A systematic review of the determinants of implementation of a locomotor training program using a powered exoskeleton for individuals with a spinal cord injury.

BACKGROUND: Wearable powered exoskeletons represent a promising rehabilitation tool for locomotor training in various populations, including in individuals with a spinal cord injury. The lack of clear evidence on how to implement a locomotor powered exoskeleton training program raises many challenges for patients, clinicians and organizations. OBJECTIVE: To report determinants of implementation in clinical practice of an overground powered exoskeleton locomotor training program for persons with a spinal cord injury. DATA SOURCES: Medline, CINAHL, Web of Science. STUDY SELECTION: Studies were included if they documented determinants of implementation of an overground powered exoskeleton locomotor training program for individuals with spinal cord injury. DATA EXTRACTION: Eligible studies were identified by two independent reviewers. Data were extracted by one reviewer, based on constructs of the Consolidated Framework for Implementation Research, and validated by a second reviewer. RESULTS: Sixty-three articles were included. 49.4% of all determinants identified were related to the intervention characteristics, 29.6% to the individuals' characteristic and 13.5% to the inner setting. Recurrent barriers identified were the high prevalence of adverse events (e.g., skin issues, falls) and device malfunctions. Adequate training for clinicians, time and resource available, as well as discussion about patients' expectations were identified as facilitators. CONCLUSIONS: Powered exoskeleton training is a complex intervention. The limited information on the context and the implementation process domains may represent a barrier to a successful transition from knowledge to action.

Does musculoskeletal pain interfere with motor learning in a gait adaptation task? A proof-of-concept study.

BACKGROUND: Experimental pain during gait has been shown to interfere with learning a new locomotor task. However, very few studies have investigated the impact of clinical pain on motor learning due to the challenges associated with clinical populations. OBJECTIVE: The first objective of this proof-of-concept study was to determine the feasibility to obtain two groups of participants with chronic ankle pathology with or without residual pain while walking. The second objective was to evaluate the impact of clinical musculoskeletal pain on motor learning during gait. METHODS: Participants with chronic isolated ankle pathology were recruited and their personal and clinical characteristics were collected (functional performance, dorsiflexion maximal strength, range of motion). To assess motor acquisition (Day 1) and retention (Day 2), participants performed an adaptation task on two consecutive days that consisted of walking while experiencing a perturbing force applied to the ankle. The level of pain during the task was measured, and participants who reported pain were attributed to the Pain group and participants without pain to the No Pain group. Learning performance was assessed by measuring ankle kinematics (Mean plantarflexion absolute error) and learning strategy was assessed by measuring the Relative timing of error and the tibialis anterior (TA) electromyographic activity. RESULTS: Twenty-five participants took part in the experiment. Eight (32%) were excluded because they could not be included in either the Pain or No Pain group due to the intermittent pain, leaving eight participants in the Pain group and nine in the No Pain group. Both groups were similar in terms of baseline characteristics. Musculoskeletal pain had no influence on learning performance, but the learning strategy were different between the two groups. The No Pain group showed a TA activity reduction before perturbation between the days, while the Pain group did not. CONCLUSION: Some barriers were identified in studying musculoskeletal pain including the high rates of participants' exclusion, leading to a small sample size. However, we showed that it is feasible to investigate clinical pain and motor learning. From the results of this study, musculoskeletal pain has no influence on motor learning performance but influences the learning strategy.

Do nociceptive stimulation intensity and temporal predictability influence pain-induced corticospinal excitability modulation?

