Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage

Application of Robotic Recovery Techniques to Stroke Survivors-Bibliometric Analysis

Stroke is a significant disability and death cause worldwide and is conventionally defined as a neurological impairment relating to the intense focal harm of the central nervous system (CNS) by vascular causative components. Although the applicability of robotic rehabilitation is a topic with considerable practical significance because it has produced noticeably higher improvements in motor function than regular (physical and occupational) therapy and exempted the therapists, most of the existing bibliometric papers were not focused on stroke survivors. Additionally, a modular system is designed by joining several medical end-effector devices to a single limb segment, which addresses the issue of potentially dangerous pathological compensatory motions. Searching the Web of Science database, 31,930 papers were identified, and using the VOSviewer software and science mapping technology, data were extracted on the most prolific countries, the connections between them, the most valuable journals according to certain factors, their average year of publication, the most influential papers, and the most relevant topical issues (bubble map of term occurrence). The most prolific country in the analyzed field and over the entire period evaluated (1975-2022) is the United States, and the most prolific journal is Neurorehabilitation and Neural Repair, observing a marked increase in the three periods of scientific interest for this field. The present paper assesses numerous scientific publications to provide, through statistical interpretation of the data, a detailed description of the use of robotic rehabilitation in stroke survivors. The findings may aid scientists, academics, and clinicians in establishing precise goals in the optimization of the management of stroke survivors via robotic rehabilitation, but also through easier access to scientifically validated literature.

Systematic review on post-stroke computerized cognitive training: Unveiling the impact of confounding factors

Background

Stroke is a highly incapacitating disease that can lead to disabilities due to cognitive impairment, physical, emotional, and social sequelae, and a decrease in the quality of life of those affected. Moreover, it has been suggested that cognitive reserve (patients' higher levels of education or having a skilled occupation), for instance, can promote faster cognitive recovery after a stroke. For this reason, this review aims to identify the cognitive, functional, and behavioral effects of computerized rehabilitation in patients aged 50 years or older who had a stroke, considering cognitive reserve proxies.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-PRISMA, and performed the search for peer-reviewed randomized controlled trials without a date restriction on CINAHL, LILACS, PubMed, Scopus, and Web of Science databases were chosen.

Results

We screened 780 papers and found 19 intervention studies, but only 4 met the inclusion criteria and shared data. These studies included computerized tools for motor and cognitive rehabilitation in the experimental groups. In all studies, computerized training was combined with other interventions, such as standard therapy, occupational therapy, and aerobic exercises. There were 104 participants affected by ischemic or hemorrhagic stroke, predominantly male (57.69%), and all with cognitive impairment.

Conclusion

Despite a limited number of studies, varied methods and insufficient information available, schooling as a CR proxy combined with high-intensity computerized cognitive training was key to mediating cognitive improvement. The systematic review also identified that the associated ischemic stroke and shorter time of onset for rehabilitation contribute to the cognitive evolution of patients. Findings do not support a greater benefit of computerized cognitive training compared to conventional cognitive therapies.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=296193], identifier [CRD42022296193].

Reading: From the Simple to the Complex

The aim of this article was to present an important perspective on reading skill development. The perspective 'READ' builds on the phonics approach which has been found to be most important in relation to reading achievement i.e., to teach children to break the reading code. In addition, READ builds on theories within learning and skill development. The Ericsson concept of 'deliberate practice' refer to baseline measurements that provide a basis for follow-up and deliberate practice. The concept of 'flow' is also of great importance where challenges are always in relation to the skills. It means that each child will be able to experience 'flow' where mastery is the key word, feeling I CAN! When mastery is experienced, the dopamine hormone gives the feeling of reward. Stimuli, experience, and repetition is also a key word in the 'training hour' where children get the possibility to strengthen the neural network that is used for specific skills which are trained. In this respect, the letter-sound knowledge is trained until the child has broken the reading code. The results from the first year in the school in Vestmannaeyjar in Iceland indicates that all the children were able to break the reading code or read simple words. In addition, 96% of the children were able to read sentences, and 88% where able to read text. These promising results are discussed in relation to Ericsson's and Csikszentmihalyi's important theories.

Evaluation of improvement of functional independence in a multicentre cohort of rehabilitation outpatients with neurological conditions

PURPOSE

The objectives were to examine: (1) the changes in independence in basic activities of daily living (ADL) following an outpatient occupational therapy (OT) intervention in people with neurological conditions; (2) the factors associated with good relative functional gain (RFG) and with good OT efficiency; (3) and the effects on instrumental activities of daily living (IADL) and caregiver assistance.

MATERIALS AND METHODS

A prospective observational study examining changes in a multicentre cohort (three urban hospitals). Ninety-eight adults were assessed on admission and after intervention. Barthel Index was the primary outcome (ADL).

RESULTS

Acquired brain damage (ABI) was the most frequent diagnosis (84.7%). There was an improvement in ADL (p < 0.001); the effect size (r) was large (r = 0.59). RFG was good for 88.8% of participants. A good RFG was significantly associated with ABI, a lower number of hours of caregiver assistance, and a greater intensity of OT. The OT efficiency was good for 43.9% of participants. Factors significantly associated with good efficiency were being young and male patients, and receiving fewer hours of caregiver assistance. Secondary measures were improved: IADL (p < 0.001) and hours of caregiver assistance (p < 0.001).

CONCLUSIONS

This study suggests that the intervention is an effective approach to improve functional independence.Implications for rehabilitationLittle is known about the outcomes of outpatient occupational therapy intervention in neurorehabilitation services for the adult population with neurological diseases.In a multicentre cohort of neurorehabilitation outpatients, the occupational therapy intervention can lead to improvements in the level of independence in basic and instrumental daily activities, as well as reducing the hours of caregiver assistance.A good relative functional gain is associated with acquired brain injury, a lower number of hours of assistance, and a greater intensity of occupational therapy.The factors associated with good efficiency are being younger, male patients, and receiving fewer hours of assistance.

Early, Intense Rehabilitation Fails to Improve Outcome After Intra-Striatal Hemorrhage in Rats

BACKGROUND

The formation and degradation of an intracerebral hemorrhage causes protracted cell death, and an extended window for intervention. Experimental studies find that rehabilitation mitigates late cell death, with accelerated hematoma clearance as a potential mechanism.

OBJECTIVE

We assessed whether early, intense, enriched rehabilitation (ER, environmental enrichment and massed skills training) enhances functional benefit, reduces brain injury, and augments hematoma clearance.

METHODS

In experiment 1, rats (n = 56) were randomized to intervention in the light (-L) or dark phase (-D) of their housing cycle, then to 10 days of ER or control (CON) treatment after collagenase-induced striatal intracerebral hemorrhage (ICH). ER rats were treated from 5 to 14 days after ICH. Behavior and residual hematoma volume was assessed on day 14. In experiment 2, rats (n = 72) were randomized to ER-D10, ER-D20, or CON-D. ER rats completed 10 or 20 days of training in the dark. Rats were euthanized on day 60 for histology. In both experiments, behavioral assessment was completed pre-ICH, pre-ER (day 4 post-ICH), and post-ER (experiment 1: days 13-14; experiment 2: days 16-17 and 30-31).

RESULTS

Reaching intensity was high but similar between ER-D10 and ER-L10. Unlike previous work, rehabilitation did not alter skilled reaching or hematoma resolution. Varying ER duration also did not affect reaching success or lesion volume.

CONCLUSIONS

In contrast to others, and under these conditions, our findings show that striatal ICH was generally unresponsive to rehabilitation. This highlights the difficulty of replicating and extending published work, perhaps owing to small inter-study differences.

Efficacy and feasibility of SENSory relearning of the UPPer limb (SENSUPP) in people with chronic stroke: A pilot randomized controlled trial

BACKGROUND

Sensorimotor impairments of the upper limb (UL) are common after stroke, but there is a lack of evidence-based interventions to improve functioning of UL.

OBJECTIVE

To evaluate (1) the efficacy of sensory relearning and task-specific training compared to task-specific training only, and (2) the feasibility of the training in chronic stroke.

DESIGN

A pilot randomized controlled trial.

SETTING

University hospital outpatient clinic.

PARTICIPANTS

Twenty-seven participants (median age; 62 years, 20 men) were randomized to an intervention group (IG; n = 15) or to a control group (CG; n = 12).

