Anodal transcranial direct current stimulation enhances the effects of motor imagery training in a finger tapping task.

Motor imagery (MI) training and anodal transcranial direct current stimulation (tDCS) applied over the primary motor cortex can independently improve hand motor function. The main objective of this double-blind, sham-controlled study was to examine whether anodal tDCS over the primary motor cortex could enhance the effects of MI training on the learning of a finger tapping sequence. Thirty-six right-handed young human adults were assigned to one of three groups: (i) who performed MI training combined with anodal tDCS applied over the primary motor cortex; (ii) who performed MI training combined with sham tDCS; and (iii) who received tDCS while reading a book. The MI training consisted of mentally rehearsing an eight-item complex finger sequence for 13 min. Before (Pre-test), immediately after (Post-test 1), and at 90 min after (Post-test 2) MI training, the participants physically repeated the sequence as fast and as accurately as possible. An anova showed that the number of sequences correctly performed significantly increased between Pre-test and Post-test 1 and remained stable at Post-test 2 in the three groups (P < 0.001). Furthermore, the percentage increase in performance between Pre-test and Post-test 1 and Post-test 2 was significantly greater in the group that performed MI training combined with anodal tDCS compared with the other two groups (P < 0.05). As a potential physiological explanation, the synaptic strength within the primary motor cortex could have been reinforced by the association of MI training and tDCS compared with MI training alone and tDCS alone.

Modulation of the response to a somatosensory stimulation of the hand during the observation of manual actions.

Observation of hand movements has been repeatedly demonstrated to increase the excitability of the motor cortical representation of the hand. Little attention, however, has been devoted to its effect on somatosensory processing. Movement execution is well known to decrease somatosensory cortical excitability, a phenomenon termed 'gating'. As executed and observed actions share common cortical representations, we hypothesized that action observation (hand movements) should also modulate the cortical response to sensory stimulation of the hand. Seventeen healthy subjects participated in these experiments in which electroencephalographic (EEG) recordings of the somatosensory steady-state response (SSSR) were obtained. The SSSR provides a continuous measure of somatosensory processing. Recordings were made during a baseline condition and five observation conditions in which videos showed either a: (1) hand action; (2) passive stimulation of a hand; (3) static hand; (4) foot action; or (5) static object. The method employed consisted of applying a continuous 25 Hz vibratory stimulation to the index finger during the six conditions and measuring potential gating effects in the SSSR within the 25 Hz band (corresponding to the stimulation frequency). A significant effect of condition was found over the contralateral parietal cortex. Observation of hand actions resulted in a significant gating effect when compared to baseline (average gating of 22%). Observation of passive touch of the hand also gated the response (17% decrease). In conclusion, the results show that viewing a hand performing an action or being touched interferes with the processing of somatosensory information arising from the hand.

Decreasing phantom limb pain through observation of action and imagery: a case series.

BACKGROUND: Phantom limb pain is often resistant to treatment. Techniques based on visual-kinesthetic feedback could help reduce it. OBJECTIVE: The objective of the current study was to test if a novel intervention combining observation and imagination of movements can reduce phantom limb pain. METHODS: This single-case multiple baseline study included six persons with upper or lower limb phantom pain. Participants' pain and imagery abilities were assessed by questionnaires. After a 3-5-week baseline, participants received a two-step intervention of 8 weeks. Intervention 1 was conducted at the laboratory with a therapist (two sessions/week) and at home (three sessions/week); and Intervention 2 was conducted at home only (five times/week). Interventions combined observation and imagination of missing limb movements. Participants rated their pain level and their ease to imagine daily throughout the study. RESULTS: Time series analyses showed that three participants rated their pain gradually and significantly lower during Intervention 1. During Intervention 2, additional changes in pain slopes were not significant. Four participants reported a reduction of pain greater than 30% from baseline to the end of Intervention 2, and only one maintained his gains after 6 months. Group analyses confirmed that average pain levels were lower after intervention than at baseline and had returned to baseline after 6 months. Social support, degree of functionality, and perception of control about their lives prior to the intervention correlated significantly with pain reduction. CONCLUSIONS: Persons with phantom limb pain may benefit from this novel intervention combining observation and motor imagery. Additional studies are needed to confirm our findings, elucidate mechanisms, and identify patients likely to respond.

The effects of body position and actual execution on motor imagery of locomotor tasks in people with a lower-limb amputation.

