Effectiveness of vestibular rehabilitation on postural balance in Parkinson's disease: a systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Postural balance impairment can affect the quality of life of patients with Parkinson's disease. Previous studies have described connections of the vestibular system with postural functions, suggesting a potential participation of the basal ganglia in receiving vestibular stimuli. This systematic review aims to summarize the evidence on the effectiveness of vestibular rehabilitation on postural balance in patients with Parkinson's disease. METHODS: A systematic review was conducted using the electronic databases: PubMed, Embase, Scopus and PEDro. The study selection was independently conducted by two reviewers, and disagreements were evaluated by a third reviewer. The included studies had no restrictions on publication dates or languages and the last update occurred in July 2023. RESULTS: From the 485 studies found in the searches, only 3 studies were deemed eligible for the systematic review involving a total of 130 participants. The Berg Balance Scale was described as the tool for evaluation of postural balance in all studies. The meta-analysis showed statistically significant results in favor of vestibular rehabilitation (MD = 5.35; 95% CI = 2.39, 8.31; P < 0.001), regardless of the stage of Parkinson's disease. Although the effect size was suggested as a useful functional gain, the analysis was done with caution, as it only included 3 randomized controlled trials. The risk of bias using the RoB-2 was considered as being of "some concern" in all studies. Furthermore, the quality of the evidence based on the Grading of Recommendations Assessment Development and Evaluation system, produced by pooling the included studies was considered very low. CONCLUSION: Compared to other interventions, vestibular rehabilitation has potential to assist the postural balance of patients with Parkinson's disease. However, the very low quality of the evidence demonstrates uncertainty about the impact of this clinical practice. More robust studies are needed to confirm the benefits of this therapy in patients with Parkinson's disease. This study was prospectively registered in PROSPERO: CRD42020210185.

Immersive VR for upper-extremity rehabilitation in patients with neurological disorders: a scoping review.

BACKGROUND: Neurological disorders, such as stroke and chronic pain syndromes, profoundly impact independence and quality of life, especially when affecting upper extremity (UE) function. While conventional physical therapy has shown effectiveness in providing some neural recovery in affected individuals, there remains a need for improved interventions. Virtual reality (VR) has emerged as a promising technology-based approach for neurorehabilitation to make the patient's experience more enjoyable. Among VR-based rehabilitation paradigms, those based on fully immersive systems with headsets have gained significant attention due to their potential to enhance patient's engagement. METHODS: This scoping review aims to investigate the current state of research on the use of immersive VR for UE rehabilitation in individuals with neurological diseases, highlighting benefits and limitations. We identified thirteen relevant studies through comprehensive searches in Scopus, PubMed, and IEEE Xplore databases. Eligible studies incorporated immersive VR for UE rehabilitation in patients with neurological disorders and evaluated participants' neurological and motor functions before and after the intervention using clinical assessments. RESULTS: Most of the included studies reported improvements in the participants rehabilitation outcomes, suggesting that immersive VR represents a valuable tool for UE rehabilitation in individuals with neurological disorders. In addition, immersive VR-based interventions hold the potential for personalized and intensive training within a telerehabilitation framework. However, further studies with better design are needed for true comparison with traditional therapy. Also, the potential side effects associated with VR head-mounted displays, such as dizziness and nausea, warrant careful consideration in the development and implementation of VR-based rehabilitation programs. CONCLUSION: This review provides valuable insights into the application of immersive VR in UE rehabilitation, offering the foundation for future research and clinical practice. By leveraging immersive VR's potential, researchers and rehabilitation specialists can design more tailored and patient-centric rehabilitation strategies, ultimately improving the functional outcome and enhancing the quality of life of individuals with neurological diseases.

