Effects and Mechanisms of Exercise on Brain-Derived Neurotrophic Factor (BDNF) Levels and Clinical Outcomes in People with Parkinson's Disease: A Systematic Review and Meta-Analysis.

INTRODUCTION: Exercise therapy may increase brain-derived neurotrophic factor (BDNF) levels and improve clinical outcomes in people living with Parkinson's disease (PD). This systematic review was performed to investigate the effect of exercise therapy on BDNF levels and clinical outcomes in human PD and to discuss mechanisms proposed by authors. METHOD: A search on the literature was performed on PubMed up to December 2023 using the following key words: Parkinson's disease AND exercise, exercise therapy, neurological rehabilitation AND brain-derived neurotrophic factor, brain-derived neurotrophic factor/blood, brain-derived neurotrophic factor/cerebrospinal fluid AND randomized clinical trial, intervention study. Only randomized clinical trials comparing an exercise intervention to treatment as usual, usual care (UC), sham intervention, or no intervention were included. RESULTS: A meta-analysis of BDNF outcomes with pooled data from five trials (N = 216 participants) resulted in a significant standardized mean difference (SMD) of 1.20 [95% CI 0.53 to 1.87; Z = 3.52, p = 0.0004, I2 = 77%], favoring exercise using motorized treadmill, Speedflex machine, rowing machine, and non-specified exercise. Significant improvements were found in Unified Parkinson's Disease Rating Scale (UPDRS), UPDRS-III, 6 Minute Walk Test (6MWT), and Berg Balance Scale (BBS). Methodological quality of trials was categorized as "good" in three trials, "fair" in one trial, and "poor" in one trial. CONCLUSION: Key results of this systematic review are that exercise therapy is effective in raising serum BDNF levels and seems effective in alleviating PD motor symptoms. Exercise therapy confers neuroplastic effects on Parkinson brain, mediated, in part, by BDNF.

The Flow State Scale for Rehabilitation Tasks: A New Flow Experience Questionnaire for Stroke Patients.

IMPORTANCE: Flow can be described as a subjective state that people report when they fully engage in an activity and experience pleasure, satisfaction, and enjoyment. Flow experiences are measured to determine the extent to which patients engage in therapy activities. Several flow questionnaires are used in neurorehabilitation. However, none have been validated for patients with (sub)acute stroke. OBJECTIVE: To develop and validate a new flow questionnaire for patients with (sub)acute stroke. DESIGN: Single-center prospective cohort study. SETTING: Neurorehabilitation unit of the Neurocenter of the Luzerner Kantonsspital in Lucerne, Switzerland. PARTICIPANTS: Fifty patients with (sub)acute stroke. OUTCOMES AND MEASURES: Development of the Flow State Scale for Rehabilitation Tasks (FSSRT) and determination of the psychometric properties of the FSSRT (internal consistency, test-retest reliability, structural and construct validity) in (sub)acute stroke patients. RESULTS: The FSSRT showed good internal consistency and excellent test-retest reliability. Composed of four components-concentration, pleasure, movement control, and absorption-the FSSRT correlated significantly negatively with the Hospital Anxiety and Depression Scale, indicating good divergent validity. CONCLUSIONS AND RELEVANCE: The FSSRT is a reliable and valid questionnaire measuring flow experience in patients with (sub)acute stroke. This questionnaire can be easily used in occupational therapy as well as in physical therapy and gives therapists important information about the flow experience of patients during therapy to adjust the therapy accordingly. Plain-Language Summary: Measuring flow experience, or the extent to which patients engage in therapy activities, in the context of occupational therapy and physical therapy is a new approach. This study confirmed that the Flow State Scale for Rehabilitation Tasks questionnaire is reliable and valid for measuring the flow experience of patients after (sub)acute stroke. Occupational therapists and physical therapists can use the FSSRT to optimally adjust the therapy program and increase patient engagement during therapy.

Profiling Daily Life Performance Recovery in the Early Subacute Phase After Stroke Using a Graphical Modeling Approach.

