Constraint-induced movement therapy: a method for harnessing neuroplasticity to treat motor disorders

Effectiveness of Intermittent Theta Burst Stimulation to Enhance Upper Extremity Recovery After Stroke: A Pilot Study

OBJECTIVES

To first investigate the effectiveness of modified constraint-ınduced movement therapy (mCIMT) in low-functioning patients with stroke (PwS). Second, we aimed to investigate the efficiency of intermittent theta-burst stimulation (iTBS), applied on intermittent days, in addition to the mCIMT in PwS.

DESIGN

A randomized, sham-controlled, single-blinded study.

SETTING

Outpatient clinic.

PARTICIPANTS

Fifteen PwS (age [mean±SD]: 66.3±9.2 years; 53% female) who were in the first 1 to 12 months after the incident were included in the study.

INTERVENTIONS

PwS were divided into 3 groups: (1) mCIMT alone; (2) mCIMT + sham iTBS; (3) mCIMT + iTBS. Each group received 15 sessions of mCIMT (1 hour/session, 3 sessions/week). iTBS was applied with 600 pulses on impaired M1 before mCIMT.

MAIN OUTCOME MEASURES

Upper extremity (UE) impairment was assessed with the Fugl-Meyer Test (FMT-UE), whereas the motor function was evaluated with the Wolf-Motor Function Test (WMFT). Motor Activity Log-28 (MAL-28) was used to evaluate the amount of use and how well (How Well Scale) the impaired UE movements.

RESULTS

With-in-group analysis revealed that all groups had statistically significant improvements based on the FMT-UE and MAL-28 (p<.05). However, the performance time and arm strength variables of WMFT were only increased in the mCIMT + iTBS group (p<.05). The only between-group difference was observed in the intracortical facilitation in favor of the mCIMT + iTBS group (p<.05). The effect size of iTBS was f=0.18.

CONCLUSIONS

Our findings suggest that mCIMT with and without the application of iTBS has increased the UE motor function in low-functioning PwS. iTBS applied on intermittent days may have additional benefits as an adjunct therapy for facilitating cortical excitability, increasing the speed and strength of the impaired UE as well as decreasing disability.

Priming constraint-induced movement therapy with intermittent theta burst stimulation to enhance upper extremity recovery in patients with stroke: protocol for a randomized controlled study

BACKGROUND

The treatments based on motor control and motor learning principles have gained popularity in the last 20 years, as well as non-invasive brain stimulations that enhance neuroplastic changes after stroke. However, the effect of intermittent theta burst stimulation (iTBS) in addition to evidence-based, intensive neurorehabilitation approaches such as modified constraint-induced movement therapy (mCIMT) is yet to be investigated.

AIM

We aim to establish a protocol for a randomized controlled study investigating the efficiency of mCIMT primed with iTBS after stroke.

METHODS

In this randomized controlled, single-blind study, patients with stroke (N = 17) will be divided into 3 groups: (a) mCIMT + real iTBS, (b) mCIMT + sham iTBS, and (c) mCIMT alone. 600-pulse iTBS will be delivered to the primary motor cortex on the ipsilesional hemisphere, and then, patients will receive mCIMT for 1 h/session, 3 sessions/week for 5 weeks. Upper extremity recovery will be assessed with Fugl-Meyer Test-Upper Extremity and Wolf Motor Function Test. Electrophysiological assessments, such as Motor-Evoked Potentials, Resting Motor Threshold, Short-Intracortical Inhibition, and Intracortical Facilitation, will also be included.

CONCLUSIONS

In this study, a protocol of an ongoing intervention study investigating the effectiveness of iTBS on ipsilesional M1 prior to the mCIMT in patients with stroke is proposed. This will be the first study to research priming mCIMT with iTBS and it may have the potential to reveal the true effect of the iTBS when it is added to the high-quality neurorehabilitation approaches.

TRIAL REGISTRATION

Trial registration number: NCT05308667.

Feasibility and usability of a virtual-reality-based sensorimotor activation apparatus for carpal tunnel syndrome patients

PURPOSE

This study aimed to assess the usability of a virtual reality-assisted sensorimotor activation (VRSMA) apparatus for individual digit rehabilitation. The study had two main objectives: Firstly, to collect preliminary data on the expectations and preferences of patients with carpal tunnel syndrome (CTS) regarding virtual reality (VR) and an apparatus-assisted therapy for their affected digits. Secondly, to evaluate the usability of the VRSMA apparatus that was developed.

METHODS

The VRSMA system consists of an apparatus that provides sensory and motor stimulation via a vibratory motor and pressure sensor attached to a button, and a virtual reality-based visual cue provided by texts overlaid on top of a 3D model of a hand. The study involved 10 CTS patients who completed five blocks of VRSMA with their affected hand, with each block corresponding to the five digits. The patients were asked to complete a user expectations questionnaire before experiencing the VRSMA, and a user evaluation questionnaire after completing the VRSMA. Expectations for VRSMA were obtained from the questionnaire results using a House of Quality (HoQ) analysis.

RESULTS

In the survey for expectations, participants rated certain attributes as important for a rehabilitation device for CTS, with mean ratings above 4 for attributes such as ease of use, ease of understanding, motivation, and improvement of hand function based on clinical evidence. The level of immersion and an interesting rehabilitation regime received lower ratings, with mean ratings above 3.5. The survey evaluating VRSMA showed that the current prototype was overall satisfactory with a mean rating of 3.9 out of 5. Based on the HoQ matrix, the highest priority for development of the VRSMA was to enhance device comfort and usage time. This was followed by the need to perform more clinical studies to provide evidence of the efficacy of the VRSMA. Other technical characteristics, such as VRSMA content and device reliability, had lower priority scores.

CONCLUSION

The current study presents a potential for an individual digit sensorimotor rehabilitation device that is well-liked by CTS patients.