Effectiveness of Motor Imagery in the Rehabilitation of People With Parkinson's Disease: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVE: With more research completed using Motor imagery (MI) in people with Parkinson's disease, this study gathered and synthesized evidence on the use of MI for Parkinson's disease in improving rehabilitation outcomes. METHODS: Medical Literature Analysis and Retrieval System Online, Embase, Web of Science, The Cochrane Library, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Scopus were searched from inception to May 2023. We included randomized controlled trials that examine the effects of MI on individuals with Parkinson's disease. Two reviewers selected articles and extracted study characteristics and results independently. The Physiotherapy Evidence Database scale was used to assess the methodological quality. Mean differences and 95% confidence intervals were calculated. Heterogeneity was assessed using the I2 statistic. RESULTS: Thirteen articles with 12 studies were included, involving 320 individuals with Parkinson's disease, with moderate to high methodological quality (mean = 6.62/10). Compared with the control group, 3 articles reported significant greater improvements in cognitive function, 7 reported significant greater improvement in motor function, 1 article reported significant greater improvement in quality of life, and 1 reported significant greater confidence in daily task performance. No statistically significant effects were found in the meta-analyses. Conclusion. Results of individual articles were in favor of the MI intervention. No statistically significant results were found in the meta-analyses. This might be due to the small number of studies and the heterogeneity of interventions and outcome measures used. MI may be effective in improving some rehabilitation outcomes, but meta-analytic evidence is lacking. More research with larger sample size and less heterogeneous samples, interventions, and outcome measures, is warranted. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number CRD42021230556.

Guía: Principios básicos de la neurorrehabilitación del paciente con daño cerebral adquirido. Recomendaciones de la Sociedad Española de Neurorrehabilitación / Guidelines: Basic principles of neurorehabilitation for patients with acquired brain injury. Recommendations of the Spanish Society of Neurorehabilitation

Introducción: Guía para la práctica clínica en neurorrehabilitación de personas adultas con daño cerebral adquirido de la Sociedad Española de Neurorrehabilitación. Documento basado en la revisión de guías de práctica clínica internacionales publicadas entre 2013-2020. Desarrollo: Se establecen recomendaciones según el nivel de evidencia que ofrecen los estudios revisados referentes a aspectos consensuados entre expertos dirigidos a definir la población, características específicas de la intervención o la exposición bajo investigación. Conclusiones: Deben recibir neurorrehabilitación todos aquellos pacientes que, tras un daño cerebral adquirido, hayan alcanzado una mínima estabilidad clínica. La neurorrehabilitación debe ofrecer tanto tratamiento como sea posible en términos de frecuencia, duración e intensidad (al menos 45-60 minutos de cada modalidad de terapia específica que el paciente precise). La neurorrehabilitación requiere un equipo transdisciplinar coordinado, con el conocimiento, la experiencia y las habilidades para trabajar en equipo tanto con pacientes como con sus familias. En la fase aguda, y para los casos más graves, se recomiendan programas de rehabilitación en unidades hospitalarias, procediéndose a tratamiento ambulatorio tan pronto como la situación clínica lo permita y se puedan mantener los criterios de intensidad. La duración del tratamiento debe basarse en la respuesta terapéutica y en las posibilidades de mejoría, en función del mayor grado de evidencia disponible. Al alta deben ofrecerse servicios de promoción de la salud, actividad física, apoyo y seguimiento para garantizar que se mantengan los beneficios alcanzados, detectar posibles complicaciones o valorar posibles cambios en la funcionalidad que hagan necesario el acceso a nuevos programas de tratamiento.(AU)

Introduction: We present the Spanish Society of Neurorehabilitation's guidelines for adult acquired brain injury (ABI) rehabilitation. These recommendations are based on a review of international clinical practice guidelines published between 2013 and 2020. Development: We establish recommendations based on the levels of evidence of the studies reviewed and expert consensus on population characteristics and the specific aspects of the intervention or procedure under research. Conclusions: All patients with ABI should receive neurorehabilitation therapy once they present a minimal level of clinical stability. Neurorehabilitation should offer as much treatment as possible in terms of frequency, duration, and intensity (at least 45–60 min of each specific form of therapy that is needed). Neurorehabilitation requires a coordinated, multidisciplinary team with the knowledge, experience, and skills needed to work in collaboration both with patients and with their families. Inpatient rehabilitation interventions are recommended for patients with more severe deficits and those in the acute phase, with outpatient treatment to be offered as soon as the patient's clinical situation allows it, as long as intensity criteria can be maintained. The duration of treatment should be based on treatment response and the possibilities for further improvement, according to the best available evidence. At discharge, patients should be offered health promotion, physical activity, support, and follow-up services to ensure that the benefits achieved are maintained, to detect possible complications, and to assess possible changes in functional status that may lead the patient to need other treatment programmes.(AU)

Neurorehabilitation across the Continuum: From the Neurocritical care unit to home.

