Neurorehabilitation Outcomes Research Articles

Augmenting mirror visual feedback‐induced performance improvements in older adults

Previous studies have indicated that age-related behavioral alterations are not irreversible but are subject to amelioration through specific training interventions. Both training paradigms and non-invasive brain stimulation (NIBS) can be used to modulate age-related brain alterations and thereby influence behavior. It has been shown that mirror visual feedback (MVF) during motor skill training improves performance of the trained and untrained hands in young adults. The question remains of whether MVF also improves motor performance in older adults and how performance improvements can be optimised via NIBS. Here, we sought to determine whether anodal transcranial direct current stimulation (a-tDCS) can be used to augment MVF-induced performance improvements in manual dexterity. We found that older adults receiving a-tDCS over the right primary motor cortex (M1) during MVF showed superior performance improvements of the (left) untrained hand relative to sham stimulation. An additional control experiment in participants receiving a-tDCS over the right M1 only (without MVF/motor training of the right hand) revealed no significant behavioral gains in the left (untrained) hand. On the basis of these findings, we propose that combining a-tDCS with MVF might be relevant for future clinical studies that aim to optimise the outcome of neurorehabilitation.

Virtual feedback for motor and pain rehabilitation after spinal cord injury.

Interventions using virtual feedback (VF) impact on motor functions and pain and may be relevant for neurorehabilitation after spinal cord injury (SCI) in which motor dysfunctions and (concomitant) pain are frequently observed. Potential mechanisms underlying VF include a modulation of cortical sensorimotor integration, increased therapy engagement and distraction from effort and pain. Still, the optimal parameters for VF and their technical implementation are currently unknown. To provide an overview of interventions that have used VF to improve motor functions or to reduce pain after SCI. Literature review. A total number of 17 studies were identified. VF interventions commonly focused on improving motor functions (n=12) or reducing pain (n=4). Only one study assessed both motor functions and pain. Studies generally report beneficial effects. However, the evidence is of low-level quality and many practical as well as theoretical issues remain unclear. Remaining knowledge gaps include: (1) optimal VF system characteristics, (2) the impact of different VF modalities and tasks, (3) dose-response relationships and (4) the identification of patients that are likely to benefit from VF. Future work should start by closing these knowledge gaps using systematic and controlled multi-session interventions and by assessing the underlying mechanisms involved. These results provide an important incentive to further assess the potential of VF interventions to simultaneously improve motor functions and reduce pain after SCI, which could contribute to better neurorehabilitation outcomes after SCI.

Post-Hospital Brain Injury Rehabilitation: Comparison of Neurobehavioral Intensity and Neurorehabilitation Outcomes

To: 1) determine outcome differences between Neurorehabilitation (NR) and Neurobehavioral (NB) clients following post-hospital brain injury rehabilitation; 2) determine effectiveness of programming to reduce symptoms of behavioral dyscontrol among NB individuals; 3) identify predictors of independent functioning for each group.

Determinants of Neurological Functional Recovery Potential after Stroke in Young Adults

Background/Objectives: Despite recent progress in stroke prevention and acute treatment, neurorehabilitation remains one of the main methods of treatment in the management of stroke patients. The aim of this study is to point out some important predicting factors of in-hospital neurorehabilitation outcomes. Methods: A rehabilitation registry including all patients who had undergone a standardized program of neurorehabilitation at the neurorehabilitation unit of the Lausanne University Hospital, Lausanne, Switzerland, was created. Patients aged <65 years and having experienced a first ever nontraumatic stroke from 2005 to 2010 were admitted. Using logistical regression models, predicting factors for each patient were compared to the exit Functional Independence Measure (FIM) score. Results: Age >55 years, gender, aphasia, hemilateral spatial neglect, spasticity, complications, length of stay >70 days, entry FIM >100 and relative possible FIM gain/week of >10% were considered to be significant and independent predicting factors of the neurorehabilitation outcome. Discussion/Conclusion: Some factors of the in-hospital rehabilitation period have been identified before (spasticity, complications, length of stay, relative possible FIM gain/week) and should be considered for a better management of the neurorehabilitation therapy. In addition, a personalized rehabilitation strategy based on the patient's individual needs should be aimed at. The question of resource allocation can also be addressed with regard to the present findings.

