Access, Readiness and Willingness to Engage in Allied Health Telerehabilitation Services for Adults: Does Cultural and Linguistic Diversity Make a Difference?

Telerehabilitation is an appealing service delivery option for optimising recovery. Internationally, the equity of telerehabilitation services for people from culturally and linguistically diverse (CALD) backgrounds has been questioned. Using a 31-item survey, our study explored the access, readiness and willingness of 260 patients receiving allied health services from a large tertiary health service located in Sydney, Australia, to use telerehabilitation for adults. Overall, 72% patients reported having access to technology, 38% met our readiness criteria and 53% reported willingness to engage in telerehabilitation. There were no differences in access, readiness and willingness to engage in telerehabilitation between patients from CALD and non-CALD backgrounds. Age was the only factor that influenced access (OR = 0.94, 95% CI 0.90 to 0.97), readiness (OR = 0.95, 95% CI 0.92 to 0.98) and willingness (OR = 0.97, 95% CI 0.95 to 1.00) to engage in telerehabilitation. Past experience of telerehabilitation was related to willingness (OR = 2.73, 95% CI 1.55-4.79) but not access (OR = 1.79, 95% CI 0.87 to 3.68) or readiness (OR = 1.90, 95% CI 0.93 to 3.87). Our findings highlight the importance of ensuring positive patient experiences to promote ongoing willingness to use telerehabilitation. Efforts are needed to improve patients' digital health literacy, especially patients from older age groups, to ensure equitable engagement in telerehabilitation services.

Increased ankle muscle coactivation in the early stages of multiple sclerosis.

BACKGROUND: Neural damage at early stages of multiple sclerosis (MS) can subtly affect gait muscle activation patterns. Detecting these changes using current clinical tools, however, is not possible. We propose using muscle coactivation measures to detect these subtle gait changes. This may also help in identifying people with MS (PwMS) that may benefit from strategies aimed at preventing further mobility impairments. OBJECTIVE: We aimed to determine if coactivation of ankle muscles during gait is greater in PwMS with Expanded Disability Status Scale (EDSS) score <3.5. A secondary aim is to determine whether coactivation increases are speed dependent. METHODS: For this study 30 PwMS and 15 healthy controls (HC) walked on a treadmill at 1.0 m/s, 1.2 m/s and 1.4 m/s. Electromyography was recorded from the tibialis anterior (TA), soleus (SO) and lateral gastrocnemius (LG). The coactivation index was calculated between SO/TA and LG/TA. Ankle kinematics data were also collected. RESULTS: Compared with HC, PwMS exhibited significantly greater SO/TA and LG/TA coactivation, which was greater during early stance and swing phases (p < .01). Speed did not affect coactivation except during early stance. Ankle kinematic changes were also observed. CONCLUSION: PwMS exhibited greater ankle muscles coactivation than controls regardless of the speed of walking. These changes in muscle activation may serve as a biomarker of neurodegeneration occurring at early stages of the disease.

A novel neuromodulation technique for the rehabilitation of balance and gait: A case study.

Cranial-nerve non-invasive neuromodulation (CN-NINM) through the tongue has been proposed as an adjuvant intervention to improve efficacy of rehabilitation. However, CN-NINM effects have only been explored in multiple sclerosis and stroke populations. In this report we used CN-NINM during a 2-week (2 × 1.5 h sessions daily) physiotherapy program for the rehabilitation of a 57 y/o woman presenting with balance and gait impairments after a surgical resection of a fourth ventricular ependymoma. Clinical and instrumented balance and gait assessments showed improved performance in all tests and without adverse effects This study shows the beneficial effects and feasibility of combined physiotherapy and CN-NINM in this patient.

The combined effect of cranial-nerve non-invasive neuromodulation with high-intensity physiotherapy on gait and balance in a patient with cerebellar degeneration: a case report.

BACKGROUND: Cranial-nerve non-invasive neuromodulation (CN-NINM) using the portable neuromodulation stimulator (PoNS™) device has been proposed as a novel adjuvant intervention to improve efficacy of gait and balance. This device modulates input and output signals during motor tasks which prompts neuroplastic changes. In this study, we investigated the efficacy of physiotherapy using the PoNS™ in a case with cerebellar degeneration. CASE PRESENTATION: The PoNS™ was used during a high-intensity physiotherapy programme delivered over 2 weeks (2 × 1.5 h sessions daily). Clinical and instrumented gait and balance tests were applied pre- and post-intervention. RESULTS: The patient improved in all tests without any adverse effects. CONCLUSION: This study showed the efficacy and feasibility of combined high-intensity physiotherapy and CN-NINM for gait and balance rehabilitation. Further studies should explore CN-NINM effects in larger and more diverse samples of neurological patients.

