Tongue-based biofeedback for balance in stroke: results of an 8-week pilot study

Minimal Clinically Important Differences and Changes in Stroke Disease-Specific Quality of Life in Stroke Survivors: A Prospective Cohort Study

The aims of the present study were to investigate changes in QOL in post-stroke patients during the first 3 months of rehabilitation treatment. We estimate minimal detectable changes (MDCs) and minimal clinically important differences (MCIDs) of the eight dimensions of QOL and assess the proportion of patients' change scores that exceed MDCs and MCIDs in stroke survivors who receive rehabilitation in a hospital ward. This prospective cohort study enrolled 40 stroke survivors (57.5% male; M_age = 58.3 years) who received in-hospital rehabilitation for a total of 3 months. The Stroke Impact Scale 3.0, which has eight subscales-strength, activities of daily living (ADLs)/instrumental ADLs (IADLs), mobility, hand function, communication, memory and thinking, emotion, and social participation-was used for assessment on the third day of rehabilitation (Time 1), 1 month later (Time 2), and 3 months later (Time 3). Our findings indicated that the MDC₉₅ and MCID proportions varied from 7.5% to 30% and 7.5% to 65%, respectively, of individuals who exhibited change based on individual change scores. The findings show compliance with MDC and MCID values in physical function, with the lowest proportion in hand function.

Effectiveness of cerebellar vermis intermittent theta-burst stimulation in improving trunk control and balance function for patients with subacute stroke: a randomised controlled trial protocol

INTRODUCTION

Balance impairments frequently occur after stroke. Achieving effective core trunk stability is the key to improving balance ability. However, there is still a lack of advanced well-defined rehabilitation protocols for balance improvement in patients with stroke. Intermittent theta-burst stimulation (iTBS) is a non-invasive brain activity modulation strategy that can produce long-term potentiation. The cerebellar vermis is a fundamental structure involved in balance and motor control. However, no study has demonstrated the therapeutic effect and potential mechanism of cerebellar vermis iTBS on balance after stroke.

METHODS AND ANALYSIS

This study will be a prospective single-centre double-blind randomised controlled clinical trial with a 3-week intervention and 3-week follow-up. Eligible participants will be randomly allocated to the experimental group or the control group in a 1:1 ratio. After routine conventional physical therapy, patients in the experimental group will receive cerebellar vermis iTBS, whereas patients in the control group will receive sham stimulation. The overall intervention period will be 5 days a week for 3 consecutive weeks. The outcomes will be measured at baseline (T0), 3 weeks postintervention (T1) and at the 3-week follow-up (T2). The primary outcomes are Berg Balance Scale and Trunk Impairment Scale scores. The secondary outcomes are balance test scores via the Balance Master system, muscle activation of the trunk and lower limbs via the surface electromyography recordings, cerebral cortex oxygen concentrations measured via the resting-state functional near-infrared spectroscopy, Fugl-Meyer Assessment of Lower Extremity and Barthel index scores.

ETHICS AND DISSEMINATION

This study was approved by the West China Hospital Clinical Trials and Biomedical Ethics Committee of Sichuan University. All participants will sign the informed consent form voluntarily. The results of this study will be published in peer-reviewed journals and disseminated at academic conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2200065369.

Electrotactile Perception Properties and Its Applications: A Review

With the increased demands of human-machine interaction, haptic feedback is becoming increasingly critical. However, the high cost, large size and low efficiency of current haptic systems severely hinder further development. As a portable and efficient technology, cutaneous electrotactile stimulation has shown promising potential for these issues. This paper presents a review on and insight into cutaneous electrotactile perception and its applications. Research results on perceptual properties and evaluation methods have been summarized and discussed to understand the effects of electrotactile stimulation on humans. Electrotactile applications are presented in categories to understand the methods and progress in various fields such as prostheses control, sensory substitution, sensory restoration and sensorimotor restoration. State of the art has demonstrated the superiority of electrotactile feedback, its efficiency and its flexibility. However, the complex factors and the limitations of evaluation methods made it challenging for precise electrotactile control. Groundbreaking innovation in electrotactile theory is expected to overcome challenges such as precise perception control, information capacity increasing, comprehension burden reducing and implementation costs.

