Effect of concurrent action observation, peripheral nerve stimulation and motor imagery on dexterity in patients after stroke: a pilot study.

Research to improve and expand treatment options for motor impairment after stroke remains an important issue in rehabilitation as the reduced ability to move affected limbs is still a limiting factor in the selection of training content for stroke patients. The combination of action observation and peripheral nerve stimulation is a promising method for inducing increased excitability and plasticity in the primary motor cortex of healthy subjects. In addition, as reported in the literature, the use of action observation and motor imagery in conjunction has an advantage over the use of one or the other alone in terms of the activation of motor-related brain regions. The aim of the pilot study was thus to combine these findings into a multimodal approach and to evaluate the potential impact of the concurrent application of the three methods on dexterity in stroke patients. The paradigm developed accordingly was tested with 10 subacute patients, in whom hand dexterity, thumb-index pinch force and thumb tapping speed were measured for a baseline assessment and directly before and after the single intervention. During the 10-min session, patients were instructed to watch a repetitive thumb-index finger tapping movement displayed on a monitor and to imagine the sensations that would arise from physically performing the same motion. They were also repeatedly electrically stimulated at the wrist on the motorically more affected body side and asked to place their hand behind the monitor for the duration of the session to support integration of the displayed hand into their own body schema. The data provide a first indication of a possible immediate effect of a single application of this procedure on the dexterity in patients after stroke.

Feasibility of an Application-Based Outpatient Rehabilitation Program for Stroke Survivors: Acceptability and Preliminary Results for Patient-Reported Outcomes.

BACKGROUND: The majority of stroke survivors experience long-term impairments. Regular physical activity and other lifestyle modifications play an important role in rehabilitation. Outpatient rehabilitation using telemedicine might be suitable to improve functional ability and long-term secondary prevention. The Strokecoach Intervention Program (SIP, Strokecoach GmbH, Cologne, Germany) comprises training, coaching and monitoring with the aim of improving or at least maintaining functional independence and preventing further stroke through more targeted physical activity. The SIP is provided as blended care, which refers to the integrated and coordinated delivery of healthcare services that combines traditional in-person interactions with technology-mediated interventions, optimizing the use of both face-to-face and virtual modalities to enhance patient outcomes. OBJECTIVE: The aim of this study was to evaluate the acceptance of the SIP by the participants and its practical application, as well as to obtain initial indications of effects of the SIP on the basis of patient-related outcome measures, blood pressure measurements and recording of physical activity in parallel with the intervention. METHODS: Data from individuals with stroke participating in the SIP were analyzed retrospectively. Within the SIP, participants received an application-based training program, were instructed to measure their blood pressure daily and to wear an activity tracker (pedometer). During the intervention period of either 6 or 12 weeks, the participants were supported and motivated by a personal coach via a messenger application. The primary outcomes of the analysis were recruitment, acceptance of and satisfaction with the SIP. Secondary outcomes included functional measures, mobility and health-related quality of life. RESULTS: A total of 122 individuals with stroke could be recruited for the SIP. A total of 96 out of 122 were able to start the program (54% female, mean age 54.8 (SD = 13.1), 6.1 (SD = 6.6) years after stroke onset) and 88 completed the SIP. Participants wore the activity tracker on 66% and tracked their blood pressure on 72% of their intervention days. A further analyzed subgroup of 38 participants showed small improvements in patient-reported outcomes such as health-related quality of life (SF-36) with an increase of 12 points in the subdomain mental health, vitality (12.6) and physical functioning (9.1). However, no statistically significant improvements were found in other performance-based measures (Timed Up and Go test, gait speed). CONCLUSIONS: This study showed that a blended therapy approach for stroke survivors with mild to moderate impairments in the chronic phase is feasible and was highly accepted by participants, who benefitted from the additional coaching.

A commentary on Eaves et al. with a special focus on clinical neurorehabilitation.

