Changes of neural coupling between cognitive and motor networks associated with dual-task performance in Parkinson's disease.

BACKGOUND: Although cognitive control is essential for efficient gait, the associations between cognitive and motor networks regarding gait in individuals with Parkinson's disease (PD) remain to be determined. Herein, we enrolled 28 PD and 28 controls to compare internetwork coupling among cognitive and motor networks and examine its relationship with single- and dual-task gait performance in PD. METHODS: The dorsal attention network (DAN), left and right frontoparietal control networks (FPNs), sensorimotor network, and lateral motor network were identified using resting-state functional magnetic resonance imaging data. The time taken to complete a 10-m walk test during cognitive or physical dual-tasks in PD was calculated representing gait performance. RESULTS: We observed that the internetwork couplings between the DAN and motor networks and between the motor networks decreased whereas those between the left FPN and DAN and motor networks increased in PD compared to controls using a permutation test. There was no significant correlation between the internetwork couplings and single- and dual-task gait performance in PD. Nevertheless, improved cognitive dual-task performance showed a positive correlation with the DAN and left FPN coupling and a negative correlation with the DAN and lateral motor network coupling in a good performance group. The opposite relationship was observed in the poor cognitive dual-task performance group. CONCLUSION: Our findings suggest a neural mechanism of cognitive control on gait to compensate for reduced goal-directed attention in PD who maintain cognitive dual-task performance.

Proteomic discovery of prognostic protein biomarkers for persisting problems after mild traumatic brain injury.

Some individuals with mild traumatic brain injury (mTBI), also known as concussion, have neuropsychiatric and physical problems that last longer than a few months. Symptoms following mTBI are not only impacted by the kind and severity of the injury but also by the post-injury experience and the individual's responses to it, making the persistence of mTBI particularly difficult to predict. We aimed to identify prognostic blood-based protein biomarkers predicting 6-month outcomes, in light of the clinical course after the injury, in a longitudinal mTBI cohort (N = 42). Among 420 target proteins quantified by multiple-reaction monitoring-mass spectrometry assays of blood samples, 31, 43, and 15 proteins were significantly associated with the poor recovery of neuropsychological symptoms at < 72 h, 1 week, and 1 month after the injury, respectively. Sequential associations among clinical assessments (depressive symptoms and cognitive function) affecting the 6-month outcomes were evaluated. Then, candidate biomarker proteins indirectly affecting the outcome via neuropsychological symptoms were identified. Using the identified proteins, prognostic models that can predict the 6-month outcome of mTBI were developed. These protein biomarkers established in the context of the clinical course of mTBI may have potential for clinical application.

A Systematic Review of the Learning Dynamics of Proprioception Training: Specificity, Acquisition, Retention, and Transfer.

OBJECTIVE: We aimed to identify key aspects of the learning dynamics of proprioception training including: 1) specificity to the training type, 2) acquisition of proprioceptive skills, 3) retention of learning effects, and 4) transfer to different proprioceptive skills. METHODS: We performed a systematic literature search using the database (MEDLINE, EMBASE, Cochrane Library, and PEDro). The inclusion criteria required adult participants who underwent any training program that could enhance proprioceptive function, and at least 1 quantitative assessment of proprioception before and after the intervention. We analyzed within-group changes to quantify the effectiveness of an intervention. RESULTS: In total, 106 studies with 343 participant-outcome groups were included. Proprioception-specific training resulted in large effect sizes with a mean improvement of 23.4 to 42.6%, nonspecific training resulted in medium effect sizes with 12.3 to 22% improvement, and no training resulted in small effect sizes with 5.0 to 8.9% improvement. Single-session training exhibited significant proprioceptive improvement immediately (10 studies). For training interventions with a midway evaluation (4 studies), trained groups improved by approximately 70% of their final value at the midway point. Proprioceptive improvements were largely maintained at a delayed follow-up of at least 1 week (12 studies). Finally, improvements in 1 assessment were significantly correlated with improvements in another assessment (10 studies). CONCLUSIONS: Proprioceptive learning appears to exhibit several features similar to motor learning, including specificity to the training type, 2 time constant learning curves, good retention, and improvements that are correlated between different assessments, suggesting a possible, common mechanism for the transfer of training.

