Neurorehabilitation Approaches Research Articles

Video Gaming in Older People: What Are the Implications for Cognitive Functions?

Mild cognitive impairment impacts a sizable segment of the older population, and often evolves into dementia within a few years. At this stage, subjects may benefit from non-pharmacological therapies that can delay or stop the progression of the mild cognitive impairment into dementia and are crucial for improvement in the subject's quality of life, while also being easily accessible and safe for use. Many research studies have shown that a variety of exercises, including cognitive training, have the potential to enhance or optimize cognitive function and general well-being. Recently, many authors have suggested video games as a promising approach for cognitive training and neurorehabilitation in older people, thanks to their increasing motivation and training effects through immersion in stimulating environments. Under this premise, our narrative review's objective is to discuss and summarize the body of existing material on the role of video games in improving cognitive performance, daily life activities, and depression symptoms in older individuals with different levels of cognitive decline. From the papers reviewed, it emerged that older subjects trained with video games showed a significant improvement in cognitive functions, sleep quality, and psychiatric symptoms, positioning video games as an intriguing and useful tool.

Bibliometric analysis of neurofeedback research from 2000 to 2022

The application of neurofeedback is gaining increasing interest among neuroscientists as a potential neurorehabilitation approach in cases of various neuro-related functional abnormalities. Discovering the current state of research and identifying gaps in the field of neurofeedback is an essential step in planning and mapping out future research efforts. This bibliometric analysis paper aims to identify the publications and research in neurofeedback from 2000 to 2022. A comprehensive Scopus database search was conducted using the keyword "neurofeedback" and relevant publications from 2000 to 2022 were retrieved. Bibliometric analyses were performed using the Harzing's Publish or Perish and VOSviewer software programmes. The number of retrieved documents was 1835. The number of publications has shown a steadily increasing trend since 2000, with a prominent spike in publications in 2014–2015, indicating a sudden interest in neurofeedback. Among the retrieved documents, 50.3% were related to neuroscience, 23.7% related to medicine, and 13.1% related to psychology. The main contributors to this research come from the United States (24.7%), Germany (13.7%), the United Kingdom (9.4%), and Switzerland (4.9%). Based on the network visualisation of author keywords, the most frequently occurring keywords were neurofeedback, real-time functional magnetic resonance imaging (fMRI), brain-computer interface (BCI), neuromodulation, and neurofeedback training. This bibliometric analysis presents the current status, knowledge base, and future neurofeedback study directions. These findings will benefit future researchers interested in applying neurofeedback as a potential neurorehabilitation approach for a wider population.

Clinical Potential of Transcranial Focused Ultrasound for Neurorehabilitation in Pediatric Cancer Survivors.

Cancer survivors are at a high risk for treatment-related late effects, particularly neurocognitive impairment in the attention and executive function domains. These can be compounded in pediatric populations still undergoing neural development, which has increased interest in survivorship studies and neurorehabilitation approaches to mitigate these effects. Cognitive training regimens have shown promise as a therapeutic intervention for improving cognitive function. Therapist-guided and computerized training programs with adaptive paradigms have been successfully implemented in pediatric populations, with positive outcomes on attention and working memory. Another interventional approach is neuromodulation to alter plasticity. Transcranial electrical stimulation can modulate cortical surface activity, and cranial nerve stimulation alters autonomic activity in afferent brainstem pathways. However, they are more systemic in nature and have diffuse spatial targeting. Transcranial focused ultrasound (tFUS) modulation overcomes these limitations with high spatial specificity and the ability to target deeper brain regions. In this review, we discuss the efficacy of tFUS for modulating specific brain regions and its potential utility to augment cognitive training programs as a complementary intervention.

Priming constraint-induced movement therapy with intermittent theta burst stimulation to enhance upper extremity recovery in patients with stroke: protocol for a randomized controlled study.

