Technology Use for Home-Based Stroke Rehabilitation in Switzerland From the Perspectives of Persons Living With Stroke, Informal Caregivers, and Therapists: Qualitative Interview and Focus Group Study.

BACKGROUND: Stroke is a leading cause for long-term disability, requiring both inpatient and outpatient rehabilitation and self-training in the home environment. Technology-based tools are gradually gaining acceptance as additional and suitable options for extending the rehabilitation process. While the experiences of persons living with stroke, therapists, and informal caregivers with respect to technology use have already been investigated in other countries, this topic is underexplored in the Swiss context. OBJECTIVE: We aimed to explore the experiences and needs of persons living with stroke, informal caregivers, and therapists in using technology-based tools in a home environment for stroke rehabilitation in Switzerland. METHODS: This study followed a qualitative descriptive methodology, including semistructured interviews and focus group discussions. We applied a deductive template analysis alongside the accessibility, adaptability, accountability, and engagement framework to analyze the qualitative data sets for technology-assisted solutions for poststroke rehabilitation. RESULTS: We collected the experiences and needs of persons living with stroke (7/23, 30%), informal caregivers (4/23, 17%), and therapists (occupational and physical therapists; 12/23, 52%). The 4 categories we used to organize the analysis and results were accessibility to quality rehabilitation, adaptability to patient differences, accountability or compliance with rehabilitation, and engagement with rehabilitation. Persons living with stroke stated that they use various tools within their rehabilitation process depending on their specific needs. They felt that there is a plethora of tools available but sometimes felt overwhelmed with the selection process. Informal caregivers indicated that they generally felt underserved and insufficiently informed throughout the rehabilitation process. They reported that they use technology-based tools to support their relatives affected by stroke in becoming more independent. Therapists appreciate the numerous possible applications of technology-based tools in rehabilitation. At the same time, however, they express dissatisfaction with the lack of clarity in Switzerland regarding cost coverage, recommendations, and training opportunities. CONCLUSIONS: Persons living with stroke, informal caregivers, and therapists in Switzerland reported varied and unique experiences and needs with the use of technology-based tools in outpatient stroke rehabilitation. Written recommendations, the assumption of financial costs, and the provision of information and education could foster increased confidence in the use of technology-based tools for patients and therapists.

Remotely Assessing Motor Function and Activity of the Upper Extremity After Stroke: A Systematic Review of Validity and Clinical Utility of Tele-Assessments.

OBJECTIVE: The aim of this systematic review is to identify currently available tele-assessments for motor impairments of the upper extremity in adults after a stroke and to assess their psychometric properties and clinical utility. DATA SOURCES: We searched for studies describing the psychometric properties of tele-assessments for the motor function of the upper extremity. A systematic search was conducted in the Cumulative Index to Nursing and Allied Health Literature, Medline via OVID, Embase, The Cochrane Library, Scopus, Web of Science and Institute of Electrical and Electronics Engineers Xplore from inception until 30 April 2024. REVIEW METHODS: The quality assessment for the included studies and the rating of the psychometric properties were performed using the COSMIN Risk of Bias Checklist for systematic reviews of patient-reported outcome measures. RESULTS: A total of 12 studies (N = 3912) describing 11 tele-assessments met the predefined inclusion criteria. The included assessments were heterogeneous in terms of quality and psychometric properties and risk of bias. None of the tele-assessments currently meets the criteria of clinical utility to be recommended for clinical practice without restriction. CONCLUSION: The quality and clinical utility of tele-assessments varied widely, suggesting a cautious consideration for immediate clinical practice application. There is potential for tele-assessments in clinical practice, but the clinical benefits need to be improved by simplifying the complexity of tele-assessments. REGISTRATION NUMBER: CRD42022335035.

Digital Health for Migrants, Ethnic and Cultural Minorities and the Role of Participatory Development: A Scoping Review.