INTERVENTION

Both groups received training twice weekly in 2.5-hour sessions for 5 weeks. The training in the IG consisted of sensory relearning, task-specific training, and home training. The training in the CG consisted of task-specific training.

MAIN OUTCOME MEASURES

Primary outcome was sensory function (touch thresholds, touch discrimination, light touch, and proprioception). Secondary outcomes were dexterity, ability to use the hand in daily activities, and perceived participation. A blinded assessor conducted the assessments at baseline (T1), post intervention (T2), and at 3-month follow-up (T3). Nonparametric analyses and effect-size calculations (r) were performed. Feasibility was evaluated by a questionnaire.

RESULTS

After the training, only touch thresholds improved significantly from T1 to T2 (p = .007, r = 0.61) in the IG compared to the CG. Within the IG, significant improvements were found from T1 to T2 regarding use of the hand in daily activities (p = .001, r = 0.96) and movement quality (p = .004, r = 0.85) and from T1 to T3 regarding satisfaction with performance in meaningful activities (p = .004, r = 0.94). The CG significantly improved the performance of using the hand in meaningful activities from T1 to T2 (p = .017, r = 0.86). The training was well tolerated by the participants and performed without any adverse events.

CONCLUSIONS

Combined sensory relearning and task-specific training may be a promising and feasible intervention to improve UL sensorimotor function after stroke.

Growing Brains, Nurturing Minds-Neuroscience as an Educational Tool to Support Students' Development as Life-Long Learners

Compared to other primates, humans are late bloomers, with exceptionally long childhood and adolescence. The extensive developmental period of humans is thought to facilitate the learning processes required for the growth and maturation of the complex human brain. During the first two and a half decades of life, the human brain is a construction site, and learning processes direct its shaping through experience-dependent neuroplasticity. Formal and informal learning, which generates long-term and accessible knowledge, is mediated by neuroplasticity to create adaptive structural and functional changes in brain networks. Since experience-dependent neuroplasticity is at full force during school years, it holds a tremendous educational opportunity. In order to fulfill this developmental and learning potential, educational practices should be human-brain-friendly and "ride" the neuroplasticity wave. Neuroscience can inform educators about the natural learning mechanisms of the brain to support student learning. This review takes a neuroscientific lens to explore central concepts in education (e.g., mindset, motivation, meaning-making, and attention) and suggests two methods of using neuroscience as an educational tool: teaching students about their brain (content level) and considering the neuro-mechanisms of learning in educational design (design level).

Corticospinal Responses Following Gait-Specific Training in Stroke Survivors: A Systematic Review

Corticospinal excitability is subject to alterations after stroke. While the reversal of these alterations has been proposed as an underlying mechanism for improved walking capacity after gait-specific training, this has not yet been clearly demonstrated. Therefore, the objective of this review is to evaluate the effect of gait-specific training on corticospinal excitability in stroke survivors. We conducted an electronic database search in four databases (i.e., Medline, Embase, CINAHL and Web of Science) in June 2022. Two authors screened in an independent way all the studies and selected those that investigated the effect of gait-specific training on variables such as motor-evoked potential amplitude, motor threshold, map size, latency, and corticospinal silent period in stroke survivors. Nineteen studies investigating the effect of gait-specific training on corticospinal excitability were included. Some studies showed an increased MEP amplitude (7/16 studies), a decreased latency (5/7studies), a decreased motor threshold (4/8 studies), an increased map size (2/3 studies) and a decreased cortical silent period (1/2 study) after gait-specific training. No change has been reported in terms of short interval intracortical inhibition after training. Five studies did not report any significant effect after gait-specific training on corticospinal excitability. The results of this systematic review suggest that gait-specific training modalities can drive neuroplastic adaptation among stroke survivors. However, given the methodological disparity of the included studies, additional clinical trials of better methodological quality are needed to establish conclusions. The results of this review can therefore be used to develop future studies to better understand the effects of gait-specific training on the central nervous system.

Biomarkers for rhythmic and discrete dynamic primitives in locomotion

Rehabilitation can promote brain plasticity and improve motor control after central nervous system injuries. Our working model is that motor control is encoded using dynamic primitives: submovements, oscillations, and mechanical impedances. We hypothesize that therapies focusing on these primitives can achieve greater motor recovery. At the observational level, these primitives lead to discrete and rhythmic movements. Here, we propose two novel biomarkers to evaluate rhythmic and discrete movements in gait based on the feet forward position: the smoothness of their relative position, using the mean-squared jerk ratio (MSJR), to assess rhythmicity; and the angle between principal components of consecutive trajectories (dPCA), to detect discrete movements amidst rhythmic motion. We applied these methods to kinematic data collected with healthy individuals during experiments employing the MIT-Skywalker: level-ground walking at five speeds, with and without imposed ankle stiffness; walking at constant speed on ascending, descending, and laterally tilted slopes; and performing sidesteps. We found a decrease in MSJR as speed increases, related to increased rhythmicity, even with imposed stiffness. Rhythmicity seems unaffected by the terrain perturbations imposed. Finally, dPCA successfully detects sidesteps, discrete events amidst rhythmic movement. These biomarkers appear to accurately assess rhythmic and discrete movements during walking and can potentially improve clinical evaluation and rehabilitation of neurological patients.

Therapists' perspectives on using brain-computer interface-triggered functional electrical stimulation therapy for individuals living with upper extremity paralysis: a qualitative case series study

BACKGROUND

Brain computer interface-triggered functional electrical stimulation therapy (BCI-FEST) has shown promise as a therapy to improve upper extremity function for individuals who have had a stroke or spinal cord injury. The next step is to determine whether BCI-FEST could be used clinically as part of broader therapy practice. To do this, we need to understand therapists' opinions on using the BCI-FEST and what limitations potentially exist. Therefore, we conducted a qualitative exploratory study to understand the perspectives of therapists on their experiences delivering BCI-FEST and the feasibility of large-scale clinical implementation.

METHODS

Semi-structured interviews were conducted with physical therapists (PTs) and occupational therapists (OTs) who have delivered BCI-FEST. Interview questions were developed using the COM-B (Capability, Opportunity, Motivation-Behaviour) model of behaviour change. COM-B components were used to inform deductive content analysis while other subthemes were detected using an inductive approach.

RESULTS

We interviewed PTs (n = 3) and OTs (n = 3), with 360 combined hours of experience delivering BCI-FEST. Components and subcomponents of the COM-B determined deductively included: (1) Capability (physical, psychological), (2) Opportunity (physical, social), and (3) Motivation (automatic, reflective). Under each deductive subcomponent, one to two inductive subthemes were identified (n = 8). Capability and Motivation were perceived as strengths, and therefore supported therapists' decisions to use BCI-FEST. Under Opportunity, for both subcomponents (physical, social), therapists recognized the need for more support to clinically implement BCI-FEST.

CONCLUSIONS

We identified facilitating and limiting factors to BCI-FEST delivery in a clinical setting according to clinicians. These factors implied that education, training, a support network or mentors, and restructuring the physical environment (e.g., scheduling) should be targeted as interventions. The results of this study may help to inform future development of new technologies and interventions.

The Feasibility of Home-Based Treatment Using Vibratory Stimulation in Chronic Severe Dysphagia

PURPOSE

Previously, externally placed vibratory laryngeal stimulation increased rates of swallowing in persons with and without dysphagia. This study examined the feasibility of using a vibratory device on the skin over the thyroid cartilage for home-based swallowing rehabilitation in long-standing dysphagia.

METHOD

Only participants with long-standing dysphagia (> 6 months) following cerebrovascular accident or head/neck cancer who had not previously benefited from dysphagia therapy participated. The device had two modes used daily for 90 days. In automatic mode, participants wore the device when awake, which vibrated for 4-8 s every 5 min to trigger a volitional swallow. In manual mode, participants practiced by activating vibration while swallowing rapidly. Study-related adverse events, such as pneumonia, and device-recorded adherence were tracked. Swallowing function on a modified barium swallow study was assessed at baseline and after 3 months of device use. Outcome measures included the Dysphagia Outcome and Severity Scale (DOSS), Penetration-Aspiration Scale (PAS), and swallowing timing measures. Participants' perceptions of the vibratory device and training were obtained.