Background Laboratory-based assessments have shown that stroke recovery is heterogeneous between patients and affected domains such as motor and language function. However, laboratory-based assessments are not ecologically valid and do not necessarily reflect patients' daily life performance. Therefore, we aimed to give an innovative view on stroke recovery by profiling daily life performance recovery across domains in patients with early subacute stroke and determine their interrelatedness, taking stroke localization into account. Methods and Results Daily life performance was observed at neurorehabilitation admission and weekly thereafter until discharge, using a scale containing 7 daily life domains. Graphical modeling was applied to investigate the conditional independence between recovery of these domains depending on stroke localization. There were 592 patients analyzed. Four clusters of interrelated domains were identified within the first 6 weeks poststroke. The first cluster included recovery in learning and applying knowledge, general tasks and demands, and domestic life. The second cluster comprised recovery in self-care and general tasks and demands. The third cluster included recovery in mobility and self-care; it incorporated interpersonal interactions and relationships in left supratentorial stroke, and learning and applying knowledge in right supratentorial stroke. The final cluster included only communication recovery. Conclusions Daily life recovery dynamics early poststroke show that although impairments in body functions are anatomically determined, their impact on performance is comparable. Second, some, but by no means all, domains show an interrelated recovery. Domains requiring cognitive abilities are especially interrelated and seem to be essential for concomitant recovery in mobility and domestic life.

Rasch validation of a new scale to measure dependency in arm use in daily life: the Upper Limb Lucerne ICF-based Multidisciplinary Observation Scale.

Introduction: About 77% of adults with stroke have upper limb impairments. Many scales are available to measure the impairment and activity level of the affected limb. However, an observational scale to assess dependency on others in upper limb performance during daily life activities instead of laboratory settings is lacking. Therefore, we developed a new 5-item Upper Limb Lucerne ICF-based Multidisciplinary Observation Scale (UL-LIMOS). As next step in the psychometric analysis, we evaluated the unidimensionality and structural validity of the UL-LIMOS with Rasch Measurement Theory and we calculated a cut-off score for independent arm use in daily life activities at discharge. Methods: This is a single-center cross-sectional study in adults with (sub) acute stroke. We applied Rasch Measurement Theory (RMT) to analyze the structural validation and unidimensionality of the UL-LIMOS. The outputs provide evidence of unidimensionality, item and person fit, overall fit, differential item functioning (DIF), principal component analysis of residuals (PCAR), person separation reliability (PSR), and residual item correlations (to identify local item dependence). Person mean location, floor and ceiling effects identify proper targeting. Results: We recruited 407 adults with (sub) acute stroke (median age 63 years, 157 women). All items and persons fit the Rasch model. The PSR of 0.90 indicates that clinicians and researchers can reliably use the scale for individual decision-making. There were small floor (2.70%) and ceiling (13.00%) effects. The average person mean location was 1.32 ± 2.99 logits. There was no DIF. PCAR eigenvalue was 2.46 with 49.23% explained variance. Paired t-tests revealed that 0.89% of person locations were significantly different, confirming unidimensionality. One pair of items (arm and hand use and fine hand use) showed residual item correlations. The ROC's AUC was 0.90, CI95% = [0.85-0.96] with cut-off score of ≥14/20, and high sensitivity (87%, CI95% = [81%-91%]), specificity (83%, CI95% = [77%-87%]) for independent arm use in daily living at discharge. Discussion: The new Rasch-based UL-LIMOS is a valid ICF-based observation performance scale at the ICF-activity level, to evaluate dependency during upper limb use in daily life in adults with stroke. Additional psychometric analyses are warranted. The UL-LIMOS would be a valuable addition to the core assessments of adults with (sub) acute stroke.

(HIIT-The Track) High-Intensity Interval Training for People with Parkinson's Disease: Individual Response Patterns of (Non-)Motor Symptoms and Blood-Based Biomarkers-A Crossover Single-Case Experimental Design.