We very much appreciate the theoretical foundations and considerations of AO, MI, and their combination AO + MI by Eaves et al. In their exploratory review, the authors highlight the beneficial effects of the combined use of AO and MI, with a particular focus on synchronous AO and MI. From a neurorehabilitation perspective, different processes may apply to patients, particularly after a stroke. As suggested by Eaves et al., the cognitive load might prevent the use of synchronous AO + MI and the asynchronous application of AO and MI might be indicated. Furthermore, some aspects should be considered when applying AO + MI in rehabilitation: screening for the patients' cognitive capabilities and MI ability, and a familiarisation programme for AO and MI, before starting with an AO + MI training. With their review, Eaves et al. propose a number of research questions in the field of neurorehabilitation that urgently need to be addressed: the use of asynchronous vs. synchronous AOMI, observation and imagination with or without errors, or use of different MI perspectives and modes in different learning stages. This commentary provides some additional suggestions on patients' MI ability and cognitive level, MI familiarisation and detailed reporting recommendations to transfer Eaves et al. findings into clinical practice.

The German Revised version of the Niigata PPPD Questionnaire (NPQ-R): Development with patient interviews and an expert Delphi consensus.

BACKGROUND: Persistent postural-perceptual dizziness (PPPD) is a functional disorder of the nervous system and currently one of the most common types of chronic dizziness. Currently existing questionnaires do not fully assess patients' specific symptoms of PPPD. The Japanese Niigata PPPD Questionnaire (NPQ) was recently developed following consensus-based diagnosis criteria. The aim of this study was to translate it into German, evaluate its content with the help of experts and patients and, if necessary, revise the original version to allow for a comprehensive assessment of patients' PPPD-related symptoms. METHODS: A 3-round expert Delphi survey and semi-structured patient interviews were conducted. 28 experts from Switzerland, Germany and Austria working in hospitals or outpatient centres were asked to complete a first questionnaire on various aspects of PPPD, on the translated, original NPQ and their own related experiences (Round one), a second questionnaire with statements regarding PPPD they could agree or disagree with using a 6-point Likert-scale (Round two), and a third survey to finally reach a consensus on statements to be integrated into the NPQ. In addition, eleven patients (mean age of 64.6±12.6 years; 6 females) were selected according to the criteria for the diagnosis of PPPD proposed by the Bárány Society and participated in a semi-structured interview asking for their opinion on the content of the original NPQ. All collected data were analysed using a descriptive evaluation and a qualitative content analysis based on verbatim transcripts. RESULTS: Seven new items were added to the NPQ based on expert and patient comments and ratings. Its revised version (NPQ-R) comprises 19 items divided into five subscales using a 7-point Likert-scale with two additional subscales relating to associated symptoms and symptom behaviour in PPPD. The new maximal score is 114 points compared to 72 for the NPQ. CONCLUSION: The NPQ-R is the first patient-reported outcome measurement for patients with PPPD in German. It should help to provide a comprehensive assessment of the intensity of PPPD in affected patients.

The challenge of measuring physiological parameters during motor imagery engagement in patients after a stroke.

Introduction: It is suggested that eye movement recordings could be used as an objective evaluation method of motor imagery (MI) engagement. Our investigation aimed to evaluate MI engagement in patients after stroke (PaS) compared with physical execution (PE) of a clinically relevant unilateral upper limb movement task of the patients' affected body side. Methods: In total, 21 PaS fulfilled the MI ability evaluation [Kinaesthetic and Visual Imagery Questionnaire (KVIQ-10), body rotation task (BRT), and mental chronometry task (MC)]. During the experiment, PaS moved a cup to distinct fields while wearing smart eyeglasses (SE) with electrooculography electrodes integrated into the nose pads and electrodes for conventional electrooculography (EOG). To verify MI engagement, heart rate (HR) and oxygen saturation (SpO2) were recorded, simultaneously with electroencephalography (EEG). Eye movements were recorded during MI, PE, and rest in two measurement sessions to compare the SE performance between conditions and SE's psychometric properties. Results: MI and PE correlation of SE signals varied between r = 0.12 and r = 0.76. Validity (cross-correlation with EOG signals) was calculated for MI (r = 0.53) and PE (r = 0.57). The SE showed moderate test-retest reliability (intraclass correlation coefficient) with r = 0.51 (95% CI 0.26-0.80) for MI and with r = 0.53 (95% CI 0.29 - 0.76) for PE. Event-related desynchronization and event-related synchronization changes of EEG showed a large variability. HR and SpO2 recordings showed similar values during MI and PE. The linear mixed model to examine HR and SpO2 between conditions (MI, PE, rest) revealed a significant difference in HR between rest and MI, and between rest and PE but not for SpO2. A Pearson correlation between MI ability assessments (KVIQ, BRT, MC) and physiological parameters showed no association between MI ability and HR and SpO2. Conclusion: The objective assessment of MI engagement in PaS remains challenging in clinical settings. However, HR was confirmed as a reliable parameter to assess MI engagement in PaS. Eye movements measured with the SE during MI did not resemble those during PE, which is presumably due to the demanding task. A re-evaluation with task adaptation is suggested.