Temporal predictability and intensity of an impending nociceptive input both shape pain experience and modulate laser-evoked potentials (LEPs) amplitude. However, it remains unclear whether and how these two factors could influence pain-induced corticospinal excitability modulation. The current study investigated the influence of nociceptive stimulation intensity and temporal predictability on motor-evoked potentials (MEPs) modulation, in parallel to their effect on pain perception and LEPs amplitude. Twenty participants completed electroencephalographic and transcranial magnetic stimulation experiments during which two laser nociceptive stimulation intensities (high and low) were either unpredictably delivered (random delay) or preceded by a fixed-timing cue (fixed delay). The amplitude of the conditioned MEPs was significantly reduced only for the high nociceptive stimulation and was not affected by the temporal predictability of pain (despite the fact that temporal predictability modulated the amplitude of P2 LEP component amplitude). However, a posteriori analyses based on patterns of pain-induced MEPs modulation revealed that participants in which nociceptive stimulation resulted in an increase in corticospinal excitability were more affected by the predictability of pain (i.e. increasing corticospinal excitability even more when pain occurrence was predictable), regardless of the nociceptive stimulation intensity; whereas participants in which nociceptive stimulation resulted in a decrease in corticospinal excitability were sensitive to the intensity of the stimulation but not its predictability. These results suggest a potential influence of cognitive factors such as temporal predictability on the response of the motor system in the presence of pain for some participants, contributing to explain, at least in part, the high variability highlighted in a number of previous studies.

Ancestral persistence of vestibulospinal reflexes in axial muscles in humans.

Most studies addressing the role of vestibulospinal reflexes in balance maintenance have mainly focused on responses in the lower limbs, while limited attention has been paid to the output in trunk and back muscles. To address this issue, we tested whether electromyographic (EMG) responses to galvanic vestibular stimulations (GVS) were modulated similarly in back and leg muscles, in situations where the leg muscle responses to GVS are known to be attenuated. Body sway and surface EMG signals were recorded in the paraspinal and limb muscles of humans (n = 19) under three complementary conditions. During treadmill locomotion, EMG responses in the lower limbs were observed only during stance, whereas responses in trunk muscles were observed during all phases of the locomotor cycle. During upright standing, a slight head contact abolished the responses in the lower limbs, while the responses remained present in back muscles. Similarly, during parabolic flight-induced microgravity, EMG responses in lower limb muscles were suppressed but remained in axial muscles despite the abolished gravitational otolithic drive. Our results suggest a differentiated control of axial and appendicular muscles when a perturbation is detected by vestibular inputs. The persistence and low modulation of axial muscle responses suggests that a hard-wired reflex is functionally efficient to maintain posture. By contrast, the ankle responses to GVS occur only in balance tasks when proprioceptive feedback is congruent. This study using GVS in microgravity is the first to present an approach delineating feedforward vestibular control in unconstrained environment.NEW & NOTEWORTHY This study addresses the extent of conservation of trunk muscle control in humans. Results show that galvanic vestibular stimulation-evoked vestibular responses in trunk muscles remain strong in conditions where leg muscle responses are downmodulated (walking, standing, microgravity). This suggests a phylogenetically conserved blueprint of sensorimotor organization, with strongly hardwired vestibulospinal inputs to axial motoneurons and a higher degree of flexibility in the later emerging limb control system.

Development and Validation of Open-Source Activity Intensity Count and Activity Intensity Classification Algorithms from Raw Acceleration Signals of Wearable Sensors.

BACKGROUND: A popular outcome in rehabilitation studies is the activity intensity count, which is typically measured from commercially available accelerometers. However, the algorithms are not openly available, which impairs long-term follow-ups and restricts the potential to adapt the algorithms for pathological populations. The objectives of this research are to design and validate open-source algorithms for activity intensity quantification and classification. METHODS: Two versions of a quantification algorithm are proposed (fixed [FB] and modifiable bandwidth [MB]) along with two versions of a classification algorithm (discrete [DM] vs. continuous methods [CM]). The results of these algorithms were compared to those of a commercial activity intensity count solution (ActiLife) with datasets from four activities (n = 24 participants). RESULTS: The FB and MB algorithms gave similar results as ActiLife (r > 0.96). The DM algorithm is similar to a ActiLife (r ≥ 0.99). The CM algorithm differs (r ≥ 0.89) but is more precise. CONCLUSION: The combination of the FB algorithm with the DM results is a solution close to that of ActiLife. However, the MB version remains valid while being more adaptable, and the CM is more precise. This paper proposes an open-source alternative for rehabilitation that is compatible with several wearable devices and not dependent on manufacturer commercial decisions.