Fully immersive virtual reality exergames with dual-task components for patients with Parkinson's disease: a feasibility study.

BACKGROUND: Dual-task training in Parkinson's disease (PD) improves spatiotemporal gait parameters, cognition, and quality of life. Virtual reality (VR) has been used as a therapeutic tool for patients to participate in activities in a safe environment, engage in multisensory experiences, and improve motivation and interest in rehabilitation. This study aimed to investigate the feasibility of fully immersive VR exergames with dual-task components in patients with PD. METHODS: We developed VR exergames (go/no-go punch game, go/no-go stepping game, and number punch game) to improve habitual behavior control using motor-cognitive dual-task performance in patients with PD. The participants underwent 10 sessions 2-3 times a week, consisting of 30 min per session. The Unified Parkinson's Disease Rating Scale, Timed Up and Go test (TUG) under single- and dual-task (cognitive and physical) conditions, Berg balance scale (BBS), Stroop test, trail-making test, and digit span were evaluated before and after intervention. The Simulator Sickness Questionnaire (SSQ) was used to assess VR cybersickness. Usability was assessed using a self-reported questionnaire. RESULTS: Twelve patients were enrolled and completed the entire training session. The mean age of participants was 73.83 ± 6.09 years; mean disease duration was 128.83 ± 76.96 months. The Hoehn and Yahr stages were 2.5 in seven patients and 3 in five patients. A significant improvement was observed in BBS and Stroop color-word test (p = 0.047 and p = 0.003, respectively). TUG time and dual-task interferences showed positive changes, but these changes were not statistically significant. The median SSQ total score was 28.05 (IQR: 29.92), 13.09 (IQR: 11.22), and 35.53 (IQR: 52.36) before, after the first session, and after the final session, respectively; the differences were not significant. Overall satisfaction with the intervention was 6.0 (IQR: 1.25) on a 7-point Likert-type scale. CONCLUSIONS: Fully immersive VR exergames combined with physical and cognitive tasks may be used for rehabilitation of patients with PD without causing serious adverse effects. Furthermore, the exergames using dual-task components improved executive function and balance. Further development of VR training content may be needed to improve motor and dual-task performances. Trial registration NCT04787549 ( https://clinicaltrials.gov/ct2/show/NCT04787549 ).

Robot-assisted gait training with auditory and visual cues in Parkinson's disease: A randomized controlled trial.

BACKGROUND: Robot-assisted gait training (RAGT) may have beneficial effects on Parkinson's disease (PD); however, the evidence to date is inconsistent. OBJECTIVES: This study compared the effects of RAGT and treadmill training (TT) on gait speed, dual-task gait performance, and changes in resting-state brain functional connectivity in individuals with PD. METHODS: In this prospective, single-center, randomized controlled trial with a parallel two-group design, 44 participants were randomly allocated to undergo 12 sessions (3 times per week for 4 weeks) of RAGT or TT. The primary outcome was gait speed on the 10-m walk test (10mWT) under comfortable walking conditions. Secondary outcomes included dual-task interference on gait speed, balance, disability scores, fear of falling, freezing of gait, and brain functional connectivity changes. All clinical outcomes were measured before (T0), immediately after (T1), and 1 month after treatment (T2). RESULTS: The mean (SD) age of the participants was 68.1 (8.1) years, and mean disease duration 108.0 (61.5) months. The groups did not significantly differ on the 10mWT (T0-T1, p = 0.726, Cohen's d = 0.133; T0-T2, p = 0.778, Cohen's d = 0.121). We observed a significant time-by-group interaction (F = 3.236, p = 0.045) for cognitive dual-task interference, controlling for confounders. After treatment, coupling was decreased to a greater extent with RAGT than TT between the visual and dorsal attention networks (p = 0.015), between bilateral fronto-parietal networks (p = 0.043), and between auditory and medial temporal networks (p = 0.018). Improvement in cognitive dual-task interference was positively correlated with enhanced visual and medial temporal network coupling overall (r = 0.386, p = 0.029) and with TT (r = 0.545, p = 0.024) but not RAGT (r = 0.151, p = 0.590). CONCLUSIONS: RAGT was not superior to intensity-matched TT on improving gait functions in individuals with PD but may be beneficial in improving gait ability under cognitive dual-task conditions. The therapeutic mechanism and key functional connectivity changes associated with improvement may differ between treatment strategies. CLINICALTRIALS: GOV: #NCT03490578.