INTRODUCTION: Physical exercise is receiving increasing interest as an augmentative non-pharmacological intervention in Parkinson's disease (PD). This pilot study primarily aimed to quantify individual response patterns of motor symptoms to alternating exercise modalities, along with non-motor functioning and blood biomarkers of neuroplasticity and neurodegeneration. MATERIALS & METHODS: People with PD performed high-intensity interval training (HIIT) and continuous aerobic exercise (CAE) using a crossover single-case experimental design. A repeated assessment of outcome measures was conducted. The trajectories of outcome measures were visualized in time series plots and interpreted relative to the minimal clinically important difference (MCID) and smallest detectable change (SDC) or as a change in the positive or negative direction using trend lines. RESULTS: Data of three participants were analyzed and engaging in physical exercise seemed beneficial for reducing motor symptoms. Participant 1 demonstrated improvement in motor function, independent of exercise modality; while for participant 2, such a clinically relevant (positive) change in motor function was only observed in response to CAE. Participant 3 showed improved motor function after HIIT, but no comparison could be made with CAE because of drop-out. Heterogeneous responses on secondary outcome measures were found, not only between exercise modalities but also among participants. CONCLUSION: Though this study underpins the positive impact of physical exercise in the management of PD, large variability in individual response patterns to the interventions among participants makes it difficult to identify clear exercise-induced adaptations in functioning and blood biomarkers. Further research is needed to overcome methodological challenges in measuring individual response patterns.

A case study of left visual neglect after right pontine lesion: pathophysiological evidence for the infratentorial involvement in human visual attention.

Hemispatial neglect, the inability to attend to the contralesional side of space, is the most common disturbance of visuospatial attention. Both hemispatial neglect and visuospatial attention are typically associated with extended cortical networks. Nevertheless, recent accounts challenge this so-called corticocentric view and postulate the participation of structures well beyond the telencephalic cortex, in particular advocating the role of the brainstem. However, to the best of our knowledge, hemispatial neglect after a brainstem lesion has not yet been described. We describe, for the first time in a human, the occurrence and remission of contralesional visual hemispatial neglect after a focal lesion in the right pons. Hemispatial neglect was assessed by means of video-oculography during free visual exploration, a very sensitive and established method, and its remission was followed up until 3 wk after stroke. Moreover, by means of a lesion-deficit approach complemented by imaging, we identify a pathophysiological mechanism involving the disconnection of cortico-ponto-cerebellar and/or tecto-cerebellar-tectal pathways passing through the pons. Our findings offer, for the first time in a human, causal, lesion-based support for recent seminal accounts postulating the role of infratentorial structures participating in the activity of cerebral cortical attentional networks mediating attentional processes.NEW & NOTEWORTHY Visuospatial attention and its most common disturbance, hemispatial neglect, are typically associated with extended cortical networks. However, recent accounts challenge this corticocentric view and advocate the role of infratentorial structures. We describe, for the first time in a human, the occurrence of contralesional visual hemispatial neglect after a focal lesion in the right pons. We provide causal, lesion-based evidence for a pathophysiological mechanism involving the disconnection of cortico-ponto-cerebellar and/or tecto-cerebellar-tectal pathways passing through the pons.

An Overview of Wearable Haptic Technologies and Their Performance in Virtual Object Exploration.

We often interact with our environment through manual handling of objects and exploration of their properties. Object properties (OP), such as texture, stiffness, size, shape, temperature, weight, and orientation provide necessary information to successfully perform interactions. The human haptic perception system plays a key role in this. As virtual reality (VR) has been a growing field of interest with many applications, adding haptic feedback to virtual experiences is another step towards more realistic virtual interactions. However, integrating haptics in a realistic manner, requires complex technological solutions and actual user-testing in virtual environments (VEs) for verification. This review provides a comprehensive overview of recent wearable haptic devices (HDs) categorized by the OP exploration for which they have been verified in a VE. We found 13 studies which specifically addressed user-testing of wearable HDs in healthy subjects. We map and discuss the different technological solutions for different OP exploration which are useful for the design of future haptic object interactions in VR, and provide future recommendations.

Feasibility and usability of a new home-based immersive virtual reality headset-based dexterity training in multiple sclerosis.

