Neurorehabilitation Services Research Articles

Harnessing Brain Plasticity: The Therapeutic Power of Repetitive Transcranial Magnetic Stimulation (rTMS) and Theta Burst Stimulation (TBS) in Neurotransmitter Modulation, Receptor Dynamics, and Neuroimaging for Neurological Innovations

Transcranial magnetic stimulation (TMS) methods have become exciting techniques for altering brain activity and improving synaptic plasticity, earning recognition as valuable non-medicine treatments for a wide range of neurological disorders. Among these methods, repetitive TMS (rTMS) and theta-burst stimulation (TBS) show significant promise in improving outcomes for adults with complex neurological and neurodegenerative conditions, such as Alzheimer’s disease, stroke, Parkinson’s disease, etc. However, optimizing their effects remains a challenge due to variability in how patients respond and a limited understanding of how these techniques interact with crucial neurotransmitter systems. This narrative review explores the mechanisms of rTMS and TBS, which enhance neuroplasticity and functional improvement. We specifically focus on their effects on GABAergic and glutamatergic pathways and how they interact with key receptors like N-Methyl-D-Aspartate (NMDA) and AMPA receptors, which play essential roles in processes like long-term potentiation (LTP) and long-term depression (LTD). Additionally, we investigate how rTMS and TBS impact neuroplasticity and functional connectivity, particularly concerning brain-derived neurotrophic factor (BDNF) and tropomyosin-related kinase receptor type B (TrkB). Here, we highlight the significant potential of this research to expand our understanding of neuroplasticity and better treatment outcomes for patients. Through clarifying the neurobiology mechanisms behind rTMS and TBS with neuroimaging findings, we aim to develop more effective, personalized treatment plans that effectively address the challenges posed by neurological disorders and ultimately enhance the quality of neurorehabilitation services and provide future directions for patients’ care.

A service evaluation of patients and clinicians experience of video consultations in a specialist outpatient neuro-rehabilitation service

IntroductionThere has been a rapid adoption of telerehabilitation services, particularly during the COVID-19 pandemic, with minimal guidance or evaluation of benefit. This survey explores experiences of video consultations in a specialist outpatient neuro-rehabilitation service. MethodsDigital surveys were designed to evaluate experience of Attend Anywhere. Anyone could answer the survey after attending a video consultation. Setting and participantsPatients and Doctors, occupational therapists, physiotherapists and speech and language therapists from a specialist outpatient neuro-rehabilitation service, between January and November 2020. ResultsA total of 637 surveys were analysed. 74.6% clinicians and 46.4% patients indicated video consultations were effective (X2=158.6, p<0.001). Physiotherapists indicated video consultation was not as effective as face to face (30.6%, X2=12.5, p=0.052). Over 95% of clinicians and patients reported they would use the video consultation system again X2=5.8, p<0.016. ConclusionsVideo consultation offers potential for improving access to healthcare for patients with complex neurological conditions.

Functional outcomes in children and adolescents with neurodisability accessing music therapy: A scoping review.

To determine the evidence for functional outcomes experienced by a population with paediatric neurodisability (such as acquired brain injury, cerebral palsy, spinal cord injury, and other neurological disorders), who access music therapy through neurorehabilitation services across the rehabilitation spectrum. Using scoping review methodology of the JBI and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), a systematic search was conducted across eight databases and expert knowledge users were consulted. Articles were screened by title and abstract, and data from eligible studies were categorized using the International Classification of Functioning, Disability and Health: Children and Youth version (ICF-CY). From 1726 records identified, 53 eligible primary sources were included in the synthesis. Most literature (n = 30) related to children and adolescents with an acquired or traumatic brain injury. Physical functionwas the most frequently reported outcome across sources(n = 27), followed by communication (n = 25), social (n = 22), cognitive (n = 17), emotional (n = 13), psychological (n = 13), behavioural (n = 8), and sensory (n = 5). Evidence for functional outcomes experienced by children and adolescents accessing music therapy as part of their neurorehabilitation is limited. More than half of the included sources were clinical descriptions with small samples. High-quality studies involving children, adolescents, families, and interprofessional teams are needed to identify the most effective music therapy methods and techniques for functional outcomes in paediatric neurodisability.

