Effectiveness of external cues to facilitate task performance in people with neurological disorders: a systematic review and meta-analysis

Coaching stroke survivors to persevere with practice: An observational behavioural mapping study

ObjectiveTo quantitatively describe therapists' use of coaching with stroke survivors, in a hospital-based rehabilitation setting, to promote perseverance with longer-term practice.DesignProspective observational behavioural mapping study.SettingRehabilitation unit of a regional public hospital in Queensland, Australia.Main measuresA custom-designed behavioural mapping tool was used to collect rehabilitation session contextual data and therapists' use of coaching. Data were captured in 3-minute epochs for a maximum of 30 minutes. Data were analysed using descriptive statistics.ResultsThirty-six rehabilitation sessions, including 34 participants (therapists n = 22, stroke survivors n = 12) were observed. Rehabilitation sessions were mostly inpatient (n = 33, 91.7%), one-on-one (n = 30, 83.3%), and conducted in the physiotherapy (n = 160, 45.5%) or occupational therapy (n = 155, 44.0%) gym. Strategies to promote perseverance were used in 76.7% (n = 267) of observed epochs. The most frequently used strategy was monitoring the quality of practice and the least frequently used strategy was utilising a support person to facilitate practice.ConclusionCoaching that may promote perseverance with practice was regularly used by therapists during hospital-based rehabilitation sessions. Coaching that may enable longer-term perseverance beyond a therapist-dependent rehabilitation model was less commonly observed.

Effect of integrated manual and verbal cueing on functional transfers in chronic stroke survivors: a randomized controlled study

PURPOSE

The profession of physical therapy has historically relied on manual facilitation to improve motor control strategies and performance in persons rehabilitating from a stroke, yet there is insufficient evidence to support its use during functional task training. The purpose of this study was to determine the effects of integrated cueing (verbal and manual) and verbal cueing approaches during sit-to-stand training on midline alignment & muscle activation in chronic stroke survivors.

METHODS

Twenty-one chronic right-brained stroke survivors with hemiplegia were randomly assigned to the Integrated Cueing or Verbal Only group and outcome measures were recorded using an 18-Camera Motion Capture System, force plates, and surface electromyography (EMG).

RESULTS

Both groups demonstrated a significant improvement in symmetry toward the midline after thirty training repetitions. Significant improvements in muscle activation were found in two muscle groups on the affected side of the body in the Integrated Cueing group, gastrocnemius and rectus femoris.

CONCLUSION

Both the Verbal Only and Integrated Cueing groups made significant progress toward more symmetrical movement, yet more significant changes in the activation of hemiparetic extensor muscles were seen in the Integrated Cueing group. These findings support the use of manual cueing in movement activation and performance during the training of functional tasks.IMPLICATIONS FOR REHABPhysical therapists commonly use manual tactile cues to facilitate movement performance but there is currently insufficient evidence to support this use with stroke survivors.In a relatively small sample size, both verbal cues and integrated cues (verbal plus manual) improved symmetry during sit to stand in chronic right brain stroke survivors.Integrated cueing enhanced motor activation and performance during sit to stand better than verbal cues alone.Manual tactile cueing should be considered during functional task retraining.

Determinants of Different Aspects of Upper-Limb Activity after Stroke

We examined factors associated with different aspects of upper-limb (UL) activity in chronic stroke to better understand and improve UL activity in daily life. Three different aspects of UL activity were represented by four sensor measures: (1) contribution to activity according to activity ratio and magnitude ratio, (2) intensity of activity according to bilateral magnitude, and (3) variability of activity according to variation ratio. We combined data from a Belgian and Danish patient cohort (n = 126) and developed four models to determine associated factors for each sensor measure. Results from standard multiple regression show that motor impairment (Fugl−Meyer assessment) accounted for the largest part of the explained variance in all sensor measures (18−61%), with less motor impairment resulting in higher UL activity values (p < 0.001). Higher activity ratio, magnitude ratio, and variation ratio were further explained by having the dominant hand affected (p < 0.007). Bilateral magnitude had the lowest explained variance (adjusted R2 = 0.376), and higher values were further associated with being young and female. As motor impairment and biological aspects accounted for only one- to two-thirds of the variance in UL activity, rehabilitation including behavioral strategies might be important to increase the different aspects of UL activity.

Motor Imagery: A Resource in the Fatigue Rehabilitation for Return-to-Work in Multiple Sclerosis Patients-A Mini Systematic Review

Fatigue is a multidimensional symptom with both physical and cognitive aspects, which can affect the quality of daily and working life activities. Motor Imagery (MI) represents an important resource for use during the rehabilitation processes, useful, among others, for job integration/reintegration, of neurological pathologies, such as Multiple Sclerosis (MS). To define the effective rehabilitation protocols that integrate MI for the reduction of fatigue in patients with MS (PwMS), a literary review was performed through August 2020. Five articles were included in the qualitative synthesis, including two feasibility pilot randomized control trials (RCTs) and 3 RCTs with good quality according to the PEDro score and a low risk of bias according to the Cochrane Collaboration tool. The literature suggested that MI, in association with rhythmic-auditory cues, may be an effective rehabilitation resource for reducing fatigue. Positive effects were observed on perceived cognitive and psychological fatigue. PwMS require greater compensatory strategies than healthy individuals, and the use of rhythmic-auditory cues may be useful for optimizing the cognitive processing of MI, which acts as an internal stimulus that is enhanced and made more vivid by outside cues. These findings provide evidence that MI is a promising rehabilitation tool for reducing fatigue in PwMS and return to work strategies.