Motor imagery (MI) is usually facilitated when performed in a congruent body position to the imagined movement, as well as after actual execution (AE). A lower-limb amputation (LLA) results in important structural and functional changes in the sensorimotor system, which can alter MI. In this study, we investigated the effects of body position and AE on the temporal characteristics of MI in people with LLA. Ten participants with LLA (mean age = 59.6 ± 13.9 years, four females) and ten gender- and age-matched healthy control participants (mean age = 60.1 ± 15.4 years, four females) were included. They performed two locomotor-related tasks (a walking task and the Timed Up and Go task) while MI times were measured in different conditions (in congruent/incongruent positions and before/after AE). We showed that MI times were significantly shorter when participants imagined walking in a congruent-standing position compared to an incongruent-sitting position, and when performing MI after actual walking compared to before, in both groups. Shorter MI times in the congruent position and after AE suggest an improvement of MI's temporal accuracy (i.e. the ability to match AE time during MI) in healthy individuals but not in the LLA group.

Normal aging and motor imagery vividness: implications for mental practice training in rehabilitation.

OBJECTIVE: To investigate the effects of normal aging on motor imagery vividness and working memory. DESIGN: Descriptive study with 3 groups. SETTING: Laboratory of a university-affiliated research rehabilitation center. PARTICIPANTS: A sample of healthy persons (N=80) divided into 3 age groups: young (26+/-5.0 y), intermediate (53.6+/-5.4 y), and elderly (67.6+/-4.6 y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The kinesthetic and visual imagery scores of the Kinesthetic and Visual Imagery Questionnaire and scores from 3 domains of working memory (visuospatial, kinesthetic, verbal). RESULTS: Results revealed that visual motor imagery scores were higher than kinesthetic scores (imagery effect: P=.001); however, there was also a significant imagery x group interaction (P=.017). Post hoc analyses showed that only the young and intermediate groups had higher visual than kinesthetic motor imagery scores (P=.005 and .001, respectively), indicating a loss of visual motor imagery dominance in the elderly group. There was no group effect (P=.963) signifying that the level of motor imagery vividness was comparable between age groups. Significant decreases (17.3% and 22.5%, respectively) in visuospatial working memory scores were found in the intermediate (P=.011) and elderly (P=.001) groups, whereas a significant reduction (P=.01) in kinesthetic working memory scores was observed only in the elderly group (26.7%). There was also an age-related significant decline of visuospatial (r= -.50) and kinesthetic (r=-.34) working memory. CONCLUSIONS: The level of motor imagery vividness does not diminish with age, but the quality changes. The dominance of visual motor imagery lessens with aging resulting in motor imagery modality-equivalence. These motor imagery alterations are associated with an age-related decline in visuospatial and kinesthetic working memory.

Recovery of Sensorimotor Functional Outcomes at Discharge from In-Patient Rehabilitation in Three Stroke Units in the Province of Quebec.

Purpose: This study aimed to portray the characteristics, process variables, and sensorimotor outcomes of patients who had received their usual post-stroke in-patient rehabilitation in three stroke rehabilitation units in Quebec in 2013-2014. Method: We assessed patients (n = 264) at admission and discharge with a subset of a standardized assessment toolkit consisting of observational and performance-based assessment tools. Results: The patients, with a mean age of 60.3 (SD 15.4) years, were admitted 27.7 (SD 8.4) days post-stroke onset. They had a mean admission FIM score of 83.0 (SD 24.0), a mean length of stay of 48.4 (SD 31.1) days, a mean FIM discharge score of 104.0 (SD 17.0), and a mean FIM efficiency score of 0.44 (SD 0.29). All patient outcomes were significantly improved (p < 0.001) and clinically meaningful at discharge (moderate to large Glass's Δ effect sizes) with the improvements greater than or equal to the minimal detectable change at the 95% confidence level in 34%-75% of the patients. Improvements were larger on five of seven outcomes in a sub-group of patients with more severe stroke. Conclusions: The use of a combination of observational and performance assessment tools was essential to capture the full range of disabilities. We have documented significant and clinically meaningful improvements in functional independence, disability, and upper and lower extremity functions after usual post-stroke in-patient rehabilitation in the province of Quebec and provided baseline data for future studies.