Digital health interventions (DHIs) are increasingly used to address the health of migrants and ethnic minorities, some of whom have reduced access to health services and worse health outcomes than majority populations. This study aims to give an overview of digital health interventions developed for ethnic or cultural minority and migrant populations, the health problems they address, their effectiveness at the individual level and the degree of participation of target populations during development. We used the methodological approach of the scoping review outlined by Tricco. We found a total of 2248 studies, of which 57 were included, mostly using mobile health technologies, followed by websites, informational videos, text messages and telehealth. Most interventions focused on illness self-management, mental health and wellbeing, followed by pregnancy and overall lifestyle habits. About half did not involve the target population in development and only a minority involved them consistently. The studies we found indicate that the increased involvement of the target population in the development of digital health tools leads to a greater acceptance of their use.

Recovery of walking in nonambulatory children with chronic spinal cord injuries: Case series.

The immature central nervous system is recognized as having substantial neuroplastic capacity. In this study, we explored the hypothesis that rehabilitation can exploit that potential and elicit reciprocal walking in nonambulatory children with chronic, severe (i.e., lower extremity motor score < 10/50) spinal cord injuries (SCIs). Seven male subjects (3-12 years of age) who were at least 1-year post-SCI and incapable of discrete leg movements believed to be required for walking, enrolled in activity-based locomotor training (ABLT; clinicaltrials.gov NCT00488280). Six children completed the study. Following a minimum of 49 sessions of ABLT, three of the six children achieved walking with reverse rolling walkers. Stepping development, however, was not accompanied by improvement in discrete leg movements as underscored by the persistence of synergistic movements and little change in lower extremity motor scores. Interestingly, acoustic startle responses exhibited by the three responding children suggested preserved reticulospinal inputs to circuitry below the level of injury capable of mediating leg movements. On the other hand, no indication of corticospinal integrity was obtained with transcranial magnetic stimulation evoked responses in the same individuals. These findings suggest some children who are not predicted to improve motor and locomotor function may have a reserve of adaptive plasticity that can emerge in response to rehabilitative strategies such as ABLT. Further studies are warranted to determine whether a critical need exists to re-examine rehabilitation approaches for pediatric SCI with poor prognosis for any ambulatory recovery.

Evidence for gender differences in the Amphetamine/Methamphetamine ratio in the hair of subjects undergoing Fitness-to-Drive testing.

BACKGROUND AND AIMS: Retrospective analysis of hair testing data provides insights in drugs abuse patterns and improves results interpretation. Cases from subjects undergoing driving fitness assessment (2010-2020) were examined to evidence patterns in methamphetamine (MA) abuse. MATERIALS AND METHODS: All cases with positive MA (≥0.025 ng/mg) were included (n = 585). Data available were gender, age, MA and A (amphetamine) in hair (h), hair color/treatment, length of proximal hair. Cases with Ah/MAh ≤ 0.35 (n = 469) were arbitrarily selected to remove as many combined A, MA users. ANOVA was performed to detect Ah/MAh predictors. RESULTS: No predictors affected Ah/MAh. A bimodal frequency distribution was observed. We clustered cases in two groups (1, Ah/MAh 0.025-0.070; 2, Ah/MAh 0.071-0.120) and performed logistic regression. Only gender exhibited significant difference across groups (p = 0.0080). Odds ratio for females falling into group 2 was 2.86 times higher (CI97.5 1.34-6.44). CONCLUSION: Literature data support the hypothesis that the two Ah/MAh groups represent different phenotypes of the CYP2D6-mediated MA N-demethylation. Whether gender plays a role in such difference could not be confirmed. However, these results provide further suggestion of an association of gender and pharmacogenomics with MA disposition, requiring these factors to be considered in future research.

Getting the Best Out of Advanced Rehabilitation Technology for the Lower Limbs: Minding Motor Learning Principles.

Advanced technology, including gait-training devices, is increasingly being integrated into neurorehabilitation. However, to use gait-training devices to their optimal potential, it is important that they are applied in accordance with motor learning and locomotor training principles. In this article, we outline the most important principles and explain how advanced gait-training devices are best used to improve therapy outcome.

Upper Limb Recovery in Spinal Cord Injury: Involvement of Central and Peripheral Motor Pathways.

