Perspectives of parents partnering with physical therapists to deliver intensive rehabilitation for their young children with perinatal stroke: A qualitative study.

BACKGROUND: Parental participation in their young children's rehabilitation has been promoted to increase intervention intensity, but parents' perspectives on increased involvement remain unclear. The objective of this study was to explore parents' experiences partnering with physical therapists (PTs) to administer early, intensive rehabilitation to their young children with cerebral palsy (CP). METHODS: Twelve mothers and one father of children between 8 months and 3 years old with CP were interviewed. Semistructured interviews were conducted before and after parents partnered with a PT to deliver a 12 week activity-based intervention targeting their child's lower extremities. The intervention occurred in the child's home and in PT clinical sites. Interviews were audio recorded and transcribed verbatim. Interpretive description was used as the methodological framework. RESULTS: The three themes were (1) focus on maximizing the child's potential, (2) participation in intensive rehabilitation is challenging, and (3) the importance of a positive experience with therapy. Families discussed a number of barriers and facilitators to participating in intensive rehabilitation. CONCLUSIONS: These results provide considerations for clinicians and researchers to facilitate meaningful engagement of parents in their young children's rehabilitation. This is especially important with increasing evidence for early, activity-based interventions for young children with CP.

Engaging the Lower Extremity via Active Therapy Early (ELEVATE) Is Feasible and May Improve Gross Motor Function in Children with Spastic Bilateral Cerebral Palsy: A Case Series.

Purpose: The feasibility of ELEVATE with respect to adherence and preliminary efficacy was determined for children with spastic bilateral cerebral palsy (CP) from encephalopathy of prematurity. Methods: A case series was used. Participants were randomized to receive ELEVATE immediately or delay the intervention by 3 months before receiving the intervention. The outcomes included feasibility measures of (1) number of children recruited, (2) percentage of sessions attended, (3) stride counts during the intervention, and preliminary efficacy measures of change over the intervention period in (4) Gross Motor Function Measure-66 (GMFM-66), and (5) kinematics and weight-bearing during treadmill walking. Results: Four boys under 3 years of age participated. All participants tolerated 60-minute intervention sessions four times/week for 12 weeks, and attended 75%-94% (min-max) of the targeted sessions. The median step count per session ranged from 833 to 2484 steps (min-max) during the final week of training. Participants showed an increase in GMFM-66 score of 2.4-7.5 points (min-max) over the 3-month intervention phase, as compared to a decrease of 1.7 for one participant and an increase of 1.3 for another over the delay period. Three participants demonstrated small improvements in their gait with the intervention. Conclusions: Engaging young children with bilateral CP in intensive rehabilitation targeting gross motor function was feasible and demonstrated preliminary efficacy. The results have guided the design of a larger clinical trial to assess efficacy of early, active interventions for children with spastic bilateral CP.

Objectif: les chercheurs ont déterminé la faisabilité d'ELEVATE en matière d'adhésion et d'efficacité préliminaire chez des enfants ayant une paralysie cérébrale spastique bilatérale (PC) causée par une encéphalopathie de la prématurité. Méthodologie: série de cas. Les participants ont été choisis au hasard entre l'utilisation immédiate d'ELEVATE ou son report de trois mois. Les résultats incluaient des mesures de fiabilité, soit 1) le nombre d'enfants recrutés, 2) le pourcentage de séances suivies, 3) le compte des foulées pendant l'intervention et les mesures d'efficacité préliminaire pendant la période de l'intervention sur le plan de 4) la mesure de la fonction motrice globale 66 (GMFM-66) et de 5) la cinématique et la mise en charge pendant la marche sur tapis roulant. Résultats: quatre garçons de moins de trois ans ont participé. Tous ont toléré des séances d'intervention de 60 minutes quatre fois par semaine pendant 12 semaines et ont assisté à 75 % à 94 % (minimum-maximum) des séances ciblées. Le compte médian de foulées par séance se situait entre 833 et 2 484 foulées (minimum­maximum) lors de la dernière semaine d'entraînement. Les participants ont présenté une augmentation de 2,4 à 7,5 points (minimum-maximum) au score du GMFM-66 pendant les trois mois de la phase d'intervention, par rapport à une diminution de 1,7 point chez un participant et à une augmentation de 1,3 point chez un autre pendant la période de report. Trois participants ont démonté de légères améliorations de leur démarche grâce à l'intervention. Conclusions: il est faisable de faire participer des jeunes enfants ayant une PC bilatérale à une réadaptation intensive visant la fonction motrice globale, et cette intervention a une efficacité préliminaire démontrée. Les résultats ont entraîné la conception d'une étude clinique plus vaste pour évaluer l'efficacité d'interventions précoces actives chez les enfants ayant une PC bilatérale spastique.

Neural Plasticity in Spinal and Corticospinal Pathways Induced by Balance Training in Neurologically Intact Adults: A Systematic Review.

