NeuroRehabilitation

Balance support is critical to a person’s overall function and health. Previous neuroimaging studies have shown that cortical structures play an essential role in postural control.

This review aims to identify differences in the pattern of neural activity induced by balance tasks with different balance control requirements.

Seventy-four articles were selected from the field of balance training and were examined based on four brain function detection technologies.

In general, most studies focused on the activity changes of various cortical areas during training at different difficulty levels, but more and more attention has also begun to focus on the functional changes of other cortical and deep subcortical structures. Our analysis also revealed the neglect of certain task types.

Based on these results, we identify and discuss future research directions that may contribute to a clear understanding of neural functional plasticity under different tasks.

Electrical stimulation (ES) of the shoulder is effective in treating subluxation and shoulder pain. However, few studies have reported on ES of the hemiplegic shoulder with motor function as an outcome; thus, the method remains unclear.

We aimed to map the existing evidence and identify the parameters for ES of the hemiplegic shoulder for motor function in stroke patients.

A literature search was performed through PubMed and Scopus to retrieve original articles from 1975 to March 2023 using the terms “stroke”, “shoulder”, and “electricity”. We selected studies in which ES was performed on hemiplegic shoulders after stroke, parameters were described, and upper extremity motor functional assessment was included as an outcome. The extracted data included study design, phase, sample size, electrode position, parameters, intervention period, evaluation frequency, outcomes, and results.

Of the 449 titles identified, 25 fulfilled the inclusion and exclusion criteria. Nineteen were randomized controlled trials. The most common electrode positions and parameters (frequency and pulse width) were over the posterior deltoid and the supraspinatus (upper trapezius) muscles, 30 Hz, and 250μs, respectively. The intervention period was 30–60 minutes per day, 5–7 days per week, for 4–5 weeks in over half of the studies.

Stimulation positions and parameters for electrical stimulation of the hemiplegic shoulder are inconsistent. Whether ES represents a significant treatment option remains unclear. Establishing universal ES methods is necessary to improve the motor function of hemiplegic shoulders.

Many overlapping factors impair motor performance and quality of life in neurological patients. Eccentric resistance training (ET) has potential benefits for improving motor performance and treating motor impairments better than some traditional rehabilitation approaches.

To estimate the effect of ET in neurological settings.

Seven databases were reviewed up to May 2022 according to PRSIMA guidelines to find randomized clinical trials involving adults with a neurological condition, who underwent ET as set by the American College of Sports Medicine. Motor performance (main outcome) was assessed as strength, power and capacities during activity. Secondary outcomes (impairments) were muscle structure, flexibility, muscle activity, tone, tremor, balance and fatigue. Tertiary outcomes were risk of fall, and self-reports of quality of life.

Ten trials were included, assessed using Risk of Bias 2.0 tool, and used to compute meta-analyses. Effective effects in favour of ET were found for strength and power, but not for capacities during activity. Mixed results were found for secondary and tertiary outcomes.

ET may be a promising intervention to better improve strength/power in neurological patients. More studies are needed to improve the quality of evidence underlying changes responsible for these results.

Sensory deficits can result in limitations regarding how well neuropsychological test findings can be interpreted. Only a few studies have investigated the influence of vision alteration on neuropsychological tests. In 2012 the Czech Republic experienced mass methanol poisoning. Methanol metabolites cause histotoxic hypoxia to the optic nerve.

In the current study, the effect of the toxic damage on the parts of the visual pathway on visual and non-visual neuropsychological measures was investigated using electrophysiological methods (visual evoked potential (VEP) and optical coherence tomography (OCT) with retinal nerve fibre layer (RNFL) thickness measurement.

53 individuals who experienced methanol poisoning participated in this research (76% men; ages 24 to 74 years, mean = 43.8±14.6 years; education 11.9±1.4 years). Each participant underwent comprehensive neurological, ophthalmological, and neuropsychological examinations.

The results of mixed-effect models revealed significant small to a medium association between the Stroop test weak interference and Grooved Pegboard with the left eye global, nasal and temporal RNFL thickness. Also, medium associations between the Finger Tapping test and the Stroop test weak interference and left eye temporal RNFL, right eye temporal RNFL, and the latency P1 of VEP in the left eye were significant.

The results of this study found a small to medium association (r = .15– .33; p = .010– .046) between RNFL thickness and cognitive visual test performance. Careful interpretation is suggested regarding results obtained from visual tests of the executive or motor functioning with participants with RNFL decrease or other types of early visual processing damage.

There is equivocal evidence regarding the effectiveness of robotic guidance on the (re)learning of voluntary motor skills. Robotic guidance can improve the performance of continuous/ tracking skills, although being seldom more effective than unassisted practice alone. However, most of the previous studies employed robotic guidance on all intervention trials. Recently, we showed that mixing robotic guidance with unassisted practice (i.e., mixed practice) can significantly improve the learning of a golf putting task. Yet, these mixed practice studies involved self-paced movements in a standing posture, thus less applicable to rehabilitation contexts.