Objectif : décrire les caractéristiques, le processus de réadaptation et les résultats sensorimoteurs de patients ayant reçu les services de réadaptation habituels après un accident vasculaire cérébral (AVC) dans trois unités de réadaptation du Québec en 2013 et 2014. Méthodologie : évaluation des patients (n = 264) à l'admission et au congé à l'aide du sous-ensemble d'une trousse d'évaluation standardisée composée d'outils d'évaluation fondés sur l'observation et la performance. Résultats : les patients, qui avaient un âge moyen de 60,3 ans (ÉT 15,4), ont été hospitalisés en réadaptation 27,7 jours (ÉT 8,4) après leur AVC. Leur mesure d'autonomie fonctionnelle (MAF) à l'admission était de 83,0 (ÉT 24,0), et leur séjour en réadaptation a duré 48,4 jours (ÉT 31,1); leur score de MAF au congé était de 104,0 (ÉT 17,0), pour un score d'efficacité de la MAF de 0,44 (ÉT 0,29). Tous les résultats cliniques des patients s'étaient considérablement améliorés (p < 0,001) et étaient cliniquement significatifs au congé (effet de taille delta de Glass de modéré à grand), et ces améliorations étaient supérieures ou égales au changement minimal décelable à un niveau de confiance de 95 % chez 34 % à 75 % des patients. Ces améliorations pour cinq des sept mesures étaient plus élevées dans le sous-groupe de patients ayant un AVC plus grave. Conclusion : une combinaison d'outils d'évaluation d'observation et de performance s'est avérée essentielle pour saisir tout l'éventail d'incapacités. Les auteures ont constaté des améliorations importantes et cliniquement significatives de l'autonomie fonctionnelle, de l'incapacité et de la fonction des membres supérieurs et inférieurs après l'hospitalisation en réadaptation habituelle des patients ayant un AVC dans la province de Québec et ont fourni des données de référence en vue de prochaines études.

Brain activity during visual versus kinesthetic imagery: an fMRI study.

Although there is ample evidence that motor imagery activates similar cerebral regions to those solicited during actual movements, it is still unknown whether visual (VI) and kinesthetic imagery (KI) recruit comparable or distinct neural networks. The present study was thus designed to identify, through functional magnetic resonance imaging at 3.0 Tesla in 13 skilled imagers, the cerebral structures implicated in VI and KI. Participants were scanned in a perceptual control condition and while physically executing or focusing during motor imagery on either the visual or kinesthetic components of an explicitly known sequence of finger movements. Subjects' imagery abilities were assessed using well-established psychological, chronometric, and new physiological measures from the autonomic nervous system. Compared with the perceptual condition, physical executing, VI, and KI resulted in overlapping (albeit non-identical) brain activations, including motor-related regions and the inferior and superior parietal lobules. By contrast, a divergent pattern of increased activity was observed when VI and KI were compared directly: VI activated predominantly the occipital regions and the superior parietal lobules, whereas KI yielded more activity in motor-associated structures and the inferior parietal lobule. These results suggest that VI and KI are mediated through separate neural systems, which contribute differently during processes of motor learning and neurological rehabilitation.

Effects of practice, visual loss, limb amputation, and disuse on motor imagery vividness.

BACKGROUND: The ability to generate vivid images of movements is variable across individuals and likely influenced by sensorimotor inputs. OBJECTIVES: The authors examined (1) the vividness of motor imagery in dancers and in persons with late blindness, with amputation or an immobilization of one lower limb; (2) the effects of prosthesis use on motor imagery; and (3) the temporal characteristics of motor imagery. METHODS: Eleven dancers, 10 persons with late blindness, 14 with amputation, 6 with immobilization, and 2 groups of age-matched healthy individuals (27 in control group A; 35 in control group B) participated. The Kinesthetic and Visual Imagery Questionnaire served to assess motor imagery vividness. Temporal characteristics were assessed with mental chronometry. RESULTS: The late blindness group and dance group displayed higher imagery scores than respective control groups. In the amputation and immobilization groups, imagery scores were lower on the affected side than the intact side and specifically for imagined foot movements. Imagery scores of the affected limb positively correlated with the time since walking with prosthesis. Movement times during imagination and execution (amputation and immobilization) were longer on the affected side than the intact side, but the temporal congruence between real and imagined movement times was similar to that in the control group. CONCLUSIONS: The mental representation of actions is highly modulated by imagery practice and motor activities. The ability to generate vivid images of movements can be specifically weakened by limb loss or disuse, but lack of movement does not affect the temporal characteristics of motor imagery.

Added value of mental practice combined with a small amount of physical practice on the relearning of rising and sitting post-stroke: a pilot study.