The Effects of Sex Hormonal Fluctuations during Menstrual Cycle on Cortical Excitability and Manual Dexterity (a Pilot Study).

AIM: To investigate whether hormonal fluctuations during the menstrual cycle affect corticospinal excitability, intracortical inhibition (ICI) or facilitation (ICF) in primary motor cortex, and also whether the hormonal fluctuations have any effect on manual dexterity in neurologically intact women. MATERIALS AND METHODS: Twenty volunteers (10 Female, 10 Male) were included in this study. The levels of progesterone and estradiol were measured from saliva during the women's menstrual follicular, ovulation and mid-luteal phases. Motor evoked potentials were recorded from the right first dorsal interosseous muscle. Single and paired-pulse Transcranial Magnetic Stimulation (TMS) were delivered in a block of 20 stimuli. With paired-pulse technique, 3ms and 10ms inter-stimulus intervals were used to assess ICI and ICF, respectively. The Grooved Pegboard Test (GPT) was completed in each session before the TMS assessments. Male participants were tested at similar time intervals as female participants. RESULTS: Mixed design ANOVA revealed that GPT score in female participants was significantly lower at the mid-luteal phase compared to the ovulation phase (p = 0.017). However, it was not correlated with progesterone or estrogen fluctuations during the menstrual cycle. The results also showed that the effect of phase, sex and the interaction of phase by sex for resting motor threshold, ICI or ICF were not significant (p > 0.05). CONCLUSION: Manual dexterity performance fluctuates during the menstrual cycle in neurologically intact women, which might be due to the balance of the neuromodulatory effects of P4 and E2 in the motor cortex during different phases.

Anodal Transcranial Pulsed Current Stimulation: The Effects of Pulse Duration on Corticospinal Excitability.

The aim is to investigate the effects of pulse duration (PD) on the modulatory effects of transcranial pulsed current (tPCS) on corticospinal excitability (CSE). CSE of the dominant primary motor cortex (M1) of right first dorsal interosseous muscle was assessed by motor evoked potentials, before, immediately, 10, 20 and 30 minutes after application of five experimental conditions: 1) anodal transcranial direct current stimulation (a-tDCS), 2) a-tPCS with 125 ms pulse duartion (a-tPCSPD = 125), 3) a-tPCS with 250 ms pulse duration (a-tPCSPD = 250), 4) a-tPCS with 500 ms pulse duration (a-tPCSPD = 500) and 5) sham a-tPCS. The total charges were kept constant in all experimental conditions except sham condition. Post-hoc comparisons indicated that a-tPCSPD = 500 produced larger CSE compared to a-tPCSPD = 125 (P<0.0001), a-tPCSPD = 250 (P = 0.009) and a-tDCS (P = 0.008). Also, there was no significant difference between a-tPCSPD = 250 and a-tDCS on CSE changes (P>0.05). All conditions except a-tPCSPD = 125 showed a significant difference to the sham group (P<0.006). All participants tolerated the applied currents. It could be concluded that a-tPCS with a PD of 500ms induces largest CSE changes, however further studies are required to identify optimal values.

Anodal transcranial pulsed current stimulation: A novel technique to enhance corticospinal excitability.