BACKGROUND: Impaired manual dexterity is frequent and disabling in patients with multiple sclerosis (MS), affecting activities of daily living and quality of life. OBJECTIVE: The aim of this study was to evaluate the feasibility, usability and patient engagement/satisfaction of a home-based immersive virtual reality (VR) headset-based dexterity training in persons with multiple sclerosis (pwMS). In addition, preliminary efficacy data on the impact of this new training on manual dexterity were collected. METHODS: Single arm prospective study. After a waiting period of two weeks, pwMS performed a specifically developed home-based VR headset-based dexterity training using the Oculus quest 2 for two weeks with five training sessions/week, each session for approximately 20 minutes. Primary endpoints were feasibility (measured by the adherence rate), usability (System Usability Scale, SUS) and patient engagement/satisfaction (Custom User Engagement Questionnaire, CUEQ). Secondary exploratory efficacy endpoints, measured before and after the waiting period as well as after the training intervention, were the Nine-hole-Peg-Test (9HPT), Coin rotation task (CRT), Handheld JAMAR dynamometer, Arm Function in Multiple Sclerosis Questionnaire (AMSQ) and the Multiple Sclerosis Impact Scale 29 (MSIS 29). RESULTS: Eleven pwMS (mean age 49 ± 10.87 SD, mean EDSS 4.28 ± 1.48 SD) participated in the study. Feasibility (adherence rate: 81.8%), usability (median SUS score 94 (IQR = 78-96)) and patient engagement/satisfaction (median 8 on scale of 1-10) of the VR training was very high. In addition, the CRT for the dominant hand improved significantly after training (p = 0.03). CONCLUSIONS: The good results on feasibility, usability, and patient engagement/satisfaction qualify this home-based immersive VR headset-based dexterity training approach for the use in home-based neurorehabilitation in pwMS. Improved fine motor skills for the dominant hand suggest preliminary efficacy, but this needs to be proven in a future randomized-controlled trials.

Feasibility of a combined intermittent theta-burst stimulation and video game-based dexterity training in Parkinson's disease.

BACKGROUND: Persons with Parkinson's disease (PD) often exhibit difficulties with dexterity during the performance of activities of daily living (ADL), inter alia due to dysfunctional supplementary motor area (SMA). Combined intermittent theta-burst stimulation (iTBS) over the SMA followed by video game-based training (VBT) may therefore improve dexterity related ADL. The VBT may induce high flow levels related to high performance during the training. The aim of this study is to evaluate the feasibility of a combined iTBS-VBT intervention in persons with PD. METHODS: A total of nine persons with PD (mean age 63.3 ± 8.76 years) with self-reported difficulties with dexterity related ADL were included in this pilot iTBS-VBT study. All participants received either iTBS or sham stimulation over the SMA followed by a 45-min VBT, three times a week for a total of three weeks. Feasibility was measured by means of the adherence rate and the system usability (System Usability Scale). Moreover, flow was measured after the last VBT session. RESULTS: Adherence rate was excellent with 100%. High system usability scores (i.e., mean 80%, range 55-97.5) and a significant Spearman's correlation with the Flow State Scale (r = .762, p = .017) further point to the high feasibility of the VBT. Neither demographic variables nor difficulties in dexterity related ADL affected the usability of the VBT. CONCLUSION: This study demonstrates the high feasibility of a combined iTBS-VBT intervention. Moreover, the level of self-reported usability was related to flow experience. Whether this kind of combined iTBS-VBT intervention improves dexterity will be evaluated in a randomized controlled trial. Trial registration clincaltrials.gov NCT04699149, date of registration 1. June 2021.

Graded peak cycle ergometer test for cognitively impaired patients with Parkinson's disease: a pilot study.