RESULTS

The intent to treat analysis showed seven of 11 participants completed the study, all with severe chronic dysphagia. Of those seven participants completing the study, two developed respiratory complications (possibly due to pneumonia) that cleared after antibiotic intervention. For prescribed practice trials, adherence was 80% or greater in four of seven participants (57%) whereas prescribed automatic stimulations were met in only two of seven participants (29%). Three participants (43%) had a modest benefit on DOSS. The time to vestibule closure after the bolus passed the ramus was reduced in five participants (71%) on the modified barium swallow study.

CONCLUSION

Overall, the results have indicated that intensive home-based practice with stimulation may provide limited functional benefits in severe chronic dysphagia.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21498591.

Evaluating the validity of a functional electrical stimulation clinical decision making tool: A qualitative study

INTRODUCTION

Following central nervous system damage, the recovery of motor function is a priority. For some neurological populations, functional electrical stimulation (FES) is recommended in best practice guidelines for neurorehabilitation. However, limited resources exist to guide FES application, despite clinicians reporting that a lack of FES knowledge prevents use in clinical practice. The FES Clinical Decision Making Tool was developed to assist clinicians with FES application and translation into clinical practice. The purpose of this study was to evaluate the content validity of the Tool from the perspectives of Canadian physical and occupational therapists using FES in neurorehabilitation.

METHODS

Thirteen participants (twelve women, one man), aged 40.5 ± 10.3 years, participated in individual semi-structured interviews to explore their clinical decision making experiences when applying FES and to evaluate the content validity (i.e., appropriateness, comprehensibility, and comprehensiveness) of the Tool. Interviews were analyzed using a qualitative conventional content analysis following the DEPICT model.

RESULTS

Three themes were identified. 1) Clinician context influences FES usage. Participants' experiences with FES use varied and application was influenced by treatment goals. 2) Parameter selection in clinical practice. Participants identified decision-making strategies and the challenges of parameter selection. 3) With modifications, the Tool is a valid resource to inform FES applications. Participants discussed its strengths, limitations, and suggested changes. While the Tool is useful, a more extensive resource (e.g., appendix) for the Tool is warranted.

DISCUSSION

A revised Tool was created to improve its comprehensiveness and comprehensibility. Thus, the Tool is a valid resource for applying FES in neurorehabilitation.

Effectiveness of virtual reality on functional mobility during treadmill training in children with cerebral palsy: a single-blind, two-arm parallel group randomised clinical trial (VirtWalkCP Project)

INTRODUCTION

Treadmill training and virtual reality have been investigated in children with cerebral palsy. However, few studies have assessed the effectiveness of the combination of both treatments on children's functional and balance activities. The project aims to compare the effects of treadmill training with and without virtual reality on walking endurance and speed, static and dynamic balance, gross motor function, functional independence, quality of life and occupational participation in children with spastic cerebral palsy between the ages of 4 and 12 years classified at levels I, II and III of the Gross Motor Function Classification System.

METHODS AND ANALYSIS

This study is a single-blind, two-arm parallel group, randomised, controlled clinical trial. Participants will be recruited at the Pediatric Department of the Vic Hospital Consortium, and the research will be conducted at the University of Vic - Central University of Catalonia. The participants will be randomly allocated into two groups: (1) the experimental group, which will receive the treadmill training at the same time as the virtual reality; and (2) the control group, which will undertake treadmill gait training alone. The training will be provided in 10 sessions over 2 weeks with 30 min for each session. Assessments will be performed on three occasions: 1 week before the intervention, 1 week following the intervention and 1 month after the end of the intervention. The evaluations will involve the 6 min walk test, stabilometry, the Berg Balance Scale, the 10 m walk test, the Gross Motor Function Measure, the Functional Independence Measure, the paediatric quality of life inventory and the Children Participation Questionnaire. For between-within group comparison, a mixed-effect linear model will be used.

ETHICS AND DISSEMINATION

The study has been approved by the Clinical Research Ethics Committee of the Osona Foundation for Health Research and Education (2021061). Results will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT05131724.

Autonomic Nerve Fibers Aberrantly Reinnervate Denervated Facial Muscles and Alter Muscle Fiber Population

The surgical redirection of efferent neural input to a denervated muscle via a nerve transfer can reestablish neuromuscular control after nerve injuries. The role of autonomic nerve fibers during the process of muscular reinnervation remains largely unknown. Here, we investigated the neurobiological mechanisms behind the spontaneous functional recovery of denervated facial muscles in male rodents. Recovered facial muscles demonstrated an abundance of cholinergic axonal endings establishing functional neuromuscular junctions. The parasympathetic source of the neuronal input was confirmed to be in the pterygopalatine ganglion. Furthermore, the autonomically reinnervated facial muscles underwent a muscle fiber change to a purely intermediate muscle fiber population myosin heavy chain type IIa. Finally, electrophysiological tests revealed that the postganglionic parasympathetic fibers travel to the facial muscles via the sensory infraorbital nerve. Our findings demonstrated expanded neuromuscular plasticity of denervated striated muscles enabling functional recovery via alien autonomic fibers. These findings may further explain the underlying mechanisms of sensory protection implemented to prevent atrophy of a denervated muscle.SIGNIFICANCE STATEMENT Nerve injuries represent significant morbidity and disability for patients. Rewiring motor nerve fibers to other target muscles has shown to be a successful approach in the restoration of motor function. This demonstrates the remarkable capacity of the CNS to adapt to the needs of the neuromuscular system. Yet, the capability of skeletal muscles being reinnervated by nonmotor axons remains largely unknown. Here, we show that under deprivation of original efferent input, the neuromuscular system can undergo functional and morphologic remodeling via autonomic nerve fibers. This may explain neurobiological mechanisms of the sensory protection phenomenon, which is because of parasympathetic reinnervation.

Reversing the Ruin: Rehabilitation, Recovery, and Restoration After Stroke

PURPOSE OF REVIEW

Stroke is a common cause of disability in aging adults. A given individual's needs after stroke vary as a function of the stroke extent and location. The purpose of this review was to discuss recent clinical investigations addressing rehabilitation of an array of overlapping functional domains.

RECENT FINDINGS

Research is ongoing in the domains of movement, cognition, attention, speech, language, swallowing, and mental health. To best assist patients' recovery, innovative research has sought to develop and evaluate behavioral approaches, identify and refine synergistic approaches that augment the response to behavioral therapy, and integrate technology where appropriate, particularly to introduce and titrate real-world complexity and improve the overall experience of therapy. Recent and ongoing trials have increasingly adopted a multidisciplinary nature - augmenting refined behavioral therapy approaches with methods for increasing their potency, such as pharmaceutical or electrical interventions. The integration of virtual reality, robotics, and other technological advancements has generated immense excitement, but has not resulted in consistent improvements over more universally accessible, lower technology therapy.

A framework for clinical utilization of robotic exoskeletons in rehabilitation

Exoskeletons are externally worn motorized devices that assist with sit-to-stand and walking in individuals with motor and functional impairments. The Food & Drug Administration (FDA) has approved several of these technologies for clinical use however, there is limited evidence to guide optimal utilization in every day clinical practice. With the diversity of technologies & equipment available, it presents a challenge for clinicians to decide which device to use, when to initiate, how to implement these technologies with different patient presentations, and when to wean off the devices. Thus, we present a clinical utilization framework specific to exoskeletons with four aims.

These aims are to assist with clinical decision making of when exoskeleton use is clinically indicated, identification of which device is most appropriate based on patient deficits and device characteristics, providing guidance on dosage parameters within a plan of care and guidance for reflection following utilization. This framework streamlines how clinicians can approach implementation through the synthesis of published evidence with appropriate clinical assessment & device selection to reflection for success and understanding of these innovative & complex technologies.

Two-Year Longitudinal Evaluation of Community Aphasia Center Participation on Linguistic, Functional Communication, and Quality of Life Measures Across People With a Range of Aphasia Presentations

PURPOSE

The purpose of this study was to evaluate potential changes on a hierarchy of language tasks and measures of functional communication and quality of life in a group of people with aphasia (PWA) who attended a community aphasia center for 2 years. A secondary purpose was to determine whether there were any predictors of change.

