Virtual reality-enhanced walking in people post-stroke: effect of optic flow speed and level of immersion on the gait biomechanics.

BACKGROUND: Optic flow-the apparent visual motion experienced while moving-is absent during treadmill walking. With virtual reality (VR), optic flow can be controlled to mediate alterations in human walking. The aim of this study was to investigate (1) the effects of fully immersive VR and optic flow speed manipulation on gait biomechanics, simulator sickness, and enjoyment in people post-stroke and healthy people, and (2) the effects of the level of immersion on optic flow speed and sense of presence. METHODS: Sixteen people post-stroke and 16 healthy controls performed two VR-enhanced treadmill walking sessions: the semi-immersive GRAIL session and fully immersive head-mounted display (HMD) session. Both consisted of five walking trials. After two habituation trials (without and with VR), participants walked three more trials under the following conditions: matched, slow, and fast optic flow. Primary outcome measures were spatiotemporal parameters and lower limb kinematics. Secondary outcomes (simulator sickness, enjoyment, and sense of presence) were assessed with the Simulator Sickness Questionnaire, Visual Analogue Scales, and Igroup Presence Questionnaire. RESULTS: When walking with the immersive HMD, the stroke group walked with a significantly slower cadence (-3.69strides/min, p = 0.006), longer stride time (+ 0.10 s, p = 0.017) and stance time for the unaffected leg (+ 1.47%, p = 0.001) and reduced swing time for the unaffected leg (- 1.47%, p = 0.001). Both groups responded to the optic flow speed manipulation such that people accelerated with a slow optic flow and decelerated with a fast optic flow. Compared to the semi-immersive GRAIL session, manipulating the optic flow speed with the fully immersive HMD had a greater effect on gait biomechanics whilst also eliciting a higher sense of presence. CONCLUSION: Adding fully immersive VR while walking on a self-paced treadmill led to a more cautious gait pattern in people post-stroke. However, walking with the HMD was well tolerated and enjoyable. People post-stroke altered their gait parameters when optic flow speed was manipulated and showed greater alterations with the fully-immersive HMD. Further work is needed to determine the most effective type of optic flow speed manipulation as well as which other principles need to be implemented to positively influence the gait pattern of people post-stroke. TRIAL REGISTRATION NUMBER: The study was pre-registered at ClinicalTrials.gov (NCT04521829).

Does robot-assisted gait rehabilitation improve balance in stroke patients? A systematic review.

The aim of this systematic review was to summarize the improvements in balance after robot-assisted gait training (RAGT) in stroke patients. Two databases were searched: PubMed and Web of Knowledge. The most important key words are "stroke," "RAGT," "balance," "Lokomat," and "gait trainer." Studies were included if stroke patients were involved in RAGT protocols, and balance was determined as an outcome measurement. The articles were checked for methodological quality by 2 reviewers (Cohen's κ = 0.72). Nine studies were included (7 true experimental and 2 pre-experimental studies; methodological quality score, 56%-81%). In total, 229 subacute or chronic stroke patients (70.5% male) were involved in RAGT (3 to 5 times per week, 3 to 10 weeks, 12 to 25 sessions). In 5 studies, the gait trainer was used; in 2, the Lokomat was used; in 1 study, a single-joint wearable knee orthosis was used; and in 1 study, the AutoAmbulator was used. Eight studies compared RAGT with other gait rehabilitation methods. Significant improvements (no to large effect sizes, Cohen's d = 0.01 to 3.01) in balance scores measured with the Berg Balance Scale, the Tinetti test, postural sway tests, and the Timed Up and Go test were found after RAGT. No significant differences in balance between the intervention and control groups were reported. RAGT can lead to improvements in balance in stroke patients; however, it is not clear whether the improvements are greater compared with those associated with other gait rehabilitation methods. Because a limited number of studies are available, more specific research (eg, randomized controlled trials with larger, specific populations) is necessary to draw stronger conclusions.

Skeletal Muscle Changes in the First Three Months of Stroke Recovery: A Systematic Review.