World Federation of Neurology Needs Registry Survey 2021

The WFN Needs Registry survey was developed and conducted over two and a half years commencing in 2020 to investigate the accessibility and affordability of neurological services and therapeutics and the most urgent needs. Method: An experienced neurologist responded in each of 118 societies to an online electronic survey comprising 13 questions. General data sought comprised the respondent's training, place of practice, duration in practice, number of neurologists in the society, health care system and types of neurological practice available. Specific data collected comprised neurological facilities, specialist services available, resources, therapeutics accessibility, challenges and three most urgent needs. ResultsResponding neurologists spent a median of 26 years in practice and represented a median of 225 neurologists per society. Of 13 classes of neuromedicines deemed readily available to 70% of the population, 41 societies listed ≥1 and 14 societies ≥3 unavailable. The three most frequent unavailable neuromedicines were second level AEDs, Dopamine agonists and MS DMTs. Of 14 neurological services, 15 societies had all services accessible and affordable, 13 had none and 72 had ≥1 services either inaccessible or unaffordable. EEG, Epilepsy, Headache and EMG services were most available; Neurogenetics, Neuropsychology, Neurorehabilitation and Neurodevelopmental services were least available. Of 13 specified challenges, lack of subspecialists and specialty centers were both identified by 61% of societies followed by costs of neurological care, neuromedicines availability and stigma. Ten societies had no challenges. ConclusionA unique insight into the inequities of neurological care globally and a potential tool to assist their remedy.

Developing a dietetic advanced practice role within a neuro-rehabilitation service

Developing a dietetic advanced practice role within a neuro-rehabilitation service

Provision and use of assistive products in patients after stroke and spinal cord injury in Germany: a qualitative interview study

Purpose Mobility impairments are a common consequence of stroke and spinal cord injury (SCI). Assistive products (APs) such as wheelchairs are often needed for activities and participation. The aim of the study was to explore the provision and use of APs in Germany and to identify associated factors underlying this practice. Materials and methods Semi-structured interviews were conducted with 19 professionals from outpatient neurorehabilitation services (three general practitioners, five physical therapists, five occupational therapists, one speech therapist, one neuropsychologist, two outpatient nurses, one rehab technician and one social worker), two patient advocates (long-term survivors, each stroke and SCI) and 20 patients (10 each after stroke and SCI with mobility impairment, and first-ever affected). Analysis was performed by qualitative content analysis. Results Reported experiences were mixed, varying from high satisfaction to unusable APs and unmet needs. Identified factors associated with these experiences were related to care pathways, care coordination, inter-professional collaboration, professionals’ knowledge and patient information, cost coverage, and approval procedures. Conclusion Overall, patients seem satisfied with the APs they receive, but patients with more severe mobility impairments in particular experience deficits in the provision and use of APs. Further research is needed to develop and test strategies for the provision and use of APs.

Dynamic Cognitive-Motor Training versus Cognitive Computer-Based Training in People with Multiple Sclerosis: A Preliminary Randomized Controlled Trial with 2-Month Follow-Up.

Background: Recent studies underscore the intricate relationship between cognitive and motor impairments in Multiple Sclerosis (MS), often exacerbated by CNS damage compromising neural connections. These cognitive-motor deficits contribute to reduced efficiency in daily activities and heightened risks of falls and accidents. The combination of challenging cognitive-motor training in a more ecological setting could improve cognitive functions in people with MS (PwMS). Objective: This study aims to compare the impact of dynamic cognitive-motor training versus computer-based cognitive training on overall cognitive efficiency in PwMS. Methods: Thirty-eight PwMS were recruited through the neurorehabilitation services of an Institute of research and health. Twenty-four participants were randomly assigned to the Cognitive-Motor group (CMg) and Cognitive Therapy group (CTg). Participants underwent three training sessions per week for four weeks, each lasting 50 min. The primary outcome was a comprehensive cognitive assessment using the Cognitive Impairment Index (CII), and the secondary outcomes were the Multiple Sclerosis Quality of Life Questionnaire MSQOL-54 and the Stroop Color Word Interference Test (SCWT). Results: Significant differences in the CII scores across T0, T1, and T2, as indicated by Friedman's test (χ2(2) = 14.558, p = .001), were found in the CMg. A significant difference in the change in health subscale of the MSQOL-54 was observed when comparing the groups across T0, T1, and T2 (χ2(2) = 6.059, p = .048). There were also statistically significant differences for the emotional well-being (χ2(2) = 7.581, p = .023) and health distress (χ2(2) = 11.902, p = .003) subscales. Post hoc analysis showed a statistically significant improvement in health-related quality of life (HRQOL) for the former at T1 vs. T0 (Z = -2.502, p = .012 and for the latter at T2 vs. T0 (Z = -2.670, p = .008), respectively. Conclusions: Our results support the combination of cognitive-motor training to enhance cognitive functional outcomes and quality of life compared to computer-based cognitive training in PwMS.