Perception and Performance of Electrical Stimulation for Proprioception

Proprioception, yielding awareness of the body's position and motion in space, is typically lacking in prostheses and supernumerary limbs. Electrical stimulation is one technique that may provide these devices with proprioception. This paper first investigates how the modalities of electrotactile cues, such as frequency and intensity, are perceived. Using the results, we designed and compared several comfortable and perceptible feedback mappings for spatial cues. Two experiments were conducted using a 16-electrode bracelet worn above the elbow to provide electrical stimuli. We found that subjects could localize the stimulating electrode with a precision of ±1 electrode (110 mm) in all feedback conditions. Moreover, within the range of pulse intensities perceived as comfortable, the participants' performance was more sensitive to changes in frequency than in intensity. The highest performance was obtained for the condition which increased both intensity and frequency with radial distance. These results suggest that electrical stimulation can be used for artificial proprioceptive feedback, which can ensure a comfortable and intuitive interaction and provides high spatial accuracy.

Characterization of muscle strength using the strength domain of the stroke impact scale: An integrative review

BACKGROUND AND OBJECTIVE: Muscle weakness is among the most common and obvious impairments in older adults and individuals with neurologic disorders. Although impairments in muscle strength are typically characterized using performance measures, the impairments have also been described using patient or observer-report. The objective of this review was to summarize literature describing use of a patient-report instrument, the Strength Domain (SD) of the Stroke Impact Scale (SIS), to grade strength impairments. METHODS: Peer-reviewed literature reporting SD scores for the SIS was identified using computerized searches of the CINAHL, PubMed, and Scopus databases followed by hand searches. Potentially relevant articles were then mined for data on the participants tested, the SIS version used, scores documented, and clinimetric properties reported. RESULTS: Sixty-five articles were judged appropriate based on inclusion and exclusion criteria. The articles involved more than 7000 residents of 22 countries. All articles focused on individuals with stroke (usually chronic), although one also included community-dwelling adults without stroke. The SIS version used was frequently unreported, but 3.0 was version most often specified. For articles reporting SD scale scores the mean ranged from 19.7 to 85.5. Construct (known groups, convergent, and discriminant) validity of the SD was supported by the literature as was its internal consistency and test-retest reliability. Responsiveness of the SD was evinced by numerous studies showing increases in SD scores with time or accompanying effective interventions. However, only one study indicated responsiveness using an anchor-based statistic. CONCLUSIONS: The SD of the SIS is a well-established and mostly clinimetrically sound patient-report measure of paretic limb strength among individuals with stroke. Its use with individuals with weakness accompanying aging or diagnoses other than stroke remains to be substantiated.

Pelvic Belt Wearing during Exercise Improves Balance of Patients with Stroke: A Randomized, Controlled, Preliminary Trial

OBJECTIVES

To investigate whether wearing a pelvic belt during a trunk stability exercise program positively affects balance in patients with stroke.

MATERIALS AND METHODS

Twenty-four patients with stroke were randomly allocated to the experimental or control group and performed a 60-min general physical therapy and an additional 30-min trunk stability exercise (five times/week for 6 weeks). Those in the experimental and control groups performed the trunk stability exercises with and without wearing the pelvic belt, respectively.

RESULTS

The experimental group showed a significantly greater magnitude of improvements in balance than the control group (Postural Assessment Scale for Stroke: +18.3%, F (1, 22)=14.350, p=.001, η²=.395; Berg Balance Scale: +11%, F (1, 22)=19.062, p=.000, η²=.464; Timed Up and Go Test: -10.5%, F (1, 22)=8.562, p=.008, η²=.280; center of pressure path length with eyes open: -15.1%, F (1, 22)=6.770, p=.016, η²=.235; center of pressure path length with eyes closed: -19.5%, F (1, 22)=9.256, p=.006, η²=.296; center of pressure path velocity with eyes open: -22.6%, F (1, 22)=37.747, p=.000, η²=.632; center of pressure path velocity with eyes closed: -13.9%, F (1, 22)=6.511, p=.018, η²=.228, respectively).

CONCLUSIONS

Wearing a pelvic belt while performing trunk stability exercise programs could be a more effective approach for improving balance in patients with stroke.