Biomechanical comparison of walking with a new, wearable rehabilitation training device to Nordic walking and regular walking in people with chronic low back pain.

Physical activity, particularly walking, is commonly used for the treatment of diseases such as low back pain. In this study, the effects of walking wearing the new ToneFit Reha training belt (TFR) were compared to both Nordic walking and regular walking. The TFR is intended to intensify the effects of walking through the integration of two adjustable resistance handles. Ten patients with low back pain performed regular walking, Nordic walking, and walking with the TFR in a movement laboratory. The kinematics of the trunk, upper extremities, and lower extremities were measured, and the activity of the trunk and upper extremity muscles recorded. Data were analyzed by repeated-measures ANOVA and paired t-test. Kinematics indicated that walking with the TFR introduces instability that was mitigated by a delayed peak trunk rotation (peak at 63.3% gait cycle, vs. 52.8% in walking (p = .001) and 51.0% in NW (p = .007)). Upper extremity kinematics (constrained elbow flexion, high peak shoulder abduction) showed movement patterns that need to be considered when training over a longer period. Increased muscle activity was observed especially for upper extremity muscles, when training with TFR. Overall, walking with the TFR was found to be a suitable therapy for use in a rehabilitation setting.

ExerG: adapting an exergame training solution to the needs of older adults using focus group and expert interviews.

BACKGROUND: Exergames are playful technology-based exercise programs. They train physical and cognitive functions to preserve independence in older adults (OAs) with disabilities in daily activities and may reduce their risk of falling. This study gathered in-depth knowledge and understanding of three different user groups' experiences in and relevant needs, worries, preferences, and expectations of technology-based training, to develop an exergame training device for OAs. METHODS: We conducted a qualitative study using semi-structured focus group interviews of primary (OAs in geriatric or neurological rehabilitation) and secondary (health professionals) end users, as well as expert interviews of tertiary end users (health insurance experts or similar), exploring user perspectives on adjusting an existing exergame to OAs' needs. Voice-recorded interviews were transcribed by researchers and analyzed using thematic analysis (TA) following an inductive, data-driven, iterative approach. RESULTS: We interviewed 24 primary, 18 secondary, and 9 tertiary end users at two rehabilitation centers in Austria and Switzerland. Our TA approach identified five to six themes per user group. Themes in the primary end user group reflected aspects of safety, training goals, individuality, game environment, social interactions, and physical and technical overload. Themes in the secondary end user group comprised facets of meaningfulness, distraction through the game environment, safety, gamification elements, the availability and accessibility of the exergame. Tertiary end users' themes addressed aspects of financial reimbursement, suitable target populations, professional training for the handling of exergame devices, training goals, and concerns about the use of exergames in geriatric rehabilitation. CONCLUSIONS: In conclusion, an exergame for OAs must be safe, motivating and fully adaptable to the target group while promoting the return to or preservation of autonomy and independence in daily life. Our findings contribute to developing hard- and software extensions for the ExerG training device. Further research is needed to expand the validity of our findings to larger populations.

