Development of a Multidimensional, Multigroup Measure of Self-Care for Inpatient Rehabilitation

OBJECTIVE

To develop and evaluate a measure of clinician-observed and patient-performed self-care function for use during inpatient rehabilitation.

DESIGN

Retrospective analysis of self-care assessments collected by therapists using confirmatory factor analysis (CFA) followed by multidimensional item response theory (MIRT).

SETTING

Freestanding inpatient rehabilitation hospital in the Midwestern United States.

PARTICIPANTS

Inpatients (N=7719) with stroke, traumatic brain injury, spinal cord injury, neurologic disorders, and musculoskeletal conditions.

INTERVENTIONS

Not applicable MAIN OUTCOME MEASURES: A total of 19 clinician-selected self-care measures including the FIM and patient-performed, clinician-rated measures of balance, upper extremity function, strength, changing body position, and swallowing. Clinicians completed assessments on admission and at least 1 interim assessment.

RESULTS

CFA was completed for 3 patient groups defined by their highest level of balance (sitting, standing, walking). We reduced the number of items by 47.5% while maintaining acceptable internal consistency; unidimensionality within each item set required development of testlets. A recursive analysis defined a self-care measure with sensitivity (Cohen d_max-min =1.13; Cohen d_last-first.=0.91) greater than the FIM self-care items (d_max-min.=0.94; d_last-first .=0.83). The CFA models provided good to acceptable fit (root mean square error of approximations 0.03-0.06). Most patients with admission FIM self-care ratings of total assistance (88%, 297 of 338) made improvements on the MIRT self-care measure that were undetected by the FIM; the FIM detected no change for 26% of these patients (78 of 297). The remaining 74% (219 of 297) improved on the MIRT-based measure an average of 14 days earlier than was detected by the FIM.

CONCLUSIONS

This MIRT self-care measure possesses measurement properties that are superior to the FIM, particularly for patients near its floor or ceiling. Methods assure accommodation for multidimensionality and high levels of sensitivity. This self-care measure has the potential to improve monitoring of self-care and manage therapy effectively during inpatient rehabilitation.

Relationship between Use of Rehabilitation Resources and ICU Readmission and ER Visits in ICU Survivors: the Korean ICU National Data Study 2008-2015

BACKGROUND

Despite the increasing importance of rehabilitation for critically ill patients, there is little information regarding how rehabilitation therapy is utilized in clinical practice. Our objectives were to evaluate the implementation rate of rehabilitation therapy in the intensive care unit (ICU) survivors and to investigate the effects of rehabilitation therapy on outcomes.

METHODS

A retrospective nationwide cohort study with including > 18 years of ages admitted to ICU between January 2008 and May 2015 (n = 1,465,776). The analyzed outcomes were readmission to ICU readmission and emergency room (ER) visit.

RESULTS

During the study period, 249,918 (17.1%) patients received rehabilitation therapy. The percentage of patients receiving any rehabilitation therapy increased annually from 14% in 2008 to 20% in 2014, and the percentages for each type of therapy also increased over time. The most common type of rehabilitation was physical therapy (91.9%), followed by neuromuscular electrical stimulation (29.6%), occupational (28.6%), respiratory, (11.6%) and swallowing (10.3%) therapies. After adjusting for confounding variables, the risk of 30-day ICU readmission was lower in patients who received rehabilitation therapy than in those who did not (P < 0.001; hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.65-0.75). And, the risk of 30-day ER visit was also lower in patients who received rehabilitation therapy (P < 0.001; HR, 0.83; 95% CI, 0.77-0.88).

CONCLUSION

In this nationwide cohort study in Korea, only 17% of all ICU patients received rehabilitation therapy. However, rehabilitation is associated with a significant reduction in the risk of 30-day ICU readmission and ER visit.

Cross-Disciplinary Medical Advances with Neuroengineering: Challenges Spur Development of Unique Rehabilitative and Therapeutic Interventions

Neuroengineering brings tools and techniques from the engineering fields into neuroscience to create new approaches for investigating the central nervous system (CNS). This fusion of disciplines is advancing our knowledge of how the CNS works and how we can enhance our natural cognitive and emotional function and restore neurological functions that are compromised by disease or injury.

[NEW OPPORTUNITIES IN NEURO-REHABILITATION: ROBOT MEDIATED THERAPY IN CONDITONS POST CENTRAL NERVOUS SYSTEM IMPAIRMENTS]

Decreasing the often-seen multiple disabilities as a consequence of central nervous system impairments requires broadening of the tools of rehabilitation. A promising opportunity for this purpose is the application of physiotherapy robots. The development of such devices goes back a quarter of century. Nowadays several robots are commercially available both for supporting upper and lower limb therapy. The aim is never to replace the therapists, but rather to support and supplement their work. It is worthwhile applying these devices for goal-oriented exercises in high repetition, which one physically fatiguing for the therapist or for the correction of functional movement by various strategies. Robot mediated therapy is also useful for motivation of the patient and making the rehabilitation programme more versatile. Robots can be used for assessment of the neuromotor status as well. Several clinical studies have been executed in this field, all over the world. Meta-analyses based on randomized, controlled trials show that supplementing the traditional physiotherapy with a robot-mediated component presents advantage for the patients. Further studies are necessary to clarify which modality and intensity of the exercises, in which group of patients, in which stage lead to the expected outcome.