Developing Proprioceptive Countermeasures to Mitigate Postural and Locomotor Control Deficits After Long-Duration Spaceflight

Astronauts experience post-flight disturbances in postural and locomotor control due to sensorimotor adaptations during spaceflight. These alterations may have adverse consequences if a rapid egress is required after landing. Although current exercise protocols can effectively mitigate cardiovascular and muscular deconditioning, the benefits to post-flight sensorimotor dysfunction are limited. Furthermore, some exercise capabilities like treadmill running are currently not feasible on exploration spaceflight vehicles. Thus, new in-flight operational countermeasures are needed to mitigate postural and locomotor control deficits after exploration missions. Data from spaceflight and from analog studies collectively suggest that body unloading decreases the utilization of proprioceptive input, and this adaptation strongly contributes to balance dysfunction after spaceflight. For example, on return to Earth, an astronaut's vestibular input may be compromised by adaptation to microgravity, but their proprioceptive input is compromised by body unloading. Since proprioceptive and tactile input are important for maintaining postural control, keeping these systems tuned to respond to upright balance challenges during flight may improve functional task performance after flight through dynamic reweighting of sensory input. Novel approaches are needed to compensate for the challenges of balance training in microgravity and must be tested in a body unloading environment such as head down bed rest. Here, we review insights from the literature and provide observations from our laboratory that could inform the development of an in-flight proprioceptive countermeasure.

Vibrotactile Feedback System From the Fingertip to the Temples for Perceptual Enhancement of Contracture Palpation

Contractures are generally assessed by a physician or physical therapist through palpation. However, contracture palpation requires skill and experience. The frictional vibration, which has a pulse-like vibration due to sliding disturbances around the affected area during palpation, is important in assessing the degree of contracture progression. This paper aims to enhance the perceptual sensitivity of frictional vibration for contracture palpation using a vibrotactile feedback system. We previously proposed an evaluation system for palpation with a wearable skin vibration sensor that detects skin-propagated vibration, allowing touch with a bare fingertip. In this paper, we propose the vibrotactile feedback system that presents the tactile information of the fingertip detected by the wearable tactile sensor to the temples with a vibrotactile display. A stimulator that gives vibrations similar to those during the palpation, which include pulse-like vibration and small vibration, was assembled. Then, psychophysical experiments on the vibrotactile feedback system were conducted using this stimulator. The results showed that the detection sensitivity of the pulse-like vibration was significantly enhanced with the feedback.

Reliability and validity of the Turkish version of Function in Sitting Test (FIST-T) in stroke

Background: Trunk control in sitting position after stroke is one of the most important determinants of independence in daily living activities and there is no gold standard assessment used to measure sitting postural control.Objectives: The aim of this study is to determine the reliability and validity of the Turkish version of Function in Sitting Test (FIST-T).Methods: After translation was conducted, Function in Sitting Test, Berg Balance Scale, Functional Independent Measure and Trunk Impairment Scale were applied to 72 stroke patients (mean age was 59.26 ± 16.38 years; post-stroke time was 95.93 ± 59.64 days). For reliability and validity analysis the spearman correlation analysis was used.Results: A positive, high correlation was found between the first application and repetition of Function in Sitting Test-T (ICC = 0.97, r = 0.95, p = .001). The internal consistency was high (Cronbach Alpha = 0.97), interrater correlation was high (Cronbach Alpha = 0.98) and a positive, high correlation was found with the scores obtained from the Berg Balance Scale (r = 0.82, p = .001), Functional Independent Measure (r = 0.84, p = .001) and Trunk Impairment Scale (r = 0.80, p = .001).Conclusions: It is concluded that the Turkish version of Function in Sitting Test is a valid and reliable scale for use in stroke patients, in clinical and scientific researches.

The Effects of a Wearable Sensory Prosthesis on Gait and Balance Function After 10 Weeks of Use in Persons With Peripheral Neuropathy and High Fall Risk - The walk2Wellness Trial

BACKGROUND

Sensory peripheral neuropathy (PN) is associated with gait, balance problems and high fall risk. The walk2Wellness trial investigates effects of long-term, home-based daily use of a wearable sensory prosthesis on gait function, balance, quality of life and fall rates in PN patients. The device (Walkasins®, RxFunction Inc., MN, United States) partially substitutes lost nerve function related to plantar sensation providing directional tactile cues reflecting plantar pressure measurements during standing and walking. We tested the null hypothesis that the Functional Gait Assessment (FGA) score would remain unchanged after 10 weeks of use.

