Science-Based Neurorehabilitation: Recommendations for Neurorehabilitation From Basic Science

Virtual, mixed, and augmented realities: A commentary on their significance in cognitive neuroscience and neuropsychology

The integration of virtual, mixed, and augmented reality technologies in cognitive neuroscience and neuropsychology represents a transformative frontier. In this Commentary, we conducted a meta-analysis of studies that explored the impact of Virtual Reality (VR), Mixed Reality (MR), and Augmented Reality (AR) on cognitive neuroscience and neuropsychology. Our review highlights the versatile applications of VR, ranging from spatial cognition assessments to rehabilitation for Traumatic Brain Injury. We found that MR and AR offer innovative avenues for cognitive training, particularly in memory-related disorders. The applications extend to addressing social cognition disorders and serving as therapeutic interventions for mental health issues. Collaborative efforts between neuroscientists and technology developers are crucial, with reinforcement learning and neuroimaging studies enhancing the potential for improved outcomes. Ethical considerations, including informed consent, privacy, and accessibility, demand careful attention. Our review identified common aspects of the meta-analysis, including the potential of VR technologies in cognitive neuroscience and neuropsychology, the use of MR and AR in memory research, and the role of VR in neurorehabilitation and therapy.

The effect of robot-assisted versus standard training on motor function following subacute rehabilitation after ischemic stroke - protocol for a randomised controlled trial nested in a prospective cohort (RoboRehab)

BACKGROUND

Body weight unloaded treadmill training has shown limited efficacy in further improving functional capacity after subacute rehabilitation of ischemic stroke patients. Dynamic robot assisted bodyweight unloading is a novel technology that may provide superior training stimuli and continued functional improvements in individuals with residual impairments in the chronic phase after the ischemic insult. The aim of the present study is to investigate the effect of dynamic robot-assisted versus standard training, initiated 6 months post-stroke, on motor function, physical function, fatigue, and quality of life in stroke-affected individuals still suffering from moderate-to-severe disabilities after subacute rehabilitation.

METHODS

Stroke-affected individuals with moderate to severe disabilities will be recruited into a prospective cohort with measurements at 3-, 6-, 12- and 18-months post-stroke. A randomised controlled trial (RCT) will be nested in the prospective cohort with measurements pre-intervention (Pre), post-intervention (Post) and at follow-up 6 months following post-intervention testing. The present RCT will be conducted as a multicentre parallel-group superiority of intervention study with assessor-blinding and a stratified block randomisation design. Following pre-intervention testing, participants in the RCT study will be randomised into robot-assisted training (intervention) or standard training (active control). Participants in both groups will train 1:1 with a physiotherapist two times a week for 6 months (groups are matched for time allocated to training). The primary outcome is the between-group difference in change score of Fugl-Meyer Lower Extremity Assessment from pre-post intervention on the intention-to-treat population. A per-protocol analysis will be conducted analysing the differences in change scores of the participants demonstrating acceptable adherence. A priori sample size calculation allowing the detection of the minimally clinically important between-group difference of 6 points in the primary outcome (standard deviation 6 point, α = 5% and β = 80%) resulted in 34 study participants. Allowing for dropout the study will include 40 participants in total.

DISCUSSION

For stroke-affected individuals still suffering from moderate to severe disabilities following subacute standard rehabilitation, training interventions based on dynamic robot-assisted body weight unloading may facilitate an appropriate intensity, volume and task-specificity in training leading to superior functional recovery compared to training without the use of body weight unloading.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT06273475.

TRIAL STATUS

Recruiting. Trial identifier: NCT06273475. Registry name: ClinicalTrials.gov. Date of registration on ClinicalTrials.gov: 22/02/2024.

Beyond pediatrics: noninvasive spinal neuromodulation improves motor function in an adult with cerebral palsy

Regaining motor function in individuals with cerebral palsy (CP) has been predominantly studied in children, resulting in an underrepresentation of adults in research efforts. We tested the efficacy of noninvasive spinal neuromodulation with neurorehabilitation (Spinal Cord Innovation in Pediatrics; SCiP™ therapy). A 60-year-old CP participant underwent 8 weeks of SCiP™ therapy, resulting in significant motor recovery measured by 14.2-points increase in gross motor function measure (GMFM-88) score, ~ three times the Minimal Clinically Important Difference (MCID) of 5-points. This represented gains in kneeling, sitting, and walking functions. The improvement in GMFM-88 score was maintained above the MCID at the follow up visit (10.3 points above the baseline), twenty weeks following the last therapy session, indicating a persistent effect of the therapy. Our preliminary findings support the therapeutic promise of SCiP™ therapy for enhancing motor function in CP adults. Broader investigations are needed to establish its wider applicability.

Task-oriented exercise effects on walking and corticospinal excitability in multiple sclerosis: protocol for a randomized controlled trial

BACKGROUND

Multiple sclerosis (MS) is a degenerative disease of the central nervous system (CNS) that disrupts walking function and results in other debilitating symptoms. This study compares the effects of 'task-oriented exercise' against 'generalized resistance and aerobic exercise' and a 'stretching control' on walking and CNS function in people with MS (PwMS). We hypothesize that task-oriented exercise will enhance walking speed and related neural changes to a greater extent than other exercise approaches.

METHODS

This study is a single-blinded, three-arm randomized controlled trial conducted in Saskatchewan, Canada. Eligible participants are those older than 18 years of age with a diagnosis of MS and an expanded Patient-Determined Disease Steps (PDDS) score between 3 ('gait disability') and 6 ('bilateral support'). Exercise interventions are delivered for 12 weeks (3 × 60-min per week) in-person under the supervision of a qualified exercise professional. Interventions differ in exercise approach, such that task-oriented exercise involves weight-bearing, walking-specific activities, while generalized resistance and aerobic exercise uses seated machine-based resistance training of major upper and lower body muscle groups and recumbent cycling, and the stretching control exercise involves seated flexibility and relaxation activities. Participants are allocated to interventions using blocked randomization that stratifies by PDDS (mild: 3-4; moderate: 5-6). Assessments are conducted at baseline, post-intervention, and at a six-week retention time point. The primary and secondary outcome measures are the Timed 25-Foot Walk Test and corticospinal excitability for the tibialis anterior muscles determined using transcranial magnetic stimulation (TMS), respectively. Tertiary outcomes include assessments of balance, additional TMS measures, blood biomarkers of neural health and inflammation, and measures of cardiorespiratory and musculoskeletal fitness.

DISCUSSION

A paradigm shift in MS healthcare towards the use of "exercise as medicine" was recently proposed to improve outcomes and alleviate the economic burden of MS. Findings will support this shift by informing the development of specialized exercise programming that targets walking and changes in corticospinal excitability in PwMS.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05496881, Registered August 11, 2022. https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05496881 . Protocol amendment number: 01; Issue date: August 1, 2023; Primary reason for amendment: Expand eligibility to include people with all forms of MS rather than progressive forms of MS only.

Mapping physical activity patterns in hospitalised patients with moderate to severe acquired brain injury - MAP-ABI: Protocol for an observational study

Introduction

The physical activity level in patients hospitalised for rehabilitation across multiple diagnoses is low. Moderate to severe acquired brain injury further reduces activity levels as impaired physical and cognitive functioning affect mobility independence. Therefore, supervised out-of-bed mobilisation and physical activity training are essential rehabilitation strategies. Few studies have measured the physical activity patterns in the early phases of rehabilitation after moderate to severe brain injury.

Objectives

To map and quantify physical activity patterns in patients admitted to brain injury rehabilitation. Further, to investigate which factors are associated with activity and if the early physical activity level is associated with functional outcome at discharge.

Methods

This observational study includes patients admitted to rehabilitation after moderate to severe acquired brain injury. Mobility and physical activity patterns are measured continuously during rehabilitation at two separate seven-day periods using a wearable activity tracker. Activity will be categorised into four levels and presented descriptively. Linear and logistic regression models will analyse associations between descriptive variables and activity levels.