Progress in the clinical application of constraint-induced therapy following stroke since 2014

Stroke is a group of cerebrovascular diseases with high prevalence and mortality rate. Stroke can induce many impairments, including motor and cognitive dysfunction, aphasia/dysarthria, dysphagia, and mood disorders, which may reduce the quality of life among the patients. Constraint-induced therapy has been proven to be an effective treatment method for stroke rehabilitation. It has been widely used in the recovery of limb motor dysfunction, aphasia, and other impairment like unilateral neglect after stroke. In recent years, constraint-induced therapy can also combine with telehealth and home rehabilitation. In addition, constraint-induced therapy produces significant neuroplastic changes in the central nervous system. Functional magnetic resonance imaging, diffusion tensor imaging, and other imaging/electrophysiology methods have been used to clarify the mechanism and neuroplasticity. However, constraint-induced therapy has some limitations. It can only be used under certain conditions, and the treatment time and effectiveness are controversial. Further research is needed to clarify the mechanism and effectiveness of CI therapy.

Upper limb intelligent feedback robot training significantly activates the cerebral cortex and promotes the functional connectivity of the cerebral cortex in patients with stroke: A functional near-infrared spectroscopy study

Background

Upper limb intelligence robots are widely used to improve the upper limb function of patients with stroke, but the treatment mechanism is still not clear. In this study, functional near-infrared spectroscopy (fNIRS) was used to evaluate the concentration changes of oxygenated hemoglobin (oxy-Hb) and deoxyhemoglobin (deoxy-Hb) in different brain regions and functional connectivity (FC) of the cerebral cortex in patients with stroke.

Method

Twenty post-stroke patients with upper limb dysfunction were included in the study. They all received three different types of shoulder joint training, namely, active intelligent feedback robot training (ACT), upper limb suspension training (SUS), and passive intelligent feedback robot training (PAS). During the training, activation of the cerebral cortex was detected by fNIRS to obtain the concentration changes of hemoglobin and FC of the cerebral cortex. The fNIRS signals were recorded over eight ROIs: bilateral prefrontal cortices (PFC), bilateral primary motor cortices (M1), bilateral primary somatosensory cortices (S1), and bilateral premotor and supplementary motor cortices (PM). For easy comparison, we defined the right hemisphere as the ipsilesional hemisphere and flipped the lesional right hemisphere in the Nirspark.

Result

Compared with the other two groups, stronger cerebral cortex activation was observed during ACT. One-way repeated measures ANOVA revealed significant differences in mean oxy-Hb changes among conditions in the four ROIs: contralesional PFC [F_{(2, 48)} = 6,798, p < 0.01], ipsilesional M1 [F_{(2, 48)} = 6.733, p < 0.01], ipsilesional S1 [F_{(2, 48)} = 4,392, p < 0.05], and ipsilesional PM [F_{(2, 48)} = 3.658, p < 0.05]. Oxy-Hb responses in the contralesional PFC region were stronger during ACT than during SUS (p < 0.01) and PAS (p < 0.05). Cortical activation in the ipsilesional M1 was significantly greater during ACT than during SUS (p < 0.01) and PAS (p < 0.05). Oxy-Hb responses in the ipsilesional S1 (p < 0.05) and ipsilesional PM (p < 0.05) were significantly higher during ACT than during PAS, and there is no significant difference in mean deoxy-Hb changes among conditions. Compared with SUS, the FC increased during ACT, which was characterized by the enhanced function of the ipsilesional cortex (p < 0.05), and there was no significant difference in FC between the ACT and PAS.

Conclusion

The study found that cortical activation during ACT was higher in the contralesional PFC, and ipsilesional M1 than during SUS, and showed tighter cortical FC between the cortices. The activation of the cerebral cortex of ACT was significantly higher than that of PAS, but there was no significant difference in FC. Our research helps to understand the difference in cerebral cortex activation between upper limb intelligent feedback robot rehabilitation and other rehabilitation training and provides an objective basis for the further application of upper limb intelligent feedback robots in the field of stroke rehabilitation.

The role of feedback in the robotic-assisted upper limb rehabilitation in people with multiple sclerosis: a systematic review

INTRODUCTION

Robotic-assisted upper limb rehabilitation might improve upper limb recovery in people with multiple sclerosis (PwMS) with moderate-to-severe disability. In the few existing studies, the training effects have been related to the type of intervention, if intensive, repetitive, or task-oriented training might promote neuroplasticity and recovery. Notably, most of these devices operate within a serious game context providing different feedback. Since feedback is a key component of motor control and thus involved in motor and cognitive rehabilitation, clinicians cannot desist from considering the potential contribution of feedback in the upper limb robot-assisted rehabilitation effects.

AREA COVERED

In this systematic review, we reported the rehabilitation protocols used in the robot-assisted upper limb training in PwMS to provide state-of-the-art on the role of feedback in robotic-assisted Upper Limb rehabilitation. PubMed, the Cochrane Library, and the Physiotherapy Evidence Database databases were systematically searched from inception to March 2022. After a literature search, the classification systems for feedback and the serious game were applied.

EXPERT OPINION

There is a need for sharing standard definitions and components of feedback and serious game in technologically assisted upper limb rehabilitation. Indeed, improving these aspects might further improve the effectiveness of such training in the management of PwMS.