Validity of Wearable Sensors at the Shoulder Joint: Combining Wireless Electromyography Sensors and Inertial Measurement Units to Perform Physical Workplace Assessments.

Background: Workplace adaptation is the preferred method of intervention to diminish risk factors associated with the development of work-related shoulder disorders. However, the majority of the workplace assessments performed are subjective (e.g., questionnaires). Quantitative assessments are required to support workplace adaptations. The aims of this study are to assess the concurrent validity of inertial measurement units (IMUs; MVN, Xsens) in comparison to a motion capture system (Vicon) during lifting tasks, and establish the discriminative validity of a wireless electromyography (EMG) system for the evaluation of muscle activity. Methods: Sixteen participants performed 12 simple tasks (shoulder flexion, abduction, scaption) and 16 complex lifting tasks (lifting crates of different weights at different heights). A Delsys Trigno EMG system was used to record anterior and middle deltoids' EMG activity, while the Xsens and Vicon simultaneously recorded shoulder kinematics. Results: For IMUs, correlation coefficients were high (simple task: >0.968; complex task: >0.84) and RMSEs were low (simple task: <6.72°; complex task: <11.5°). For EMG, a significant effect of weight, height and a weight x height interaction (anterior: p < 0.001; middle: p < 0.03) were observed for RMS EMG activity. Conclusions: These results suggest that wireless EMG and IMUs are valid units that can be used to measure physical demand in workplace assessments.

Validity and Reliability of Wearable Sensors for Joint Angle Estimation: A Systematic Review.

Motion capture systems are recognized as the gold standard for joint angle calculation. However, studies using these systems are restricted to laboratory settings for technical reasons, which may lead to findings that are not representative of real-life context. Recently developed commercial and home-made inertial measurement sensors (M/IMU) are potentially good alternatives to the laboratory-based systems, and recent technology improvements required a synthesis of the current evidence. The aim of this systematic review was to determine the criterion validity and reliability of M/IMU for each body joint and for tasks of different levels of complexity. Five different databases were screened (Pubmed, Cinhal, Embase, Ergonomic abstract, and Compendex). Two evaluators performed independent selection, quality assessment (consensus-based standards for the selection of health measurement instruments [COSMIN] and quality appraisal tools), and data extraction. Forty-two studies were included. Reported validity varied according to task complexity (higher validity for simple tasks) and the joint evaluated (better validity for lower limb joints). More studies on reliability are needed to make stronger conclusions, as the number of studies addressing this psychometric property was limited. M/IMU should be considered as a valid tool to assess whole body range of motion, but further studies are needed to standardize technical procedures to obtain more accurate data.

Effect of movement-related pain on behaviour and corticospinal excitability changes associated with arm movement preparation.