[Robot-assisted and computer-based neurorehabilitation for children: the story behind]

Impairments of the central motor system can either be congenital (e. g. cerebral palsy) or acquired (e. g. traumatic brain injury, stroke). These lesions are the most frequent morbidities necessitating neuro-rehabilitative measures in childhood. Robot-assisted rehabilitation in combination with virtual reality can complement conventional therapies and provide a task-specific training, with a high number of repetitions over a prolonged time period. The advantage of virtual reality is that it can provide a real time feedback about the patient's performance. Furthermore, challenging virtual scenarios especially motivate young patients to continue with otherwise monotonous exercises. Preliminary findings indicate that robot-assisted training in children with central motor impairment could be beneficial, but conclusive evidence about its efficacy is still missing.

[The influence of the pearl baths on the dynamics of cerebral circulation in the children presenting with the consequences of perinatal lesions in the central nervous system]

The present article is concerned with the problem of rehabilitation of the children at the age from 6 to 12 months presenting with perinatal lesions in the central nervous system (CNS) and the role of cerebral hemodynamics in the development of this disease. The results of dynamic clinical and laboratory examination of the children presenting with the consequences of perinatal lesions in the central nervous system are presented with special reference to the influence of the pearl baths on the dynamics of cerebral circulation. The study involving 65 patients showed that the inclusion of bubble bath sin the combined rehabilitative treatment of the children with this condition helps to optimize parameters of the disturbed cerebral blood flow. The positive influence of bubble bath son the dynamics of clinical symptoms and the state of the cardiovascular system has been demonstrated.

Five years later: achieving professional effectiveness to move neurorehabilitation forward

The AOTA Centennial Vision outlined in 2007 challenged the occupational therapy profession to become a "powerful, widely recognized, science-driven, and evidence-based" profession that could adapt to changing societal and cultural needs and flourish well into the future. That challenge can be met by simply being effective at what we do; this will increase our value and validate our worth. Neurorehabilitation in occupational therapy can also thrive if we verify that the interventions we use and the strategies we implement are grounded in evidence. Professional effectiveness will emerge by (1) increasing the dissemination of research that supports the methods we use and informs others of the successful patient outcomes we achieve and (2) expanding development and validation of instruments that quantitatively and qualitatively measure functional outcomes. Occupational therapists can individually develop professional effectiveness by fostering greater academic-clinical alliances, objectifying evaluation and intervention methods, and preparing future practitioners appropriately for evidence-driven practice.

[The early comprehensive rehabilitation of the children with perinatal pathology of the craniovertebral region and cerebrospinal neurological symptoms]

This paper is designed to report the results of a clinical study of the children presenting with neurologic pathology for the detection of the most common concomitant craniovertebral disorders. In addition, the experience of application of the methods for comprehensive rehabilitation is presented with special reference to remedial exercises, manual therapy, massage, and other physiotherapeutic procedures. Positive experience with the application of orthopedic devices is described including the Shants collars and corsets as well as the observance of the specific orthopedic locomotor regimen. These combined measures are designed to enhance the quality of life of the patients, correct their neurologic symptoms, and improve the compromised academic performance.

Neural tissue transplantation, repair, and rehabilitation

Transplants of cells and tissues to the central nervous system of adult mammals can, under appropriate conditions, survive, integrate, and function. In particular, the grafted cells can sustain functional recovery in animal models of a range of neurodegenerative conditions including genetic and idiopathic neurodegenerative diseases of adulthood and aging, ischemic stroke, and brain and spinal cord trauma. In a restricted subset of such conditions, cell transplantation has progressed to application in humans in early-stage clinical trials. At the present stage of play, there is clear evidence of clinical efficacy of fetal cell transplants in Parkinson disease (notwithstanding a range of technical difficulties still to be fully resolved), and preliminary claims of promising outcomes in several other severe neurodegenerative conditions, including Huntington disease and stroke. Moreover, the experimental literature is increasingly suggesting that the experience and training of the graft recipient materially affects the functional outcome. For example, environmental enrichment, behavioral activity, and specific training can enhance the recovery process to maximize functional recovery. There are even circumstances where the grafted cells have been demonstrated to restore the neural substrate for new learning. Consequently, it is not sufficient to replace lost cells anatomically; rather, for the grafts to be effective, they need to be integrated functionally into the host circuitry, and the host animal requires training and rehabilitation to maximize function of the reconstructed graft-host circuitry. Such observations require reconsideration of the design of the next generation of clinical trials and subsequent service delivery, to include physiotherapists, cognitive therapists, and rehabilitation experts as core members of the transplant team, along with the neurologists and neurosurgeons that have conventionally led the field.

Accuracy of a Brain Computer Interface (P300 spelling device) used by people with motor impairments

A Brain-Computer Interface (BCI) provides a completely new output pathway and so, an additional possible way a person can express himself if he/she suffers from disorders like amyotrophic lateral sclerosis (ALS), brainstem stroke, brain or spinal cord injury, or other diseases which impair the function of the common output pathways which are responsible for the control of muscles or impair the muscles. Although most BCIs are thought to help people with disabilities, they are mainly tested on healthy, young subjects who may achieve better results than people with impairments. In this study we compare measurements, performed on 10 physically disabled people, to the results of a previous study, taken using 100 healthy participants. We prove that, under certain constraints, most patients are able to control a P300-based spelling device with almost the same accuracy as the healthy ones. Tuning parameters are discussed, as well as criteria for people who are not able to use this device.