Children admitted to neurocritical care units often experience new neurodevelopmental disabilities due to both their acquired neurologic injuries and deconditioning from prolonged hospitalizations. Rehabilitation for critically ill children is multifactorial and begins in the intensive care unit itself. The goals of rehabilitation include prevention of complications associated with immobilization and evolving tone, comprehensive evaluation and treatment of functional deficits, and implementation of adaptive strategies with the goal of maximizing recovery. As a child progresses along the medical continuum from the neurocritical care unit to acute care to post-hospitalization settings, their rehabilitative needs and interventions should also evolve. A child in the neurocritical care unit is likely to have sustained an acquired brain injury. Whether resulting from traumatic or non-traumatic causes, all etiologies of pediatric acquired brain injury can result in significant challenges for the child and their family. Post-intensive care syndrome-pediatrics is a clinical construct that that systematically organizes the range of physical, cognitive, psychological, and social symptoms that emerge in both a child and their family members following a critical illness. Ideally, outpatient care for this population evaluates and supports all areas of post-intensive care syndrome-pediatrics through an interdisciplinary clinical care model. Proactive and comprehensive rehabilitation across the continuum provides the opportunity to support the child and their family in all areas affected, thereby minimizing distress, maximizing function, and optimizing outcomes.

[Follow-up of cerebral palsy patients in neurological rehabilitation departments]. / Le suivi des patients cérébrolésés en service de rééducation neurologique.

Patients suffering from head trauma or hemorrhagic cardiovascular accident can be cared for in special facilities. Located near Grenoble, the Fondation santé des étudiants de France Grenoble La Tronche (ex-clinique du Grésivaudan) (38) provides post-resuscitation care for brain-damaged patients. This article presents the department, its specific features and their daily routine, as shared with us by Mélanie, Leslie and her fellow nurses in the neurological rehabilitation department.

The role of stroke-induced immunosuppression as a predictor of functional outcome in the neurorehabilitation setting.

Stroke affects the interconnection between the nervous and immune systems, leading to a down-regulation of immunity called stroke-induced immunosuppression (SII). The primary aim of this study is to investigate SII role as a predictor of functional, neurological, and motor outcomes in the neurorehabilitation setting (NRB). We conducted a prospective observational study enrolling post-acute stroke patients hospitalized for neurorehabilitation. At NRB admission (T0) and discharge (T1), we assessed presence of SII (defined by a neutrophil-to-lymphocyte ratio ≥ 5) and we evaluated functional independence (Functional Independence Measure-FIM, Barthel Index-BI), motor performances (Tinetti Score, Hauser Ambulation Index) and neurological impairment (NIHSS). We enrolled 96 patients (45.8% females, 70.6 ± 13.9 years, 88.5% ischemic stroke). At T0, 15.6% of patients (15/96) had SII. When compared to immunocompetent patients (IC), the SII group was characterized by worse baseline functional independence, motor performances and neurological disability. The same was confirmed at T1 (FIM p = 0.012, BI p = 0.007, Tinetti p = 0.034, NIHSS p = 0.001). Neurological disability demonstrated a less pronounced improvement in SII (ΔNIHSS: SII: - 2.1 ± 2.3 vs. IC: - 3.1 ± 2.5, p = 0.035). SII group presented a higher percentage of infectious complications during the neurorehabilitation period (SII 80% vs. IC 25.9%; p = 0.001). SII may represent a negative prognostic factor in the neurorehabilitation setting. SII patients were characterized by poorer functional, motor, neurological performances and higher risk of infectious complications. ClinicaTrial registration: NCT05889169.

Use of noninvasive brain stimulation and neurorehabilitation devices to enhance poststroke recovery: review of the current evidence and pitfalls.

