Neurorehabilitation

Published by IOS Press
Online ISSN: 1878-6448
Print ISSN: 1053-8135
Publications
Mirror therapy (MT) was found to improve motor function after stroke, but its neural mechanisms remain unclear, especially in single stroke patients. The following imaging study was designed to compare brain activation patterns evoked by the mirror illusion in single stroke patients with normal subjects. Fifteen normal volunteers and five stroke patients with severe arm paresis were recruited. Cerebral activations during movement mirroring by means of a video chain were recorded with functional magnetic resonance imaging (fMRI). Single-subject analysis was performed using SPM 8. For normal subjects, ten and thirteen subjects displayed lateralized cerebral activations evoked by the mirror illusion while moving their right and left hand respectively. The magnitude of this effect in the precuneus contralateral to the seen hand was not dependent on movement speed or subjective experience. Negative correlation of activation strength with age was found for the right hand only. The activation pattern in stroke patients is comparable to that of normal subjects and present in four out of five patients. In summary, the mirror illusion can elicit cerebral activation contralateral to the perceived hand in the majority of single normal subjects, but not in all of them. This is similar even in stroke patients with severe hemiparesis.
 
There has been considerable controversy concerning the problem of the persisting post-concussive syndrome and whether cognitive or other sequelae might be attributed to the effects of brain injury or other causes. Headache is the predominant problem in virtually all surveys of the post-concussive syndrome. It is suggested that pain and related problems may account for most of the difficulties in those presenting with the persisting post-concussive syndrome or other cases in which mild to moderate brain injury is suspected. A survey of the literature concerning the relationship of pain, cognition and traumatic brain injury indicates that cognitive difficulties are common in acute or chronic pain, with or without any indication of brain injury. However, numerous methodological problems are apparent and there is clearly need for further study. Consideration is given both to psychosocial and neurobiological effects underlying any such relationships.
 
Pharmacological agents, known to modulate practice-dependent plasticity in animal models of brain damage, have recently received increased interest for treatment of motor recovery after stroke. The present paper gives an overview of agents that are currently available. Amphetamines have been repeatedly shown to promote recovery of function in animals, but clinical data remain inconclusive. Other pharmacological agents evaluated for motor recovery include selective norepinephrine re-uptake inhibitors, dopamine, dopamine agonists, cholinergic substances, serotonin re-uptake inhibitors, and granulocyte-colony stimulating factor. Although preliminary data from animal and human experimental studies on these agents are promising, larger clinical trials are needed before any of the available agents may be recommended for routine use.
 
Lumbar disk prolapses are among the most common neurological conditions. In this open study, we asked whether repeated end-range spinal movements (McKenzie method) as physiotherapy in patients with lumbar disk prolapse induce early changes in location, size and signal intensity of lumbar disc material detectable by magnetic resonance imaging (MRI). We compared clinical with radiographic changes. The clinical efficacy of mechanical physiotherapy according to the McKenzie method within 5 days was documented. Eleven consecutive patients with lumbar disk prolapse were included. Patients were treated with repeated end-range spinal movements and MRI was performed before and after 2-5 treatments. All patients achieved a reduction in symptoms and signs of disk prolapse during and after these procedures but none showed any change in the MRI features of the prolapses. Beneficial effects of specific mechanical physiotherapy in patients with radicular syndromes from lumbar disk prolapse are not paralleled by changes in the MRI appearance of the prolapses. Alternative explanations for the early clinical responses in some patients with lumbar disc prolapse treated according to the McKenzie method must be sought.
 
This paper, written from the perspective of a psychologist working in a tertiary care chronic pain program, presents an overview of chronic pain with suggestions as to what may be important directions for research and treatment in the future. It is suggested that the monumental problem of chronic pain needs to be better appreciated, that both biological and psychosocial factors contributing to presentation need to be better understood, and that the most fruitful avenue of research may be an exploration of the interface between psychosocial and biological components, i.e., the neurobiological substrate mediating psychological effects or the nature of brain-behavior relationships involved in chronic pain. A method to assist in the differentiation of central from peripheral and organic from psychosocial components, and the outline of a novel neuropsychobiological model are described.
 
This study highlights the effects of a comprehensive neurorehabilitation (CN) on neuroplasticity and motor recovery in a 25 years old adult with right hippocampal sclerosis and the temporal lobectomy and amygdalotomy. The patient received 8-month course of comprehensive neurorehabilitation, comprised of five times/week. Motor behavioral and 1.5 T functional magnetic resonance imaging (fMRI) tests were implemented to determine the restoration of motor function and neuroplasitic changes, respectively. In fMRI measure, a laterality index (LI) was used to determine any shift in the symmetry of cortical activation between the hemispheres. Additionally, motor behavioral changes were measured to probe long-term retention of learned motor skills at the 6-month post-treatment follow-up test. Motor behavioral tests showed that comprehensive neurorehabilitation enhanced functional reaching, grasping, and hand manipulation skills, which were well retained even at the 6-month post-treatment. Baseline fMRI showed asymmetry of the contralesional sensori-motor cortex (SMC) activation (Laterality index score: 0.54), but was restored to normal symmetry (Lateral index: 1.0) during affected hand movement after comprehensive neurorehabilitation. Our novel findings suggest that comprehensive neurorehabilitation may facilitate restitution of normal symmetry of cortical activation, thereby enhancing motor function. This case provides the first neuroimaging evidence about a long-term comprehensive neurorehabilitation-induced neuroplasticity of the individual with a complex brain injury in the literature.
 