The current study aimed to investigate the influence of mixed practice on the timing accuracy of an upper-limb, rhythmic, sequential task. The goal was to assess the feasibility of integrating mixed practice with music-based interventions.

Two groups of participants performed circle-drawing sequences in synchrony with rhythmic auditory signals. They completed a pre-test and an acquisition phase, followed by immediate retention and transfer tests. One group received robotic guidance on 50% of the acquisition trials (i.e., mixed practice), whereas another group always practiced unassisted. The pre-test, retention, and transfer tests were performed unassisted.

Both groups significantly improved their timing accuracy and precision between the pre-test and the retention test.

This study provides further evidence that mixed practice can facilitate the (re)learning of voluntary actions, especially with the type of externally paced upper-limb movements employed in music-based interventions.

Management of respiratory-related functional problems using sensory rehabilitation strategies has been poorly researched in patients with stroke.

This study aimed to investigate whether whole body vibration (WBV) training has an effect on functional capacity and respiratory functions in patients with stroke.

In the randomized-controlled study, 28 participants were randomized into two groups: one receiving Neurodevelopmental Treatment (NDT; n = 13) and one receiving both NDT and WBV (NDT + WBV; n = 15). The primary outcome measures were 6-Minute Walking Test (6MWT) and Pulmonary Function Test which evaluate functional and respiratory capacity. Secondary outcome included the chest circumference measurement to evaluate the thoracic expansion ability.

Both groups showed positive significant changes in walking distance and maximum oxygen consumption volume (VO₂max), inspiratory capacity, vital capacity and chest circumference measurement scores (p < 0.05). While the NDT +WBV group showed a significantly greater increase in walking distance and VO₂max levels than the NDT group (p < 0.05), there were no significant group differences in respiratory function flow and volume parameters, and chest circumference measurement.

The addition of WBV training to the treatment program has some incremental benefits on increasing functional capacity and thoracic expansion, and rehabilitating respiratory dysfunction.

Neurogenic bowel dysfunction (NBD) is a common complication in stroke patients.

To investigate the effect of rectal balloon ice water stimulation on the rehabilitation of patients with NBD after a cerebral stroke.

Forty stroke patients with NBD were selected between March and August 2022 and randomly divided into a study group (n = 20) and a control group (n = 20). Based on routine rehabilitation training, rectal balloon ice water stimulation or finger rectal stimulation were performed on the study or control group, respectively. After two weeks, the changes in the NBD, self-rating depression scale (SDS) and self-rating anxiety scale (SAS) scores were compared between the two groups.

Before the intervention, there were no significant differences in age, sex ratio, and NBD, SDS and SAS scores between the two groups (p > 0.05). The NBD, SDS and SAS scores of both groups were significantly decreased following intervention (p < 0.05). After 2 weeks of intervention, the NBD score of the study group was significantly lower than that of the control group (5.50±1.28 vs 6.45±1.05; p = 0.014). The SDS score of the study group was lower than that of the control group, and the difference was statistically significant (32.30±2.81 vs 44.05±2.19; p = 0.014). The study group also had significantly lower SAS scores than the control group (p = 0.024). In addition, the incidence of dizziness, headaches, nausea, vomiting and abdominal pain and distension in the study group was significantly lower than in the control group (p < 0.05).

Rectal balloon ice water stimulation can significantly improve stroke patients with NBD’s intestinal function and psychological status.

Post-stroke arm impairment at rehabilitation admission as predictor of discharge arm impairment was consistently reported as extremely useful. Several models for acute prediction exist (e.g. the Scandinavian), though lacking external validation and larger time-window admission assessments.

(1) use the 33 Fugl-Meyer Assessment-Upper Extremity (FMA-UE) individual items to predict total FMA-UE score at discharge of patients with ischemic stroke admitted to rehabilitation within 90 days post-injury, (2) use eight individual items (seven from the Scandinavian study plus the top predictor item from objective 1) to predict mild impairment (FMA-UE≥48) at discharge and (3) adjust the top three models from objective 2 with known confounders.

This was an observational study including 287 patients (from eight settings) admitted to rehabilitation (2009-2020). We applied regression models to candidate predictors, reporting adjusted R², odds ratios and ROC-AUC using 10-fold cross-validation.

We achieved good predictive power for the eight item-level models (AUC: 0.70-0.82) and for the three adjusted models (AUC: 0.85-0.88). We identified finger mass flexion as new item-level top predictor (AUC:0.88) and time to admission (OR = 0.9(0.9;1.0)) as only common significant confounder.

Scandinavian item-level predictors are valid in a different context, finger mass flexion outperformed known predictors, days-to-admission predict discharge mild arm impairment.

