Treadmill Training with HAL Exoskeleton-A Novel Approach for Symptomatic Therapy in Patients with Limb-Girdle Muscular Dystrophy-Preliminary Study.

Purpose: Exoskeletons have been developed for rehabilitation of patients with walking impairment due to neurological disorders. Recent studies have shown that the voluntary-driven exoskeleton HAL® (hybrid assistive limb) can improve walking functions in spinal cord injury and stroke. The aim of this study was to assess safety and effects on walking function of HAL® supported treadmill therapy in patients with limb-girdle muscular dystrophy (LGMD). Materials and Methods: Three LGMD patients received 8 weeks of treadmill training with HAL® 3 times a week. Outcome parameters were 10-meter walk test (10 MWT), 6-minute walk test, and timed-up-and-go test (TUG). Parameters were assessed pre and post training and 6 weeks later (follow-up). Results: All patients completed the therapy without adverse reactions and reported about improvement in endurance. Improvements in outcome parameters after 8 weeks could be demonstrated. Persisting effects were observed after 6 weeks for the 10 MWT and TUG test (follow-up). Conclusions: HAL® treadmill training in LGMD patients can be performed safely and enables an intensive highly repetitive locomotor training. All patients benefitted from this innovative method. Upcoming controlled studies with larger cohorts should prove its effects in different types of LGMD and other myopathies.

Quantitative assessment of joint position sense recovery in subacute stroke patients: a pilot study.

OBJECTIVE: To assess joint position sense performance in subacute stroke patients using a novel quantitative assessment. DESIGN: Proof-of-principle pilot study with a group of subacute stroke patients. Assessment at baseline and after 2 weeks of intervention. Additional data for a healthy age-matched control group. SUBJECTS/PATIENTS: Ten subacute stroke patients (aged 65.41 years (standard deviation 2.5), 4 females, 2.3 weeks (standard deviation 0.2)) post-stroke receiving in-patient standard rehabilitation and repetitive electrical stimulation of the affected hand. METHODS: Joint position sense was assessed based on the ability of correctly perceiving the opening angles of the finger joints. Patients had to report size differences of polystyrene balls of various sizes, whilst the balls were enclosed simultaneously by the affected and the non-affected hands. A total of 21 pairwise size comparisons was used to quantify joint position performance. RESULTS: After 2 weeks of therapeutic intervention a significant improvement in joint position sense performance was observed; however, the performance level was still below that of a healthy control group. CONCLUSIONS: The results indicate high feasibility and sensitivity of the joint position test in subacute stroke patients. Testing allowed quantification of both the deficit and the rehabilitation outcome.

Age-related changes in the joint position sense of the human hand.

Age-related changes in lower limb joint position sense and their contributions to postural stability are well documented. In contrast, only a few studies have investigated the effect of age on proprioceptive hand function. Here, we introduce a novel test for measuring joint position sense in the fingers of the human hand. In a concurrent matching task, subjects had to detect volume differences between polystyrene balls grasped with their dominant (seven test stimuli: 126-505 cm(3)) and their nondominant hand (three reference stimuli: 210, 294, and 505 cm(3)). A total of 21 comparisons were performed to assess the number of errors, the weight of errors (ie, the volume difference between test and reference stimuli), and the direction of errors (ie, over- or underestimation of test stimulus). The test was applied to 45 healthy subjects aged 21 to 79 years. Our results revealed that all variables changed significantly with age, with the number of errors showing the strongest increase. We also assessed tactile acuity (two-point discrimination thresholds) and sensorimotor performance (pegboard performance) in a subset of subjects, but these scores did not correlate with joint position sense performance, indicating that the test reveals specific information about joint position sense that is not captured with pure sensory or motor tests. The average test-retest reliability assessed on 3 consecutive days was 0.8 (Cronbach's alpha). Our results demonstrate that this novel test reveals age-related decline in joint position sense acuity that is independent from sensorimotor performance.

