improving spatio-temporal gait parameters, and postural stability in the course of PD. The 55 PD-diagnosed subjects invited to the study were divided into two groups: 30 in the experimental and 25 in the control group. Inclusion criteria included Hoehn and Yahr stages 2 or 3, the ability to walk independently without any aid and stable pharmacological treatment for the duration of the experiment. In order to evaluate the efficacy of the chosen therapy procedure the following measures were applied: Optoelectrical 3D Movement Analysis, System BTS Smart for gait, and Computerized Dynamic Posturography CQ Stab for stability and balance. All measures were conducted both before and after the therapy cycle. The subjects from the experimental group attended music therapy sessions four times a week for 4 weeks. Therapeutic Instrumental Music Performance (TIMP), Pattern Sensory Enhancement (PSE) and RAS were used in every 45-min session for practicing daily life activities, balance, pre-gait, and gait pattern. Percussion instruments, the metronome and rhythmic music were the basis for each session. The subjects from the control group were asked to stay active and perform daily life activities between the measures. The research showed that the combination of the three NMT sensorimotor techniques can be used to improve gait and other rhythmical activities in PD rehabilitation. The results demonstrated significant improvement in the majority of the spatiotemporal gait parameters in the experimental group in comparison to the control group. In the stability tests with eyes closed, substantial differences were revealed, indicating improvement of proprioception (the sense of body position and movement). These findings suggest a new compensatory strategy for movement and postural control through the use of the auditory system.

Forced Aerobic Exercise Enhances Motor Recovery After Stroke: A Case Report

OBJECTIVE

Previously, we demonstrated that forced aerobic exercise (FE) increases the pattern of neural activation in Parkinson's disease. We sought to evaluate whether FE, when coupled with repetitive task practice, could promote motor recovery poststroke.

METHOD

A 46-yr-old man with ischemic stroke exhibited chronic residual upper-extremity deficits, scoring 35/66 on the Fugl-Meyer Assessment (FMA) at baseline. He completed 24 training sessions comprising 45 min of FE on a motorized stationary bicycle followed by 45 min of upper-extremity repetitive task practice.

RESULTS

From baseline to end of treatment, the FMA score improved by 20 points, perceived level of recovery on the Stroke Impact Scale increased by 20 percentage points, and cardiovascular function measured by peak oxygen uptake improved 30%. These improvements persisted 4 wk after the intervention ceased.

CONCLUSION

FE may be a safe and feasible rehabilitation approach to augment recovery of motor and nonmotor function while improving aerobic fitness in people with chronic stroke.

Motor planning poststroke: impairment in vector-coded reach plans

Healthy individuals appear to use both vector‐coded reach plans that encode movements in terms of their desired direction and extent, and target‐coded reach plans that encode the desired endpoint position of the effector. We examined whether these vector and target reach‐planning codes are differentially affected after stroke. Participants with stroke and healthy controls made blocks of reaches that were grouped by target location (providing target‐specific practice) and by movement vector (providing vector‐specific practice). Reach accuracy was impaired in the more affected arm after stroke, but not distinguishable for target‐ versus vector‐grouped reaches. Reach velocity and acceleration were not only impaired in both the less and more affected arms poststroke, but also not distinguishable for target‐ versus vector‐grouped reaches. As previously reported in controls, target‐grouped reaches yielded isotropic (circular) error distributions and vector‐grouped reaches yielded error distributions elongated in the direction of the reach. In stroke, the pattern of variability was similar. However, the more affected arm showed less elongated error ellipses for vector‐grouped reaches compared to the less affected arm, particularly in individuals with right‐hemispheric stroke. The results suggest greater impairment to the vector‐coded movement‐planning system after stroke, and have implications for the development of personalized approaches to poststroke rehabilitation: Motor learning may be enhanced by practice that uses the preserved code or, conversely, by retraining the more impaired code to restore function.

Two is More Than One: How to Combine Brain Stimulation Rehabilitative Training for Functional Recovery?

A number of studies have shown that non-invasive brain stimulation has an additional effect in combination with rehabilitative therapy to enhance functional recovery than either therapy alone. The combination enhances use-dependent plasticity induced by repetitive training. The neurophysiological mechanism of the effects of this combination is based on associative plasticity. However, these effects were not reported in all cases. We propose a list of possible strategies to achieve an effective association between rehabilitative training with brain stimulation for plasticity: (1) control of temporal aspect between stimulation and task execution; (2) the use of a shaped task for the combination; (3) the appropriate stimulation of neuronal circuits where use-dependent plastic changes occur; and (4) phase synchronization between rhythmically patterned brain stimulation and task-related patterned activities of neurons. To better utilize brain stimulation in neuro-rehabilitation, it is important to develop more effective techniques to combine them.

Effects of a wearable exoskeleton stride management assist system (SMA®) on spatiotemporal gait characteristics in individuals after stroke: a randomized controlled trial

Background

Robots offer an alternative, potentially advantageous method of providing repetitive, high-dosage, and high-intensity training to address the gait impairments caused by stroke. In this study, we compared the effects of the Stride Management Assist (SMA®) System, a new wearable robotic device developed by Honda R&D Corporation, Japan, with functional task specific training (FTST) on spatiotemporal gait parameters in stroke survivors.