Idiopathic toe walking is characterized by persistent toe walking in the absence of clinically diagnosed neuromuscular disease. Treatment options in children diagnosed with idiopathic toe walking include: observation, physical therapy, serial casting, or Achilles tendon (heel cord) lengthening surgery. In this case report, we present a non-invasive serial casting protocol to treat severe and persistent toe walking in an 18-month old child, diagnosed as an idiopathic toe walker following neurological examination. A series of below knee casts was used to provide a consistent stretch to the plantar flexor muscles. Upon removal of each set of casts, passive range of motion at the ankles was measured with a goniometer. Four sets of casts, each lasting approximately one week, increased passive ankle dorsiflexion to 10° of neutral and established a heel-toe walking gait. Improvements in ankle range of motion and gait were maintained upon repeated examinations at 3, 7, and 12 months post-casting. These results demonstrate that non-invasive procedures, such as serial casting, can be successful in very young children diagnosed as idiopathic toe walkers. Early identification and intervention for this diagnosis may eliminate the need for invasive surgeries and associated risks in this population.
 
Background: In patients with Multiple Sclerosis (MS), comparative leg muscle strength asymmetries are common and typically accompanied by walking difficulties. Underlying mechanisms for these asymmetries are not completely known, but altered muscle energetics may play a role. Objective: To investigate glucose uptake asymmetries in leg muscles of patients with mild MS during walking. Methods: Eight MS and 8 healthy control (CON) participants performed a 15-min treadmill walking test at self-selected speed. They were injected with a glucose tracer (18F-FDG) two minutes into the test and immediately upon completion, underwent Positron Emission Tomography/Computed Tomography (PET/CT) imaging. Results: MS group walked at a lower speed than the healthy control group (P < 0.01), however it was found that: 1) ([18F]-FDG) uptake in knee and hip flexors was higher compared to the CON group (P = 0.02); 2) the MS group exhibited asymmetrical strength of the knee flexors (P = 0.03); 3) [18F]-FDG uptake was significantly lower in the weaker knee flexors of patients with MS (P < 0.01). Conclusions: [18F]-FDG uptake and strength asymmetries in the legs of patients with MS indicate greater metabolic costs during activity, which may play a major role in premature muscle fatigability and subsequent impaired walking capacity.
 
The efficacy of rehabilitation in ischemic stroke patients likely varies because of brain plasticity. One of the main neurotrophins in the central nervous system is brain-derived neurotrophic factor (BDNF). This study aimed to determine allelic and genotypic distribution of BDNF-196 G>A and -270 C>T polymorphisms, and to assess the impact of repetitive transcranial magnetic stimulation (rTMS) on serum BDNF concentrations measured before rehabilitation, after the first 6 h of rehabilitation, and after 3 weeks of rehabilitation. Twenty-six patients with hand paresis and 20 with aphasia were randomly assigned to treatment with rTMS or sham stimulation (placebo group). In men with aphasia, after the first 6 h of rTMS-supported rehabilitation, BDNF concentration was lower among rTMS-treated patients than placebo-treated patients. A similar difference was observed in women with aphasia after 3 weeks of rTMS-supported rehabilitation. No significant differences in serum BDNF concentration were observed in patients with different BDNF-196 G>A or -270 C>T genotypes. During the observation period, BDNF concentration did not differ significantly between patients who improved and those who did not. One possible explanation for the observed difference between rTMS-stimulated and sham-stimulated patients is the suppression of BDNF production by rTMS in the healthy brain hemisphere.
 
The purpose of this study was to establish national point prevalence rates for traumatic brain injury, resulting in recognizable disability among adults living in institutions or in the community. The report is based on the Canadian Health and Activity Limitation Surveys (1986-1987), conducted in households and in institutions by Statistics Canada. These surveys used multi-stage cluster design with stratification, unequal probabilities of selection and computer linkage to the 1986 census of the population (households only). A combined representative sample of 632 adults with disabilities resulting from an injury to the brain provides a total population estimate of 15 000 adults. Participation rate by potential respondents was 90% in the household survey, and 97% for the institutional survey. The overall national prevalence rate of traumatic brain injury is 74.3 per 100 000 (95% CI 66.3-82.4) adults. Prevalence rates are highest in the 45-64 age range. Gender specific rates are 96.9 per 100 000 males and 52.9 per 100 000 females, with a 1.8:1 male to female ratio. The vast majority (84%) of adults with traumatic brain injury reside in household, rather than institutional settings. Prevalence rates allow estimates of the national public health burden of traumatic brain injury. Findings point to the health care burden of middle aged individuals living primarily in community settings.
 
Relapses in MS may affect the acquisition and maintenance of employment due to associated neurological deficits. Several disease modifying drugs (DMD) like interferons or glatiramer reduce the frequency of relapses and decrease their severity in MS. To investigate the influence of DMD on employment prevalence and employment rate with relapsing remitting Multiple Sclerosis (RR-MS) in the German working population from 1994 to 2009. Database assessment of working patients with MS and German labour market statistic database. Four DMD have been introduced in Germany for the treatment of RR-MS during the observation time: Interferon beta-1b (Betaferon) was approved 1996 whereas interferon beta-1a has been available in intramuscular formulation since 1997 (Avonex) and subcutaneous formulation since 1998 (Rebif). The non-interferon glatiramer (Copaxone) was introduced in 2001. Both general employment and employment with MS have increased during this period. The employment increase with RR-MS was higher than in general population only after the availability of all four DMD during the time period 2002-2009 (p = 0.008). The overall mean employment prevalence of RR-MS subjects was 0.82 ± 0.03 among 1,000 workers. The annual prescription volume of all DMD rose every year since their introduction until the end of our observation of about 10% annually. Employment increases among RR-MS patients highly correlated with the time frame of DMD availability (correlation rate 0.88, p < 0.0001). The employment rate with DMD was higher than without treatment (p < 0.0001). The introduction of DMD may have positively influenced the employment with MS.
 
to determine the potential impacts of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) on the incidence of TBI-related hospitalization in the active duty US Army. All active duty Army personnel hospitalized with a TBI diagnosis during fiscal years 2000 through 2006 were identified in an administrative database. Annual crude incidence rates were calculated. Two-year adjusted incidence rates were calculated to compare TBI-related hospitalization rates in the Army to rates in the age-comparable segment of the US civilian population. The overall incidence of TBI-related hospitalization in the active duty Army increased 105% from FY2000 to FY2006. There was a 60-fold increase in the hospitalization rate for TBIs attributed to weapons. The increases in TBI hospitalizations coincided with the occurrence of OEF/OIF. During OEF/OIF, the Army's hospitalization rates for moderate and severe TBIs were lower than civilian rates; however, the Army's hospitalization rate for mild TBIs was higher than civilian rates. OEF/OIF appear to have had a substantial impact on TBI-related hospitalization rates in the active duty US Army but differences between Army and civilian rates were not as excessive as expected.
 