Defining paediatric neurorehabilitation: You cannot improve what you cannot characterize.

Neurorehabilitation is the primary therapy for neurological impairment in children, yet its potential to achieve change remains incompletely understood and probably underestimated. Understanding 'the difference neurorehabilitation can make' against a background of neurological repair and recovery as well as ongoing neurological development is an enormous challenge, exacerbated to no small extent by the lack of a 'common currency' for the description and measurement of the neurorehabilitation services a child is receiving. This review addresses attempts to parse neurorehabilitation treatment content in theoretically and mechanistically valid ways that might help address this challenge.

Current Status of Neurorehabilitation Services in the OIC Countries: Results of an International Online Survey

Objectives: Neurorehabilitation services are not widely available to most persons with disability (PWD) in the Organization of Islamic Cooperation countries. This study aimed to document status of neurorehabilitation services in OIC countries. Study Design and Setting: Cross-sectional online survey. Methods: Self-administered online survey conducted using Google Forms. Key resource persons for each OIC country working in field of neurorehabilitation were identified from various databases. The questionnaire was emailed to 20 identified resource persons. The response rate was 60% (12/20). Results: Neurorehabilitation services were available in 9 out of 12 surveyed countries. Only 2 countries reported providing access to neurorehabilitation services to 76-100% of their population. Five countries reported less than 25% of population had access to these services. Most commonly available neurorehabilitation services included services for stroke, spinal cord injury, pediatric neurorehabilitation, brain injury, and neuromuscular rehabilitation. Three countries had none of these specialized services. Five countries had neurorehabilitation training programs for physicians and other rehabilitation professionals. Patients had to pay out of pocket for these services in most of surveyed countries, followed by public funding and private insurance. Tele-neurorehabilitation and local disease-specific neurorehabilitation guidelines were not available in most of surveyed countries. Conclusion: Neurorehabilitation services in OIC region are not widely available, with significant variability in availability and quality. There is a need to develop and improve these services. Sharing knowledge and expertise through various forms, such as exchange visits and online sessions, can help improve neurorehabilitation services in these countries

Telerehabilitation! Is it time to rethink Neurorehabilitation services in Pakistan?

Telemedicine or Telehealth is a healthcare support utilizing communication technology when the participants are distant.1 After COVID-19 pandemic, there was an expansion in telehealth which changed the healthcare system.2 Telerehabilitation, defined as the therapy provided by physical therapist, occupational therapist, speech and language pathologist has however been used as an adjunct to the inperson care instead of completely replacing it.2 Telerehabilitation can be delivered using synchronous or real time telecommunication technologies or asynchronous 2-way interactive mediums can be used including audio/video calls for virtual visits, recorded educational materials and applications.3 It helps people living in areas with shortage of medical facilities have an access to healthcare.4 Although arguments have been raised regarding in-person limitation, patient satisfaction and reduced quality of healthcare, there are various studies that have proved to be contrary

Views of Service Users, Their Family or Carers, and Health Care Professionals on Telerehabilitation for People With Neurological Conditions in Ghana: Qualitative Study.