BACKGROUND AND PURPOSE: : The additional effects of combining mental practice with a small amount of physical practice on the relearning of a motor task post-stroke are unknown. This study investigated the added value of mental practice on the relearning of rising up from a chair and sitting down when combined with a small amount of physical practice. METHODS: : Twelve individuals with chronic stroke were randomly assigned to one of three groups: a group that combined mental practice with physical practice (MP), a group that combined physical practice with cognitive training (Cog) and a group without training (NOT.). Training was provided three times per week for four weeks, and participants were assessed at baseline, after training, and three weeks later. The vertical forces were recorded under each foot, and the vertical impulse was calculated for five trials and converted in percent of body weight. RESULTS: : The MP and Cog groups received the same amount of physical training. Significant gains (P < 0.04) in limb loading found only in the MP group were retained. Larger (P < 0.03) change scores in limb loading for rising up from a chair and sitting down were found in the MP group (median = rising up: 18.4%; sitting down: 12.2%) compared with Cog group (median = rising up: -6.8%; sitting down: 5.4%) and a group without training (median = rising up: 6.2%; sitting down: 5.4%). CONCLUSION: : Combining series of mental repetitions ( approximately 1100 repetitions) with minimal physical repetitions ( approximately 120 repetitions) yielded significant gains and retention of those gains. These preliminary results provide some support to the added value of combining mental repetitions with a small number of physical repetitions to promote the relearning of motor strategies post-stroke and warrant further investigation in clinical trials.

Development, Implementation, and Clinician Adherence to a Standardized Assessment Toolkit for Sensorimotor Rehabilitation after Stroke.

Purpose: This study describes the development of a standardized assessment toolkit (SAT) and associated clinical database focusing on sensorimotor rehabilitation in three stroke rehabilitation units (SRUs). Implementation of the SAT was confirmed using objective measures of clinician adherence while exploring reasons for varied adherence. Method: Participants were patients post-stroke admitted for inpatient rehabilitation and clinicians from the three SRUs. A collaborative and iterative process was used to develop the SAT. Implementation was measured by clinician adherence, which was charted by means of assessment entries in patient records and transferred to the clinical database. Reasons for lower adherence were interpreted from therapist data logs at one SRU. Results: The SAT consisted of 25 assessment tools. Clinician adherence to a subset of the tools ranged from 33% to 99% at admission and from 28% to 94% at discharge. At one site, lower adherence among the tools was explained by patient-related factors (1%-36%) and protocol or logistical reasons (0%-7%) at admission; missing data ranged from 0% to 3%, except for the Montreal Cognitive Assessment (17%). Conclusions: In this pragmatic study, objective measures of clinician adherence demonstrated the feasibility of implementing an SAT in daily practice. Moreover, the reasons for lower adherence rates may be related to the patients, protocol, and logistics, all of which may vary with the assessment tool, rather than clinician compliance.

Objectif : décrire la création d'une trousse d'évaluation standardisée (TÉS) et d'une base de données cliniques connexe axée sur la réadaptation sensorimotrice dans trois unités de réadaptation fonctionnelle (URF). Les chercheurs ont confirmé la mise en application de la TÉS au moyen de mesures objectives de l'adhésion des cliniciens et ont exploré les raisons expliquant les variations à cette adhésion. Méthodologie : les participants étaient des patients victimes d'un accident vasculaire cérébral (AVC) admis en réadaptation et les cliniciens des trois URF. Les chercheurs ont utilisé un processus coopératif et itératif pour créer la TÉS. Ils en ont mesuré la mise en application par l'adhésion des cliniciens, recensée d'après les résultats d'évaluation dans les dossiers des patients, puis les ont transférées dans la base de données cliniques. Ils ont interprété les raisons d'une plus faible adhésion à partir des notes inscrites sur les feuilles de collecte de données des thérapeutes d'une des URF. Résultats : la TÉS se composait de 25 outils d'évaluation. L'adhésion des cliniciens à un sous-groupe d'outils se situait entre 33% et 99% à l'admission en réadaptation et entre 28% et 94% au congé. Dans un établissement, une plus faible adhésion aux outils s'expliquait par des facteurs liés aux patients (de 1% à 36%), au protocole ou à la logistique (0% à 7%) à l'admission, alors que les données manquantes variaient de 0% à 3%, sauf pour le « Montreal Cognitive Assessment ¼ (17%). Conclusions : dans cette étude pragmatique, les mesures objectives d'adhérence des cliniciens ont démontré la faisabilité de mettre en application une TÉS dans la pratique quotidienne. De plus, les raisons d'un taux d'adhérence plus faible peuvent être liées aux patients, au protocole ou à la logistique, facteurs qui peuvent varier en fonction de l'outil d'évaluation, plutôt qu'aux cliniciens.

Motor imagery ability of patients with lower-limb amputation: exploring the course of rehabilitation effects.