Effects of gait training on structural brain changes in Parkinson's disease.

BACKGROUND: Gait training may lead to functional brain changes in Parkinson's disease (PD); however, there is a lack of studies investigating structural brain changes after gait training in PD. OBJECTIVE: To investigate structural brain changes induced by 4 weeks of gait training in individuals with PD. METHODS: Diffusion tensor imaging and structural T1 images were acquired in PD group before and after robot-assisted gait training or treadmill training, and in healthy control group. Tract-based spatial statistics and tensor-based morphometry were conducted to analyze the data. The outcome of gait training was assessed by gait speed and dual-task interference of cognitive or physical tests of the 10-meter walking test representing gait automaticity. The associations between structural brain changes and these outcomes were investigated using correlation analysis. RESULTS: A total of 31 individuals with PD (68.5±8.7 years, the Hoehn & Yahr stage of 2.5 or 3) and 28 healthy controls (66.6±8.8 years) participated in this study. Compared to the controls, PD group at baseline showed a significant increased fractional anisotropy (FA) in the right forceps minor and bilateral brainstem and reduced radial diffusivity (RD) in the right superior longitudinal fasciculus, as well as the expanded structural volumes in the several brain areas. After gait training, FA increased in the left internal capsule and it decreased in the left cerebellum Crus I, while the structural volume did not change. The increased FA in the left internal capsule positively correlated with the baseline gait speed and negatively correlated with gait speed improvement; moreover, the decreased FA in the left cerebellum Crus I negatively correlated with the baseline gait speed during the cognitive task. CONCLUSIONS: Gait training induces white matter changes in the brain of individuals with PD, which suggests the improvement of brain structural pathology to mitigate the impact of neurodegenerative consequences.

Statin use and pneumonia risk in Parkinson's disease.

INTRODUCTION: Previous studies reported that statin use was related to a lower risk of pneumonia in the general population. This study investigated the association between statin use and pneumonia risk in patients with Parkinson's disease (PD). METHODS: Patients that had been newly diagnosed with PD between 2004 and 2006 in the 2002-2017 National Health Insurance Service database in South Korea were identified. PD patients who had received one or more statin prescriptions, and experienced pneumonia during the observation period were included in the self-controlled case series (SCCS) analysis. Patients who had no previous statin prescription record were included in the Cox proportional hazard model with a time-varying covariate (statin use). The risk of pneumonia in PD patients with statin use was estimated after adjusting potential confounders. RESULTS: Of the 10,159 patients with PD, 337 individuals were eligible for the SCCS analysis. The median duration of statin exposure was 2.63 years (IQR, 0.83-5.83). The incidence of pneumonia was reduced in the statin-exposed period compared to the unexposed period (incidence rate ratio, 0.88; 95% CI, 0.86-0.91). A total of 8,022 patients were included in the Cox proportional hazard model. Statin use was related to a significantly reduced pneumonia risk (adjusted hazard ratio, 0.69; 95% CI, 0.62-0.78). CONCLUSIONS: Statin use was associated with a lower risk of pneumonia in PD patients. Statins might affect pneumonia occurrence by lowering cholesterol levels or slowing the progression of PD as neuroprotective agents. Further clinical studies are needed to delineate our findings with the underlying biological mechanisms.

Exercise Management Using a Mobile App in Patients With Parkinsonism: Prospective, Open-Label, Single-Arm Pilot Study.