The current theoretical assumptions of the Bobath concept as determined by the members of BBTA

The Bobath concept is a problem-solving approach to the assessment and treatment of individuals following a lesion of the central nervous system that offers therapists a framework for their clinical practice. The aim of this study was to facilitate a group of experts in determining the current theoretical assumptions underpinning the Bobath concept.A four-round Delphi study was used. The expert sample included all 15 members of the British Bobath Tutors Association. Initial statements were identified from the literature with respondents generating additional statements. Level of agreement was determined by using a five-point Likert scale. Level of consensus was set at 80%. Eighty-five statements were rated from the literature along with 115 generated by the group. Ninety-three statements were identified as representing the theoretical underpinning of the Bobath concept. The Bobath experts agreed that therapists need to be aware of the principles of motor learning such as active participation, opportunities for practice and meaningful goals. They emphasized that therapy is an interactive process between individual, therapist, and the environment and aims to promote efficiency of movement to the individual's maximum potential rather than normal movement. Treatment was identified by the experts as having "change of functional outcome" at its center.

[Early neurological-neurosurgical rehabilitation. Current state]

In German neurorehabilitation, the ambiguous term "early rehabilitation" reflects the multidisciplinary, rehabilitative treatment of severely impaired patients in continuing need of acute and intensive care (including weaning from the respirator in selected cases). The actual definition of this treatment is discussed, which hitherto corresponded to Phase B according to recommendations of the German Federal Study Group for Rehabilitation (BAR) and now has started to be integrated into the diagnosis-related group system. The tasks and aims of early rehabilitation are to support and enhance neuroplastic remission of nervous system functional loss and continued medical care, improve vigilance, establish cooperativity, and evaluate the rehabilitation potential including compensatory and adaptive strategies organizing posthospital care, reducing the need of nursing support, and improving quality of life. Some special aspects of early rehabilitative care are presented here in more detail. To fulfill these tasks, a multidisciplinary team is required including various therapists qualified for neurorehabilition, physicians (including a neurologist), nurses, and social workers. Outcome data were assessed using our 5-year prospective early rehabilitation registry. Fifty-five percent of patients improved to reach the next step of neurorehabilitation (Phase C), with significant gain in function even in the subgroup of aged and most severely disabled patients. The trend to transfer patients very early in the postacute Phase to early rehabilitation facilities, with open medical problems and increased risk of complications, makes close cooperation and interaction with acute medical centers necessary.

New advances in the rehabilitation of CNS diseases applying rTMS

Transcranial magnetic stimulation (TMS) can directly stimulate the CNS, modifying the brain's plasticity to enhance the behavior of the paretic extremities. Studies with low-frequency repetitive TMS (rTMS) on the intact hemisphere and those with high frequencies on the affected hemisphere could increase the speed of movement in the hand affected by CNS injury. Stimulation of the motor pathway may contribute to faster improvement in patients with spinal cord injury. Symptoms of Parkinson's disease (such as cognition and working memory, neglect syndrome and global aphasia) can be influenced by rTMS. However, the site of stimulation and the parameters of rTMS are different. Processes that contribute to the behavior of rTMS include the modification of brain plasticity, induction of neurogenesis, growth of new fibers in the spinal cord or all of these together. According to previous research, rTMS may be suitable as an add-on therapy to rehabilitation in CNS diseases.

Balance of a Multijoint Biomechanical System in Natural and Artificial Environments: A Simulation Model

The paper is devoted to a neurobionic simulation model for controlling balance in a biomechanical pendulum. The model is realized by a complex of fuzzy regulators and an artificial neural network. Fuzzy regulators are used for simulating the physiological characteristics of the motor system and the functions of the sensory systems. The second level of control is the central integrator. It is realized as an artificial neural network (ANN), which simulates a real process of analysis and synthesis of afferent signals, formation of the model of action, etc.Equilibrium control in a multijoint biomechanical object is a specific example of a self-developing multilevel system of movement control. In the course of elaboration of the model and further examination of its behavior we have received model results which revealed correspondence with the results demonstrated by real subjects in stabilographic tests performed after long-term space flights. We concluded that the model permits us to simulate the peculiarities of human movement control and can be used for creating individual plans of recovery and rehabilitation of patients after long-term motionless or learning movement control in unknown environments.

Defining the Bobath concept using the Delphi technique

BACKGROUND AND PURPOSE

The Bobath concept, based on the work of Berta and Karel Bobath, offers therapists working in the field of neurological rehabilitation a framework for their clinical interventions. It is the most commonly used approach in the UK. Although they recognize that over the last half-century the concept has undergone considerable developments, proponents of the Bobath concept have been criticized for not publishing these changes. The aim of the present study was to use the Delphi technique to enable experts in the field to define the current Bobath concept.

METHOD

A four-round Delphi study design was used. The sample included all members of the British Bobath Tutor's Association, who are considered experts in the field. Initial statements were identified from the literature, with respondents generating additional statements during the study. The level of agreement was determined using a five-point Likert scale. The respondents were then provided with feedback on group opinions and given an opportunity to re-rate each statement. The level of group consensus was set at 80%.