Discussion

This protocol describes an observational study investigating patients' mobility and physical activity patterns with moderate to severe acquired brain injury during in-hospital rehabilitation. The ability to increase the amount of mobilisation and physical activity in subgroups may have profound consequences on the rehabilitation outcome. Furthermore, data from this study may be used to inform a large variety of trials investigating physical rehabilitation interventions. (NCT05571462).

Patient-tailored transcranial direct current stimulation to improve stroke rehabilitation: study protocol of a randomized sham-controlled trial

BACKGROUND

Many patients do not fully regain motor function after ischemic stroke. Transcranial direct current stimulation (TDCS) targeting the motor cortex may improve motor outcome as an add-on intervention to physical rehabilitation. However, beneficial effects on motor function vary largely among patients within and across TDCS trials. In addition to a large heterogeneity of study designs, this variability may be caused by the fact that TDCS was given as a one-size-fits-all protocol without accounting for anatomical differences between subjects. The efficacy and consistency of TDCS might be improved by a patient-tailored design that ensures precise targeting of a physiologically relevant area with an appropriate current strength.

METHODS

In a randomized, double-blinded, sham-controlled trial, patients with subacute ischemic stroke and residual upper-extremity paresis will receive two times 20 min of focal TDCS of ipsilesional primary motor hand area (M1-HAND) during supervised rehabilitation training three times weekly for 4 weeks. Anticipated 60 patients will be randomly assigned to active or sham TDCS of ipsilesional M1-HAND, using a central anode and four equidistant cathodes. The placement of the electrode grid on the scalp and current strength at each cathode will be personalized based on individual electrical field models to induce an electrical current of 0.2 V/m in the cortical target region resulting in current strengths between 1 and 4 mA. Primary endpoint will be the difference in change of Fugl-Meyer Assessment of Upper Extremity (FMA-UE) score between active TDCS and sham at the end of the intervention. Exploratory endpoints will include UE-FMA at 12 weeks. Effects of TDCS on motor network connectivity and interhemispheric inhibition will be assessed with functional MRI and transcranial magnetic stimulation.

DISCUSSION

The study will show the feasibility and test the efficacy of personalized, multi-electrode anodal TDCS of M1-HAND in patients with subacute stroke patients with upper-extremity paresis. Concurrent multimodal brain mapping will shed light into the mechanisms of action of therapeutic personalized TDCS of M1-HAND. Together, the results from this trial may inform future personalized TDCS studies in patients with focal neurological deficits after stroke.

Hand rehabilitation based on the RobHand exoskeleton in stroke patients: A case series study

Introduction: The RobHand (Robot for Hand Rehabilitation) is a robotic neuromotor rehabilitation exoskeleton that assists in performing flexion and extension movements of the fingers. The present case study assesses changes in manual function and hand muscle strength of four selected stroke patients after completion of an established training program. In addition, safety and user satisfaction are also evaluated. Methods: The training program consisted of 16 sessions; two 60-minute training sessions per week for eight consecutive weeks. During each session, patients moved through six consecutive rehabilitation stages using the RobHand. Manual function assessments were applied before and after the training program and safety tests were carried out after each session. A user evaluation questionnaire was filled out after each patient completed the program. Results: The safety test showed the absence of significant adverse events, such as skin lesions or fatigue. An average score of 4 out of 5 was obtained on the Quebec User Evaluation of Satisfaction with Assistive Technology 2.0 Scale. Users were very satisfied with the weight, comfort, and quality of professional services. A Kruskal-Wallis test revealed that there were not statistically significant changes in the manual function tests between the beginning and the end of the training program. Discussion: It can be concluded that the RobHand is a safe rehabilitation technology and users were satisfied with the system. No statistically significant differences in manual function were found. This could be due to the high influence of the stroke stage on motor recovery since the study was performed with chronic patients. Hence, future studies should evaluate the rehabilitation effectiveness of the repetitive use of the RobHand exoskeleton on subacute patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT05598892?id=NCT05598892&draw=2&rank=1, identifier NCT05598892.

Clinical recommendations: The role of mechanisms in the GRADE framework

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework has become one of the most influential frameworks for assessing quality of research and developing clinical recommendations. The GRADE framework has been presented as an evolution in the Evidence-Based Medicine (EBM) movement. Both GRADE and EBM emphasize effect estimates derived from population-level clinical trials and, as a consequence, devalue the role of mechanisms as the basis for clinical decisions. Although mechanisms do not hold the epistemic privilege of rigorous clinical trials in EBM reasoning, this paper will argue that mechanisms appear to be important in the use and application of GRADE, as described in the literature. The seemingly necessary role of mechanisms in the development of clinical recommendations has, so far, received little attention and is not explicitly featured in the literature describing GRADE. The analysis of the GRADE framework presented in this paper reveals an apparent tension between EBM's willingness to downplay mechanisms and what seems their inevitable use in GRADE. In this paper, we take the position that if mechanistic reasoning is inevitable in the use of GRADE, then the instructional literature on the framework would benefit from more explicit discussion of how to consider and integrate mechanisms.

Developing guiding principles for technology-based rehabilitation program by engaging people with motor incomplete tetraplegia

BACKGROUND

Technology-aided rehabilitation is well established in the field of neurologic rehabilitation. Despite the widespread availability, the development of technology-based interventions that incorporate perspectives of the people who will use them is lacking.

OBJECTIVES

This qualitative study aims to understand how people with chronic motor incomplete cervical spinal cord injury view rehabilitation technology to improve upper extremity function and neuromuscular recovery to inform future intervention development.

METHODS

Seven participants with chronic upper extremity impairment due to spinal cord injury/dysfunction trialed five rehabilitation technology devices. After a 30-45 min trial for each device, participants engaged in a semi-structured interview. Interviews were analyzed using a qualitative approach to explore the experience using and understand features that support motivation to use of rehabilitation technology.

RESULTS

Qualitative analysis revealed three major themes: (1) devices must be flexible to meet diverse needs; (2) intervention protocols must be individualized to address unique needs and contexts of users; (3) intervention protocols should be developed and updated by a skilled clinician. These themes and subthemes were used to describe guiding principles to inform future intervention design.

CONCLUSION

The experiences of people with cervical spinal cord injury can be elicited as part of the intervention design process to systematically develop protocols for future feasibility trials. The findings from this study can be used to inform the development of technology-aided rehabilitation programs to improve upper extremity function in people with chronic motor incomplete tetraplegia.

CLINICAL TRIALS REGISTRATION NUMBER

NCT04000256.

Randomised controlled pilot and feasibility study of multimodal agility-based exercise training (MAT) versus strength and endurance training (SET) to improve multiple sclerosis-related fatigue and fatigability during inpatient rehabilitation (ReFEx): study protocol

INTRODUCTION

Subjective fatigue and objectively assessed fatigability are common symptoms in persons with multiple sclerosis (pwMS). Recent work has suggested a positive effect of balance and motor control training (BMCT) in reducing fatigue. It is unclear whether this effect can also be attained during inpatient rehabilitation. Multimodal agility-based exercise training (MAT) has been developed as a framework that incorporates BMCT with added agility components but has not been applied to pwMS. Therefore, this study will evaluate the feasibility of a randomised controlled trial comparing MAT against strength and endurance training (SET) for the improvement of MS-related fatigue and fatigability in a German neurological rehabilitation centre.

METHODS AND ANALYSIS

A total of 24 pwMS (Expanded Disability Status Scale ≤5.0, Fatigue Scale for Motor and Cognitive Functions ≥53) will be randomly assigned to either SET or land and water-based MAT for 4-6 weeks during inpatient rehabilitation. Assessments of subjective fatigue, motor and cognitive fatigability, cognitive and cardiorespiratory performance, and balance confidence will be performed at admission and discharge. Subjective fatigue will also be assessed at 1, 4 and 12 weeks after discharge. Feasibility outcomes will include patients' acceptance of study procedures and interventions, recruitment rate, retention rate, time needed to complete baseline assessments, intervention adherence and fidelity. All quantitative outcomes will be reported descriptively. A total of 12 pwMS (6 per group) will be interviewed to gain insights into participants' experiences during study participation.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Ethics Committee of the University of Bonn (reference number: 543/20). Dissemination of findings is planned via peer-reviewed journals, conferences and media releases.