METHODS

Participants had PN with lost plantar sensation, gait and balance problems, an FGA score < 23 (high fall risk), and ability to sense tactile stimuli above the ankle. Clinical outcomes included FGA, Gait Speed, Timed Up&Go (TUG) and 4-Stage Balance Test. Patient-reported outcomes included Activities-Specific Balance Confidence (ABC) scale, Vestibular Disorders Activities of Daily Living Scale, PROMIS participation and satisfaction scores, pain rating, and falls. Evaluations were performed at baseline and after 2, 6, and 10 weeks. Subjects were not made aware of changes in outcomes. No additional balance interventions were allowed.

RESULTS

Forty-five participants of 52 enrolled across four sites completed in-clinic assessments. FGA scores improved from 15.0 to 19.1 (p < 0.0001), normal and fast gait speed from 0.86 m/s to 0.95 m/s (p < 0.0001) and 1.24 m/s to 1.33 m/s (p = 0.002), respectively, and TUG from 13.8 s to 12.5 s (p = 0.012). Four-Stage Balance Test did not improve. Several patient-reported outcomes were normal at baseline and remained largely unchanged. Interestingly, subjects with baseline ABC scores lower than 67% (high fall risk cut-off) increased their ABC scores (49.9% to 59.3%, p = 0.01), whereas subjects with ABC scores above 67% showed a decrease (76.6% to 71.8%, p = 0.019). Subjects who reported falls in the prior 6 months (n = 25) showed a decrease in the number of fall-risk factors (5.1 to 4.3, p = 0.023) and a decrease in fall rate (13.8 to 7.4 falls/1000 days, p = 0.014). Four pre-study non-fallers (n = 20) fell during the 10 weeks.

CONCLUSION

A wearable sensory prosthesis presents a new way to treat gait and balance problems and manage falls in high fall-risk patients with PN.

TRIAL REGISTRATION

ClinicalTrials.gov (#NCT03538756).

Exploration of a novel physical therapy protocol that uses a sensory substitution device to improve the standing postural balance of children with balance disorders

OBJECTIVE

To explore if an intensive balance training protocol that incorporated the BrainPort sensory substitution device improves the standing postural balance of children with balance disorders.

METHODS

Eight children with balance disorders received 8-weeks of balance training while using the BrainPort device. Pre- and post-intervention changes in the Bruininks-Oseretsky Test of Motor Proficiency balance subtest (BOT-2) scores, standing duration on an unstable surface, and center of pressure (COP) sway were assessed.

RESULTS

Post-intervention, the BOT-2 balance subtest scores increased by 29.6% and demonstrated clinically meaningful improvements. Overall, the standing duration with vision increased. The standing duration on the unstable surface without vision increased significantly from pre- to post-intervention. However, anterior-posterior (AP) and medial-lateral (ML) sway did not change post-intervention. The children also reported new functional activities (i.e. riding a bike, standing on unsteady or narrow surfaces).

CONCLUSION

Balance training with the BrainPort sensory substitution device has the potential to result in clinically relevant improvements in the standing postural balance of children with balance disorders.

The Effect of Biofeedback on the Motor- Muscular Situation in Rehabilitation of Stroke Patients: a Randomized Controlled Trial

Introduction: Stroke is the most common debilitating neurological disease in adults. Therefore, rehabilitation is a major consideration to reduce costs and relief disabilities. Biofeedback, a newly recommended method is claimed to be able to improve the consequences following stroke by enhancing the understanding of the psychological functions of the body. The purpose of this study was to investigate the effects of biofeedback on the motor- muscular situation in balance and ability to walk, muscle stiffness (spasticity), hand muscles strength of stroke patients. Methods: The present study was a randomized clinical trial done in 2016. The participants were randomly divided into 2 groups (case and control group). In the intervention group, biofeedback was performed. The check list of main variables, including balance and ability to walk, muscle stiffness (spasticity) and hand muscles strength was completed by a physician before the intervention and at the end of the intervention (16th session). The statistical analysis was conducted, using SPSS version 13. Results: The mean score of balance in intervention group versus control group showed significant differences. The results showed that by eliminating the effects of muscular strength before the intervention, this variable had made improvements and significant differences in both intervention and control groups after the intervention. Comparison of the average spasticity showed that spasticity evaluation score before and after the intervention revealed no significant difference between the two groups. Conclusion: Biofeedback therapy is a promising treatment modality for improving the motor-muscular situation of patients after stroke.