RESULTS

Fifteen experts took part. The response rate was 85% in the first round, and 93% in each subsequent round. Ten statements from the literature were rated with a further 12 generated by the experts. Thirteen statements achieved consensus for agreement and seven for disagreement.

CONCLUSIONS

The Delphi study was an effective research tool, maintaining anonymity of responses and exploring expert opinions on the Bobath concept. The experts stated that Bobath's work has been misunderstood if it is considered as the inhibition of spasticity and the facilitation of normal movement, as described in some literature. They agreed that the Bobath concept was developed by the Bobaths as a living concept, understanding that as therapists' knowledge base grows their view of treatment broadens.

Understanding Guillain-Barré Syndrome and Central Nervous System Involvement

Guillain-Barré syndrome is a rare neurological disease that causes paralysis and may necessitate hospitalization for some patients in its acute stages. It primarily affects the peripheral nervous system, though recent research has shown that for some patients, the central nervous system is involved. The acute phase often requires intensive care services. Recognition is growing that recovery is not as smooth and free of symptoms as previously thought. Following "recovery" some people endure long-term residual symptoms, such as fatigue and pain. Nursing input can be of value by providing support, information, explanations, and empathy to reassure patients and families. A greater understanding of the nature and course of the disease and its ramifications can lead to more effective nursing management and a faster rehabilitation process.

Effect of augmented feedback on motor function of the affected upper extremity in rehabilitation patients: a systematic review of randomized controlled trials

OBJECTIVE

Assessment of the available evidence regarding the effect of augmented feedback on motor function of the upper extremity in rehabilitation patients.

METHODS

A systematic literature search was performed to identify randomized controlled trials that evaluated the effect of augmented feedback on motor function. Two reviewers systematically assessed the methodological quality of the trials. The reported effects were examined to evaluate the effect of therapeutic interventions using augmented feedback and to identify a possible relationship with patient characteristics, type of intervention, or methodological quality.

RESULTS

Twenty-six randomized controlled trials were included, 9 of which reported a positive effect on arm function tests. Follow-up measurements were performed in 8 trials, 1 of which reported a positive effect. Different therapeutic interventions using augmented feedback, i.e. electromyographic biofeedback, kinetic feedback, kinematic feedback, or knowledge of results, show no difference in effectiveness.

CONCLUSION

No firm evidence was found of effectiveness regarding the use of augmented feedback to improve motor function of the upper extremity in rehabilitation patients. Future studies should focus more on the content, form and timing of augmented feedback concerning the therapeutic intervention. It should be emphasized that motor learning effects can only be determined by re-examining the population after a follow-up period.

Evaluating neurorehabilitation: lessons from routine data collection

BACKGROUND

Clinical databases are being used increasingly to assess outcomes in healthcare services to provide evidence of clinical effectiveness in routine clinical practice.

OBJECTIVES

To explore the benefits of a database for routine collection of clinical outcomes within an inpatient neurorehabilitation setting; determine the effectiveness of inpatient neurorehabilitation in a range of neurological conditions; and determine variables influencing change in functional outcome.

METHODS

Over a nine year period, demographic and diagnostic characteristics were collected for the 1458 patients admitted consecutively to a neurorehabilitation unit. The level of function was measured on admission and discharge using the Barthel Index (BI) and Functional Independence Measure (FIM). Patient perception of rehabilitation benefit was evaluated using visual analogue scales (VAS).

RESULTS

Of the 1413 patients (mean (SD) age 48 (14.8), range 16 to 87) whose length of stay was more than 10 days (mean 34 (24) range 10 to 184), 282 had stroke, 614 multiple sclerosis, 248 spinal cord injuries, 93 a neuromuscular condition, and 176 other brain pathology. Patients improved in functional ability as measured by both BI and the FIM motor subscale (effect sizes 0.93 to 1.44 and 1.01 to 1.48, respectively). VAS ratings demonstrated high levels of patient perceived benefit. Diagnosis, functional activity score on admission, and length of stay were significant predictors of functional gain, explaining 44% of the variability in the change scores.

CONCLUSIONS

Systematic collection, analysis, and interpretation of standardised clinical outcomes data are feasible within routine clinical practice, and provide evidence that inpatient rehabilitation is effective in improving functional level in neurologically impaired patients. These data complement those of clinical trials and are useful in informing and developing clinical and research practice.

[Can music therapy for patients with neurological disorders?]

Recent developments in brain research and in the field of music therapy have led to the development of music-based methods specifically aimed at relieving symptoms of Parkinson's disease and other neurologic disorders. Rhythmic auditory stimulation uses external rhythmic auditory cues from song, music or metronome to aid patients improving their walking functioning and has been shown to be effective both within sessions and as a result of training over time. Melodic intonation therapy and related vocal techniques can improve expressive dysphasia and aid rehabilitation of neurologic disorders, particularly Parkinson's disease, stroke and developmental disorders.

Exploring rating scale responsiveness: does the total score reflect the sum of its parts?

Evaluating rehabilitation requires rating scales that detect change. The authors examined Barthel Index (BI) data from 1,495 patients at a neurorehabilitation unit to determine whether total scale responsiveness accurately reflects item responsiveness. Total score effect sizes were moderate to large (0.47 to 1.09). Item-level effect sizes (0.13 to 1.16) reveal floor (3.5 to 82.3%) and ceiling (9.7 to 95.4%) effects. Results suggest BI total score effect sizes may hide item-level weaknesses and may underestimate the impact of rehabilitation.