Up to 50% of people in low- and middle-income countries do not receive the rehabilitation they require. Telerehabilitation has the potential to improve access to neurorehabilitation services especially in low- and middle-income countries. Although there are reports of the barriers and facilitators to telerehabilitation in such settings, almost all are anecdotal. Furthermore, family or carers have a significant influence on the adoption and success of telerehabilitation, but their views have not been reported. This study aimed to investigate the views of service users, their family or carers, and health care professionals (HCPs) on telerehabilitation for people with neurological conditions in Ghana. Two focus groups were held at Komfo Anokye Hospital in Kumasi, Ghana: one in person for service users (n=11) and their family or carers (n=9), conducted in the Ghanaian language of Twi, and one hybrid for HCPs (n=18) conducted in English. The mean (SD) age of the service users was 59.8 (8.6) years; 5 users had a stroke and 6 had Parkinson disease. The HCP group consisted of 7 speech and language therapists, 3 physiotherapists, 3 occupational therapists, 3 medical staff, 1 nurse, and 1 industry representative. Focus groups were semi-structured and explored previous experiences of telerehabilitation, perceived benefits and challenges, and solutions to overcome these challenges. Focus groups were audio transcribed, and the service user transcript was translated into English. The resulting transcripts were analyzed using thematic analysis. Overall, participants were positive about the role of telerehabilitation but recommended hybrid delivery, with in-person rehabilitation in the early stages and telerehabilitation in the later stages. In relation to telerehabilitation in Ghana, there were 3 main themes: benefits, challenges or barriers, and implementation. Benefits included the convenience and lower cost for service users, the higher dose of therapy possible, and increased access for people in remote areas. However, challenges included lack of a stable internet connection, cost of phones and data packages, and low levels of literacy. Implementation issues included cultural relevance, information governance, and the platform used to deliver telerehabilitation, with most participants being familiar with WhatsApp. Telerehabilitation has the potential to be a useful method of delivering rehabilitation to people with neurological conditions in Ghana, especially in a hybrid rehabilitation model with telerehabilitation augmenting in-person sessions. However, many people were unaware of telerehabilitation, and challenges such as a reliable internet connection, cultural relevance, and costs need to be addressed. Clinical trials of low-cost telerehabilitation interventions contextualized to the specific user group are required.

A hub and spoke model to supply the Sicilian neurorehabilitation demand: effects on hospitalization rates and patient mobility.

Cerebrovascular diseases in Sicily have led to high mortality and healthcare challenges, with a notable gap between healthcare demand and supply. The mobility of patients seeking care, both within and outside Sicily, has economic and organizational impacts on the healthcare system. The Hub and Spoke model implemented by the IRCCS Centro Neurolesi "Bonino-Pulejo" of Messina aims to distribute advanced neurorehabilitation services throughout Sicily, potentially reducing health mobility and improving service accessibility. The evaluation was based on calculating hospitalization rates, examining patient mobility across Sicilian provinces, and assessing the financial implications of neurorehabilitation admissions. Data from 2016 to 2018, covering the period before and after the implementation of the Hub and Spoke network, were analyzed to understand the changes brought about by this model. The analysis revealed a significant increase in hospitalization rates for neurorehabilitation in the Sicilian provinces where spokes were established. This increase coincided with a marked decrease in interregional health mobility, indicating that patients were able to receive high-quality care closer to their residences. Furthermore, there was a decrease in both intra-regional and inter-regional escape rates in provinces within the Hub and Spoke network, demonstrating the network's efficacy in improving accessibility and quality of healthcare services. The implementation of the Hub and Spoke network substantially improved neurorehabilitation healthcare in Sicily, enhancing both accessibility and quality of care for patients. The network's establishment led to a more efficient utilization of healthcare resources and balanced distribution of services. These advancements are vital steps toward equitable and effective healthcare delivery in Sicily.

What are the key influences and challenges around weight management faced by patients in UK adult secure mental health settings? A focused ethnographic approach

ObjectivesExcess weight is highly prevalent in secure (forensic) mental health services and impacts negatively on patients’ physical and mental health. This study sought to identify the key influences and challenges...