TRIAL REGISTRATION NUMBER

DRKS00023943.

After 55 Years of Neurorehabilitation, What Is the Plan?

Neurological disorders often cause severe long-term disabilities with substantial activity limitations and participation restrictions such as community integration, family functioning, employment, social interaction and participation. Increasing understanding of brain functioning has opened new perspectives for more integrative interventions, boosting the intrinsic central nervous system neuroplastic capabilities in order to achieve efficient behavioral restitution. Neurorehabilitation must take into account the many aspects of the individual through a comprehensive analysis of actual and potential cognitive, behavioral, emotional and physical skills, while increasing awareness and understanding of the new self of the person being dealt with. The exclusive adoption by the rehabilitator of objective functional measures often overlooks the values and goals of the disabled person. Indeed, each individual has their own rhythm, unique life history and personality construct. In this challenging context, it is essential to deepen the assessment through subjective measures, which more adequately reflect the patient’s perspective in order to shape genuinely tailored instead of standardized neurorehabilitation approaches. In this overly complex panorama, where confounding and prognostic factors also strongly influence potential functional recovery, the healthcare community needs to rethink neurorehabilitation formats.

Effect of home-based virtual reality training and telerehabilitation on balance in individuals with Parkinson disease, multiple sclerosis, and stroke: a systematic review and meta-analysis

OBJECTIVE

In the last decade, there is a growing interest in the use of virtual reality for rehabilitation in clinical and home settings. The aim of this systematic review is to do a summary of the current evidence on the effect of home-based virtual reality training and telerehabilitation on postural balance in individuals with central neurological disorders.

METHODS

Literature was searched in PubMed, Web of Science, PEDro, ScienceDirect, and MEDLINE. Randomized controlled trials (RCTs) evaluating the effect of home-based virtual reality (VR) training and telerehabilitation (TR) on postural balance in patients with Parkinson's disease, Multiple sclerosis or stroke. Studies were imported to EndNote and Excel to perform two screening phases by four reviewers. Risk of bias was assessed using PEDro scale and Cochrane assessment tool for risk of bias. Synthesis of the data on comparative outcomes was performed using RevMan software.

RESULTS

Seven RCTs were included, with all three pathologies represented. VR and TR consisted of a training device (e.g., Nintendo Wii or Xbox 360) and a monitoring device (e.g., Skype or Microsoft Kinect). Five studies used the Berg Balance Scale (BBS) for measuring postural balance. Across studies, there was an improvement in BBS scores over time in both experimental and control groups, and the effect remained at follow-up for both groups. However, there was no significant difference between  groups post-intervention (MD = 0.74, p = 0.45).

CONCLUSION

Home-based VR and TR can be used as prolongation to conventional therapy.

Early, Intensive, Lower Extremity Rehabilitation Shows Preliminary Efficacy After Perinatal Stroke: Results of a Pilot Randomized Controlled Trial

Background

Perinatal stroke injures motor regions of the brain, compromising movement for life. Early, intensive, active interventions for the upper extremity are efficacious, but interventions for the lower extremity remain understudied.

Objective

To determine the feasibility and potential efficacy of ELEVATE—Engaging the Lower Extremity Via Active Therapy Early—on gross motor function.

Methods

We conducted a single-blind, two-arm, randomized controlled trial (RCT), with the Immediate Group receiving the intervention while the Delay Group served as a 3-month waitlist control. A separate cohort living beyond commuting distance was trained by their parents with guidance from physical therapists. Participants were 8 months to 3 years old, with MRI-confirmed perinatal ischemic stroke and early signs of hemiparesis. The intervention was play-based, focused on weight-bearing, balance and walking for 1 hour/day, 4 days/week for 12 weeks. The primary outcome was the Gross Motor Function Measure-66 (GMFM-66). Secondary outcomes included steps and gait analyses. Final follow-up occurred at age 4.

Results

Thirty-four children participated (25 RCT, 9 Parent-trained). The improvement in GMFM-66 over 12 weeks was greater for the Immediate than the Delay Group in the RCT (average change 3.4 units higher) and greater in younger children. Average step counts reached 1370-3750 steps/session in the last week of training for all children. Parent-trained children also improved but with greater variability.

Conclusions

Early, activity-intensive lower extremity therapy for young children with perinatal stroke is feasible and improves gross motor function in the short term. Longer term improvement may require additional bouts of intervention.

Clinical trial registration

This study was registered at ClinicalTrials.gov (NCT01773369).

Neurologic Music Therapy Improves Participation in Children With Severe Cerebral Palsy

Positive effects after neurologic music therapy (NMT) have been described regarding the motor function of children with severe cerebral palsy (CP). This study aimed to quantify improvements in participation, as well as complexity on task-related manual activities in children with severe bilateral CP. This analytic quasi-experimental study exposed 17 children with severe cerebral palsy to 13 NMT sessions to improve motor learning through therapeutic instrumental music performance (TIMP), using principally percussion musical instruments. Hoisan software video recording was used to quantify participation involved in creating music. In addition, the number of active movements performed in each NMT session was quantified. Significant improvements were found in the participation variables “visual contact,” “motor participation” and “motor participation repetitions.” Significant differences were also found in the subcategory “reaching and stroke,” “hitting with the hand” and “grasping and hitting.” The use of therapeutic of TIMP in children with severe CP improves participation during manual activities utilizing percussion instruments, therefore increasing the intensity of the psychomotor intervention.

Neuroplasticity at Home: Improving Home-Based Motor Learning Through Technological Solutions. A Review

Background: Effective science-based motor rehabilitation requires high volume of individualized, intense physical training, which can be difficult to achieve exclusively through physical 1-on-1 sessions with a therapist. Home-based training, enhanced by technological solutions, could be a tool to help facilitate the important factors for neuroplastic motor improvements.

Objectives: This review aimed to discover how the inclusion of modern information and communications technology in home-based training programs can promote key neuroplastic factors associated with motor learning in neurological disabilities and identify which challenges are still needed to overcome.

Methods: We conducted a thorough literature search on technological home-based training solutions and categorized the different fundamental approaches that were used. We then analyzed how these approaches can be used to promote certain key factors of neuroplasticity and which challenges still need to be solved or require external personalized input from a therapist.

Conclusions: The technological approaches to home-based training were divided into three categories: sensory stimuli training, digital exchange of information training, and telerehabilitation. Generally, some technologies could be characterized as easily applicable, which gave the opportunity to promote flexible scheduling and a larger overall training volume, but limited options for individualized variation and progression. Other technologies included individualization options through personalized feedback that might increase the training effect, but also increases the workload of the therapist. Further development of easily applicable and intelligent solutions, which can return precise feedback and individualized training suggestions, is needed to fully realize the potential of home-based training in motor learning activities.