BACKGROUND: Rehabilitation is important in the first months after a stroke for recovery of functional ability, but it is also challenging, since distinct recovery trajectories are seen. Therefore, studying the early changes in muscle characteristics over time (e.g. muscle strength, muscle mass and muscle volume), which are known to be associated with functional abilities, may deepen our understanding of underlying recovery mechanisms of stroke survivors. OBJECTIVE: This systematic review aims to describe the longitudinal changes in skeletal muscles, including muscle strength, muscle mass and muscle volume, during the first 3 months post-stroke. METHODS: Electronic searches were conducted in Medline, Scopus and CENTRAL. Longitudinal cohort studies or controlled interventional trials that report data about patients in the first 3 months after stroke were identified. Skeletal muscle characteristics should be measured at least twice within 3 months post-stroke by objective, quantitative assessment methods (e.g. dynamometry, ultrasound, computed tomography). Effect sizes were calculated as Hedges' g using standardized mean differences. RESULTS: A total of 38 studies (1,097 subjects) were found eligible. Results revealed an mean increase on the paretic side for upper and lower limb muscle strength (small to moderate effect sizes), whereas muscle thickness decreased (moderate to large effect sizes). Similar, but smaller, effects were found on the non-paretic side. There were insufficient data available to draw conclusions about lean muscle mass and muscle cross-sectional area. No studies aimed at investigating distinct trajectories of the muscle changes. CONCLUSION: Muscle strength and thickness changes during the first 3 months after stroke in both the paretic and non-paretic side. Future studies should aim to understand "how" the stroke-induced muscle strength changes are achieved. Exploring existing data from longitudinal studies, by using cluster analyses, such as pattern recognition, could add to the current knowledge-base.

Transcranial direct-current stimulation enhances implicit motor sequence learning in persons with Parkinson's disease with mild cognitive impairment.

Implicit motor sequence learning (IMSL) is affected in Parkinson's disease (PD). Research in healthy young participants shows the potential for transcranial direct-current stimulation (tDCS) over the primary motor cortex (M1) to enhance IMSL. In PD, only null effects have been reported to date. We determined concurrent, short-term, and long-term effects of anodal tDCS over M1 on IMSL, as measured by the serial reaction time (SRT) task, in persons with PD with mild cognitive impairment (MCI). Concurrent (anodal/sham tDCS intervention during the SRT task), short-term (5 min post-intervention), and long-term (1 week post-intervention) effects on IMSL were evaluated in persons with idiopathic PD (Hoehn and Yahr stage II-III) with MCI. Results of 11 persons with PD (8 men and 3 women; mean age = 77.1 years; mean disease duration = 7.7 years) showed significant IMSL in the anodal (p = .016), but not in the sham tDCS condition (p = .937). Post-hoc analyses showed that IMSL reached statistical significance at 1 week post-intervention (p < .001). Anodal tDCS over M1 exerted beneficial effects on IMSL in persons with PD with MCI, in particular one week post-intervention. Our study is the first to report a positive effect of tDCS on IMSL in PD. Further research should include a larger, more cognitively diverse sample and additional follow-up periods.

Physiological responses and perceived exertion during robot-assisted treadmill walking in non-ambulatory stroke survivors.

PURPOSE: To examine physiological responses and perceived exertion during robot-assisted treadmill walking in non-ambulatory stroke survivors; compare these outcomes with aerobic exercise recommendations; and investigate the effect of robotic assistance. MATERIALS AND METHODS: Twelve non-ambulatory stroke survivors (67 ± 11 years-old, 84 ± 38 d post-stroke) participated. Subjects walked three times 20 min (1 session/day) in the Lokomat: once with conventional exercise parameters, once with 60% robotic assistance and once with 100% robotic assistance. Gas exchange and heart rate were monitored continuously. Perceived exertion was assessed every 3 min during walking. RESULTS: During conventional robot-assisted treadmill walking, net perceived exertion (0-14 scale) significantly increased between minute 6 (median = 2, interquartile range = 4) and 18 (median = 5, interquartile range = 4). Net physiological responses did not significantly change over time. Throughout exercise, percentage of predicted heart rate reserve was significantly below the 40% threshold (medians: 11-14%) and percentage of predicted maximum heart rate reached the 55% threshold (medians: 59-60%). Perceived exertion reached the 11-point threshold halfway. Net physiological responses and perceived exertion did not significantly differ between 60% and 100% robotic assistance. CONCLUSIONS: The assistance level that non-ambulatory stroke survivors require at their highest tolerable walking speed seems too high to sufficiently stress the cardiorespiratory system during robot-assisted treadmill walking.Implications for rehabilitationThe exercise intensity of 20-minute conventional robot-assisted treadmill walking can be low, and might be too low to challenge the cardiorespiratory system of non-ambulatory stroke survivors.Lowering the level of robotic assistance from 100% to 60% does not seem to increase the exercise intensity of 20-minute robot-assisted treadmill walking.