A robot-aided visuo-motor training that improves proprioception and spatial accuracy of untrained movement

Proprioceptive function can become enhanced during motor learning. Yet, we have incomplete knowledge to what extent proprioceptive function is trainable and how a training that enhances proprioception may influence performance in untrained motor skills. To address this knowledge gap, healthy young adults (N = 14) trained in a visuomotor task that required learners to make increasingly accurate wrist movements. Using a robotic exoskeleton coupled with a virtual visual environment, participants tilted a virtual table through continuous wrist flexion/extension movements with the goal to position a rolling ball on table into a target. With learning progress, the level of difficulty increased by altering the virtual ball mechanics and the gain between joint movement and ball velocity. Before and after training, wrist position sense acuity and spatial movement accuracy in an untrained, discrete wrist-pointing task was assessed using the same robot. All participants showed evidence of proprioceptive-motor learning. Mean position sense discrimination threshold improved by 34%. Wrist movement accuracy in the untrained pointing task improved by 27% in 13/14 participants. This demonstrates that a short sensorimotor training challenging proprioception can a) effectively enhance proprioceptive acuity and b) improve the accuracy of untrained movement. These findings provide a scientific basis for applying such somatosensory-based motor training to clinical populations with known proprioceptive dysfunction to enhance sensorimotor performance.

Supplemental vibrotactile feedback control of stabilization and reaching actions of the arm using limb state and position error encodings

Background

Deficits of kinesthesia (limb position and movement sensation) commonly limit sensorimotor function and its recovery after neuromotor injury. Sensory substitution technologies providing synthetic kinesthetic feedback might re-establish or enhance closed-loop control of goal-directed behaviors in people with impaired kinesthesia.

Methods

As a first step toward this goal, we evaluated the ability of unimpaired people to use vibrotactile sensory substitution to enhance stabilization and reaching tasks. Through two experiments, we compared the objective and subjective utility of two forms of supplemental feedback – limb state information or hand position error – to eliminate hand position drift, which develops naturally during stabilization tasks after removing visual feedback.

Results

Experiment 1 optimized the encoding of limb state feedback; the best form included hand position and velocity information, but was weighted much more heavily toward position feedback. Upon comparing optimal limb state feedback vs. hand position error feedback in Experiment 2, we found both encoding schemes capable of enhancing stabilization and reach performance in the absence of vision. However, error encoding yielded superior outcomes - objective and subjective - due to the additional task-relevant information it contains.

Conclusions

The results of this study have established the immediate utility and relative merits of two forms of vibrotactile kinesthetic feedback in enhancing stabilization and reaching actions performed with the arm and hand in neurotypical people. These findings can guide future development of vibrotactile sensory substitution technologies for improving sensorimotor function after neuromotor injury in survivors who retain motor capacity, but lack proprioceptive integrity in their more affected arm.

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-017-0248-8) contains supplementary material, which is available to authorized users.

Noninvasive tongue stimulation combined with intensive cognitive and physical rehabilitation induces neuroplastic changes in patients with multiple sclerosis: A multimodal neuroimaging study

BACKGROUND

Multiple sclerosis (MS) patients have central nervous system (CNS) lesions that may impede cognitive and sensorimotor function. Few rehabilitative therapies are available.

OBJECTIVES

The objective of this paper is to study effects of noninvasive tongue stimulation using the Portable Neuromodulation Stimulator (PoNS™) combined with intensive cognitive and physical rehabilitation on working memory, gait, balance and concomitant changes in the brain.

METHODS

Fourteen MS patients, seven each in an active and a sham stimulation group, participated. Participants received intensive physical therapy and working memory training for 14 weeks. Functional magnetic resonance imaging (fMRI) using motor imagery and working-memory tasks were completed prior to and following therapy, as were sensory organization tests (SOT), motor performance measures, and neuropsychological assessment.

