Showing papers in "NeuroRehabilitation in 2017"

Virtual and augmented reality in the treatment of phantom limb pain: A literature review.

Abstract: Background Phantom limb pain (PLP), the perception of discomfort in a limb no longer present, commonly occurs following amputation. A variety of interventions have been employed for PLP, including mirror therapy. Virtual Reality (VR) and augmented reality (AR) mirror therapy treatments have also been utilized and have the potential to provide an even greater immersive experience for the amputee. However, there is not currently a consensus on the efficacy of VR and AR therapy. Objective The aim of this review is to evaluate and summarize the current research on the effect of immersive VR and AR in the treatment of PLP. Methods A comprehensive literature search was conducted utilizing PubMed and Google Scholar in order to collect all available studies concerning the use of VR and/or AR in the treatment of PLP using the search terms "virtual reality," "augmented reality," and "phantom limb pain." Eight studies in total were evaluated, with six of those reporting quantitative data and the other two reporting qualitative findings. Results All studies located were of low-level evidence. Each noted improved pain with VR and AR treatment for phantom limb pain, through quantitative or qualitative reporting. Additionally, adverse effects were limited only to simulator sickness occurring in one trial for one patient. Conclusions Despite the positive findings, all of the studies were confined purely to case studies and case report series. No studies of higher evidence have been conducted, thus considerably limiting the strength of the findings. As such, the current use of VR and AR for PLP management, while attractive due to the increasing levels of immersion, customizable environments, and decreasing cost, is yet to be fully proven and continues to need further research with higher quality studies to fully explore its benefits.

Dance therapy improves motor and cognitive functions in patients with Parkinson’s disease

Abstract: Objective To explore the effects of Dance Therapy (DT) and Traditional Rehabilitation (TR) on both motor and cognitive domains in Parkinson's Disease patients (PD) with postural instability. Methods Sixteen PD patients with recent history of falls were divided in two groups (Dance Therapy, DT and Traditional Rehabilitation, TR); nine patients received 1-hour DT classes twice per week, completing 20 lessons within 10 weeks; seven patients received a similar cycle of 20 group sessions of 60 minutes TR. Motor (Berg Balance Scale - BBS, Gait Dynamic Index - GDI, Timed Up and Go Test - TUG, 4 Square-Step Test - 4SST, 6-Minute Walking Test - 6MWT) and cognitive measures (Frontal Assessment Battery - FAB, Trail Making Test A & B - TMT A&B, Stroop Test) were tested at baseline, after the treatment completion and after 8-week follow-up. Results In the DT group, but not in the TR group, motor and cognitive outcomes significantly improved after treatment and retained after follow-up. Significant changes were found for 6MWT (p = 0.028), TUG (p = 0.007), TMT-A (p = 0.014) and TMT-B (p = 0.036). Conclusions DT is an unconventional physical therapy for PD patients which effectively impacts on motor (endurance and risk of falls) and non-motor functions (executive functions).

A systematic review of the effect of physical exercise on cognition in stroke and traumatic brain injury patients.

Abstract: Objective To determine whether physical exercise enhances cognition following TBI or stroke. Data sources Studies were identified through searches of PubMed, ScienceDirect and the reference lists of papers that were included for full-text evaluation. Medical subject headings from three concepts, i.e. brain injury, physical exercise and cognition, were used to incorporate related search terms. Study selection Included were all trials published in English that assessed cognition before and after an exercise intervention in human adults with TBI or stroke. Nine randomized and two non-randomized controlled trials, as well as three single group pre-post studies were included. Data extraction Relevant data concerning the methods and results of the included studies were extracted. Methodological quality of the RCT's was evaluated using the PEDro scale. Non-randomized trials were assessed using the Downs and Black checklist. Data synthesis The included trials were generally of medium methodological quality, though often plagued with issues of internal and external validity. The studies exhibited great heterogeneity, rendering a meta-analysis infeasible. Conclusions Though well-designed studies are still needed, the preponderance of evidence suggests a positive effect of physical exercise on global cognitive functioning, especially in the chronic stages of a brain injury. Time after injury as well as the duration of the exercise program are mediating factors.

Effects of gait training using the Hybrid Assistive Limb® in recovery-phase stroke patients: A 2-month follow-up, randomized, controlled study.

Abstract: Background Gait training using the Hybrid Assistive Limb® (HAL®) may have beneficial effects on post-stroke gait function and independent walking. However, the long-term and medium-term efficacies of gait training using HAL® in stroke patients remain unclear. Objective To compare the medium-term efficacy of gait training using a single-leg version of the Hybrid Assistive Limb® (HAL®) on the paretic side with conventional gait training (CGT) in recovery-phase stroke patients. Methods Twenty-four post-stroke participants (HAL® group: n = 12, CGT group: n = 12) completed the trial. Over 4 weeks, all participants received twelve 20-min sessions of either HAL® (using the single-leg version of HAL® on the paretic side) or conventional (performed by skilled and experienced physical therapists) gait training. Outcome measures were evaluated prior to training, after 12 sessions, and at 8 and 12 weeks after intervention initiation. Functional Ambulation Category (FAC) was the primary outcome measure. Results The HAL® group showed significant improvement in FAC after 12 sessions, and at 8 and 12 weeks compared to the conventional group (P = 0.02). Conclusions The results suggested that a gait training program based on HAL® may improve independent walking more efficiently than CGT at 1 and 2 months after intervention.