BACKGROUND AND OBJECTIVE: The course of central and peripheral motor recovery after cervical spinal cord injury (SCI) may be investigated by electrophysiological measures. The goal of this study was to compare the 2 over the first year after injury in relation to motor gains. METHODS: Compound motor action potentials (CMAPs), motor-evoked potentials (MEPs), and F-waves were recorded from the abductor digiti minimi and CMAP and F-waves from abductor hallucis muscles in 305 patients at about 15 days, 1 month, 3 months, 6 months, and 12 months following an acute traumatic SCI. RESULTS: The MEP amplitudes and F-wave persistences were lower with more severe sensorimotor impairment. They steadily increased in most subgroups within 6 months after SCI. The amplitude of the CMAPs was low for the first 3 months in the most severely affected participants. This was also found for CMAPs from tibial nerve originating well below the cervical lesion level. Improvement in neurophysiological parameters correlated with improved upper extremity motor scores. CONCLUSION: The results point to a systematic interrelation of corticospinal transmission, spinal motoneuron excitability, and its axon function, respectively. Electrophysiological correlates of neural excitability show distinct spatial and temporal interrelations within central and peripheral motor pathways following acute cervical SCI. A strong secondary deterioration within the peripheral motor system with incomplete or no recovery depends on anatomical distance caudal to lesion and on lesion severity. Electrophysiological assessments may increase the sensitivity of interventional studies in addition to clinical measures.

Retraining walking adaptability following incomplete spinal cord injury.

INTRODUCTION: Functional walking requires the ability to modify one's gait pattern to environmental demands and task goals-gait adaptability. Following incomplete spinal cord injury (ISCI), gait rehabilitation such as locomotor training (Basic-LT) emphasizes intense, repetitive stepping practice. Rehabilitation approaches focusing on practice of gait adaptability tasks have not been established for individuals with ISCIs but may promote recovery of higher level walking skills. The primary purpose of this case series was to describe and determine the feasibility of administering a gait adaptability retraining approach-Adapt-LT-by comparing the dose and intensity of Adapt-LT to Basic-LT. CASE PRESENTATION: Three individuals with ISCIs (>1 year, AIS C or D) completed three weeks each (15 sessions) of Basic-LT and Adapt-LT. Interventions included practice on a treadmill with body weight support and practice overground (≥30 mins total). Adapt-LT focused on speed changes, obstacle negotiation, and backward walking. Training parameters (step counts, speeds, perceived exertion) were compared and outcomes assessed pre and post interventions. Based on completion of the protocol and similarities in training parameters in the two interventions, it was feasible to administer Adapt-LT with a similar dosage and intensity as Basic-LT. Additionally, the participants demonstrated gains in walking function and balance following each training type. DISCUSSION: Rehabilitation that includes stepping practice with adaptability tasks is feasible for individuals with ISCIs. Further investigation is needed to determine the efficacy of Adapt-LT.

Long-term facilitation of ventilation in humans with chronic spinal cord injury.

RATIONALE: Intermittent stimulation of the respiratory system with hypoxia causes persistent increases in respiratory motor output (i.e., long-term facilitation) in animals with spinal cord injury. This paradigm, therefore, has been touted as a potential respiratory rehabilitation strategy. OBJECTIVES: To determine whether acute (daily) exposure to intermittent hypoxia can also evoke long-term facilitation of ventilation after chronic spinal cord injury in humans, and whether repeated daily exposure to intermittent hypoxia enhances the magnitude of this response. METHODS: Eight individuals with incomplete spinal cord injury (>1 yr; cervical [n = 6], thoracic [n = 2]) were exposed to intermittent hypoxia (eight 2-min intervals of 8% oxygen) for 10 days. During all exposures, end-tidal carbon dioxide levels were maintained, on average, 2 mm Hg above resting values. Minute ventilation, tidal volume, and breathing frequency were measured before (baseline), during, and 30 minutes after intermittent hypoxia. Sham protocols consisted of exposure to room air and were administered to a subset of the participants (n = 4). MEASUREMENTS AND MAIN RESULTS: Minute ventilation increased significantly for 30 minutes after acute exposure to intermittent hypoxia (P < 0.001), but not after sham exposure. However, the magnitude of ventilatory long-term facilitation was not enhanced over 10 days of intermittent hypoxia exposures. CONCLUSIONS: Ventilatory long-term facilitation can be evoked by brief periods of hypoxia in humans with chronic spinal cord injury. Thus, intermittent hypoxia may represent a strategy for inducing respiratory neuroplasticity after declines in respiratory function that are related to neurological impairment. Clinical trial registered with www.clinicaltrials.gov (NCT01272011).