The treatments based on motor control and motor learning principles have gained popularity in the last 20 years, as well as non-invasive brain stimulations that enhance neuroplastic changes after stroke. However, the effect of intermittent theta burst stimulation (iTBS) in addition to evidence-based, intensive neurorehabilitation approaches such as modified constraint-induced movement therapy (mCIMT) is yet to be investigated. We aim to establish a protocol for a randomized controlled study investigating the efficiency of mCIMT primed with iTBS after stroke. In this randomized controlled, single-blind study, patients with stroke (N = 17) will be divided into 3 groups: (a) mCIMT + real iTBS, (b) mCIMT + sham iTBS, and (c) mCIMT alone. 600-pulse iTBS will be delivered to the primary motor cortex on the ipsilesional hemisphere, and then, patients will receive mCIMT for 1h/session, 3 sessions/week for 5weeks. Upper extremity recovery will be assessed with Fugl-Meyer Test-Upper Extremity and Wolf Motor Function Test. Electrophysiological assessments, such as Motor-Evoked Potentials, Resting Motor Threshold, Short-Intracortical Inhibition, and Intracortical Facilitation, will also be included. In this study, a protocol of an ongoing intervention study investigating the effectiveness of iTBS on ipsilesional M1 prior to the mCIMT in patients with stroke is proposed. This will be the first study to research priming mCIMT with iTBS and it may have the potential to reveal the true effect of the iTBS when it is added to the high-quality neurorehabilitation approaches. Trial registration number: NCT05308667.

Effects of transcranial magnetic stimulation on cortical structures during motor imagination performance in the brain-computer interface

The aftermath of a stroke can frequently result in impaired motor functions causing problems performing habitual limb movements. These movement disorders stem from damage to the cerebral cortex and disruptions to neuronal connections in the central pyramidal pathways [1]. Restoring motor skills following a stroke is a time-consuming and challenging process, requiring resources from both external medical sources and the patient. Despite these challenges, it is still feasible for patients to regain control over their limb movements. The common approach for stroke neurorehabilitation consists of therapeutic physical activities and kinesiotherapy. These methods rely on afferent information during motor tasks to repair connections between intact brain areas [2]. Through exercising the impacted limbs, synaptic rearrangement happens in the cortex, awakening dormant neurons and increasing cortical areas adjacent to inactive regions. Although these techniques can partially restore movement, a significant number of stroke patients still face impairments. It is crucial to acknowledge the limitations of the current interventions and explore new approaches for better outcomes. Traditional rehabilitation methods often do not fully restore movement control, prompting researchers to explore alternative approaches. Motor-imagery-based brain-computer interfaces (BCIs) have gained attention recently [3, 4]. They allow for integrating various feedback mechanisms, which can be combined with upper and lower limb exoskeletons. The level of control a subject has over a BCI system directly affects the recovery process [5]. Introducing transcranial magnetic stimulation (TMS) into motor-imagery BCIs shows promise for developing a unified and highly efficient approach to post-stroke rehabilitation. Twenty-nine healthy adult participants (21 females) with a mean age of 20.93±2.14 years were recruited for this experiment. All participants were right-handed and had no prior experience with brain-computer interfaces. Ethical approval was obtained from the local ethics committee of Lobachevsky State University of Nizhny Novgorod (ethical approval No. 2, dated 03/19/2021), and written informed consent was obtained from all participants. Subjects were randomly assigned to receive either a sham intervention (n=15) or active TMS (n=14). The experiment displayed tasks on a 24-inch LCD screen placed 2 meters away. Participants sat in a reclining chair with hands on adjustable armrests for EEG signal recording. Motor-imagery-based BCI training took place over two days with four daily tasks: motor performance, quasi-motor, and two motor imaginations of the dominant hand. EEG activity was recorded prior to and after completing the tasks. Each task comprised of 20 trials, each lasting 10 seconds. TMS was administered in between two motor imagination tasks, and a rest period of 2 minutes followed the stimulation. The researcher objectively monitored electromyography (EMG) in real-time during motor tasks. Certified NVX 52 amplifiers with 32 Cl/Ag electrodes positioned according to the international 10-10 system recorded electroencephalography (EEG) signals. The EEG was digitized at a sampling rate of 1000 Hz and filtered with a 50 Hz Notch filter. Disposable electrodes were used to record EMG data from musculus flexor digitorum superficialis on the right hand. EMG signals were digitized at 1000 Hz and filtered using a 50 Hz Notch filter. TMS was applied to the dorsolateral prefrontal cortex (dlPFC) using a figure-8 coil connected to a Neuro MS/D magnetic stimulator. Sham stimulation was performed with the same parameters, except the coil was tilted 90 degrees to simulate the sound of real stimulation. A nonparametric permutation test was conducted to assess the statistically significant dissimilarities between rest periods and periods subsequent to conducting motor imagery after TMS. Significant clusters of the highest event-related desynchronization (ERD) were observed. The analysis demonstrated a significant negative cluster in the theta rhythm (0–6 Hz) that was distinct from the magnetic stimulation site. Similar significant ERD clusters were identified during the first and second series of imaginary movements. The study examined alterations in motor cortex function following targeted rTMS. The results demonstrated that TMS using particular parameters resulted in the pre-activation of brain regions comparable to those stimulated during motor imagery. The implementation of this stimulation protocol increased activity in cortical regions related to motor imagery. The outcomes propose the probable effectiveness of TMS in elevating motor cortex activation during the rehabilitation process.