Neurorehabilitation devices and technologies are crucial for enhancing stroke recovery. These include noninvasive brain stimulation devices that provide repetitive transcranial magnetic stimulation or transcranial direct current stimulation, which can remodulate an injured brain. Technologies such as robotics, virtual reality, and telerehabilitation are suitable add-ons or complements to physical therapy. However, the appropriate application of these devices and technologies, which target specific deficits and stages, for stroke therapy must be clarified. Accordingly, a literature review was conducted to evaluate the theoretical and practical evidence on the use of neurorehabilitation devices and technologies for stroke therapy. This narrative review provides a practical guide for the use of neurorehabilitation devices and describes the implications of use and potential integration of these devices into healthcare.

NSF DARE-Transforming modeling in neurorehabilitation: Four threads for catalyzing progress.

We present an overview of the Conference on Transformative Opportunities for Modeling in Neurorehabilitation held in March 2023. It was supported by the Disability and Rehabilitation Engineering (DARE) program from the National Science Foundation's Engineering Biology and Health Cluster. The conference brought together experts and trainees from around the world to discuss critical questions, challenges, and opportunities at the intersection of computational modeling and neurorehabilitation to understand, optimize, and improve clinical translation of neurorehabilitation. We organized the conference around four key, relevant, and promising Focus Areas for modeling: Adaptation & Plasticity, Personalization, Human-Device Interactions, and Modeling 'In-the-Wild'. We identified four common threads across the Focus Areas that, if addressed, can catalyze progress in the short, medium, and long terms. These were: (i) the need to capture and curate appropriate and useful data necessary to develop, validate, and deploy useful computational models (ii) the need to create multi-scale models that span the personalization spectrum from individuals to populations, and from cellular to behavioral levels (iii) the need for algorithms that extract as much information from available data, while requiring as little data as possible from each client (iv) the insistence on leveraging readily available sensors and data systems to push model-driven treatments from the lab, and into the clinic, home, workplace, and community. The conference archive can be found at (dare2023.usc.edu). These topics are also extended by three perspective papers prepared by trainees and junior faculty, clinician researchers, and federal funding agency representatives who attended the conference.

Management of Sleep-Disordered Breathing in a Spinal Cord Injury Rehabilitation Center: Model of Care Adaptation and Implementation.

Background: Obstructive sleep apnea (OSA) is highly prevalent and poorly managed in spinal cord injury (SCI). Alternative management models are urgently needed to improve access to care. We previously described the unique models of three SCI rehabilitation centers that independently manage uncomplicated OSA. Objectives: The primary objective was to adapt and implement a similar rehabilitation-led model of managing OSA in an SCI rehabilitation center in Australia. Secondary objectives were to identify the local barriers to implementation and develop and deliver tailored interventions to address them. Methods: A clinical advisory group comprised of rehabilitation clinicians, external respiratory clinicians, and researchers adapted and developed the care model. A theory-informed needs analysis was performed to identify local barriers to implementation. Tailored behavior change interventions were developed to address the barriers and prepare the center for implementation. Results: Pathways for ambulatory assessments and treatments were developed, which included referral for specialist respiratory management of complicated cases. Roles were allocated to the team of rehabilitation doctors, physiotherapists, and nurses. The team initially lacked sufficient knowledge, skills, and confidence to deliver the OSA care model. To address this, comprehensive education and training were provided. Diagnostic and treatment equipment were acquired. The OSA care model was implemented in July 2022. Conclusion: This is the first time a rehabilitation-led model of managing OSA has been implemented in an SCI rehabilitation center in Australia. We describe a theory-informed method of adapting the model of care, assessing the barriers, and delivering interventions to overcome them. Results of the mixed-methods evaluation will be reported separately.

Novel Wearable Device for Mindful Sensorimotor Training: Integrating Motor Decoding and Somatosensory Stimulation for Neurorehabilitation.