Feasibility and cost description of highly intensive rehabilitation involving new technologies in patients with post-acute stroke-a trial of the Swiss RehabTech Initiative.

BACKGROUND: There is a need to provide highly repetitive and intensive therapy programs for patients after stroke to improve sensorimotor impairment. The employment of technology-assisted training may facilitate access to individualized rehabilitation of high intensity. The purpose of this study was to evaluate the safety and acceptance of a high-intensity technology-assisted training for patients after stroke in the subacute or chronic phase and to establish its feasibility for a subsequent randomized controlled trial. METHODS: A longitudinal, multi-center, single-group study was conducted in four rehabilitation clinics. Patients participated in a high-intensity 4-week technology-assisted trainings consisting of 3 to 5 training days per week and at least 5 training sessions per day with a duration of 45 min each. Feasibility was evaluated by examining recruitment, intervention-related outcomes (adherence, subjectively perceived effort and effectiveness, adverse events), patient-related outcomes, and efficiency gains. Secondary outcomes focused on all three domains of the International Classification of Functioning Disability and Health. Data were analyzed and presented in a descriptive manner. RESULTS: In total, 14 patients after stroke were included. Participants exercised between 12 and 21 days and received between 28 and 82 (mean 46 ± 15) technology-assisted trainings during the study period, which corresponded to 2 to 7 daily interventions. Treatment was safe. No serious adverse events were reported. Minor adverse events were related to tiredness and exertion. From baseline to the end of the intervention, patients improved in several functional performance assessments of the upper and lower extremities. The efficiency gains of the trainings amounted to 10% to 58%, in particular for training of the whole body and for walking training in severely impaired patients. CONCLUSIONS: Highly intensive technology-assisted training appears to be feasible for in- and outpatients in the subacute or chronic phase after stroke. Further clinical trials are warranted in order to define the most comprehensive approach to highly intensive technology-assisted training and to investigate its efficacy in patients with neurological disorders. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03641651 at August 31st 2018.

Intervention Platform for Action Observation and Motor Imagery Training After Stroke: Usability Test.

Action observation (AO) and motor imagery (MI) are considered as promising therapeutic approaches in the rehabilitation of patients after a stroke (PaS). Observing and mentally rehearsing motor movements stimulate the motor system in the brain and result in a positive effect on movement execution. To support patients in the early rehabilitation phase after a stroke, ANIMATE, a digital health intervention platform was developed. The platform guides the user through 6 activities of daily living by observing and imagining the corresponding movements. We conducted a scenario-based usability test with 9 PaS at a rehabilitation centre to identify existing usability issues. PaS found the app easy to use and they could interact with it without problems. Although they judged the app as useful, they stated to be not willing to use the app on a regular basis. Including features for customising ANIMATE regarding the individual rehabilitation goals and needs of PaS, as well as personalisation could help in increasing the motivation to use and the benefits of the platform.

Influence of combined action observation and motor imagery of walking on lower limb reflex modulation in patients after stroke-preliminary results.

OBJECTIVE: The combined use of action observation and motor imagery (AOMI) is a promising technique in neurorehabilitation that can be usefully applied in addition to conventional forms of therapy. Previous studies with healthy participants showed that the mere passive observation of walking results in a phase-dependent reflex modulation in the tibialis anterior muscle that resembles the pattern occurring when walking. In patients after stroke, a similar reflex modulation was found in several lower limb muscles during the real execution of walking, but responses were blunted. To clarify whether and how lower limb reflex responses are also modulated in such patients during the combined synchronous observation and imagery of walking, medium-latency cutaneous reflexes from the tibialis anterior muscle were measured. We compared the reflex responses of seven patients after stroke during the AOMI of walking from two different conditions: (a) elicited during the end stance phase and (b) during the end swing phase, both normalized to a baseline condition. RESULTS: So far, using the identical methodological set-up as in our study with healthy individuals, we could not find any noteworthy reflex response modulation. The study was registered with the German Clinical Trials Register (DRKS00028255). TRIAL REGISTRATION: The study was registered with the German Clinical Trials Register: DRKS00028255.