A Novel Clinical-Driven Design for Robotic Hand Rehabilitation: Combining Sensory Training, Effortless Setup, and Large Range of Motion in a Palmar Device

Neurorehabilitation research suggests that not only high training intensity, but also somatosensory information plays a fundamental role in the recovery of stroke patients. Yet, there is currently a lack of easy-to-use robotic solutions for sensorimotor hand rehabilitation. We addressed this shortcoming by developing a novel clinical-driven robotic hand rehabilitation device, which is capable of fine haptic rendering, and that supports physiological full flexion/extension of the fingers while offering an effortless setup. Our palmar design, based on a parallelogram coupled to a principal revolute joint, introduces the following novelties: (1) While allowing for an effortless installation of the user's hand, it offers large range of motion of the fingers (full extension to 180° flexion). (2) The kinematic design ensures that all fingers are supported through the full range of motion and that the little finger does not lose contact with the finger support in extension. (3) We took into consideration that a handle is usually comfortably grasped such that its longitudinal axis runs obliquely from the metacarpophalangeal joint of the index finger to the base of the hypothenar eminence. (4) The fingertip path was optimized to guarantee physiologically correct finger movements for a large variety of hand sizes. Moreover, the device possesses a high mechanical transparency, which was achieved using a backdrivable cable transmission. The transparency was further improved with the implementation of friction and gravity compensation. In a test with six healthy participants, the root mean square of the human-robot interaction force was found to remain as low as 1.37 N in a dynamic task. With its clinical-driven design and easy-to-use setup, our robotic device for hand sensorimotor rehabilitation has the potential for high clinical acceptance, applicability and effectiveness.

Advancing motor rehabilitation for adults with chronic neurological conditions through increased involvement of kinesiologists: a perspective review

Many people with neurological conditions experience challenges with movement. Although rehabilitation is often provided acutely and sub-acutely following the onset of a condition, motor deficits commonly persist in the long-term and are exacerbated by disuse and inactivity. Notably, motor rehabilitation approaches that incorporate exercise and physical activity can support gains in motor function even in the chronic stages of many neurological conditions. However, delivering motor rehabilitation on a long-term basis to people with chronic neurological conditions is a challenge within health care systems, and the onus is often placed on patients to find and pay for services. While neurological motor rehabilitation is largely the domain of physical and occupational therapists, kinesiologists may be able to complement existing care and support delivery of long-term neurological motor rehabilitation, specifically through provision of supported exercise and physical activity programs. In this perspective style review article, we discuss potential contributions of kinesiologists to advancing the field through exercise programming, focusing on community-based interventions that increase physical activity levels. We conclude with recommendations on how kinesiologists' role might be further optimized towards improving long-term outcomes for people with chronic neurological conditions, considering issues related to professional regulation and models of care.

COpenhagen Neuroplastic TRaining Against Contractures in Toddlers (CONTRACT): protocol of an open-label randomised clinical trial with blinded assessment for prevention of contractures in infants with high risk of cerebral palsy

INTRODUCTION

Contractures are frequent causes of reduced mobility in children with cerebral palsy (CP) already at the age of 2-3 years. Reduced muscle use and muscle growth have been suggested as key factors in the development of contractures, suggesting that effective early prevention may have to involve stimuli that can facilitate muscle growth before the age of 1 year. The present study protocol was developed to assess the effectiveness of an early multicomponent intervention, CONTRACT, involving family-oriented and supervised home-based training, diet and electrical muscle stimulation directed at facilitating muscle growth and thus reduce the risk of contractures in children at high risk of CP compared with standard care.

METHODS AND ANALYSIS

A two-group, parallel, open-label randomised clinical trial with blinded assessment (n=50) will be conducted. Infants diagnosed with CP or designated at high risk of CP based on abnormal neuroimaging or absent fidgety movement determined as part of General Movement Assessment, age 9-17 weeks corrected age (CA) will be recruited. A balanced 1:1 randomisation will be made by a computer. The intervention will last for 6 months aiming to support parents in providing daily individualised, goal-directed activities and primarily in lower legs that may stimulate their child to move more and increase muscle growth. Guidance and education of the parents regarding the nutritional benefits of docosahexaenic acid (DHA) and vitamin D for the developing brain and muscle growth will be provided. Infants will receive DHA drops as nutritional supplements and neuromuscular stimulation to facilitate muscle growth. The control group will receive standard care as offered by their local hospital or community. Outcome measures will be taken at 9, 12, 18, 24, 36 and 48 months CA. Primary and secondary outcome measure will be lower leg muscle volume and stiffness of the triceps surae musculotendinous unit together with infant motor profile, respectively.

ETHICS AND DISSEMINATION

Full approval from the local ethics committee, Danish Committee System on Health Research Ethics, Region H (H-19041562). Experimental procedures conform with the Declaration of Helsinki.

TRIAL REGISTRATION NUMBER

NCT04250454.

EXPECTED RECRUITMENT PERIOD

1 January 2021-1 January 2025.

Motor-learning based activities may improve functional ability in adults with severe cerebral palsy: A controlled pilot study

BACKGROUND

Cerebral palsy (CP) is a neurodevelopmental disturbance characterized by impaired control of movement. Function often decreases and 15% of adults are classified as severely affected (Gross Motor Function Classification Scale III-V). Little is known about interventions that aim to improve functional abilities in this population.

OBJECTIVE

To evaluate a 12-week intervention based on motor learning principles on functional ability in adults with severe CP.

METHODS

16 adults (36±10 years, GMFCS III-V) were enrolled and divided into an intervention group (Active group) and a standard care group (Control group). Primary outcome measure was Gross Motor Function Measure (GMFM-88). Secondary measures were neurological status. The Active group were measured at baseline, after the intervention and at one-month follow-up. The Control group were measured at baseline and after one month.

RESULTS

Analysis showed statistically significant improvement in GMFM-88 for the Active group from baseline to post assessment compared with the Control group (group difference: 5 points, SE 14.5, p = 0.008, CI: 1.2 to 8.7). Improvements were maintained at follow-up. Results from the neurological screening showed no clear tendencies.

CONCLUSIONS

The study provides support that activities based on motor learning principles may improve gross motor function in adults with severe CP.

Home Activity-based Interventions for the Neurologically Impaired Upper Extremity: A Scoping Review

Background:

Activity-based therapy (ABT) for the upper extremity (UE) enables neurologic recovery with tasks that are functional, intense, and highly repetitive. A large proportion of rehabilitation occurs in the home and there is a gap in literature on the application of ABT within the home. The objective of this scoping review was to describe ABT in the home-setting for the neurologically-impaired UE.

Methods:

A systematic scoping review included searches of: MEDLINE, CINAHL, Cochrane, and OTSeeker.

Results:

A systematic search yielded 51 final studies. About 61% of ABT studies were exclusively within the home, others included outpatient visits (37%). Telerehabilitation was used in 37% of the studies with live-video and store forward techniques equally represented. ABT supported by technology was used in 61% of studies. Dosing of intervention ranged from 7 to 120 hours, with a mean of 34.5 hours of practice. Adherence with intended dosing was reported in 27% of studies and subjects completed a mean of 86% of the intended practice time. Sixty-seven percent of studies reported some degree of practice without therapist supervision.

Conclusions:

The results showed wide variability in the intervention methods, dosing and technology used in homebased settings. The high rate of adherence with dosing is encouraging for the application of homebased neurologic UE interventions. This scoping review highlights feasibility of UE ABT within the home and need for further research.

The realization of robotic neurorehabilitation in clinical: use of computational intelligence and future prospects analysis

Introduction: Although there is a need for rehabilitation treatment with the increase in the aging population, the shortage of skilled physicians frustrates this necessity. Robotic technology has been advocated as one of the most viable methods with the potential to replace humans in providing physical rehabilitation of patients with neurological impairment. However, because the pioneering robot devices suffer several reservations such as safety and comfort concerns in clinical practice, there is an urgent need to provide upgraded replacements. The rapid development of intelligent computing has attracted the attention of researchers concerning the utilization of computational intelligence algorithms for robots in rehabilitation. Areas covered: This article reviews the state of the art and advances of robotic neurorehabilitation with computational intelligence. We classified advances into two categories: mechanical structures and control methods. Prospective outlooks of rehabilitation robots also have been discussed. Expert opinion: The aggravation of global aging has promoted the application of robotic technology in neurorehabilitation. However, this approach is not mature enough to guarantee the safety of patients. Our critical review summarizes multiple computation algorithms which have been proved to be valuable for better robotic use in clinical settings and guide the possible future advances in this industry.