BACKGROUND: Cognitive decline affects up to 50% of patients with Parkinson's disease (PD) in the course of the disease and may be amenable to exercise interventions. To accurately set adequate training intensities, standardized exercise testing is required but such testing takes considerable time and effort. The aim of this pilot study was to investigate the feasibility of a graded peak cycle ergometer exercise test in cognitively impaired patients with Parkinson's Disease (PD), and to define whether age-predicted maximal heart rate (HRmax) matched measured HRmax. METHODS: A convenience sample of seven patients with PD (Hoehn and Yahr: 2-4, and cognitive impairment (Montreal Cognitive Assessment (MoCA) ≤ 26) completed a graded peak cycle ergometer test to voluntary exhaustion. Borg Rating of Perceived Exertion was used to record the individual's perception of exertion. Pre-defined age-predicted HRmax (calculated as 208-(0.7 × age) was compared with the measured HRmax using Bland-Altman plot and a two-one-sided test. RESULTS: All PD patients completed the graded exercise test between 8-12 minutes, showing therefore 100% compliance to the test protocol. No adverse events occurred. Predicted HRmax and measured HRmax did not differ. CONCLUSION: We demonstrate feasibility of graded peak cycle ergometer testing in PD patients with cognitive impairment. The good correspondence of age-predicted HRmax equation with measured HRmax, in this small sample, may in the future provide clinicians with a tool to define training intensities in cognitively impaired PD, without cardiac disease. However, further research is needed to confirm these results.

Joint impact on attention, alertness and inhibition of lesions at a frontal white matter crossroad.

In everyday life, information from different cognitive domains-such as visuospatial attention, alertness and inhibition-needs to be integrated between different brain regions. Early models suggested that completely segregated brain networks control these three cognitive domains. However, more recent accounts, mainly based on neuroimaging data in healthy participants, indicate that different tasks lead to specific patterns of activation within the same, higher-order and 'multiple-demand' network. If so, then a lesion to critical substrates of this common network should determine a concomitant impairment in all three cognitive domains. The aim of the present study was to critically investigate this hypothesis, i.e. to identify focal stroke lesions within the network that can concomitantly affect visuospatial attention, alertness and inhibition. We studied an unselected sample of 60 first-ever right-hemispheric, subacute stroke patients using a data-driven, bottom-up approach. Patients performed 12 standardized neuropsychological and oculomotor tests, four per cognitive domain. A principal component analysis revealed a strong relationship between all three cognitive domains: 10 of 12 tests loaded on a first, common component. Analysis of the neuroanatomical lesion correlates using different approaches (i.e. voxel-based and tractwise lesion-symptom mapping, disconnectome maps) provided convergent evidence on the association between severe impairment of this common component and lesions at the intersection of superior longitudinal fasciculus II and III, frontal aslant tract and, to a lesser extent, the putamen and inferior fronto-occipital fasciculus. Moreover, patients with a lesion involving this region were significantly more impaired in daily living cognition, which provides an ecological validation of our results. A probabilistic functional atlas of the multiple-demand network was performed to confirm the potential relationship between patients' lesion substrates and observed cognitive impairments as a function of the multiple-demand network connectivity disruption. These findings show, for the first time, that a lesion to a specific white matter crossroad can determine a concurrent breakdown in all three considered cognitive domains. Our results support the multiple-demand network model, proposing that different cognitive operations depend on specific collaborators and their interaction, within the same underlying neural network. Our findings also extend this hypothesis by showing (i) the contribution of superior longitudinal fasciculus and frontal aslant tract to the multiple-demand network; and (ii) a critical neuroanatomical intersection, crossed by a vast amount of long-range white matter tracts, many of which interconnect cortical areas of the multiple-demand network. The vulnerability of this crossroad to stroke has specific cognitive and clinical consequences; this has the potential to influence future rehabilitative approaches.

Speed up discharge planning at the acute stroke unit: A development and external validation study for the early prediction of discharge home.

Background: To reduce healthcare costs, it has become increasingly important to shorten the length of stay in acute stroke units. The goal of this study was to develop and externally validate a decision tree model applicable < 48 h poststroke for discharge home from an acute stroke unit with a short length of stay, and to assess the inappropriate home discharge rate. Methods: A prospective study including two samples of stroke patients admitted to an acute stroke unit. The outcome was discharge home (yes/no). A classification and regression tree analysis was performed in Sample 1. The model's performance was tested in Sample 2. Results: In total, 953 patients were included. The final decision tree included the patients' activities of daily living (ADL) performance <48 h poststroke, including motor function, cognition, and communication, and had an area under the curve (AUC) of 0.84 (95% confidence interval 0.76, 0.91). External validation resulted in an AUC of 0.74 (95% confidence interval 0.72, 0.77). None of the patients discharged home were re-admitted < 2 months after discharge to a hospital or admitted to a rehabilitation center for symptoms that had needed inpatient neurorehabilitation. Conclusions: The developed decision tree shows acceptable external validity in predicting discharge home in a heterogeneous sample of stroke patients, only based on the patient's actual ADL performance <48 h poststroke. Importantly, discharge was safe, i.e., no re-hospitalization was registered. The tree's application to speed up discharge planning should now be further evaluated.