Effects of constraint-induced movement therapy for the lower extremity among individuals post-stroke: A randomized controlled clinical trial

BACKGROUND: Stroke often leads to lower extremity impairments that significantly hinders functional recovery. OBJECTIVE: To investigate the effectiveness of constraint-induced movement therapy for the lower extremity (CIMT-LE) for improving balance and ambulation among people post-stroke. METHODS: A randomized controlled, single-blinded clinical trial was conducted. Participants were recruited and randomized into one of two groups: CIMT-LE group and control. Outcome measures were the Fugl-Meyer assessment of lower extremity, Berg balance scale, ten-meter walk test and six-minute walk test. Outcome measures were collected at baseline, following the conclusion of the therapeutic programs and after three months. RESULTS: 38 participants were enrolled in the study (19 in each group). No significant differences were found between groups at baseline. At the conclusion of therapeutic programs, both groups showed significant changes compared to baseline. However, changes seen in the CIMT-LE were clinically significant. Further, at three months following the conclusion of the program, the recorded improvements were retained by participants. CONCLUSION: A CIMT-LE program compared to an intensity-matched conventional program yielded significant clinical improvements among people post-stroke. These improvements were seen in lower extremity motor recovery, postural balance and gait speed. Furthermore, these improvements were retained three months following the conclusion of the therapeutic program.

Effective brain network analysis in unilateral and bilateral upper limb exercise training in subjects with stroke

PURPOSE

Knowing the patterns of brain activation that occur and networks involved under different interventions is important for motor recovery in subjects with stroke. This study aimed to study the patterns of brain activation and networks in two interventions, affected upper limb side and bilateral exercise training, using concurrent functional near-infrared spectroscopy (fNIRS) imaging.

METHODS

Thirty-two patients in the early subacute stage were randomly divided into two groups: unilateral and bilateral groups. The patients in the unilateral group underwent isokinetic muscle strength training on the affected upper limb side and patients in the bilateral group underwent bilateral upper limb training. Oxyhemoglobin and deoxyhemoglobin concentration changes (ΔHbO₂ and ΔHbR, respectively) were recorded in the ipsilateral and contralateral prefrontal cortex (IPFC and CPFC, respectively) and ipsilateral and contralateral motor cortex (IMC and CMC, respectively) by fNIRS equipment in the resting state and training conditions. The phase information of a 0.01-0.08 Hz fNIRS signal was extracted by the wavelet transform method. Dynamic Bayesian inference was adopted to calculate the coupling strength and direction of effective connectivity. The network threshold was determined by surrogate signal method, the global (weighted clustering coefficient, global efficiency and small-worldness) and local (degree, betweenness centrality and local efficiency) network metrics were calculated. The degree of cerebral lateralization was also compared between the two groups.

RESULTS

The results of covariance analysis showed that, compared with bilateral training, the coupling effect of CMC→IMC was significantly enhanced (p = 0.03); also, the local efficiency of the IMC (p = 0.01), IPFC (p<0.001), and CPFC (p = 0.006) and the hemispheric autonomy index of IPFC (p = 0.007) were significantly increased in unilateral training. In addition, there was a significant positive correlation between the coupling intensity of the inter-hemispheric motor area and the shifted local efficiency.

CONCLUSIONS

The results indicated that unilateral upper limb training could more effectively promote the interaction and balance of bilateral motor hemispheres and help brain reorganization in the IMC and prefrontal cortex in stroke patients. The method provided in this study could be used to evaluate dynamic brain activation and network reorganization under different interventions, thus improving the strategy of rehabilitation intervention in a timely manner and resulting in better motor recovery. This article is protected by copyright. All rights reserved.

Contralesional plasticity following constraint-induced movement therapy benefits outcome: contributions of the intact hemisphere to functional recovery

Stroke is a leading cause of death and disability worldwide. A common, chronic deficit after stroke is upper limb impairment, which can be exacerbated by compensatory use of the nonparetic limb. Resulting in learned nonuse of the paretic limb, compensatory reliance on the nonparetic limb can be discouraged with constraint-induced movement therapy (CIMT). CIMT is a rehabilitative strategy that may promote functional recovery of the paretic limb in both acute and chronic stroke patients through intensive practice of the paretic limb combined with binding, or otherwise preventing activation of, the nonparetic limb during daily living exercises. The neural mechanisms that support CIMT have been described in the lesioned hemisphere, but there is a less thorough understanding of the contralesional changes that support improved functional outcome following CIMT. Using both human and non-human animal studies, the current review explores the role of the contralesional hemisphere in functional recovery of stroke as it relates to CIMT. Current findings point to a need for a better understanding of the functional significance of contralesional changes, which may be determined by lesion size, location, and severity as well stroke chronicity.

Resting motor threshold in the course of hand motor recovery after stroke: a systematic review

Background

Resting motor threshold is an objective measure of cortical excitability. Numerous studies indicate that the success of motor recovery after stroke is significantly determined by the direction and extent of cortical excitability changes. A better understanding of this topic (particularly with regard to the level of motor impairment and the contribution of either cortical hemisphere) may contribute to the development of effective therapeutical strategies in this cohort.

Objectives

This systematic review collects and analyses the available evidence on resting motor threshold and hand motor recovery in stroke patients.

Methods

PubMed was searched from its inception through to 31/10/2020 on studies investigating resting motor threshold of the affected and/or the non-affected hemisphere and motor function of the affected hand in stroke cohorts.

Results

Overall, 92 appropriate studies (including 1978 stroke patients and 377 healthy controls) were identified. The analysis of the data indicates that severe hand impairment is associated with suppressed cortical excitability within both hemispheres and with great between-hemispheric imbalance of cortical excitability. Favorable motor recovery is associated with an increase of ipsilesional motor cortex excitability and reduction of between-hemispheric imbalance. The direction of change of contralesional motor cortex excitability depends on the amount of hand motor impairment. Severely disabled patients show an increase of contralesional motor cortex excitability during motor recovery. In contrast, recovery of moderate to mild hand motor impairment is associated with a decrease of contralesional motor cortex excitability.

Conclusions

This data encourages a differential use of rehabilitation strategies to modulate cortical excitability. Facilitation of the ipsilesional hemisphere may support recovery in general, whereas facilitation and inhibition of the contralesional hemisphere may enhance recovery in severe and less severely impaired patients, respectively.