One-year evolution of ulnar somatosensory potentials after trauma in 365 tetraplegic patients: early prediction of potential upper limb function.

Early prediction of hand function is crucial for efficient rehabilitation of cervical spinal cord injury (cSCI). This study investigated correlations between ulnar somatosensory evoked potentials (ulnar SSEPs) and functional outcome of hand function following acute traumatic cervical cord injury. Neurological assessment of sensory scores and hand function were compared with five ulnar SSEP categories of similar persistence and quality in 365 patients throughout the first year after cSCI. Of the 365 patients, 218 (68%) exhibited ulnar SSEP potentials at any one stage during the year, and in 147 patients (40.3%) ulnar SSEPs were obtainable at every assessment stage. While ulnar SSEP latency and amplitude assessments remained largely unchanged over time in the majority of patients, hand function improved remarkably during the first year following cSCI. One year outcome of hand function was predetermined by ulnar SSEP category due to distinct differences in the ulnar SSEP parameters. Additionally, an early prognostic group allocation by ulnar SSEP criteria at the first assessment stage within 4 weeks after spinal trauma allowed reliable prediction of hand function outcome after 1 year. We conclude that early assessment of ulnar SSEP as a non-invasive and objective neurophysiological test is a valuable marker of prospective hand function and independence 1 year after cSCI. This could be most relevant for planning neurorehabilitation, and in prospective clinical SCI trials.

Spinal cord injury: one-year evolution of motor-evoked potentials and recovery of leg motor function in 255 patients.

BACKGROUND: The description of the natural course of recovery from a spinal cord injury (SCI) with spontaneous improvement of neurological, neurophysiological, and functional measures is an important prerequisite in appraising effects of upcoming interventional therapies. OBJECTIVE: To describe the spontaneous evolution of motor-evoked potentials of the anterior tibial muscle (TA-MEP) and their relation to outcomes of lower extremity motor scores (LEMS) and walking function in patients recovering from an acute SCI. METHODS: TA-MEPs were assessed in 255 SCI subjects within 5 time intervals throughout the first year after SCI with combined neurological and functional measures. Tibial nerve conduction studies were performed to screen for peripheral nerve damage. RESULTS: TA-MEP allowed stratification of SCI according to lesion severity and outcome. As MEP amplitudes increased over 12 months after SCI, this was paralleled by a significant improvement of LEMS and walking function. TA-MEP latencies remained usually stable. CONCLUSION: Clinical outcome and walking function after SCI can be predicted independent of clinical measures by assessment of TA-MEP reflecting corticospinal tract integrity.

Unexpected recovery after robotic locomotor training at physiologic stepping speed: a single-case design.

OBJECTIVES: To investigate the effect of walking speed on the emergence of locomotor electromyogram (EMG) patterns in an individual with chronic incomplete spinal cord injury (SCI), and to determine whether central pattern generator activity during robotic locomotor training (RLT) transfers to volitional EMG activity during overground walking. DESIGN: Single-case (B-A-B; experimental treatment-withdrawal-experimental treatment) design. SETTING: Freestanding rehabilitation research center. PARTICIPANT: A 50-year-old man who was nonambulatory for 16 months after incomplete SCI (sub-T11). INTERVENTIONS: The participant completed two 6-week blocks of RLT, training 4 times per week for 30 minutes per session at walking speeds up to 5km/h (1.4m/s) over continuous bouts lasting up to 17 minutes. MAIN OUTCOME MEASURES: Surface EMG was recorded weekly during RLT and overground walking. The Walking Index for Spinal Cord Injury (WISCI-II) was assessed daily during training blocks. RESULTS: During week 4, reciprocal, patterned EMG emerged during RLT. EMG amplitude modulation revealed a curvilinear relationship over the range of walking speeds from 1.5 to 5km/h (1.4m/s). Functionally, the participant improved from being nonambulatory (WISCI-II 1/20), to walking overground with reciprocal stepping using knee-ankle-foot orthoses and a walker (WISCI-II 9/20). EMG was also observed during overground walking. These functional gains were maintained greater than 4 years after locomotor training (LT). CONCLUSIONS: Here we report an unexpected course of locomotor recovery in an individual with chronic incomplete SCI. Through RLT at physiologic walking speeds, it was possible to activate the central pattern generator even 16 months postinjury. Further, to a certain degree, improvements from RLT transferred to overground walking. Our results suggest that LT-induced changes affect the central pattern generator and allow supraspinal inputs to engage residual spinal pathways.