Development and Validation of the Short-LIMOS for the Acute Stroke Unit-A Short Version of the Lucerne ICF-Based Multidisciplinary Observation Scale.

Introduction: At hospital stroke units, the time available to assess the patient's limitations in activities and participation is limited, although being essential for discharge planning. Till date, there is no quick-to-perform instrument available that captures the patient's actual performance during daily activities from a motor, cognitive, and communication perspective within the International Classification of Functioning, Disability and Health (ICF) framework. Therefore, the aim was to develop and validate a shortened version of the Lucerne ICF-Based Multidisciplinary Observation Scale (Short-LIMOS) that observes the patient's performance across ICF-domains and is applicable in the context of an acute stroke unit. Methods: The Short-LIMOS was developed by reducing the original 45-item LIMOS to the ten most important items using a multivariable linear regression ANOVA with data of 836 stroke patients collected during inpatient neurorehabilitation. The Short-LIMOS's reliability, validity, and responsiveness were evaluated with data of 416 stroke patients in the acute stroke unit. Results: A significant equation [F (10,825) = 232.083] with R 2 of 0.738 was found for the following ten items for the Short-LIMOS: maintaining a body position (d415), changing basic body position (d410), climbing stairs (d4551), eating (d550), dressing (d540), communicating with-receiving-written messages (reading) (d325), applying knowledge, remembering facts (d179), solving complex problems (d1751), making simple decisions (d177), and undertaking a simple task (d2100). Principal component analysis revealed a Short-LIMOS motor and a Short-LIMOS cognition/communication component. The Short-LIMOS had a high internal consistency and good test-retest reliability. A moderate construct validity was shown by the significant correlation with the Barthel Index. The Short-LIMOS had neither floor nor ceiling effects. Discussion and Conclusion: The developed Short-LIMOS was found to be reliable and valid within a population of (hyper)acute and subacute stroke patients. The added value of this multidisciplinary assessment is its comprehensiveness by capturing the patient's actual performance on the motor, cognitive, and communication domain embedded in an ICF-framework in <10 mins.

Tablet app-based dexterity training in multiple sclerosis (TAD-MS): a randomized controlled trial.

PURPOSE: Mobile health applications (mHealth apps) may lead to health benefits. In recent years, the use of apps in multiple sclerosis (MS) has increased. Apps to train and improve dexterity in MS are scarce. This study investigated the effectiveness of a tablet app-based home-based training to improve dexterity in individuals with MS. MATERIALS AND METHODS: In a randomized controlled trial, two standardized 4-week home-based interventions focussing on different aspects of dexterity and upper limb function were compared. Assessments were done at baseline, post-intervention and 12-week follow-up. The primary endpoint was the Arm Function in Multiple Sclerosis Questionnaire, a dexterity-related measure of patient-reported activities of daily living. Secondary endpoints were dexterous function, grip strength and health-related quality of life. RESULTS: Forty-eight individuals were randomly assigned to a tablet app-based program (n = 26) or a control strengthening exercise program (n = 22). No significant differences were found for the primary endpoint (p = 0.35). Some significant differences in favour of the app-group were found in fine coordinated finger movements and strength. No significant differences were found at the 12-week follow-up for all endpoints. Adherence in both groups was above 90%. CONCLUSIONS: App-based training was not superior compared to a control strengthening exercise program concerning the arm- and hand function from the participant's perspective. However, app-based training was found to be effective in improving specific dimensions (finger movements and strength), and can easily be applied at home. Therefore, individuals living with MS with impaired dexterity should consider app-based training. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov NCT03369470.