Methods

A single blinded randomized control trial was performed to assess the effect of FTST and task-specific walking training with the SMA® device on spatiotemporal gait parameters. Participants (n = 50) were randomly assigned to FTST or SMA. Subjects in both groups received training 3 times per week for 6–8 weeks for a maximum of 18 training sessions. The GAITRite® system was used to collect data on subjects’ spatiotemporal gait characteristics before training (baseline), at mid-training, post-training, and at a 3-month follow-up.

Results

After training, significant improvements in gait parameters were observed in both training groups compared to baseline, including an increase in velocity and cadence, a decrease in swing time on the impaired side, a decrease in double support time, an increase in stride length on impaired and non-impaired sides, and an increase in step length on impaired and non-impaired sides. No significant differences were observed between training groups; except for SMA group, step length on the impaired side increased significantly during self-selected walking speed trials and spatial asymmetry decreased significantly during fast-velocity walking trials.

Conclusions

SMA and FTST interventions provided similar, significant improvements in spatiotemporal gait parameters; however, the SMA group showed additional improvements across more parameters at various time points. These results indicate that the SMA® device could be a useful therapeutic tool to improve spatiotemporal parameters and contribute to improved functional mobility in stroke survivors. Further research is needed to determine the feasibility of using this device in a home setting vs a clinic setting, and whether such home use provides continued benefits.

Trial registration

This study is registered under the title “Development of walk assist device to improve community ambulation” and can be located in clinicaltrials.gov with the study identifier: NCT01994395.

Robotic therapy for chronic stroke: general recovery of impairment or improved task-specific skill?

There is a great need to develop new approaches for rehabilitation of the upper limb after stroke. Robotic therapy is a promising form of neurorehabilitation that can be delivered in higher doses than conventional therapy. Here we sought to determine whether the reported effects of robotic therapy, which have been based on clinical measures of impairment and function, are accompanied by improved motor control. Patients with chronic hemiparesis were trained for 3 wk, 3 days a week, with titrated assistive robotic therapy in two and three dimensions. Motor control improvements (i.e., skill) in both arms were assessed with a separate untrained visually guided reaching task. We devised a novel PCA-based analysis of arm trajectories that is sensitive to changes in the quality of entire movement trajectories without needing to prespecify particular kinematic features. Robotic therapy led to skill improvements in the contralesional arm. These changes were not accompanied by changes in clinical measures of impairment or function. There are two possible interpretations of these results. One is that robotic therapy only leads to small task-specific improvements in motor control via normal skill-learning mechanisms. The other is that kinematic assays are more sensitive than clinical measures to a small general improvement in motor control.

Task-Based Mirror Therapy Augmenting Motor Recovery in Poststroke Hemiparesis: A Randomized Controlled Trial

BACKGROUND

To establish the effect of the task-based mirror therapy (TBMT) on the upper limb recovery in stroke.

METHODS

A pilot, randomized, controlled, assessor-blinded trial was conducted in a rehabilitation institute. A convenience sample of 33 poststroke (mean duration, 12.5 months) hemiparetic subjects was randomized into 2 groups (experimental, 17; control, 16). The subjects were allocated to receive either TBMT or standard motor rehabilitation-40 sessions (5/week) for a period of 8 weeks. The TBMT group received movements using various goal-directed tasks and a mirror box. The movements were performed by the less-affected side superimposed on the affected side. The main outcome measures were Brunnstrom recovery stage (BRS) and Fugl-Meyer assessment (FMA)-FMA of upper extremity (FMA-UE), including upper arm (FMA-UA) and wrist-hand (FMA-WH).

RESULTS

The TBMT group exhibited highly significant improvement on mean scores of FMA-WH (P < .001) and FMA-UE (P < .001) at postassessment in comparison to the control group. Furthermore, there was a 12% increase in the number of subjects at BRS stage 5 (out of synergy movement) in the experimental group as compared to a 0% rise at the same stage in the control group.

CONCLUSIONS

This pilot trial confirmed the role of TBMT in improving the wrist-hand motor recovery in poststroke hemiparesis. MT using tasks may be used as an adjunct in stroke rehabilitation.

Design and control of an active 1-DoF mechanism for knee rehabilitation

A 1-DoF robot is designed and fabricated to be used for knee rehabilitation training. The mechanism (robot) is designed to perform specific set of exercises while the patient is sitting on a chair. The therapy process for patients has different stages; each stage consists of specific exercises to recover the knee to its condition before injury. The maximum torque of healthy joint during the extension/flexion exercise is evaluated by simulation and suitable actuator is selected based on the results. A prototype is then fabricated as a platform to evaluate the design and control concepts. The experiment procedure consisting of three stages of therapy indicates good tracking performance and safe operation of the system. Implication for Rehabilitation A 1-DoF mechanism for knee rehabilitation has been designed to perform three stages of therapy: passive, active assist and active resist. The assistive and resistive torque, during active assist and active resist stages, can be set according to the progress in therapy. The results of this study suggest the system has the potential to result in various benefits including reduction of physical workload of physiotherapists and improved repeatability.

