A randomized controlled trial on the effects induced by robot-assisted and usual-care rehabilitation on upper limb muscle synergies in post-stroke subjects.

Muscle synergies are hypothesized to reflect connections among motoneurons in the spinal cord activated by central commands and sensory feedback. Robotic rehabilitation of upper limb in post-stroke subjects has shown promising results in terms of improvement of arm function and motor control achieved by reassembling muscle synergies into a set more similar to that of healthy people. However, in stroke survivors the potentially neurophysiological changes induced by robot-mediated learning versus usual care have not yet been investigated. We quantified upper limb motor deficits and the changes induced by rehabilitation in 32 post-stroke subjects through the movement analysis of two virtual untrained tasks of object placing and pronation. The sample analyzed in this study is part of a larger bi-center study and included all subjects who underwent kinematic analysis and were randomized into robot and usual care groups. Post-stroke subjects who followed robotic rehabilitation showed larger improvements in axial-to-proximal muscle synergies with respect to those who underwent usual care. This was associated to a significant improvement of the proximal kinematics. Both treatments had negative effects in muscle synergies controlling the distal district. This study supports the definition of new rehabilitative treatments for improving the neurophysiological recovery after stroke.

The impact of balance specific physiotherapy, intensity of therapy and disability on static and dynamic balance in people with multiple sclerosis: A multi-center prospective study.

BACKGROUND: A high-quality research identifying the best physiotherapeutic approach for the improvement of balance in people with multiple sclerosis is missing. This study compared aspects of balance improvement such as therapy specificity to balance, therapy method and category, country, intensity and medical conditions. METHODS: A multicentric randomised rater-blinded controlled trial comprised three different physiotherapy programs (Czech and Italian outpatient or inpatient programs). All patients received 20 therapy sessions. Experimental group underwent balance specific physiotherapy (it was Motor Program Activating Therapy in the Czech cohort and Sensory-motor Integration Training in the Italian cohort), control group underwent non-balance specific physiotherapy (it was Vojta reflex locomotion in the Czech cohort and conventional dynamic strengthening exercises in the Italian cohort, respectively). Static balance was evaluated by Berg Balance Scale and dynamic balance was assessed by Timed Up-and-Go Test. RESULTS: A total of 149 patients entered the study. Physiotherapy significantly improved static balance (p < 0.0001, increase by mean 2.6 points (95% confidence interval 2.0-3.5) in BBS score). Balance specific approach had a higher effect than non-specific balance approach (increase in BBS by 1.9 points, 95% confidence interval 0.9-3.7 points). The intensity of the physiotherapy significantly influenced static balance (BBS by 2.7 points higher in the inpatient setting, p= 0.007). Dynamic balance was also improved (TUG decrease by -0.8 s (95% CI -1.4 - -0.1s, p = 0.011)); the balance specificity had no impact. The level of disability played the most important role (p= 0.022). CONCLUSION: Although the overall changes in static and dynamic balance were statistically significant, they were quite small in a clinical sense. A small statistically significant difference between balance specific and non-specific treatment was found. It seems that a high intensity of the therapy is critical to maximize the effectiveness.

Comparison of upright balance in stroke, Parkinson and multiple sclerosis.

OBJECTIVE: Multiple sclerosis (MS), Parkinson's disease (PD) and stroke (ST) subjects show balance impairments due to damage of the balance control system. The objective of the study was to assess the impact of MS, PD and ST on upright posture in eyes open condition and when visual and/or proprioceptive inputs are altered. MATERIALS AND METHODS: A total of 188 subjects with MS (n = 80), PD (n = 58) and ST (n = 50), mean age (SD), 57.9 (14.6) years, and 32 healthy subjects (HS) aged 53.7 (15.7) years were assessed by a stabilometric platform in a cross-sectional study. RESULTS: Compared to HS, MS showed large deviations from normal performances with respect to magnitude (P < 0.001) and regularity (P < 0.05) of body sway irrespective of the altered sensory information. Similarly to MS, PD showed large and abnormal levels of body sway (P < 0.001) and postural tremor (P < 0.05), while ST was the least impaired except for an asymmetrical distribution of body weight between legs (P < 0.001). Finally, the MS group compared to PD and ST showed the largest body instability after eye closure (P < 0.05) and when visual and proprioceptive inputs were removed (P < 0.05). PD showed instability mainly after the alteration of proprioceptive inputs (P < 0.05), while ST showed the smallest increase of body instability when sensory inputs were reduced. DISCUSSION: Objective assessment revealed pathology-specific balance disorders and showed the differential impact of MS, PD and ST on the ability to use sensory information for balance control.

Monitoring game-based motor rehabilitation of patients at home for better plans of care and quality of life.

This paper describes the biomedical, remote monitoring infrastructure developed and currently tested in the EU REHAB@HOME project to support home rehabilitation of the upper extremity of persons post-stroke and in persons with other neurological disorders, such as Multiple Sclerosis patients, in order to track their progress over therapy and improve their Quality of Life. The paper will specifically focus on describing the initial testing of the tele-rehabilitation system's components for patients' biomedical monitoring over therapy, which support the delivery and monitoring of more personalized, engaging plans of care by rehabilitation centers and services.

Myoelectrically driven functional electrical stimulation may increase motor recovery of upper limb in poststroke subjects: a randomized controlled pilot study.