Muscle changes after stroke and their impact on recovery: time for a paradigm shift? Review and commentary.

In stroke rehabilitation there is a growing body of evidence that not all patients have the same potential to recover. Understanding the processes that give rise to the heterogeneous treatment responses in stroke survivors will lay foundations for any conceivable advance in future rehabilitation interventions. This review was set out to shine new light on the debate of biomarkers in stroke rehabilitation by linking fundamental insights from biogerontological sciences to neurorehabilitation sciences. In particular, skeletal muscle changes and inflammation are addressed as two potential constructs from which biomarkers for stroke rehabilitation can be derived. Understanding the interplay between these constructs as well as their relation to recovery could enhance stroke rehabilitation in the future. The rationale for the selection of these constructs is three-fold: first, recent stroke literature emphasizes the importance of identifying muscle wasting (also called stroke-induced muscle wasting) in stroke patients, a concept that is widely investigated in geriatrics but less in the stroke population. Second, insights from transdisciplinary research domains such as gerontology have shown that inflammation has severe catabolic effects on muscles, which may impede rehabilitation outcomes such as gait recovery. Last, it has been proven that (high-intensity) muscle strengthening exercises have strong anti-inflammatory effects in a non-stroke population. Therefore, an evidence-based rationale is presented for developing research on individual changes of muscle and inflammation after a stroke.

Freezing of gait in Parkinson's disease: the impact of dual-tasking and turning.

BACKGROUND: Turning is the most important trigger for freezing of gait (FOG) in Parkinson's disease (PD), and dual-tasking has been suggested to influence FOG as well. OBJECTIVE: To understand the effects of dual tasking and turning on FOG. METHODS: 14 Freezers and 14 non-freezers matched for disease severity and 14 age-matched controls were asked to turn 180° and 360° with and without a cognitive dual-task during the off-period of the medication cycle. Total number of steps, duration, cadence, freezing-frequency, and secondary-task performance were measured. RESULTS: Seven freezers froze during the protocol. Freezing occurred in 37.5% of trials during 180° turning compared to 0% during straight-line walking (X(2) = 10.44, p < 0.01). The occurrence of FOG increased during 360° when also a dual-task was added (X(2) = 4.23, p = 0.04). Freezers took significantly more steps and were slower than controls in all conditions. The presence of a dual-task increased these differences. Cadence increased significantly for freezers during 360° and 180° compared to straight-line walking. In contrast, cadence was decreased during turning in controls and non-freezers. During straight-line walking, only freezers made errors in the secondary task. Controls increased their error-rate during 180° turning, whereas freezers deteriorated their secondary task performance during 360°. CONCLUSIONS: 360° turning in combination with a dual-task is the most important trigger for freezing. During turning, non-freezers and controls decreased their cadence whereas freezers increased it, which may be related to FOG. Freezers adopted a posture second strategy in contrast to non-freezers when confronted with a dual task.

Energy consumption and cost during walking with different modalities of assistance after stroke: a systematic review and meta-analysis.

Purpose: To estimate pooled rates of gross and net energy consumption (ml/kg/min and J/kg/min) and energy cost (ml/kg/m and J/kg/m) during level surface walking with different assistance modalities post-stroke.Materials and Methods: Four databases were searched using keywords related to stroke, walking, and energy requirements. Three independent reviewers screened 3296 records and included 42 studies in quantitative analysis.Results: Pooled rates without significant important heterogeneity were identified for: gross energy consumption during unassisted overground walking at comfortable walking speed (10.55 ml/kg/min; 95% CI [9.93-11.16]), gross energy consumption during treadmill walking with rigid exoskeleton assistance (7.08 ml/kg/min; 95% CI [6.52-7.65]), gross energy cost during unassisted overground walking in patients with chronic stroke (0.24 ml/kg/m; 95% CI [0.28-0.48]), gross energy cost during unassisted treadmill walking in patients with subacute stroke (0.45 ml/kg/m; 95% CI 0.45-0.45]), and net energy cost during overground walking with assistive devices and orthoses in patients with chronic stroke (4.12 J/kg/m, 95% CI [3.55-4.69]).Conclusions: Walking, unassisted and with the use of assistive devices and lower limb orthoses, induces low- to moderate-intensity exercise as recommended by exercise guidelines for stroke survivors. Future studies should explore whether bodyweight-supported or robot-assisted walking can also reach moderate-intensity.Implications for RehabilitationTo induce sufficient cardiorespiratory stress during gait rehabilitation (i.e., moderate-intensity), therapists should train ambulatory patients with stroke without any assistance or if needed with the help of assistive devices or lower limb orthoses.For severely impaired patients who cannot walk independently, therapists could use bodyweight support systems, exoskeletons, or end-effectors to induce low-intensity aerobic exercise.