The impact of Body Mass Index on functional rehabilitation outcomes of working-age inpatients with stroke

BACKGROUND

Stroke is the most relevant cause of acquired persistent disability in adulthood. The relationship between patient's weight during rehabilitation and stroke functional outcome is controversial, previous research reported positive, negative and no effects, with scarce studies specifically addressing working-age patients.

AIM

To evaluate the association between Body Mass Index (BMI) and the functional progress of adult (<65 years) patients with stroke admitted to a rehabilitation hospital.

DESIGN

Retrospective observational cohort study.

SETTING

Inpatient rehabilitation center.

POPULATION

178 stroke patients (ischemic or hemorrhagic).

METHODS

Point-biserial and Spearman's correlations, multivariate linear regressions and analysis of covariance were used to describe differences in functional outcomes after adjusting for age, sex, severity, dysphagia, depression and BMI category. Functional Independence Measure (FIM), FIM gain, efficiency and effectiveness were assessed.

RESULTS

Participants were separated in 3 BMI categories: normal weight (47%), overweight (33%) and obese (20%). There were no significant differences between BMI categories in any functional outcome (total FIM [T-FIM], cognitive [C-FIM]), motor [M-FIM]) at discharge, admission, gain, efficiency or effectiveness. In regression models BMI (as continuous variable) was not significant predictor of T-FIM at discharge after adjusting for age, sex, severity, dysphagia, depression and ataxia (R²=0.4813), significant predictors were T-FIM at admission (β=0.528) and NIHSS (β=-0.208). M-FIM efficiency did not significantly differ by BMI subgroups, neither did C-FIM efficiency. Length of stay (LOS) and T-FIM effectiveness were associated for normal (r=0.33) and overweight (r=0.43), but not for obese. LOS and T-FIM efficiency were strongly negatively associated only for obese (r=-0.50).

CONCLUSIONS

FIM outcomes were not associated to BMI, nevertheless each BMI category when individually considered (normal weight, overweight or obese) was characterized by different associations involving FIM outcomes and clinical factors.

CLINICAL REHABILITATION IMPACT

In subacute post-stroke working-age patients undergoing rehabilitation, BMI was not associated to FIM outcomes (no obesity paradox was reported in this sample). Distinctive significant associations emerged within each BMI category, (supporting their characterization) such as length of stay and T-FIM effectiveness were associated for normal weight and overweight, but not for obese. Length of stay and T-FIM efficiency were strongly negatively associated only for obese.

Subacute ischemic stroke rehabilitation outcomes in working-age adults: The role of aphasia in cognitive functional independence

BACKGROUND

About one-third of adult stroke patients suffer from aphasia when they are discharged from hospital. Aphasia seems to be a negative predictive factor affecting post-stroke functional recovery after rehabilitation, but this association has been scarcely addressed in previous research.

OBJECTIVES

We aim to evaluate the impact of aphasia in cognitive functional outcomes in working-age first-ever ischemic stroke adults.

METHODS

Retrospective observational cohort study. One hundred and thirty ischemic (≤ 64 years old) adult stroke patients (43.07% with aphasia) admitted to a rehabilitation center between 2007 and 2019 were analyzed. Univariate and multivariate linear regressions were performed using state-of-the-art variables (stroke severity, gender, age) extending them with potential confounders (e.g. diabetes, medication for depression). The cognitive subtest (C-FIM) of the Functional Independence Measure (FIM) at discharge and C-FIM gain were the dependent variables.

RESULTS

Patients with aphasia (PWA) had lower C-FIM scores at admission and at discharge. No significant differences were observed in relation to C-FIM gain, C-FIM efficiency, C-FIM effectiveness and length of stay (LOS).C-FIM gain was remarkably higher though non-significant (p = .059) in PWA. Regression analysis identifies C-FIM at admission and aphasia as significant predictors of C-FIM at discharge (R² = 0.72). The same variables plus taking medication for depression predicted C-FIM gain (R² = 0.38).

CONCLUSIONS

We identified no significant differences in C-FIM outcomes (gain, efficiency and effectiveness) either in LOS between PWA and patients without aphasia, though C-FIM differences were significant at admission and discharge. Aphasia was a significant predictor of C-FIM gain and C-FIM at discharge.

Self-powered robots to reduce motor slacking during upper-extremity rehabilitation: a proof of concept study

BACKGROUND

Robotic rehabilitation is a highly promising approach to recover lost functions after stroke or other neurological disorders. Unfortunately, robotic rehabilitation currently suffers from "motor slacking", a phenomenon in which the human motor system reduces muscle activation levels and movement excursions, ostensibly to minimize metabolic- and movement-related costs. Consequently, the patient remains passive and is not fully engaged during therapy. To overcome this limitation, we envision a new class of body-powered robots and hypothesize that motor slacking could be reduced if individuals must provide the power to move their impaired limbs via their own body (i.e., through the motion of a healthy limb).

OBJECTIVE

To test whether a body-powered exoskeleton (i.e. robot) could reduce motor slacking during robotic training.

METHODS

We developed a body-powered robot that mechanically coupled the motions of the user's elbow joints. We tested this passive robot in two groups of subjects (stroke and able-bodied) during four exercise conditions in which we controlled whether the robotic device was powered by the subject or by the experimenter, and whether the subject's driven arm was engaged or at rest. Motor slacking was quantified by computing the muscle activation changes of the elbow flexor and extensor muscles using surface electromyography.

RESULTS

Subjects had higher levels of muscle activation in their driven arm during self-powered conditions compared to externally-powered conditions. Most notably, subjects unintentionally activated their driven arm even when explicitly told to relax when the device was self-powered. This behavior was persistent throughout the trial and did not wane after the initiation of the trial.

