Error Enhancement for Upper Limb Rehabilitation in the Chronic Phase after Stroke: A 5-Day Pre-Post Intervention Study.

A large proportion of chronic stroke survivors still struggle with upper limb (UL) problems in daily activities, typically reaching tasks. During three-dimensional reaching movements, the deXtreme robot offers error enhancement forces. Error enhancement aims to improve the quality of movement. We investigated clinical and patient-reported outcomes and assessed the quality of movement before and after a 5 h error enhancement training with the deXtreme robot. This pilot study had a pre-post intervention design, recruiting 22 patients (mean age: 57 years, mean days post-stroke: 1571, male/female: 12/10) in the chronic phase post-stroke with UL motor impairments. Patients received 1 h robot treatment for five days and were assessed at baseline and after training, collecting (1) clinical, (2) patient-reported, and (3) kinematic (KINARM, BKIN Technologies Ltd., Kingston, ON, Canada) outcome measures. Our analysis revealed significant improvements (median improvement (Q1-Q3)) in (1) UL Fugl-Meyer assessment (1.0 (0.8-3.0), p < 0.001) and action research arm test (2.0 (0.8-2.0), p < 0.001); (2) motor activity log, amount of use (0.1 (0.0-0.3), p < 0.001) and quality of use (0.1 (0.1-0.5), p < 0.001) subscale; (3) KINARM-evaluated position sense (-0.45 (-0.81-0.09), p = 0.030) after training. These findings provide insight into clinical self-reported and kinematic improvements in UL functioning after five hours of error enhancement UL training.

Should inclusion have an expiry date? Older people's attitudes on intellectual disabilities.

BACKGROUND: Older people with intellectual disabilities represent a new and neglected population in need of services, yet it may be problematic to include them in generic services without having a clear idea of how elderly people from the general population feel towards them. To the best of our knowledge, this topic has not been addressed quantitatively. METHOD: Seventy-three participants over 63 years of age (23 females and 50 males) from the general population without an intellectual disability completed two valid measures: the CLAS-MR and the WHOQOL-OLD. RESULTS: Level of education and quality of life were positively associated with attitudes towards people with intellectual disabilities. Age was negatively associated with knowledge regarding intellectual disability. CONCLUSIONS: When preparing for the inclusion of older people with intellectual disabilities in generic services, attention should be given to members' level of education, quality of life, and knowledge regarding intellectual disabilities. Sensitivity should be applied to potential tendencies to shelter people with intellectual disabilities.

Relationship between Occupational Identity Post-Stroke and Outcomes of a Self-Management Participation-Focused Intervention: A Preliminary Investigation.

Self-management programs are used to assist stroke survivors to manage their condition and participation. This study was designed to examine correlations between occupational identity and outcomes of participation-focused self-management program using the Occupational Performance History Interview for the occupational identity and participation and self-efficacy as outcome measures. Spearman's rho correlations were calculated between occupational Identity and the program's outcomes. Results showed moderate significant positive correlations with self-efficacy for self-management and self-efficacy for participation scales at baseline; few were found at post-intervention and follow-up. Non-significant correlations were found between occupational identity and the change in outcome measures from baseline to post-intervention and to follow-up. Findings suggest occupational identity is strongly related to self-efficacy after stroke, and less related to intervention outcomes. However, other factors may possibly affect the effectiveness of self-management programs for a stroke population. Exploration of these factors might help develop programs better tailored to each stroke survivor.

Impaired Coordination and Recruitment of Muscle Agonists, But Not Abnormal Synergies or Co-contraction, Have a Significant Effect on Motor Impairments After Stroke.

Movement synergies, muscle co-contraction, and decreased motor drive to muscle agonists were suggested to be major factors in motor impairments after stroke. The purpose of this study was to investigate the major muscle mechanisms contributing to motor impairment after stroke. Twelve healthy and 13 post-stroke patients participated in this observational study. Both groups participated in a single experimental session, performing hand pointing movements in multiple directions, during which EMG was assessed. Additionally, the patients underwent the Fugl-Meyer assessment. A set of features from the electromyography (EMG) signal and co-contraction ratios were used to compare the capacity to modulate the muscle activity between the two groups of participants. A correlation analysis was applied between the Euclidian distances of each target and the Fugl-Meyer scoring assessment in the post-stroke patients. We found that impaired modulation of muscle activity in post-stroke patients was characterized by significantly increased Euclidian distances between the EMG features of different target directions and by a higher variability between muscle activation compared to healthy subjects. Impaired capacity to modulate muscle activity significantly correlated with the impairment status. In conclusion, impaired motor performance post-stroke systematic disturbance in the control signal to limb muscles, which manifests as decreased capacity to modulate muscle activity, rather than co-contraction of muscle antagonists or stereotyped movement patterns.