Neurorehabilitation for Adults with Brain and Spine Tumors.

Central nervous system (CNS) malignancies (i.e. brain and spine tumors) and their treatments can result in a multitude of neurologic deficits. Patients with CNS malignancies experience physical, cognitive, and psychosocial sequelae that can impact their mobility and quality of life. Neurorehabilitation can play a critical role in maintaining independence, preventing disability, and optimizing safety with activities of daily living. This review provides an overview of the neurorehabilitation approaches for patients with CNS malignancies, neurologic impairments frequently treated, and rehabilitation interventions in various health care settings. In addition, we will highlight rehabilitative outcomes between patients with nononcologic neurologic conditions compared to brain and spine tumors. Finally, we address medical challenges that may impact rehabilitation care in these medically complex cancer patients.

Environmental enrichment and cerebrolysin improve motor and cognitive performance in a rat model of stroke, in conjunction with an increase in hippocampal AMPA but not NMDA receptor subunits

Stroke is a pathology related to the vascular system in the brain and it is one of the main causes of disability, representing a burden on public health. This lesion provokes a disorganization of sensory-motor and cognitive systems, the latter associated with hippocampal activity, a structure in which α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and NMDA N-methyl-D-aspartate (NMDA) receptors are important for the integration of information. Several molecules have been studied for their capacity to enhance recovery from a stroke, including cerebrolysin that could potentially be reinforced by environmental enrichment. Here, stroke was induced in 40 male rats and 24 h later, they were administered cerebrolysin (2.5 ml/kg), put in an environmentally enriched arena or given both treatments, for 10 days. Subsequently, motor functioning was assessed with the Bederson test and the cognitive domain was assessed through novel object recognition. Hematoxylin/eosin staining was then used to assess the infarct size, and AMPA-GRIA1 and NMDA-R1 subunits in the hippocampus were measured by ELISA. In motor and cognitive performance, the administration of cerebrolysin and environmental enrichment enhanced recovery. Moreover, the infarct size decreased in all the groups that received a treatment, but an increase occurred in AMPA-GRIA1 only in experimental group regarding to control group, while NMDA-R1 had no differences. These results suggest that cerebrolysin and environmental enrichment could act in synergy to recover after a stroke, leading to a smaller infarct area and the presence of more AMPA-GRIA1 subunits in the hippocampus of experimental group. These data encourage further studies in which neurorehabilitation approaches can be combined with cerebrolysin administration to treat the motor and cognitive symptoms of stroke.