This study provides initial evidence for the effectiveness of a home-based app-based program for improving dexterous function in individuals living with multiple sclerosis through the implementation of a tablet app-based dexterity training.App-based training was not superior compared to a control strengthening exercise program concerning the arm- and hand function from the participant's perspective.Patients attending the app-based dexterity program showed some statistically significant improvements in fine coordinated finger movements and strength.

Usability of Two New Interactive Game Sensor-Based Hand Training Devices in Parkinson's Disease.

This pilot cross-sectional study aimed to evaluate the usability of two new interactive game sensor-based hand devices (GripAble and Smart Sensor Egg) in both healthy adults as well as in persons with Parkinson's Disease (PD). Eight healthy adults and eight persons with PD participated in this study. Besides a standardised usability measure, the state of flow after one training session and the effect of cognitive abilities on flow were evaluated. High system usability scores (SUS) were obtained both in healthy participants (72.5, IQR = 64.375-90, GripAble) as well as persons with PD (77.5, IQR = 70-80.625, GripAble; 77.5, IQR = 75-82.5, Smart Sensor Egg). Similarly, high FSSOT scores were achieved after one training session (42.5, IQR = 39.75-50, GripAble; 50, IQR = 47-50, Smart Sensor Egg; maximum score 55). Across both groups, FSSOT scores correlated significantly with SUS scores (r = 0.52, p = 0.039). Finally, MoCA did not correlate significantly with FSSOT scores (r = 0.02, p = 0.9). The present study shows high usability for both interactive game sensor-based hand training devices, for persons with PD and healthy participants.

Validation of the Apraxia Screen TULIA (AST) in Schizophrenia.

INTRODUCTION: Deficits in social interaction and community functioning, including impaired use, performance, and perception of hand gestures, are key features in schizophrenia. A well-established tool to assess gesture deficits is the test of upper limb apraxia (TULIA). However, given its time-consuming application based on video analyses, research has proposed the bedside apraxia screen of TULIA (AST). This study aims to test the validity and reliability of the AST to detect gesture abnormalities at bedside in a sample of 27 patients diagnosed with schizophrenia, schizotypal disorder, acute and transient psychotic disorders, or schizoaffective disorder. METHODS: Patients completed the 48-item TULIA and the 12-item AST. Two different raters assessed the AST: one at bedside (online) and the other based on the video recordings. RESULTS: The total AST scores demonstrated a high parallel reliability, moderate inter-rater reliability on a single-item level, and good construct validities. CONCLUSIONS: The psychometric properties of the AST suggest it can well be used for the clinical assessment of gesture deficits in schizophrenia. However, when detailed information is required, the AST rated from video or conducting the full TULIA is recommended. The findings call for refining the selection of the TULIA items for a psychosis-AST bedside test to increase specificity.

Improved gesturing in left-hemispheric stroke by right inferior parietal theta burst stimulation.

Objectives: Apraxia is a common syndrome of left hemispheric stroke. A parieto-premotor-prefrontal network has been associated with apraxia, in which the left inferior parietal lobe (IPL-L) plays a major role. We hypothesized that transcranial continuous theta burst stimulation (cTBS) over the right inferior parietal lobe (IPL-R) improves gesturing by reducing its inhibition on the contralateral IPL in left hemispheric stroke patients. It was assumed that this effect is independent of lesion volume and that transcallosal connectivity is predictive for gestural effect after stimulation. Materials and methods: Nineteen stroke patients were recruited. Lesion volume and fractional anisotropy of the corpus callosum were acquired with structural magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI). Each patient had pseudorandomised sessions with sham or with stimulation over the IPL-R or over the right inferior frontal gyrus IFG-R. Gesturing was assessed in a double-blinded manner before and after each session. We tested the effects of stimulation on gesture performance using a linear mixed-effects model. Results: Pairwise treatment contrasts showed, that, compared to sham, the behavioral effect was higher after stimulation over IPL-R (12.08, 95% CI 6.04 - 18.13, p < 0.001). This treatment effect was approximately twice as high as the contrasts for IFG-R vs. sham (6.25, 95% CI -0.20 - 12.70, p = 0.058) and IPL-R vs. IFG-R vs. sham (5.83, 95% CI -0.49 - 12.15, p = 0.071). Furthermore, higher fractional anisotropy in the splenium (connecting the left and right IPL) were associated with higher behavioral effect. Relative lesion volume did not affect the changes after sham or stimulation over IPL-R or IFG-R. Conclusion: One single session of cTBS over the IPL-R improved gesturing after left hemispheric stroke. Denser microstructure in the corpus callosum correlated with favorable gestural response. We therefore propose the indirect transcallosal modulation of the IPL-L as a promising model of restoring interhemispheric balance, which may be useful in rehabilitation of apraxia.