A consensus conference on cognitive rehabilitation for mild traumatic brain injury was conducted by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and the Defense and Veterans Brain Injury Center. Fifty military and civilian subject matter experts from a broad range of clinical and scientific disciplines developed clinical guidance for the care of Service Members with persistent post-concussion cognitive symptoms three or more months post injury. "Cognitive rehabilitation" was identified to be a broad group of diverse services. Specific services within this rubric were identified as effective or not, and were evaluated both as single-services and as combined integrated cognitive rehabilitation programs. Co-morbidities were acknowledged and addressed, but the conference and ensuing guidance focused primarily upon treatment of cognitive impairment. Guidance regarding effective services addressed the areas of assessment, intervention, outcome measurement, and treatment program implementation.
 
Mean Modified Ashworth Scale score in upper (A) and lower (B) limbs of patients with BI and CP after BTX-A injection at baseline, and at 4 and 16 weeks. Legend: BI = brain injury, CP = cerebral palsy; SD = standard deviation. 
Clinical characteristics of enrolled BI and CP subjects with severe spasticity 
Spasticity can be a severe disabling disorder requiring high-dose injections of botulinum toxin type A (BoNT-A). Efficacy and safety of high BoNT-A doses in reducing multi-level spasticity of subjects with brain injury and cerebral palsy were investigated. Pain and functional outcome were also assessed. High doses (up to 840 IU) of incobotulinumtoxinA were injected in adult subjects with severe spasticity of the upper and lower limbs due to brain injury (BI) and cerebral palsy (CP). The Modified Ashworth Scale, Visual Analogue scale, Glasgow Outcome Scale, Franchay Arm Test (FAT) and Barthel Scale were employed to assess spasticity, pain and functional outcome at baseline, and 4 and 16 weeks after BoNT-A injection. Twenty-two (12 M, 10 F; mean age 38.1 ± 13.7 years) subjects - 16 subjects with BI and 6 with CP - were enrolled. Elbow, wrist, fingers and ankle muscles showed significant spasticity reduction after BoNT-A injections. The mean FAT score improved, but the benefit was not significant. Three (13.6%) subjects complained of mild adverse events. High-dose BoNT-A injections were effective and safe in reducing spasticity of BI and CP subjects. A significant reduction of the pain was also observed, but global functionality and arm dexterity were unchanged.
 
Patients suffering from unilateral neglect syndrome (UNS) are not able to respond to stimuli administered to the side of the body opposite to the lesion. UNS is most commonly seen after right-hemisphere lesions. Patients with UNS experience more problems with activities of daily living and recovery after stroke is delayed. To investigate which treatment modalities can alleviate the symptoms of UNS after stroke and to determine their effectiveness. Databases PubMed, Web of knowledge and PEDro have been searched. Quality assessment was conducted using the 9-item Delphi list. Data extraction was performed by the first author. Effect sizes have been calculated using Cohen's d. 15 RCT's have been included. Most studies used add-on therapies. Almost all studies found improvements in both groups, but only 7 trials showed statistically significant between group differences in favor of the experimental group. Large effect sizes were found in only four studies. All the interventions discussed in this review can reduce the symptoms of UNS. However, TENS, optokinetic stimulation, somatosensory electrostimulation, mirror therapy and virtual reality training seem to be the most effective treatment methods (d > 0,80). Future research should focus on producing studies of higher methodological quality with larger sample sizes.
 
Limited evidence is available about the effectiveness of virtual reality using low cost commercial consoles for children with developmental delay. The aim of this preliminary study is to evaluate the usefulness of a videogame system based on non-immersive virtual reality technology (Xbox 360 KinectTM) to support conventional rehabilitation treatment of children with cerebral palsy. Secondarily, to objectify changes in psychomotor status of children with cerebral palsy after receiving rehabilitation treatment in addition with this last generation game console. 11 children with cerebral palsy were included the study. A baseline, a post-treatment and a follow-up assessment were performed related to motor and the process skills, balance, gait speed, running and jumping and fine and manual finger dexterity. All the participants completed 8 weeks of videogame treatment, added to their conventional physiotherapy treatment, with Xbox 360 Kinect™ (Microsoft) game console. The Friedman test showed significant differences among the three assessments for each variable: GMFM (p = 0.001), AMPS motor (p = 0.001), AMPS process (p = 0.010), PRT (p = 0.005) and 10 MW (p = 0.029). Wilcoxon test showed significant statistically differences pre and post-treatment, in all the values. Similarly, results revealed significant differences between basal and follow-up assessment. There were not statistical differences between post-treatment and follow-up evaluation, indicating a long-term maintenance of the improvements achieved after treatment. Low cost video games based on motion capture are potential tools in the rehabilitation context in children with CP. Our Kinect Xbox 360 protocol has showed improvements in balance and ADL in CP participants in a school environment, but further studies are need to validate the potential benefits of these video game systems as a supplement for rehabilitation of children with CP.
 
