NeuroRehabilitation

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.

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

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.

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.

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

Trunk alignment is thought to contribute to upper limb (UL) function. However, this common assumption is not clear in patients with Parkinson’s Disease (PD) suffering from Pisa syndrome (PS). PS is a postural abnormality, characterized by revisable lateral trunk flexion more than 10 degrees.

To investigate the UL functioning and activities of daily living in PD patients with PS.

Forty-five participants distributed equally in three groups PD patients with PS, PD patients without PS and age/sex matched healthy controls (HC). The function and disability of UL was assessed by Arm Shoulder and Hand (DASH) questionnaire for all groups. PD groups then completed clinical assessments by the Unified Parkinson’s Disease Rating Scale (UPDRS) part II-III, Modified Hoenh & Yahr (mH&Y) staging and the Levodopa Equivalent Daily Dose (LEDD).

Three groups showed significant differences in DASH questionnaire (p < 0.001) with higher scores for PS group, intermediate for PD group and lower for HC group. PS group also showed higher score in UPDRS-II and mH&Y (p = 0.019), while no differences emerged between PD and PS in UPDRS-III score and LEDD.

Our results demonstrated that PS is associated with major impairment of both UL functioning and activities of daily living in PD patients.

The purpose of this study was to evaluate the effect of treadmill training with body weight support on gait kinematics parameters in patients with PD using DBS.

Twelve patients completed the protocols (age: 60.9±10.6 years; disease duration: 20±7 years; and time since DBS surgery: 20±4 months). The same set of patients underwent two trainings protocols and four gait analyses (before and after each training). They received eight weeks of treadmill training without body weight support (16 sessions) in conjunction with physiotherapy program followed by six weeks of wash out period, followed by eight weeks of body-weight-supported treadmill training in conjunction with a same physiotherapy program. The Gait Kinematic Analysis involved eight infrared cameras that detected 19 reflective spherical markers attached in limb lower of patients. Statistical analysis used the Wilcoxon test (p≤0.05).

Both the training no showed significant differences in linear variables. As the angular variables, only training with support showed significant increase of ranges of motion: pelvis tilt, obliquity and rotation amplitude; hip adduction-abduction and rotation amplitude; percentage of peak flexion in swing phase; foot progression amplitude.

The body weight supported treadmill training may promote increase of mobility of lower limbs during gait and it could be a targeted intervention for PD patients treated with DBS.

Recent studies indicate that vagus nerve stimulation (VNS) paired with rehabilitation can enhance neural plasticity in the primary sensory and motor cortices, improve forelimb function after stroke in animal models and improve motor function in patients with arm weakness after stroke.

To gain “first-in-man” experience of VNS paired with tactile training in a patient with severe sensory impairment after stroke.

During the long-term follow-up phase of a clinical trial of VNS paired with motor rehabilitation, a 71-year-old man who had made good motor recovery had ongoing severe sensory loss in his left hand and arm. He received VNS paired with tactile therapy in an attempt to improve his sensory function. During twenty 2-hour sessions, each passive and active tactile event was paired with a 0.5 second burst of 0.8 mA VNS. Sensory function was measured before, halfway through, and after this therapy.

The patient did not report any side effects during or following VNS+Tactile therapy. Quantitative measures revealed lasting and clinically meaningful improvements in tactile threshold, proprioception, and stereognosis. After VNS+Tactile therapy, the patient was able to detect tactile stimulation to his affected hand that was eight times less intense, identify the joint position of his fingers in the affected hand three times more often, and identify everyday objects using his affected hand seven times more often, compared to baseline.

Sensory function significantly improved in this man following VNS paired with tactile stimulation. This approach merits further study in controlled clinical trials.

Neurological rehabilitation specialists must determine appropriate dosage, consisting of frequency, intensity, and duration of specified treatments.

The objective of this study was to perform a content analysis of the current literature related to dosage (duration, frequency and intensity) for constraint-induced movement therapy (CIMT) in the adult population.

A content analysis was conducted which yielded 62 scholarly articles.