OBJECTIVE: We aimed to compare the effects of anodal-transcranial pulsed current stimulation (a-tPCS) with conventional anodal transcranial direct current stimulation (a-tDCS) on corticospinal excitability (CSE) in healthy individuals. METHODS: CSE of the dominant primary motor cortex of the resting right extensor carpi radialis muscle was assessed before, immediately, 10, 20 and 30min after application of four experimental conditions: (1) a-tDCS, (2) a-tPCS with short inter-pulse interval (a-tPCSSIPI, 50ms), (3) a-tPCS with long inter-pulse interval (a-tPCSLIPI., 650ms) and (4) sham a-tPCS. The total charges were kept constant in all experimental conditions except sham condition. The outcome measure in this study was motor evoked potentials. RESULTS: Only a-tDCS and a-tPCSSIPI (P<0.05) induced significant increases in CSE, lasted for at least 30min. Post-hoc tests indicated that this increase was larger in a-tPCSSIPI (P<0.05). There were no significant changes following application of a-tPCSLIPI and sham a-tPCS. All participants tolerated the applied currents in all experimental conditions very well. CONCLUSIONS: Compared to a-tDCS, a-tPCSSIPI is a better technique for enhancement of CSE. There were no sham effects for application of a-tPCS. However, unlike a-tDCS which modifies neuronal excitability by tonic depolarization of the resting membrane potential, a-tPCS modifies neuronal excitability by a combination of tonic and phasic effects. SIGNIFICANCE: a-tPCS could be considered as a promising neuromodulatory tool in basic neuroscience and as a therapeutic technique in neurorehabilitation.

Differential modulation of corticospinal excitability by different current densities of anodal transcranial direct current stimulation.

BACKGROUND: Novel non-invasive brain stimulation techniques such as transcranial direct current stimulation (tDCS) have been developed in recent years. TDCS-induced corticospinal excitability changes depend on two important factors current intensity and stimulation duration. Despite clinical success with existing tDCS parameters, optimal protocols are still not entirely set. OBJECTIVE/HYPOTHESIS: The current study aimed to investigate the effects of four different anodal tDCS (a-tDCS) current densities on corticospinal excitability. METHODS: Four current intensities of 0.3, 0.7, 1.4 and 2 mA resulting in current densities (CDs) of 0.013, 0.029, 0.058 and 0.083 mA/cm(2) were applied on twelve right-handed (mean age 34.5±10.32 yrs) healthy individuals in different sessions at least 48 hours apart. a-tDCS was applied continuously for 10 minute, with constant active and reference electrode sizes of 24 and 35 cm(2) respectively. The corticospinal excitability of the extensor carpi radialis muscle (ECR) was measured before and immediately after the intervention and at 10, 20 and 30 minutes thereafter. RESULTS: Post hoc comparisons showed significant differences in corticospinal excitability changes for CDs of 0.013 mA/cm(2) and 0.029 mA/cm(2) (P = 0.003). There were no significant differences between excitability changes for the 0.013 mA/cm(2) and 0.058 mA/cm(2) (P = 0.080) or 0.013 mA/cm(2) and 0.083 mA/cm(2) (P = 0.484) conditions. CONCLUSION: This study found that a-tDCS with a current density of 0.013 mA/cm(2) induces significantly larger corticospinal excitability changes than CDs of 0.029 mA/cm(2). The implication is that might help to avoid applying unwanted amount of current to the cortical areas.

A higher number of TMS-elicited MEP from a combined hotspot improves intra- and inter-session reliability of the upper limb muscles in healthy individuals.

We aimed to determine, using transcranial magnetic stimulation (TMS), the number of elicited motor evoked potentials (MEPs) that induces the highest intra- and inter-sessions reliability for the extensor carpi radialis (ECR) and first dorsal interosseus (FDI) muscles. Twelve healthy subjects participated in this study on two separate days. Single pulse magnetic stimuli were triggered with Magstim 200(2) to obtain MEPs from the muscles of interest, with the subjects in a relaxed position. Reliability of MEP responses was investigated in three blocks of 5, 10 and 15 trials. The intra- and inter-session reliability of the MEPs' amplitudes and latencies were assessed using intraclass correlation coefficients (ICCs). Repeated measures ANOVA and paired t-tests revealed no significant time effect in the MEP amplitude and latency measurements (P>0.05). The ICCs indicated high intra-session reliability in the MEPs' amplitudes for the ECR and FDI muscles (0.77 to 0.99, 0.90 to 0.99, respectively) and latency (0.80 to 1.00, 0.75 to 0.97, respectively). The MEPs' amplitudes also had high inter-session reliability (0.84 to 0.97, 0.88 to 0.93, respectively), as did their latency (0.80 to 0.90, 0.75 to 0.97, respectively). Highest intra- and inter-session reliability was achieved for blocks of 10 and 15 trials. Our data suggest that intra- and inter-session comparisons should be performed using at least 10 MEPs in "combined hotspot" stimulation technique to ensure highest reliability.