The Effect of Optic Flow Speed on Active Participation During Robot-Assisted Treadmill Walking in Healthy Adults.

This study aimed to investigate: 1) the effect of optic flow speed manipulation on active participation during robot-assisted treadmill walking (RATW), 2) the influence of the type of virtual environment, and 3) the level of motion sickness and enjoyment. Twenty-eight healthy older adults were randomized in two groups: "stimulus rich" Park group (50% male, 61± 6 year) and "stimulus poor" Hallway group (43% male, 62± 5 year). Subjects walked in the Lokomat with immersive virtual reality (VR) with a matched, slow and fast optic flow speed, each lasting 7 minutes. Active participation was measured by continuously assessing the human-machine interaction torques at the hip and knee joints and muscle activity of the Vastus Medialis and Biceps Femoris. Motion sickness and enjoyment were assessed with the Simulator Sickness Questionnaire (SSQ) and Physical Activity Enjoyment Scale (PACES) respectively. In both groups optic flow speed manipulation in both directions led to a decrease in bilateral hip interaction torques towards flexion at the end of the stance phase compared to matched speed. In the Hallway group, walking with slow optic flow elicited 32% more muscle activity of the Vastus Medialis. There were no significant differences between both groups for the SSQ and PACES. Optic flow speed manipulation appears to have only a small effect on the active participation of healthy people during RATW. The type of virtual environment did not affect their activity, motion sickness or enjoyment. However, the addition of immersive VR during RATW was well tolerated and enjoyable. Further research with patients is necessary.

Does implicit learning in non-demented Parkinson's disease depend on the level of cognitive functioning?

We investigated the influence of the level of cognitive functioning on sequence-specific learning in Parkinson's disease (PD). This was done by examining the relationship between the scales for outcomes in Parkinson's disease-cognition [SCOPA-COG, Marinus, J., Visser, M., Verwey, N. A., Verhey, F. R. J., Middelkoop, H. A. M.,Stiggelbout, A., et al. (2003). Assessment of cognition in Parkinson's disease. Neurology, 61, 1222-1228] and the serial reaction time (SRT) task [Nissen, M. J., & Bullemer, P. T. (1987). Attentional requirements for learning: Evidence from performance measures. Cognitive Psychology, 19, 1-32] in a homogeneous sample, consisting of 25 PD patients diagnosed in Stage 3 of the Hoehn and Yahr [Hoehn, M. M., & Yahr, M. D. (1967). Parkinsonism: onset, progression, and mortality. Neurology, 17, 427-442] scale. Six patients in the low scoring cognitive group, 11 patients in the average scoring and eight patients in the high scoring group, conducted a SRT task with a deterministic sequence. Sequence-specific learning was assessed by inserting a random block to determine whether the acquisition of sequence movements differed between groups. Our results indicate an association between cognitive functioning in PD patients and sequence learning. These findings emphasize the use of assessing cognition in addition to the well-known motor aspects in PD.

Virtual reality during gait training: does it improve gait function in persons with central nervous system movement disorders? A systematic review and meta-analysis.

BACKGROUND: During gait training in persons with central nervous system (CNS) movement disorders, virtual reality (VR) can offer added value by providing task-specific gait training in more interactive and motivating environments. OBJECTIVE: To summarize current evidence for the effectiveness of VR-enhanced gait training in persons with CNS movement disorders. METHODS: PubMed, Web of Science and CENTRAL were systematically searched for studies using VR during walking to improve gait outcomes (spatiotemporal, functional, kinematic and kinetic). Meta-analyses were performed to estimate pooled effects. RESULTS: Eighteen studies with in total 337 patients were included (12 studies with people post-stroke, 4 with multiple sclerosis, 1 with Parkinson's disease, 1 with traumatic brain injury). Spatiotemporal and functional parameters significantly improved in each population after the VR training. Compared to gait training without VR, differences in favor of VR were found for spatiotemporal and functional parameters only in people post-stroke. CONCLUSION: VR-enhanced gait training is an effective method to improve spatiotemporal and functional parameters in persons with CNS movement disorders. Current evidence supports that, in comparison to training without VR, for people post-stroke VR-enhanced gait training is more effective to improve gait function. Future research regarding other outcome measures and other CNS movement disorders is necessary.