Patterns of change and stability in caregiver burden and life satisfaction from 1 to 2 years after severe traumatic brain injury : a Norwegian longitudinal study

Abstract: Objectives: To assess burden and life satisfaction in caregivers of patients with severe traumatic brain injury (sTBI) at 1 and 2 years post-injury, to examine if change in burden can be predicted by caregiver and patient demographics, patient’s functional status, caregiver’s social network or caregiver’s level of burden at 1 year. Design: Prospective national multicenter study. Self-report from caregivers, patient data collected from a national cohort study on patients with sTBI. Participants: 80 caregivers. Main outcome measure: The Caregiver Burden Scale (CBS), life satisfaction. Results: The total caregiver burden increased significantly between years 1 and 2 post-injury (p=0.04). Life Satisfaction was significantly lower at 2 years follow-up (p=0.03) than at 1 year. Thirty percent of the caregivers reported an increased burden, 55% were stable, and 15% had a decrease in burden between the two follow-up times. Logistic regression analyses revealed that experiencing loneliness was an independent predictor of increased burden from 1 to 2 years post-injury (OR=4.35, p<0.05). Conclusions: The results demonstrate a need for long-term follow-up of patients and caregivers that particularly focuses on professional support to relieve caregiver burden and risk of loneliness or social isolation. This group may benefit from additional follow-up interventions tailored to their needs.

Methodology for the development of normative data for Spanish-speaking pediatric populations.

Abstract: Objective To describe the methodology utilized to calculate reliability and the generation of norms for 10 neuropsychological tests for children in Spanish-speaking countries. Method The study sample consisted of over 4,373 healthy children from nine countries in Latin America (Chile, Cuba, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Peru, and Puerto Rico) and Spain. Inclusion criteria for all countries were to have between 6 to 17 years of age, an Intelligence Quotient of≥80 on the Test of Non-Verbal Intelligence (TONI-2), and score of Results Test-retest analysis showed excellent or good- reliability on all tests (r's>0.55; p's 0.05) were removed and the analysis were run again. Conclusions This is the largest Spanish-speaking children and adolescents normative study in the world. For the generation of normative data, the method based on linear regression models and the standard deviation of residual values was used. This method allows determination of the specific variables that predict test scores, helps identify and control for collinearity of predictive variables, and generates continuous and more reliable norms than those of traditional methods.

Effect of medical complications on the after-stroke rehabilitation outcome.

Abstract: Background Post-stroke rehabilitation should begin immediately and continue while improvement is seen. After stroke, patients are at risk of developing medical complications, which can hinder optimal recovery. Objective We aimed to determine the incidence of complications occurring during early inpatient rehabilitation and to assess their influence on patients' functionality. Methods For 1075 patients (585 men), we recorded neurological deficits, activities of everyday living, functionality before and after rehabilitation, and the incidence of complications. The main measure of functional outcome was the discharge Barthel Index score. Results At least one complication was reported by 76.9% of patients, and 20% experienced three or more complications. The most common problems were: urinary tract infection (23.2%), depression (18.9%), falls (17.9%), unstable hypertension (17.6%), and shoulder pain (14.9%). Patients with a severe discharge disability were 2.5-fold more likely to experience complications than subjects with a mild disability. Conclusions Complications during the post stroke rehabilitation process had a significantly decreased chance for improvement. Knowledge of the most common type of complications, as well as their early prevention and treatment, may improve patient outcomes.

Pilot study of the Sub-Symptom Threshold Exercise Program (SSTEP) for persistent concussion symptoms in youth.

Abstract: Background Prior studies suggest potential benefit using monitored aerobic exercise to treat youth with persistent concussion symptoms, but these studies have been small. Objectives To explore the safety and potential benefits of a rehabilitative exercise intervention, the Sub-symptom Threshold Exercise Program (SSTEP), for treating youth with persistent concussion symptoms >1 month. Methods We conducted a retrospective cohort study of 83 youth who participated in SSTEP, completing trajectory analysis of concussion symptoms using the symptom subscale of the Sport Concussion Assessment Tool, version 2 (SCAT-2). Results The average age of patients was 14.9+/-2.3 years and 54% were female. Most concussions (76%) were due to sports, the majority from football and girls' soccer, and 55% had a previous concussion. Comorbidity was not uncommon: 14% had history of ADHD and 16% history of depression and/or anxiety. Most patients improved following the intervention, and none reported worsening. Symptoms decreased exponentially following initiation of SSTEP, and trajectory did not differ by duration of symptoms at presentation ( 12 weeks). Conclusions Monitored exercise programs appear to be safe and potentially beneficial for youth with persistent concussive symptoms. Large-scale controlled studies are needed to examine efficacy, ideal timing and duration.