Cognitive Stimulation (CS) trainings are non-pharmacological treatments widely used in dementia care. 3R Mental Stimulation is a particular type of CS, which consists of sequential association of ROT, Reminiscence and Remotivation during the same session. This pilot study sought to investigate whether CS, based on 3R program, could benefit cognitive functions, autonomy and behavioral disorders. 3R-CS treatment was applied to 36 patients, which are part of the "TREDEM" study sample, and their caregivers. All patients received a multidimensional assessment consisting of a socio-demographic, clinical and neuropsychological data collection. After CS treatment a significant improvement was detected in cognition and autonomy in basic activities of daily living. Caregiver distress was decreased. Behavioral disturbances were reduced even when considering a potential confounding factor such as treatment with anticholinesterase or NMDA receptor antagonist drugs. The findings demonstrated that 3R-CS can benefit cognitive functions and level of autonomy in the basic activities of daily living and also it can reduce behavioral disorders and caregiver's distress.
 
Event-related potentials (ERPs) can provide valuable information about cognitive capabilities in severely brain-damaged patients. This study examined 120 patients with severe brain damage using event related potentials ERPs (N 400) to gain information about their remaining semantic processing capabilities and to contribute to differential diagnosis. Patients were classified into three diagnostic groups: patients in vegetative state (VS), patients in near vegetative state (NEVS) and patients not in vegetative state (NOVS). N400 ERPs were analyzed on an individual basis. All three groups could be differentiated by N400. While VS-patients as a group were least likely to show N400, some VS-patients (approx. 12%) showed clear semantic N400 potentials as an indication of semantic processing capabilities. Patients in NEVS showed significantly more intact semantic capabilities (76.74%) than the VS-group despite little clinical differences between the two groups. Thus, ERPs provide valuable information about patients with brain injury whose clinical conditions often do not allow a true assessment of their cognitive capabilities. Given these findings, we would espouse that both ethical and legal debate should take into account results of ERP studies of such patients.
 
Non-paretic arm exercises using a tubing band: (a) horizontal abduction; (b) extension; (c) flexion. 
Trunk muscle activity (%RVC) during non-paretic arm exercises 
Abdominal strengthening exercises are important for stroke patients; however, there is a lack of research on therapeutic exercises for increasing abdominal muscle activity in stroke patients. We investigated the effects of non-paretic arm exercises using a tubing band on abdominal muscle activity in stroke patients. In total, 18 hemiplegic subjects (13 males, 5 females) were recruited. All subjects performed non-paretic arm exercises involving three different shoulder movements (extension, flexion, and horizontal abduction) using an elastic tubing band. Surface electromyography (EMG) signals were recorded from the rectus abdominis (RA), external oblique (EO), and internal oblique (IO) muscles bilaterally during non-paretic arm exercises. EMG activities of abdominal muscles during non-paretic arm extension and horizontal abduction were increased significantly versus shoulder flexion when subjects performed the arm exercise in a seated position. Muscle activity of the EO was significantly greater in the paretic than the non-paretic side during non-paretic arm extension and horizontal abduction. We suggest that non-paretic arm extension and horizontal abduction exercises using an elastic tubing band may be effective in increasing abdominal muscle activity.
 
With the general population in the United States becoming increasingly diverse, it is important for rehabilitation professionals to develop the capacity to provide culturally sensitive treatment. This is especially relevant when working with minority populations who have a higher risk for brain injury and poorer rehabilitation outcomes. This article presents a number of clinical vignettes to illustrate how cultural factors can influence behavior in patients recovering from brain injury, as well as rehabilitation staff. The main objectives are to raise awareness among clinicians and stimulate research ideas by highlighting some real world examples of situations where a specialized, patient-centered approach needs to consider factors of cultural diversity. Because one's own world view impacts the way we see the world and interpret behavior, it is important to understand one's own ethnocentrism when dealing with a diverse population of patients with brain injury where behavioral sequelae are often expected. Being able to see behavior after brain injury with an open mind and taking into account cultural and contextual factors is an important step in developing culturally competent rehabilitation practices.
 
A Taxonomy of literature reviews [11,12]. 
Growing evidence suggests that acquired brain injury (ABI) rehabilitation and research should be guided by a philosophy that focuses on: restoration, compensation, function and participation in all aspects of daily life. Such a broad, more pluralistic approach influences ABI rehabilitation research at a number of levels, including both the generation of evidence, and in searching for, critiquing and applying the evidence to practice. The objective of evidence based medicine/practice (EBM/EBP) is to apply and integrate clinical expertise with evidence gained through systematic research and scientific inquiry to medical/clinical practice. While there is abundant literature debating the practical and sociological implications of EBP, there has been limited examination of EBP within the inherently complex nature of ABI rehabilitation and rehabilitation research. This paper provides a framework for clinical decision making regarding evidence based practice in the context of ABI rehab including: 1. A discussion of the purpose of evidence based practice, 2. Levels of evidence relevant to ABI rehabilitation research, and 3. A rationale for incorporating a broader, more pluralistic concept of evidence or "person-centred EBP". We conclude with a series of key questions for the evaluation and application of systematic reviews of the evidence in the context of ABI rehabilitation.
 
The present study reports the results of 103 persons with acquired brain injury who were randomly assigned to one of three 20-session analogy problem-solving skill training groups, namely: online training (through computer video conferencing with interactive software); computer-assisted training (through interactive patient-directed software); therapist administered training (face-to-face therapist guided training activities); and a "no-treatment" control group. Pre- and post-test quasi-experimental design. Individuals' problem-solving skills and self-efficacy in all four groups were assessed over a four-week period. Overall, the training methods were found to be effective in improving problem solving skills regardless of the modes of delivery (except in the case of the control group). The continuous "human touch" characteristics of the therapist-administered group showed significant better improvements in self-efficacy in problem-solving. The statistically significantly improvement in problem solving skills in the online-group suggests that this approach could effectively improve cognitive functions of person with ABI and yield training outcomes comparable to other modes of delivery such as the face-to-face training. The conceptualization and applicability of tele-cognitive rehabilitation, its implications for persons with ABI, and future studies in this research area are also discussed.
 