Principles of Neurorehabilitation After Stroke Based on Motor Learning and Brain Plasticity Mechanisms

What are the principles underlying effective neurorehabilitation? The aim of neurorehabilitation is to exploit interventions based on human and animal studies about learning and adaptation, as well as to show that the activation of experience-dependent neuronal plasticity augments functional recovery after stroke. Instead of teaching compensatory strategies that do not reduce impairment but allow the patient to return home as soon as possible, functional recovery might be more sustainable as it ensures a long-term reduction in impairment and an improvement in quality of life. At the same time, neurorehabilitation permits the scientific community to collect valuable data, which allows inferring about the principles of brain organization. Hence neuroscience sheds light on the mechanisms of learning new functions or relearning lost ones. However, current rehabilitation methods lack the exact operationalization of evidence gained from skill learning literature, leading to an urgent need to bridge motor learning theory and present clinical work in order to identify a set of ingredients and practical applications that could guide future interventions. This work aims to unify the neuroscientific literature relevant to the recovery process and rehabilitation practice in order to provide a synthesis of the principles that constitute an effective neurorehabilitation approach. Previous attempts to achieve this goal either focused on a subset of principles or did not link clinical application to the principles of motor learning and recovery. We identified 15 principles of motor learning based on existing literature: massed practice, spaced practice, dosage, task-specific practice, goal-oriented practice, variable practice, increasing difficulty, multisensory stimulation, rhythmic cueing, explicit feedback/knowledge of results, implicit feedback/knowledge of performance, modulate effector selection, action observation/embodied practice, motor imagery, and social interaction. We comment on trials that successfully implemented these principles and report evidence from experiments with healthy individuals as well as clinical work.

Activity-Based Therapy in a Community Setting for Independence, Mobility, and Sitting Balance for People With Spinal Cord Injuries

INTRODUCTION

Activity-based therapy (ABT) aims to activate the neuromuscular system below the level of the spinal cord lesion and promote recovery of motor tasks through spinal reorganisation, motor learning and changes to muscles and sensory system. We investigated the effects of a multimodal ABT program on mobility, independence and sitting balance in individuals with spinal cord injury (SCI).

METHODS

Retrospective clinical data from 91 adults who independently enrolled in four community-based ABT centres in Australia were analysed. The multimodal ABT program was delivered for 3 to 12 months, one to four times per week. Assessments were undertaken every 3 months and included the Modified Rivermead Mobility Index (MRMI), Spinal Cord Independence Measure (SCIM) and seated reach distance (SRD). A linear mixed model analysis was used to determine time-based and other predictors of change.

RESULTS

There was a significant improvement after 12 months for all outcome measures, with a mean change score of 4 points in the SCIM (95% confidence interval [CI]: 2.7-5.3, d = 0.19), 2 points in the MRMI (95% CI: 1-2.3, d = 0.19) and 0.2 in the SRD (95% CI: 0.1-2.2, d = 0.52). Greater improvements occurred in the first 3 months of intervention. There were no interaction effects between time and the neurological level of injury, American Spinal Injury Association Impairment Scale classification, or duration post-injury for most outcomes.

CONCLUSIONS

A community-based ABT exercise program for people with SCI can lead to small improvements in mobility, independence and balance in sitting, with greater improvements occurring early during intervention.

Effects of Hand Configuration on the Grasping, Holding, and Placement of an Instrumented Object in Patients With Hemiparesis

Objective: Limitations with manual dexterity are an important problem for patients suffering from hemiparesis post stroke. Sensorimotor deficits, compensatory strategies and the use of alternative grasping configurations may influence the efficiency of prehensile motor behavior. The aim of the present study is to examine how different grasp configurations affect patient ability to regulate both grip forces and object orientation when lifting, holding and placing an object.

Methods: Twelve stroke patients with mild to moderate hemiparesis were recruited. Each was required to lift, hold and replace an instrumented object. Four different grasp configurations were tested on both the hemiparetic and less affected arms. Load cells from each of the 6 faces of the instrumented object and an integrated inertial measurement unit were used to extract data regarding the timing of unloading/loading phases, regulation of grip forces, and object orientation throughout the task.

Results: Grip forces were greatest when using a palmar-digital grasp and lowest when using a top grasp. The time delay between peak acceleration and maximum grip force was also greatest for palmar-digital grasp and lowest for the top grasp. Use of the hemiparetic arm was associated with increased duration of the unloading phase and greater difficulty with maintaining the vertical orientation of the object at the transitions to object lifting and object placement. The occurrence of touch and push errors at the onset of grasp varied according to both grasp configuration and use of the hemiparetic arm.

Conclusion: Stroke patients exhibit impairments in the scale and temporal precision of grip force adjustments and reduced ability to maintain object orientation with various grasp configurations using the hemiparetic arm. Nonetheless, the timing and magnitude of grip force adjustments may be facilitated using a top grasp configuration. Conversely, whole hand prehension strategies compound difficulties with grip force scaling and inhibit the synchrony of grasp onset and object release.

Walking and balance outcomes for stroke survivors: a randomized clinical trial comparing body-weight-supported treadmill training with versus without challenging mobility skills

Background

Treadmill training, with or without body-weight support (BWSTT), typically involves high step count, faster walking speed, and higher heart-rate intensity than overground walking training. The addition of challenging mobility skill practice may offer increased opportunities to improve walking and balance skills. Here we compare walking and balance outcomes of chronic stroke survivors performing BWSTT with BWSTT including challenging mobility skills.

Methods

Single-blind randomized clinical trial comparing two BWSTT interventions performed in a rehabilitation research laboratory facility over 6 weeks. Participants were 18+ years of age with chronic (≥5 months) poststroke hemiparesis due to a cortical or subcortical ischemic or hemorrhagic stroke and walking speeds < 1.1 m/s at baseline. A hands-free group (HF; n = 15) performed BWSTT without assistance from handrails or assistive devices, and a hands-free plus challenge group (HF + C; n = 14) performed the same protocol while additionally practicing challenging mobility skills. The primary outcome was change in comfortable walking speed (CWS), with secondary outcomes of fast walk speed (FWS), six-minute walk distance, Berg Balance Scale (BBS) scores, and Activities Specific Balance Confidence (ABC) scores.

Results

Significant pre-post improvement of CWS (Z = − 4.2, p ≤ 0.0001) from a median of 0.35 m/s (range 0.10 to 1.09) to a median of 0.54 m/s (range 0.1 to 1.17), but no difference observed between groups (U = 96.0, p = 0.69). Pre-post improvements across all participants resulted in reclassified baseline ambulation status from sixteen to ten household ambulators, three to seven limited community ambulators, and ten to twelve community ambulators. Secondary outcomes showed similar pre-post improvements with no between-group differences.

Conclusions

The addition of challenging mobility skills to a hands-free BWSTT protocol did not lead to greater improvements in CWS following 6 weeks of training. One reason for lack of group differences may be that both groups were adequately challenged by walking in an active, self-driven treadmill environment without use of handrails or assistive devices.

Trial registration

NCT02787759 Falls-based Training for Walking Post-Stroke (FBT); retrospectively registered June 1st, 2016.

How does strength training and balance training affect gait and fatigue in patients with Multiple Sclerosis? A study protocol of a randomized controlled trial

INTRODUCTION

Multiple sclerosis (MS) is characterized by a demyelination that results in reduced conductivity in the somatosensory nervous system, decreased muscle strength, vestibular alteration, and severe fatigue. Progressive resistance training (PRT) has proven to be a promising intervention showing a positive effect on muscle strength. Another promising intervention frequently used in neuro-rehabilitation is task specific training where also Balance and Motor Control Training (BMCT) are incorporated. Interestingly, the principles of BMCT do fundamentally contrast the principles of PRT in terms of variation in movement pattern, loading and repetitions. Consequently, knowledge of any diverse effect would be of clinical relevance.

AIM

To evaluate the effects of PRT and BMCT on gait, balance and fatigue in persons with MS.