KEY POINTS: Experimental pain or its anticipation influence motor preparation processes as well as upcoming movement execution, but the underlying physiological mechanisms remain unknown. Our results showed that movement-related pain modulates corticospinal excitability during motor preparation. In accordance with the pain adaptation theory, corticospinal excitability was higher when the muscle has an antagonist (vs. an agonist) role for the upcoming movement associated with pain. Anticipation of movement-related pain also affects motor initiation and execution, with slower movement initiation (longer reaction times) and faster movement execution compared to movements that do not evoke pain. These results confirm the implementation of protective strategies during motor preparation known to be relevant for acute pain, but which may potentially have detrimental long-term consequences and lead to the development of chronic pain. ABSTRACT: When a movement repeatedly generates pain, we anticipate movement-related pain and establish self-protective strategies during motor preparation, but the underlying mechanisms remains poorly understood. The current study investigated the effect of movement-related pain anticipation on the modulation of behaviour and corticospinal excitability during the preparation of arm movements. Participants completed an instructed-delay reaction-time (RT) task consisting of elbow flexions and extensions instructed by visual cues. Nociceptive laser stimulations (unconditioned stimuli) were applied to the lateral epicondyle during movement execution in a specific direction (CS+) but not in the other (CS-), depending on experimental group. During motor preparation, transcranial magnetic stimulation was used to measure corticospinal excitability in the biceps brachii (BB). RT and peak end-point velocity were also measured. Neurophysiological results revealed an opposite modulation of corticospinal excitability in BB depending on whether it plays an agonist (i.e. flexion) or antagonist (i.e. extension) role for the CS+ movements (P < 0.001). Moreover, behavioural results showed that for the CS+ movements RT did not change relative to baseline, whereas the CS- movements were initiated more quickly (P = 0.023) and the CS+ flexion movements were faster relative to the CS- flexion movements (P < 0.001). This is consistent with the pain adaptation theory which proposes that in order to protect the body from further pain, agonist muscle activity is reduced and antagonist muscle activity is increased. If these strategies are initially relevant and lead to short-term pain alleviation, they may potentially have detrimental long-term consequences and lead to the development of chronic pain.

Effect of experimental muscle pain on the acquisition and retention of locomotor adaptation: different motor strategies for a similar performance.

As individuals with musculoskeletal disorders often experience motor impairments, contemporary rehabilitation relies heavily on the use of motor learning principles. However, motor impairments are often associated with pain. Although there is substantial evidence that muscle pain interferes with motor control, much less is known on its impact on motor learning. The objective of the present study was to assess the effects of muscle pain on locomotor learning. Two groups (Pain and Control) of healthy participants performed a locomotor adaptation task (robotized ankle-foot orthosis perturbing ankle movements during swing) on two consecutive days. On day 1 (acquisition), hypertonic saline was injected in the tibialis anterior (TA) muscle of the Pain group participants, while Control group participants were pain free. All participants were pain free on day 2 (retention). Changes in movement errors caused by the perturbation were assessed as an indicator of motor performance. Detailed analysis of kinematic and electromyographic data provided information about motor strategies. No between-group differences were observed on motor performance measured during the acquisition and retention phases. However, Pain group participants had a residual movement error later in the swing phase and smaller early TA activation than Control group participants, thereby suggesting a reduction in the use of anticipatory motor strategies to overcome the perturbation. Muscle pain did not interfere with global motor performance during locomotor adaptation. The different motor strategies used in the presence of muscle pain may reflect a diminished ability to anticipate the consequences of a perturbation. NEW & NOTEWORTHY This study shows that experimental muscle pain does not influence global motor performance during the acquisition or next-day retention phases of locomotor learning. This contrasts with previous results obtained with cutaneous pain, emphasizing the risk of directly extrapolating from one pain modality to another. Muscle pain affected motor strategies used when performing the task, however: it reduced the ability to use increased feedforward control to overcome the force field.

Body-foot geometries as revealed by perturbed obstacle position with different time constraints.

This study examined the geometrical relationships between the feet, pelvis and an environmental obstruction when crossing an obstacle with unexpected changes to its position. Nine healthy young adults stepped over an obstacle 19 cm high with their right leg leading. The obstacle could be static or advanced at either lead (early detection) or trail (late detection) foot contact prior to clearance to force an adaptive reorganization of body-foot geometry and foot proximity to the obstacle. Stride length, minimum foot clearance over the obstacle, and foot-obstacle horizontal proximity before and after clearance were measured along with the relative position of the pelvis to each foot at eight points (four for each foot) during approach and clearance: heel contacts before and after crossing the obstacle, maximum foot heights and foot clearances. With early obstacle movement, trail limb stride length before crossing was lengthened, but foot proximity was still far from the final obstacle position. Clearance was less affected for the trail foot as compared to the lead foot. Proximity of the lead limb following clearance was the same for both early and late perturbations and closer than for the static obstacle condition. For relative body-foot positioning, significant differences were found only in the anterior-posterior direction. Following obstacle displacement, body-foot geometry was initially adapted, but then re-established to static obstacle values with an apparent focus on a balance geometry with the forward placed foot establishing new contact. These findings support an overall balance geometry that can be temporarily adjusted and coordinated with foot proximity to the obstruction to maintain continual gait and safe clearance.