Video-fluoroscopic study of swallowing in children with neurodevelopmental disorders

BACKGROUND

Children with neurodevelopmental disorders can have feeding problems. Malnutrition and recurrent aspiration pneumonia can increase the risk of morbidity and mortality. Video-fluoroscopic study of swallowing (VFSS) is essential in understanding the pathological mechanisms involved during swallowing.

METHODS

The aim of the present study was to assess the role of VFSS in assessment and management of four children with various neurodevelopmental disorders in a multidisciplinary feeding team. We describe the team approach, with the participation of child neurologist, radiologist with the rehabilitation team including the speech therapist, occupational therapist and dietician, in the assessment and plan of management.

RESULTS

Video-fluoroscopic study of swallowing had been useful in assessing the type of swallowing problems with treatment goals targeted to the basic underlying pathophysiological mechanism.

CONCLUSION

A child neurologist should be involved in the multidisciplinary oromotor rehabilitation program for neurologically impaired children with feeding problems.

Neurodevelopmental care in the NICU

Neurodevelopmental care, which is any NICU intervention undertaken to improve neurodevelopmental outcome, includes NICU design, nursing routines, nursing care plans, management of pain, feeding methods and, most importantly, encouraging parental involvement with their NICU infant. Recognition that sensory stimulation can overwhelm preterm infants and increase physiologic signs of stress led to attempts to reduce sensory input. More recent approaches judiciously add back soothing sensory input (e.g., therapeutic touch, soft music). Circadian light/dark cycles and physical activity improve preterm growth. Attention to infant positioning and handling affects physiologic variables and joint mobility, if not functional motor abilities. A highly organized system of care for NICU infants is Als' NIDCAP (i.e., Neonatal Individualized Developmental Care and Assessment Program). Although NIDCAP may reduce need for respiratory support and hospital length of stay, it does not significantly influence neurodevelopmental outcome at 2-3 years. Pain management includes benign interventions (e.g., nonnutritive sucking, oral glucose), but the prolonged use of narcotics must be balanced against the consequences of sedation and dependency. The foremost challenge for NICUs remains parent disenfranchisement. Kangaroo care, which involves parent/infant skin-to-skin contact, improves preterm growth, decreases nosocomial infections and may shorten hospital length of stay. A great deal of work needs to be done to identify and demonstrate efficacy of specific interventions and changes that humanize the NICU, encourage parental involvement, support infant development and optimize preterm neurodevelopmental outcomes.

Late outcome following central nervous system injury in child abuse

OBJECTIVE

The object of this study was to increase our understanding of the social, clinical, radiographic and psychological consequences of child abuse after the initial insult and to describe the role of neurosurgery and other specialties in this context.

METHODS

A review of the literature on child abuse (using scientific journals, textbooks, and internet reports) was conducted, with special attention given to child abuse in infants. The biomechanical patterns of injury, the long-term neurological, psychological, and social outcomes and methods of rehabilitation are reviewed.

CONCLUSIONS

Head injury associated with physical abuse carries a significantly worse clinical outcome than accidental trauma. Late findings in CT scans and MRI show evidence of cerebral atrophy in 100% and cerebral ischemia in 50% of physical abuse cases. Abuse and neglect have a strong impact in developing children, producing emotional, cognitive, and social problems that may persist throughout the rest of their lives. Outcome cannot be improved without an integrated rehabilitation strategy encompassing early field management, hospital therapy, precise targeting of educational and cognitive needs, and finally return to the community. New ancillary tests have emerged that are aimed at improving rehabilitation and illuminating the long-term physiological and functional impact of abuse.

Biopotentials as command and feedback signals in functional electrical stimulation systems

Today Functional Electrical Stimulation (FES) is available as a clinical tool in muscle activation used for picking up objects, for standing and walking, for controlling bladder emptying, and for breathing. Despite substantial progress in development and new knowledge, many challenges remain to be resolved to provide a more efficient functionality of FES systems. The most important task of these challenges is to improve control of the activated muscles through open loop or feedback systems. Command and feedback signals can be extracted from biopotentials recorded from muscles (Electromyogram, EMG), nerves (Electroneurogram, ENG), and the brain (Electroencephalogram (EEG) or individual cells). This paper reviews work in which EMG, ENG, and EEG signals in humans have been used as command and feedback signals in systems using electrical stimulation of motor nerves to restore movements after an injury to the Central Nervous System (CNS). It is concluded that the technology is ready to push for more substantial clinical FES investigations in applying muscle and nerve signals. Brain-computer interface systems hold great prospects, but require further development of faster and clinically more acceptable technologies.

Control of neural prostheses for grasping and reaching

In recent years several neural prostheses have been developed and tested as orthoses or as therapeutic systems for hemiplegic and tetraplegic subjects aiming to improve the upper extremities function. The use of neural prostheses demonstrated that the targeted group of subjects could significantly benefit from functional electrical stimulation that is integrated in goal directed movements. In this paper the control for neural prostheses is explained using available systems that apply either surface or implantable interfaces to sensory-motor systems. Further more, a new strategy that has been tested for control of reaching and grasping within a neural prosthesis especially designed for neurorehabilitation is described. This, so-called, coordination strategy was based on mimicking the output space model of natural control determined in reach/grasp/release movements of healthy humans.