Changes in cortical activation patterns accompanying somatosensory recovery in a stroke patient: a functional magnetic resonance imaging study

The somatosensory system plays a crucial role in executing precise movements by providing sensory feedback (Farrer et al., 2003; Rabin and Gordon, 2004). Somatosensory dysfunction is a common problem following stroke. In particular, somatosensory impairments, such as impairment in touch, proprioception, light touch, and vibration have been frequently observed (Carey et al., 1993; Sullivan and Hedman, 2008; Tyson et al., 2008). Patients with somatosensory dysfunction show negative effects on motor control, and it sometimes becomes difficult to perform daily activities independently. In addition, these patients require more time to recover functions compared with those without somatosensory deficits (Doyle et al., 2010; Sommerfeld and von Arbin, 2004; Sullivan and Hedman, 2008). Therefore, a better understanding of the recovery mechanism underlying somatosensory dysfunction is necessary for a successful neurorehabilitation outcome.

Pediatric Arm Function Test: reliability and validity for assessing more-affected arm motor capacity in children with cerebral palsy.

Although there are several validated upper-extremity measures in young children with cerebral palsy, none of these primarily assess the capacity to carry out actions and tasks with the more-affected arm. To address this need, we developed the Pediatric Arm Function Test (PAFT), which involves the behavioral observation of how children use their more-affected arm during structured play in a laboratory or clinic. This article evaluates the reliability and validity of the PAFT Functional Ability scale. In study 1, a total of 20 children between 2 and 8 yrs old with a wide range of upper-extremity hemiparesis caused by cerebral palsy completed the PAFT on two occasions separated by 3 wks. In study 2, a total of 41 children between 2 and 6 yrs old with similar characteristics completed the PAFT and received a grade reflecting the severity of more-affected arm motor impairment. In study 1, the PAFT test-retest reliability correlation coefficient was 0.74. In study 2, convergent validity was supported by a strong inverse correlation (r = -0.6, P < 0.001) between the PAFT scores and the grade of impairment. The PAFT Functional Ability scale is a reliable and valid measure of more-affected arm motor capacity in children between 2 and 6 yrs old with cerebral palsy. It can be used to measure upper-extremity neurorehabilitation outcome.

Pediatric traumatic brain injury: Neuroimaging and neurorehabilitation outcome

Brain injury in the pediatric patient not only occurs in an immature brain, but potentially influences all subsequent brain and neurodevelopmental maturation. This presents unique challenges in neuroimaging the developing central nervous system, which is reviewed herein. The most significant neuroimaging advances in assessing pediatric traumatic brain injury (TBI) have occurred with magnetic resonance imaging (MRI), particularly diffusion tensor imaging and the multiple emerging techniques using functional MRI (fMRI). Pediatric neuroimaging findings of TBI are discussed in terms of techniques that can assess underlying neural networks and provide information about neuroplasticity of recovery. Neuroimaging methods also provide insights into the complexities of brain injury, cognitive and neurobehavioral recovery, and how multimodality contemporary neuroimaging methods best demonstrate underlying neuropathology that affects outcome.

Neuroimaging after critical illness: Implications for neurorehabilitation outcome

Survivors of critical illness frequently have severe and long-lasting cognitive impairments and psychiatric disorders, which adversely affect functional outcomes including return to work, and quality of life. While data regarding cognitive outcomes has increased over the last 15 years, neuroimaging data in medical and surgical critical populations is extremely limited. The abrupt development of new significant cognitive impairments after critical illness along with abnormalities on neuroimaging suggest that critical illness results in new acquired brain injury, similar to that observed in other acquired brain injuries. Abnormalities on neuroimaging including cortical and subcortical lesions, brain atrophy, and white matter hyperintensities (WMH) which occur in widely distributed brain regions. Patients admitted to neurorehabilitation who received critical care related to their primary diagnosis may have sustained neurological injury from the nonspecific effects of their critical illness and as demonstrated in this review, generalized, non-specific neuroimaging findings may be observed and quantified. Given the high prevalence rate of cognitive impairments in this population, neuroimaging is important to help elucidate neuropathology of critical illness acquired brain injury and may be beneficial in guiding rehabilitation outcomes in this population.

The Pediatric Motor Activity Log-Revised: Assessing real-world arm use in children with cerebral palsy.