BACKGROUND: Amputation of a lower-limb results in a severe decrease of functional mobility that deeply alters independent living. Motor imagery (MI) refers to the mental representation of an action without engaging its actual execution. The repetitive use of MI has been shown to contribute to promote motor recovery and phantom-limb pain alleviation. AIM: Given the importance of invoking accurate images to benefit from MI practice, and considering the link between motor capacities and MI, the present study investigated the effect of a rehabilitation program on MI ability in patients with lower-limb amputation. DESIGN: Observational and longitudinal study. SETTING: Patients recruited from the Amputation program at the Institut de Réadaptation en Déficience Physique de Québec (IRDPQ), in Quebec City, Canada. POPULATION: Patients with trans-tibial or transfemoral amputation, following a rehabilitation program as outpatients. METHODS: MI ability of the patients was measured at three different time points along the course of physical therapy. RESULTS: The data revealed a positive effect of the rehabilitation program on MI accuracy of locomotor tasks, and greater MI vividness and accuracy for single-joint movements that patients were still able to physically perform. CONCLUSIONS: These findings suggest that MI abilities and actual motor performance are mirrored in a congruent fashion. CLINICAL REHABILITATION IMPACT: Therapists should consider this critical aspect when including MI practice in rehabilitation programs among patients with lower-limb amputation.

Is Cerebral Palsy Changing in High Resource Settings? Data From the Quebec Cerebral Palsy Registry.

Advances in maternal and perinatal care in developed countries have led to improved health outcomes for children. These changes may have impacted the profile of children with a cerebral palsy (CP) and groups at risk for CP over time. Using data from the Canadian CP Registry, the objectives of this retrospective cohort study were to describe the profile of children with CP in Quebec born between 1999 and 2010 and identify possible temporal variation in CP risk factors and phenotypic profile. Our sample consisted of 662 children with CP in Quebec. No change in profile or associated risk factors was observed across the birth cohorts 1999 to 2010. Prematurity remains the largest risk factor for CP in Quebec, and children with CP have multiple comorbidities that contribute to overall CP burden. CP registries offer a unique platform to study spectrum disorders and their longitudinal changes over time.

Clinical assessment of motor imagery after stroke.

OBJECTIVE: The aim of this study was to investigate: (1) the effects of a stroke on motor imagery vividness as measured by the Kinesthetic and Visual Imagery Questionnaire (KVIQ-20); (2) the influence of the lesion side; and (3) the symmetry of motor imagery. METHODS: Thirty-two persons who had sustained a stroke, in the right (n = 19) or left (n = 13) cerebral hemisphere, and 32 age-matched healthy persons participated. The KVIQ-20 assesses on a 5-point ordinal scale the clarity of the image (visual scale) and the intensity of the sensations (kinesthetic scale) that the subjects are able to imagine from the first-person perspective. RESULTS: In both groups, the visual scores were higher (P = .0001) than the kinesthetic scores and there was no group difference. Likewise, visual scores remained higher than kinesthetic scores irrespective of the lesion side. The visual scores poststroke were higher (P = .001) when imagining upper limb movements on the unaffected side than those on the affected side. When focusing on the lower limb only, however, the kinesthetic scores were higher (P = .001) when imagining movements of the unaffected compared to those on the affected side. CONCLUSIONS: The vividness of motor imagery poststroke remains similar to that of age-matched healthy persons and is not affected by the side of the lesion. However, after stroke motor imagery is not symmetrical and motor imagery vividness is better when imagining movements on the unaffected than on the affected side, indicating an overestimation possibly related to a hemispheric imbalance or a recalibration of motor imagery perception.

Reliability of mental chronometry for assessing motor imagery ability after stroke.

OBJECTIVE: To examine the reproducibility of 2 chronometric tests: time-dependent motor imagery (TDMI) screening test and temporal congruence test. DESIGN: Test-retest 10 to 14 days apart. SETTING: Laboratory of a university-affiliated center for research in rehabilitation. PARTICIPANTS: Twenty persons post cerebrovascular accident (CVA) and 46 healthy persons (controls). INTERVENTION: The reproducibility of the TDMI screening test, wherein the number of stepping movements (performed in sitting) imagined over 15, 25, and 45 seconds is recorded, and of the temporal congruence test wherein the duration of physically executed (E) and imagined (I) stepping movements is recorded, was evaluated. MAIN OUTCOME MEASURES: The test-retest reliability of the number of imagined movements (TDMI screening test), movement duration and I/E time ratios (temporal congruence test), and intrasession reliability of the temporal congruence test were assessed by using intraclass correlation coefficients (ICCs). RESULTS: For the TDMI screening test, the ICCs ranged from .88 to .93 (CVA, n=20) and from .87 to .92 (controls, n=9). For the temporal congruence test, when the total duration of 2 series of 5 stepping movements was averaged, ICCs ranged from .76 to .97 (CVA, n=20) and from .77 to .93 (controls, n=46), whereas for 1 series the ICCs ranged from .71 to .95 and from .63 to .95 in the CVA and control groups, respectively. The ICCs for intrasession reliability for the CVA (n=20) and control (n=46) groups, respectively, ranged from .90 to .98 and .95 to .97. CONCLUSIONS: The present findings support the reproducibility of both tests in both groups. Mental chronometry can be used reliably for the screening of patients capable of motor imagery or for measuring temporal congruence between real and imagined movements poststroke.