Functional electrical stimulation and rehabilitation--an hypothesis

Functional Electrical Stimulation (FES), used to mimic a weak or paralysed movement, sometimes is followed by a specific recovery of voluntary power in that movement. The mechanism by which this occurs is unclear, and the presumption has often been that FES may somehow promote adaptive changes in cortical connectivity. However, the unique feature of electrical stimulation is that it activates nerve fibres both orthodromically and antidromically. The antidromic impulse in motor nerve fibres will reach the anterior horn cell, but it can go no further up the neuraxis. If the corticospinal-anterior horn cell synapse is a Hebb-type modifiable synapse (i.e. one that is strengthened by the coincidence of presynaptic and postsynaptic activity), then FES, combined with coincident voluntary effort through a damaged pyramidal motor system, could help to promote restorative synaptic modifications at anterior horn cell level, by this unique adaptive mechanism.

Comparison of virtual and real electric powered wheelchair driving using a position sensing joystick and an isometric joystick

There are limited interface options for electric powered wheelchairs, which results in the inability of some individuals to drive independently. In addition, the development of new interface technologies will necessitate the development of alternative training methods. This study compares a conventional position sensing joystick to a novel isometric joystick during a driving task in a virtual environment and a real environment. The results revealed that there were few differences in task completion time and root-mean-square error (RMSE) between the two types of joysticks. There were significant correlations between the RMSE in the virtual environment and the real environment for both types of joysticks. The data indicate that performance in the virtual environment was representative of driving ability in the real environment, and the isometric joystick performed comparably to the position sensing joystick.

Neurogenic bladder management and cutaneous non-continent ileal conduit

STUDY DESIGN

Prospective monocentric follow-up study.

OBJECTIVES

To assess the results of cutaneous non-continent diversion for neurogenic bladder management.

SETTINGS

Department of Urology (Pitié-Salpétrière Hospital), Department of Neurological Rehabilitation (Raymond Poincaré Hospital), Assistance Publique-Hopitaux de Paris, University Paris VI and V.

METHODS

We reviewed the charts of 33 consecutive patients (19 women, 14 men), operated between 1979 and 1999. Twenty-one patients had spinal cord injury (SCI), four had multiple sclerosis, three had various forms of myelitis and five had central neurological diseases. Diversion was indicated for upper urinary tract protection (17), perineal dryness (14) and/or functional or social reasons (20). Before the operation, 20 of the 33 patients (60.6%) presented urologic complications related to bladder management, including triggered micturition, indwelling catheter or intermittent catheterization: urethrocutaneous fistula (4), complicated enterocystoplasty (2), watering pot perineum and severe decubitus ulcerations (14). Ileal conduit (also named ileoureterostomy) was performed alone for 19 patients (57.6%), and in combination with simultaneous cystectomy in 14 patients. We reviewed patient outcome and early and late complications.

RESULTS

Mean follow-up was 48 months (1 to 20 years). All problems related to catheters or incontinence had resolved. There were no deaths or early re-operations. Twelve patients (12 out of 33, 36%) had one or more peri-operative complication, including ileus (1), uretero-ileal anastomosis leak (1) and sepsis (1). During follow-up, four of the 19 patients who did not undergo cystectomy developed pyocystitis (3 secondary cystectomies performed between 6 and 56 months). All patients achieved perineal dryness.

CONCLUSIONS

The ileal conduit procedure is a safe and well-tolerated procedure in neurologically impaired patients. This procedure is suitable for most neurogenic patients with refractory lower urinary tract dysfunctions.

[Recent progress in pediatric neurological rehabilitation]

New challenges in rehabilitation for children with neurological diseases directly depend on advances made in medical research and on the quality of the environment. This is relevant to motor function as a whole, to new therapeutic avenues in spasticity, to global approaches in the evaluation of cognitive and learning disabilities, as well as curative perspectives in neuromuscular disease. Networking with the family and other actors in the environmental field is essential to achieve a better social integration. A true collaboration between physicians and pediatricians is necessary to work toward more progress.

On-line measurement of human CNS re-organization

Based on measurements of relative phase and frequency coordination of time-space distributed firing of neurons in the human nervous system, methods have been developed with which it is possible to functionally re-organize the lesioned or not optimally functioning human central nervous system (CNS) and to measure on-line the organization (the coordination dynamics) of the CNS non-invasively. By measuring the present coordination dynamics at different times with ongoing coordination dynamic therapy when exercising on a special coordination dynamic therapy device, the progress in re-organization of the lesioned CNS can be quantified. The coordination dynamic recording method is derived from measurements of natural firing patterns of single neurons in the human CNS. The method is explained with load changes in the healthy CNS and with essential improvement in CNS organization following coordination dynamic therapy in traumatic brain lesion, spinal cord lesion, stroke, cerebral palsy, and myelomeningocele. Evaluations of CNS re-organization are discussed with respect to usefullness and ethics.

[Activation of sanogenesis mechanisms in central nervous system disorders]

Brain dysfunctions develop in brain injuries. Drug therapy is aimed at restitution processes which are often insufficient for recovery of impaired functions. Activation of the compensatory mechanisms of damaged and intact hemispheres will modify the time and qualitative characteristics of the restitution period. With this aim in view, transcranial electromagnetic stimulation in physiological range of efferent pathways and audiovisual stimulation of afferent pathways are recommended.