Computer implementation of the international standards for neurological classification of spinal cord injury for consistent and efficient derivation of its subscores including handling of data from not testable segments.

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), defined by the American Spinal Injury Association (ASIA), and particularly the ASIA Impairment Scale (AIS) are widely used for research and clinical purposes. Although detailed procedures for scaling, scoring, and classification have been defined, misclassifications remain a major problem, especially for cases with missing (i.e., not testable [NT]) data. This work aimed to implement computer-based classification algorithms that included rules for handling NT data. A consistent and structured algorithmic scoring, scaling, and classification scheme, and a computerized application have been developed by redefining logical/mathematical imprecisions. Existing scoring rules are extended for handling NT segments. Design criterion is a pure logical approach so that substitution of non-testability for all valid examination scores leads to concordant results. Nine percent of 5542 datasets from 1594 patients in the database of the European Multicenter Study of Human Spinal Cord Injury (EM-SCI) contained NT segments. After adjusting computational algorithms, the classification accuracy was equivalent between clinical experts and the computational approach and resulted in 84% valid AIS classifications within datasets containing NT. Additionally, the computational method is much more efficient, processing approximately 200,000 classifications/sec. Computational algorithms offer the ability to classify ISNCSCI subscores efficiently and without the risk of human-induced errors. This is of particular clinical relevance, since these scores are used for early predictions of neurological recovery and functional outcome for patients with spinal cord injuries.

Conversion in ASIA impairment scale during the first year after traumatic spinal cord injury.

The neurological severity of a spinal cord injury (SCI) is commonly classified according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS). The aim of this study was to assess the course of the AIS following SCI, and to discern the nature of any changes in the classification that occur. Assessments were performed in a European cohort of SCI patients within 2 weeks and at 1, 3, 6, and 12 months after the initial injury. Overall, about 70% of the patients initially diagnosed as AIS A did not convert, as did 90% of the AIS D patients. When only evaluating patients with complete datasets, 68% did not convert, while the AIS category improved in 30% of patients and deteriorated in 2%. A change in the last sacral segments (40%), motor improvement (31%), sensory improvement (19%), and a change in the neurological level of the SCI (10%) contributed to or accompanied the AIS conversion. When the AIS remained unchanged between successive assessment points, there was no change in the number of muscles graded three or more (NMG3(+)) in 73% of the transitions. An improvement in AIS was associated with a gain in NMG3(+) in 49% of the transitions, while an aggravation in AIS was accompanied by a loss in NMG3(+) in 10% of the transitions. These results, documenting a substantial amount of spontaneous AIS conversions, should be taken into consideration when designing clinical trials to assess the effects of potential new treatments for SCI.

Evolution of tibial SSEP after traumatic spinal cord injury: baseline for clinical trials.

OBJECTIVE: To describe the spontaneous evolution of tibial somatosensory evoked potentials (tSSEPs) after spinal cord injury (SCI) and its relation to neurological and functional parameters. METHODS: tSSEPs were assessed in 297 patients within five standardized time intervals throughout the first year after injury, along with neurological and functional parameters. RESULTS: Roughly 60% of the patients did not show any recordable tSSEP throughout the first year after injury. Approximately 20% had recordable potentials at every assessment stage and showed an improvement of tSSEP parameters over time. In about 10% of the patients, a potential recovered during the first year. In the remaining cases, potentials were inconsistently recordable. All groups showed a similar amount of neurological and functional improvement. CONCLUSIONS: Recordability, latencies and amplitudes of tSSEPs can change over time after SCI. The early recordability of a tSSEP is associated with a favorable functional and neurological status and outcome. In contrast, an initially absent tSSEP is not always associated with a poorer status and outcome but only in those 75% of the patients in whom the potential remains absent. SIGNIFICANCE: This exact description of the spontaneous improvements of neurophysiological, neurological and functional parameters after SCI is an important prerequisite in appraising the efficacy of new interventional therapies.