Task Selection and Enriched Environments: A Functional Upper Extremity Training Program for Stroke Survivors

Functional tasks using real-life objects in an enriched environment provide a multidimensional approach to treatment. Functional tasks are therapeutic for stroke survivors, because they require the simultaneous use of motor control, cognition, visual perception, sensation, and motor planning. Therapists utilizing functional tasks as treatment modalities must also be multidimensional in their implementation. This article provides a systematic approach to guide therapists in developing a functional upper extremity training program for stroke survivors.

A review of technological and clinical aspects of robot-aided rehabilitation of upper-extremity after stroke

Cerebrovascular accident (CVA) or stroke is one of the leading causes of disability and loss of motor function. Millions of people around the world are effected by it each year. Stroke results in disabled arm function. Restoration of arm function is essential to regaining activities of daily living (ADL). Along with traditional rehabilitation methods, robot-aided therapy has emerged in recent years. Robot-aided rehabilitation is more intensive, of longer duration and more repetitive. Using robots, repetitive dull exercises can turn into a more challenging and motivating tasks such as games. Besides, robots can provide a quantitative measure of the rehabilitation progress. This article overviews the terms used in robot-aided upper-limb rehabilitation. It continues by investigating the requirements for rehabilitation robots. Then the most outstanding works in robot-aided upper-limb rehabilitation and their control schemes have been investigated. The clinical outcomes of the built robots are also given that demonstrates the usability of these robots in real-life applications and their acceptance. This article summarizes a review done along with a research on the design, simulation and control of a robot for use in upper-limb rehabilitation after stroke. Implications for Rehabilitation Reviewing common terms in rehabilitation of upper limb using robots Reviewing rehabilitation robots built up to date Reviewing clinical outcomes of the mentioned rehabilitation robots.

Use of Accelerometer-Based Feedback of Walking Activity for Appraising Progress With Walking-Related Goals in Inpatient Stroke Rehabilitation: A Randomized Controlled Trial

BACKGROUND

Regaining independent ambulation is important to those with stroke. Increased walking practice during "down time" in rehabilitation could improve walking function for individuals with stroke.

OBJECTIVE

To determine the effect of providing physiotherapists with accelerometer-based feedback on patient activity and walking-related goals during inpatient stroke rehabilitation.

METHODS

Participants with stroke wore accelerometers around both ankles every weekday during inpatient rehabilitation. Participants were randomly assigned to receive daily feedback about walking activity via their physiotherapists (n = 29) or to receive no feedback (n = 28). Changes in measures of daily walking (walking time, number of steps, average cadence, longest bout duration, and number of "long" walking bouts) and changes in gait control and function assessed in-laboratory were compared between groups.

RESULTS

There was no significant increase in walking time, number of steps, longest bout duration, or number of long walking bouts for the feedback group compared with the control group (P values > .20). However, individuals who received feedback significantly increased cadence of daily walking more than the control group (P = .013). From the in-laboratory gait assessment, individuals who received feedback had a greater increase in walking speed and decrease in step time variability than the control group (P values < .030).

CONCLUSION

Feedback did not increase the amount of walking completed by individuals with stroke. However, there was a significant increase in cadence, indicating that intensity of daily walking was greater for those who received feedback than the control group. Additionally, more intense daily walking activity appeared to translate to greater improvements in walking speed.

The promotion of recovery through rehabilitation after acquired brain injury in children

A degree of motor recovery is typically seen after acquired brain injury in children. The extent to which rehabilitation efforts can claim credit for this is disputed. Strong correlations between late impairment outcomes and early severity and impairment indices are seen both in adults and children. These correlations have been interpreted by some as evidence that recovery is largely intrinsic and that any additional rehabilitation effects are small. Such views are belied by published animal studies demonstrating the possibility of large rehabilitation effects. Animal models suggest that to achieve similar rehabilitation treatment effect sizes in clinical practice, rehabilitation 'doses' should be greater, rehabilitation efforts should start sooner, and premature accommodation of impairment should be avoided.

Functional Mobility Training for Individuals Admitted to Acute Care Following a Stroke: A Prospective Study

PURPOSE

This study describes current stroke care within hospital acute care settings.

METHOD

Twenty-two acute care hospital sites in Central South Ontario were mailed a survey exploring the prevalence of stroke admissions, use of protocols and policies, staff resources, stroke-specific training, and available equipment. Corresponding site data from the Canadian Institute for Health Information were also analyzed.

RESULTS

An 82% survey response rate was obtained. In 2003-2004, stroke admissions represented 1.9% of total admissions, with a mean admitting resource intensity weight of 1.99. Average length of stay was 12.5 days, with 3.4 of these days designated awaiting an alternate level of care. One third of the sites reported that they had no written guidelines on how to position or mobilize individuals following a stroke, and very few of the sites reported providing stroke-specific education.

CONCLUSION

The lack of a consistent coordinated approach to early mobilization and physical care for individuals admitted to an acute care setting following a stroke necessitates that new opportunities to coordinate educational resources and services to promote evidence-based practice in acute stroke care be pursued.