Widely accepted models of disability suggest that actual use of an impaired upper extremity in everyday life frequently deviates from its motor capacity, as measured by laboratory tests. Yet, direct measures of real-world use of an impaired upper extremity are rare in pediatric neurorehabilitation. This paper examines how well the Pediatric Motor Activity Log-Revised (PMAL-R) measures this parameter, when the PMAL-R is administered as a structured interview as originally designed. Parents of 60 children between 2 and 8 years of age with upper-extremity hemiparesis due to cerebral palsy completed the PMAL-R twice. Additionally, the children were videotaped during play structured to elicit spontaneous arm use. More-affected arm use was scored by masked raters; it was thought to reflect everyday activity since no cues were given about which arm to employ. Testing sessions were separated by 3 weeks, during which 29 children received upper-extremity rehabilitation and 31 did not. The PMAL-R had high internal consistency (Cronbach's alpha = .93) and test-retest reliability (r = .89). Convergent validity was supported by a strong correlation between changes in PMAL-R scores and more-affected arm use during play, r(53) = .5, p < .001. The PMAL-R interview is a reliable and valid measure of upper-extremity pediatric neurorehabilitation outcome.

Neurorehabilitation of stroke

Despite ongoing improvements in the acute treatment of cerebrovascular diseases and organization of stroke services, many stroke survivors are in need of neurorehabilitation, as more than two-thirds show persisting neurologic deficits. While early elements of neurorehabilitation are already taking place on the stroke unit, after the acute treatment, the patient with relevant neurologic deficits usually takes part in an organized inpatient multidisciplinary rehabilitation program and eventually continues with therapies in an ambulatory setting afterwards. A specialized multidisciplinary neurorehabilitation team with structured organization and processes provides a multimodal, intense treatment program for stroke patients which is adapted in detail to the individual goals of rehabilitation. There are many parallels between postlesional neuroplasticity (relearning) and learning in the development of individuals as well as task learning of healthy persons. One key principle of neurorehabilitation is the repetitive creation of specific learning situations to promote mechanisms of neural plasticity in stroke recovery. There is evidence of achieving a better outcome of neurorehabilitation with early initiation of treatment, high intensity, with specific goals and active therapies, and the coordinated work and multimodality of a specialized team. In this context, interdisciplinary goal-setting and regular assessments of the patient are important. Furthermore, several further potential enhancers of neural plasticity, e.g., peripheral and brain stimulation techniques, pharmacological augmentation, and use of robotics, are under evaluation.

Levodopa Improves Procedural Motor Learning in Chronic Stroke Patients

Rösser N, Heuschmann P, Wersching H, Breitenstein C, Knecht S, Flöel A. Levodopa improves procedural motor learning in chronic stroke patients. Objective To test the hypothesis that administration of dopamine precursor levodopa improves procedural motor learning (defined as the ability to acquire novel movement patterns gradually through practice) in patients with residual motor deficits in the chronic phase after stroke (≥1y after stroke). Design A double-blind, placebo-controlled, randomized crossover design. Setting Neurology department in a German university. Participants Eighteen patients with chronic motor dysfunction because of stroke (13 men, 5 women; age range, 53–78y; mean time poststroke ± SD, 3.3±2.1y). Intervention Patients received 3 doses of levodopa (100mg of levodopa plus 25mg of carbidopa) or placebo before 1 session of procedural motor learning. Main Outcome Measures Procedural motor learning performed by using the paretic hand assessed by using a modified version of the serial reaction time task with a probabilistic sequence. The primary outcome measure was the difference in reaction times between random and sequential elements. Results Levodopa significantly improved our primary outcome measure, procedural motor learning, compared with placebo ( P<.05). Reaction times to random elements, analysis of error rates, psychophysical assessments, and performance in a simple motor task were comparable between conditions, indicating that better learning under levodopa was not caused by differences in response styles, arousal, mood, or motor reaction times but that levodopa modulated learning. Conclusions Our results show that levodopa may improve procedural motor learning in patients with chronic stroke, in line with our hypothesis. These findings suggest that this interventional strategy in combination with customary rehabilitative treatments could significantly improve the outcome of neurorehabilitation in the chronic stage after stroke. ( Clinicaltrials.gov identifier NCT00126087.)

Guillain-Barre Syndrome: A Review and Analysis of Current Neurorehabilitation Approaches and Outcomes

Guillain-Barre Syndrome: A Review and Analysis of Current Neurorehabilitation Approaches and Outcomes

Cognitive behaviour therapy for the treatment of depression in individuals with brain injury

This article focuses on depression and its psychological management following brain injury or stroke in the adult population. The presentation of depression in the context of brain injury is discussed and a summary of the psychosocial aetiological factors for the development of depression in this context is provided. The links between depression and neuropsychological functioning are explored and the significant impact of depression on neurorehabilitation outcome highlights the need for the development of effective interventions in this area. Cognitive behaviour therapy (CBT) is presented as a potentially suitable treatment: The model is described with ideas for the clinician on how to adapt the delivery of CBT for clients with neuropsychological impairment. To date, there have been a very small number of studies evaluating CBT for the treatment of depression in brain injury, however their results have been promising. It is concluded that further research is necessary.