Electrical stimulation: a reflection on current clinical practices

This paper briefly reviews the basic principles of several clinical applications of electrical stimulation for therapeutic purposes. It is intended to facilitate the integration of electrical stimulation into routine clinical practice by clarifying the terminology and standard conventions of the field, explaining the delivery capabilities of common electrical stimulators commercially available for clinical use, summarizing several examples of evidence-based therapeutic applications, and providing guidelines for selection of most commonly used treatment parameters. Rather than an exhaustive survey of the field, the presentation touches broadly on guidelines for use of transcutaneous electrical stimulation employing surface electrodes for the purposes of analgesia (TENS), drug delivery (iontophoresis), or neuromuscular rehabilitation (NMES), as well as other selected clinical applications. The paper is a general review of common clinical practices of electrotherapy and should serve as an introduction to the important factors for clinicians to consider when contemplating electrical stimulation as a treatment option.

Reorganization of the human central nervous system

The key strategies on which the discovery of the functional organization of the central nervous system (CNS) under physiologic and pathophysiologic conditions have been based included (1) our measurements of phase and frequency coordination between the firings of alpha- and gamma-motoneurons and secondary muscle spindle afferents in the human spinal cord, (2) knowledge on CNS reorganization derived upon the improvement of the functions of the lesioned CNS in our patients in the short-term memory and the long-term memory (reorganization), and (3) the dynamic pattern approach for re-learning rhythmic coordinated behavior. The theory of self-organization and pattern formation in nonequilibrium systems is explicitly related to our measurements of the natural firing patterns of sets of identified single neurons in the human spinal premotor network and re-learned coordinated movements following spinal cord and brain lesions. Therapy induced cell proliferation, and maybe, neurogenesis seem to contribute to the host of structural changes during the process of re-learning of the lesioned CNS. So far, coordinated functions like movements could substantially be improved in every of the more than 100 patients with a CNS lesion by applying coordination dynamic therapy. As suggested by the data of our patients on re-learning, the human CNS seems to have a second integrative strategy for learning, re-learning, storing and recalling, which makes an essential contribution of the functional plasticity following a CNS lesion. A method has been developed by us for the simultaneous recording with wire electrodes of extracellular action potentials from single human afferent and efferent nerve fibres of undamaged sacral nerve roots. A classification scheme of the nerve fibres in the human peripheral nervous system (PNS) could be set up in which the individual classes of nerve fibres are characterized by group conduction velocities and group nerve fibre diameters. Natural impulse patterns of several identified single afferent and efferent nerve fibres (motoneuron axons) were extracted from multi-unit impulse patterns, and human CNS functions could be analyzed under physiologic and pathophysiologic conditions. With our discovery of premotor spinal oscillators it became possible to judge upon CNS neuronal network organization based on the firing patterns of these spinal oscillators and their driving afferents. Since motoneurons fire occasionally for low activation and oscillatory for high activation, the coherent organization of subnetworks to generate macroscopic function is very complex and for the time being, may be best described by the theory of coordination dynamics. Since oscillatory firing has also been observed by us in single motor unit firing patterns measured electromyographically, it seems possible to follow up therapeutic intervention in patients with spinal cord and brain lesions not only based on the activity levels and phases of motor programs during locomotion but also based on the physiologic and pathophysiologic firing patterns and recruitment of spinal oscillators. The improvement of the coordination dynamics of the CNS can be partly measured directly by rhythmicity upon the patient performing rhythmic movements coordinated up to milliseconds. Since rhythmic dynamic, coordinated, stereotyped movements are mainly located in the spinal cord and only little supraspinal drive is necessary to initiate, maintain, and terminate them, rhythmic, dynamic, coordinated movements were used in therapy to enforce reorganization of the lesioned CNS by improving the self-organization and relative coordination of spinal oscillators (and their interactions with occasionally firing motoneurons) which became pathologic in their firing following CNS lesion. Paraparetic, tetraparetic spinal cord and brain-lesioned patients re-learned running and other movements by an oscillator formation and coordination dynamic therapy. Our development in neurorehabilitation is in accordance with those of theoretical and computational neurosciences which deal with the self-organization of neuronal networks. In particular, jumping on a springboard 'in-phase' and in 'anti-phase' to re-learn phase relations of oscillator coupling can be understood in the framework of the Haken-Kelso-Bunz coordination dynamic model. By introducing broken symmetry, intention, learning and spasticity in the landscape of the potential function of the integrated CNS activity, the change in self-organization becomes understandable. Movement patterns re-learned by oscillator formation and coordination dynamic therapy evolve from reorganization and regeneration of the lesioned CNS by cooperative and competitive interplay between intrinsic coordination dynamics, extrinsic therapy related inputs with physiologic re-afferent input, including intention, motivation, supervised learning, interpersonal coordination, and genetic constraints including neurogenesis. (ABSTRACT TRUNCATED)

[Virtual reality: a simple joke or therapeutic instrument?]

Virtual reality is a relatively new application for rehabilitative neurology, and achieve many successes in assessment and treatment of CNS damages. The Authors describe a prototype computer simulation for virtual environment reconstruction to assess the fundamental living skills of every day dedicated to persons in which CNS injury was occurred.