Gait training with Hybrid Assistive Limb enhances the gait functions in subacute stroke patients: A pilot study.

Abstract: Background The robotic Hybrid Assistive Limb (HAL) provides motion according to the wearer's voluntary activity. HAL training effects on walking speed and capacity have not been clarified in subacute stroke. Objectives To determine improvement in walking ability by HAL and the most effective improvement measure for use in future large-scale trials. Methods Sixteen first-ever hemiplegic stroke patients completed at least 20 sessions over 5 weeks. Per session, the experimental group received no more than 20 min of gait training with HAL (HT) and 40 min of conventional physiotherapy, whereas the control group received at least 60 min of conventional physiotherapy. Primary outcome was maximum walking speed (MWS). Results The change in MWS from baseline at week 5 was 11.6±10.6 m/min (HAL group) and 2.2±4.1 m/min (control group) (adjusted mean difference = 9.24 m/min, 95% confidence interval 0.48-18.01, P = 0.040). In HAL subjects there were significant increases in Self-selected walking speed (SWS; a secondary outcome) and in step length (a secondary outcome) at MWS and SWS compared with controls. Conclusions HT improved walking speed in hemiplegic sub-acute stroke patients. In future, randomized controlled trials are needed to confirm the utility of HT.

Application of virtual environments in a multi-disciplinary day neurorehabilitation program to improve executive functioning using the Stroop task

Abstract: Background Virtual reality (VR) technology has demonstrated usefulness in diagnosis, education, and training. Studies supporting use of VR as a therapeutic treatment in medical rehabilitation settings remain limited. This study examines the use of VR in a treatment capacity, and whether it can be effectively integrated into neurorehabilitation. Objective To determine whether immersive VR treatment interventions improve executive dysfunction in patients with brain injury and whether performance is stronger on a VR version of the Stroop than traditional Stroop formats. Methods 15 patients with brain injury admitted to day neurorehabilitation. Outcome measures reaction time, inhibition, and accuracy indices on VR Stroop; Automated Neuropsychological Assessment Metrics (ANAM) Stroop, Delis-Kaplan Executive Function System Stroop, Golden Stroop, and Woodcock-Johnson, 3rd Edition (WJ-III): Pair Cancellation. Results Participants demonstrated significantly reduced response time on the word-reading condition of VR Stroop and non-significantly reduced response time on the interference condition. Non-significant improvements in accuracy and inhibition were demonstrated on the color-naming condition of VR Stroop. Significantly improved accuracy under time pressure was found for the ANAM, after VR intervention. Conclusion Implementation of immersive VR interventions during neurorehabilitation is effective in improving specific executive functions and information processing speed in brain-injured patients during the subacute period.

Depression one year after hemorrhagic stroke is associated with late worsening of outcomes.

Abstract: Background Poststroke depression is the most common psychiatric sequelae of stroke, and it's independently associated with increased morbidity and mortality. Few studies have examined depression after intracranial hemorrhage (ICH). Objective To investigate the relationship between depression, ICH and outcomes. Methods A substudy of the prospective Diagnostic Accuracy of MRI in Spontaneous Intracerebral Hemorrhage (DASH) study, we included 89 subjects assessed for depression 1 year after hemorrhage. A Hamilton Depression Rating Scale score >10 defined depression. Univariate, multivariable, and trend analyses evaluated relationships between depression, clinical, radiographic, and inflammatory factors and modified Rankin score (mRS) at 90 days and one year. Results Prevalence of depression at one year was 15%. Depression was not associated with hematoma volumes, presence of IVH or admission NIHSS, nor with demographic factors. Despite this, depressed patients had worse 1-year outcomes (p = 0.004) and were less likely to improve between 3 and 12 months, and more likely to worsen (p = 0.042). Conclusion This is the first study to investigate depression one year after ICH. Post-ICH depression was common and associated with late worsening of disability unrelated to initial hemorrhage severity. Further research is needed to understand whether depression is caused by worsened disability, or whether the converse is true.

Improved grasp function with transcranial direct current stimulation in chronic spinal cord injury.

Abstract: Background Recovering hand function has important implications for improving independence of patients with tetraplegia after traumatic spinal cord injury (SCI). Transcranial direct current stimulation (tDCS) is a noninvasive neuromodulation technique that has potential to improve motor function. Objective To investigate the effects of one session of 1 mA, 2 mA, and sham anodal tDCS (a-tDCS) in the upper extremity (hand) motor performance (grasp and lease) in patients with chronic cervical SCI. Methods Eleven participants with incomplete SCI were randomized to receive 20 minutes of 1 mA, 2 mA, or sham stimulation over the targeted motor cortex over three separated sessions. Hand motor performance was measured by a hand robotic evaluation (kinematics) and the Box and Blocks (BB) test before and after the stimulation period. Results A significant improvement on the grasp mean to peak speed ratio (GMP) was observed in the 2 mA group (pre: 0.38±0.02; post: 0.43±0.03; mean±SEM; p = 0.031). There was no statistically significant difference in BB test results, however the 2 mA intervention showed a positive trend for improvement. Conclusions A single session of 2 mA of a-tDCS showed gains in hand motor function in patients with chronic SCI that were not observed in functional clinical scales. The use of robotic kinematics showed promising results in assessing small changes in motor performance. Further studies are necessary to determine whether tDCS can be an effective long-term rehabilitation strategy for individuals with SCI.