Sensorimotor impairment is a prevalent condition requiring effective rehabilitation strategies. This study introduces a novel wearable device for Mindful Sensorimotor Training (MiSMT) designed for sensory and motor rehabilitation. Our MiSMT device combines motor training using myoelectric pattern recognition along sensory training using two tactile displays. This device offers a comprehensive solution, integrating electromyography and haptic feedback, lacking in existing devices. The device features eight electromyography channels, a rechargeable battery, and wireless Bluetooth or Wi-Fi connectivity for seamless communication with a computer or mobile device. Its flexible material allows for adaptability to various body parts, ensuring ease of use in diverse patients. The two tactile displays, with 16 electromagnetic actuators each, provide touch and vibration sensations up to 250 Hz. In this proof-of-concept study, we show improved two-point discrimination after 5 training sessions in participants with intact limbs (p=0.047). We also demonstrated successful acquisition, processing, and decoding of myoelectric signals in offline and online evaluations. In conclusion, the MiSMT device presents a promising tool for sensorimotor rehabilitation by combining motor execution and sensory training benefits. Further studies are required to assess its effectiveness in individuals with sensorimotor impairments. Integrating mindful sensory and motor training with innovative technology can enhance rehabilitation outcomes and improve the quality of life for those with sensorimotor impairments.

Ludificación y neurorrehabilitación motora en niños y adolescentes: revisión sistemática / Gamification and neurological motor rehabilitation in children and adolescents: A systematic review

Introducción La ludificación consiste en emplear el juego en contextos no lúdicos. Su uso en la rehabilitación motora de patologías neurológicas está muy extendido, pero sobre todo en pacientes adultos. El objetivo de esta revisión fue describir el uso de la ludificación en los tratamientos de rehabilitación en niños y adolescentes con afectación neuromotora. Métodos Se realizó una revisión sistemática de ensayos clínicos en diferentes bases de datos: Medline (a través de Pubmed), Scielo, SCOPUS, Dialnet, Cinahl y PEDro de la literatura científica publicada hasta la fecha siguiendo el protocolo PRISMA. La calidad metodológica de los estudios identificados se evaluó a través de la escala PEDro. Resultados De un total de 469 estudios localizados se seleccionaron 10 ensayos clínicos que cumplieron los criterios de inclusión. Se analizaron los sistemas de ludificación utilizados como parte del tratamiento rehabilitador en distintas afecciones neuromotoras en niños y adolescentes. La parálisis cerebral fue la afección con mayor número de estudios (n = 6), seguida del trastorno del desarrollo de la coordinación (n = 3). También se estudió la alteración del equilibrio y coordinación por causa neurológica (n = 1). Conclusión El uso de la ludificación en rehabilitación aporta beneficios al tratamiento convencional de las alteraciones neuromotoras en niños y adolescentes, siendo el incremento de la motivación y de la adherencia terapéutica los que mayor consenso han alcanzado entre autores. Fuerza, equilibrio, funcionalidad y coordinación son otras variables analizadas que, si bien sugieren mejoras, necesitarían futuras investigaciones para determinar una óptima dosificación. (AU)

Introduction Gamification consists of the use of games in non-playful contexts. It is widely employed in the motor rehabilitation of neurological diseases, but mainly in adult patients. The objective of this review was to describe the use of gamification in the rehabilitation of children and adolescents with neuromotor impairment. Methods We performed a systematic review of clinical trials published to date on the MEDLINE (PubMed), Scielo, SCOPUS, Dialnet, CINAHL, and PEDro databases, following the PRISMA protocol. The methodological quality of the studies identified was assessed using the PEDro scale. Results From a total of 469 studies, 10 clinical trials met the inclusion criteria. We analysed the gamification systems used as part of the rehabilitation treatment of different neuromotor conditions in children and adolescents. Cerebral palsy was the most frequently studied condition (6 studies), followed by developmental coordination disorder (3), and neurological impairment of balance and coordination (1). Conclusion The use of gamification in rehabilitation is helpful in the conventional treatment of neuromotor disorders in children and adolescents, with increased motivation and therapeutic adherence being the benefits with the greatest consensus among authors. While strength, balance, functional status, and coordination also appear to improve, future research should aim to determine an optimal dosage. (AU)

Ludificación y neurorrehabilitación motora en niños y adolescentes: revisión sistemática / Gamification and neurological motor rehabilitation in children and adolescents: A systematic review