Patients with capsular infarct and Wallerian degeneration show persistent regional premotor cortex activation on functional magnetic resonance imaging

Background and Purpose: By using neurorehabilitation outcome measures and functional magnetic resonance imaging (fMRI), we attempted to elucidate the effect of Wallerian degeneration (WD) in the pyramidal tract distal to a posterior capsular stroke on functional recovery. Methods: In 18 patients with pure motor hemiparesis caused by capsular infarct, we identified the presence of WD and then tested whether it affected the rate of motor improvement and the final motor outcome. The discharge T2-weighted MRI (139 ± 5 days on average after stroke) showed WD in 10 of 18 patients (WD-positive, n = 10; WD-negative, n = 8). All patients performed mass grasping of paretic fingers before and after inpatient neurorehabilitation for the fMRI. Results: Demographic characteristics, rate of disability change, final motor status, and volume of lesion were comparable between the groups. On the first fMRI, patterns of fMRI activation in the sensorimotor cortex, premotor cortex (PMC), and supplementary motor area were comparable. However, on the second fMRI, considerably more patients in the WD-positive group (8 out of 10) exhibited persistent contralateral activation in PMC than in the WD-negative group (1 out of 8; P =.0044, chi-square test). Ipsilateral PMC was also more frequently activated (P =.04) in WD-positive patients than in WD-negative patients. Conclusions: Persistent WD had no effect on the impairment or disability outcome; however, it was associated with novel regional activation on repeat fMRI after recovery. To determine whether persistent PMC activation resulted from effort or represents a general effect of WD on motor recovery will require a longer follow-up time and more precise control of functional measurement during imaging. Copyright © 2001 by National Stroke Association

Middle cerebral artery stroke that includes the premotor cortex reduces mobility outcome.

The premotor cortex (PMC) (Brodmann 6) contributes uniquely to proximal upper and lower limb power and plays a role in the organization of motor behaviors. We assessed the degree to which PMC damage affected functional outcome. We prospectively compared the functional outcome of patients with a first stroke in the middle cerebral artery distribution that either left the PMC intact (PMC-; n=19) or damaged the PMC (PMC+; n=12). The Functional Independence Measure for disability and the motor score of the Stroke Impairment Assessment Set for impairment assessed outcome. Demographic and clinical features and lesion volume were comparable for the PMC+ and PMC- groups. However, the PMC- group demonstrated significant gain in mobility and in proximal leg movement. This focal improvement contributed to the trend in the PMC- group toward greater independent ambulation. Decreased motor recovery of proximal lower limbs in humans with PMC damage supports the idea that it is the origin of corticoreticulospinal pathways that subserve proximal lower extremity function. Furthermore, persistent proximal weakness after PMC damage may amplify other motor impairments, which include defects in planning, initiating, and sequencing. Neurorehabilitation outcomes may contribute to a more detailed functional anatomy after stroke and partial recovery.

Multiple sclerosis: a preliminary study of selected variables affecting rehabilitation outcome.

The diversity of physical and cognitive impairments seen in progressive multiple sclerosis (MS), make it difficult to identify the factors that influence neurorehabilitation outcome. Improvements in a motor disability scale must be considered in the context of the patient's physical and cognitive starting points, if the process of neurorehabilitation is to be properly understood. Data was collected from 38 patients (mean age 41 years, 16 men and 22 women) with clinically definite MS (of whom all but one were in the progressive phase of the disease), who were consecutively admitted to a neurorehabilitation unit. Patients' physical disability was assessed on the motor scale of the Functional Independence Measure (FIM) on admission and discharge. Cognitive and neurological assessments were completed on admission. The cognitive battery comprised the WAIS-R, NART, RMT, CVLT CMT, GNT, GDA, and VOSP (some in short form). Emotional measures were the STAI, STAXI and BDI. The mean improvement on the FIM was 6 points. A multiple regression analysis was performed to determine which cognitive and neurological variables related to reduced disability after neurorehabilitation. To take account of each patient's starting point, the model included their FIM admission score. This variable, together with vocabulary skills and cerebellar function accounted for 57% of the variance in the patients' improvements. These results suggest that verbal intelligence and cerebellar function are influential in determining rehabilitation outcome. Although these findings will be unsurprising to clinicians, this is the first quantitative demonstration of these effects.