METHOD

A three-armed multi-center, single-blinded cluster randomized controlled trial with two intervention groups (1. PRT of the lower extremities. 2. BMCT that challenges gait function) and a control group that receives usual care while on a waitlist for a combined PRT + BMCT intervention performed after the two interventions groups have completed their interventions. The interventions last ten weeks with two sessions per week, in groups of 3-6 participants. Number of participants is 30 per intervention - 90 in total. Primary outcome measures for gait function are the Timed 25 Foot Walk (T25FW) and the Six Spot Step Test (SSST). Secondary outcomes are fatigue, perceived gait function, temporo-spatial gait characteristics, balance and strength.Inclusion criteria are: EDSS 2-6, SSST >8 sec and T25FW >5 sec. Exclusion: Recent attacks and ongoing intensive rehabilitation.

ANALYSIS

The effects in the three groups are examined in a mixed effects regression analysis with group and time as fixed effects and center and patient within center as random effects. Spearman or Pearson correlation analysis will be conducted on baseline data to determine associations between the primary outcomes on gait function and the secondary outcomes on fatigue, spatial gait parameters, balance and patient reported measures.

TRIAL REGISTRATION

The study is approved by the Regional ethical committee and registered at clinicaltrials.gov, NCT02870023.

"The whole perimeter is difficult": Parkinson's disease and the conscious experience of walking in everyday environments

Purpose: This study sought to characterize the way patients with Parkinson's disease consciously perceive and respond to their surroundings while walking in everyday situations.Method: A qualitative research program designed around an ecological data collection protocol was employed. A convenience sample of 14 patients with a diagnosis of Parkinson's disease and a history of gait difficulties were recruited. Details regarding patients' subjective experience of walking in everyday environments were obtained using first person interviewing techniques with the support of video footage from their daily-life activity. Interview transcripts were analyzed using an interpretive phenomenological approach in order to derive key themes.Results: The sense of proximity and the way in which an individual perceived themselves with respect to their surroundings appeared central to the way patients organized their locomotor behavior. Further to this, the patient relationship to different features and obstacles appeared conditioned by prior experiences in those circumstances. Patients described managing gait difficulties by consciously regulating their walking trajectory and gaze with respect to their environment.Conclusion: Perceptual challenges, visual flow and the dynamic valence of features in the patient's surroundings may have important effects upon the gait stability of patients with Parkinson's disease and warrant further attention in planning rehabilitation interventions.Implications for rehabilitationWalking abilities of patients with Parkinson's disease should be conceptualized in terms of perceptuomotor coupling to a given environment.The functional significance of a patient's environment is dynamic and might be seen to vary in accordance with their physical capacities.Valency, or the subjective relationship between a patient and their surrounds, appears to be an important component of the "fit" between a person and their environment.Novel rehabilitation strategies for the management of parkinsonian gait disturbances might seek to integrate psychological, sensorimotor and environmental elements in order to have individually tailored, ecologically valid home assessment and community rehabilitation programs.

A Challenge-Based Approach to Body Weight-Supported Treadmill Training Poststroke: Protocol for a Randomized Controlled Trial

Background

Body weight support treadmill training protocols in conjunction with other modalities are commonly used to improve poststroke balance and walking function. However, typical body weight support paradigms tend to use consistently stable balance conditions, often with handrail support and or manual assistance.

Objective

In this paper, we describe our study protocol, which involved 2 unique body weight support treadmill training paradigms of similar training intensity that integrated dynamic balance challenges to help improve ambulatory function post stroke. The first paradigm emphasized walking without any handrails or manual assistance, that is, hands-free walking, and served as the control group, whereas the second paradigm incorporated practicing 9 essential challenging mobility skills, akin to environmental barriers encountered during community ambulation along with hands-free walking (ie hands-free + challenge walking).

Methods

We recruited individuals with chronic poststroke hemiparesis and randomized them to either group. Participants trained for 6 weeks on a self-driven, robotic treadmill interface that provided body weight support and a safe gait-training environment. We assessed participants at pre-, mid- and post 6 weeks of intervention-training, with a 6-month follow-up. We hypothesized greater walking improvements in the hands-free + challenge walking group following training because of increased practice opportunity of essential mobility skills along with hands-free walking.

Results

We assessed 77 individuals with chronic hemiparesis, and enrolled and randomized 30 individuals poststroke for our study (hands-free group=19 and hands-free + challenge walking group=20) from June 2012 to January 2015. Data collection along with 6-month follow-up continued until January 2016. Our primary outcome measure is change in comfortable walking speed from pre to post intervention for each group. We will also assess feasibility, adherence, postintervention efficacy, and changes in various exploratory secondary outcome measures. Additionally, we will also assess participant responses to a study survey, conducted at the end of training week, to gauge each group's training experiences.

Conclusions

Our treadmill training paradigms, and study protocol represent advances in standardized approaches to selecting body weight support levels without the necessity for using handrails or manual assistance, while progressively providing dynamic challenges for improving poststroke ambulatory function during rehabilitation.

Trial Registration

ClinicalTrials.gov NCT02787759; https://clinicaltrials.gov/ct2/show/NCT02787759 (Archived by Webcite at http://www.webcitation.org/6yJZCrIea)

Locomotor training using an overground robotic exoskeleton in long-term manual wheelchair users with a chronic spinal cord injury living in the community: Lessons learned from a feasibility study in terms of recruitment, attendance, learnability, performance and safety

Background

For individuals who sustain a complete motor spinal cord injury (SCI) and rely on a wheelchair as their primary mode of locomotion, overground robotic exoskeletons represent a promising solution to stand and walk again. Although overground robotic exoskeletons have gained tremendous attention over the past decade and are now being transferred from laboratories to clinical settings, their effects remain unclear given the paucity of scientific evidence and the absence of large-scale clinical trials. This study aims to examine the feasibility of a locomotor training program with an overground robotic exoskeleton in terms of recruitment, attendance, and drop-out rates as well as walking performance, learnability, and safety.

Methods

Individuals with a SCI were invited to participate in a 6 to 8-week locomotor training program with a robotic exoskeleton encompassing 18 sessions. Selected participants underwent a comprehensive screening process and completed two familiarization sessions with the robotic exoskeleton. The outcome measures were the rate of recruitment of potential participants, the rate of attendance at training sessions, the rate of drop-outs, the ability to walk with the exoskeleton, and its progression over the program as well as the adverse events.

Results

Out of 49 individuals who expressed their interest in participating in the study, only 14 initiated the program (recruitment rate = 28.6%). Of these, 13 individuals completed the program (drop-out rate = 7.1%) and attended 17.6 ± 1.1 sessions (attendance rate = 97.9%). Their greatest standing time, walking time, and number of steps taken during a session were 64.5 ± 10.2 min, 47.2 ± 11.3 min, and 1843 ± 577 steps, respectively. During the training program, these last three parameters increased by 45.3%, 102.1%, and 248.7%, respectively. At the end of the program, when walking with the exoskeleton, most participants required one therapist (85.7%), needed stand-by or contact-guard assistance (57.1%), used forearm crutches (71.4%), and reached a walking speed of 0.25 ± 0.05 m/s. Five participants reported training-related pain or stiffness in the upper extremities during the program. One participant sustained bilateral calcaneal fractures and stopped the program.

Conclusions

This study confirms that larger clinical trials investigating the effects of a locomotor training program with an overground robotic exoskeleton are feasible and relatively safe in individuals with complete motor SCI. Moreover, to optimize the recruitment rate and safety in future trials, this study now highlights the need of developing pre-training rehabilitation programs to increase passive lower extremity range of motion and standing tolerance. This study also calls for the development of clinical practice guidelines targeting fragility fracture risk assessment linked to the use of overground robotic exoskeletons.