BACKGROUND: Patients with parkinsonism have higher inactivity levels than the general population, and this results in increased comorbidities. Although exercise has benefits for motor function and quality of life (QOL) in patients with parkinsonism, these patients face many barriers to exercise participation, such as lack of motivation, fatigue, depression, and time constraints. Recently, the use of mobile apps has been highlighted as a remote exercise management strategy for patients with chronic diseases. OBJECTIVE: This study aimed to evaluate the effects of home-based exercise management with a customized mobile app on the exercise amount, physical activity, and QOL of patients with parkinsonism. METHODS: This was a prospective, open-label, single-arm pilot study. The therapist installed the app in the smartphones of the participants and educated them on how to use the app. The therapist developed an individualized multimodal exercise program that consisted of stretching, strengthening, aerobic, balance and coordination, and oral-motor and vocal exercises. Participants were encouraged to engage in an 8-week home-based exercise program delivered through a customized app. The alarm notifications of the app provided reminders to exercise regularly at home. The primary outcome was the exercise amount. The secondary outcomes were assessed using the International Physical Activity Questionnaire (IPAQ), Parkinson's Disease Questionnaire-39 (PDQ-39), and Geriatric Depression Scale (GDS). The usability of the customized app was assessed using a self-report questionnaire. RESULTS: A total of 21 participants with parkinsonism completed the intervention and assessment between September and December 2020 (mean age: 72 years; women: 17/21, 81%; men: 4/21, 19%). The participants reported a significant increase in the total amount of exercise (baseline: mean 343.33, SD 206.70 min/week; 8-week follow-up: mean 693.10, SD 373.45 min/week; P<.001) and in the amount of each exercise component, including stretching, strengthening, balance and coordination, and oral-motor and vocal exercise after 8 weeks. Analysis of the secondary outcomes revealed significant improvements in the IPAQ (P=.006), PDQ-39 (P=.02), and GDS (P=.04) scores. The usability of the program with the mobile app was verified based on the positive responses such as "intention to use" and "role expectation for rehabilitation." CONCLUSIONS: Exercise management with a customized mobile app may be beneficial for improving exercise adherence, physical activity levels, depression management, and QOL in patients with parkinsonism. This remotely supervised technology-based, reinforcing, and multimodal exercise management strategy is recommended for use in patients with parkinsonism. In addition, this program proved useful as an alternative exercise management strategy during the COVID-19 pandemic when patients with Parkinson disease were less physically active than before and showed aggravation of symptoms. However, additional clinical trials are needed to evaluate the efficacy of this exercise program in a large population and to confirm its disease-modifying effects.

Effects of percutaneous injection laryngoplasty on voice and swallowing problems in cancer-related unilateral vocal cord paralysis.

BACKGROUND: Unilateral vocal cord paralysis may result from nerve compression by tumors or direct nerve injuries during tumor resections, which can cause dysphonia or dysphagia, and reduced quality of life. OBJECTIVES: This prospective, single-group study aimed to investigate the effect of percutaneous injection laryngoplasty on voice and swallowing function in patients with cancer-related unilateral vocal cord paralysis. METHODS: Patients underwent percutaneous injection laryngoplasty with hyaluronic acid under local anesthesia. Stroboscopy and videofluoroscopic swallowing study were conducted to evaluate the voice- and swallowing-related outcome measures, respectively. The participants were evaluated before injection laryngoplasty, as well as after two weeks and three months. RESULTS: Injection laryngoplasty significantly improved the glottal gap, vocal fold position, Maximum Phonation Time, and Voice Handicap Index-10. Post-hoc analysis using Bonferroni correction showed that the improvements occurred within two post-treatment weeks and remained at three post-treatment months. In the subgroup analysis, the patients who underwent injection laryngoplasty within 8 weeks from onset showed significantly higher improvements in the videofluoroscopic dysphagia scale and swallowing function than the patients who received the procedure after 8 weeks or more. CONCLUSION: Percutaneous injection laryngoplasty improves glottal closure and voice in patients with cancer-related unilateral vocal cord paralysis. Early injection laryngoplasty may lead to greater benefits on swallowing function. LEVEL OF EVIDENCE: 4.