A manual-based family intervention for families living with acquired brain or spinal cord injury: a qualitative study of families’ experiences

Purpose To explore families’ experiences of participating in a family intervention, targeting families living with the consequences of acquired brain injury (ABI) or spinal cord injury (SCI). Materials and methods Individuals with ABI or SCI and their family members were recruited from a randomised controlled trial investigating the effectiveness of the manual-based family intervention, which consisted of eight weekly sessions. Semi-structured interviews were conducted with 16 families (n = 33). The data were analyzed through reflexive thematic analysis. Results One central theme was developed “A sense of belonging together again”, describing the value of the reciprocal format of the family intervention, where individuals with ABI or SCI and their family members gained new insights into each other while building up their relationship. The central theme was supported by three additional themes: “Strengthened communication and emotional control”, “Acknowledging the changed life situation” and “Being seen as a whole person”. Conclusions The family intervention supported the families to strengthen family cohesion and to be capable to manage the changed life situation. The findings emphasize the importance of a family-centered approach in neurorehabilitation, and how healthcare professionals play a significant role in facilitating families to achieve a balanced level of family cohesion.

Mastering Our Own Magic in the Evolution Toward Precision Practice.

Edelle (Edee) Field-Fote, PT, PhD, FASIA, FAPTA, the 54th Mary McMillan lecturer, is director of the Shepherd Center Spinal Cord Injury Research Program & Hulse Laboratory; professor in the division of physical therapy at Emory University School of Medicine; and professor of the practice in the school of biological sciences at the Georgia Institute of Technology. In her role as the director of spinal cord injury (SCI) research at Shepherd Center, Field-Fote leads a team dedicated to improving motor function in people with SCI through the development of neuromodulation and neurorehabilitation approaches informed by the latest neuroscience research and guided by outcomes that have meaning for people with SCI. With a clinical background as a physical therapist, PhD training in a preclinical model of SCI, and postdoctoral training in motor control physiology, her 25-plus years of SCI research have spanned the breadth of basic and clinical/translational research related to SCI. Dr Field-Fote has conducted randomized clinical trials with funding from the National Institutes of Health since 1997; other clinical trials in her lab have been funded by the Department of Defense, the National Institute on Disability Independent Living and Rehabilitation Research, and numerous foundations. Field-Fote is the recipient of multiple honors from the American Physical Therapy Association (APTA) and its components. She is a Fellow of APTA and a Fellow of the American Spinal Injury Association. She has also served in numerous APTA and APTA component appointed or elected positions and as a member and president of the Foundation for Physical Therapy Research Board of Trustees.

88 Considering Lateralization and Localization of Neurosurgical Intervention for Predicting Treatment Response to Computerized Cognitive Remediation (CCR) Targeting Attention and Working Memory: A Case Series

Objective:Lateralization and localization of neuropathology helps determine the extent to which eloquent cortex and diseased brain tissue share loci, important information for neurosurgical decision-making, and predicting neurocognitive outcomes. Emerging data suggest that lateralization and localization can inform specific neurorehabilitation approaches following acquired brain injury (ABI). In recent years, computerized cognitive remediation (CCR) of attention and working memory (WM) has been included among treatment guidelines to enhance cognition in post-acute recovery following ABI. Although CCR has shown promise for improving attention and executive functioning in ABI, it is unknown how treatment response may be predicted by locus of ABI. Even less is known about the effects of CCR following neurosurgery. The current study explores neurosurgical lateralization and localization as potential variables for predicting treatment response to CCR.Participants and Methods:Adult patients with a variety of neurological diagnoses (N = 17; ∼47% women) completed a full course of Cogmed Working Memory Training (CWMT) s/p neurosurgical intervention. All participants engaged in 30 sessions of CWMT over eight weeks, as well as neuropsychological (NP) assessment at pre-training baseline, immediate post-training, and at 3-month follow-up. Objective and subjective indices of attention, working memory, executive functioning, and emotional well-being were evaluated at three time-points. Neurosurgical loci included left-hemisphere frontal, temporal, and temporoparietal lobes, as well as right-hemisphere frontal, frontotemporal, and temporal lobes.Results:NP data were reviewed and yielded a clinical impression of cognitive and affective functioning for a cohort of patients with heterogeneous diagnoses (e.g., brain tumor, epilepsy, NPH). Preliminary NP findings suggested that treatment response to CCR for WM was consistent with extant literature on brain-behavior relationships according to lateralization and localization of neurosurgical intervention.Conclusions:Neurosurgical patients experience neurocognitive and affective dysfunction that may respond well to cognitive rehabilitation (CR) that includes CCR. Additionally, it is possible that lateralization and localization of surgical intervention may contribute to individual differences in treatment response. Further neurorehabilitation research is warranted to identify patients most likely to benefit from CCR and better tailor CR modalities to optimize recovery s/p neurological surgery.