Improvement in Hand Trajectory of Reaching Movements by Error-Augmentation.

The purpose of this study was to investigate whether adaptive responses to error-augmentation force fields, would decrease the trajectory errors in hand-reaching movements in multiple directions in healthy individuals. The study was conducted, as a randomized controlled trial, in 41 healthy subjects. The study group trained on a 3D robotic system, applying error-augmenting forces on the hand during the execution of tasks. The control group carried out the same protocol in null-field conditions. A mixed-model ANOVA was implemented to investigate the interaction between groups and time, and changes in outcome measures within groups. The findings were that there was a significant interaction effect for group × time in terms of the magnitude of movement errors across game-sets. The trajectory error of the study group significantly decreased from 0.035 ± 0.013 m at baseline to 0.029 ± 0.011 m at a follow-up, which amounted to a 14.8% improvement. The degree of movement errors were not significantly changed within a game-set. We conclude that practicing hand-reaching movement in multiple random directions, using the error-augmentation technique, decreases the deviation of the hand trajectory from a straight line. However, this type of training prevents the generalizability of adaptation between consecutive reaching movements. Further studies should investigate the feasibility of this training method for rehabilitation of post-stroke individuals.

Specialized Pain Clinics in Primary Care: Common Diagnoses, Referral Patterns and Clinical Outcomes - Novel Pain Management Model.

An estimated 19% of the adult population in western countries lives with chronic pain. Pain management lies mainly within the primary care and community setting. We evaluated the outcome of a new model of secondary care clinics, conducted by primary care physicians with specialized training in pain medicine. Data on referral patterns, prevalence of pain diagnosis, and medication consumption were recorded at five secondary pain management clinics in the community setting. In total, 997 patients with pain attended 2,652 visits (average 2.7 visits per patient) during 12 mo. Patients' age ranged from 18 to 92 yr (mean 59 ± 19). Mean pain intensity on the first visit, evaluated by the visual analogue scale was 7.7/10. Myofascial pain syndrome was the most common diagnosis (82%). Treatment included dry needling or trigger point injection (82%), manual myofascial release (23%), and pharmacotherapy (38%). Significant short-term improvement after treatment was reported by 75% of patients, and 72% reported long-term improvement. Four percent were referred to tertiary care pain clinics, 5% were referred to other specialists, and 5% to imaging. Secondary, community-based pain clinics, run by specially-trained primary physicians, demonstrated feasibility. The vast majority of patients referred to the clinics were treated using simple, inexpensive modalities, while sparing referrals to unnecessary consultation visits, imaging tests, and medications.

Two-Year Follow-Up of Fall Prediction Among Older Adults in an Independent-Living Community.

Adults over the age of 70 are at risk of falls. Early detection of risk of falls can suggest early interventions. In this study, we attempted to determine valid clinical tests that can differentiate older individuals who are at risk of falling. Older adults from an independent-living community volunteered to participate in this descriptive, cohort study. They were administered the Berg Balance Scale (BBS), Zur Balance Scale (ZBS), Head Shaking Nystagmus Head Impulse Test, Dynamic Visual Acuity, and the Hallpike maneuver for evaluating benign paroxysmal positional vertigo (BPPV); a questionnaire including sociodemographics and a health characteristics survey. Multivariate analysis indicated that a ZBS score < 51, previous fall, and number of medications strongly predict falls in older adults. ZBS score, BBS score, Hallpike maneuver, number of medications, deficit of vestibular ocular reflex, along with positive ZBS score and past fall differentiate between fallers and non-fallers. ZBS <51, taking >6 medications, and history of falls were a benchmark for high-risk of falling.

Very High Frequency Oscillations of Heart Rate Variability in Healthy Humans and in Patients with Cardiovascular Autonomic Neuropathy.

Literature reports on the very high frequency (VHF) range of 0.4-0.9 Hz in heart rate variability (HRV) are scanty. The VHF presence in cardiac transplant patients and other conditions associated with reduced vagal influence on the heart encouraged us to explore this spectral band in healthy subjects and in patients diagnosed with cardiac autonomic neuropathy (CAN), and to assess the potential clinical value of some VHF indices. The study included 80 healthy controls and 48 patients with spinocerebellar ataxia type 2 (SCA2) with CAN. The electrocardiographic recordings of short 5-min duration were submitted to three different spectral analysis methods, including the most generally accepted procedure, and the two novel methods using the Hilbert-Huang transform. We demonstrated the presence of VHF activity in both groups of subjects. However, VHF power spectral density, expressed in relative normalized units, was significantly greater in the SCA2 patients than that in healthy subjects, amounting to 36.1 ± 17.4% vs. 22.9 ± 14.1%, respectively, as also was the instantaneous VHF spectral frequency, 0.58 ± 0.05 vs. 0.64 ± 0.07 Hz, respectively. These findings were related to the severity of CAN. We conclude that VHF activity of HRV is integral to the cardiovascular autonomic control.