Measurement and Correction of Stooped Posture during Gait Using Wearable Sensors in Patients with Parkinsonism: A Preliminary Study.

Stooped posture, which is usually aggravated during walking, is one of the typical postural deformities in patients with parkinsonism. However, the degree of stooped posture is difficult to quantitatively measure during walking. Furthermore, continuous feedback on posture is also difficult to provide. The purpose of this study is to measure the degree of stooped posture during gait and to investigate whether vibration feedback from sensor modules can improve a patient's posture. Parkinsonian patients with stooped posture were recruited for this study. Two wearable sensors with three-axis accelerometers were attached, one at the upper neck and the other just below the C7 spinous process of the patients. After being calibrated in the most upright posture, the sensors continuously recorded the sagittal angles at 20 Hz and averaged the data at every second during a 6 min walk test. In the control session, the patients walked with the sensors as usual. In the vibration session, sensory feedback was provided through vibrations from the neck sensor module when the sagittal angle exceeded a programmable threshold value. Data were collected and analyzed successfully in a total of 10 patients. The neck flexion and back flexion were slightly aggravated during gait, although the average change was <10° in most patients in both measurement sessions. Therefore, it was difficult to evaluate the effect of sensory feedback through vibration. However, some patients showed immediate response to the feedback and corrected their posture during gait. In conclusion, this preliminary study suggests that stooped posture could be quantitatively measured during gait by using wearable sensors in patients with parkinsonism. Sensory feedback through vibration from sensor modules may help in correcting posture during gait in selected patients.

Effect of robot-assisted gait training on gait automaticity in Parkinson disease: A prospective, open-label, single-arm, pilot study.

ABSTRACT: Gait automaticity is reduced in patients with Parkinson disease (PD) due to impaired habitual control. The aim of this study was to investigate the effect of robot-assisted gait training (RAGT) on gait automaticity as well as gait speed and balance in patients with PD.This study was a prospective, open-label, single-arm, pilot study. We planned to recruit 12 patients with idiopathic PD. Participants received 12 sessions of RAGT using exoskeleton-type robotic device. Sessions were 45-minute each, 3 days a week, for 4 consecutive weeks using an exoskeleton-type gait robot. The primary outcome was the percentage of dual-task interference measured by the 10-Meter Walk Test (10MWT) under single and dual-task (cognitive and physical) conditions. Secondary outcomes were the Berg Balance Scale and Korean version of the Falls Efficacy Scale-International. All measures were evaluated before treatment (T0), after treatment (T1), and 1-month post-treatment (T2).Twelve patients were enrolled and 1 dropped out. Finally, 11 patients with idiopathic PD were analyzed. The mean age of 11 patients (5 males) was 66.46 ±â€Š5.66 years, and disease duration was 112.91 ±â€Š50.19 months. The Hoehn and Yahr stages were 2.5 in 8 patients and 3 in 3 patients. Linear mixed-effect model analysis showed a significant change over time only in single-task gait speed of the 10MWT (P = .007), but not in dual-task gait speed, dual-task interferences, and Korean version of the Falls Efficacy Scale-International. Cognitive dual-task interference significantly increased (P = .026) at T1, but not at T2 (P = .203). No significant changes were observed for physical dual-task interference at T1 and T2. Single-task gait speed of the 10MWT was significantly increased at T1 (P = .041), but not at T2 (P = .445). There were no significant changes in the dual-task gait speed of 10MWT. A significant improvement was observed in Berg Balance Scale score at T1 and T2 (P = .004 and P = .024, respectively).In this pilot study, despite improvement in walking speed and balance, gait automaticity in patients with PD was not improved by RAGT using an exoskeleton-type robot. Additional therapeutic components may be needed to improve gait automaticity using RAGT in patients with PD.

Changes in Epidemiological Trends and Rehabilitation Usage in Neurological Diseases in Korea: Parkinson's Disease.