The effects of Mat Pilates and Reformer Pilates in patients with Multiple Sclerosis: A randomized controlled study.

Abstract: Background Pilates is an exercise method which increases strength and endurance of core muscles and improves flexibility, dynamic postural control and balance. Objective To analyze and compare the effects of Mat and Reformer Pilates methods in Patients with Multiple Sclerosis (MS). Methods Thirty-eight patients with MS were included in the study. Participants were randomly divided into 3 groups as Mat Pilates, Reformer Pilates and control groups. The subjects in the Pilates groups did Mat or Reformer Pilates for 8 weeks, 2 days a week. The control group did breathing and relaxation exercises at home. Balance, functional mobility, core stability, fatigue severity and quality of life were evaluated. Results Balance, functional mobility, core stability, fatigue severity and quality of life improved after Pilates in Mat and Reformer Pilates groups (p 0.05). When the gain obtained in the Pilates groups is compared, it has been observed that progress has been more in trunk flexor muscle strength in the Reformer Pilates group (p 0.05). Conclusions As a result, patients with MS have seen similar benefits in Reformer Pilates and Mat Pilates methods.

Multiple sclerosis and sexual dysfunction: A need for further education and interdisciplinary care.

Abstract: Background Multiple sclerosis (MS) is an autoimmune condition affecting young women and men, resulting in varied disabilities, including sexual dysfunction. Objective This narrative review aims to describe the prevalence, pathophysiology, and impact of sexual dysfunction in people with MS (PwMS); provide a review of current assessment and treatment strategies; and offer considerations for future care. Methods Literature review was performed to identify primary and secondary sources discussing sexual dysfunction in PwMS. Results Sexual dysfunction is common in PwMS and can occur throughout the disease course. Sexual dysfunction is associated with depression, reduced quality of life, and may have broader implications related to relationships, fertility, pregnancy, and parenting. The etiology is often multifactorial and can be classified as primary, secondary, or tertiary dysfunction. Sexual dysfunction in PwMS is underdiagnosed and undertreated; however, many healthcare providers may already have the skills required to care for PwMS with sexual dysfunction. Conclusions Additional education for providers regarding the approach to assessment and management of sexual dysfunction, their potential role in treatment, and available specialized resources is needed. The role of interdisciplinary care with collaboration among providers should be considered. Further research should evaluate the impact of specific assessment tools and treatments on sexual dysfunction in PwMS.

A single group, pretest-posttest clinical trial for the effects of dry needling on wrist flexors spasticity after stroke.

Abstract: Background Spasticity is a common complication after stroke. Dry needling (DN) is suggested as a novel method for treatment of muscle spasticity. Objective To explore the effects of DN on wrist flexors spasticity poststroke. Methods A single group, pretest-posttest clinical trial was used. Twenty nine patients with stroke (16 male; mean age 54.3 years) were tested at baseline (T0), immediately after DN (T1), and one hour after DN (T2). DN was applied for flexor carpi radialis (FCR) and flexor carpi ulnaris on the affected arm for single session, one minute per muscle. The Modified Modified Ashworth Scale (MMAS), passive resistance force, wrist active and passive range of motion, Box and Block Test, and FCR H-reflex were outcome measures. Results Significant reductions in MMAS scores were seen both immediately after DN and at 1-hour follow-up (median 2 at T0 to 1 at T1 and T2). There were significant improvements in other measures between the baseline values at T0 and those recorded immediately after the DN at T1 or one hour later at T2. Conclusions This study suggests that DN reduced wrist flexors spasticity and alpha motor neuron excitability in patients with stroke, and improvements persisted for one hour after DN.

Correlation of the gait speed with the quality of life and the quality of life classified according to speed-based community ambulation in Thai stroke survivors

Abstract: BACKGROUND Gait abnormality commonly resulted from stroke which affected patients living and probably quality of life (QOL) OBJECTIVE To assess the relationship between gait speed and the QOL in Thai stroke patients and to compare the QOL among three patient groups that were categorized by gait speed: i) household ambulators 08 m/s METHODS This was a cross-sectional descriptive research study The demographic data of 92 stroke patients at Songklanagarind Hospital in Thailand were collected The gait speed was calculated by the 10 meter walk test The Thai version of the Stroke Impact Scale (SIS) 30 evaluated the QOL of the patients RESULTS The gait speed was correlated with the SIS score (r = 064, p < 0001) The relationship between the gait speed and most domains of the SIS (ie, strength, mobility, hand function, activities of daily living [ADL], emotion, social participation and thinking of recovery) were also statistically significant The community ambulators had a higher total SIS score (7298) than the limited community (6008) or household ambulators (4788) (p < 0001) For each SIS domain mentioned above, there were significant mean scores except for emotion in the community ambulators compared with the others CONCLUSIONS The gait speed was significantly correlated with the physical domains of the QOL in stroke patients The community ambulators had the highest QOL among the three groups

Augmented effects of EMG biofeedback interfaced with virtual reality on neuromuscular control and movement coordination during reaching in children with cerebral palsy.