Characteristics of participants * Groups 
Self-Concept Scale for Children (SCSC) 
Evaluation Scale of Elementary School Learning Strategies (ESESLS) 
evaluation: frequency of children with lesions in each given location, by treatment groups * 
The aim of this randomized clinical trial study was to evaluate the efficacy of an intervention program based on social mediation, cooperative learning and metacognition (Metacognitive Dimension) in preadolescents with acquired brain injury (ABI). Participants were 29 ABI preadolescents: 14 in the experimental group and 15 in the control group (average age, 10.4 y.o.; average time of lesion, 5.3 years). Evaluations were conducted 3 months after the start of the intervention, using the Evaluation Scale of Elementary School Learning Strategies (ESESLS) to assess metacognitive strategies, Self-Concept Scale for Children (SCSC) and Behavioral Rating Inventory of Executive Functions (BRIEF). The experimental group had superior outcomes to the control. The results of metacognitive strategies (ESESLS) and self-concept (SCSC) were better in the experimental than in the control group (p< 0.05). BRIEF did not reveal any significant differences between the groups, although we observed better results in the experimental group for 5 sub items of the scale, in the broader index and global executive composite score. Three months of an intervention based on cooperative learning helped preadolescents with acquired brain injury develop metacognitive strategies and improve self-concept, thereby helping empower the preadolescents in their social relationships.
 
Few studies have addressed factors that contribute to functional recovery in people with hemorrhagic stroke. We assessed the value of using pre-training functional level and cognitive abilities measured at admission in order to predict functional gain in a sample of stroke patients. The Functional Independence Measure (FIM) was administered to 85 hemorrhagic stroke patients. Three multiple regression models were constructed using total gain in FIM scores, gain in scores in the cognitive domain of FIM, and gain in scores in the motor domain of FIM as outcome variables. Predictor variables were age; scores on the Digit Span Forward Test (DSF), Digit Span Backward Test (DSB), and Chinese Auditory Verbal Learning Test (CAVLT); and the FIM scores measured at admission. All regression models were significant, Ps < 0.001, and each explained over 73% of the variance in the FIM gains. Age and admission FIM scores were both significant predictors in each of the three models. The DSB span score was a significant predictor of the total FIM and the cognitive FIM gains. The CAVLT recognition score was also a significant predictor of the cognitive FIM gain. Functional improvement in patients with hemorrhagic stroke after in-patient rehabilitation was predicted by age, pre-training functional level, and cognitive abilities measured at admission.
 
Means, Standard Deviations, and Correlations of Self-Report Variables in Study 1 
Means and Standard Deviations for Self-Report Variables and Demographic Characteristics by Group in Study 2 
, continued 
The relationship of social problem solving abilities, health locus of control beliefs, and psychosocial impairment were examined among individuals with spinal cord injuries who were hospitalized following surgical repair of severe pressure sores. Individuals were approached after surgical repair and completed measures of problem solving, health locus of control beliefs, and psychosocial impairment after admission to the rehabilitation hospital. The sample reported greater psychosocial impairment than observed in comparative data, but they did not differ from another sample in terms of health locus of control beliefs. Correlational analyses revealed that a negative orientation toward problem solving was significantly predictive of psychosocial impairment, consistent with prior research. However, a second study found persons assigned to a brief problem solving intervention did not differ on any measure from participants in a control group. Implications of these results are discussed from theoretical and clinical perspectives. Although social problem solving abilities were predictive of psychosocial impairment in a predicted direction, the lack of effects for the intervention suggests greater precision is needed to understand individual needs and to develop individualized intervention protocols.
 
Comparison of demographic variables for both groups 
Research suggests that the occurrence of a traumatic brain injury (TBI) in childhood may disrupt self-regulation abilities, putting children at risk for difficulty on everyday tasks requiring self-regulation throughout their development. In the current exploratory study, a novel age-appropriate task assessed the ability to perform three familiar tasks using real objects while adhering to specific rules. Performance of children (ages 8-16) with severe TBI (n = 11) on the naturalistic task was compared to that of typically developing children (n = 21), including measures of the amount/types of errors and number of broken rules. The children with TBI exhibited significantly increased use of distractor objects in place of target objects as compared to the non-injured children. Additionally, children with TBI demonstrated trends of increased breaking of rules during the task and failure to include necessary steps. The preliminary results support the theory that children with severe TBI possess inefficient supervisory processes of self-regulation, corresponding to a decreased ability to carry out goal-based top-down processing. They may instead exhibit a bias towards a bottom-up approach, depending primarily on environmental cues such as the objects present to guide their actions, thus impeding self-regulation abilities.
 
To characterize and determine the pre-injury and injury-related variables that are linked to the extent of functional recovery following rehabilitation at a mixed therapy and educational residential programme and whether these variables differ for traumatic brain injury (TBI) and non traumatic brain injury (nonTBI). 106 young adults (age 16-36 years) with moderate-to-severe TBI who had attended and been discharged from the centre since 2002 were included. Clients received 5 hours of education and/or therapy each day. Functional level was assessed using the FIM + FAM. Regression analysis was used to determine possible predictors of functional independence at discharge. Clients with TBI and nonTBI made clinically and statistically significant improvements in their functional abilities during their neurorehabilitation. For the combined TBI and nonTBI group, FIM + FAM scores at discharge were predicted by FIM + FAM at admission and length of stay. These two predictors explained 80% of the variance in the FIM + FAM score at discharge. Both clients with TBI and nonTBI benefited from a mixed inpatient neurorehabilitation programme. This benefit was predicted by their functional abilities at admission and the length of stay. These findings are of importance as it becomes increasingly necessary to demonstrate who will benefit from residential intensive neurorehabilitation as opposed to community therapy.
 