A contextual transferability analysis identified group-based circuit training (GCT) as an optimal intervention in German and Austrian outpatient physical therapy to improve mobility post-stroke. GCT incorporates task-oriented, high-repetitive, balance, aerobic and strength training and allows for increased therapy time without increasing personnel.

To determine the extent to which German and Austrian physical therapists (PTs) use GCT and its components in the outpatient treatment of stroke-related mobility deficits and to identify factors associated with using GCT components.

A cross-sectional online survey was conducted. Data were analyzed descriptively and using ordinal regression.

Ninety-three PTs participated. None reported using GCT moderately to frequently (4–10/10 patients). The percentage of PTs reporting frequent use (7–10/10 patients) of task-oriented, balance, strength, aerobic, and high-repetitive training was 45.2%, 43.0%, 26.9%, 19.4%, and 8.6%, respectively. Teaching or supervising students, time for evidence-based practice activities at work, and working in Austria was associated with using GCT components frequently.

German and Austrian PTs do not yet use GCT in outpatient physical therapy for stroke. Almost half of PTs, however, employ task-oriented training as recommended across guidelines. A detailed, theory-driven and country-specific evaluation of barriers to GCT uptake is necessary to inform implementation.

The balance and postural control of humans is related to the coordination of dynamic perception and movement. Multiple senses, such as vision, vestibular sense, proprioception, and/or a single sensory disorder, would lead to its integration disorder and induce imbalance and abnormal gait.

The present study aimed to determine the effects of dynamic motion instability system training (DMIST) on the balance and motor function of hemiplegic patients after stroke.

In this assessor-blinded, randomized controlled trial, the participants allocated to the intervention group (n = 20) received 30 minutes of conventional treatment and 20 minutes of DMIST training. Participants randomized to the control group (n = 20) received the same dose of conventional therapy and 20 minutes of general balance training. Rehabilitation was performed 5 times per week for 8 weeks. The primary outcome was the Fugl-Meyer assessment for the lower extremity (FMA-LE), and the secondary outcomes were the Berg balance scale (BBS) and gait function. Data were collected at baseline and immediately after the intervention.

After 8 weeks (t1), both groups showed significant post-intervention improvements in BBS, FMA-LE, gait speed and stride length (P < 0.05); there were significant positive correlations between the increase in FMA-LE and gait speed and stride length. Compared with the control group, the DMIST group showed significant post-intervention improvements in FMA-LE, gait speed and stride length (P < 0.05). However, no significant differences between the groups were found over time with respect to BBS (P > 0.05). The experiences of patients with DMIST were positive, and no serious adverse events were related to the interventions.

Supervised DMIST could be highly effective in treating lower-limb motor function in patients with stroke. Frequent (weekly) and medium-term (8 weeks) dynamic motion instability-guided interventions might be highly effective in enhancing motor function, and subsequently improving gait in stroke patients.

Lower-extremity spasticity and impaired gait control after central nervous system injury are challenging to improve, because spasticity limits residual motor control while providing mechanical support. Highly selective partial neurectomies (HSPNs) can substantially reduce spasticity but may have greater risks in patients with complex lower-extremity spastic gait.

To examine the potential of ultrasound- and stimulation-guided highly selective motor nerve blocks (HSMNBs) to assess the potential impact of reduced spasticity on gait.

In this retrospective series, six patients underwent HSMNBs with movement assessment before and after the block. Range of motion, strength, position angles, surface electromyography, lower limb kinematics, and patient satisfaction were assessed.

Pre- and post-HSMNB movement analysis yielded dichotomous gait kinematics, which facilitated surgical decisions. Of the 59 metrics evaluated, 82% demonstrated a positive improvement post-block (62% improved more than one standard deviation (SD) of typically developing means, 49% improved > 2 SD) and 16% demonstrated a negative change (2% worsened > 1 SD).

HSMNB provided clear efficacy in changing clinical, surface electromyography, and gait parameters. Movement analysis provided clear and robust objective and patient-centered evidence for surgical guidance. This protocol may provide utility in evaluation of patients being considered for HSPNs for complex spastic gait patterns.

Venous thromboembolism (VTE) is a concern following the onset of spinal cord lesions (SCL).

To assess the current efficacy and risks of anticoagulation after SCL and consider changes in thromboprophylaxis.

This retrospective cohort study included individuals admitted to inpatient rehabilitation within 3 months of SCL onset. Main outcome measures were the incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, thrombocytopenia, or death, which occurred within 1 year of the SCL onset.