Variable impact of tizanidine on the medium latency reflex of upper and lower limbs.

Sudden limb displacement evokes a complex sequence of compensatory muscle activity. Following the short-latency reflex and preceding voluntary reactions is an epoch termed the medium-latency reflex (MLR) that could reflect spinal processing of group II muscle afferents. One way to test this possibility is oral ingestion of tizanidine, an alpha-2 adrenergic agonist that inhibits the interneurons transmitting group II signals onto spinal motor neurons. We examined whether group II afferents contribute to MLR activity throughout the major muscles that span the elbow and shoulder. MLRs of ankle muscles were also tested during walking on the same day, in the same participants as well as during sitting in a different group of subjects. In contrast to previous reports, the ingestion of tizanidine had minimal impact on MLRs of arm or leg muscles during motor actions. A significant decrease in magnitude was observed for 2/16 contrasts in arm muscles and 0/4 contrasts in leg muscles. This discrepancy with previous studies could indicate that tizanidine's efficacy is altered by subtle changes in protocol or that group II afferents do not substantially contribute to MLRs.

Effect of Cutaneous Heat Pain on Corticospinal Excitability of the Tibialis Anterior at Rest and during Submaximal Contraction.

Previous studies have shown that pain can interfere with motor control. The neural mechanisms underlying these effects remain largely unknown. At the upper limb, mounting evidence suggests that pain-induced reduction in corticospinal excitability is involved. No equivalent data is currently available at the lower limb. The present study therefore examined the effect of thermal pain on the corticospinal drive to tibialis anterior (TA) at rest and during an isometric submaximal dorsiflexion. Transcranial magnetic stimulation was used to induce motor-evoked potentials (MEPs) in the TA at rest and during contraction in the presence or absence of cutaneous heat pain induced by a thermode positioned above the TA (51°C during 1 s). With similar pain ratings between conditions (3.9/10 at rest and 3.6/10 during contraction), results indicate significant decreases in MEP amplitude during both rest (-9%) and active conditions (-13%) (main effect of pain, p = 0.02). These results therefore suggest that cutaneous heat pain can reduce corticospinal excitability in the TA muscle and that such reduction in corticospinal excitability could contribute to the interference of pain on motor control/motor learning.

Contribution of sensory feedback to plantar flexor muscle activation during push-off in adults with cerebral palsy.

Exaggerated sensory activity has been assumed to contribute to functional impairment following lesion of the central motor pathway. However, recent studies have suggested that sensory contribution to muscle activity during gait is reduced in stroke patients and children with cerebral palsy (CP). We investigated whether this also occurs in CP adults and whether daily treadmill training is accompanied by alterations in sensory contribution to muscle activity. Seventeen adults with CP and 12 uninjured individuals participated. The participants walked on a treadmill while a robotized ankle-foot orthosis applied unload perturbations at the ankle, thereby removing sensory feedback naturally activated during push-off. Reduction of electromyographic (EMG) activity in the soleus muscle caused by unloads was compared and related to kinematics and ankle joint stiffness measurements. Similar measures were obtained after 6 wk of gait training. We found that sensory contribution to soleus EMG activation was reduced in CP adults compared with uninjured adults. The lowest contribution of sensory feedback was found in participants with lowest maximal gait speed. This was related to increased ankle plantar flexor stiffness. Six weeks of gait training did not alter the contribution of sensory feedback. We conclude that exaggerated sensory activity is unlikely to contribute to impaired gait in CP adults, because sensory contribution to muscle activity during gait was reduced compared with in uninjured individuals. Increased passive stiffness around the ankle joint is likely to diminish sensory feedback during gait so that a larger part of plantar flexor muscle activity must be generated by descending motor commands.NEW & NOTEWORTHY Findings suggest that adults with cerebral palsy have less contribution of sensory feedback to ongoing soleus muscle activation during push-off than uninjured individuals. Increased passive stiffness around the ankle joint is likely to diminish sensory feedback during gait, and/or sensory feedback is less integrated with central motor commands in the activation of spinal motor neurons. Consequently, muscle activation must to a larger extent rely on descending drive, which is already decreased because of the cerebral lesion.