The frequency of CIMT ranged from 1 to 7 days per week with the average frequency being 4.98 days. The duration of CIMT, ranged from 2 to 10 weeks with the average duration 3.14 weeks. All three components of dosage were reported collectively in outcomes studies conducted in inpatient settings and rehabilitation clinics.

The findings provide a groundwork for evidence based practice for clinician in the application of CIMT dosage with consideration of settings and CIMT components.

The purpose of this study was to confirm the intra-rater reliability and absolute reliability of Lissajous Index (LI) in evaluating the symmetry of trunk movement during gait in patients with stroke and to examine the relation between LI and body function in patients with stroke.

Twenty-one healthy subjects (11 males and 10 females, age 63.3±2.0 yrs) and 45 patients with stroke (33 males and 12 females, age 58.7±13.4 yrs) were included in the study. The accelerometer was fixed to a belt at the level of the L3 spinous process. The 10-m walk test was performed twice to record definitive data on trunk acceleration. LI was calculated from trunk accelerations. We confirmed the intra-rater reliability and absolute reliability of LI in patients with stroke and we examined the relation between LI and body function in patients with stroke.

There was no fixed bias and proportional bias in the LI of patients with stroke. It was found that BBS significantly correlated with LI in stroke patients (p < 0.05, r = –0.413).

It was clear that LI during gait was effective at evaluating gait symmetry and balance. LI was indicated to be useful in evaluating gait in patients with stroke.

Robotic-assisted gait training (RAGT) has been proposed as a novel, promising intervention paradigm to improve gait function in subacute or chronic stroke neurorehabilitation. However, the benefits of RAGT combined with conventional physical therapy for gait recovery in patients with subacute and chronic hemiparetic stroke remain unclear.

The aim of the present study was to compare the effect of RAGT combine with conventional physical therapy on hip joint kinetics, kinematics, and clinical function characteristics between subacute and chronic hemiparetic stroke.

Seventeen patients with hemiparetic stroke (nine subacute and eight chronic patients) performed progressive RAGT (session 1, 40 min) combined with conventional physical therapy (session 1, 40 min) 5 days per week, for an average of 86 sessions over 8 weeks. The clinical outcomes included the Functional Ambulation Category (FAC), modified Rankin scale (mRS), Korean version of the modified Barthel index (K-MBI), and modified Ashworth scale, in addition to hip joint kinetics and kinematics before and after intervention.

The mean change in active torque, resistive torque, and stiffness in the paretic hip joint did not differ significantly between the two groups. However, Cohen’s effect size suggested a moderate difference between the groups in the hip flexion phase (d = 0.58, d = 0.70, and d = 0.70). The mean change in maximal hip flexion kinematics in the chronic group was significantly greater than that in the subacute group (p = 0.04, d = –0.70). The mean change in the clinical function test results between the groups was not statistically significant. However, both groups showed significantly improved FAC, mRS, and K-MBI scores.

RAGT combine with conventional physical therapy may be useful when selecting therapeutic interventions to improve the active torque, resistive torque, and stiffness in the paretic hip flexion phase in patients with chronic hemiparetic stroke who reached a plateau in the maximum locomotor recovery after conventional locomotor training.

Recently, chin tuck against resistance exercise (CTAR) has been reported as a remedial treatment for pharyngeal dysphagia. However, the clinical evidence of the effect is still lacking.

This study investigated the effect of CTAR on the swallowing function in patients with dysphagia following subacute stroke.

The patients were randomly assigned to an experimental (n = 11) or a control group (n = 11). The experimental group performed CTAR using the CTAR device. The control group received only conventional dysphagia treatment. Both groups received training on five days a week, for four weeks. The swallowing function was measured using functional dysphagia scale (FDS) and penetration-aspiration scale (PAS), based on a videofluoroscopic swallowing study (VFSS).

The experimental group showed more improvements in the oral cavity, laryngeal elevation/epiglottic closure, residue in valleculae, and residue in pyriform sinuses of FDS and PAS compared to the control group (p < 0.05, all).