Increased excitability of somatosensory cortex in aged humans is associated with impaired tactile acuity.

Aging affects all levels of neural processing, including changes of intracortical inhibition and cortical excitability. Paired-pulse stimulation, the application of two stimuli in close succession, is a useful tool to investigate cortical excitability in humans. The paired-pulse behavior is characterized by the second response being significantly suppressed at short stimulus onset asynchronies. While in rat somatosensory cortex, intracortical inhibition has been demonstrated to decline with increasing age, data from human motor cortex of elderly subjects are controversial and there are no data for the human somatosensory cortex (SI). Moreover, behavioral implications of age-related changes of cortical excitability remain elusive. We therefore assessed SI excitability by combining paired-pulse median nerve stimulation with recording somatosensory evoked potentials in 138 healthy subjects aged 17-86 years. We found that paired-pulse suppression was characterized by substantial interindividual variability, but declined significantly with age, confirming reduced intracortical inhibition in elderly subjects. To link the age-related increase of cortical excitability to perceptual changes, we measured tactile two-point discrimination in a subsample of 26 aged participants who showed either low or high paired-pulse suppression. We found that tactile performance was particularly impaired in subjects showing markedly enhanced cortical excitability. Our data demonstrate that paired-pulse suppression of human SI is significantly reduced in older adults, and that age-related enhancement of cortical excitability correlates with degradation of tactile perception. These findings indicate that cortical excitability constitutes an important mechanism that links age-related neurophysiological changes to behavioral alterations in humans.

Improved acuity and dexterity but unchanged touch and pain thresholds following repetitive sensory stimulation of the fingers.

Neuroplasticity underlies the brain's ability to alter perception and behavior through training, practice, or simply exposure to sensory stimulation. Improvement of tactile discrimination has been repeatedly demonstrated after repetitive sensory stimulation (rSS) of the fingers; however, it remains unknown if such protocols also affect hand dexterity or pain thresholds. We therefore stimulated the thumb and index finger of young adults to investigate, besides testing tactile discrimination, the impact of rSS on dexterity, pain, and touch thresholds. We observed an improvement in the pegboard task where subjects used the thumb and index finger only. Accordingly, stimulating 2 fingers simultaneously potentiates the efficacy of rSS. In fact, we observed a higher gain of discrimination performance as compared to a single-finger rSS. In contrast, pain and touch thresholds remained unaffected. Our data suggest that selecting particular fingers modulates the efficacy of rSS, thereby affecting processes controlling sensorimotor integration.

Cognitive and tactile factors affecting human haptic performance in later life.

BACKGROUND: Vision and haptics are the key modalities by which humans perceive objects and interact with their environment in a target-oriented manner. Both modalities share higher-order neural resources and the mechanisms required for object exploration. Compared to vision, the understanding of haptic information processing is still rudimentary. Although it is known that haptic performance, similar to many other skills, decreases in old age, the underlying mechanisms are not clear. It is yet to be determined to what extent this decrease is related to the age-related loss of tactile acuity or cognitive capacity. METHODOLOGY/PRINCIPAL FINDINGS: We investigated the haptic performance of 81 older adults by means of a cross-modal object recognition test. Additionally, we assessed the subjects' tactile acuity with an apparatus-based two-point discrimination paradigm, and their cognitive performance by means of the non-verbal Raven-Standard-Progressive matrices test. As expected, there was a significant age-related decline in performance on all 3 tests. With the exception of tactile acuity, this decline was found to be more distinct in female subjects. Correlation analyses revealed a strong relationship between haptic and cognitive performance for all subjects. Tactile performance, on the contrary, was only significantly correlated with male subjects' haptic performance. CONCLUSIONS: Haptic object recognition is a demanding task in old age, especially when it comes to the exploration of complex, unfamiliar objects. Our data support a disproportionately higher impact of cognition on haptic performance as compared to the impact of tactile acuity. Our findings are in agreement with studies reporting an increase in co-variation between individual sensory performance and general cognitive functioning in old age.