Abstract: Background The purpose of the present study was to compare therapeutic effects of an electromyography (EMG) biofeedback augmented by virtual reality (VR) and EMG biofeedback alone on the triceps and biceps (T:B) muscle activity imbalance and elbow joint movement coordination during a reaching motor taskOBJECTIVE: To compare therapeutic effects of an electromyography (EMG) biofeedback augmented by virtual reality (VR) and EMG biofeedback alone on the triceps and biceps muscle activity imbalance and elbow joint movement coordination during a reaching motor task in normal children and children with spastic cerebral palsy (CP). Methods 18 children with spastic CP (2 females; mean±standard deviation = 9.5 ± 1.96 years) and 8 normal children (3 females; mean ± standard deviation = 9.75 ± 2.55 years) were recruited from a local community center. All children with CP first underwent one intensive session of EMG feedback (30 minutes), followed by one session of the EMG-VR feedback (30 minutes) after a 1-week washout period. Clinical tests included elbow extension range of motion (ROM), biceps muscle strength, and box and block test. EMG triceps and biceps (T:B) muscle activity imbalance and reaching movement acceleration coordination were concurrently determined by EMG and 3-axis accelerometer measurements respectively. Independent t-test and one-way repeated analysis of variance (ANOVA) were performed at p Results The one-way repeated ANOVA was revealed to be significantly effective in elbow extension ROM (p = 0.01), biceps muscle strength (p = 0.01), and box and block test (p = 0.03). The one-way repeated ANOVA also revealed to be significantly effective in the peak triceps muscle activity (p = 0.01). However, one-way repeated ANOVA produced no statistical significance in the composite 3-dimensional movement acceleration coordination data (p = 0.12). Conclusions The present study is a first clinical trial that demonstrated the superior benefits of the EMG biofeedback when augmented by virtual reality exercise games in children with spastic CP. The augmented EMG and VR feedback produced better neuromuscular balance control in the elbow joint than the EMG biofeedback alone.

Depression following traumatic brain injury: Impact on post-hospital residential rehabilitation outcomes.

Abstract: Background A need exists to better understand the impact of depression on functional outcomes following TBI. Objectives To evaluate the prevalence and severity of depression among a large group of chronic TBI adults; to determine the impact of depression on outcomes of post-hospital residential rehabilitation programs; and to assess effectiveness of post-hospital residential rehabilitation programs in treating depression. Methods 820 adults with moderate to severe traumatic brain injury (TBI) were assigned to one of four groups based on MPAI- 4 depression ratings: (1) Not Depressed, (2) Mildly Depressed, (3) Moderately Depressed, and (4) Severely Depressed. Functional status was assessed at admission and discharge with the MPAI-4 Participation Index. Differences among groups were evaluated using conventional parametric tests. Rasch analysis established reliability and validity of MPAI-4 data. Results Rasch analysis demonstrated satisfactory construct validity and internal consistency (Person reliability = 0.89-0.92, Item reliability = 0.99). Of the 820 subjects, 39% presented with moderate to severe depressive symptoms at admission, These subjects demonstrated significantly higher MPAI-4 Participation scores than the mild and not depressed groups. Depressed groups realized significant improvement in symptoms, but, those remaining depressed at discharge had significantly greater disability than those who improved. Conclusions Depressive symptoms had a deleterious impact on outcome. Remediation of symptoms during rehabilitation significantly improved outcomes.

Peabody Picture Vocabulary Test-III: Normative data for Spanish-speaking pediatric population.

Abstract: OBJECTIVE: To generate normative data for the Peabody Picture Vocabulary Test-III (PPVT-III) in Spanish-speaking pediatric populations. METHOD: The sample consisted of 4,373 healthy children from nine countries in Latin America (Chile, Cuba, Ecuador, Honduras, Guatemala, Mexico, Paraguay, Peru, and Puerto Rico) and Spain. Each participant was administered the PPVT-III as part of a larger neuropsychological battery. PPVT-III scores were normed using multiple linear regressions and standard deviations of residual values. Age, age 2, sex, and mean level of parental education (MLPE) were included as predictors in the analyses. RESULTS: The final multiple linear regression models showed main effects for age in all countries, such that scores increased linearly as a function of age. In addition, age 2 had a significant effect in all countries, except Guatemala and Paraguay. Models showed that children whose parent(s) had a MLPE >12 years obtained higher scores compared to children whose parent(s) had a MLPE ≤12 years in all countries, except for Cuba, Peru, and Puerto Rico. Sex affected scores for Chile, Ecuador, Guatemala, Mexico, and Spain. CONCLUSIONS: This is the largest Spanish-speaking pediatric normative study in the world, and it will allow neuropsychologists from these countries to have a more accurate interpretation of the PPVT-III when used in pediatric populations. © 2017 - IOS Press and the authors. All rights reserved.