This study demonstrated that CTAR is effective in improving the pharyngeal swallowing function in patients with dysphagia after stroke. Therefore, we recommend CTAR as a new remedial training alternative to HLE.

Spasticity is a frequent complication after severe brain injury, which may prevent the rehabilitation process and worsen the patients’ quality of life.

In this study, we investigated the correlation between spasticity, muscle contracture, and the frequency of physical therapy (PT) in subacute and chronic patients with disorders of consciousness (DOC).

109 patients with subacute and chronic disorders of consciousness (Vegetative state/Unresponsive wakefulness syndrome – VS/UWS; minimally conscious state – MCS and patients who emerged from MCS – EMCS) were included in the study (39 female; mean age: 40±13.5y; 60 with traumatic etiology; 35 VS/UWS, 68 MCS, 6 EMCS; time since insult: 38±42months). The number of PT sessions (i.e., 20 to 30 minutes of conventional stretching of the four limbs) was collected based on patients’ medical record and varied between 0 to 6 times per week (low PT = 0–3 and high PT = 4–6 sessions per week). Spasticity was measured with the Modified Ashworth Scale (MAS) on every segment for both upper (UL) and lower limbs (LL). The presence of muscle contracture was assessed in every joint. We tested the relationship between spasticity and muscle contracture with the frequency of PT as well as other potential confounders such as time since injury or anti-spastic medication intake.

We identified a negative correlation between the frequency of PT and MAS scores as well as the presence of muscle contracture. We also identified that patients who received less than four sessions per week were more likely to be spastic and suffer from muscle contracture than patients receiving 4 sessions or more. When separating subacute (3 to 12 months post-insult) and chronic (>12months post-insult) patients, these negative correlations were only observed in chronic patients. A logit regression model showed that frequency of PT influenced spasticity, whereas neither time since insult nor medication had a significant impact on the presence of spasticity. On the other hand, PT, time since injury and medication seemed to be associated with the presence of muscle contracture.

Our results suggest that, in subacute and chronic patients with DOC, PT could have an impact on patients’ spasticity and muscles contractures. Beside PT, other factors such as time since onset and medication seem to influence the development of muscle contractures. These findings support the need for frequent PT sessions and regular re-evaluation of the overall spastic treatment for patients with DOC.

Rehabilitation following severe Traumatic Brain Injury (TBI) often involves the use of temporary tracheostomies. Tracheostomy weaning is influenced by physiological parameters, which are abnormal in the concomitant complication of Paroxysmal Sympathetic Hyperactivity (PSH).

To investigate the association between PSH and tracheostomy weaning in severe TBI.

This was a retrospective cohort study of consecutive patients with TBI and tracheostomy admitted to a Hyper-Acute Neurorehabilitation Unit over a 34-month period. Duration of tracheostomy wean and influencing characteristics were statistically compared between those with and without PSH.

Fifty-one patients admitted with TBI required a tracheostomy. Of these, 10 patients were also diagnosed with PSH. The mean tracheostomy wean in the PSH group was longer compared to the non-PSH group (72.3, SD 61.0 versus 30.0 days, SD 16.2). This difference was statistically significant (p = 0.007, using Mann Whitney U test). The PSH group had more respiratory and oral secretions, but this was not statistically significant (p = 0.16 and 0.29).

This is the first study to demonstrate that PSH is associated with prolonged tracheostomy weaning in severe TBI. Awareness of this association should enable those planning rehabilitation to set realistic goals for a patient’s tracheostomy weaning programme.

Virtual reality technology allows neuropsychologists to examine complex, real-world behaviors with high ecological validity and can provide an understanding of the impact of demanding dual-tasks on driving performance.

We hypothesized that a task imposing high cognitive and physical demands (coin-sorting) would result in the greatest reduction in driving maintenance performance.

Twenty participants with acquired brain injury and 28 healthy controls were included in the current study. All participants were licensed and drove regularly. Participants completed two standardized VRDS drives: (1) a baseline drive with no distractions, and (2) the same route with three, counterbalanced dual-tasks representing differing demands.