Introducción La ludificación consiste en emplear el juego en contextos no lúdicos. Su uso en la rehabilitación motora de patologías neurológicas está muy extendido, pero sobre todo en pacientes adultos. El objetivo de esta revisión fue describir el uso de la ludificación en los tratamientos de rehabilitación en niños y adolescentes con afectación neuromotora. Métodos Se realizó una revisión sistemática de ensayos clínicos en diferentes bases de datos: Medline (a través de Pubmed), Scielo, SCOPUS, Dialnet, Cinahl y PEDro de la literatura científica publicada hasta la fecha siguiendo el protocolo PRISMA. La calidad metodológica de los estudios identificados se evaluó a través de la escala PEDro. Resultados De un total de 469 estudios localizados se seleccionaron 10 ensayos clínicos que cumplieron los criterios de inclusión. Se analizaron los sistemas de ludificación utilizados como parte del tratamiento rehabilitador en distintas afecciones neuromotoras en niños y adolescentes. La parálisis cerebral fue la afección con mayor número de estudios (n = 6), seguida del trastorno del desarrollo de la coordinación (n = 3). También se estudió la alteración del equilibrio y coordinación por causa neurológica (n = 1). Conclusión El uso de la ludificación en rehabilitación aporta beneficios al tratamiento convencional de las alteraciones neuromotoras en niños y adolescentes, siendo el incremento de la motivación y de la adherencia terapéutica los que mayor consenso han alcanzado entre autores. Fuerza, equilibrio, funcionalidad y coordinación son otras variables analizadas que, si bien sugieren mejoras, necesitarían futuras investigaciones para determinar una óptima dosificación. (AU)

Introduction Gamification consists of the use of games in non-playful contexts. It is widely employed in the motor rehabilitation of neurological diseases, but mainly in adult patients. The objective of this review was to describe the use of gamification in the rehabilitation of children and adolescents with neuromotor impairment. Methods We performed a systematic review of clinical trials published to date on the MEDLINE (PubMed), Scielo, SCOPUS, Dialnet, CINAHL, and PEDro databases, following the PRISMA protocol. The methodological quality of the studies identified was assessed using the PEDro scale. Results From a total of 469 studies, 10 clinical trials met the inclusion criteria. We analysed the gamification systems used as part of the rehabilitation treatment of different neuromotor conditions in children and adolescents. Cerebral palsy was the most frequently studied condition (6 studies), followed by developmental coordination disorder (3), and neurological impairment of balance and coordination (1). Conclusion The use of gamification in rehabilitation is helpful in the conventional treatment of neuromotor disorders in children and adolescents, with increased motivation and therapeutic adherence being the benefits with the greatest consensus among authors. While strength, balance, functional status, and coordination also appear to improve, future research should aim to determine an optimal dosage. (AU)

NSF DARE-transforming modeling in neurorehabilitation: perspectives and opportunities from US funding agencies.

In recognition of the importance and timeliness of computational models for accelerating progress in neurorehabilitation, the U.S. National Science Foundation (NSF) and the National Institutes of Health (NIH) sponsored a conference in March 2023 at the University of Southern California that drew global participation from engineers, scientists, clinicians, and trainees. This commentary highlights promising applications of computational models to understand neurorehabilitation ("Using computational models to understand complex mechanisms in neurorehabilitation" section), improve rehabilitation care in the context of digital twin frameworks ("Using computational models to improve delivery and implementation of rehabilitation care" section), and empower future interdisciplinary workforces to deliver higher-quality clinical care using computational models ("Using computational models in neurorehabilitation requires an interdisciplinary workforce" section). The authors describe near-term gaps and opportunities, all of which encourage interdisciplinary team science. Four major opportunities were identified including (1) deciphering the relationship between engineering figures of merit-a term commonly used by engineers to objectively quantify the performance of a device, system, method, or material relative to existing state of the art-and clinical outcome measures, (2) validating computational models from engineering and patient perspectives, (3) creating and curating datasets that are made publicly accessible, and (4) developing new transdisciplinary frameworks, theories, and models that incorporate the complexities of the nervous and musculoskeletal systems. This commentary summarizes U.S. funding opportunities by two Federal agencies that support computational research in neurorehabilitation. The NSF has funding programs that support high-risk/high-reward research proposals on computational methods in neurorehabilitation informed by theory- and data-driven approaches. The NIH supports the development of new interventions and therapies for a wide range of nervous system injuries and impairments informed by the field of computational modeling. The conference materials can be found at https://dare2023.usc.edu/ .

