Time to reconcile research findings and clinical practice on upper limb neurorehabilitation.

The problem: In the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs. Proposed solutions: The objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions. Conclusions: It's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery.

Light aerobic exercise modulates executive function and cortical excitability.

Single bouts of aerobic exercise can modulate cortical excitability and executive cognitive function, but less is known about the effect of light-intensity exercise, an intensity of exercise more achievable for certain clinical populations. Fourteen healthy adults (aged 22 to 30) completed the following study procedures twice (≥7 days apart) before and after 30 min of either light aerobic exercise (cycling) or seated rest: neurocognitive battery (multitasking performance, inhibitory control and spatial working memory), paired-pulse TMS measures of cortical excitability. Significant improvements in response times during multitasking performance and increases in intracortical facilitation (ICF) were seen following light aerobic exercise. Light aerobic exercise can modulate cortical excitability and some executive function tasks. Populations with deficits in multitasking ability may benefit from this intervention.

Traumatic Brain Injury Modifies the Relationship Between Physical Activity and Global and Cognitive Health: Results From the Barcelona Brain Health Initiative.

Physical activity has many health benefits for individuals with and without history of brain injury. Here, we evaluated in a large cohort study the impact of physical activity on global and cognitive health as measured by the PROMIS global health and NeuroQoL cognitive function questionnaires. A nested case control study assessed the influence of a history of traumatic brain injury (TBI) on the effects of physical activity since underlying pathophysiology and barriers to physical activity in individuals with TBI may mean the effects of physical activity on perceived health outcomes differ compared to the general population. Those with a history of TBI (n = 81) had significantly lower Global health (ß = -1.66, p = 0.010) and NeuroQoL cognitive function (ß = -2.65, p = 0.006) compared to healthy adults (n = 405). A similar proportion of individuals in both groups reported being active compared to being insufficiently active ( X ( 1 ) 2 = 0.519 p = 0.471). Furthermore, the effect of physical activity on global health (ß = 0.061, p = 0.076) and particularly for NeuroQoL (ß = 0.159, p = 0.002) was greater in those with a history of TBI. Individuals with a history of TBI can adhere to a physically active lifestyle, and if so, that is associated with higher global and cognitive health perceptions. Adhering to a physically active lifestyle is non-trivial, particularly for individuals with TBI, and therefore adapted strategies to increase participation in physical activity is critical for the promotion of public health.

Feasibility of Aerobic Exercise in the Subacute Phase of Recovery From Traumatic Brain Injury: A Case Series.

BACKGROUND AND PURPOSE: Aerobic exercise is as important for individuals with traumatic brain injury (TBI) as for the general population; however, the approach to aerobic training may require some adaptation. The objective of the trial program was to examine the feasibility of introducing aerobic physical exercise programs into the subacute phase of multidisciplinary rehabilitation from moderate to severe TBI, which includes computerized cognitive training. CASE DESCRIPTION: Five individuals undergoing inpatient rehabilitation with moderate or severe TBIs who also have concomitant physical injuries. All of these individuals were in the subacute phase of recovery from TBIs. INTERVENTION: An 8-week progressive aerobic physical exercise program. Participants were monitored to ensure that they could both adhere to and tolerate the exercise program. In addition to the physical exercise, individuals were undergoing their standard rehabilitation procedures that included cognitive training. Neuropsychological testing was performed to gain an understanding of each individual's cognitive function. OUTCOMES: Participants adhered to both aerobic exercise and cognitive training. Poor correlations were noted between heart rate reserve and ratings of perceived effort. Two minor adverse events were reported. DISCUSSION: Despite concomitant physical injuries and cognitive impairments, progressive aerobic exercise programs seem feasible and well tolerated in subacute rehabilitation from moderate to severe TBI. Findings highlight the difficulty in measuring exercise intensity in this population.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A235).

The role of physical exercise in cognitive recovery after traumatic brain injury: A systematic review.

BACKGROUND: There is a growing body of evidence revealing exercise-induced effects on brain structure and cognitive function across the lifespan. Animal models of traumatic brain injury also suggest exercise is capable of modulating not only the pathophysiological changes following trauma but also the associated cognitive deficits. OBJECTIVE: To evaluate the effect of physical exercise on cognitive impairment following traumatic brain injury in humans. METHODS: A systematic search of the PubMed database was performed using the search terms "cognition" and "executive function, memory or attention", "traumatic brain injury" and "physical exercise". Adult human traumatic brain injury studies that assessed cognitive function as an outcome measure (primary or secondary) and used physical exercise as a treatment (single or combined) were assessed by two independent reviewers. Data was extracted under the guidance of the population intervention comparison outcome framework wherein, characteristics of included studies (exercise duration, intensity, combined or single intervention, control groups and cognitive measures) were collected, after which, methodological quality (Cochrane criteria) was assessed. RESULTS: A total of 240 citations were identified, but only 6 met our inclusion criteria (3 from search records, 3 from reference lists. Only a small number of studies have evaluated the effect of exercise on cognition following traumatic brain injury in humans, and of those, assessment of efficacy is difficult due to low methodological strength and a high risk of different types of bias. CONCLUSION: Evidence of an effect of physical exercise on cognitive recovery suggests further studies should explore this treatment option with greater methodological approaches. Recommendations to reduce risk of bias and methodological shortfalls are discussed and include stricter inclusion criteria to create homogenous groups and larger patient pools, more rigorous cognitive assessments and the study and reporting of additional and combined rehabilitation techniques.