A series of 3 (Task)×2 (Group) ANOVAs revealed that the ABI group tended to go slower than the HC group in the presence of a dual-task, F (1, 111) = 6.24, p = 0.01. Importantly, the ABI group also showed greater variability in speed, F (1, 110) = 10.97, p < 0.01, and lane position, F (1, 108) = 7.81, p < 0.01, an effect driven by dual-tasks with both a cognitive and motor demand.

These results indicate that long-term driving difficulties following ABI are subtle and likely due to reduced cognitive resources.

Oculomotor dysfunction affects a significant number of adults with neurological conditions and binocular diplopia is a common symptom which impacts an individual’s ability to participate in meaningful daily activities. Occupational therapists use partial and complete occlusion to minimize binocular diplopia, however a review of the literature reflected a lack of standardized protocol for each intervention technique. The purpose of this study was to examine occupational therapists’ perspectives on the use of partial and complete occlusion and the clinical reasoning process used.

An electronic survey was distributed to occupational therapists working in a variety of practice settings. The survey contained questions relating to demographics, the selected occlusion technique, and clinical reasoning for that selection.

More than half of the 106 respondents used partial occlusion more frequently than complete occlusion. There was no correlation between respondent experience and self-report of competence in managing binocular diplopia. Respondents based their clinical reasoning on available evidence, client factors, and clinical expertise.

Respondents offered conflicting perspectives on each occlusion technique. Future studies are required to examine which occlusion technique benefits clients.

Chronic Fatigue Syndrome (CFS) is a disorder of unknown etiology associated with debilitating fatigue. One symptom commonly reported is disequilibrium. The goal of this study was to determine if CFS patients demonstrated verified balance deficits and if this was effected by comorbid fibromyalgia (FM).

Twenty-seven patients with CFS (12 with comorbid FM) and 22 age and gender matched controls performed posturography.

Balance scores were significantly correlated with physical functional status in the CFS group (R² = 0.43, P < 0.001), which was not found for mental functional status (R² = 0.06, P > 0.5). CFS patients (regardless of FM) had significantly higher anxiety subscale of the vertigo symptom scale scores. CFS patients, regardless of FM status, demonstrated significantly lower overall composite balance scores (Controls - 78.8±1.5; CFS – 69.0±1.4, P < 0.005) even when controlling for anxiety and also had worse preference scores, indicating they relied on visual information preferentially even when visual information was incorrect. Interestingly, the CFS+FM group, not CFS only, demonstrated significantly worse vestibular scores (Controls – 70.2±2.4; CFS only - 67.9±3.8; CFS with FM - 55.4±4.6, P = 0.013).

The major findings are that poor balance may be associated with poorer self-reported physical health. In addition, CFS patients seemed to rely preferentially on visual inputs, regardless of whether it was correct. The finding that vestibular function may be impaired in patients with CFS+FM but not in those with CFS alone suggests that the pathophysiology of CFS+FM may differ as has been suggested by some.

Postural instability is an important pathomarker in children with cerebral palsy (CP), and is often implicated in gait disturbance.

The purpose of this study was to investigate the therapeutic effects of long-term robotic hippotherapy (HPOT) on postural muscles size and static and dynamic postural stability in a child with CP.

Ultrasonography was used to measure postural muscles size. We also evaluated the magnitude of the separation between the center of pressure (COP) and center of mass (COM) during quiet stance and gait initiation (GI) using an eight-camera motion capture system and two force plates. Robotic HPOT was provided as a 45-minute session once per week for 12 weeks.

As transverse abdominal (12%) and lumbar multifidus (60%) muscles size improved, normalized sway area (16%) during the quiet stance decreased. Similarly, the maximal resultant COP-COM distance (12.84%) during the initial phase of GI increased.

In a child with CP, robotic HPOT may be an important treatment for improving postural muscles size and postural stability in static and dynamic states.