Balance training, defined here as training of postural equilibrium, improves postural control and reduces the rate of falls especially in older adults. This systematic review aimed to determine the neuroplasticity induced by such training in younger (18-30 years old) and older adults (≥65 years old). We focused on spinal and corticospinal pathways, as studied with electrophysiology, in people without neurological or other systemic disorders. We were specifically interested in the change in the excitability of these pathways before and after training. Searches were conducted in four databases: MEDLINE, CINAHL, Scopus, and Embase. A total of 1,172 abstracts were screened, and 14 articles were included. Quality of the studies was evaluated with the Downs and Black checklist. Twelve of the studies measured spinal reflexes, with ten measuring the soleus H-reflex. The H-reflex amplitude was consistently reduced in younger adults after balance training, while mixed results were found in older adults, with many showing an increase in the H-reflex after training. The differences in results between studies of younger vs. older adults may be related to the differences in their H-reflexes at baseline, with older adults showing much smaller H-reflexes than younger adults. Five studies measured corticospinal and intracortical excitability using transcranial magnetic stimulation. Younger adults showed reduced corticospinal excitability and enhanced intracortical inhibition after balance training. Two studies on older adults reported mixed results after training. No conclusions could be drawn for corticospinal and intracortical plasticity given the small number of studies. Overall, balance training induced measurable change in spinal excitability, with different changes seen in younger compared to older adults.

Parent-therapist partnership to ELEVATE gross motor function in children with perinatal stroke: protocol for a mixed methods randomized controlled trial.

BACKGROUND: There is increasing evidence for early, active rehabilitation to enhance motor function following early brain injury. This is clear for interventions targeting the upper extremity, whereas passive treatment approaches for the lower extremity persist. The purpose of this trial is to evaluate the effectiveness of early, intensive rehabilitation targeting the lower extremity and delivered in a parent-therapist partnership model for children with perinatal stroke. METHODS: We describe a protocol for a waitlist-control, single-blind, mixed methods effectiveness randomized controlled trial, with an embedded qualitative study using interpretative description. Participants are children with perinatal stroke aged eight months to three years with signs of hemiparesis. Participants will be randomly allocated to an immediate ELEVATE (Engaging the Lower Extremity Via Active Therapy Early) intervention group, or a waitlist-control group, who will receive usual care for six months. The ELEVATE intervention involves one hour of training four days per week for 12 weeks, with a pediatric therapist and a parent or guardian each delivering two sessions per week. The intervention targets the affected lower extremity by progressively challenging the child while standing and walking. The primary outcome measure is the Gross Motor Function Measure-66. Secondary outcomes include the Pediatric Quality of Life Inventory™, Young Children's Participation and Environment Measure, and an instrumented measure of spasticity. A cost-effectiveness analysis and qualitative component will explore benefit to costs ratios and parents' perspectives of early, intensive rehabilitation, and their role as a partner in the rehabilitation, respectively. DISCUSSION: This study has the potential to change current rehabilitation for young children with perinatal stroke if the ELEVATE intervention is effective. The parent interviews will provide further insight into benefits and challenges of a partnership model of rehabilitation. The mixed methods design will enable optimization for transfer of this collaborative approach into physical therapy practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT03672864 . Registered 17 September 2018.

Retraining walking over ground in a powered exoskeleton after spinal cord injury: a prospective cohort study to examine functional gains and neuroplasticity.

BACKGROUND: Powered exoskeletons provide a way to stand and walk for people with severe spinal cord injury. Here, we used the ReWalk exoskeleton to determine the training dosage required for walking proficiency, the sensory and motor changes in the nervous system with training, and the functionality of the device in a home-like environment. METHODS: Participants with chronic (> 1 yr) motor complete or incomplete spinal cord injury, who were primarily wheelchair users, were trained to walk in the ReWalk for 12 weeks. Measures were taken before, during, immediately after, and 2-3 months after training. Measures included walking progression, sitting balance, skin sensation, spasticity, and strength of the corticospinal tracts. RESULTS: Twelve participants were enrolled with 10 completing training. Training progression and walking ability: The progression in training indicated about 45 sessions to reach 80% of final performance in training. By the end of training, participants walked at speeds of 0.28-0.60 m/s, and distances of 0.74-1.97 km in 1 h. The effort of walking was about 3.3 times that for manual wheelchair propulsion. One non-walker with an incomplete injury became a walker without the ReWalk after training. Sensory and motor measures: Sitting balance was improved in some, as seen from the limits of stability and sway speed. Neuropathic pain showed no long term changes. Change in spasticity was mixed with suggestion of differences between those with high versus low spasticity prior to training. The strength of motor pathways from the brain to back extensor muscles remained unchanged. Adverse events: Minor adverse events were encountered by the participants and trainer (skin abrasions, non-injurious falls). Field testing: The majority of participants could walk on uneven surfaces outdoors. Some limitations were encountered in home-like environments. CONCLUSION: For individuals with severe SCI, walking proficiency in the ReWalk requires about 45 sessions of training. The training was accompanied by functional improvements in some, especially in people with incomplete injuries. TRIAL REGISTRATION: NCT02322125 Registered 22 December 2014.