Dystonia is a disabling movement disorder, which is characterized by an abnormal pattern of muscle activity with co-contraction of agonist and antagonist muscles. In the case of focal hand dystonia (FHD), these abnormal movements affect muscles of the forearm and hand while performing a specific task. Patients may initially present with dystonic symptoms occurring with a selective task (simple writer's cramp or musician's cramp), and may progress to develop symptoms with multiple tasks (dystonic writer's cramp). The underlying cause of this disabling condition remains unclear. This review examines recent studies designed to further elucidate the underlying pathophysiological processes in focal dystonia. Animal research work, and neurophysiological and neuroimaging studies in humans, have identified several possible mechanisms that may contribute to the underlying pathophysiology, including impaired sensorimotor integration, motor cortex activation and surround inhibition. Pharmacological treatment for dystonia is currently suboptimal. Based on these recent pathophysiological findings, several promising and novel non-pharmacological treatment modalities have recently been developed. Attempts at modulating impaired sensorimotor integration and cortical inhibition using sensorimotor retraining, and the range of sensory training techniques recently described, are further discussed in this review.
 
Changes in clinical gait parameters 
Changes in pelvic and hip kinematic parameters 
Gait disorders are common in multiple sclerosis (MS) and lead to a progressive reduction of function and quality of life. Test the effects of robot-assisted gait rehabilitation in MS subjects through a pilot randomized-controlled study. We enrolled MS subjects with Expanded Disability Status Scale scores within 4.5-6.5. The experimental group received 12 robot-assisted gait training sessions over 6 weeks. The control group received the same amount of conventional physiotherapy. Outcomes measures were both biomechanical assessment of gait, including kinematics and spatio-temporal parameters, and clinical test of walking endurance (six-minute walk test) and mobility (Up and Go Test). 16 subjects (n = 8 experimental group, n = 8 control group) were included in the final analysis. At baseline the two groups were similar in all variables, except for step length. Data showed walking endurance, as well as spatio-temporal gait parameters improvements after robot-assisted gait training. Pelvic antiversion and reduced hip extension during terminal stance ameliorated after aforementioned intervention. Robot-assisted gait training seems to be effective in increasing walking competency in MS subjects. Moreover, it could be helpful in restoring the kinematic of the hip and pelvis.
 
High frequency stimulation (HFS) of the subthalamic nucleus is one of the most effective treatments for advanced Parkinson's disease (PD). HFS has provided beneficial improvements in the cardinal features of PD, but has not been proven as effective for addressing the axial predominant levodopa resistant symptoms, such as speech disturbances, gait disturbances, and postural instability. Recent studies have suggested that changes in stimulation parameters may influence differing PD symptoms. The purpose of this study was to compare the effects of low frequency stimulation (LFS) versus HFS on the Unified Parkinson's Disease Rating Scale (UPDRS), gait, balance, and verbal fluency. Eight tremor dominant and nine non-tremor dominant participants with bilateral deep brain stimulation of the subthalamic nucleus were tested off stimulation, during LFS, and during HFS. Results revealed that HFS significantly reduced UPDRS tremor score in the tremor dominant group; however no differences emerged within the non-tremor dominant group. No differences between groups or stimulation conditions were found for gait, balance, and verbal fluency measures. These results may suggest that HFS is better than LFS for reducing tremor in tremor dominant patients. However, patients with mild or no tremor show no acute differences in benefit from LFS as compared to HFS.
 
Abulia is a disorder of the executive and frontal lobe function. It is characterised by severe psychomotor slowing that is not due to depressive illness or catatonic schizophrenia. Abulia is thought to be due to disruption of the meso-cortico-limbic dopaminergic system. Preliminary evidence suggests that patients with abulia may respond to treatment with dopaminergic drugs. We extend this evidence by reporting a significant and sustained functional improvement in a severely abulic patient after treatment with co-beneldopa (Madopar).
 
The highest incidence of TBI is among young adult males who also have the highest incidence of substance abuse [1]. Since these individuals have long life expectancies, it is important that they are productive post injury; however, the employment rate is extremely low. This is understandable, given the fact that a person with either a TBI or substance abuse disorder would have difficulties with work. Naturally, the combination of the two compounds the problem and further complicates matters. This article provides an overview of how a Supported Employment approach can be used to assist persons with a TBI and substance abuse problems with returning to work.
 
There is little information regarding the impact that traumatic brain injury (TBI) has on the functioning of mothers at risk of child abuse. This study evaluated adult functioning (e.g. child abuse, substance use, criminal convictions, and mental health problems) of mothers, at high risk for child abuse, who also had a history of TBI compared with those without TBI. It was hypothesised that mothers with a history of TBI would engage in higher rates of dysfunctional behaviour compared to those with no history of TBI. Participants were 206 women engaged in a child abuse prevention programme for mothers who are highly socially disadvantaged, and at high risk for child abuse. Using historical data collected as part of the referral, and self report intake process, this study compared child abuse, mental health problems (depression, anxiety, substance use) and rates of criminal offending for mothers with a history of TBI versus those with no history of TBI. Mothers with TBI were no more likely than those without TBI to have engaged in child abuse. However, mothers with a history of TBI were significantly more likely to have one or more mental health problems, engage in substance use and have a history of criminal offending. Parents with TBI who have been identified as high risk for engaging in child abuse have increased risk for mental health problems and criminal offending. These issues need to be considered when designing parenting programmes in order for intervention strategies to be effective.
 