Efficacy of MCIMT with Auditory Cueing in order to Augment Functional Motor Recovery of Chronic Hemiparetic Arm

Background: Stroke is a leading cause of functional impairments globally, often resulting in long-term disability and a substantial impact on individuals, families, and caregivers. Learned nonuse, a phenomenon where motor deficits persist after a stroke due to central nervous system suppression, is a significant challenge in stroke rehabilitation. Constraint-Induced Movement Therapy (CIMT) is a well-established neurorehabilitation approach based on behavioural training, which includes repetitive task-specific training, behavioural techniques, and constraining the use of the more affected upper extremity. CIMT has been successful in improving functionality in chronic hemiparetic stroke patients, promoting cortical reorganization and neural plasticity.
 Method: This study involved 60 stroke survivors aged 20 or older, selected purposively and meeting specific criteria. Participants underwent an 8-week Modified CIMT (M-CIMT) program with auditory cueing for the hemiparetic upper limb. Data collection included pre-test and post-test assessments using the Wolf Motor Function Test (WMFT) and the Motor Activity Log (MAL) to evaluate functional activity. The M-CIMT program comprised warm-up sessions, M-CIMT protocols, and cool-down exercises, conducted five days a week.
 Results: Following participation in the M-CIMT program, significant improvements were observed in WMFT and MAL scores. The mean pre-test score of 46.60 seconds decreased to a mean post-test score of 16.85 seconds, with highly significant t-values of 14.292 and -51.356 and a p-value of 0.0, indicating a strong correlation between the two datasets. The analysis revealed that M-CIMT effectively enhanced upper extremity function in chronic stroke patients.
 Conclusion: This study highlights the effectiveness of the Modified CIMT protocol, emphasizing repeated use and a distributed practice schedule, in reducing upper-limb impairment and improving upper-limb use and function in chronic stroke patients. The significant improvement in post-test scores underscores the promise of M-CIMT as a valuable approach for upper extremity rehabilitation following chronic stroke, offering hope for enhanced recovery and improved quality of life for affected individuals.
 Keywords: Stroke; Rehabilitation; Upper Extremity; Constraint-Induced Movement Therapy; Motor Activity

Effectiveness of motor and prefrontal cortical areas for brain-controlled functional electrical stimulation neuromodulation

Objective. Brain-computer interface (BCI)-controlled functional electrical stimulation (FES) could excite the central nervous system to enhance upper limb motor recovery. Our current study assessed the effectiveness of motor and prefrontal cortical activity-based BCI-FES to help elucidate the underlying neuromodulation mechanisms of this neurorehabilitation approach. Approach. The primary motor cortex (M1) and prefrontal cortex (PFC) BCI-FES interventions were performed for 25 min on separate days with twelve non-disabled participants. During the interventions, a single electrode from the contralateral M1 or PFC was used to detect event-related desynchronization (ERD) in the calibrated frequency range. If the BCI system detected ERD within 15 s of motor imagery, FES activated wrist extensor muscles. Otherwise, if the BCI system did not detect ERD within 15 s, a subsequent trial was initiated without FES. To evaluate neuromodulation effects, corticospinal excitability was assessed using single-pulse transcranial magnetic stimulation, and cortical excitability was assessed by motor imagery ERD and resting-state functional connectivity before, immediately, 30 min, and 60 min after each intervention. Main results. M1 and PFC BCI-FES interventions had similar success rates of approximately 80%, while the M1 intervention was faster in detecting ERD activity. Consequently, only the M1 intervention effectively elicited corticospinal excitability changes for at least 60 min around the targeted cortical area in the M1, suggesting a degree of spatial localization. However, cortical excitability measures did not indicate changes after either M1 or PFC BCI-FES. Significance. Neural mechanisms underlying the effectiveness of BCI-FES neuromodulation may be attributed to the M1 direct corticospinal projections and/or the closer timing between ERD detection and FES, which likely enhanced Hebbian-like plasticity by synchronizing cortical activation detected by the BCI system with the sensory nerve activation and movement related reafference elicited by FES.