Effects of resistance expiratory muscle strength training in elderly patients with dysphagic stroke.

Abstract: Background Recently, resistance expiratory muscle strength training (EMST) has been reported as a remedial treatment for dysphagia. Objective To investigate the effect of resistance EMST on the swallowing function in stroke patients with oropharyngeal dysphagia. Methods Forty-two stroke patients with dysphagia were randomly assigned to two groups: an experimental group (n = 13) and a placebo group (n = 13). The experimental group performed EMST using a portable EMST device, while the placebo group performed EMST using a sham EMST device with no loading. The intervention was performed 5 days per week for 4weeks, in five sets of 5 breaths through the device for a total of 25 breaths per day. Both groups underwent conventional dysphagia treatment for 30 minutes/day, 5 days/week, for 4 weeks. Videofluoroscopic dysphagia scale (VDS) and penetration-aspiration scale (PAS) based on a videofluoroscopic swallowing study (VFSS) were assessed to analyze the oropharyngeal swallowing function. Results The experimental group showed more improvement in pharyngeal phase of the VDS (p = 0.018 and 0.006, respectively) and PAS compared to the placebo group (p = 0.014). Conclusions We suggest that EMST could improve the effects of dysphagia observed in post-stroke elderly patients based on swallowing function.

Gait and balance deterioration over a 12-month period in multiple sclerosis patients with EDSS scores ≤ 3.0.

Abstract: BACKGROUND AND PURPOSE It is not currently known whether gait and balance measures are responsive to deterioration of motor function in multiple sclerosis (MS) patients with low EDSS scores (≤3.0). The aim of this study was to quantify MS-related gait and balance deterioration over a 12-month period. METHODS Thirty-eight participants with MS (33 female, mean age: 41.1 ± 8.3 years), mean time since diagnosis 2.2 ± 4.1 years, EDSS score ≤3.0 and without clinical evidence of gait deterioration, were recruited. Participants performed walking trials and Functional and Lateral Reach Tests. Kinematics of the ankle and knee, and electromyography of the tibialis anterior and medial gastrocnemius muscles were also measured. RESULTS Three participants reported relapses with worsening EDSS scores and 4 non-relapsing participants had worse EDSS scores at 12 months. There were significant decreases in mean gait speed, stride length and balance scores, and a significant increase in double support. Marked changes in ankle kinematics, with decreased medial gastrocnemius activity were observed. CONCLUSION Gait and balance performance of non-disabled RRMS participants may progressively decline, even in the absence of both acute clinical relapse and change in clinical status measured by the EDSS.

Sexual concerns after Spinal Cord Injury: An update on management.

Abstract: Background Spinal Cord Injury (SCI) causes neurological impairment with resultant neurogenic sexual dysfunction which can compound preexisting psychological and medical sexual concerns. Understanding these concerns is important in managing the lifelong needs of persons with SCIs. Objectives To provide an overview of the impact of SCI on sexuality along with a framework for treatment of sexual concerns. To briefly review male infertility and its treatments and pregnancy in females after SCI. Methods Interdisciplinary literature review and synthesis of information. Results The average age at SCI is increased, thus persons with SCIs may have preexisting sexual concerns. Sexual activity and satisfaction are decreased after SCI. Psychogenic sexual arousal is related to remaining sensation in the T11-L2 dermatomes. Orgasm occurs in approximately 50% of persons with SCIs with all injuries except subjects with complete lower motor neuron (LMN) injuries affecting the lowest sacral segments A structured approach to treatment including assessing preinjury function, determining the impact of injury, education, assessing and treating iatrogenic sexual dysfunction and treatment of concomitant problems is recommended. Basic and advanced methods to improve sexual arousal and orgasm are discussed and treatment of anejaculation and issues associated with pregnancy and SCI are reviewed. Conclusions Sexual satisfaction is impaired after SCI; however, education and new therapies can improve responsiveness. Future research is warranted to improve sexual function and fertility potential in persons with SCIs.

Immune biomarkers for the diagnosis of mild traumatic brain injury.