Amount and Content of Sensorimotor Therapy Delivered in Three Stroke Rehabilitation Units in Quebec, Canada.

Purpose: This study creates a baseline clinical portrait of sensorimotor rehabilitation in three stroke rehabilitation units (SRUs) as a first step in implementing a multi-centre clinical research platform. Method: Participants in this cross-sectional, descriptive study were the patients and rehabilitation teams in these SRUs. Prospective (recording of therapy time and content and a Web-based questionnaire) and retrospective (chart audit) methods were combined to characterize the practice of the rehabilitation professionals. Results: The 24- to 39-bed SRUs admitted 100-240 inpatients in the year audited. The mean combined duration of individual occupational and physical therapy was 6.3-7.5 hours/week/patient. When evening hours and the contributions of other professionals as well as group therapy and self-practice were included, the total amount of therapy was 13.0 (SD 3) hours/patient/week. Chart audit and questionnaire data revealed the Berg Balance Scale was the most often used outcome measure (98%-100%), and other outcome measure use varied. Clinicians favoured task-oriented therapy (35%-100%), and constraint-induced movement therapy (0%-15%), electrical stimulation of the tibialis anterior (0%-15%), and body weight-supported treadmill training (0%-1%) were less often used. Conclusions: This study is the first to provide objective data on therapy time and content of stroke rehabilitation in Quebec SRUs.

Objectif : créer un portrait clinique de base de la réadaptation sensorimotrice offerte après un accident vasculaire cérébral dans trois unités de réadaptation fonctionnelle intensive (URFI) comme première étape en vue de la mise en œuvre d'une plateforme de recherche clinique multicentrique. Méthodologie : les participants à cette étude descriptive transversale étaient des patients et des équipes de réadaptation de ces URFI. Les chercheurs ont combiné la méthode prospective (consignation de la durée et du contenu du traitement et questionnaire en ligne) et la méthode rétrospective (audit de dossiers) pour caractériser la pratique des professionnels en réadaptation. Résultats : les URFI de 24 à 39 lits ont admis de 100 à 240 patients hospitalisés pendant l'année de l'audit. Les interventions en ergothérapie et physiothérapie étaient d'une durée moyenne combinée de 6,3 à 7,5 heures par semaine par patient. Lorsqu'on incluait les soirées, l'apport d'autres professionnels, la thérapie de groupe et la pratique autonome, le total s'élevait à 13,0 heures (ÉT 3,0) par semaine par patient. Les données tirées de l'audit des dossiers et des questionnaires ont révélé que l'échelle d'évaluation de l'équilibre de Berg était la plus utilisée (98 % à 100 %), alors que l'utilisation des autres mesures était variable. Les cliniciens favorisaient les traitements orientés vers les tâches (35 % à 100 %), et utilisaient moins la thérapie par contrainte induite (0 % à 15 %), la stimulation électrique du jambier antérieur (0 % à 15 %) et l'entraînement sur tapis roulant avec support de poids (0 % à 1 %). Conclusions : la présente étude est la première à fournir des données objectives sur la durée et le contenu de la réadaptation après un accident vasculaire cérébral dans les URFI du Québec.

Gait Training after Stroke on a Self-Paced Treadmill with and without Virtual Environment Scenarios: A Proof-of-Principle Study.