Transforming modeling in neurorehabilitation: clinical insights for personalized rehabilitation.

Practicing clinicians in neurorehabilitation continue to lack a systematic evidence base to personalize rehabilitation therapies to individual patients and thereby maximize outcomes. Computational modeling- collecting, analyzing, and modeling neurorehabilitation data- holds great promise. A key question is how can computational modeling contribute to the evidence base for personalized rehabilitation? As representatives of the clinicians and clinician-scientists who attended the 2023 NSF DARE conference at USC, here we offer our perspectives and discussion on this topic. Our overarching thesis is that clinical insight should inform all steps of modeling, from construction to output, in neurorehabilitation and that this process requires close collaboration between researchers and the clinical community. We start with two clinical case examples focused on motor rehabilitation after stroke which provide context to the heterogeneity of neurologic injury, the complexity of post-acute neurologic care, the neuroscience of recovery, and the current state of outcome assessment in rehabilitation clinical care. Do we provide different therapies to these two different patients to maximize outcomes? Asking this question leads to a corollary: how do we build the evidence base to support the use of different therapies for individual patients? We discuss seven points critical to clinical translation of computational modeling research in neurorehabilitation- (i) clinical endpoints, (ii) hypothesis- versus data-driven models, (iii) biological processes, (iv) contextualizing outcome measures, (v) clinical collaboration for device translation, (vi) modeling in the real world and (vii) clinical touchpoints across all stages of research. We conclude with our views on key avenues for future investment (clinical-research collaboration, new educational pathways, interdisciplinary engagement) to enable maximal translational value of computational modeling research in neurorehabilitation.

NSF DARE-transforming modeling in neurorehabilitation: a patient-in-the-loop framework.

In 2023, the National Science Foundation (NSF) and the National Institute of Health (NIH) brought together engineers, scientists, and clinicians by sponsoring a conference on computational modelling in neurorehabiilitation. To facilitate multidisciplinary collaborations and improve patient care, in this perspective piece we identify where and how computational modelling can support neurorehabilitation. To address the where, we developed a patient-in-the-loop framework that uses multiple and/or continual measurements to update diagnostic and treatment model parameters, treatment type, and treatment prescription, with the goal of maximizing clinically-relevant functional outcomes. This patient-in-the-loop framework has several key features: (i) it includes diagnostic and treatment models, (ii) it is clinically-grounded with the International Classification of Functioning, Disability and Health (ICF) and patient involvement, (iii) it uses multiple or continual data measurements over time, and (iv) it is applicable to a range of neurological and neurodevelopmental conditions. To address the how, we identify state-of-the-art and highlight promising avenues of future research across the realms of sensorimotor adaptation, neuroplasticity, musculoskeletal, and sensory & pain computational modelling. We also discuss both the importance of and how to perform model validation, as well as challenges to overcome when implementing computational models within a clinical setting. The patient-in-the-loop approach offers a unifying framework to guide multidisciplinary collaboration between computational and clinical stakeholders in the field of neurorehabilitation.

Exoskeleton-Assisted Rehabilitation and Neuroplasticity in Spinal Cord Injury.

Spinal cord injury (SCI) results in neurological deficits below the level of injury, causing motor dysfunction and various severe multisystem complications. Rehabilitative training plays a crucial role in the recovery of individuals with SCI, and exoskeleton serves as an emerging and promising tool for rehabilitation, especially in promoting neuroplasticity and alleviating SCI-related complications. This article reviews the classifications and research progresses of medical exoskeletons designed for SCI patients and describes their performances in practical application separately. Meanwhile, we discuss their mechanisms for enhancing neuroplasticity and functional remodeling, as well as their palliative impacts on secondary complications. The potential trends in exoskeleton design are raised according to current progress and requirements on SCI rehabilitation.