How to empower patients? A systematic review and meta-analysis.

Patient empowerment, a concept focused on patient-centeredness and patients autonomy, is a well-discussed topic in health literature. However, translating theory into practice is a challenge. The purpose of this study was to assess the effectiveness of interventions on patient empowerment and to identify and compare the modalities of these interventions. For this systematic review including meta-analysis, eligibility criteria were as follows: (i) adult participants with one or more chronic somatic diseases, (ii) "patient empowerment" was explicitly measured (i.e., outcome or measuring instrument), (iii) randomized controlled designs, and (iv) written in English, French, Dutch, or German. A systematic search strategy was applied in five online databases (last search: March 29, 2017). Thirty-two studies were included in this review, of which 23 studies could be included in the meta-analysis. Overall effect estimate was significant in favor of the intervention; however, heterogeneity was high. Subgroup analyses revealed that the effect estimate was higher in studies with interventions that comprised individual sessions. The most recurrent behavioral change technique identified in our review was "knowledge", though this is not sufficient to empower. "Goal setting" and "action planning" were more likely to be applied in successful interventions. "Knowledge" could be combined with "goal setting" and "action planning" to empower. Thorough understanding of the concept of patient empowerment remains necessary. Future research should focus on somatic chronic diseases other than diabetes, a consensus definition for patient empowerment, and clinimetric properties of instruments.

Physiological Responses and Perceived Exertion During Robot-Assisted and Body Weight-Supported Gait After Stroke.

INTRODUCTION: Physiological responses are rarely considered during walking after stroke and if considered, only during a short period (3-6 minutes). The aims of this study were to examine physiological responses during 30-minute robot-assisted and body weight-supported treadmill and overground walking and compare intensities with exercise guidelines. METHODS: A total of 14 ambulatory stroke survivors (age: 61 ± 9 years; time after stroke: 2.8 ± 2.8 months) participated in 3 separate randomized walking trials. Patients walked overground, on a treadmill, and in the Lokomat (60% robotic guidance) for 30 minutes at matched speeds (2.0 ± 0.5 km/h) and matched levels of body weight support (BWS; 41% ± 16%). Breath-by-breath gas analysis, heart rate, and perceived exertion were assessed continuously. RESULTS: Net oxygen consumption, net carbon dioxide production, net heart rate, and net minute ventilation were about half as high during robot-assisted gait as during body weight-supported treadmill and overground walking ( P < .05). Net minute ventilation, net breathing frequency, and net perceived exertion significantly increased between 6 and 30 minutes (respectively, 1.8 L/min, 2 breaths/min, and 3.8 units). During Lokomat walking, exercise intensity was significantly below exercise recommendations; during body weight-supported overground and treadmill walking, minimum thresholds were reached (except for percentage of heart rate reserve during treadmill walking). CONCLUSION: In ambulatory stroke survivors, the oxygen and cardiorespiratory demand during robot-assisted gait at constant workload are considerably lower than during overground and treadmill walking at matched speeds and levels of body weight support. Future studies should examine how robotic devices can be Future studies should examine how robotic devices can be exploited to induce aerobic exercise.

What is the opinion of patients with multiple sclerosis and their healthcare professionals about lower limb orthoses? A qualitative study using focus group discussions.

OBJECTIVE: The aim of this study was to collect patients' and healthcare professionals' opinions about lower limb orthoses (LL-orthoses): 1) the positive and negative aspects; 2) the differences in wearing them according to location; and 3) their recommendations for future modifications. METHODS: Four focus group discussions were performed, with in total twenty patients with MS with a prescribed LL-orthosis and seven healthcare professionals. Audiotaped discussions were transcribed and qualitatively processed (NVivo11). RESULTS: Healthcare professionals and patients state that a LL-orthosis improves gait and reduces the risk of falling. Some negative aspects were indicated like stigmatization, difficulties to put on and off the LL-orthosis and the aesthetic aspects. Several patients mentioned that they did not get enough or no correct information about the adaptability and use of the orthoses. Opinions regarding differences in wearing according to location (e.g. in and outside the rehabilitation center) were diverse. Recommendations for future changes were e.g. more refined and firmer orthoses. CONCLUSIONS: The opinions collected are interesting for taking into account in the process of construction and delivering of LL-orthoses. Future research should focus on the opinions concerning different types of LL-orthosis in relation with the severity of the limitations of the patients.