Potential for bias of data from functional status measures

a meta-analysis of rehabilitation outcomes research, results recorded by observers who knew patients' treatment status tended to be higher than outcomes recorded by blind observers. 22 Blinding of raters to treatment group is taken for granted in research studies as a guarantee of the integrity of data; grant proposals to evaluate treatment outcomes in rehabilitation are expected to include such safeguards. The precaution of blinding FSM raters has been recommended as a check on potential gaming, l but has rarely been implemented in clinical settings. Self-serving bias, the tendency to attribute one's own successes to personal characteristics, but one's failures to external circumstances, has been noted in research by Macchiochi and EatonJ 7 In their study, therapists who were surveyed regarding their explanations for neurorehabilitation outcomes did not spontaneously mention the single most predictive variable (injury severity), and tended to provide therapist-related explanations for good outcomes while providing non-therapist-related explanations (eg, patient motivation) for poorer outcomes. Such attribution biases could be reflected in FSM scoring patterns in real-world decision making. For example, an up-coding at discharge might result from a self-serving bias regarding the efficacy of therapy provided when the raters are therapists who had participated in treatment. Similarly, a down-coding at admission would make any improvement by discharge seem even greater, as well as providing a self-handicap 23 to explain any failure of the patient to show gains after treatment. Other biases have been described that can lead to distortion and inaccuracy (eg, confirmation bias where initial opinion is subsequently always confirmed and contrary data are ignored). 2Z'24 Staff group discussion of patient data may increase bias, causing opinions to become more extreme either toward improvement or worsening, z5 In treatment or teaching situations a staff member may act according to expectations of the patient/ student, thereby actively contributing to the anticipated resultwhether positive or negative (self-fulfilling prophecy). 26'27 Decisions may also be influenced by the information available in memory to the decision-maker or rater, creating an availability bias) 1 Information is more likely to be remembered and available when it is vivid (because of recency, interest, or emotional charge) than when it is less vivid but perhaps more characteristic of the patient's functioning. Macchiochi and Eaton I7 demonstrated the importance of availability in clinical judgment by cuing raters to potentially important data or omitting cues. When raters were so cued, they did notice and utilize key information otherwise neglected. Information stored through professional training appears to produce some bias; research indicates that disciplinary differences emerge in ratings on FSMs. 28'29 Another potential source of bias is missing data, ie, ratings not marked on FSM items. Study results from a variety of disciplines indicate that severe bias may appear when such gaps in data sets are random; if item ratings are missing in some systematic way, the distortion may be even more serious. 3° These briefly mentioned biases, while worth noting, are bidirectional, ie, thinking may be biased either for improvement or against it. The situation in rehabilitation outcomes seems more likely to stimulate directional bias in favor of improvement. Some of the biases and heuristics mentioned above have been shown to occur undonsciously and in the absence of external

Postacute neurorehabilitation: Roles and responsibilities within a national information system

The definition of a “postacute neurorehabilitation provider” has broadened considerably in the last 10 years. The postacute domain, once the purview of community re-entry (aka transitional) programs now includes hospital-based day and outpatient services, home health agencies, assisted living programs, subacute programs, and employment agencies to name but a few. Consequently, a range of outcome variables are considered, in large part as related to the clinical and/or business missions of the providers. This article reviews the postacute neurorehabilitation outcome literature with an eye toward establishing a concensus as to what outcomes are germane to these providers, with the patients and payers as the preferred primary consumers of the outcome-related information.

Neurorehabilitation outcome in moyamoya disease

Moyamoya is a disease characterized by occlusion of the internal carotid, anterior, and middle cerebral arteries with associated rich collateral flow that presents a cloudy appearance on angiogram resembling a puff of smoke. The disease is most often progressive with associated hemiparesis and cognitive impairment. The functional outcome of patients with moyamoya is not well described in the literature. We describe four women (ages 25–36) who were transferred to a rehabilitation service after an average 17 days (12–26 days) in an acute care setting. Initial functional impairment was estimated using the Functional Independence Measure (FIM) score after discharge from inpatient rehabilitation (23–53 days) and was compared to the Uniform Data System for Medical Rehabilitation (UDSMR) for “first stroke” patients. Average admission FIM scores were similar in the two groups. The patients with moyamoya had a higher discharge FIM, longer length of stay, and slower rate of progress. Data on long-term survival and functional level would be useful, but it appears patients with moyamoya disease may benefit from rehabilitation oriented toward neurological deficits.

Prediction of neurorehabilitation outcome by assessment data at intake: The predictive power lies in the psychological measures

Prediction of neurorehabilitation outcome by assessment data at intake: The predictive power lies in the psychological measures