Abstract: Background In 2010, there were approximately 2.2 million emergency room visits associated with traumatic brain injury (TBI), with 80 percent diagnosed as mild TBI or concussion. In addition, there are a large number of TBIs, especially mild TBIs, which go either unreported by patients or initially undiagnosed by clinicians. Our team has previously identified a panel of immune-related genes that can diagnose ischemic stroke at triage, and due to shared pathophysiological mechanisms of TBI and stroke, we hypothesized that this panel of genes may also be utilized for the diagnosis of TBI. Objectives The primary aims of this pilot study were to: (1) characterize changes in a panel of immune-related genes in TBI; (2) identify immune-related biomarkers that may be used to diagnose TBI and (3) describe the peripheral immune response following TBI. Methods Blood was drawn from TBI patients no later than 24 h of injury onset and matched control subjects. Real-time PCR was used to measure gene expression, and a white blood cell differential was performed to obtain neutrophil and lymphocyte percentages. Results Relative mRNA expression of ARG1, LY96, MMP9, s100a12 was significantly increased and CCR7 was significantly decreased in peripheral blood of TBI patients within 24 hours of injury compared to control subjects. We also observed a different pattern of leukocyte dynamics following TBI between mild and severe TBI. Conclusions We have described a panel of immune-related genes that can accurately predict/diagnose TBI with higher sensitivity and specificity of other biomarkers to date.

Effects of dynamic neuromuscular stabilization on diaphragm movement, postural control, balance and gait performance in cerebral palsy.

Abstract: PURPOSE To determine the effects of a novel dynamic neuromuscular stabilization (DNS) technique on gross motor function, diaphragm movement, and activation of the external oblique (EO) and internal oblique (IO)/transversus abdominal (TrA) muscles in participants with cerebral palsy (CP). METHOD Fifteen participants with CP (7 females) underwent DNS intervention for 30 minutes/day, 3 days a week for 4 weeks. Gross motor function, diaphragm movement, and muscle activation were determined using a gross motor function measure (GMFM-88), ultrasound, and electromyography measurements, respectively, before and after the DNS core stabilization intervention. Paired t-tests were used at p < 0.05. DESIGN A single-arm, pretest-posttest clinical trial. RESULTS GMFM scores for standing, walking, and jumping domains were significantly improved after the intervention (P < 0.05). Diaphragm descending movement (P = 0.0001) and activation of the internal oblique and transversus abdominals were initially undetectable, but remarkably increased after the intervention (P = 0.012). CONCLUSIONS DNS is a promising, effective intervention for facilitating deep core muscle activation of the underactive muscle chain comprising the diaphragm, internal oblique, and transversus abdominals, thereby improving age-appropriate standing, walking, and jumping in participants with spastic diplegic CP.

Effect of expiratory muscle strength training intervention on the maximum expiratory pressure and quality of life of patients with Parkinson disease.

Abstract: PURPOSE The purpose of this study was to investigate the effects of 4-weeks expiratory muscle strength training (EMST) on the maximum expiratory pressure (PEmax) and quality of life (QoL) in patients with Parkinson disease (PD) METHODS Thirteen outpatients diagnosed with PD participated in this study, and were assigned into either a 5DE training group (5DE group; n = 4; 75% PEmax for 5-d/wk), 3DE training group (3DE group; n = 5; 75% PEmax for 3-d/wk) and control group (3DC group; n = 4; 0% PEmax for 3-d/wk) by matching their Hoehn and Yahr scale, genders, and age The PEmax and Parkinson disease questionnaire-39 item (PDQ-39) were evaluated pre- and post-intervention RESULTS The posttest PEmax of the 5DE was significantly higher than that of the 3DC (P < 005) Moreover, 5DE and 3DE but not 3DC significantly increased PEmax after training There were no differences in the overall quality of life in PD patients measured by PDQ-39 among three groups, but the 5DE group significantly improved the mobility constructs of PDQ-39 compared with 3DC (P < 005) CONCLUSION Both 5 d/wk and 3 d/wk of EMST effectively enhance respiratory muscle strength and improve mobility construct measured by PDQ-39 in patients with PD

Pediatric robotic rehabilitation: Current knowledge and future trends in treating children with sensorimotor impairments

Abstract: Background Robot-aided sensorimotor therapy imposes highly repetitive tasks that can translate to substantial improvement when patients remain cognitively engaged into the clinical procedure, a goal that most children find hard to pursue. Knowing that the child's brain is much more plastic than an adult's, it is reasonable to expect that the clinical gains observed in the adult population during the last two decades would be followed up by even greater gains in children. Nonetheless, and despite the multitude of adult studies, in children we are just getting started: There is scarcity of pediatric robotic rehabilitation devices that are currently available and the number of clinical studies that employ them is also very limited. Purpose We have recently developed the MIT's pedi-Anklebot, an adaptive habilitation robotic device that continuously motivates physically impaired children to do their best by tracking the child's performance and modifying their therapy accordingly. The robot's design is based on a multitude of studies we conducted focusing on the ankle sensorimotor control. In this paper, we briefly describe the device and the adaptive environment we built around the impaired children, present the initial clinical results and discuss how they could steer future trends in pediatric robotic therapy. Conclusions The results support the potential for future interventions to account for the differences in the sensorimotor control of the targeted limbs and their functional use (rhythmic vs. discrete movements and mechanical impedance training) and explore how the new technological advancements such as the augmented reality would employ new knowledge from neuroscience.