Visual gait analysis: the development of a clinical assessment and scale

OBJECTIVES

To develop and evaluate a four-point scale visual gait assessment form, the Rivermead Visual Gait Assessment (RVGA), for clinical use with patients with neurological deficits.

DESIGN

Preliminary clinical testing of reliability, validity and sensitivity to change.

SETTING

Patients were recruited from the Rivermead Rehabilitation Centre (RRC), a centre specializing in rehabilitation for patients with neurological disease.

PATIENTS

Ten inpatients were assessed by up to seven physiotherapists for the main reliability study, and eight different patients were also assessed by two raters one week apart. Twenty outpatients with multiple sclerosis (MS) who were receiving physiotherapy to improve their mobility and 27 inpatients with various neurological conditions were also assessed and the data used to examine validity, re iability and sensitivity to change.

OUTCOME

The other comparative measures used were walking time, stride length, step length asymmetry, balance and the Rivermead Mobility Index.

RESULTS

Inter-rater reliability between multiple raters was reasonable both for the global scores from the gait assessment form (Kendall's coefficient of concordance; p < 0.001), and for individual items (complete agreement occurred on 63.8% of all observations). There was a significant correlation between the global RVGA score and the various criterion measures (r = 0.53-0.79; p < 0.001) and between change in the RVGA score and change in walking time in patients who received treatment (r = 0.68; p < 0.01).

CONCLUSIONS

The RVGA provides the clinician with a clinical assessment of the quality of gait which may be used in conjunction with other measures to inform and monitor the value of physiotherapy treatment for people with MS and stroke, and possibly other neurological deficits.

The Barthel Index and its relationship to nursing dependency in rehabilitation

OBJECTIVES

To investigate the clinical application of the Barthel Index as an indicator of nursing dependency in a younger disabled unit.

DESIGN

A prospective study of 132 patients (mean age 49) with chronic neurological problems.

SETTING

A younger disabled unit at a District General Hospital, Oxford.

MAIN OUTCOME MEASURES

The Barthel Index, and total nursing hours.

RESULTS

The Median Barthel Index was 7 (95% confidence interval 6-9). The mean nursing hours were 2.7 +/- 1.7 (CI 2.41-2.99). Spearman rank order correlation coefficient between the Barthel Index and nursing hours was r = -0.69 (CI -0.79 to -0.59).

CONCLUSIONS

Regression analysis showed that it was possible to use the Barthel Index as an indicator of nursing dependency particularly in physical care, and that it was independent of age and diagnosis.

Occupational therapy for patients with chronic diseases: CVA, rheumatoid arthritis and progressive diseases of the central nervous system

A substantial proportion of the patients treated by occupational therapists have a chronic disease. The aim of this study was to describe the outlines of occupational therapy treatment for three specific groups of chronic diseases: progressive neurological diseases, cerebrovascular accident and rheumatoid arthritis. A total of 143 therapists, working in 49 occupational therapy departments in The Netherlands, were asked to complete a standard registration from based on the ICIDH. This form consisted of three sections: (a) patient characteristics, (b) occupational therapy diagnosis and treatment goals in terms of ICIDH and (c) treatment characteristics. The present study concerns 507 patients: 102 had progressive neurological diseases (PND), 338 had a CVA and 67 had rheumatoid arthritis (RA). Our results showed that each patient group was characterized by a specific treatment approach. Especially at the level of treatment programmes substantial differences between groups were observed. Besides the clear differences, similarities in approaches were found between the PND and RA group, e.g. total time spent on therapy differed largely between the PND and RA patients (both averages 6 h) and the CVA patients (average 14 h).

Physician and patient-oriented outcomes in progressive neurological disease: which to measure?

Outcomes can be described as either physician or patient-oriented depending on whose perspective is adopted. Both perspectives offer different yet complementary information. Traditionally, the effectiveness of interventions has been evaluated in terms of physician-oriented outcomes. recently there has been a growing recognition of the importance of the patient's point of view in assessing the outcomes of medical care. This is now held to be central to the monitoring and evaluation of health care. This review describes these two perspectives and compares the nature of the information provided by each.

Therapeutic neural effects of electrical stimulation

The use of a functional neuromuscular stimulation (FNS) device can have therapeutic effects that persist when the device is not in use. Clinicians have reported changes in both voluntary and electrically assisted neuromuscular function and improvements in the condition of soft tissue. Motor recovery has been observed in people with incomplete spinal cord injury, stroke, or traumatic brain injury after the use of motor prostheses. Improvement in voluntary dorsiflexion and overall gait pattern has been reported both in the short term (several hours) and permanently. Electrical stimulation of skin over flexor muscles in the upper limb produced substantial reductions for up to 1 h in the severity of spasticity in brain-injured subjects, as measured by the change in torque generation during ramp-and-hold muscle stretch. There was typically an aggravation of the severity of spasticity when surface stimulation reached intensities sufficient to also excite muscle. Animals were trained to alter the size of the H-reflex to obtain a reward. The plasticity that underlies this operantly conditioned H-reflex change includes changes in the spinal cord itself. Comparable changes appear to occur with acquisition of certain motor skills. Current studies are exploring such changes in humans and animals with spinal cord injuries with the goal of using conditioning methods to assess function after injury and to promote and guide recovery of function. A better understanding of the mechanisms of neural plasticity, achieved through human and animal studies, may help us to design and implement FNS systems that have the potential to produce beneficial changes in the subject's central nervous systems.