Error signals driving locomotor adaptation: cutaneous feedback from the foot is used to adapt movement during perturbed walking.

KEY POINTS: Sensory input from peripheral receptors are important for the regulation of walking patterns. Cutaneous input mediates muscle responses to deal with immediate external perturbations. In this study we focused on the role of cutaneous feedback in locomotor adaptation that takes place over minutes of training. We show that interfering with cutaneous feedback reduced adaptation to ankle perturbations during walking. These results help us understand the neural mechanisms underlying walking adaptation, and have clinical implications for treating walking impairments after neurological injuries. ABSTRACT: Locomotor patterns must be adapted to external forces encountered during daily activities. The contribution of different sensory inputs to detecting perturbations and adapting movements during walking is unclear. In the present study, we examined the role of cutaneous feedback in adapting walking patterns to force perturbations. Forces were applied to the ankle joint during the early swing phase using an electrohydraulic ankle-foot orthosis. Repetitive 80 Hz electrical stimulation was applied to disrupt cutaneous feedback from the superficial peroneal nerve (foot dorsum) and medial plantar nerve (foot sole) during walking (Choi et al. 2013). Sensory tests were performed to measure the cutaneous touch threshold and perceptual threshold of force perturbations. Ankle movement were measured when the subjects walked on the treadmill over three periods: baseline (1 min), adaptation (1 min) and post-adaptation (3 min). Subjects (n = 10) showed increased touch thresholds measured with Von Frey monofilaments and increased force perception thresholds with stimulation. Stimulation reduced the magnitude of walking adaptation to force perturbation. In addition, we compared the effects of interrupting cutaneous feedback using anaesthesia (n = 5) instead of repetitive nerve stimulation. Foot anaesthesia reduced ankle adaptation to external force perturbations during walking. The results of the present study suggest that cutaneous input plays a role in force perception, and may contribute to the 'error' signal involved in driving walking adaptation when there is a mismatch between expected and actual force.

Disruption of Locomotor Adaptation with Repetitive Transcranial Magnetic Stimulation Over the Motor Cortex.

Locomotor patterns are adapted on a trial-and-error basis to account for predictable dynamics. Once a walking pattern is adapted, the new calibration is stored and must be actively de-adapted. Here, we tested the hypothesis that storage of newly acquired ankle adaptation in walking is dependent on corticospinal mechanisms. Subjects were exposed to an elastic force that resisted ankle dorsiflexion during treadmill walking. Ankle movement was adapted in <30 strides, leading to after-effects on removal of the force. We used a crossover design to study the effects of repetitive transcranial magnetic stimulation (TMS) over the primary motor cortex (M1), compared with normal adaptation without TMS. In addition, we tested the effects of TMS over the primary sensory cortex (S1) and premotor cortex (PMC) during adaptation. We found that M1 TMS, but not S1 TMS and PMC TMS, reduced the size of ankle dorsiflexion after-effects. The results suggest that suprathreshold M1 TMS disrupted the initial processes underlying locomotor adaptation. These results are consistent with the hypothesis that corticospinal mechanisms underlie storage of ankle adaptation in walking.