Imagery ability assessments: a cross-disciplinary systematic review and quality evaluation of psychometric properties.

BACKGROUND: Over the last two centuries, researchers developed several assessments to evaluate the multidimensional construct of imagery. However, no comprehensive systematic review (SR) exists for imagery ability evaluation methods and an in-depth quality evaluation of their psychometric properties. METHODS: We performed a comprehensive systematic search in six databases in the disciplines of sport, psychology, medicine, education: SPORTDiscus, PsycINFO, Cochrane Library, Scopus, Web of Science, and ERIC. Two reviewers independently identified and screened articles for selection. COSMIN checklist was used to evaluate the methodological quality of the studies. All included assessments were evaluated for quality using criteria for good measurement properties. The evidence synthesis was summarised by using the GRADE approach. RESULTS: In total, 121 articles reporting 155 studies and describing 65 assessments were included. We categorised assessments based on their construct on: (1) motor imagery (n = 15), (2) mental imagery (n = 48) and (3) mental chronometry (n = 2). Methodological quality of studies was mainly doubtful or inadequate. The psychometric properties of most assessments were insufficient or indeterminate. The best rated assessments with sufficient psychometric properties were MIQ, MIQ-R, MIQ-3, and VMIQ-2 for evaluation of motor imagery ability. Regarding mental imagery evaluation, only SIAQ and VVIQ showed sufficient psychometric properties. CONCLUSION: Various assessments exist to evaluate an individual's imagery ability within different dimensions or modalities of imagery in different disciplines. However, the psychometric properties of most assessments are insufficient or indeterminate. Several assessments should be revised and further validated. Moreover, most studies were only evaluated with students. Further cross-disciplinary validation studies are needed including older populations with a larger age range. Our findings allow clinicians, coaches, teachers, and researchers to select a suitable imagery ability assessment for their setting and goals based on information about the focus and quality of the assessments. SYSTEMATIC REVIEWS REGISTER: PROSPERO CRD42017077004 .

Effect of Motor Imagery Training on Motor Learning in Children and Adolescents: A Systematic Review and Meta-Analysis.

Background: There is an urgent need to systematically analyze the growing body of literature on the effect of motor imagery (MI) training in children and adolescents. Methods: Seven databases and clinicaltrials.gov were searched. Two reviewers independently screened references and full texts, and extracted data (studies' methodology, MI elements, temporal parameters). Two studies were meta-analyzed providing the standard mean difference (SDM). Selected studies were evaluated with the risk of bias (RoB) and GRADE tools. Results: A total of 7238 references were retrieved. The sample size of the 22 included studies, published between 1995 and 2021, ranged from 18 to 136 participants, totaling 934 (nine to 18 years). Studies included healthy pupils, mentally retarded adolescents, children with motor coordination difficulties or with mild mental disabilities. The motor learning tasks focused on upper, lower and whole body movements. SMDs for the primary outcome of pooled studies varied between 0.83 to 1.87 (95% CI, I2, T2 varied 0.33-3.10; p = 0.001; 0-74%; 0-0.59). RoB varied between some concerns and high risk. GRADE rating was low. Conclusions: MI combined with physical practice (PP) might have a high potential for healthy and impaired children and adolescents. However, important reporting recommendations (PETTLEP, TIDieR, CONSORT) should be followed. The systematic review was registered with PROSPERO: CRD42021237361.

A different point of view: the evaluation of motor imagery perspectives in patients with sensorimotor impairments in a longitudinal study.