METHOD

Twenty-seven PWA who attended Brooks Rehabilitation Aphasia Center (BRAC) were evaluated on an aphasia battery, confrontation naming, and structured discourse in addition to completing self-reported measures of functional communication and quality of life at three time points: before attending BRAC and after 1 (N = 27) and 2 (N = 20) years of BRAC participation. Twenty-six communication partners who communicated regularly with the PWA completed a questionnaire about their functional communication at the same time points. A mixed linear model was conducted for all dependent variables to determine change over time. Tau-b correlations were conducted between demographic and aphasia-related variables and difference scores for outcome measures that exhibited significant improvements.

RESULTS

At 1-year testing, significant improvements were observed on the aphasia battery, object and action naming, and all self- and communication partner-reported measures. At 2-year testing, all improvements were maintained except for the self-reported measure of functional communication. Structured discourse showed increases in average number of words, percentage of meaningful words and utterances, and efficiency of meaningful word production after 2 years. No significant correlations were observed between predictor variables and difference scores.

CONCLUSIONS

Participation in aphasia centers can result in significant changes in language, functional communication, and quality of life in people with chronic aphasia. These findings support the importance of aphasia centers in the continuum of care for PWA.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21313689.

Nintendo® Wii Therapy Improves Upper Extremity Motor Function in Children with Cerebral Palsy: A Systematic Review with Meta-Analysis

BACKGROUND

Nintendo^® Wii-based therapy (NWT) is a non-immersive virtual reality therapy used to recover upper extremity (UE) motor function in children with cerebral palsy (CP). We aimed primarily to elucidate the effectiveness of NWT in improving UE motor and functional impaired abilities in children with CP, compared to conventional therapy or no intervention. The secondary aim was to assess if NWT is more effective when used alone or combined with conventional therapy.

METHODS

A systematic review with meta-analysis was conducted from a bibliographic search in PubMed, Scopus, PEDro, Web of Science, and CINHAL, ending in October 2021, in accordance with PRISMA guidelines. We included randomized controlled trials that compared NWT vs. conventional therapy or no intervention in terms of their impact on different UE impaired abilities (grip strength, tip grip strength, UE dissociated movements, functional capacity in daily living activities, gross and fine motor dexterity, and grasping ability) in children with CP. Effect size was calculated with standardized mean difference (SMD) and its 95% confidence interval (95% CI).

RESULTS

Nine studies (276 participants) were included. NWT is more effective than conventional therapy at improving grip strength (SMD = 0.5, 95% CI 0.08, 0.91), tip grip strength (SMD = 0.95, 95% CI 0.3, 1.61), and grasping ability (SMD = 0.72, 95%CI 0.14, 1.3). NWT is more effective than conventional therapy at improving functional capacity in daily living activities (SMD = 0.83, 95% CI 0.07, 1.56). For fine manual dexterity, NWT was better than no intervention (SMD = 3.12, 95% CI 1.5, 4.7).

CONCLUSIONS

Our results indicate that NWT is effective at improving various UE impaired motor skills in children with CP.

Revisiting dose and intensity of training: Opportunities to enhance recovery following stroke

PURPOSE

Stroke is a global leading cause of adult disability with survivors often enduring persistent impairments and loss of function. Both intensity and dosage of training appear to be important factors to help restore behavior. However, current practice fails to achieve sufficient intensity and dose of training to promote meaningful recovery. The purpose of this review is to propose therapeutic solutions that can help achieve a higher dose and/or intensity of therapy. Raising awareness of these intensive, high-dose, treatment strategies might encourage clinicians to re-evaluate current practice and optimize delivery of stroke rehabilitation for maximal recovery.

METHODS

Literature that tested and evaluated solutions to increase dose or intensity of training was reviewed. For each therapeutic strategy, we outline evidence of clinical benefit, supporting neurophysiological data (where available) and discuss feasibility of clinical implementation.

RESULTS

Possible therapeutic solutions included constraint induced movement therapy, robotics, circuit therapy, bursts of training, gaming technologies, goal-oriented instructions, and cardiovascular exercise.

CONCLUSION

Our view is that clinicians should evaluate current practice to determine how intensive high-dose training can be implemented to promote greater recovery after stroke.

Parkinsonics: A Randomized, Blinded, Cross-Over Trial of Group Singing for Motor and Nonmotor Symptoms in Idiopathic Parkinson Disease

Introduction

Parkinson's disease (PD) frequently causes communication difficulties due to various voice impairments and there are few treatment options for vocal/communication complaints. We assessed the effects of weekly group singing on PD patients' objective vocal and motoric function, cognition, mood, self-efficacy, and quality of life.

Methods

Thirty-two participants were randomly assigned to either a singing group or a facilitated discussion group weekly over 12 weeks. After 12 weeks, participants crossed over for an additional 12 weeks. Evaluations were performed at baseline and every six weeks for 30 weeks. Objective voice measures included volume/loudness (decibels), held vowel duration, jitter, shimmer, and harmonic-to-noise ratio. Additional outcome measures included patient-centered quality of life, voice-related quality of life, MDS-UPDRS, Montreal Cognitive Assessment, and questionnaires assessing depression, self-efficacy, and overall well-being.

Results

Twenty-six participants (16 M/10F; Hoehn & Yahr stage 2.3 (range 2-3); and age 68.6 (55-89)) completed the study. Across participants in both groups (intention-to-treat analyses), there was significant improvement from baseline in average loudness on the Cookie Theft picture description at 24 weeks (end of interventions), corresponding with improved minimal reading volumes at 24 weeks and 30 weeks (end of study). Similarly, there were improvements in minimal loudness on Rainbow passage reading at 24 and 30 weeks. There were improvements observed in the Emotional Well-Being (mean delta -12.7 points, p = 0.037) and Body Discomfort (mean delta -18.6 points, p = 0.001) domains of the PDQ-39 from baseline to week 24 in the overall cohort and greater improvement in the Communication domain for Group S than Group D after 12 weeks of singing (delta -12.9 points, p = 0.016). Baseline differences between the participant groups (age, gender, Hoehn & Yahr stage, and several voice loudness measures) and observed improvements during the weekly discussion group period limited our ability to attribute all of the above results specifically to singing (per-protocol analyses). No significant changes in other assessed outcome measures were found.

Conclusions

Weekly group singing may improve some aspects of conversational voice volume and quality of life in PD. Some improvements were sustained at least six weeks after interventions ended. Further investigations of the mechanism of benefit and randomized controlled studies (without crossover) to assess the longitudinal effects of singing in PD are necessary.

Therapeutic exercise interventions in pediatric survivors of brain cancer and other solid tumors: A scoping review

Background

Improved survival rates for children with solid tumors presents an ongoing challenge of how to maximize quality of survivorship and effectively manage the short- and long-term complications of disease and treatment. To gain an understanding of the extent and nature of research pertaining to therapeutic exercise interventions and identify knowledge gaps, we conducted a scoping review of exercise training studies conducted in pediatric survivors of brain cancer and other solid tumors.

Method

A systematic literature search was performed across four electronic databases. Papers were selected for full-text review if they included participants treated for brain cancer or other solid tumors, with at least 50% of participants aged ≤ 21 years, evaluated an exercise intervention ≥2-weeks in duration, and were published in an English, peer-reviewed journal. We included the following quantitative study designs; randomized controlled trials, non-randomized trials, and single-arm pre-test-post-test.

Results

Of the 7,482 citations identified, 17 papers met the inclusion criteria (presenting findings from eleven studies). Two studies were randomized controlled trials, five studies were non-randomized controlled trials, and four studies were a single-arm pre-test post-test design. Average age of participants ranged from 7.3-15.5 years, and time since diagnosis ranged from 3 to 70 months. Five studies included participants with brain tumors exclusively, three studies included other solid tumors, and three studies included a mixed sample (brain and other solid tumors). A wide range of exercise modalities were employed, including cycle ergometry, resistance training, sport, yoga, and active gaming. The length of the exercise program ranged from 3-40 weeks and frequency from 3-11 sessions per week. Exercise session duration ranged from 15-180 min, with most studies reporting 30-90-min sessions. Adherence ranged from 77 to 100%, with none of the studies reporting adverse events. Studies reported improvements in cardiorespiratory fitness, functional strength, physical activity, and quality of life.

Conclusions

A small number of mostly low methodological quality studies have examined the effects of therapeutic exercise in pediatric survivors of solid tumors. Although limited, the extant literature supports the feasibility and safety of therapeutic exercise interventions for pediatric survivors of brain cancer and other solid tumors.