Measuring Dynamic Leg Length during Normal Gait.

Dynamic leg length [DLL] is a resultant factor of anatomic leg length and lower limb movement that is measured by the distance from the hip to the heel, ankle, and forefoot during the gait cycle. The aim of this study was to present DLL measurement during normal gait. Forty healthy participants underwent a gait evaluation using a motion analysis system. The average DLLs were compared between sides during the gait cycle using the paired t-test at 51 sample points. Time of maximal and minimal DLLs and the ratio between maximal and minimal DLLs during the gait cycle were calculated. DLLs were found to be consistent, indicated by a within standard deviation of <6.65 mm and by being symmetrical with no significant differences between sides [p > 0.103]. DLL patterns and time of maximal and minimal DLLs were established. The ratio between maximal DLLs during the stance phase and minimal DLLs during the swing phase was also defined and found to be symmetrical. Normative data of DLL measures were set with respect to magnitude and pattern during the gait cycle. These data might serve as a reference for abnormal gait deviation reflected by abnormal DLLs, thus promoting a new perspective in gait analysis.

Frailty and Primary Sarcopenia: A Review.

Increasing longevity, coupled with rising frailty and sarcopenia of aging, significantly affects function and quality of life of older adults. This review discusses the definition, assessment, and management of frailty and sarcopenia, and examines the relationship between them. Medline, Scopus and Psychoinfo databases were searched using the keywords frailty, sarcopenia, aging, and functional disability. The findings are that frailty and sarcopenia are often assessed clinically with such methods such as DeXA, CT scan, MRI, bioelectrical impedance, or anthropometry. Frailty and sarcopenia differentially affect older adults. Both conditions are characterized by decreased energy reserves and resistance to external and internal stressors, resulting in susceptibility to fatigue, comorbidity, sedentary life style, functional decline, hospitalization, quality of life, and even death. The estimated prevalence of frailty with sarcopenia is relatively low; however, the condition requires early detection and careful management.

Vitamin B12 screening in metformin-treated diabetics in primary care: were elderly patients less likely to be tested?

Low serum B12 level is a common occurrence in patients with type 2 diabetes (T2DM) treated with metformin. There is lack of evidence concerning blood testing of vitamin B12 and current clinical guidelines make no recommendations on the detection or prevention of vitamin B-12 deficiency during metformin treatment. Our objective was to examine the current practice and clinical determinants of vitamin B12 testing in metformin treated T2DM patients. Data were collected from health maintenance organization patients, and consisted of T2DM patients who were newly prescribed metformin from 2008 to 2013. Patients were randomly divided into two subgroups: referred for a vitamin B12 blood test, and did not receive a referral. The demographic data and medical characteristics were analyzed. 5131 patients began taking metformin during the study period. Of these 2332 (44.5 %) had vitamin B12 tested. Significant differences were found between the groups in regard to glycosylated hemoglobin, low density lipoprotein, systolic blood pressure, dyslipidemia, chronic renal failure, and disease duration. A significant positive association (p < .05) was found between vitamin B12 testing and insulin treatment, retinopathy, neuropathy and hypertension. Vitamin B12 in elderly (>75 years) patients was significantly lower (p < .01). Insulin treatment, hypertension, and chronic diabetic complications in metformin treated T2DM patients are associated with higher rates of vitamin B12 testing. T2DM patients 75 years and above were less likely to be tested for B12 deficiency.

[HORIZONTAL CANAL - BENIGN PAROXYSMAL POSITIONAL VERTIGO (HC-BPPV) - CLINICAL DIAGNOSTIC PROCEDURES].

INTRODUCTION: Horizontal canal benign paroxysmal positional vertigo (HCBPPV) is one form of benign paroxysmal positional vertigo. HC-BPPV is characterized by intermittent recurrent episodes of vertigo following a change in head position relative to gravity. HC-BPPV prevalence ranges from 5%-33% of all dizziness cases seen in otolaryngology, neurology and family physician clinics. Various factors, such as ear and head injury, can cause HC-BPPV. Cardiovascular disease and iatrogenic reasons are also implicated. Despite the prevalence of the disease, there are various forms of diagnostic procedures, some of which are unfamiliar to the therapist and some are controversial. This review aims to present the full range of methods of diagnosis of HC-BPPV, presenting their advantages and disadvantages.