BACKGROUND: Motor imagery (MI) has been successfully applied in neurological rehabilitation. Little is known about the spontaneous selection of the MI perspectives in patients with sensorimotor impairments. What perspective is selected: internal (first-person view), or external (third-person view)? The aim was to evaluate the MI perspective preference in patients with sensorimotor impairments. METHODS: In a longitudinal study including four measurement sessions, 55 patients (25 stroke, 25 multiple sclerosis, 5 Parkinson's disease; 25 females; mean age 58 ± 14 years) were included. MI ability and perspective preference in both visual and kinaesthetic imagery modalities were assessed using the Kinaesthetic and Visual Imagery Questionnaire-20 (KVIQ-20), the body rotation task (BRT), and mental chronometry (MC). Additionally, patients' activity level was assessed. Descriptive analyses were performed regarding different age- (< 45, 45-64, > 64), activity levels (inactive, partially active, active), and KVIQ-20 movement classifications (axial, proximal, distal, upper and lower limb). A mixed-effects model was used to investiage the relationship between the primary outcome (MI perspective: internal, external) with the explanatory variables age, MI modality (visual, kinaesthetic), movement type (axial, proximal, distal), activity levels and the different assessments (KVIQ-20, BRT, MC). RESULTS: Imagery modality was not a significant predictor of perspective preference. Over the four measurement sessions, patients tended to become more consistent in their perspective selection, however, time point was not a significant predictor. Movement type was a significant predictor: imagination of distal vs. axial and proximal vs. axial movements were both associated with preference for external perspective. Patients with increased physical activity level tend to use internal imagery, however, this effect was borderline not statistically significant. Age was neither a significant precictor. Regarding the MI assessments, the KVIQ- 20 score was a significant predictor. The patients with higher test scores tend to use the external perspective. CONCLUSION: It is recommended to evaluate the spontaneous MI perspective selection to design patient-specific MI training interventions. Distal movements (foot, finger) may be an indicator when evaluating the consistency of the MI perspective in patients with sensorimotor impairments.

Effect of brain-computer interface training based on non-invasive electroencephalography using motor imagery on functional recovery after stroke - a systematic review and meta-analysis.

BACKGROUND: Training with brain-computer interface (BCI) technology in the rehabilitation of patients after a stroke is rapidly developing. Numerous RCT investigated the effects of BCI training (BCIT) on recovery of motor and brain function in patients after stroke. METHODS: A systematic literature search was performed in Medline, IEEE Xplore Digital Library, Cochrane library, and Embase in July 2018 and was repeated in March 2019. RCT or controlled clinical trials that included BCIT for improving motor and brain recovery in patients after a stroke were identified. Data were meta-analysed using the random-effects model. Standardized mean difference (SMD) with 95% confidence (95%CI) and 95% prediction interval (95%PI) were calculated. A meta-regression was performed to evaluate the effects of covariates on the pooled effect-size. RESULTS: In total, 14 studies, including 362 patients after ischemic and hemorrhagic stroke (cortical, subcortical, 121 females; mean age 53.0+/- 5.8; mean time since stroke onset 15.7+/- 18.2 months) were included. Main motor recovery outcome measure used was the Fugl-Meyer Assessment. Quantitative analysis showed that a BCI training compared to conventional therapy alone in patients after stroke was effective with an SMD of 0.39 (95%CI: 0.17 to 0.62; 95%PI of 0.13 to 0.66) for motor function recovery of the upper extremity. An SMD of 0.41 (95%CI: - 0.29 to 1.12) for motor function recovery of the lower extremity was found. BCI training enhanced brain function recovery with an SMD of 1.11 (95%CI: 0.64 to 1.59; 95%PI ranging from 0.33 to 1.89). Covariates such as training duration, impairment level of the upper extremity, and the combination of both did not show significant effects on the overall pooled estimate. CONCLUSION: This meta-analysis showed evidence that BCI training added to conventional therapy may enhance motor functioning of the upper extremity and brain function recovery in patients after a stroke. We recommend a standardised evaluation of motor imagery ability of included patients and the assessment of brain function recovery should consider neuropsychological aspects (attention, concentration). Further influencing factors on motor recovery due to BCI technology might consider factors such as age, lesion type and location, quality of performance of motor imagery, or neuropsychological aspects. TRIAL REGISTRATION: PROSPERO registration: CRD42018105832 .

German version of the Chedoke McMaster arm and hand activity inventory (CAHAI-G): intra-rater reliability and responsiveness.