Parkinson's disease (PD) is a neurodegenerative disorder characterized by typical motor symptoms such as resting tremor, bradykinesia, and rigidity, as well as non-motor manifestations, including psychiatric symptoms, autonomic dysfunction, and cognitive impairment. These symptoms induce a marked impact on functional independence in daily activities and quality of life in PD patients. Recent guidelines recommend adequate rehabilitation education and treatment from the early stages of PD, and rehabilitation has become part of standard care for PD. In Korea, the number of patients with PD has more than tripled over 15 years, from 39,265 in 2004 to 125,607 in 2019. However, the rehabilitation usage of PD patients has not changed remarkably, and it remains suboptimal in Korea compared to several developed countries, which have advanced and disseminated guidelines and implemented specialized care delivery systems for PD over the past 20 years. Additional efforts are warranted to provide adequate rehabilitation therapies for PD patients in Korea.

Associated Factors on Quality of Life in Patients with Parkinson's Disease.

The objective of this study is to investigate the clinical and demographic factors that influence the quality of life in patients with Parkinson's disease (PD). This is a cross-sectional observational study of 47 patients in 2 hospitals with PD. All participants were asked to complete a disease-specific quality of life (QoL) questionnaire (PDQ-39). We gave a structured questionnaire interview and did a complete neurological examination on the same day. Additionally, we measured depression and dependency with the Geriatric Depression Scale-Short Form (GDS-SF) and the Korean version of the Modified Barthel Index (K-MBI). The PDQ-39 had a significant relationship with each motor part of the Unified Parkinson's Disease Rating Scale, the Korean Mini-Mental State Examination (K-MMSE), the GDS-SF, and the K-MBI (p < 0.05). The factors that independently contributed to the PDQ-39 scores were K-MMSE, GDS-SF, and K-MBI (p < 0.05). Factors having the greatest influence on the PDQ-39 were K-MBI, K-MMSE, and GDS-SF in that order. In addition, the mobility item in the K-MBI was independently a significant relating factor in the PDQ-39 (p < 0.05). These results demonstrated that dependency, especially with the mobility issue, was the greatest influence on the QoL in patients with PD.

Reduced Brainstem Volume After Mild Traumatic Brain Injury.

OBJECTIVE: The aims of this study were to investigate changes in regional brain volume after concussion (mild traumatic brain injury) and to examine the relationship between change in brain volume and cognitive deficits. DESIGN: Twenty-eight patients with mild traumatic brain injury and 27 age-matched controls were included in this study. Magnetic resonance imaging (3 T) data were obtained from the participants. Structural brain volume changes were examined using tensor-based morphometry, which identifies regional structural differences in the whole brain, including cerebrospinal fluid, gray matter, and white matter. Volume contraction and expansion were compared between groups using a two-sample t test. The association between time post-injury or neurocognitive function and volumetric changes was examined using regression analysis. RESULTS: Individuals with mild traumatic brain injury exhibited volume reduction in the brainstem, including the pontine reticular formation. Regional cerebral volume changes were not associated with time post-injury but were significantly associated with neurocognitive function, especially with executive card sorting test, forward digit span test, and performance on verbal learning test. The greater regional cerebral volume was associated with better cognitive performance after mild traumatic brain injury. CONCLUSION: Decreased brainstem volume may indicate its vulnerability to traumatic injury, and cerebral volume in specific regions was positively associated with patients' cognitive function after injury.

Effects of Upper-Extremity Rehabilitation Using Smart Glove in Patients With Subacute Stroke: Results of a Prematurely Terminated Multicenter Randomized Controlled Trial.