Effects of rehabilitation approaches for runners with patellofemoral pain: protocol of a randomised clinical trial addressing specific underlying mechanisms.

BACKGROUND: Patellofemoral pain (PFP) is highly prevalent in runners, and often leads to functional limitations and cessation of running. Training errors as well as decreased lower limb strength and control during running have all been associated with PFP. While strengthening and gait retraining are commonly used by clinicians, no randomised clinical trial has compared these modalities in runners with PFP. The primary objective of this randomised clinical trial will be to compare the effects of three rehabilitation programs targeting different key factors on symptoms and functional limitations of runners with PFP. The secondary objective will be to explore the factors leading to clinical improvement. METHODS/DESIGN: We will conduct a single-blind randomised clinical trial to compare three different 8 week rehabilitation programs: Group 1 will receive education on symptoms management based on training modifications; Group 2 will receive an exercise program targeting lower limb strengthening and control in addition to the education component of Group 1; Group 3 will receive running gait retraining advice as well as the education component of Group 1. Sixty-nine runners with PFP will be recruited and will be seen by independent physiotherapists on five visits through 8 weeks. The primary outcome measure will be symptoms and functional limitations measured by the Knee Outcome Survey - Activities of Daily Living Scale questionnaire at baseline, and at the four, eight and 20 weeks follow-up. Secondary outcomes will include pain level measured using visual analog scales, and running mileage. Lower limb kinematics and kinetics during running, and isometric strength will also be evaluated at baseline and 8 weeks follow-up. The effects of rehabilitation programs on measures of symptoms and functional limitations will be assessed using a 2-way ANOVA (Groups x Time). Regression analyses will be used to identify if changes in running mechanics or strength are determinants of clinical success. DISCUSSION: Studies with a high level of evidence are needed to determine the best rehabilitation interventions for runners with PFP. This randomised clinical trial will be the first to compare programs targeting different key factors linked with PFP. Results may guide clinicians and improve their clinical outcomes when treating runners with PFP. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02352909. Registered on December 3, 2014.

Pain Induced during Both the Acquisition and Retention Phases of Locomotor Adaptation Does Not Interfere with Improvements in Motor Performance.

Cutaneous pain experienced during locomotor training was previously reported to interfere with retention assessed in pain-free conditions. To determine whether this interference reflects consolidation deficits or a difficulty to transfer motor skills acquired in the presence of pain to a pain-free context, this study evaluated the effect of pain induced during both the acquisition and retention phases of locomotor learning. Healthy participants performed a locomotor adaptation task (robotized orthosis perturbing ankle movements during swing) on two consecutive days. Capsaicin cream was applied around participants' ankle on both days for the Pain group, while the Control group was always pain-free. Changes in movement errors caused by the perturbation were measured to assess global motor performance; temporal distribution of errors and electromyographic activity were used to characterize motor strategies. Pain did not interfere with global performance during the acquisition or the retention phases but was associated with a shift in movement error center of gravity to later in the swing phase, suggesting a reduction in anticipatory strategy. Therefore, previously reported retention deficits could be explained by contextual changes between acquisition and retention tests. This difficulty in transferring skills from one context to another could be due to pain-related changes in motor strategy.

Acute Physical Exercise Affects Cognitive Functioning in Children With Cerebral Palsy.