Alterations in the preferred direction of individual arm muscle activation after stroke.

Stroke survivors have challenges appropriately coordinating the multiple muscles, resulting in a deficit in motor control. Therefore, comprehending the mechanism underlying abnormal intermuscular coordination becomes crucial in developing effective rehabilitation strategies. Quantitative analyses have been employed at pairwise or multi-dimensional levels to understand the underlying mechanism of abnormal intermuscular coordination and its relationship to motor impairment. However, how alterations in individual muscle activation contribute to abnormal intermuscular coordination, motor impairment, and motor performance remains unclear. Thus, we investigated the alterations in the preferred direction of individual muscles after stroke and their relationship with stroke-induced changes in intermuscular coordination, clinical motor impairment, and qualities of motor performance during isometric force generation in the upper extremity. Twenty-four stroke survivors and six age-matched controls were recruited and performed isometric force target matches while recording electromyographic signals from eight upper limb muscles. We determined the preferred activation direction of each muscle, evaluated abnormal intermuscular coordination through a muscle synergy analysis, assessed motor impairment using upper extremity Fugl-Meyer Assessment scores, and examined motor performance characteristics defined by force trajectory features. The post-stroke alterations in the preferred direction of the brachioradialis, anterior, middle, and posterior deltoid were correlated with the motor impairment level and attributed to the changes in muscle synergy characteristics. Only alterations in the preferred direction of the brachioradialis and posterior deltoid activation in forward-backward and upward-downward axes were associated with the qualities of isometric force generation, respectively. These findings imply that alterations in the preferred direction of individual muscle activation contribute to various aspects of motor deficit following stroke. This insight may serve as a foundation for the development of innovative stroke neurorehabilitation approaches that take into account specific attributes of individual muscle activation, including their preferred activation direction.

Uncertainty-aware automated assessment of the arm impedance with upper-limb exoskeletons.

Providing high degree of personalization to a specific need of each patient is invaluable to improve the utility of robot-driven neurorehabilitation. For the desired customization of treatment strategies, precise and reliable estimation of the patient's state becomes important, as it can be used to continuously monitor the patient during training and to document the rehabilitation progress. Wearable robotics have emerged as a valuable tool for this quantitative assessment as the actuation and sensing are performed on the joint level. However, upper-limb exoskeletons introduce various sources of uncertainty, which primarily result from the complex interaction dynamics at the physical interface between the patient and the robotic device. These sources of uncertainty must be considered to ensure the correctness of estimation results when performing the clinical assessment of the patient state. In this work, we analyze these sources of uncertainty and quantify their influence on the estimation of the human arm impedance. We argue that this mitigates the risk of relying on overconfident estimates and promotes more precise computational approaches in robot-based neurorehabilitation.

Diagnostic and Therapeutic Approaches in Neurorehabilitation after Traumatic Brain Injury and Disorders of Consciousness