Expanding Rehabilitation Options for Dysphagia: Skill-Based Swallowing Training

Over the past four decades, our understanding of swallowing neural control has expanded dramatically. However, until recently, advances in rehabilitation approaches for dysphagia have not kept pace, with a persistent focussing on strengthening peripheral muscle. This approach is no doubt very appropriate for some if not many of our patients. But what if the dysphagia is not due to muscles weakness? The purpose of this clinical manuscript is to reflect on where we have been, where we are now and perhaps where we need to go in terms of our understanding of swallowing motor control and rehabilitation of motor control impairments. This compilation is presented to clinicians in the hope that suggesting approaches "outside the box" will inspire clinicians to focus their attention "inside the box" to ultimately improve rehabilitation and long-term outcomes for patients with dysphagia.

An EEG-based asynchronous MI-BCI system to reduce false positives with a small number of channels for neurorehabilitation: A pilot study

Many studies have used motor imagery-based brain–computer interface (MI-BCI) systems for stroke rehabilitation to induce brain plasticity. However, they mainly focused on detecting motor imagery but did not consider the effect of false positive (FP) detection. The FP could be a threat to patients with stroke as it can induce wrong-directed brain plasticity that would result in adverse effects. In this study, we proposed a rehabilitative MI-BCI system that focuses on rejecting the FP. To this end, we first identified numerous electroencephalogram (EEG) signals as the causes of the FP, and based on the characteristics of the signals, we designed a novel two-phase classifier using a small number of EEG channels, including the source of the FP. Through experiments with eight healthy participants and nine patients with stroke, our proposed MI-BCI system showed 71.76% selectivity and 13.70% FP rate by using only four EEG channels in the patient group with stroke. Moreover, our system can compensate for day-to-day variations for prolonged session intervals by recalibration. The results suggest that our proposed system, a practical approach for the clinical setting, could improve the therapeutic effect of MI-BCI by reducing the adverse effect of the FP.

Exploring Patient Outcomes After Participation in an Inpatient Occupation-Based Group: A Longitudinal Observational Cohort Study

IMPORTANCE

Occupation-based interventions are used during inpatient rehabilitation, and group models may enhance intervention delivery. However, little is known about the impact of occupation-based groups on patient outcomes.

OBJECTIVE

To examine the effect of an occupation-based group on patient outcome measures of instrumental activities of daily living (IADL) skills over time and explore demographic differences among patients.

DESIGN

Longitudinal observational cohort study with four time points: preintervention, postintervention, 30-day follow-up, and 90-day follow-up.

SETTING

Tertiary hospital general rehabilitation ward.

PARTICIPANTS

Inpatient adults age 18 or older recruited using consecutive sampling from those referred to the group.

INTERVENTION

The LifeSkills group, which focused on repetitive practice of meaningful occupation-based activities.

OUTCOMES AND MEASURES

Demographic data were obtained, and the Canadian Occupational Performance Measure (COPM), Goal Attainment Scaling, Lawton IADL scale, and a self-efficacy scale were administered at each data point.

RESULTS

Thirty people (21 women, 9 men; ages 35-91 yr) participated, with 5 lost to follow-up. A statistically significant increase in scores postintervention occurred on all measures and was also seen at 90-day follow-up for COPM occupational performance, satisfaction, and self-efficacy scores. Lawton IADL scale scores at follow-up were lower than those at preintervention and statistically significant. No significant differences were found for age and diagnosis.

CONCLUSIONS AND RELEVANCE

Positive patient outcomes of goal achievement, occupational performance, satisfaction, and self-efficacy were seen at discharge, with evidence of sustainability over time. This could be a resource alternative for addressing skill retraining because people with different diagnoses and in different age groups benefited equally. What This Article Adds: Occupation-based group programs have encouraging application in general inpatient rehabilitation for addressing patient outcomes.

Monitoring Arm Movements Post-Stroke for Applications in Rehabilitation and Home Settings

Optimal recovery of arm function following stroke requires patients to perform a large number of functional arm movements in clinical therapy sessions, as well as at home. Technology to monitor adherence to this activity would be helpful to patients and clinicians. Current approaches to monitoring arm movements are limited because of challenges in distinguishing between functional and non-functional movements. Here, we present an Arm Rehabilitation Monitor (ARM), a device intended to make such measurements in an unobtrusive manner. The ARM device is based on a single Inertial Measurement Unit (IMU) worn on the wrist and uses machine learning techniques to interpret the resulting signals. We characterized the ability of the ARM to detect reaching actions in a functional assessment dataset (functional assessment tasks) and an Activities-of-Daily-Living (ADL) dataset (pizza-making and walking task) from 12 participants with stroke. The Convolutional Neural Network (CNN) and Random Forests (RF) classifiers had a Matthews Correlation Coefficient score of 0.59 and 0.58 when trained and tested on the functional dataset, 0.50 and 0.49 when trained and tested on the ADL dataset, and 0.37 and 0.36 when trained on the functional dataset and tested on the ADL dataset, respectively. The latter is the most relevant scenario for the intended application of training during a clinical visit for monitoring movements in the in-home setting. The classifiers showed good performance in estimating the time spent reaching and number of reaching gestures and showed low sensitivity to irrelevant arm movements produced during walking. We conclude that the ARM has sufficient accuracy and robustness to merit being used in preliminary studies to monitor arm activity in rehabilitation or home applications.

Examining the effectiveness of virtual, augmented, and mixed reality (VAMR) therapy for upper limb recovery and activities of daily living in stroke patients: a systematic review and meta-analysis

INTRODUCTION

Virtual reality (VR), augmented reality (AR), and mixed reality (MR) are emerging technologies in the field of stroke rehabilitation that have the potential to overcome the limitations of conventional treatment. Enhancing upper limb (UL) function is critical in stroke impairments because the upper limb is involved in the majority of activities of daily living (ADL).

METHODS

This study reviewed the use of virtual, augmented and mixed reality (VAMR) methods for improving UL recovery and ADL, and compared the effectiveness of VAMR treatment to conventional rehabilitation therapy. The databases ScienceDirect, PubMed, IEEE Xplore, and Web of Science were examined, and 50 randomized control trials comparing VAMR treatment to standard therapy were determined. The random effect model and fixed effect model are applied based on heterogeneity.

RESULTS

The most often used outcomes of UL recovery and ADL in stroke rehabilitation were the Fugl-Meyer Assessment for Upper Extremities (FMA-UE), followed by the Box and Block Test (BBT), the Wolf Motor Function Test (WMFT), and the Functional Independence Measure (FIM). According to the meta-analysis, VR, AR, and MR all have a significant positive effect on improving FMA-UE for UL impairment (36 studies, MD = 3.91, 95 percent CI = 1.70-6.12, P = 0.0005) and FIM for ADL (10 studies, MD = 4.25, 95 percent CI = 1.47-7.03, P = 0.003), but not on BBT and WMFT for the UL function tests (16 studies, MD = 2.07, 95 percent CI = - 0.58-4.72, P = 0.13), CONCLUSIONS: VAMR therapy was superior to conventional treatment in UL impairment and daily function outcomes, but not UL function measures. Future studies might include further high-quality trials examining the effect of VR, AR, and MR on UL function measures, with an emphasis on subgroup meta-analysis by stroke type and recovery stage.

Motion, Relation, and Passion in Brain Physiological and Cognitive Aging

The aim of the current paper was to present important factors for keeping the basic structures of a person’s brain function, i.e., the grey and white matter, intact. Several lines of evidence have shown that motion, relation, and passion are central factors for preserving the neural system in the grey and white matter during ageing. An active lifestyle has shown to contribute to the development of the central nervous system and to contrast brain ageing. Interpersonal relationships, and interactions, have shown to contribute to complex biological factors that benefit the cognitive resilience to decline. Furthermore, the current scientific literature suggests that passion, strong interest, could be the driving factor motivating individuals to learn new things, thus influencing the development and maintenance of the neural functional network over time. The present theoretical perspective paper aims to convey several key messages: (1) brain development is critically affected by lifestyle; (2) physical training allows one to develop and maintain brain structures during ageing, and may be one of the keys for good quality of life as an older person; (3) diverse stimuli are a key factor in maintaining brain structures; (4) motion, relation, and passion are key elements for contrasting the loss of the grey and white matter of the brain.