Little is known about the effects of acute exercise on the cognitive functioning of children with cerebral palsy (CP). Selected cognitive functions were thus measured using a pediatric version of the Stroop test before and after maximal, locomotor based aerobic exercise in 16 independently ambulatory children (8 children with CP), 6-15 years old. Intense exercise had: 1) a significant, large, positive effect on reaction time (RT) for the CP group (preexercise: 892 ± 56.5 ms vs. postexercise: 798 ± 45.6 ms, p < .002, d = 1.87) with a trend for a similar but smaller response for the typically developing (TD) group (preexercise: 855 ± 56.5 ms vs. postexercise: 822 ± 45.6 ms, p < .08, d = 0.59), and 2) a significant, medium, negative effect on the interference effect for the CP group (preexercise: 4.5 ± 2.5%RT vs. postexercise: 13 ± 2.9%RT, p < .04, d = 0.77) with no significant effect for the TD group (preexercise: 7.2 ± 2.5%RT vs. postexercise: 6.9 ± 2.9%RT, p > .4, d = 0.03). Response accuracy was high in both groups pre- and postexercise (>96%). In conclusion, intense exercise impacts cognitive functioning in children with CP, both by increasing processing speed and decreasing executive function.

The Effects of Acute Intense Physical Exercise on Postural Stability in Children With Cerebral Palsy.

This study evaluated the effects of intense physical exercise on postural stability of children with cerebral palsy (CP). Center of pressure (CoP) was measured in 9 typically developing (TD) children and 8 with CP before and after a maximal aerobic shuttle-run test (SRT) using a single force plate. Anteroposterior and mediolateral sway velocities, sway area, and sway regularity were calculated from the CoP data and compared between pre- and postexercise levels and between groups. Children with CP demonstrated significantly higher pre-SRT CoP velocities than TD children in the sagittal (18.6 ± 7.6 vs. 6.75 1.78 m/s) and frontal planes (15.4 ± 5.3 vs. 8.04 ± 1.51 m/s). Post-SRT, CoP velocities significantly increased for children with CP in the sagittal plane (27.0 ± 1.2 m/s), with near-significant increases in the frontal plane (25.0 ± 1.5m/s). Similarly, children with CP evidenced larger sway areas than the TD children both pre- and postexercise. The diminished postural stability in children with CP after short but intense physical exercise may have important implications including increased risk of falls and injury.

The Effects of a Multimodal Rehabilitation Program on Symptoms and Ground-Reaction Forces in Runners With Patellofemoral Pain Syndrome.

CONTEXT: Patellofemoral pain (PFP) is one of the most frequent running-related injuries. However, few interventions taking into consideration the specificity of running have been shown to be effective in runners with PFP. OBJECTIVE: To evaluate the effects of a multimodal rehabilitation program including lower-limb-strengthening/ motor-control exercises, advice on running biomechanics, and symptoms management on symptoms, strength, and ground-reaction forces in runners with PFP. DESIGN: Pre- to post- quasi-experimental. SETTING: Gait-analysis laboratory and private physical therapy clinic. PARTICIPANTS: 21 runners with PFP (34.1 ± 6.0 y old, symptoms duration 38.1 ± 45.5 mo). INTERVENTION: An 8-wk multimodal rehabilitation program including lower-limb- and core-strengthening and motor-control exercises, as well as advice on running gait and symptoms management. MAIN OUTCOME MEASURES: The Activities of Daily Living Scale of the Knee Outcome Survey (KOS-ADLS) questionnaire and visual analog scales for usual pain (VAS-U), worst pain (VAS-W), and pain during running (VAS-R) were used to assess changes in symptoms and function. Vertical ground-reaction forces (VGRF) during running and lower-limb isometric strength were also measured. RESULTS: Statistically and clinically significant improvements (P < .001) were reported on KOS-ADLS (+17.8 pts), VAS-U (-19.2 pts), VAS-W (-28.7 pts), and VAS-R (-32.2 pts) after the intervention. No significant changes in isometric strength were observed. The instantaneous vertical loading rate was decreased after the intervention (P = .002), and this reduction was correlated with changes in KOS-ADLS scores (P = .028). CONCLUSION: This multimodal intervention was successful in reducing pain and improving function of runners with PFP. However, no significant changes in lower-limb strength were observed. It appears that changes in VGRF combined with appropriate training advice could explain the clinical outcomes.