Purpose: The purpose of this proof-of-principle study was to show that virtual reality (VR) technology could be coupled with a self-paced treadmill to further improve walking competency in individuals with chronic stroke. Method: A 62-year-old man with a chronic right hemispheric stroke participated in a treadmill walking programme involving first a control (CTL) protocol, then VR training. In CTL training, he walked without time constraints while viewing still pictures and reacting to treadmill movements similar to those that he would have experienced later in VR training. In VR training, he experienced treadmill movements programmed to simulate changes encountered in five virtual environments rear-projected onto a large screen. Training difficulty in nine sessions over 3 weeks was increased by varying the time constraints, terrain surface changes, and obstacles to avoid. Effects on walking competency were assessed using clinical measures (5 m walk test, 6 min walk test, Berg Balance Scale, Activities-specific Balance Confidence scale) and questionnaires (Assessment of Life Habits Scale and personal appraisal). Results: CTL and VR training resulted in a similar progression through the training sessions of total time walked on the treadmill. The VR training led to an additional increase in speed as measured by walking 5 metres as fast as possible and distance walked in 6 minutes, as well as improved balance self-efficacy and anticipatory locomotor adjustments. As reported by the participant, these improved outcomes transferred to real-life situations. Conclusions: Despite the limited potential for functional recovery from chronic stroke, an individual can achieve improvements in mobility and self-efficacy after participating in VR-coupled treadmill training, compared with treadmill training with the same intensity and surface perturbations but without VR immersion. A larger scale, randomized controlled trial is warranted to determine the efficacy of VR-coupled treadmill training for mobility intervention post-stroke.

Objectif : la présente étude de validation visait à démontrer que la réalité virtuelle (RV) peut être jumelée à un tapis roulant autocontrôlé pour améliorer l'aptitude à marcher des personnes ayant un accident vasculaire cérébral (AVC) chronique. Méthodologie : un homme de 62 ans ayant un AVC chronique de l'hémisphère droit a participé à un programme de marche sur tapis roulant, d'abord au moyen d'un protocole de contrôle (CTL), puis d'un entraînement en RV. Pendant l'entraînement CTL, l'homme a marché sans contrainte de temps tout en regardant des images fixes et en réagissant aux mouvements du tapis roulant semblables à ceux repris par la suite en RV. Pendant l'entraînement en RV, il a ressenti les mouvements du tapis roulant programmés pour simuler les changements observés dans cinq environnements virtuels rétroprojetés sur grand écran. La difficulté de l'entraînement au cours de neuf séances réparties sur trois semaines a augmenté en variant les contraintes de temps, les changements de surface du terrain et les obstacles à éviter. Les chercheurs ont évalué les effets sur l'aptitude à marcher à l'aide de mesures cliniques (tests de marche de cinq mètres et de six minutes, échelle d'évaluation de l'équilibre de Berg, échelle de confiance en l'équilibre pendant des activités) et de questionnaires (échelle d'évaluation des habitudes de vie et évaluation personnelle). Résultats : l'entraînement CTL et celui en RV ont suscité une progression similaire de la durée totale de marche sur le tapis roulant pendant les séances d'entraînement. L'entraînement en RV a favorisé une amélioration supplémentaire de la marche rapide sur cinq mètres et de la distance parcourue en six minutes, de même qu'une meilleure auto-efficacité de l'équilibre et de meilleurs ajustements locomoteurs anticipés. Comme l'a indiqué le participant, cette amélioration des résultats se transposait dans la vie quotidienne. Conclusions : malgré le potentiel limité de récupération fonctionnelle en cas d'AVC chronique, une personne peut améliorer sa mobilité et son auto-efficacité après avoir participé à un entraînement sur tapis roulant jumelé à la RV, par rapport à un entraînement sur tapis roulant de la même intensité et selon les mêmes perturbations de la surface du sol, mais sans l'immersion de la RV. Un essai aléatoire et contrôlé à plus vaste échelle s'impose pour déterminer l'efficacité de l'entraînement sur tapis roulant jumelé à la RV dans le cadre d'une intervention de mobilité après un AVC.

Side difference in the hip and knee joint moments during sit-to-stand and stand-to-sit tasks in individuals with hemiparesis.

BACKGROUND: No study has reported the differences between sides in the net muscular moment of lower limbs of subjects with hemiparesis during sit-to-stand and stand-to-sit tasks in various foot positions. Moreover, the asymmetry of lower-joint moments has not yet been related to muscular weakness of the lower limbs in this population. METHODS: A convenience sample of 12 individuals (mean age (standard deviation): 49.7 (9.0) years) with chronic hemiparesis due to stroke were asked to stand up and sit down at their natural speed in four foot positions. The joint moments at the hip and knee on both sides during the tasks were estimated with an inverse dynamic approach while the dynamic concentric strength in extension at the hip and knee was assessed with a Biodex dynamometric system. Statistical analyses (paired t-tests and ANOVAs) were used to assess the effects of sides and foot position factor on the asymmetry in the hip and knee joint moments. The level of association between muscle weakness and the asymmetry in the joint moments was quantified with Pearson correlation coefficients (r). FINDINGS: At the knee, the extensor moments were significantly lower on the affected side (P<0.05) and were affected by the foot position. At the hip, the moments were not significantly different between sides and were slightly modified by the foot positions. There were also strong correlations (0.70

Accuracy of administrative claims data for cerebral palsy diagnosis: a retrospective cohort study.