CONCLUSIONS

Our findings provide novel evidence indicating that motor slacking can be reduced by self-powered robots; thus demonstrating promise for rehabilitation of impaired subjects using this new class of wearable system. The results also serve as a foundation to develop more sophisticated body-powered robots (e.g., with controllable transmissions) for rehabilitation purposes.

Athletes with Brain Injury: Pathophysiologic and Medical Challenges

Participation in elite sporting activities is becoming increasingly popular for individuals with brain injury. This article outlines the types of brain injury and the associated movement dysfunctions. In addition, specific pathophysiologic and medical challenges facing athletes with brain injury are discussed. Further research conducted using athletes with brain injury will add to the existing literature indicating the benefits of athletic training in this population. Increased scientific study within this area stands to further improve understanding of the complex interaction between neuromuscular impairment and athletic performance.

Management of Pediatric Movement Disorders: Present and Future

Management of movement disorders in children is an evolving field. This article outlines the major categories of treatment options for pediatric movement disorders and general guidelines for their use. We review the evidence for existing therapies, which continue to lack large-scale controlled trials to guide treatment decisions. The field continues to rely on extrapolations from adult studies and lower quality evidence such as case reports and case series to guide treatment guidelines and consensus statements. Developments in new pharmaceuticals for rare diseases have begun to provide hope for those cases in which a genetic diagnosis can be made. Advances in surgical therapies such as deep brain stimulation as well as new modes of treatment such as gene therapy, epigenetic modulation, and stem cell therapy hold promise for improving outcomes in both primary and secondary causes of movement disorders. There is a critical need for larger, multicenter, controlled clinical trials to fully evaluate treatments for pediatric movement disorders.

Restoring Motor Functions After Stroke: Multiple Approaches and Opportunities

More than 1.5 million people suffer a stroke in Europe per year and more than 70% of stroke survivors experience limited functional recovery of their upper limb, resulting in diminished quality of life. Therefore, interventions to address upper-limb impairment are a priority for stroke survivors and clinicians. While a significant body of evidence supports the use of conventional treatments, such as intensive motor training or constraint-induced movement therapy, the limited and heterogeneous improvements they allow are, for most patients, usually not sufficient to return to full autonomy. Various innovative neurorehabilitation strategies are emerging in order to enhance beneficial plasticity and improve motor recovery. Among them, robotic technologies, brain-computer interfaces, or noninvasive brain stimulation (NIBS) are showing encouraging results. These innovative interventions, such as NIBS, will only provide maximized effects, if the field moves away from the “one-fits all” approach toward a “patient-tailored” approach. After summarizing the most commonly used rehabilitation approaches, we will focus on NIBS and highlight the factors that limit its widespread use in clinical settings. Subsequently, we will propose potential biomarkers that might help to stratify stroke patients in order to identify the individualized optimal therapy. We will discuss future methodological developments, which could open new avenues for poststroke rehabilitation, toward more patient-tailored precision medicine approaches and pathophysiologically motivated strategies.

Multidisciplinary Rehabilitation is Efficacious and Induces Neural Plasticity in Multiple Sclerosis even when Complicated by Progressive Multifocal Leukoencephalopathy

A 48-year-old woman with multiple sclerosis (MS), treated with natalizumab for more than one year without clinical and magnetic resonance imaging (MRI) signs of disease activity, was diagnosed with definite progressive multifocal leukoencephalopathy (PML). She presented with subacute motor deficit of the right upper limb (UL), followed by involvement of the homolateral leg and urinary urgency. The patient was treated with steroids and plasma exchange. On follow-up MRI scans, the PML lesion remained stable and no MS rebounds were observed, but the patient complained of a progressive worsening of the right UL motor impairment, becoming dependent in most activities of daily living. A cycle of multidisciplinary rehabilitation (MDR) was then started, including daily sessions of UL robot therapy and occupational therapy. Functional MRI (fMRI) was acquired before and at the end of the MDR cycle using a motor task which consisted of 2 runs: in one run the patient was asked to observe while the second one consisted of hand grasping movements. At the end of the rehabilitation period, both the velocity and the smoothness of arm trajectories during robot-based reaching movements were significantly improved. After MDR, compared with baseline, fMRI showed significantly increased functional activation within the sensory-motor network in the active, motor task, while no significant differences were found in the observational task. MDR in MS, including robot-assisted UL training, seems to be clinically efficacious and to have a significant impact on brain functional reorganization on a short-term, even in the presence of superimposed tissue damage provoked by PML.

A textured insole improves gait symmetry in individuals with stroke

PURPOSE

Gait asymmetry is a common consequence of stroke and improving gait symmetry is an important goal of rehabilitation. We investigated the effect of a single textured insole in improving gait symmetry in individuals with stroke.

METHOD

Seventeen individuals with stroke who had asymmetrical gait were recruited and required to walk with a textured insole positioned in the shoe on the unaffected side or without the insole. Gait parameters were evaluated using the instrumented walkway. Gait velocity, cadence, and symmetry indices for the spatial and temporal parameters of gait and center of pressure displacements were obtained.

RESULTS

When walking with a textured insole, symmetry indexes for stance, single support phases of gait, as well as center of pressure displacements improved significantly. While using a textured insole, the duration of the stance phase and a single support phase decreased on the unaffected side and increased on the affected side significantly. Gait velocity and cadence were not affected by the use of the insole.

CONCLUSIONS

Individuals with stroke walking with a textured insole placed in the shoe on the unaffected side improved the symmetry of their gait. The outcome provides a foundation for future investigations of the efficacy of using a single textured insole in gait rehabilitation of individuals with unilateral impairment. Implications for Rehabilitation A single textured insole positioned in the shoe on the unaffected side improved gait symmetry in individuals with stroke. Gait velocity and cadence were not affected by the use of the insole.