Parent-therapist partnership to ELEVATE gross motor function in children with perinatal stroke: protocol for a mixed methods randomized controlled trial

Background

There is increasing evidence for early, active rehabilitation to enhance motor function following early brain injury. This is clear for interventions targeting the upper extremity, whereas passive treatment approaches for the lower extremity persist. The purpose of this trial is to evaluate the effectiveness of early, intensive rehabilitation targeting the lower extremity and delivered in a parent-therapist partnership model for children with perinatal stroke.

Methods

We describe a protocol for a waitlist-control, single-blind, mixed methods effectiveness randomized controlled trial, with an embedded qualitative study using interpretative description. Participants are children with perinatal stroke aged eight months to three years with signs of hemiparesis. Participants will be randomly allocated to an immediate ELEVATE (Engaging the Lower Extremity Via Active Therapy Early) intervention group, or a waitlist-control group, who will receive usual care for six months. The ELEVATE intervention involves one hour of training four days per week for 12 weeks, with a pediatric therapist and a parent or guardian each delivering two sessions per week. The intervention targets the affected lower extremity by progressively challenging the child while standing and walking. The primary outcome measure is the Gross Motor Function Measure-66. Secondary outcomes include the Pediatric Quality of Life Inventory™, Young Children's Participation and Environment Measure, and an instrumented measure of spasticity. A cost-effectiveness analysis and qualitative component will explore benefit to costs ratios and parents’ perspectives of early, intensive rehabilitation, and their role as a partner in the rehabilitation, respectively.

Discussion

This study has the potential to change current rehabilitation for young children with perinatal stroke if the ELEVATE intervention is effective. The parent interviews will provide further insight into benefits and challenges of a partnership model of rehabilitation. The mixed methods design will enable optimization for transfer of this collaborative approach into physical therapy practice.

Trial registration

ClinicalTrials.gov NCT03672864. Registered 17 September 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03525-6.

Automating provision of feedback to stroke patients with and without information on compensatory movements: A pilot study

Providing effective feedback to patients in a rehabilitation training program is essential. As technologies are being developed to support patient training, they need to be able to provide the users with feedback on their performance. As there are various aspects on which feedback can be given (e.g., task success and presence of compensatory movements), it is important to ensure that users are not overwhelmed by too much information given too frequently by the assistive technology. We created a rule-based set of guidelines for the desired hierarchy, timing, and content of feedback to be used when stroke patients train with an upper-limb exercise platform which we developed. The feedback applies to both success on task completion and to the execution of compensatory movements, and is based on input collected from clinicians in a previous study. We recruited 11 stroke patients 1–72 months from injury onset. Ten participants completed the training; each trained with the rehabilitation platform in two configurations: with motor feedback (MF) and with no motor feedback (control condition) (CT). The two conditions were identical, except for the feedback content provided: in both conditions they received feedback on task success; in the MF condition they also received feedback on making undesired compensatory movements during the task. Participants preferred the configuration that provided feedback on both task success and quality of movement (MF). This pilot experiment demonstrates the feasibility of a system providing both task-success and movement-quality feedback to patients based on a decision tree which we developed.

Effects of Cross-Education on Neural Adaptations Following Non-Paretic Limb Training in Stroke: A Scoping Review with Implications for Neurorehabilitation

Current stroke rehabilitation interventions focus on intensive task specific training of the paretic limb, which may not be feasible for individuals with higher levels of impairment or in the early phase of stroke. Cross-education, a mechanism that improves strength or skill of the untrained limb following unilateral motor training, has high clinical relevance for stroke rehabilitation. Despite its potential benefits, our knowledge on the application and efficacy of cross-education in stroke is limited. We performed a scoping review to synthesize the current evidence regarding neurophysiological and motor effects of cross-education training in stroke. Low to strong evidence from five studies demonstrated strength gains ranging from 31-200% in the untrained paretic limb following non-paretic muscle training. Neurophysiological mechanisms underlying cross-education were unclear as the three studies that used transcranial magnetic stimulation to probe functional connectivity demonstrated mixed results in low sample size. Our review suggests that cross-education is a promising clinical approach in stroke, however high quality studies focusing on neurophysiological mechanisms are required to establish the efficacy and underlying mechanisms of cross-education in stroke. Recommendations regarding future directions and clinical utility are provided.

Personalized practice dosages may improve motor learning in older adults compared to "standard of care" practice dosages: A randomized controlled trial

Standard dosages of motor practice in clinical physical rehabilitation are insufficient to optimize motor learning, particularly for older patients who often learn at a slower rate than younger patients. Personalized practice dosing (i.e., practicing a task to or beyond one's plateau in performance) may provide a clinically feasible method for determining a dose of practice that is both standardized and individualized, and may improve motor learning. The purpose of this study was to investigate whether personalized practice dosages [practice to plateau (PtP) and overpractice (OVP)] improve retention and transfer of a motor task, compared to low dose [LD] practice that mimics standard clinical dosages. In this pilot randomized controlled trial (NCT02898701, ClinicalTrials.gov), community-dwelling older adults (n = 41, 25 female, mean age 68.9 years) with a range of balance ability performed a standing serial reaction time task in which they stepped to specific targets. Presented stimuli included random sequences and a blinded repeating sequence. Participants were randomly assigned to one of three groups: LD (n = 15, 6 practice trials equaling 144 steps), PtP (n = 14, practice until reaching an estimated personal plateau in performance), or OVP (n = 12, practice 100% more trials after reaching an estimated plateau in performance). Measures of task-specific learning (i.e., faster speed on retention tests) and transfer of learning were performed after 2-4 days of no practice. Learning of the random sequence was greater for the OVP group compared to the LD group (p = 0.020). The OVP (p = 0.004) and PtP (p = 0.010) groups learned the repeated sequence more than the LD group, although the number of practice trials across groups more strongly predicted learning (p = 0.020) than did group assignment (OVP vs. PtP, p = 0.270). No group effect was observed for transfer, although significant transfer was observed in this study as a whole (p < 0.001). Overall, high and personalized dosages of postural training were well-tolerated by older adults, suggesting that this approach is clinically feasible. Practicing well-beyond standard dosages also improved motor learning. Further research should determine the clinical benefit of this personalized approach, and if one of the personalized approaches (PtP vs. OVP) is more beneficial than the other for older patients.

Return to School Outcomes among Adults with TBI One Year After Rehabilitation Discharge: A TBIMS Study

OBJECTIVE

To examine return to school outcomes 1 year after traumatic brain injury (TBI) rehabilitation discharge.

DESIGN

Longitudinal observational study using Traumatic Brain Injury Model Systems National Database (TBIMS-NDB) data at 1-year post-TBI.

SETTING

Inpatient rehabilitation centers using follow-up telephone calls.

INDIVIDUALS

Individuals (n = 237) enrolled in the TBIMS-NDB since 2001 between the ages of 18 and 59 years who were engaged in postsecondary education (full or part-time) before recorded TBI.

MAIN MEASURES

Return to school, categorized as in a postsecondary setting at first follow-up (reported hours in school greater than zero at one-year follow-up).

RESULTS

Using an alpha level of 0.05 binary logistic regression analysis identified four predictive variables. Significant predictors of return to school include being of lower age, possessing a higher level of functioning at discharge, reporting lower ratings of disability at discharge, and being able to use a vehicle independently for transportation.

CONCLUSION

Pursuit of higher education is a viable means of community reintegration after TBI. Some individuals with TBI face a myriad of barriers and challenges when returning to school. Study findings may facilitate understanding of how TBI affects return to school and community reintegration outcomes.