BACKGROUND: Cerebral palsy is the most common cause of childhood physical disability, with multiple associated comorbidities. Administrative claims data provide population-level prevalence estimates for cerebral palsy surveillance; however, their diagnostic accuracy has never been validated in Quebec. This study aimed to assess the accuracy of administrative claims data for the diagnosis of cerebral palsy. METHODS: We conducted a retrospective cohort study of children with cerebral palsy born between 1999 and 2002 within 6 health administrative regions of Quebec. Provincial cerebral palsy registry data (reference standard) and administrative physician claims were linked. We explored differences between true-positive and false-negative cases using subgroup sensitivity analysis. RESULTS: A total of 301 children were identified with confirmed cerebral palsy from the provincial registry, for an estimated prevalence of 1.8 (95% confidence interval [CI] 1.6-2.1) per 1000 children 5 years of age. The sensitivity and specificity of administrative claims data for cerebral palsy were 65.5% (95% CI 59.8%-70.8%) and 99.9% (95% CI 99.9%-99.9%), respectively, yielding a prevalence of 2.0 (95% CI 1.9-2.3) per 1000 children 5 years of age. The positive and negative predictive values were 58.8% (95% CI 53.3%-64.1%) and 99.9% (95% CI 99.9%-99.9%), respectively. The κ value was 0.62 (95% CI 0.57-0.67). Administrative claims data were more sensitive for children from rural regions, born preterm, with spastic quadriparesis and with higher levels of motor impairment. INTERPRETATION: Administrative claims data do not capture the full spectrum of children with cerebral palsy. This suggests the need for a more sensitive case definition and caution when using such data without validation.

The effect of foot position and chair height on the asymmetry of vertical forces during sit-to-stand and stand-to-sit tasks in individuals with hemiparesis.

BACKGROUND: The asymmetrical motor pattern of persons with hemiparesis influences the performance of activities that require interactions between the two sides of the body. METHODS: Twelve subjects with a chronic hemiparesis were asked to stand up and sit down at their natural speed in the following foot positions: (1) spontaneous; (2) symmetrical; (3) asymmetrical with the affected foot placed backward; and (4) asymmetrical with the unaffected foot placed backward. Forces were recorded under each foot using two force plates and under each thigh with an instrumented chair. Each foot position was tested at two chair heights corresponding to 100% and 120% of leg length. For each condition, the duration and the asymmetry of loading expressed by the vertical forces were calculated for four different events: onset, transition (forces under feet and thighs), seat-off or seat-on and at the end of the task. FINDINGS: The time to execute the tasks ranged from 2.31 s to 3.69 s with higher values observed for the stand-to-sit task than for the sit-to-stand task. Overall, the asymmetry of vertical forces was greatest in the middle part of the tasks and was not influenced by the chair height. When the subjects were still in contact with the seat, the loading asymmetry originated from a difference between sides at both the thigh and the foot. The asymmetrical foot position with the affected foot backward promoted loading on the affected side during both tasks. Interpretation. This study shows that loading asymmetry was present before seat-off and after seat-on in sit-to-stand and stand-to-sit tasks, respectively. It shows that positioning the affected foot behind reduces the asymmetry whereas positioning the unaffected foot behind increases the asymmetry. Foot position should be taken into consideration when clinicians assess or train for these mobility tasks.

A treadmill and motion coupled virtual reality system for gait training post-stroke.

A virtual reality (VR)-based locomotor training system has been developed for gait rehabilitation post-stroke. The system consists of a self-paced treadmill mounted onto a 6-degrees-of-freedom motion platform. Virtual environments (VEs) that are synchronized with the speed of the treadmill and the motions of the platform are rear-projected onto a screen in front of the walking subject. A feasibility study was conducted to test the capability of two stroke patients and one healthy control to be trained with the system. Three VE scenarios (corridor walking, street crossing, and park stroll) were woven into a gait-training program that provided three levels of complexity (walking speed, slopes, collision avoidances), progression criteria (number of successful trials) and knowledge of results. Results show that, with practice, patients can effectively increase their gait speed as demanded by the task and adapt their gait with respect to the change in physical terrain. However, successful completion of tasks requiring adaptation to increasing demands related to speed and physical terrains does not necessarily predict the patient's ability to anticipate and avoid collision with obstacles during walking. This feasibility study demonstrates that persons with stroke are able to adapt to this novel VR system and be immersed in the VEs for gait training.