Subject characteristics 
Results of aerodynamic and acoustical data 
Results of DDK rate 
Based on the anatomical and functional commonality between singing and speech, various types of musical elements have been employed in music therapy research for speech rehabilitation. This study was to develop an accent-based music speech protocol to address voice problems of stroke patients with mixed dysarthria. Subjects were 6 stroke patients with mixed dysarthria and they received individual music therapy sessions. Each session was conducted for 30 minutes and 12 sessions including pre- and post-test were administered for each patient. For examining the protocol efficacy, the measures of maximum phonation time (MPT), fundamental frequency (F0), average intensity (dB), jitter, shimmer, noise to harmonics ratio (NHR), and diadochokinesis (DDK) were compared between pre and post-test and analyzed with a paired sample t-test. The results showed that the measures of MPT, F0, dB, and sequential motion rates (SMR) were significantly increased after administering the protocol. Also, there were statistically significant differences in the measures of shimmer, and alternating motion rates (AMR) of the syllable /K$\inve$/ between pre- and post-test. The results indicated that the accent-based music speech protocol may improve speech motor coordination including respiration, phonation, articulation, resonance, and prosody of patients with dysarthria. This suggests the possibility of utilizing the music speech protocol to maximize immediate treatment effects in the course of a long-term treatment for patients with dysarthria.
 
Advances in computer technology and the Internet have meant that more and more occupations can be made available to disabled individuals, including occupations generally considered to be leisure. However, computers and the Internet also provide barriers to access for these individuals. This article discusses some of these barriers, solutions to them and highlights the complexities involved in the provision of a computer-based assistive technology solution for access to leisure for a profoundly disabled young lady. It also points out the need for the input of a highly skilled, multi-disciplinary team in the assessment for and provision of such a system.
 
WayFinder’s Main Menu showing four travel routes (left); at beginning of route (center) and during transit (right). Note progress bar showing relative route position at bottom of screen. 
WayFinder display showing a Landmark waypoint (left); a Not-Your-Stop waypoint (center), and a Signal Stop waypoint (right). 
Route Builder interface with waypoint options (left) and Route Editor interface (center and right). 
The concept of community access is a multidimensional term, which may involve issues related to physical access, knowledge and information, power and control, relationships and communications, advocacy, participation and quality of life [21]. This paper discusses historical and emerging practices and interventions related to physical access to community and community based information for individuals with cognitive disabilities such as intellectual disability, autism or traumatic brain injury. While much societal attention has been paid to features of independent community access for populations such as individuals with hearing, vision or physical disabilities, less attention has focused on independent community access for people with intellectual and other significant cognitive disabilities. Attitudes and actions by families and professional service communities are often mixed for some individuals in this population. The somewhat limited research base in these areas is explored, including a case study review and results from several promising feasibility studies. The paper concludes with comments concerning future prospects and recommendations for improving independent community access for persons with significant cognitive disabilities.
 
Computers, telephones, and assistive technology hold promise for increasing the independence, productivity, and participation of individuals with disabilities in academic, employment, recreation, and other activities. However, to reach this goal, technology must be accessible to, available to, and usable by everyone. The authors of this article share computer and telephone access challenges faced by individuals with neurological and other impairments, assistive technology solutions, issues that impact product adoption and use, needs for new technologies, and recommendations for practitioners and researchers. They highlight the stories of three individuals with neurological/mobility impairments, the technology they have found useful to them, and their recommendations for future product development.
 
Elevated beds with varying knee clearance heights. (Chicago Botanic Garden, photo credit National Center on Accessibility).  
Hanging baskets with pulleys. (Chicago Botanic Garden, photo credit National Center on Accessibility).  
Telescoping garden tools extend the reach of a gardener.  
The outdoor environment can provide many positive and therapeutic benefits for persons with complex neurological conditions. In order to benefit from outdoor exposure and experiences, individuals need to be able to access that environment. This article provides a discussion of physical and programmatic access to outdoor living elements in homes and residential facilities for persons with neuro-disabilities. Design considerations for outdoor elements such as common gathering areas, walking paths and paths to/between elements, gardens (viewing and working), and resting areas are presented using legal standards or universal design principles as guides.
 
Survivors of traumatic brain injury (TBI) often experience cognitive and physical impairments. The aims of this study were to: 1) build an internet-based, "Virtual Rehabilitation Center" (VRC) that provides rehabilitation, education and support services to individuals with TBI; and 2) to determine the relationships between the nature and severity of the participants' cognitive impairments and their ability to use the VRC. Eight individuals with brain injuries (Age: M=43, SD=15.4; Years of Education: M=13.8, SD=3.15) participated. The Neurobehavioral Cognitive Status Exam (NBCSE) was used to assess intellectual functioning. The VRC modules consisted of reaction time, functional modules, and communication capabilities. All participants learned how to use the VRC. However, those requiring more "trials to acquisition" showed greater cognitive impairment than those requiring fewer trials in: Construction (p=0.02), Reasoning-Similarities (p=0.01) and in calculation and language repetition.(i.e., a non-significant trend). Importantly, all participants learned how to use the system although learning rates varied. Moreover, one case-study demonstrated that learning on the VRC generalized to the community. Overall, impairments on the NBCSE in visual-constructional integration and executive-type functions, as well as language processing appeared to be related to how effectively participants learned how to use the VRC.
 
This study was designed to consider the feasibility and effectiveness of combined body weight support (BWS) treadmill and overground training for a 71-year-old woman 19 months post left embolic middle cerebral artery stroke. The study used a modified single subject withdrawal design (ABAA). Initial baseline performance (A1) was established using a set of functional assessment tools for balance, mobility and gait. Intervention (B) was introduced and removed, and a second baseline performance (A2) was recorded. After a one-month delay, final baseline performance was established. During intervention, the participant was involved in combined BWS training three times/week for eight weeks. Single subject analyses and pre/posttest analyses were conducted. Results revealed that 17 of 20 indicators (85%) nine indicators (89%) performance one-month post intervention. Combined BWS training was feasible and effective in improving and maintaining functional performance in this participant.
 