Video Game Rehabilitation for Outpatient Stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis

Background

Constraint-Induced Movement therapy (CI therapy) is shown to reduce disability, increase use of the more affected arm/hand, and promote brain plasticity for individuals with upper extremity hemiparesis post-stroke. Randomized controlled trials consistently demonstrate that CI therapy is superior to other rehabilitation paradigms, yet it is available to only a small minority of the estimated 1.2 million chronic stroke survivors with upper extremity disability. The current study aims to establish the comparative effectiveness of a novel, patient-centered approach to rehabilitation utilizing newly developed, inexpensive, and commercially available gaming technology to disseminate CI therapy to underserved individuals. Video game delivery of CI therapy will be compared against traditional clinic-based CI therapy and standard upper extremity rehabilitation. Additionally, individual factors that differentially influence response to one treatment versus another will be examined.

Methods

This protocol outlines a multi-site, randomized controlled trial with parallel group design. Two hundred twenty four adults with chronic hemiparesis post-stroke will be recruited at four sites. Participants are randomized to one of four study groups: (1) traditional clinic-based CI therapy, (2) therapist-as-consultant video game CI therapy, (3) therapist-as-consultant video game CI therapy with additional therapist contact via telerehabilitation/video consultation, and (4) standard upper extremity rehabilitation. After 6-month follow-up, individuals assigned to the standard upper extremity rehabilitation condition crossover to stand-alone video game CI therapy preceded by a therapist consultation. All interventions are delivered over a period of three weeks. Primary outcome measures include motor improvement as measured by the Wolf Motor Function Test (WMFT), quality of arm use for daily activities as measured by Motor Activity Log (MAL), and quality of life as measured by the Quality of Life in Neurological Disorders (NeuroQOL).

Discussion

This multi-site RCT is designed to determine comparative effectiveness of in-home technology-based delivery of CI therapy versus standard upper extremity rehabilitation and in-clinic CI therapy. The study design also enables evaluation of the effect of therapist contact time on treatment outcomes within a therapist-as-consultant model of gaming and technology-based rehabilitation.

Trial registration

Clinicaltrials.gov, NCT02631850.

Using Biophysical Models to Understand the Effect of tDCS on Neurorehabilitation: Searching for Optimal Covariates to Enhance Poststroke Recovery

Stroke is a leading cause of worldwide disability, and up to 75% of survivors suffer from some degree of arm paresis. Recently, rehabilitation of stroke patients has focused on recovering motor skills by taking advantage of use-dependent neuroplasticity, where high-repetition of goal-oriented movement is at times combined with non-invasive brain stimulation, such as transcranial direct current stimulation (tDCS). Merging the two approaches is thought to provide outlasting clinical gains, by enhancing synaptic plasticity and motor relearning in the motor cortex primary area. However, this general approach has shown mixed results across the stroke population. In particular, stroke location has been found to correlate with the likelihood of success, which suggests that different patients might require different protocols. Understanding how motor rehabilitation and stimulation interact with ongoing neural dynamics is crucial to optimize rehabilitation strategies, but it requires theoretical and computational models to consider the multiple levels at which this complex phenomenon operate. In this work, we argue that biophysical models of cortical dynamics are uniquely suited to address this problem. Specifically, biophysical models can predict treatment efficacy by introducing explicit variables and dynamics for damaged connections, changes in neural excitability, neurotransmitters, neuromodulators, plasticity mechanisms, and repetitive movement, which together can represent brain state, effect of incoming stimulus, and movement-induced activity. In this work, we hypothesize that effects of tDCS depend on ongoing neural activity and that tDCS effects on plasticity may be also related to enhancing inhibitory processes. We propose a model design for each step of this complex system, and highlight strengths and limitations of the different modeling choices within our approach. Our theoretical framework proposes a change in paradigm, where biophysical models can contribute to the future design of novel protocols, in which combined tDCS and motor rehabilitation strategies are tailored to the ongoing dynamics that they interact with, by considering the known biophysical factors recruited by such protocols and their interaction.

Neuroplasticity-Based Technologies and Interventions for Restoring Motor Functions in Multiple Sclerosis

Motor impairments are very common in multiple sclerosis (MS), leading to a reduced Quality of Life and active participation. In the past decades, new insights into the functional reorganization processes that occur after a brain injury have been introduced. Specifically, the motor practice seems to be determinant to induce neuroplastic changes and motor recovery. More recently, these findings have been extended to multiple sclerosis, in particular, it has been hypothesized that disease progression, functional reorganization and disability are mutually related. For this reason, neuroplasticity-based technologies and interventions have been rapidly introduced in MS rehabilitation. Constraint-induced movement therapy (CIMT), robotics and virtual reality training are new rehabilitative interventions that deliver an intensive e task-specific practice, which are two critical factors associated with functional improvements and cortical reorganization. Another promising strategy for enhancing neuroplastic changes is non-invasive brain stimulation that can be used with a priming effect on motor training. The aims of this chapter are to review the evidence of neuroplastic changes in multiple sclerosis and to present technologies and interventions that have been tested in clinical trials.

Neurorehabilitation Strategies Focusing on Ankle Control Improve Mobility and Posture in Persons With Multiple Sclerosis

BACKGROUND AND PURPOSE

The neuromuscular impairments seen in the ankle plantarflexors have been identified as a primary factor that limits the mobility and standing postural balance of individuals with multiple sclerosis (MS). However, few efforts have been made to find effective treatment strategies that will improve the ankle plantarflexor control. Our objective was to determine whether an intensive 14-week neurorehabilitation protocol has the potential to improve the ankle plantarflexor control of individuals with MS. The secondary objectives were to determine whether the protocol would also improve postural control, plantarflexion strength, and mobility.

METHODS

Fifteen individuals with MS participated in a 14-week neurorehabilitation protocol, and 20 healthy adults served as a comparison group. The primary measure was the amount of variability in the submaximal steady-state isometric torque, which assessed plantarflexor control. Secondary measures were the Sensory Organization Test composite score, maximum plantarflexion torque, and the spatiotemporal gait kinematics.