Severe traumatic brain injury (TBI) may cause disorders of consciousness (DoC) in the form of coma, unresponsive wakefulness syndrome (UWS), or minimally conscious state (MCS). Despite significant advancements made over the last two decades in detecting, predicting, and promoting the recovery of consciousness in TBI patients with DoC, the available diagnostic and treatment choices remain limited. In cases of severe TBI, the dissolution of consciousness both in the acute and post-acute phases constitutes one of the major clinical findings and challenges. In clinical settings, neurologists and neurorehabilitation specialists are called on to discern the level of consciousness in patients who are unable to communicate, and to project outcomes and recommend approaches to treatment. Standards of care are not available to guide clinical decision-making for this population, often leading to inconsistent, inaccurate, and inappropriate care. Recent studies refer to network-based mechanisms of consciousness as a more promising method to predict outcomes and functional recovery. A further goal is the modulation of neural networks underlying awareness and arousal as the main components of consciousness. This review centers on the difficulties in characterizing individuals experiencing post-traumatic DoC and on the recent advancements made in the identification and prognostication of consciousness recovery through the utilization of advanced neuroimaging and electrophysiological techniques as well as biomarkers. Moreover, we discuss new treatment approaches and summarize recent therapeutic recommendations.

Stroke – Some Risk Factors, Neuropathological Aspects and Neurorehabilitation Approaches

Stroke – Some Risk Factors, Neuropathological Aspects and Neurorehabilitation Approaches

Neurofunctional correlates of a neurorehabilitation system based on eye movements in chronic stroke impairment levels: A pilot study.

Rehabilitation after a stroke is widely considered fundamental to improve secondary functional impairments. Accessible methods based on motor learning, motor transfer and virtual environments are necessary to help to improve stroke patients' quality of life. Continuing the line of our previous studies, this work investigated the effect of our new and innovative game-based virtual reality training using the control of virtual objects with gaze in three chronic stroke survivors. All participants performed an eye-controlled virtual training task for 4 weeks. Pre- and post-training evaluation were carried out with the Fugl-Meyer Assessment for upper extremity scale as well as performing a tracking task inside an MRI scanner with a MRI-compatible eye-tracker or a joystick. Neural results for each participant show the increase of activity in the motor cortex, basal ganglia and cerebellum for both effectors (hand or eye). These promising results have a potential application as a new game-based neurorehabilitation approach to enhance the motor activity of stroke patients.

Comparing Walking-Related Everyday Life Tasks of Children with Gait Disorders in a Virtual Reality Setup With a Physical Setup: Cross-Sectional Noninferiority Study.

A frequent rehabilitation goal for children with gait disorders is to practice daily-life walking activities. Unfortunately, these are often difficult to practice in a conventional therapeutic setting. Virtual reality (VR) with head-mounted displays (HMDs) could be a promising approach in neurorehabilitation to train such activities in a safe environment. First, however, we must know whether obstacles in VR are indeed mastered as obstacles. This study aimed to provide information on whether VR is feasible and motivating to induce and practice movements needed to master real obstacles in children and adolescents with gait disorders. Furthermore, this project aims to evaluate which kinds of everyday walking activities are appropriate to be practiced in VR. In this cross-sectional study, participants stepped over a bar, crossed a gap, balanced over a beam, and circumvented stationary obstructions arranged in a course under real physical and virtual conditions wearing a VR HMD. We recorded the respective primary outcomes (step height, step length, step width, and minimal shoulder-obstacle distance) with motion capture. We then calculated the mean differences and 95% CI of the spatiotemporal parameters between the VR and physical setup and later compared them using noninferiority analysis with margins defined a priori by a clinical expert panel. Additionally, the participants responded to a standardized questionnaire while the therapists observed and evaluated their movement performance. We recruited 20 participants (mean age 12.0, range 6.6-17.8 years) with various diagnoses affecting their walking ability. At 3.77 (95% CI 1.28 to 6.26) cm, the mean difference in step height of the leading foot in the overstepping task did not exceed the predefined margin of -2 cm, thus signifying noninferiority of the VR condition compared to mastering the physical obstacles. The same was true for step length (-1.75, 95% CI -4.91 to 1.41 cm; margin -10 cm), step width (1.05, 95% CI 0.20 to -1.90 cm; margin 3 cm), and the minimal shoulder-obstacle distance (0.25, 95% CI -0.85 to 0.35 cm; margin -2 cm) in the other tasks. Only the trailing foot in the overstepping task yielded inconclusive results. Children with gait disorders perform everyday walking tasks like overstepping, crossing, balancing, or circumventing similarly in physical and VR environments, suggesting that VR could be a feasible therapeutic tool to practice everyday walking tasks.