Enhancing the Management of Pediatric Sickle Cell Disease by Integrating Functional Evaluation to Mitigate the Burden of Vaso-Occlusive Crises

Sickle cell disease (SCD) imposes a significant health burden, particularly in low- and middle-income countries where healthcare professionals and resources are scarce. This opinion paper delves into the management strategies employed for vaso-occlusive crises (VOCs) in pediatric patients with SCD, advocating for the adoption of a transformative strategy. We explore the integration of functional assessment approaches into existing procedures, highlighting the potential of technology-assisted rehabilitation, including wearable sensors and digital biomarkers, to enhance the effectiveness of managing and preventing VOCs. Rehabilomics, as a comprehensive framework, merges rehabilitation-related data with biomarkers, providing a basis for personalized therapeutic interventions. Despite the promising advantages of these approaches, persistent obstacles such as the limited availability of rehabilitation programs, especially in resource-limited settings, pose challenges. This paper underscores the importance of a collaborative strategy to effectively address the unique obstacles faced by patients with SCD. This collaborative approach involves improving accessibility to rehabilitation services, incorporating technology-supported therapy, and fostering focused research endeavors. The primary objective of this comprehensive approach is to enhance the overall care of SCD patients, with a specific focus on preventing VOCs, as well as providing tailored (neuro)rehabilitation services in resource-limited settings. By examining the current state of SCD management and proposing transformative strategies, this opinion paper seeks to inspire collective action and collaboration to improve outcomes for pediatric SCD patients globally.

Parents’ experience of children with acquired brain injury undergoing neurorehabilitation: a systematic review

BackgroundThis systematic review aims to synthesise the qualitative evidence exploring parents’ experiences of children with acquired brain injury (ABI) undergoing neurorehabilitation during the first year post-injury.MethodsA systematic review of qualitative...

Comorbid treatment of traumatic brain injury and mental health disorders.

The Emory Healthcare Veterans Program (EHVP) is a multidisciplinary intensive outpatient treatment program for post-9/11 veterans and service members with invisible wounds, including posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), substance use disorders (SUD), and other anxiety- and depression-related disorders. This article reviews the EHVP. The different treatment tracks that provide integrated and comprehensive treatment are highlighted along with a review of the standard, adjunctive, and auxiliary services that complement individualized treatment plans. This review particularly emphasizes the adjunctive neurorehabilitation service offered to veterans and service members with a TBI history and the EVHP data that indicate large reductions in PTSD and depression symptoms across treatment tracks that are maintained across 12 months follow up. Finally, there is a discussion of possible suboptimal treatment response and the pilot programs related to different treatment augmentation strategies being deploying to ensure optimal treatment response for all. Published data indicate that the two-week intensive outpatient program is an effective treatment program for a variety of complex presentations of PTSD, TBI, SUD, and other anxiety- and depression-related disorders in veterans and active duty service members.

Health Services for Young Adults with Stroke: A Service Mapping Study over Two Australian States

Despite increased incidence of stroke in young adulthood across the world, young adults report significant difficulties finding services with the expertise and experience to meet their needs. This service mapping study sought to identify and characterise the availability, accessibility, and accommodation of services to meet the needs of young adults (aged 18–44 years) with stroke in two Australian states. Methods. Relevant clinical, rehabilitation, and allied health services were systematically identified from previous publications; the National Health Service Directory; professional association “find a provider” listings; and Stroke Foundation service lists. Desktop audit (n = 465 services) and key informant interviews (n = 321 services) were used to collect service design and delivery characteristics; level of experience, confidence, and willingness to work with young adults with stroke; and accommodation of communication impairments. Results. Most services (85%) were in major cities or inner regional areas. No services worked solely with young adults with stroke; however, several reported having relevant expertise, training, experience, and programmes to provide neurological rehabilitation to meet the needs of young adults with stroke. Reported willingness (91.0%) to work with young adults with stroke was high, but only 57.0% were very confident to do so. Most services with neurorehabilitation expertise addressed psychosocial recovery needs (e.g., emotional adjustment and relationships) as well as functional recovery, but few supported return‐to‐driving, peer support, and sensory processing disturbances. Further gaps were the use of accessible communication materials in only 50.2% of services, and staff had completed communication training at only 60.4% of services. Conclusion. Findings highlight that while expert neurorehabilitation services exist, they are not sufficiently available, accessible, or accommodating of the needs of young adults with stroke. There remains a need to improve access to services where clinicians have the skills to meet the rehabilitation needs of young adults with stroke in Australia.