RESULTS

There was less variability in the plantarflexion torques after the neurorehabilitation protocol (preintervention, 4.15% ± 0.5%; postintervention, 2.27% ± 0.3%). In addition, there were less postural sway (preintervention, 51.87 ± 0.2 points; postintervention, 67.8 ± 0.5 points), greater plantarflexion strength (preintervention, 0.46 ± 0.04 Nm/kg; postintervention, 0.57 ± 0.05 Nm/kg), and faster walking speeds (preferred preintervention, 0.71 ± 0.05 m/s; preferred postintervention, 0.81 ± 0.05 m/s; fast-as-possible preintervention, 0.95 ± 0.06 m/s; postintervention, 1.11 ± 0.07 m/s). All of the outcome variables matched or trended toward those seen in the controls.

DISCUSSION AND CONCLUSIONS

The outcomes of this exploratory study suggest that the neurorehabilitation protocol employed in this investigation has the potential to promote clinically relevant improvements in the ankle plantarflexor control, standing postural balance, ankle plantarflexion strength, and the mobility of individuals with MS. Video abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A110).

Stroke Treatment Associated with Rehabilitation Therapy and Transcranial DC Stimulation (START-tDCS): a study protocol for a randomized controlled trial

Background

Traditional treatment for motor impairment after stroke includes medication and physical rehabilitation. The transcranial direct current stimulation associated with a standard physical therapy program may be an effective therapeutic alternative for these patients.

Methods

This study is a sham-controlled, double-blind, randomized clinical trial aiming to evaluate the efficacy of transcranial direct current stimulation in activities of daily living and motor function post subacute stroke. In total there will be 40 patients enrolled, diagnosed with subacute, ischemic, unilateral, non-recurring stroke. Participants will be randomized to two groups, one with active stimulation and the other with a placebo current. Patients and investigators will be blinded. Everyone will receive systematic physical therapy, based on constraint-induced movement therapy. The intervention will be applied for 10 consecutive days. Patients will undergo three functional assessments: at baseline, week 2, and week 4. Neuropsychological tests will be performed at baseline and week 4. Adverse effects will be computed at each session. On completion of the baseline measures, randomization will be conducted using random permuted blocks. The randomization will be concealed until group allocation.

Discussion

This study will investigate the combined effects of transcranial direct current stimulation and physical therapy on functional improvement after stroke. We tested whether the combination of these treatments is more effective than physical therapy alone when administered in the early stages after stroke.

Trial registration

NCT02156635 - May 30, 2014. Randomization is ongoing (40 participants randomized as of the end of December 2015).

[Evaluation of a method based on the principle of CI therapy in the correction of walking function in patients with post-stroke hemiparesis syndrome]

AIM

To develop a new, effective, affordable method of neurorehabilitation for the correction of walking functions based on the principle of CI (constraint-induced movement therapy) therapy in patients with the syndrome of hemiparesis of post-stroke origin.

MATERIAL AND METHODS

The study included 100 patients with moderate to marked syndrome of central hemiparesis in the recovery period of stroke. Patients were randomized into two groups. In the main group, the walk recovery was carried out using CI-therapy in complex with traditional methods of neurorehabilitation and in the comparison group, walk correction was performed by generally accepted methods of kinesiotherapy and physical therapy. Both groups were comparable by stage of stroke, the severity of paresis, age.

RESULTS AND CONCLUSION

The risk of fall significantly decreased in both groups of patients. The length and paretic step time significantly decreased in the main group. The effectiveness of the restoration of the function of walking was higher in the main group that allows us to recommend the method of correction of the walk based on the principle of CI therapy in the complex neurorehabilitation.

Upper Limb Immobilisation: A Neural Plasticity Model with Relevance to Poststroke Motor Rehabilitation

Advances in our understanding of the neural plasticity that occurs after hemiparetic stroke have contributed to the formulation of theories of poststroke motor recovery. These theories, in turn, have underpinned contemporary motor rehabilitation strategies for treating motor deficits after stroke, such as upper limb hemiparesis. However, a relative drawback has been that, in general, these strategies are most compatible with the recovery profiles of relatively high-functioning stroke survivors and therefore do not easily translate into benefit to those individuals sustaining low-functioning upper limb hemiparesis, who otherwise have poorer residual function. For these individuals, alternative motor rehabilitation strategies are currently needed. In this paper, we will review upper limb immobilisation studies that have been conducted with healthy adult humans and animals. Then, we will discuss how the findings from these studies could inspire the creation of a neural plasticity model that is likely to be of particular relevance to the context of motor rehabilitation after stroke. For instance, as will be elaborated, such model could contribute to the development of alternative motor rehabilitation strategies for treating poststroke upper limb hemiparesis. The implications of the findings from those immobilisation studies for contemporary motor rehabilitation strategies will also be discussed and perspectives for future research in this arena will be provided as well.

Paralympic athletes with cerebral palsy display altered pacing strategies in distance-deceived shuttle running trials

This study investigated performance and physiology to understand pacing strategies in elite Paralympic athletes with cerebral palsy (CP). Six Paralympic athletes with CP and 13 able-bodied (AB) athletes performed two trials of eight sets of 10 shuttles (total 1600m). One trial was distance-deceived (DEC, 1000 m + 600 m) one trial was nondeceived (N-DEC, 1600 m). Time (s), heart rate (HR, bpm), ratings of perceived exertion (RPE, units), and electromyography of five bilateral muscles (EMG) were recorded for each set of both trials. The CP group ran slower than the AB group, and pacing differences were seen in the CP DEC trial, presenting as a flat pacing profile over the trial (P < 0.05). HR was higher and RPE was lower in the CP group in both trials (P < 0.05). EMG showed small differences between groups, sides, and trials. The present study provides evidence for a possible pacing strategy underlying exercise performance and fatigue in CP. The results of this study show (1) underperformance of the CP group, and (2) altered pacing strategy utilization in the CP group. We proposed that even at high levels of performance, the residual effects of CP may negatively affect performance through selection of conservative pacing strategies during exercise.