A Novel Neurorehabilitation Approach for Neural Plasticity Overstimulation and Reorganization in Patients with Neurological Disorders

AbstractNeurological disorders are those that are associated with impairments in the nervous system. These impairments affect the patient’s activities of daily living. Recently, many advanced modalities have been used in the rehabilitation field to treat various neurological impairments. However, many of these modalities are available only in clinics, and some are expensive. Most patients with neurological disorders have difficulty reaching clinics. This review was designed to establish a new neurorehabilitation approach based on the scientific way to improve patients’ functional recovery following neurological disorders in clinics or at home. The human brain is a network, an intricate, integrated system that coordinates operations among billions of units. In fact, grey matter contains most of the neuronal cell bodies. It includes the brain and the spinal cord areas involved in muscle control, sensory perception, memory, emotions, decision-making, and self-control. Consequently, patients’ functional ability results from complex interactions among various brain and spinal cord areas and neuromuscular systems. While white matter fibers connect numerous brain areas, stimulating or improving non-motor symptoms, such as motivation, cognitive, and sensory symptoms besides motor symptoms may enhance functional recovery in patients with neurological disorders. The basic principles of the current treatment approach are established based on brain connectivity. Using motor, sensory, motivation, and cognitive (MSMC) interventions during rehabilitation may promote neural plasticity and maximize functional recovery in patients with neurological disorders. Experimental studies are strongly needed to verify our theories and hypothesis.

Abstract 150: Vagus Nerve Stimulation (VNS) Paired With Upper Extremity Rehabilitation In Chronic Stroke: Improvements In Wrist And Hand Impairment And Function

Introduction: In the VNS-REHAB trial, vagus nerve stimulation (VNS) paired with task-specific arm and hand rehabilitation (Paired VNS) led to clinically meaningful improvements in both impairment and function of the upper extremity in people with chronic ischemic stroke. In this post hoc analysis of trial data, we assessed whether improvements were driven by proximal (shoulder and elbow) and/or distal (wrist and hand) components of the Upper Extremity Fugl-Meyer Assessment (FMA-UE). We also wanted to determine whether FMA-UE improvements correlated with improvements in functional outcome. Methods: Chronic stroke participants (n=108) with moderate-severe UE impairment (FMA-UE 35.1±8) were implanted with the VNS device and randomized to Paired VNS (n=53) or Controls (n=55). Participants underwent 6 weeks of in-clinic therapy followed by 90 days of a home exercise program. Outcomes, including the FMA-UE and Wolf Motor Function Test (WMFT), were collected after in-clinic therapy (Post-1) and 90 days of home therapy (Post-90). Results: Distal FMA-UE change was significantly greater after Paired VNS compared to Controls, both at Post-1 (2.43±2.52 vs. 0.64±2.33; 95% CI 0.87-2.72, p<0.001, Cohen’s d=0.74) and Post-90 (2.58±2.88 vs. 0.93±3.16; 95% CI 0.5-2.81, p=0.005, Cohen’s d=0.55). Proximal FMA-UE change was also greater after Paired VNS compared to Controls but did not reach statistical significance at either timepoint. At Post-90, both proximal (r=0.50, p<0.0001) and distal (r=0.42, p=0.001) FMA-UE change significantly correlated with WMFT change after Paired VNS, but not in Controls (proximal: r=0.24, p=0.06; distal: r=0.14, p=0.24). Conclusions: The data suggest that Paired VNS leads to greater improvement in the distal upper extremity compared to rehabilitation alone and that improvements in FMA-UE scores are correlated with improvements in function. These findings suggest that the improvements seen with Paired VNS are of functional importance. A greater understanding of region-specific arm and hand recovery after Paired VNS therapy will facilitate planning and implementation of a personalized neurorehabilitation approach based on patient-specific impairments.