Concurrent Validity and Reliability of a New Balance Scale Used in Older Adults.

Adults over the age of 70 are at risk of falling. Various balance tests have been developed to identify balance dysfunctions. Their disadvantages including ceiling effects and low sensitivity and duration led to the development of a new balance test. The present study was conducted to determine the concurrent validity, reliability, sensitivity, and specificity of the Zur Balance Scale (ZBS). In this descriptive, cross-sectional study, 76 senior adults were recruited from an independent senior living community and were administered the Berg Balance Scale (BBS) and the ZBS. The BBS was used as the standard of comparison. The ZBS includes head movements and time to maintain to balance. All the subjects completed the tests. Concurrent validity was r = 0.782 (p < 0.0001). The ZBS had high intra-test (0.897) and inter-test (0.934) correlation coefficients. Its sensitivity was 60 % and specificity 91 % for identifying falls. The dynamic portions of the ZBS capture the integration of the visual, vestibular, and somatosensory systems, as it mimics dynamic spatial aspects of daily activities. We conclude that the ZBS is reliable compared with BBS. It is a simple, easy to administer test that may predict future risk of falls.

Error augmentation as a possible technique for improving upper extremity motor performance after a stroke - a systematic review.

BACKGROUND: Improvement of motor performance is crucial in rehabilitation after a stroke. A new concept in motor learning and rehabilitation is error augmentation (EA): using erroneous sensory feedback to enhance adaptation to a new environment. However, the clinical efficacy of this method to enhance motor learning after a stroke needs to be evaluated. OBJECTIVES: To determine whether there is enough evidence-based knowledge to justify using the EA concept for upper extremity rehabilitation after a stroke over traditional rehabilitation methods. METHODS: Two reviewers systematically searched the English-language literature in six databases: PubMed, Web of science, PEDro, CINAHL, Cochrane, and Scopus, using the key words: "error augmentation" or "error enhancement" or "negative viscosity" and "stroke" and "upper extremity." The studies were evaluated based on their main characteristics and methodology. RESULTS: There is limited evidence about the effectiveness of this new method, as only eight studies, with limited methodological quality were found. The participants were usually in the chronic stage after the stroke. Two studies were randomized controlled trials, four used a crossover design, and two were pilot studies. Fugl-Meyer was the most common clinical outcome measure used to assess the effect of treatment. Three studies reported a significant improvement in the effects of EA training compared to control training, and two studies reported a significant treatment effect over time. CONCLUSIONS: Most of the studies reviewed have significant methodological drawbacks that resulted in equivocal results. Therefore, we recommend that additional randomized controlled trials, with larger sample sizes and acceptable protocols be conducted to determine the long-term efficacy of EA training.

How Do Skeletal Muscles Die? An Overview.

Clarifying the confusion regarding the term "muscle death" is of great importance, especially for clinicians. In response to various stimuli, skeletal muscle may undergo pathological changes, leading to muscle atrophy and consequently resulting in the loss of muscle strength and function. Depending on the stimulus, skeletal muscles can be induced to die through different mechanisms mainly via apoptosis, autophagy and necrosis. Muscle death may occur secondary to various physiological and pathological conditions such as aging, starvation, immobilization, denervation, inflammation, muscle diseases and cancer. This overview aims to elucidate the medical terminology and pathways used to describe muscle death, which are commonly confused. In addition, some of the common pathological conditions that lead to muscle death such as cachexia and sarcopenia of aging are dwelled on.

Identification and reduction of retained primitive reflexes by sensory stimulation in autism spectrum disorder: effects on qEEG networks and cognitive functions.

Several authors have reported finding retained primitive reflexes (RPRs) in individuals with autism spectrum disorders (ASD). This case report describes the reduction of RPRs and changes in cognitive function after transcutaneous electrical nerve stimulation (TENS) of muscle. Three individuals were examined in a study at the Institute for Neurology and Neurosurgery in Havana, Cuba. Two child neurologists, not involved in the study, conducted clinical examinations on each participant and diagnosed each with ASD based on DSM-V criteria and the Autism Diagnostic Interview-Revised (an autism evaluation tool). Each child with ASD possessed a triad of impairments in three domains: social interaction, communication, and repetitive behaviour. Individuals were evaluated by quantitative electroencephalographic measures and tested by standardised cognitive function tests before and after 12 weeks of intervention. These interventions were associated with reduced ASD symptoms in the three domains, significant changes in qEEG network connectivity and significantly improved performance on standardised cognitive tests.