Children with cerebral palsy have uncharacteristic somatosensory cortical oscillations after stimulation of the hand mechanoreceptors

Numerous clinical investigations have reported that children with cerebral palsy (CP) have tactile discrimination deficits that likely limit their ability to plan and manipulate objects. Despite this clinical awareness, we still have a substantial knowledge gap in our understanding of the neurological basis for these tactile discrimination deficits. Previously, we have shown that children with CP have aberrant theta-alpha (4-14 Hz) oscillations in the somatosensory cortices following tactile stimulation of the foot. In this investigation, we evaluated if these aberrant theta-alpha oscillations also extend to the hand. Magnetoencephalography was used to evaluate event-related changes in the theta-alpha and beta (18-34 Hz) somatosensory cortical oscillations in groups of children with CP and typically developing (TD) children following tactile stimulation of their hands. Our results showed that the somatosensory theta-alpha oscillations were relatively intact in children with CP, which is in contrast to our previous results for foot tactile stimulations. We suspect that these inter-study differences may be related to the higher probability that the neural tracts serving the lower extremities are damaged in children with CP, compared to those serving the upper extremities. This inference is plausible since the participating children with CP had Manual Ability Classification System (MACS) levels between I and II. In contrast to the theta-alpha results, children with CP did exhibit a sharp increase in beta activity during the same time period, which was not observed in TD children. This suggests that children with CP still have deficits in the computational aspect of somatosensory processing.

Diagnosis and treatment of dystonia

The dystonias are a group of disorders characterized by excessive involuntary muscle contractions leading to abnormal postures and/or repetitive movements. A careful assessment of the clinical manifestations is helpful for identifying syndromic patterns that focus diagnostic testing on potential causes. If a cause is identified, specific etiology-based treatments may be available. In most cases, a specific cause cannot be identified, and treatments are based on symptoms. Treatment options include counseling, education, oral medications, botulinum toxin injections, and several surgical procedures. A substantial reduction in symptoms and improved quality of life is achieved in most patients by combining these options.

Current and emerging strategies for treatment of childhood dystonia

Childhood dystonia is a movement disorder characterized by involuntary sustained or intermittent muscle contractions causing twisting and repetitive movements, abnormal postures, or both (Sanger et al, 2003). Dystonia is a devastating neurological condition that prevents the acquisition of normal motor skills during critical periods of development in children. Moreover, it is particularly debilitating in children when dystonia affects the upper extremities such that learning and consolidation of common daily motor actions are impeded. Thus, the treatment and rehabilitation of dystonia is a challenge that continuously requires exploration of novel interventions. This review will initially describe the underlying neurophysiological mechanisms of the motor impairments found in childhood dystonia followed by the clinical measurement tools that are available to document the presence and severity of symptoms. Finally, we will discuss the state-of-the-art of therapeutic options for childhood dystonia, with particular emphasis on emergent and innovative strategies.

The magnitude of the somatosensory cortical activity is related to the mobility and strength impairments seen in children with cerebral palsy

The noted disruption of thalamocortical connections and abnormalities in tactile sensory function has resulted in a new definition of cerebral palsy (CP) that recognizes the sensorimotor integration process as central to the motor impairments seen in these children. Despite this updated definition, the connection between a child's motor impairments and somatosensory processing remains almost entirely unknown. In this investigation, we explored the relationship between the magnitude of neural activity within the somatosensory cortices, the strength of the ankle plantarflexors, and the gait spatiotemporal kinematics of a group of children with CP and a typically developing matched cohort. Our results revealed that the magnitude of somatosensory cortical activity in children with CP had a strong positive relationship with the ankle strength, step length, and walking speed. These results suggest that stronger activity within the somatosensory cortices in response to foot somatosensations was related to enhanced ankle plantarflexor strength and improved mobility in the children with CP. These results provide further support for the notion that children with CP exhibit, not only musculoskeletal deficits, but also somatosensory deficits that potentially contribute to their overall functional mobility and strength limitations.

The functional significance of cortical reorganization and the parallel development of CI therapy

For the nineteenth and the better part of the twentieth centuries two correlative beliefs were strongly held by almost all neuroscientists and practitioners in the field of neurorehabilitation. The first was that after maturity the adult CNS was hardwired and fixed, and second that in the chronic phase after CNS injury no substantial recovery of function could take place no matter what intervention was employed. However, in the last part of the twentieth century evidence began to accumulate that neither belief was correct. First, in the 1960s and 1970s, in research with primates given a surgical abolition of somatic sensation from a single forelimb, which rendered the extremity useless, it was found that behavioral techniques could convert the limb into an extremity that could be used extensively. Beginning in the late 1980s, the techniques employed with deafferented monkeys were translated into a rehabilitation treatment, termed Constraint Induced Movement therapy or CI therapy, for substantially improving the motor deficit in humans of the upper and lower extremities in the chronic phase after stroke. CI therapy has been applied successfully to other types of damage to the CNS such as traumatic brain injury, cerebral palsy, multiple sclerosis, and spinal cord injury, and it has also been used to improve function in focal hand dystonia and for aphasia after stroke. As this work was proceeding, it was being shown during the 1980s and 1990s that sustained modulation of afferent input could alter the structure of the CNS and that this topographic reorganization could have relevance to the function of the individual. The alteration in these once fundamental beliefs has given rise to important recent developments in neuroscience and neurorehabilitation and holds promise for further increasing our understanding of CNS function and extending the boundaries of what is possible in neurorehabilitation.