Association between gait variability, falls and mobility in people with multiple sclerosis: a specific observation on the EDSS 4.0-4.5 level

Abstract: Background We previously demonstrated that gait variability increases throughout the disease process in people with multiple sclerosis (PwMS). While gait variability tends to remain steady in the lower levels of disability, a significant increase occurs once patients reach the moderate neurological level. Objective To examine the relationship between variability of major spatio-temporal parameters of gait and falls, in PwMS with an expanded disability status scale score of 4.0 and 4.5. Methods The study included 91 PwMS, 50 women. Gait variability was studied using an electronic mat. Clinical gait measures included the Two-minute walk test, Timed Up and Go test and the Timed 25-foot walk. Results Fifty patients were classified as fallers, 41, non-fallers. The MS fallers presented a higher variability score in the step length (37.3% increase) and single support (28.2% increase) compared to participants in the non-fallers. Additionally, gait variability scores were significantly correlated with clinical walking tests. The strongest correlation scores were for variability of the step length. Pearson's rho scores for the Timed Up and Go test, 2-min walk and Timed 25-foot walk were 0.541, - 0.448 and 0.425, respectively. Conclusions This study confirms that gait variability is a potential treatment target for PwMS moderately disabled, in order to decrease risk of falls.

Three-dimensional evaluation of postural stability in Parkinson's disease with mobile technology.

Abstract: BACKGROUND Postural instability is a hallmark of Parkinson's disease Objective metrics to characterize postural stability are necessary for the development of treatment algorithms to aid in the clinical setting OBJECTIVE The aim of this project was to validate a mobile device platform and resultant three-dimensional balance metric that characterizes postural stability METHODS A mobile Application was developed, in which biomechanical data from inertial sensors within a mobile device were processed to characterize movement of center of mass in the medial-lateral, anterior-posterior and trunk rotation directions Twenty-seven individuals with Parkinson's disease and 27 age-matched controls completed various balance tasks A postural stability metric quantifying the amplitude (peak-to-peak) of sway acceleration in each movement direction was compared between groups The peak-to-peak value in each direction for each individual with Parkinson's disease across all trials was expressed as a normalized value of the control data to identify individuals with severe postural instability, termed Cleveland Clinic-Postural Stability Index RESULTS In all conditions, the balance metric for peak-to-peak was significantly greater in Parkinson's disease compared to controls (p < 001 for all tests) CONCLUSIONS The balance metric, in conjunction with mobile device sensors, provides a rapid and systematic metric for quantifying postural stability in Parkinson's disease

Effects of Shaker exercise in stroke survivors with oropharyngeal dysphagia.

Abstract: BACKGROUND Dysphagia after stroke can cause a variety of complications, especially aspiration pneumonia, which can be life-threatening. Therefore, rehabilitation methods to reduce aspiration in patients with dysphagia are important. OBJECTIVE In the present study, we aimed to investigate the effects of Shaker exercise on aspiration and oral diet level in stroke survivors with dysphagia. METHODS Participants were randomly assigned to an experimental group (n = 16) or a control group (n = 16). Participants in the experimental group performed Shaker exercise and conventional dysphagia therapy, whereas those in the control group performed only conventional dysphagia therapy. All participants performed training 5 days a week for 4 weeks. Degree of aspiration was assessed using the Penetration-Aspiration Scale (PAS) based on videofluoroscopic swallowing study, while oral diet level was assessed using the Functional Oral Intake Scale (FOIS). RESULTS The experimental group showed greater improvement on both the PAS (p < 0.05) and FOIS (p < 0.05) compared with the control group. CONCLUSIONS The results of this study suggest that Shaker exercise is a effective exercise for recovery of swallowing function in stroke survivors with dysphagia.

Comparison of Cognitive Orientation to daily Occupational Performance and conventional occupational therapy on occupational performance in individuals with stroke: A randomized controlled trial

Abstract: Background Cognitive Orientation to daily Occupational Performance (CO-OP) approach based on cognitive strategy in occupational therapy. Objectives To investigate the effects of CO-OP approach on occupational performance in individuals with hemiparetic stroke. Methods This study was designed as a 5-week, randomized, single-blind. Forty-three participants who had a diagnosis of first stroke were enrolled in this study. The participants were randomly assigned to the experimental group (n = 20) or the control group (n = 23). The experimental group conducted CO-OP approach while the control group conducted conventional occupational therapy based on occupational performance components. This study measured Canadian Occupational Performance Measure (COPM) and Performance Quality Rating Scale (PQRS). Outcome measurements were performed at baseline and post-intervention. Results After training, the scores of COPM and PQRS in trained task were significantly higher for the score in the experimental group than the control group. In addition, the non-trained task was significantly higher for the score in the experimental group than the control group in COPM and the PQRS. Conclusions This study suggests that the CO-OP approach is beneficial effects on the occupational performance to improvement in individuals with hemiparetic stroke, and have positive effects on generalization and transfer of acquired skills.