[Factors Modulating Motor Function Changes in Stroke Patients During Inpatient Neurological Rehabilitation]. / Welche Faktoren beeinflussen die motorischen Funktionsveränderungen bei Schlaganfall-Patienten während einer neurologischen Rehabilitationsbehandlung?

PURPOSE: To identify factors that have an impact on the degree of functional improvements in stroke patients during inpatient neurological rehabilitation. METHODS: Retrospective analysis of 398 stroke patients who participated in an inpatient Phase C rehabilitation (Barthel index between 30 and 70 points). We correlated changes in 3 physiotherapeutic assessments (transfer from sitting to standing; transfer from bed to (wheel)chair; climbing stairs) and 3 occupational therapeutic assessments (eating/drinking; dressing of the upper part of the body; object manipulation) with the factors age, gender, Barthel-Index at admission, time since stroke, length of stay in inpatient rehab, number and extent of therapies and ischemic versus hemorrhagic stroke. In addition, a stepwise regression analysis was performed. RESULTS: The patient group showed significant improvements in all assessments. Length of stay in inpatient rehab and number/extent of therapies correlated with improvements of transfer from sitting to standing, transfer from bed to (wheel)chair, climbing stairs, and dressing of the upper part of the body. Number/extent of therapies also correlated with eating/drinking. Barthel-Index at admission was negatively correlated with transfer from sitting to standing, transfer from bed to (wheel)chair, and dressing of the upper part of the body. No correlation between changes of motor functions and age or gender or type of stroke (ischemic versus hemorrhagic) was found. Patients<3 months after stroke showed stronger improvements of transfer from sitting to standing, transfer from bed to (wheel)chair, climbing stairs, dressing of the upper part of the body, and object manipulation than patients>6 months after stroke. However, patients<3 months after stroke also stayed 10 days longer in inpatient rehab. The stepwise regression analysis identified the number of physiotherapies and Barthel-Index at admission as the most important factors for changes in transfer from sitting to standing and transfer from bed to (wheel)chair, number of physiotherapies and time since stroke for climbing stairs, number of occupational therapies for eating/drinking, number of occupational therapies and time since stroke for dressing the upper part of the body and number of occupational therapies and length of inpatient rehab for object manipulation. CONCLUSION: In stroke patients, a higher number of therapies is associated with greater improvements of motor functions. Age, gender and type of stroke have no relevant impact on changes of motor functions during inpatient rehabilitation.

Myoelectric interface for neurorehabilitation conditioning to reduce abnormal leg co-activation after stroke: a pilot study.

BACKGROUND: The ability to walk is an important factor in quality of life after stroke. Co-activation of hip adductors and knee extensors has been shown to correlate with gait impairment. We have shown previously that training with a myoelectric interface for neurorehabilitation (MINT) can reduce abnormal muscle co-activation in the arms of stroke survivors. METHODS: Here, we extend MINT conditioning to stroke survivors with leg impairment. The aim of this pilot study was to assess the safety and feasibility of using MINT to reduce abnormal co-activation between hip adductors and knee extensors and assess any effects on gait. Nine stroke survivors with moderate to severe gait impairment received 6 h of MINT conditioning over six sessions, either in the laboratory or at home. RESULTS: MINT participants completed a mean of 159 repetitions per session without any adverse events. Further, participants learned to isolate their muscles effectively, resulting in a mean reduction of co-activation of 70% compared to baseline. Moreover, gait speed increased by a mean of 0.15 m/s, more than the minimum clinically important difference. Knee flexion angle increased substantially, and hip circumduction decreased. CONCLUSION: MINT conditioning is safe, feasible at home, and enables reduction of co-activation in the leg. Further investigation of MINT's potential to improve leg movement and function after stroke is warranted. Abnormal co-activation of hip adductors and knee extensors may contribute to impaired gait after stroke. Trial registration This study was registered at ClinicalTrials.gov (NCT03401762, Registered 15 January 2018, https://clinicaltrials.gov/study/NCT03401762?tab=history&a=4 ).