Background: Although there have been many trials and interventions for reducing upper-extremity impairment in stroke survivors, it remains a challenge. A novel intervention is needed to provide high-repetition task-specific training early after stroke. Objective: This study aimed to investigate the effect of smart glove training (SGT) for upper-extremity rehabilitation in patients with subacute stroke. Methods: A prospective, multicenter, randomized, controlled study was conducted in patients with upper-extremity hemiparesis with Brunnstrom stage for arm 2-5 in the subacute phase after stroke. Eligible participants were randomly allocated to the SGT group or the control group. The SGT group underwent 30 min of standard occupational therapy plus 30 min of upper-extremity training with smart glove. The control group underwent standard occupational therapy for 30 min plus upper-extremity self-training (homework tasks at bedside) for 30 min. All participants underwent each intervention 5 days/week for 2 consecutive weeks. They were evaluated before, immediately after, and 4 weeks after the intervention. The primary outcome measure was the change in the score of the Fugl-Meyer assessment of the upper extremity (FMA-UE). Results: Twenty-three patients were enrolled. Repeated-measures analysis of covariance after controlling for age and disease duration showed significant time × group interaction effects in the FMA-UE, FMA-distal, and FMA-coordination/speed (p = 0.018, p = 0.002, p = 0.006). Repeated-measures analysis of variance showed significant time × group interaction effects in the FMA-UE, FMA-distal, and Box and Block Test (p = 0.034, p = 0.010, p = 0.046). Mann-Whitney U-test showed a statistically higher increase in the FMA-UE and FMA-distal in the SGT group than in the control group (p = 0.023, p = 0.032). Conclusion: Upper-extremity rehabilitation with a smart glove may reduce upper-extremity impairment in patients with subacute stroke. Clinical Trial Registration: ClinicalTrials.gov (NCT02592759).

Cognitive Training Using Fully Immersive, Enriched Environment Virtual Reality for Patients With Mild Cognitive Impairment and Mild Dementia: Feasibility and Usability Study.

BACKGROUND: Cognitive training using virtual reality (VR) may result in motivational and playful training for patients with mild cognitive impairment and mild dementia. Fully immersive VR sets patients free from external interference and thus encourages patients with cognitive impairment to maintain selective attention. The enriched environment, which refers to a rich and stimulating environment, has a positive effect on cognitive function and mood. OBJECTIVE: The aim of this study was to investigate the feasibility and usability of cognitive training using fully immersive VR programs in enriched environments with physiatrists, occupational therapists (OTs), and patients with mild cognitive impairment and mild dementia. METHODS: The VR interface system consisted of a commercialized head-mounted display and a custom-made hand motion tracking module. We developed the virtual harvest and cook programs in enriched environments representing rural scenery. Physiatrists, OTs, and patients with mild cognitive impairment and mild dementia received 30 minutes of VR training to evaluate the feasibility and usability of the test for cognitive training. At the end of the test, the usability and feasibility were assessed by a self-report questionnaire based on a 7-point Likert-type scale. Response time and finger tapping were measured in patients before and after the test. RESULTS: Participants included 10 physiatrists, 6 OTs, and 11 patients with mild cognitive impairment and mild dementia. The mean scores for overall satisfaction with the program were 5.75 (SD 1.00) for rehabilitation specialists and 5.64 (SD 1.43) for patients. The response time of the dominant hand in patients decreased after the single session of cognitive training using VR, but this was not statistically significant (P=.25). There was no significant change in finger tapping in either the right or left hand (P=.48 and P=.42, respectively). None of the participants reported headaches, dizziness, or any other motion sickness after the test. CONCLUSIONS: A fully immersive VR cognitive training program may be feasible and usable in patients with mild cognitive impairment and mild dementia based on the positive satisfaction and willingness to use the program reported by physiatrists, OTs, and patients. Although not statistically significant, decreased response time without a change in finger tapping rate may reflect a temporary increase in attention after the test. Additional clinical trials are needed to investigate the effect on cognitive function, mood, and physical outcomes.

Correction to: Effects of robot-assisted gait training in patients with Parkinson's disease: study protocol for a randomized controlled trial.

An amendment to this paper has been published and can be accessed via the original article.

Upper Extremity Rehabilitation Using Fully Immersive Virtual Reality Games With a Head Mount Display: A Feasibility Study.