VTE occurred in 37 of the 685 patients included in the study (5.4%, 95% CI 3.7–7.1%, 2.8% PE), and in 16 of 526 patients who received prophylactic anticoagulation at rehabilitation (3%, 95% CI 1.6–4.5%, 1.1% PE, with at least 1 fatality). Of these 526, 1.3% developed clinically significant bleeding and 0.8% thrombocytopenia. Prophylactic anticoagulation, most commonly 40 mg/day, continued until a median period of 6.4 weeks after SCL onset (25% –75% percentiles 5.8–9.7), but in 29.7%, VTE occurred more than 3 months after SCL onset.

The VTE prophylaxis used for the present cohort contributed to a considerable but limited reduction of VTE incidence. The authors recommend conducting a prospective study to assess the efficacy and safety of an updated preventive anticoagulation regimen.

The aim of this case report is to present the successful management of both diplopia and amblyopia in a specific clinical situation, demonstrating neuroplasticity of the visual system in an adult patient. Causes of diplopia include eye pathologies in monocular diplopia and ischemic ocular motor nerve palsies, sudden life-threatening and chronic conditions in central nervous system in binocular diplopia. Strabismic amblyopia and nonarteritic anterior ischemic optic neuropathy are quite often ophthalmic conditions, first one is caused by suppression during developmental period and the latter one by ischemia of the optic nerve in adults. Coexistence of aforementioned conditions may cause unusual clinical situation in which ability of nervous system to functional reorganization could be demonstrated.

In our adult patient, diplopia was incited by the loss of suppression of the strabismic amblyopic eye, which was the consequence of a sudden decrease of the visual acuity in the previously better eye in the course of nonarteritic anterior ischemic optic neuropathy. This led to impairment in daily activities.

Visual training rehabilitation improved distance and near visual acuity in the amblyopic eye over three months, and prescribing two pairs of glasses with prisms enabled the patient to return to daily activities.

The discussed patient lost the suppression of the strabismic amblyopic eye. Management of amblyopia is usually undertaken in children, however considering neuroplasticity we successfully attempted to improve visual functioning of our patient, despite lower intensity of neuroplasticity functions in an adult brain.

Backbend-induced pediatric thoracic spinal cord injury without radiologic abnormality (BBPT-SCIWORA) in children is rare in clinical practice and leads to lower limb motor dysfunction. There are few clinical studies on BBPT-SCIWORA and even fewer on treatments for BBPT-SCIWORA-induced lower limb motor dysfunction.

To explore the therapeutic effect of acupuncture at bilateral spine acupoints combined with lower limb acupoints in BBPT-SCIWORA.

This study reported four cases of BBPT-SCIWORA after dancing, two of which received a unique medium-frequency electroacupuncture treatment. They were all females aged between 5 and 12 years old. They were diagnosed with BBPT-SCIWORA by magnetic resonance imaging (MRI), transferred to the rehabilitation department for lower limb dysfunction, and received rehabilitation treatments and acupuncture. Cases 1 and 2 received acupuncture treatment for lower limb acupoints, while Cases 3 and 4 received acupuncture treatment at the bilateral spine acupoints beside the lesion and lower limb acupoints. Cases 3 and 4 achieved better American spinal injury association (AIS) grades and lower extremity motor scores (LEMS) than Cases 1 and 2 after treatment.

Acupuncture treatment of beside bilateral spine acupoints plus lower limb acupoints therapy might facilitate early lower limb motor function recovery in children with BBPT-SCIWORA.

Cognitive Impairment (CI) after stroke is frequent and often persistent, and is associated with poor functional outcome. Occupational therapy (OT) is aimed at restoring functioning also by addressing CI.

Commentary on the review by Gibson et al. (2022) updating a previous Cochrane Review (Hoffmann et al., 2010) to investigate the effectiveness of OT on CI after stroke.

This review included randomised and quasi-randomised controlled trials evaluating OT for adults with clinically defined stroke and confirmed CI. Outcomes included basic activities of daily living (BADL) (primary), instrumental ADL (IADL), community integration and participation, global cognitive function and specific cognitive abilities.

Overall, 24 trials from 11 countries including 1142 participants. For BADL, a small effect below the minimal clinically important difference (MCID) was found immediately after intervention and at six months’ follow-up (low certainty evidence), but not at three months follow-up (insufficient evidence). For IADL, the evidence was very uncertain about an effect, while for community integration, there was insufficient evidence of an effect. For global cognitive performance, there was an improvement of clinical importance after the intervention (low-certainty). There was some effect for attention overall, and for executive functional performance overall (very low-certainty). Of the cognitive subdomains, there was evidence of effect of possible clinical importance, immediately after intervention, only for sustained visual attention (moderate certainty), for working memory (low certainty), and thinking flexibly (low certainty), while there was only low or very low certainty or insufficient evidence of an effect for other cognitive domains/subdomains;

The authors concluded that the body of evidence for the effectiveness of OT interventions has improved since their first review. However, although their findings provide some support for the potential benefits of OT (mostly based on low certainty evidence), OT effectiveness for stroke patients remains unclear.