BACKGROUND: The English version of the Chedoke Arm and Hand Activity Inventory is a validated, upper-limb measure with the purpose of assessing functional recovery of the arm and hand after a stroke. A German translation and cross-cultural adaptation was recently produced and demonstrated high validity, inter-rater reliability and internal consistency. As a follow-up, the present study evaluated the intra-rater reliability and responsiveness of the CAHAI-G for the long and all shortened versions. METHODS: The CAHAI-G and the Action Research Arm Test were assessed on three different measurement events: upon entry (ME1), two to 3 days after entry (ME2), and after three to 4 weeks (ME3). For the intra-rater reliability analysis, the ME1 CAHAI assessments were recorded on video and rated by three therapists to obtain the intraclass coefficients (ICC). The data of all three MEs were analysed in a group of stroke inpatients for the evaluation of responsiveness. To test for responsiveness, the CAHAI-G change data were compared to concurrent instruments: The Global Rating of Change-questionnaire and the Global Rating of Concept-questionnaire. Both served as external criteria. For all CAHAI-G versions (7, 8, 9 or 13 items), the same analysis procedures for the evaluation of the responsiveness parameter were performed. RESULTS: In total, 27 patients (9 females, age 63 ± 13.7) were enrolled in the study. The ICCs for the intra-rater reliability were calculated to be between 0.988 and 0.998 for all CAHAI versions. Responsiveness parameters were as follows from CAHAI-G 7 to 13: Minimal Detectable Change (MDC90) 5.3, 6.0, 6.1, 8.2; Pearson's correlation coefficients CAHAI-Gs with ARAT 0.365, 0.409*, 0.500**, 0.597**. The Area und Under the Curve and the Minimal Clinical Important Difference values for all CAHAI-G versions and the three external criteria ranged between 0.483 to 0.603 and 2.5 to 9.0, respectively. CONCLUSION: In addition to the high validity, inter-rater reliability and internal consistency, the CAHAI-G revealed high intra-rater reliability. The data also suggest an adequate responsiveness of the CAHAI-G versions 9 and 13.

Experience of an upper limb training program with a non-immersive virtual reality system in patients after stroke: a qualitative study.

OBJECTIVES: The YouGrabber (YG) is a new virtual reality training system that focuses on unilateral and bimanual activities. This nested study was part of a larger multicenter randomized controlled trial and explored experiences of people with chronic stroke during a 4 weeks intensive upper limb training with YG. DESIGN: A qualitative design using semi-structured, face-to-face interviews. A phenomenological descriptive approach was used, with data coded, categorized and summarized using a thematic analysis. Topics investigated included: the experience of YG training, perceived impact of YG training on arm function, and the role of the treating therapist. RESULTS: Five people were interviewed (one female, age range 55 to 75 years, 1 to 6 years poststroke). Seven main themes were identified: (1) general experience, (2) expectations, (3) feedback, (4) arm function, (5) physiotherapist's role, (6) fatigue, (7) motivation. Key experiences reported included feelings of motivation and satisfaction, with positive factors identified as challenge, competition, fun and effort. The YG training appeared to trigger greater effort, however fatigue was experienced at the end of the training. Overall, patients described positive changes in upper limb motor function and activity level, e.g. automatic arm use. While the opportunity for self-practice was appreciated, input from the therapist at the start of the intervention was deemed important for safety and confidence. CONCLUSIONS: Reported experiences were mostly positive and the participants were motivated to practice intensively. They enjoyed the challenging component of the games.

Efficacy of inpatient personalized multidisciplinary rehabilitation in multiple sclerosis: behavioural and functional imaging results.