BACKGROUND: Rehabilitation therapy using a virtual reality (VR) system for stroke patients has gained attention. However, few studies have investigated fully immersive VR using a head-mount display (HMD) for upper extremity rehabilitation in stroke patients. OBJECTIVE: To investigate the feasibility, preliminary efficacy, and usability of a fully immersive VR rehabilitation program using a commercially available HMD for upper-limb rehabilitation in stroke patients. DESIGN: A feasibility study. SETTING: Two rehabilitation centers. PARTICIPANTS: Twelve stroke patients with upper extremity weakness. INTERVENTIONS: Five upper extremity rehabilitation tasks were implemented in a virtual environment, and the participants wore an HMD (HTC Vive) and trained with appropriate tasks. Participants received a total of 10 sessions two to three times a week, consisting of 30 minutes per session. MAIN OUTCOME MEASURES: Both patient participation and adverse effects of VR training were monitored. Primary efficacy was assessed using functional outcomes (Action Research Arm Test, Box and Block Test, and modified Barthel Index), before and after the intervention. Usability was assessed using a self-reported questionnaire. RESULTS: Three patients discontinued VR training, and nine patients completed the entire training sessions and there were no adverse effects due to motion sickness. The patients who received all sessions showed significant functional improvement in all outcome measures after training (P < .05 for all measures). The overall satisfaction was 6.3 ± 0.8 on a 7-point Likert scale in all participants. CONCLUSIONS: A fully immersive VR rehabilitation program using an HMD for rehabilitation of the upper extremities following stroke is feasible and, in this small study, no serious adverse effects were identified. LEVEL OF EVIDENCE: IV.

A Study on Breast Cancer Patients’ Commitment to a Plan for Exercise based on Health Beliefs / 기본간호학회지

Purpose@#The purpose of this study was to identify the factors relating to commitment to a plan for exercise in the breast cancer patient following a mastectomy and to examine the relationship between these factors. @*Methods@#This study was a correlational research and the participants were 152 patients with breast cancer. Data were collected using a structured questionnaire from June to October, 2015. @*Results@#The final regression model showed that income, experience of exercise and current exercise were significant predictors related to commitment to a plan for exercise in patients with breast cancer and explained for 65.9% of the variance in commitment to a plan for exercise. @*Conclusion@#The findings indicate that patients in breast cancer-oriented intervention programs have an enhancing experience of exercise. Current exercise should be provided for patients with breast cancer in order to promote health and quality of life.

Effects of robot-assisted gait training in patients with Parkinson's disease: study protocol for a randomized controlled trial.

BACKGROUND: Robot-assisted gait training (RAGT) was developed to restore gait function by promoting neuroplasticity through repetitive locomotor training and has been utilized in gait training. However, contradictory outcomes of RAGT have been reported for patients with Parkinson's disease (PD). In addition, the mechanism of the RAGT treatment effect is still unknown. This study aims to investigate the effects of RAGT on gait velocity in patients with PD and to unveil the mechanisms of these effects. METHODS: This is a prospective, single-blind, single-center, randomized controlled trial. Eligible participants will be randomly allocated to: 1) a Walkbot-S™ RAGT group or 2) a treadmill training group. The participants will receive three 45-min sessions of each intervention per week for 4 weeks. Gait speed during RAGT will be targeted to the maximal speed depending on the participant's height; the same principle will be applied to the treadmill training group to match the training intensity. The primary outcome measure is gait speed measured by the 10-Meter Walk Test at a comfortable pace under single-task conditions. Secondary outcomes include dual-task interference, the Berg Balance Scale, Timed Up and Go test, the Korean version of the Falls Efficacy Scale-International, New Freezing of Gait Questionnaire, Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale, and functional connectivity measured by resting-state functional magnetic resonance imaging. Baseline assessments (T0) will be conducted to acquire clinical characteristics and outcome measure values before the intervention. Postintervention assessments (T1) will compare immediate efficacies within 3 days after the intervention. Follow-up assessments (T2) will be conducted 1 month after the intervention. Considering an alpha of 0.05 and a power of 80%, the total number of participants to be recruited is 44. DISCUSSION: This study will reveal the effect of RAGT using an exoskeletal robot, not only on gait speed, but also on gait automaticity, balance function, fall risk, quality of life, and disease severity. In addition, the study will shed new light on the mechanism of the RAGT effect by evaluating changes in gait automaticity and brain functional networks. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03490578 . Registered on 21 March 2018.