Low-cost technology solutions to improve neurorehabilitation services in LMICS: Assistive devices and telerehabilitation

Low-cost technology solutions to improve neurorehabilitation services in LMICS: Assistive devices and telerehabilitation

Patterns and predictors of dental hospitalizations in patients with acquired brain injury from pre-injury to acute and post-acute injury.

Acquired brain injury (ABI) can cause long-term disability and functional impairment. This study aims to determine the prevalence of dental hospitalizations in an ABI cohort across different phases of injury and identify factors associated with such hospitalizations. The cohort comprises patients with ABI (n = 683), traumatic (n = 282) and non-traumatic (n = 401) who were admitted to a neurorehabilitation service in Western Australia between 1991 and 2016. De-identified patient data were linked to the Hospital Morbidity Data Collection. The incidence of dental hospitalizations was calculated per 1,000 person-years (PY), and associated factors were investigated using multilevel mixed-effects logistic regression. Dental hospitalizations significantly increased from pre-injury (3.35/1,000PY) to acute injury (302.65, Δ+299.3) and remained elevated in the post-acute phase (23.98, Δ+20.63). Dental caries had the highest incidence rate among all diagnoses in the pre-injury and post-acute phases (0.68 and 8.93, respectively), followed by gingivitis and periodontal diseases (3.60) in the post-acute phase. Tooth extractions were performed more often than restorative and preventive treatment in the pre-and post-injury phase, p < 0.001. Dental hospitalizations were associated with the type of ABI, age at injury, remoteness, and history of pre-injury hospitalization. Implementing comprehensive preventive dental care can reduce potentially preventable dental hospitalization among ABI patients.

INNV-30. DEVELOPMENT AND IMPLEMENTATION OF A NOVEL, BRIEF NEUROCOGNITIVE SCREENING AND REHABILITATION SERVICE IN A CLINICAL NEURO-ONCOLOGY SETTING

Abstract BACKGROUND Although neurocognitive dysfunction is common in patients with brain tumors, existing screening methods (e.g., Montreal Cognitive Assessment) lack sensitivity for detecting neurocognitive difficulties. Moreover, existing neurocognitive screens provide only modest clinical utility for characterizing individual neurocognitive strengths/weaknesses critical for treatment planning. METHODS Beginning in February 2023, the Alvord Brain Tumor Center at the University of Washington Medical Center (UWMC) implemented the Rehabilitation Neuropsychology Screening Service (RNSS). The RNSS is an internal outpatient service staffed by a rehabilitation neuropsychologist from the Department of Rehabilitation Medicine at UWMC. Neuro-oncologists and advanced practice providers placed referrals to the RNSS based on clinical need and cognitive symptoms. On average, 1-2 referrals per week were received. RESULTS Patients referred to the RNSS have included those with high- and low-grade gliomas with varying degrees of everyday functioning status (e.g., independence at home, goals to return to work/school) and neurocognitive symptoms. The goal of the RNSS is to explore inclusion and exclusion criteria that optimize patient experience and outcomes while maximizing outreach to patients in need of neurorehabilitation services. The RNSS includes brief, repeatable neuropsychological testing (90-minutes) and patient-reported outcomes (e.g., mood, quality of life). A separate feedback appointment is then held with patients to describe personal neurocognitive strengths/weaknesses and provide neurorehabilitation strategies or rehabilitation resources/referrals based on findings. In select cases, RNSS has served as a triage stage for stepped care towards referrals to a more comprehensive neuropsychological evaluation. CONCLUSION The development and implementation of this novel approach to neurocognitive screening and rehabilitation, including the rationale, workflow of patient care, and expected outcomes, is described. With additional quality assessment/improvement, the RNSS may serve as a model for integrating neurorehabilitation services into existing neuro-oncology clinics, and may be an additional guide for patients and families towards neurorehabilitation resources and education.