Neurologic music therapy in upper-limb rehabilitation in children with severe bilateral cerebral palsy: a randomized controlled trial

BACKGROUND

After receiving neurologic music therapy, functional improvements in children with severe bilateral cerebral palsy have not been found in the literature. Musical training with instruments allows interrelationships between movement, emotions and cognition for task-based learning, in order to improve motor control.

AIM

To understand whether neurologic music therapy has an impact on the functionality of children with severe cerebral palsy.

DESIGN

A randomized controlled assessor-blind trial was carried out.

SETTING

Children were recruited and treated in their own community center.

POPULATION

Eighteen children with severe bilateral cerebral palsy between 4 and 16 years old were studied.

METHODS

The intervention group (N.=18) received music therapy for 16 weeks, in addition to its usual physiotherapy input. Two music therapists implemented a neurologic music therapy program of therapeutic instrumental music performance. The control group (N.=9) received its usual therapeutic input, similar to the intervention group, but not neurologic music therapy. Overall and specific "Chailey levels of Ability" were quantified, as well as the locomotor stages.

RESULTS

Significant improvements in the overall and specific "arm and hand position" as well as "activities" from the Chailey Levels of Ability and the locomotor stages were observed (P<0.05) in the group which received the music therapy. All these improvements persisted after 4 months. The control group showed no improvements after a four-month follow-up.

CONCLUSIONS

Optimized intervention of neurologic music therapy can improve the functionality of children with severe bilateral cerebral palsy.

CLINICAL REHABILITATION IMPACT

Music therapy is a useful tool in rehabilitation and its positive effects remain four months after completing the treatment.

Progressive practice promotes motor learning and repeated transient increases in corticospinal excitability across multiple days

BACKGROUND

A session of motor skill learning is accompanied by transient increases in corticospinal excitability(CSE), which are thought to reflect acute changes in neuronal connectivity associated with improvements in sensorimotor performance. Factors influencing changes in excitability and motor skill with continued practice remain however to be elucidated.

OBJECTIVE/HYPOTHESIS

Here we investigate the hypothesis that progressive motor practice during consecutive days can induce repeated transient increases in corticospinal excitability and promote motor skill learning.

METHODS

Changes in motor performance and CSE were assessed during 4 consecutive days of skill learning and 8 days after the last practice session. CSE was assessed as area under recruitment curves(RC) using transcranial magnetic stimulation(TMS). Two groups of participants(n = 12) practiced a visuomotor tracking-task with task difficulty progressively increased with individual proficiency(PPG) or with the same task level throughout all 4 days(NPPG).

RESULTS

Progressive practice resulted in superior motor learning compared to NPPG(p < 0.001). Whereas NPPG displayed increased CSE following only the first day of practice(p < 0.001), progressive motor practice was accompanied by increases in CSE on both the first and the final session of motor practice(p = 0.006). Eight days after ended practice, the groups showed similar CSE, but PPG maintained superior performance at a skilled task level and transfer task performance(p < 0.005,p = 0.029).

CONCLUSION

The results demonstrate that progressive practice promotes both motor learning and repeated increases in CSE across multiple days. While changes in CSE did not relate to learning our results suggest that they signify successful training. Progressive practice is thus important for optimizing neurorehabilitation and motor practice protocols in general.

Interacting Learning Processes during Skill Acquisition: Learning to control with gradually changing system dynamics

There is increasing evidence that sensorimotor learning under real-life conditions relies on a composition of several learning processes. Nevertheless, most studies examine learning behaviour in relation to one specific learning mechanism. In this study, we examined the interaction between reward-based skill acquisition and motor adaptation to changes of object dynamics. Thirty healthy subjects, split into two groups, acquired the skill of balancing a pole on a cart in virtual reality. In one group, we gradually increased the gravity, making the task easier in the beginning and more difficult towards the end. In the second group, subjects had to acquire the skill on the maximum, most difficult gravity level. We hypothesized that the gradual increase in gravity during skill acquisition supports learning despite the necessary adjustments to changes in cart-pole dynamics. We found that the gradual group benefits from the slow increment, although overall improvement was interrupted by the changes in gravity and resulting system dynamics, which caused short-term degradations in performance and timing of actions. In conclusion, our results deliver evidence for an interaction of reward-based skill acquisition and motor adaptation processes, which indicates the importance of both processes for the development of optimized skill acquisition schedules.

Rehabilitation for Individuals With Genetic Degenerative Ataxia: A Systematic Review

BACKGROUND

Treatment of genetic degenerative ataxia is currently based on symptom management and maintenance of function. However, utilization of rehabilitation is limited due to a lack of evidence supporting its efficacy.

OBJECTIVE

This systematic review evaluated rehabilitation interventions for individuals with genetic degenerative ataxia. In addition, long-term outcomes from rehabilitation and optimal duration and intensity of rehabilitation were examined.

METHODS

A comprehensive search of 4 databases (MEDLINE, CINAHL, PEDro, and Cochrane) identified randomized, nonrandomized controlled, and cohort studies published from inception through to January 2016. The studies included at least one measure examining function, ataxia, balance, or gait. Methodological quality was assessed with the Australian National Health and Medical Research Council (NHMRC) Hierarchy of Evidence and the randomized controlled trials were rated according to the PEDro scale.

RESULTS

Seventeen studies met eligibility criteria. Five randomized controlled trials were included; however, the majority were classified as level III-3 and IV studies. Of 292 participants included, 148 had autosomal dominant ataxia, and 85 had autosomal recessive ataxia. Rehabilitation interventions included coordination and balance training, multifaceted inpatient rehabilitation, a cycling regime, balance exercises with technology assisted biofeedback, respiratory muscle training, and treadmill training. Two studies examined adjuncts to rehabilitation. Fifteen of the 17 studies demonstrated a statistically significant improvement in at least 1 outcome measuring ataxia, function, gait, or balance. Less than half of the studies included assessment of long-term outcomes and follow-up time frames varied considerably.

CONCLUSION

There is consistent evidence that rehabilitation improves function, mobility, ataxia, and balance in genetic degenerative ataxia.

Effects of Activity-Based Therapy Interventions on Mobility, Independence, and Quality of Life for People with Spinal Cord Injuries: A Systematic Review and Meta-Analysis

The aim of this study was to review the literature about the effects of activity-based therapy (ABT) interventions on mobility, functional independence, and quality of life for people with a spinal cord injury (SCI). A systematic review with meta-analysis of randomized and non-randomized trials was performed, including adults with a non-progressive SCI at any level. The intervention of interest was ABT, defined as any intervention that sought to improve muscle activation or sensory function below the level of injury in the spinal cord and does not rely on compensatory mechanisms for improving function. The comparison was either no intervention or conventional physical interventions targeted to regions above the level of injury. The outcome measures were quality-of-life questionnaires, mobility assessments, and functional independence scales. Nineteen trials were included in this systematic review. Three compared ABT to no intervention and 16 to conventional physical rehabilitation. The methodological quality of the trials was assessed using the PEDro scale as moderate. Six studies investigated the effects of ABT interventions for the upper limbs, 11 investigated gait-related interventions, and two applied multi-modal interventions. Compared with no intervention, the meta-analysis found that ABT was not more effective for improving independence or lower limb mobility, but conferred a large positive effect on upper limb function. Compared with conventional physical interventions, there was no significant effect of ABT on lower limb mobility, independence, or quality of life; however, it had positive effects on upper limbs. In conclusion, there is evidence that ABT can improve independence and functional ability when applied to the upper limbs in people with SCI. However, it is not superior to conventional physical interventions when applied to the lower limbs.