Participants' perspective on a COVID-19 online vocal group stimulation for people with Parkinson's disease

The COVID-19 related confinement and social distancing had negative consequences on the health of individuals living with Parkinson's Disease (PD). In collaboration with a non-profit organization, we developed and implemented a daily online vocal stimulation group named “Musculation de la Voix” (MdlV) in April 2020. To better understand the potential of MdlV to diversify existing services available to people with PD experiencing vocal symptoms, this study aimed to explore participants' experience and perception of MdlV in terms of participation, motivations, feelings, perceived changes, and appreciation. The 45 individuals who registered to the Summer 2020 Semester of MdlV were invited to complete an online ten-question survey. Responses to the four close-ended questions were analyzed using descriptive statistics while statements provided in response to the six open-ended questions were subjected to an inductive qualitative content analysis. Thirty seven participants completed the survey. Results revealed that the sample of respondents was mostly constituted of individuals who were engaged in this activity since its very beginning (62,2%), participated daily (59,5%), intended to keep participating in the activity (97,3%), and had never received speech-language therapy (SLT) services before (72,97%). The qualitative analysis yielded one theme relating to prior services: “Previous SLT services are variable and perceived as beneficial but with limitations,” and three themes pertaining to MdlV: “Seeking improvement and support as initial motivations to engage in MdlV,” “Unanticipated benefits and desired gains catalyzing motivation to participate in MdlV,” and “Perceived limitations of MdlV and persisting needs.” Our study participants' engagement and motivation toward MdlV as well as the benefits they perceived in relation to this activity suggest that an online vocal stimulation group may be a promising complement to currently limited SLT services. As limitations and persisting needs were also identified, future studies are required to elucidate what aspect of MdlV works, for whom and how.

Swallowing difficulties in adolescents: A case report and suggestion of treatment model

Dysphagia or difficulty swallowing in childhood necessitates multi-disciplinary evaluation and management. This case report highlights the teamwork required for diagnostic work-up to distinguish functional dysphagia from organic and psychiatric conditions in an adolescent girl. Treatment model based on cognitive behavioral therapy is also presented.

Active Videogame Training Combined with Conventional Therapy Alters Body Oscillation in Children with Cerebral Palsy: A Randomized Controlled Trial

Objective: Assess the effect of nonimmersive virtual reality (VR) training as complementary rehabilitation on body oscillation in children with cerebral palsy (CP) while standing on different bases of support and surfaces. Materials and Methods: Twenty-three children with unilateral CP randomly allocated to an intervention group (IG, n = 12) or control group (CG, n = 11). The IG underwent two weekly 50-minute sessions of VR training over 8 weeks, associated with conventional therapy, while the CG was submitted to two 45-minute sessions of conventional neurodevelopmental-based physiotherapy a week over the same time period. Participants were evaluated on a force platform under control conditions (CCs) (rigid surface, feet parallel); semitandem stance; flexible surface (FS) with feet parallel; and flexible surface in a semitandem (FSST) stance. The effect of the group and time factors on the center of pressure oscillation variables was analyzed by repeated-measures analysis of variance (ANOVA), with significance set at 0.05. Results: The main effect observed was for time on the FS, with a decline in the amplitude of mediolateral (ML Amp) (P = 0.01) and mediolateral root mean square (P = 0.01) after intervention. In the IG, ML Amp also declined after intervention under CCs (P = 0.02) and total velocity increased for FSST (P = 0.04). The percentage change was significant only in the IG. Conclusion: VR training as complementary rehabilitation can help improve body oscillation in children with CP and mild functional impairment. Nonimmersive VR can be considered a complementary tool for the physical rehabilitation of children with CP. This study was registered with the Brazilian Clinical Trials Registry (RBR-3zty4w).

rTMS/iTBS and Cognitive Rehabilitation for Deficits Associated With TBI and PTSD: A Theoretical Framework and Review

Rehabilitation of cognitive and psychosocial deficits resulting from traumatic brain injury (TBI) continues to be an area of concern in health care. Commonly co-occurring psychiatric disorders, such as major depressive disorder and posttraumatic stress disorder, create additional hurdles when attempting to remediate cognitive sequelae. There is increased need for procedures that will yield consistent gains indicative of recovery of function. Intermittent theta-burst stimulation (iTBS), a form of repetitive transcranial magnetic stimulation, has potential as an instrument that can be tailored to aid cognitive processes and support functional gains. The use of iTBS enables direct stimulation of desired neural systems. iTBS, performed in conjunction with behavioral interventions (e.g., cognitive rehabilitation, psychotherapy), may result in additive success in facilitating cognitive restoration and adaptation. The purpose of this theoretical review is to illustrate how the technical and physiological aspects of iTBS may enhance other forms of neurorehabilitation for individuals with TBI. Future research on combinatorial iTBS interventions has the potential to translate to other complex neuropsychiatric conditions.

Activity-dependent plasticity and spinal cord stimulation for motor recovery following spinal cord injury

Spinal cord injuries lead to permanent physical impairment despite most often being anatomically incomplete disruptions of the spinal cord. Remaining connections between the brain and spinal cord create the potential for inducing neural plasticity to improve sensorimotor function, even many years after injury. This narrative review provides an overview of the current evidence for spontaneous motor recovery, activity-dependent plasticity, and interventions for restoring motor control to residual brain and spinal cord networks via spinal cord stimulation. In addition to open-loop spinal cord stimulation to promote long-term neuroplasticity, we also review a more targeted approach: closed-loop stimulation. Lastly, we review mechanisms of spinal cord neuromodulation to promote sensorimotor recovery, with the goal of advancing the field of rehabilitation for physical impairments following spinal cord injury.

Rehabilitation efficacy comparison of virtual reality technology and computer-assisted cognitive rehabilitation in patients with post-stroke cognitive impairment: A network meta-analysis

OBJECTIVE

Virtual reality (VR) and computer-assisted cognitive rehabilitation (CACR) are two emerging rehabilitation therapies for stroke patients. The aim of this study was to compare the rehabilitation efficacy of these two treatments for patients with post-stroke cognitive impairment (PSCI).

METHODS

A network search of Embase, Web of Science, PubMed, Cochrane Library, VIP, WanFang Data, and CNKI databases was performed from their inception to February 2022 for screening randomized controlled trials related to VR and CACR in the treatment of PSCI. The quality of the included studies was assessed using the Cochrane risk bias assessment tool. The primary outcomes of the included studies contained at least one of the following clinical outcome measures: Mini-mental state examination (MMSE) or Montreal Cognitive Assessment (MoCA). After screening the literature, assessing the quality and extracting the data, a network meta-analysis was performed with STATA software.

RESULTS

A total of 21 randomized controlled trials were included, including 1,047 patients. The results of network meta-analysis showed that under MMSE index, VR group (p = 0.067) and CACR group (p = 0.054) tended to be superior to CT group, but it was not significant. Both the VR (p = 0.024) and CACR (p < 0.001) groups had significantly better outcomes compared to the conventional therapy group in terms of MoCA. The ranking results under both indicators showed that CACR had the best treatment effect, followed by VR.

CONCLUSION

In general, VR and CACR have superior efficacy compared with conventional therapy, in which CACR may be the best treatment option.

Feasibility of virtual reality and treadmill training in traumatic brain injury: a randomized controlled pilot trial

OBJECTIVE

To evaluate the safety and efficacy of treadmill training with virtual reality compared to treadmill training alone and standard of care balance and mobility treatment in chronic traumatic brain injury (TBI).

PARTICIPANTS AND DESIGN

Thirty-one individuals with chronic TBI with self-reported and objective balance deficits participated in a 4-week 12 session intervention of treadmill training with virtual reality, treadmill training alone, or standard of care overground therapy.

OUTCOME MEASURES

Primary measures included recruitment and enrollment rates, retention, tolerance to intervention, completeness of outcome measures, and adverse events. Secondary measures included the Community Balance and Mobility Scale, 10 Meter Walk Test, 6 Minute Walk Test, and Timed Up and Go.

RESULTS

No serious adverse events were reported. All participants completed all training sessions and assessments at all time points. Recruitment, enrollment, and retention rates were high. All groups showed a trend toward improvement in all balance and mobility measures following treatment.

CONCLUSION

Virtual reality and treadmill training are safe and feasibile for individuals with TBI. Participants show improvements on balance and mobility measures following a 4-week intervention. Future research is needed to evaluate the efficacy of this intervention compared to other modes of balance and mobility training.

Painting for a Purpose: A Visual Arts Program as a Method to Promote Engagement, Communication, Cognition, and Quality of Life for Individuals With Dementia

PURPOSE

The arts (e.g., music and painting) have received considerable theoretical and observational support as a cognitive stimulation technique for persons living with dementia (PLWD). However, particularly for visual arts, limited empirical support exists. Therefore, the purpose of this study was to pilot a free-form arts program for PLWD in the context of a cognitive stimulation paradigm and measure subsequent engagement, communication, cognitive-linguistic function, and quality of life.