Male and female opinions about orthotic devices of the lower limb: A multicentre, observational study in patients with central neurological movement disorders.

BACKGROUND AND OBJECTIVE: Because user-satisfaction and acceptance may partly determine the grade of compliance to an orthotic device (OD), the aim of this multicentre observational study was to inquire the reasons for acceptance and the user-satisfaction of an OD of the lower limb in male and female central neurological movement disorders (CNMD) patients. METHODS: Persons with CNMD having at least one prescribed OD of the lower limb were included. Two questionnaires were used: the MIRAD-ACCORT-II (reasons for acceptance) and a modified version of the D-QUEST 2.0 (user-satisfaction). Descriptive analyses were performed and to analyse the differences between the males' and females' answers Chi2- and Mann-Whitney U tests were used. RESULTS: Twenty-six stroke and 23 multiple sclerosis patients participated (53% males). "Comfort", "safety", "effectiveness" and "ease of use" were reported as most important aspects. 86% of the patients were (very) satisfied about their OD. Only for the aspect safety, compared to males, significant more females reported that if the OD is not safe enough they will not use it. CONCLUSION: For both, males and females, aspects related to comfort and functionality were reported as much more important than the esthetical aspects, and in general they are quite satisfied with the OD and the process of providing the OD. Orthopaedic technicians and health care providers can take these aspects into account when developing, constructing and providing OD's.

Measuring activity patterns using actigraphy in multiple sclerosis.

Multiple sclerosis (MS) is a demyelinating disease resulting in impairments in motor and mental performance and restrictions in activities. Self-report instruments are commonly used to measure activity patterns; alternatively, actigraphs can be placed on several parts of the body. The aims of this study were to evaluate the superiority and specificity of actigraph placement (wrist vs. ankle) in subjects with MS and healthy controls and explore the relationship between self-report and objective activity patterns. A total of 19 subjects with definite MS and 10 healthy volunteers wore actigraphs on the non-dominant wrist and ankle for three days while they kept a log to register performed activities every .5 h. Wrist and ankle actigraphs produced similar activity patterns during the most active hours (09:00-20:30 h) (ANOVA, timexlocation interaction: F=.901, df=23, p=.597) in individuals with MS and healthy controls (between subjects factor F=3.275, p=.083). Wrist placement of the actigraphs was better tolerated than ankle placement. Wrist actigraph data corresponded to a higher degree with self-reported activities of the upper limbs in the early afternoon, whereas ankle data seem to reflect better whole body movements in the later afternoon/early evening. Overall, actigraph data correlated moderately with self-reported activity (r=.57 for ankle and r=.59 for wrist). The regression model revealed that self-reported activities explained 44% of the variance in ankle and 50% of wrist data. Wrist and ankle actigraphs produce similar activity patterns in subjects with MS and in healthy controls; however, the placement of actigraphs on the wrist is better tolerated. Ankle actigraphs reflect general movement but underestimate upper body activity. Subjective registration of activity level partly matches with objective actigraph measurement. A combination of both objective and subjective activity registration is recommended to evaluate the physical activity pattern of subjects with MS.

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

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

The immediate effects of robot-assistance on energy consumption and cardiorespiratory load during walking compared to walking without robot-assistance: a systematic review.