Getting into a "Flow" state: a systematic review of flow experience in neurological diseases.

BACKGROUND: Flow is a subjective psychological state that people report when they are fully involved in an activity to the point of forgetting time and their surrounding except the activity itself. Being in flow during physical/cognitive rehabilitation may have a considerable impact on functional outcome, especially when patients with neurological diseases engage in exercises using robotics, virtual/augmented reality, or serious games on tablets/computer. When developing new therapy games, measuring flow experience can indicate whether the game motivates one to train. The purpose of this study was to identify and systematically review current literature on flow experience assessed in patients with stroke, traumatic brain injury, multiple sclerosis and Parkinson's disease. Additionally, we critically appraised, compared and summarized the measurement properties of self-reported flow questionnaires used in neurorehabilitation setting. DESIGN: A systematic review using PRISMA and COSMIN guidelines. METHODS: MEDLINE Ovid, EMBASE Ovid, CINAHL EBSCO, SCOPUS were searched. Inclusion criteria were (1) peer-reviewed studies that (2) focused on the investigation of flow experience in (3) patients with neurological diseases (i.e., stroke, traumatic brain injury, multiple sclerosis and/or Parkinson's disease). A qualitative data synthesis was performed to present the measurement properties of the used flow questionnaires. RESULTS: Ten studies out of 911 records met the inclusion criteria. Seven studies measured flow in the context of serious games in patients with stroke, traumatic brain injury, multiple sclerosis and Parkinson's disease. Three studies assessed flow in other activities than gaming (song-writing intervention and activities of daily living). Six different flow questionnaires were used, all of which were originally validated in healthy people. None of the studies presented psychometric data in their respective research population. CONCLUSION: The present review indicates that flow experience is increasingly measured in the physical/cognitive rehabilitation setting in patients with neurological diseases. However, psychometric properties of used flow questionnaires are lacking. For exergame developers working in the field of physical/cognitive rehabilitation in patients with neurological diseases, a valid flow questionnaire can help to further optimize the content of the games so that optimal engagement can occur during the gameplay. Whether flow experiences can ultimately have positive effects on physical/cognitive parameters needs further study.

Non-invasive brain stimulation in limb praxis and apraxia: A scoping review in healthy subjects and patients with stroke.

Non-invasive brain stimulation (NIBS) techniques are widely used in research settings to investigate brain mechanisms and increasingly being used for treatment purposes. The aim of this study was to systematically identify and review the current literature on NIBS studies of limb praxis and apraxia in healthy subjects and stroke patients with a scoping review using PRISMA-ScR guidelines. MEDLINE-PubMed, EMBASE and PsycINFO were searched. Inclusion criteria were English peer-reviewed studies focusing on the investigation of limb praxis/apraxia using repetitive transcranial magnetic stimulation (rTMS), or transcranial direct current stimulation (tDCS). Fourteen out of 139 records met the inclusion criteria, including thirteen studies with healthy subjects and one with stroke patients. The results of our systematic review suggest that in healthy subjects NIBS over left inferior parietal lobe (IPL) mainly interfered with gesture processing, by either affecting reaction times in judgment tasks or real gesturing. First promising results suggest that inhibitory continuous theta burst stimulation (cTBS) over right IPL may enhance gesturing in healthy subjects, explained by transcallosal facilitation of left IPL. In stroke patients, excitatory anodal tDCS over left IPL may improve limb apraxia. However, larger well powered and sham-controlled clinical trials are needed to expand on these proof-of-concept results, before NIBS could be a treatment option to improve limb apraxia in stroke patients.