A Novel Elastic Force-Field to Influence Mediolateral Foot Placement During Walking

Bipedal gait can be stabilized through mechanically-appropriate mediolateral foot placement, although this strategy is disrupted in a subset of neurologically injured individuals with balance deficits. The goal of the present work was to develop a device to influence mediolateral foot placement during treadmill walking. We created a novel force-field using a combination of passive elasticity and active control; wires in series with extension springs run parallel to the treadmill belts and can be rapidly repositioned to exert mediolateral forces on the legs of users. This mechanical structure creates a channel-like force landscape that resists displacements of each leg away from its prescribed mediolateral position, producing near-linear effective mediolateral stiffness. The depth of these force-field channels can be predictably controlled by manipulating extension spring initial tension. In human testing, we found that the force-field can effectively "get-out-of-the-way" when desired, closely following the mediolateral leg trajectory with a delay of approximately 110 ms. The force-field can also encourage users to adjust their mediolateral foot placement in order to walk with either narrower or wider steps, without interfering with forward gait progression. Future work will test whether this novel device can help retrain a stable gait pattern in clinical populations.

Exercise Training for Persons with Alzheimer's Disease and Caregivers: A Review of Dyadic Exercise Interventions

Alzheimer's disease (AD) is the most common form of dementia and the prevalence will increase dramatically in the next decades. Although exercise has shown benefits for people with dementia due to AD as well as their caregivers, the impact of a dyadic exercise intervention including both groups as study participants remains to be determined. The authors review the current clinical evidence for dyadic exercise interventions, which are exercise regimens applied to both the person with dementia and the caregiver. A total of 4 controlled trials were reviewed. This review shows that dyadic exercise interventions are feasible and may produce a positive effect on functional independence and caregiver burden. However, there was insufficient evidence to support a benefit of dyadic exercise intervention on cognitive performance and on behavioral and neuropsychiatric symptoms in participants with dementia due to AD. A dyadic exercise intervention improves functional independence and caregiver burden. However, there is a need for well-designed randomized controlled clinical trials to confirm these benefits and to investigate several important points such as the effects of a dyadic exercise intervention on cognitive and noncognitive outcomes of AD, the optimal intensity of exercise training, and the cost effectiveness of such a program.

Action research in rehabilitation with chronic stroke recovery: A case report with a focus on neural plasticity

BACKGROUND

Chronic stroke patients are primarily referred to general rehabilitation, rather than to specific neurorehabilitation. Currently, there are no Danish clinical guidelines for chronic stroke, but recent research in neuroplasticity has contributed to possible rehabilitation interventions for these patients.

OBJECTIVE

The purpose of this project is to describe the use of a specialized neuroplastic approach in combination with an already existing training program.

METHODS

The project is designed as an action research project concerning four participants with chronic stroke. Through ten intervention, a neuroplastic focus has been added to their group training program including daily home training. Participants were tested before and after the intervention with MAS, DGI, 6MWT, SSQLS.

RESULTS

All four participants improved their functional levels and their quality of life following the intervention.

CONCLUSIONS

This report indicates that a specific neuroplastic focus in combination with action research has an impact on the participants with chronic stroke. However, there is still no clarity regarding what type of rehabilitation methods can be considered the most efficacious in promoting neuroplasticity. This case report serves as a pilot project for further studies of how to implement neuroplasticity in physical therapy.

Effect of a mixed reality-based intervention on arm, hand, and finger function on chronic stroke

Background

Virtual and mixed reality systems have been suggested to promote motor recovery after stroke. Basing on the existing evidence on motor learning, we have developed a portable and low-cost mixed reality tabletop system that transforms a conventional table in a virtual environment for upper limb rehabilitation. The system allows intensive and customized training of a wide range of arm, hand, and finger movements and enables interaction with tangible objects, while providing audiovisual feedback of the participants’ performance in gamified tasks. This study evaluates the clinical effectiveness and the acceptance of an experimental intervention with the system in chronic stroke survivors.

Methods

Thirty individuals with stroke were included in a reversal (A-B-A) study. Phase A consisted of 30 sessions of conventional physical therapy. Phase B consisted of 30 training sessions with the experimental system. Both interventions involved flexion and extension of the elbow, wrist, and fingers, and grasping of different objects. Sessions were 45-min long and were administered three to five days a week. The body structures (Modified Ashworth Scale), functions (Motricity Index, Fugl-Meyer Assessment Scale), activities (Manual Function Test, Wolf Motor Function Test, Box and Blocks Test, Nine Hole Peg Test), and participation (Motor Activity Log) were assessed before and after each phase. Acceptance of the system was also assessed after phase B (System Usability Scale, Intrinsic Motivation Inventory).

Results

Significant improvement was detected after the intervention with the system in the activity, both in arm function measured by the Wolf Motor Function Test (p < 0.01) and finger dexterity measured by the Box and Blocks Test (p < 0.01) and the Nine Hole Peg Test (p < 0.01); and participation (p < 0.01), which was maintained to the end of the study. The experimental system was reported as highly usable, enjoyable, and motivating.

Conclusions

Our results support the clinical effectiveness of mixed reality interventions that satisfy the motor learning principles for upper limb rehabilitation in chronic stroke survivors. This characteristic, together with the low cost of the system, its portability, and its acceptance could promote the integration of these systems in the clinical practice as an alternative to more expensive systems, such as robotic instruments.

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-016-0153-6) contains supplementary material, which is available to authorized users.

Preparing a neuropediatric upper limb exergame rehabilitation system for home-use: a feasibility study

Background

Home-based, computer-enhanced therapy of hand and arm function can complement conventional interventions and increase the amount and intensity of training, without interfering too much with family routines. The objective of the present study was to investigate the feasibility and usability of the new portable version of the YouGrabber® system (YouRehab AG, Zurich, Switzerland) in the home setting.

Methods

Fifteen families of children (7 girls, mean age: 11.3y) with neuromotor disorders and affected upper limbs participated. They received instructions and took the system home to train for 2 weeks. After returning it, they answered questions about usability, motivation, and their general opinion of the system (Visual Analogue Scale; 0 indicating worst score, 100 indicating best score; ≤30 not satisfied, 31–69 average, ≥70 satisfied). Furthermore, total pure playtime and number of training sessions were quantified. To prove the usability of the system, number and sort of support requests were logged.

Results

The usability of the system was considered average to satisfying (mean 60.1–93.1). The lowest score was given for the occurrence of technical errors. Parents had to motivate their children to start (mean 66.5) and continue (mean 68.5) with the training. But in general, parents estimated the therapeutic benefit as high (mean 73.1) and the whole system as very good (mean 87.4). Children played on average 7 times during the 2 weeks; total pure playtime was 185 ± 45 min. Especially at the beginning of the trial, systems were very error-prone. Fortunately, we, or the company, solved most problems before the patients took the systems home. Nevertheless, 10 of 15 families contacted us at least once because of technical problems.

Conclusions

Despite that the YouGrabber® is a promising and highly accepted training tool for home-use, currently, it is still error-prone, and the requested support exceeds the support that can be provided by clinical therapists. A technically more robust system, combined with additional attractive games, likely results in higher patient motivation and better compliance. This would reduce the need for parents to motivate their children extrinsically and allow for clinical trials to investigate the effectiveness of the system.

Trial registration

ClinicalTrials.gov NCT02368223

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-016-0141-x) contains supplementary material, which is available to authorized users.

Subjective Visual Vertical during Caloric Stimulation in Healthy Subjects: Implications to Research and Neurorehabilitation

Background. The subjective visual vertical (SVV) is a perception often impaired in patients with neurologic disorders and is considered a sensitive tool to detect otolithic dysfunctions. However, it remains unclear whether the semicircular canals (SCCs) are also involved in the visual vertical perception. Objective. The aim of this study was to analyze the influence of horizontal SCCs on SVV by caloric stimulation in healthy subjects. Methods. SVV was performed before and during the ice-cold caloric stimulation (4°C, right ear) in 30 healthy subjects. Results. The mean SVV tilts before and during the caloric stimulation were 0.31° ± 0.39 and −0.28° ± 0.40, respectively. There was no significant difference between the mean SVV tilts before and during stimulation (p = 0.113). Conclusion. These results suggest that horizontal SCCs do not influence SVV. Therefore, investigations and rehabilitation approaches for SVV misperceptions should be focused on otolithic and cognitive strategies.