PURPOSE: The integration of sufficient cardiovascular stress into robot-assisted gait (RAG) training could combine the benefits of both RAG and aerobic training. The aim was to summarize literature data on the immediate effects of RAG compared to walking without robot-assistance on metabolic-, cardiorespiratory- and fatigue-related parameters. METHODS: PubMed and Web of Science were searched for eligible articles till February 2016. Means, SDs and significance values were extracted. Effect sizes were calculated. RESULTS: Fourteen studies were included, concerning 155 participants (85 healthy subjects, 39 stroke and 31 spinal cord injury patients), 9 robots (2 end-effectors, 1 treadmill-based and 6 wearable exoskeletons), and 7 outcome parameters (mostly oxygen consumption and heart rate). Overall, metabolic and cardiorespiratory parameters were lower during RAG compared to walking without robot-assistance (moderate to large effect sizes). In healthy subjects, when no body-weight support (BWS) was provided, RAG with an end-effector device was more energy demanding than walking overground (p > .05, large effect sizes). CONCLUSIONS: Generally, results suggest that RAG is less energy-consuming and cardiorespiratory stressful than walking without robot-assistance, but results depend on factors such as robot type, walking speed, BWS and effort. Additional research is needed to draw firm conclusions. Implications for Rehabilitation Awareness of the energy consumption and cardiorespiratory load of robot-assisted gait (RAG) training is important in the rehabilitation of (neurological) patients with impaired cardiorespiratory fitness and patients who are at risk of cardiovascular diseases. On the other hand, the integration of sufficient cardiometabolic stress in RAG training could combine the effects of both RAG and aerobic training. Energy consumption and cardiorespiratory load during walking with robot-assistance seems to depend on factors such as robot type, walking speed, body-weight support or amount of effort. These parameters could be adjusted in RAG rehabilitation to make RAG more or less energy-consuming and cardiorespiratory stressful. Overall, short duration exoskeleton walking seems less energy-consuming and cardiorespiratory stressful than walking without robot-assistance. This might implicate that the exercise intensity is safe for (neurological) patients at risk of cardiovascular diseases. How this changes in extended walking time is unclear.

Influence of bouncing and assisted autogenic drainage on acid gastro-oesophageal reflux in infants.

OBJECTIVES: To determine the influence of modern airway clearance techniques using assisted autogenic drainage (AAD), whether or not combined with bouncing, on acid gastro-oesophageal reflux (GOR) in infants <1 year. METHODS: In this controlled trial with intra-subject design infants were studied using oesophageal pH monitoring over 24 h, during which they received one 15 min session of bouncing, AAD or bouncing combined with AAD (BAAD). The number of reflux episodes (RE) and the refluxindex (RI) were the outcome measures. The results obtained during (T15) and 15 min after the intervention (T30) were compared to a period of 15 min before treatment (T0). RESULTS: The results of 150 infants, evenly distributed over the three treatment groups, were analyzed. No significant differences were found in number of RE at T15 and T30 compared to T0 in the bouncing group (P = 0.42), the AAD group (P = 0.14), and the BAAD group (P = 0.91). RI was significantly lower in the AAD group at T15 compared to T0 (P < 0.01). No differences in RI were found in the bouncing group (P = 0.28), nor in the BAAD group (P = 0.81). CONCLUSION: Bouncing, AAD and BAAD do not induce, nor aggravate acid GOR in infants under the age of 1 year.

Neurological patients and their lower limb orthotics: An observational pilot study about acceptance and satisfaction.

BACKGROUND: Although an orthotic device of the lower limb improves the functionality of neurological patients, anecdotally clinical experience suggests that the compliance is rather limited. OBJECTIVES: The aim was to determine the satisfaction and acceptance of a lower limb orthotic device. STUDY DESIGN: A qualitative observational pilot study with a mix-method design. METHODS: Adult neurological patients who had a prescribed lower limb orthotic device were included. One published and clinically used questionnaire about satisfaction (D-Quest) and one ad hoc constructed questionnaire about acceptance of the orthotic device (MIRAD-ACCORT questionnaire) were used for data collection. RESULTS: In total, 33 patients participated (28 ankle-foot orthotic device, 3 knee-ankle-foot orthotic device and 2 other types). In general, they were satisfied about their orthotic device and the services. Less than one-fourth of the patients had some negative comments about the 'visual aspects' and the 'ability to hide' of their orthotic device. These, however, had a lower priority when compared with functionality, which was reported as a main advantage and is a reason for continuing the use of their orthotic device. CONCLUSION: Patients were satisfied in relation to their lower limb orthotic device. With regard to acceptance, it can be concluded that factors associated with functionality and comfort are more important than the aesthetic and psychological aspects of the orthotic device. Clinical relevance Patients were satisfied with their lower limb orthotic device. Some patients had some negative comments about the 'aesthetics aspects' and the 'ability to hide' their orthotic device. However, improvements in functionality were mostly reported as a main advantage and a reason for continuing the use of their orthotic device.