RESULTS

On the SOT, the active group showed significant improvement from baseline. fMRI revealed significant blood oxygen level-dependent signal changes in the left primary motor cortex for the Active Group, while the sham group had increased activity in bilateral premotor cortices. All individuals improved on working-memory tasks, but only the active group showed increased dorsolateral prefrontal cortex activity.

CONCLUSIONS

In this cohort of MS patients, the results suggest that PoNS stimulation can enhance motor performance and working memory while also driving neuroplasticity. Further studies are warranted to explore these findings.

Prospective comparative study for the evaluation of prosthetic rehabilitation users with transtibial amputation

Individuals with transtibial amputations have difficulties in performing march and stay in balance, directly affecting their quality of life. The use of prostheses can enable the rehabilitation of the individual, but we question how effective are for certain tasks and how they can still improve. To evaluate the prosthesis for transtibial amputation, a comparative study was conducted with two groups: Amputee and NOT Amputees. With the help of Motion Capture technology was held measuring the angles of static balance, walking speed and scores in the execution of daily activities. The results indicate that dispersions of larger static equilibrium angles belonging to the group amputees. In terms of average speed march and in scores of Daily Activities, there was better performance for the group of NOT amputees. From this it was also identified that the technical characteristics of transtibial prosthetic could impact rehabilitation of its members.

Haptic wearables as sensory replacement, sensory augmentation and trainer - a review

Sensory impairments decrease quality of life and can slow or hinder rehabilitation. Small, computationally powerful electronics have enabled the recent development of wearable systems aimed to improve function for individuals with sensory impairments. The purpose of this review is to synthesize current haptic wearable research for clinical applications involving sensory impairments. We define haptic wearables as untethered, ungrounded body worn devices that interact with skin directly or through clothing and can be used in natural environments outside a laboratory. Results of this review are categorized by degree of sensory impairment. Total impairment, such as in an amputee, blind, or deaf individual, involves haptics acting as sensory replacement; partial impairment, as is common in rehabilitation, involves haptics as sensory augmentation; and no impairment involves haptics as trainer. This review found that wearable haptic devices improved function for a variety of clinical applications including: rehabilitation, prosthetics, vestibular loss, osteoarthritis, vision loss and hearing loss. Future haptic wearables development should focus on clinical needs, intuitive and multimodal haptic displays, low energy demands, and biomechanical compliance for long-term usage.

The effectiveness of proprioceptive training for improving motor function: a systematic review

OBJECTIVE

Numerous reports advocate that training of the proprioceptive sense is a viable behavioral therapy for improving impaired motor function. However, there is little agreement of what constitutes proprioceptive training and how effective it is. We therefore conducted a comprehensive, systematic review of the available literature in order to provide clarity to the notion of training the proprioceptive system.

METHODS

Four major scientific databases were searched. The following criteria were subsequently applied: (1) A quantified pre- and post-treatment measure of proprioceptive function. (2) An intervention or training program believed to influence or enhance proprioceptive function. (3) Contained at least one form of treatment or outcome measure that is indicative of somatosensory function. From a total of 1284 articles, 51 studies fulfilled all criteria and were selected for further review.

RESULTS

Overall, proprioceptive training resulted in an average improvement of 52% across all outcome measures. Applying muscle vibration above 30 Hz for longer durations (i.e., min vs. s) induced outcome improvements of up to 60%. Joint position and target reaching training consistently enhanced joint position sense (up to 109%) showing an average improvement of 48%. Cortical stroke was the most studied disease entity but no clear evidence indicated that proprioceptive training is differentially beneficial across the reported diseases.

CONCLUSIONS

There is converging evidence that proprioceptive training can yield meaningful improvements in somatosensory and sensorimotor function. However, there is a clear need for further work. Those forms of training utilizing both passive and active movements with and without visual feedback tended to be most beneficial. There is also initial evidence suggesting that proprioceptive training induces cortical reorganization, reinforcing the notion that proprioceptive training is a viable method for improving sensorimotor function.