METHOD

Three PLWD (one each in mild-to-moderate, moderate, and moderate-to-severe stages) were referred for study participation by a local long-term care facility. A single subject across subjects, ABA reversal design was used to assess intervention effects over a period of 8 weeks, in comparison to an active control condition (cooking activity). Cognitive-linguistic function and quality of life were assessed using standardized measures at baseline and follow-up. Engagement and communication were probed regularly across each study phase.

RESULTS

Significant changes were seen in participants' engagement and communication during painting sessions compared to the control activity. A nonsignificant positive trend was noted for self-rated quality of life from baseline to follow-up. Pre-post testing revealed nominal change in cognitive-linguistic functions.

CONCLUSIONS

An arts program led to significant increases in constructive engagement and communication and a trend toward increased self-rated quality of life for the three PLWD. The fact that these changes were not sustained outside intervention sessions (i.e., pre-post testing) is consistent with the need for a larger paradigm shift in which rehabilitation specialists-including speech-language pathologists-better integrate creative, meaningful activities into the everyday lives of PLWD to maximize ongoing engagement, communication, and quality of life.

Transcranial Current Stimulation as a Tool of Neuromodulation of Cognitive Functions in Parkinson’s Disease

Decrease in cognitive function is one of the most common causes of poor life quality and early disability in patients with Parkinson’s disease (PD). Existing methods of treatment are aimed at both correction of motor and non-motor symptoms. Methods of adjuvant therapy (or complementary therapy) for maintaining cognitive functions in patients with PD are of interest. A promising subject of research in this regard is the method of transcranial electric current stimulation (tES). Here we reviewed the current understanding of the pathogenesis of cognitive impairment in PD and of the effects of transcranial direct current stimulation and transcranial alternating current stimulation on the cognitive function of patients with PD-MCI (Parkinson’s Disease–Mild Cognitive Impairment).

Motor Control: A Conceptual Framework for Rehabilitation

There is a lack of conceptual and theoretical clarity among clinicians and researchers regarding the control of motor actions based on the use of the term "motor control." It is important to differentiate control processes from observations of motor output to improve communication and to make progress in understanding motor disorders and their remediation. This article clarifies terminology related to theoretical concepts underlying the control of motor actions, emphasizing how the term "motor control" is applied in neurorehabilitation. Two major opposing theoretical frameworks are described (i.e., direct and indirect), and their strengths and pitfalls are discussed. Then, based on the proposition that sensorimotor rehabilitation should be predicated on one comprehensive theory instead of an eclectic mix of theories and models, several solutions are offered about how to address controversies in motor learning, optimality, and adaptability of movement.

Memory rehabilitation: restorative, specific knowledge acquisition, compensatory, and holistic approaches

Memory impairment following an acquired brain injury can negatively impact daily living and quality of life—but can be reduced by memory rehabilitation. Here, we review the literature on four approaches for memory rehabilitation and their associated strategies: (1) the restorative approach, aimed at a return to pre-morbid functioning, (2) the knowledge acquisition approach, involving training on specific information relevant to daily life, (3) the compensatory approach, targeted at improving daily functioning, and (4) the holistic approach, in which social, emotional, and behavioral deficits are addressed alongside cognitive consequences of acquired brain injury. Each memory rehabilitation approach includes specific strategies such as drill and practice (restorative), spaced retrieval (knowledge acquisition), memory aids (compensatory), or a combination of psychotherapy and cognitive strategies (holistic). Past research has demonstrated mixed support for the use of restorative strategies to improve memory function, whereas knowledge acquisition strategies show promising results on trained tasks but little generalization to untrained tasks and activities of daily living. Compensatory strategies remain widely used but require intensive training to be effectively employed. Finally, the holistic approach is becoming more widespread due to improvements in psychosocial wellbeing, yet there are considerable resource and cost requirements. Several factors can influence rehabilitation outcomes including metacognition and emotional disturbances. Considerations for future research to improve the applicability of strategies for memory rehabilitation include assessing memory impairment severity, examining memory needs in daily life, and exploring the long-term effects of memory rehabilitation.

Non-invasive brain stimulation as therapeutic approach for ischemic stroke: Insights into the (sub)cellular mechanisms

Although spontaneous recovery can occur following ischemic stroke due to endogenous neuronal reorganization and neuroplastic events, the degree of functional improvement is highly variable, causing many patients to remain permanently impaired. In the last decades, non-invasive brain stimulation (NIBS) techniques have emerged as potential add-on interventions to the standard neurorehabilitation programs to improve post-stroke recovery. Due to their ability to modulate cortical excitability and to induce neuroreparative processes in the brain, multiple studies have assessed the safety, efficacy and (sub)cellular mechanisms of NIBS following ischemic stroke. In this review, an overview will be provided of the different NIBS techniques that are currently being investigated in (pre)clinical stroke studies. The NIBS therapies that will be discussed include transcranial magnetic stimulation, transcranial direct current stimulation and extremely low frequency electromagnetic stimulation. First, an overview will be given of the cellular mechanisms induced by NIBS that are associated with enhanced stroke outcome in preclinical models. Furthermore, the current knowledge on safety and efficacy of these NIBS techniques in stroke patients will be reviewed.

Cerebellar Differences after Rehabilitation in Children with Developmental Coordination Disorder

Developmental coordination disorder (DCD) affects a child's ability to learn motor skills. Cognitive Orientation to daily Occupational Performance (CO-OP) is one of the recommended treatments to help achieve functional motor goals. The purpose of this study was to determine if CO-OP intervention induces functional improvements and structural changes in the cerebellum of children with DCD. Using a randomized waitlist-controlled trial, we investigated the effects of CO-OP intervention on cerebellar volume in 47 children with DCD (8-12 years old). Outcome measures included the Canadian Occupational Performance Measure, Performance Quality Rating Scale (PQRS), and Bruininks-Oseretsky Test of Motor Proficiency-2. The SUIT toolbox was used to carry out voxel-based morphometry using T1-weighted MRI scans. Children with DCD showed improved motor outcomes and increased gray matter volume in the brainstem, right crus II, bilateral lobules VIIIb, and left lobule IX following CO-OP. Significant associations were found between PQRS scores and regional gray matter changes in the brainstem, right crus II, right lobule VIIb, right and left lobule VIIIb, and vermis IX. Given the improved motor and brain outcomes with CO-OP, it is recommended that children with DCD be referred for this rehabilitation intervention.

A Wearable Mixed Reality Platform to Augment Overground Walking: A Feasibility Study

Humans routinely modify their walking speed to adapt to functional goals and physical demands. However, damage to the central nervous system (CNS) often results in abnormal modulation of walking speed and increased risk of falls. There is considerable interest in treatment modalities that can provide safe and salient training opportunities, feedback about walking performance, and that may augment less reliable sensory feedback within the CNS after injury or disease. Fully immersive virtual reality technologies show benefits in boosting training-related gains in walking performance; however, they lack views of the real world that may limit functional carryover. Augmented reality and mixed reality head-mount displays (MR-HMD) provide partially immersive environments to extend the virtual reality benefits of interacting with virtual objects but within an unobstructed view of the real world. Despite this potential advantage, the feasibility of using MR-HMD visual feedback to promote goal-directed changes in overground walking speed remains unclear. Thus, we developed and evaluated a novel mixed reality application using the Microsoft HoloLens MR-HMD that provided real-time walking speed targets and augmented visual feedback during overground walking. We tested the application in a group of adults not living with disability and examined if they could use the targets and visual feedback to walk at 85%, 100%, and 115% of each individual’s self-selected speed. We examined whether individuals were able to meet each target gait speed and explored differences in accuracy across repeated trials and at the different speeds. Additionally, given the importance of task-specificity to therapeutic interventions, we examined if walking speed adjustment strategies were consistent with those observed during usual overground walking, and if walking with the MR-HMD resulted in increased variability in gait parameters. Overall, participants matched their overground walking speed to the target speed of the MR-HMD visual feedback conditions (all p-values > 0.05). The percent inaccuracy was approximately 5% across all speed matching conditions and remained consistent across walking trials after the first overall walking trial. Walking with the MR-HMD did not result in more variability in walking speed, however, we observed more variability in stride length and time when walking with feedback from the MR-HMD compared to walking without feedback. The findings offer support for mixed reality-based visual feedback as a method to provoke goal-specific changes in overground walking behavior. Further studies are necessary to determine the clinical safety and efficacy of this MR-HMD technology to provide extrinsic sensory feedback in combination with traditional treatments in rehabilitation.