Obtaining accurate information about the neuropsychological functioning of elderly individuals with physical or sensorimotor limitations may be fostered by judicious use of nonstandard testing strategies. We review professional documents that support this position and discuss selected "flexible" testing techniques that can serve this goal. These approaches may permit assessment of skills that might otherwise go unmeasured (e.g., naming ability or executive function in persons with visual impairment). This perspective is particularly critical when clinicians are asked to assess an older adult's capacity and competence in daily life functions.
 
In this study, the AIMS, a measure of community integration developed from acculturation theory, was used to explore the various ways that people with brain injuries, a smaller cultural or minority group, are involved with the larger cultural group and to evaluate rehabilitation outcome (i.e., reintegration into the community). Specifically, the AIMS assesses whether the needs of individuals with brain injuries in a number of areas are identified and supported in a way that supports community participation. In addition, the opinions of persons with a brain injury regarding their level of community integration were compared to the opinions of individuals who knew them well. The results of this study indicate that while a large proportion of the participants with brain injuries were integrated in traditional areas of service delivery such as medical services, housing and social activity, their disability-related needs were not being identified and supported adequately in the areas of spirituality and productive activity.
 
The vocational assessment of brain-damaged clients can be approached through the disciplines of vocational evaluation or neuropsychology. Each avenue has its strength and pitfalls. Vocational evaluation focuses on specific cognitive, educational, and physical attributes that are required to negotiate positions within the competitive labor market. Neuropsychological evaluation dovetails with this criteria to amplify other less structured but important aspects of the client's vocational profile, particularly those variables that relate to "executive" functions, novel learning, and neurobehavioral syndromes. Coordination of both spheres is essential if brain-damaged clients' vocational placement is to be enhanced. Suggestions are made regarding coordinating these disciplines; a case report is additionally presented.
 
Correlation matrix of the indices computed in this study
Robotic rehabilitation devices for upper limb function (ULF) provide global indicators of a patient's ability, but the temporal evolution of motion related to motor control is disregarded. To determine normative values for indices of accuracy, speed and smoothness in the evaluation of upper limb function. Twenty-five healthy individuals performed the Armeo®Spring device "Vertical Capture" task. Custom stand-alone software was developed to provide the following indices: global Hand Path Ratio (HPR), local HPR in the target area (locHPR), vertical and horizontal overshoot (vertOS, horOS), maximum and mean velocity (maxVel, meanVel), mean/maximum velocity, number of peaks in velocity profiles (NVelPeaks) and normalized jerk (NormJerk). The dependence of indices on task characteristics was analyzed by an ANCOVA test. Indices inner relationships were assessed by a correlation and a factor analysis. Normative values were then provided. 4,268 single reaching movements were analyzed. Four indices were not affected by movement direction. Indices were minimally influenced by the difficulty level. Based upon correlation and factor analysis indices and can be grouped into three assessment fields, dealing with precision, velocity and smoothness. We have developed a tool to assess ULF in dynamic condition. Normative values were obtained to be used as references in assessing patients.
 
The purpose of this study was to evaluate the relationship between the recovery of gross motor function and cerebrovascular reserve (CVR) capacity measured by brain perfusion single-photon emission computed tomography (SPECT) in patients with first-ever supratentorial infarction. Gross motor function was assessed according to the locomotor and mobility subset of the functional independence measure. The CVR was measured as the difference in the regional cerebral blood flow (rCBF) after acetazolamide (ACZ)-challenged(99m)Tc-ECD perfusion SPECT from baseline rCBF. All 22 hemiplegic patients (mean age, 60.97 years) enrolled were admitted at a mean of 20.86 days from onset and received rehabilitation care for an average of 38.82 days. The recovery of gross motor function was significantly correlated with baseline rCBF and CVR of ACZ-SPECT in the areas of affected supratentorial hemisphere (r=0.447 and r=0.444, respectively, p < 0.05). Analysis of the linear regression model, adjusted for time to SPECT testing, revealed that the CVR in the affected supratentorial hemisphere was a significant predictor of the gross motor outcome (p< 0.05). In conclusion, the CVR of the affected supratentorial hemisphere may be employed along with other parameters to predict the gross motor recovery of patients with subacute infarction.
 
A good motor outcome after stroke is often equated with independence in functional performance. However, for patients with severe motor disability a good outcome is unlikely, but an important change may be achievable. Determine if patients admitted to inpatient rehabilitation with severe motor disability can achieve clinically important improvements in motor function. A prospective observational study of 239 patients with stroke admitted to inpatient rehabilitation in Brisbane, Australia was conducted. On admission and discharge, participants were assessed using the motor items of the Functional Independence Measure (m-FIM). The importance of change achieved on the m-FIM was evaluated according to: 1) a statistical significant outcome; 2) achievement of a MCID based on a physician-anchored rating of change; and 3) shift in disability status e.g., severe to moderate disability. Patients with severe motor disability achieved a significant improvement in motor function (p < 0.001), which saw up to 83% achieve a MCID and 85% shift out of 'severe' to either moderate or mild motor disability on discharge from inpatient rehabilitation. This study demonstrates that patients admitted to inpatient rehabilitation with severe motor disability can achieve clinically important improvements in motor function on discharge from inpatient rehabilitation.
 
Top-cited authors
Juan Carlos Arango-Lasprilla
  • Giunti Psychometrics
Sung Ho Jang
  • Yeungnam University
Paul B Perrin
  • Virginia Commonwealth University
Daniel AGUILAR Rivera
  • Instituto Nacional de Enfermedades Neoplásicas
Su Min Son
  • Yeungnam University