Non-invasive neuromodulation to improve gait in chronic multiple sclerosis: a randomized double blind controlled pilot trial

BACKGROUND

This study sought to examine the effect of targeted physical therapy with and without cranial nerve non-invasive neuromodulation (CN-NINM), on the walking ability of people with MS who exhibited a dysfunctional gait. We hypothesized that subjects who received electrical stimulation would have greater improvement than those who had a control device after a 14-week intervention. Gait disturbance is a common problem for people with multiple sclerosis (MS). Current management may include exercise, pharmacology, functional electrical stimulation, compensatory strategies, use of assistive devices, and implanted electrical devices. We have developed an effective rehabilitative strategy using neuromodulation of the cranial nerves via electrical stimulation of the tongue to enhance the plasticity of the brain.

METHODS

The study is a within-subject blinded randomized control design. Twenty chronic MS subjects with an identified gait disturbance were assigned to either an active or control group. Both groups completed a 14-week intervention program using a standardized combination of exercise and a device that provided electrical stimulation to the tongue. Those in the active group received electrical stimulation on the tongue that they could perceive. Those in the control group used a device that did not provide a physiologically significant stimulus and was not perceivable. Subjects were assessed with the Dynamic Gait Index (DGI).

RESULTS

The DGI scores improved for both groups. There were significant between-group differences, with the active group showing statistically greater improvement than the control group mean.

CONCLUSION

People with MS demonstrated improved gait with CN-NINM training in a pilot randomized controlled trial. This study suggests that tongue-based neurostimulation may amplify the benefits of exercise for improving gait in people with chronic MS.

Improving the motor skill of children with posterior fossa syndrome: a case series

Children who receive treatment for medulloblastoma have a high survival rate, but also a high likelihood of developing posterior fossa syndrome, a condition that includes devastating balance and motor problems. This case series used 2 novel neuromodulation devices in conjunction with an intensive physical therapy intervention for 2 children who were 5 years post tumor treatment with a diagnosis of posterior fossa syndrome. Pre- and postclinical measures, in addition to magnetoencephalography brain imaging, describe positive behavioral and neuroplastic changes resulting from the intervention. The positive outcomes in these cases suggest that further study is needed using neuromodulatory devices and long-term rehabilitation in children with balance and movement disorders resulting from cancer treatment.

Expanding the scoring system for the Dynamic Gait Index

BACKGROUND

The Dynamic Gait Index (DGI) measures the capacity to adapt gait to complex tasks. The current scoring system combining gait pattern (GP) and level of assistance (LOA) lacks clarity, and the test has a limited range of measurement.

OBJECTIVE

This study developed a new scoring system based on 3 facets of performance (LOA, GP, and time) and examined the psychometric properties of the modified DGI (mDGI).

DESIGN

A cross-sectional, descriptive study was conducted.

METHODS

Nine hundred ninety-five participants (855 patients with neurologic pathology and mobility impairments [MI group] and 140 patients without neurological impairment [control group]) were tested. Interrater reliability was calculated using kappa coefficients. Internal consistency was computed using the Cronbach alpha coefficient. Factor analysis and Rasch analysis investigated unidimensionality and range of difficulty. Internal validity was determined by comparing groups using multiple t tests. Minimal detectable change (MDC) was calculated for total score and 3 facet scores using the reliability estimate for the alpha coefficients.

RESULTS

Interrater agreement was strong, with kappa coefficients ranging from 90% to 98% for time scores, 59% to 88% for GP scores, and 84% to 100% for LOA scores. Test-retest correlations (r) for time, GP, and LOA were .91, .91, and .87, respectively. Three factors (time, LOA, GP) had eigenvalues greater than 1.3 and explained 79% of the variance in scores. All group differences were significant, with moderate to large effect sizes. The 95% minimal detectable change (MDC95) was 4 for the mDGI total score, 2 for the time and GP total scores, and 1 for the LOA total score.

LIMITATIONS

The limitations included uneven sample sizes in the 2 groups. The MI group were patients receiving physical therapy; therefore, they may not be representative of this population.

CONCLUSIONS

The mDGI, with its expanded scoring system, improves the range, discrimination, and facets of measurement related to walking function. The strength of the psychometric properties of the mDGI warrants its adoption for both clinical and research purposes.