BACKGROUND: Although multidisciplinary rehabilitation programs are commonly used in clinical practice for patients with multiple sclerosis (MS), they are currently underexamined. OBJECTIVE: This study aims to investigate the efficacy and underlying brain mechanisms of an inpatient multidisciplinary rehabilitation. METHODS: Twenty-four patients with relapse-onset MS underwent a 4-week personalized inpatient multidisciplinary rehabilitation and three assessment sessions including MRI, clinical, cognitive and motor function evaluation. Twenty-four healthy controls underwent two assessment sessions 4 weeks apart. Test performances were compared using repeated measures ANOVA, Tukey and t tests. A motor sequence learning (MSL) task was presented during fMRI and data were analysed using FSL. RESULTS: Patients had less perceived fatigue, improved walking speed and quality of life following the rehabilitation, which could be maintained at follow-up 4 weeks after rehabilitation. After rehabilitation, differences in accuracy of the MSL task between groups diminished, indicating an improved performance in patients. Improved accuracy went along with changes of brain activity in the left cerebellum and right frontal lobe post-rehabilitation, which could be maintained at follow-up. No changes between sessions were observed in controls. CONCLUSION: Multidisciplinary rehabilitation may improve highly impacting symptoms through more efficient recruitment of brain regions and therefore positively influence MS patients' quality of life.

EMG Muscle Activation Pattern of Four Lower Extremity Muscles during Stair Climbing, Motor Imagery, and Robot-Assisted Stepping: A Cross-Sectional Study in Healthy Individuals.

BACKGROUND: Stair climbing can be a challenging part of daily life and a limiting factor for social participation, in particular for patients after stroke. In order to promote motor relearning of stair climbing, different therapeutical measures can be applied such as motor imagery and robot-assisted stepping therapy. Both are common therapy measures and a positive influence on the rehabilitation process has been reported. However, there are contradictory results regarding the neuromuscular effect of motor imagery, and the effect of robot-assisted tilt table stepping on the EMG activation compared to stair climbing itself is not known. Thus, we investigated the EMG activity during (1) a stepping task on the robot-assisted tilt table Erigo, (2) motor imagery of stair climbing, and (3) real stair climbing in healthy individuals for a subsequent study on patients with lower limb motor impairment. The aim was to assess potential amplitude independent changes of the EMG activation as a function of the different conditions. METHODS: EMG data of four muscles of the dominant leg were recorded in m. rectus femoris, m. biceps femoris, m. tibialis anterior, and m. gastrocnemius medialis. The cross-correlation analysis was performed to measure similarity/dissimilarity of the EMG curves. RESULTS: The data of the study participants revealed high cross-correlation coefficients comparing the EMG activation modulation of stair climbing and robot-assisted tilt table stepping in three muscles except for the m. gastrocnemius medialis. As the EMG activation amplitude did not differ between motor imagery and the resting phase the according EMG data of the motor imagery condition were not subjected to a further analysis. CONCLUSION: Robot-assisted tilt table stepping, but rather not motor imagery, evokes a similar activation in certain leg muscles compared to real stair climbing.

Comparison of proprioceptive acuity of the cervical spine in healthy adults and adults with chronic non-specific low back pain: A cross-sectional study.

BACKGROUND: It has been suggested that patients with chronic non-specific low back pain (CNSLBP) perform poorly in postural tasks when compared to healthy individuals. Despite its importance in posture and alignment of the trunk in relation to the head, neck proprioception has not been examined in patients with low back pain. The purpose of this study was to compare neck proprioception in patients with CNSLBP with healthy individuals. METHODS: Cervical joint reposition error was measured five times consecutively in the neutral head position, 30° and 60° left and right head rotation. The main outcome measure was the mean cervical joint repositioning error of the head. RESULTS: Forty-six participants with (n = 24, 54 ± 16yrs SD, 14 females) and without (n = 22, 36 ± 13yrs SD, 13 females) CNSLBP were included in the study. Comparison of mean cervical joint repositioning error between patients and healthy controls showed no statistically significant group difference in any of the applied positions. The range of deviation in CNSLBP patients was between 1.57° and 3.27° compared to 1.46° to 2.26° in healthy controls. An overshooting tendency for both groups was found in the neutral head position. CONCLUSION: The ability to accurately position the head does not seem to be impaired in patients with CNSLBP. This may suggest that sensorimotor control is affected on other levels of the movement system and future research should focus on methods to identify the source of these aberrations.