Reliability, validity and normal ranges of the Zur Balance Scale for detecting mild postural control differences: introducing the modified, short version mZBS.

Introduction: Balance is achieved through interactions between the vestibular, somatosensory, and visual systems. There are several clinical tests to measure postural stability. However, most of them do not assess postural stability with head movements, which is the main function of the vestibular system, and those that do, require the use of sizeable, expensive equipment. Therefore, an applicable, easy-to-perform test that challenges the function of the visual, somatosensory and vestibular systems, using head movements, is needed. The Zur Balance Scale (ZBS) contains ten conditions, which are a combination of surfaces (floor or Styrofoam with subject standing on its width in Romberg position or its length in tandem position), stances (Romberg or tandem), tasks (no head movement with eyes open or closed and horizontal or vertical head movements with eyes open). The purpose of this study was to determine the validity, inter- and intra-examiner reliability, and normal performance values of the ZBS among individuals 29-70-years of age and to introduce the modified version: the mZBS, using kinetic measurements. Methods: Healthy participants ages 29-70 years were evaluated for inter- and intra-tester reliability (n = 65), kinetic measurements on a force plate, and validity compared to the modified clinical test of sensory interaction and balance (mCTSIB) (n = 44) and characterization of normal values (n = 251). Results: Zur Balance Scale head movements, duration of each condition (up to 10 s) and the total ZBS score agreed across examiners (ICC > 0.8). Normal ZBS scores were negatively correlated with age (r = -0.34; P < 0.0001). Older subjects (60-70 years) had a median score of 95.5 compared with younger subjects, where medians ranged from 97.6 to 98.9. Kinetic parameters showed positive correlations between ZBS and the mCTSIB scores, with the highest correlation between the five Romberg tasks (modified ZBS). Conclusion: Zur Balance Scale is a valid and reliable test. Its advantages include using head movements and the ability to detect minimal differences in postural control, even in healthy populations. Kinetic evaluation of the ZBS enables the use of a modified, shorter version of the ZBS (mZBS).

The Relationship between Retained Primitive Reflexes and Hemispheric Connectivity in Autism Spectrum Disorders.

BACKGROUND: Autism Spectrum Disorder (ASD) can be identified by a general tendency toward a reduction in the expression of low-band, widely dispersed integrative activities, which is made up for by an increase in localized, high-frequency, regionally dispersed activity. The study assessed ASD children and adults all possessing retained primitive reflexes (RPRs) compared with a control group that did not attempt to reduce or remove those RPRs and then examined the effects on qEEG and brain network connectivity. METHODS: Analysis of qEEG spectral and functional connectivity was performed, to identify associations with the presence or absence of retained primitive reflexes (RPRs), before and after an intervention based on TENS unilateral stimulation. RESULTS: The results point to abnormal lateralization in ASD, including long-range underconnectivity, a greater left-over-right qEEG functional connectivity ratio, and short-range overconnectivity in ASD. CONCLUSIONS: Clinical improvement and the absence of RPRs may be linked to variations in qEEG frequency bands and more optimized brain networks, resulting in more developmentally appropriate long-range connectivity links, primarily in the right hemisphere.

Retained Primitive Reflexes and Potential for Intervention in Autistic Spectrum Disorders.

We provide evidence to support the contention that many aspects of Autistic Spectrum Disorder (ASD) are related to interregional brain functional disconnectivity associated with maturational delays in the development of brain networks. We think a delay in brain maturation in some networks may result in an increase in cortical maturation and development in other networks, leading to a developmental asynchrony and an unevenness of functional skills and symptoms. The paper supports the close relationship between retained primitive reflexes and cognitive and motor function in general and in ASD in particular provided to indicate that the inhibition of RPRs can effect positive change in ASD.

Retrospective trial of complete decongestive physical therapy for lower extremity secondary lymphedema in melanoma patients.

BACKGROUND: Melanoma is a malignant tumour of melanocytes, which are found predominantly in skin, and at least 10-45% of patients develop secondary lymphedema (SL). PURPOSE: This study seeks to investigate if individual's lymphatic system can benefit from complete decongestive physical therapy (CDPT) 1 year after discharge from CDPT and consequently endorsing a better quality of life. METHODS: Male and female(n=12) melanoma survivors 1-4 years post diagnosis with unilateral SL. Questionnaire and limb measurements were used to asses retrospective outcomes. RESULTS: A significant improvements (p<0.05) has been in the categories of localisation, staging, disability and symptoms of SL. CONCLUSIONS: CDPT provides relief in signs and symptoms for patients with SL following groyne dissection.