The objective of this randomized controlled pilot study was to assess the feasibility and effectiveness of myoelectrically controlled functional electrical stimulation (MeCFES) for rehabilitation of the upper limb in poststroke subjects. Eleven poststroke hemiparetic subjects with residual proximal control of the arm, but impaired volitional opening of the paretic hand, were enrolled and randomized into a treated and a control group. Subjects received 3 to 5 treatment sessions per week until totaling 25 sessions. In the experimental group, myoelectric activity from wrist and finger extensors was used to control stimulation of the same muscles. Patients treated with MeCFES (n = 5) had a significant (p = 0.04) and clinically important improvement in Action Research Arm Test score (median change 9 points), confirmed by an Individually Prioritized Problem Assessment self-evaluation score. This improvement was maintained at follow-up. The control group did not show a significant improvement (p = 0.13). The reduced sample size of participants, together with confounding factors such as spontaneous recovery, calls for larger studies to draw definite conclusions. However, the large and persistent treatment effect seen in our results indicate that MeCFES could play an important role as a clinical tool for stroke rehabilitation.

Functional resources to increase gait speed in people with stroke: strategies adopted compared to healthy controls.

Thirty-nine adult individuals with stroke in the stable phase were asked to walk at their preferred speed and then as fast as possible. A set of gait indexes were computed, including spatial temporal parameters, ankle and hip mechanical work, and timing of ankle push-off onset, for comparison with normal velocity-dependent profiles. Algorithms were used to classify the resulting gait patterns when the patients walked at their preferred speed and fast and to identify the patients' strategies to maximise speed. Patients' strategies were characterised by a variation in the parameters, which were reduced, equal or increased, in relation to normal patterns. At both speeds, stroke individuals tended to walk at higher cadence and with shorter stride length. At the preferred speed the investigated parameters for all patients were mostly within the normal profile (71.8-94.9%). The exception was the finding of positive work at the ankle where 64% of the stroke individuals showed reduced work production. At fast speed (increments to 36%BH/s) fewer patients presented values within the normal profile for all the parameters (17.9-74.4%), with the exception of negative work at the ankle and hip. The parameter variations showed a more consistently abnormal picture. The results indicate that, in order to increase gait speed, patients with hemiparesis have different functional resources on which to draw, and these vary from individual to individual. Thus, gait analysis at different gait speed should be adopted to develop individualised programs that will improve quality of life for the patients.

Sensory impairments in quiet standing in subjects with multiple sclerosis.

Balance disorders and falls are frequently observed in subjects with multiple sclerosis (MS). Along with motor impairment, sensory disorders and integration deficits of sensory inputs lead to inadequate motor responses. The assessment of these sensory disorders in an every day tasks, such as upright stance, increases our knowledge of postural control in this pathology, thus promoting more effective treatments. The aim of the study was to describe sensory impairments and sensory strategies in different sensory conditions. A stabilometric assessment was carried out in a consecutive convenience sample of 53 subjects. The age of the sample was 52.7 (21.1) years; the onset of pathology was 27.20 (14.5) years before the assessment. Balance was assessed in six sensory conditions. The impact of pathology on balance control was shown by the high percentage of abnormal scores: 75% of subjects with MS showed abnormal scores even in the eyes open condition. The alteration of a single sensory input led to an increase of abnormal scores in up to 82% of subjects. Almost all subjects showed abnormal scores in the vestibular conditions where 22% of them fell. The pattern of the subjects' performance in the six sensory conditions suggests that balance control may be more correlated to the number of reliable sensory inputs than the nature of the sensory input itself.

Effects of balance exercises on people with multiple sclerosis: a pilot study.

OBJECTIVE: To evaluate the effects of balance retraining in a sample of people with multiple sclerosis. DESIGN: Randomized controlled trial. SETTING: Rehabilitation unit. SUBJECTS: A consecutive sample of 44 subjects was randomized into two experimental groups and one control group. The inclusion criteria were: ability to stand independently more than 30 seconds, ability to walk for 6 m. INTERVENTIONS: Group 1 received balance rehabilitation to improve motor and sensory strategies. Group 2 received balance rehabilitation to improve motor strategy. Group 3 received treatments not specifically aimed at improving balance. MAIN OUTCOME MEASURE: Berg Balance Scale, Dynamic Gait Index and fall frequency were used to assess balance impairments. Dizziness Handicap Inventory and Activities-specific Balance Confidence were used to assess handicap and the level of balance confidence. RESULTS: Frequency of falls post treatment was statistically different among groups (P=0.0001); The Berg Balance Scale showed an overall statistically significant difference (P=0.0008) among groups. Change pre-post scores were 6.7, 4.6 and 0.8 points for groups 1, 2 and 3. Dynamic Gait Index showed an overall near statistically significant difference among groups (P=0.14), with change pre-post scores of 3.85, 1.6 and 1.75 points for groups 1, 2 and 3; after the exclusion of drop-outs a statistically significant difference was observed (P=0.04). The self-administered tests (Activities-specific Balance Confidence and Dizziness Handicap Inventory) did not show clinically relevant improvements. CONCLUSIONS: Balance rehabilitation appeared to be a useful tool in reducing the fall rate and improving balance skills in subjects with multiple sclerosis. Exercises in different sensory contexts may have an impact in improving dynamic balance.