Targeted verbal cues can immediately alter gait following stroke

Background: Physical therapists use verbal cueing extensively during gait rehabilitation. Nevertheless, little is known about the ability of individuals post-stroke to make immediate changes to targeted spatiotemporal gait parameters from verbal commands. Additionally, adequate muscle strength may be necessary to promote positive alterations in gait.Objectives: To determine the influence of targeted verbal cues on spatiotemporal gait parameters for individuals with chronic stroke. Further, we assessed the potential of a relationship between cue-induced gait modifications and paretic lower limb strength.Methods: Using a within-subjects design, twenty-seven adults with chronic stroke walked over a pressure mat with verbal cues to walk at (1) comfortable and (2) fast speeds, with increased (3) arm swing, (4) foot height, (5) step length, (6) push off, and (7) cadence. We also assessed lower extremity strength using a hand-held dynamometer. We measured gait speed, step length, stance time, and cadence for comparisons between conditions and performed correlational analyses to assess the influence of strength on gait alterations.Results: Specific cues elicited increased walking speed, cadence, step lengths and paretic limb stance time. Only greater paretic hip and knee flexion strength was related to the ability to increase cadence when cued to do so (r > 0.41).Conclusion: With targeted verbal cueing, clinicians can improve step length, gait speed, stance time and cadence for individuals with chronic stroke. Lower extremity strength does not appear to be related to the ability to alter gait with verbal cueing in individuals with chronic stroke.

The Impact of Exercise Intervention with Rhythmic Auditory Stimulation to Improve Gait and Mobility in Parkinson Disease: An Umbrella Review

Difficulties in walking, controlling balance, and performing activities of daily living are common problems encountered by individuals affected by Parkinson disease. Scientific evidence suggests that exercise performed with music or auditory or rhythmical cues facilitates movement and improves balance, gait, mobility, and activities of daily living (ADL) performance in patients with PD. The aim of this umbrella review was to summarize available high-quality evidence from systematic reviews and meta-analyses on the effectiveness of rhythmically cued exercise to improve gait, mobility, and ADL performance in individuals with PD. PubMed, Cochrane, and Embase databases were searched from January 2010 to October 2020 for systematic reviews and meta-analyses which had to be (1) written in English, (2) include studies on populations of males and females with PD of any age, (3) analyze outcomes related to gait, mobility, and ADL, and (4) apply exercise interventions with music or auditory or rhythmical cues. Two independent authors screened potentially eligible studies and assessed the methodological quality of the studies using the AMSTAR 2 tool. Four studies, two systematic reviews and meta-analyses, one a systematic review, and one a meta-analysis, were selected. Overall results indicated positive effects for gait and mobility of the use of rhythmic auditory cueing with exercise and suggested that it should be incorporated into a regular rehabilitation program for patients affected by PD. Nonetheless, more primary level research is needed to address the identified gaps regarding the application of this method to physical exercise interventions.

Vibrotactile sensitivity testing for occupational and disease-induce peripheral neuropathies

The International Standard Organization (ISO) standard 13091-1 describes methods and procedures for performing the vibrotactile perception threshold (VPT) testing to diagnose changes in tactile sensory function associated with occupational exposures. However, the VPT test also has been used in the diagnosis of peripheral neuropathies associated with a number of disorders. This review examines the VPT test, variations in procedures that have been used, as well as disorders and diseases in which this test has been reliable for the detection of sensory changes. Mechanisms potentially underlying the changes in VPTs are also discussed along with procedural and subject/patient factors that may affect the interpretation of test results. Based upon the review of the literature, there are also suggestions for where additional research might improve the administration of this test, depending upon the subject/patient population and interpretation of data.

Effectiveness of Motor Imagery on Motor Recovery in Patients with Multiple Sclerosis: Systematic Review

The effects of motor imagery (MI) on functional recovery of patients with neurological pathologies, such as stroke, has been recently proven. The aim of this study is to evaluate the effectiveness of MI on motor recovery and quality of life (QOL) in patients with multiple sclerosis (pwMS). A search was carried out in the following scientific databases: PubMed, CINAHL, PEDro, Scopus, Cochrane and Web of Science, up to November 2020. The grey literature and reference lists of potentially relevant articles were also searched. The Checklist for Measuring Quality and The Cochrane collaboration’s tool were used to assess the methodological quality and risk of bias of the studies. Five studies were included in the systematic review. Findings showed that pwMS using MI had significant improvements in walking speed and distance, fatigue and QOL. In addition, several benefits were also found in dynamic balance and perceived walking ability. Although the evidence is limited, rehabilitation using MI with the application of musical and verbal guides (compared to non-intervention or other interventions), can produce benefits on gait, fatigue and QOL in pwMS with a low score in the Expanded Disability Status Scale.

Neurorehabilitation for an individual with bilateral thalamic stroke and preexisting visual impairment presenting with impaired use of sensory cues: a case report

Introduction: Impaired balance is one of the primary causes of functional limitations. Related to sensory deficits specifically, balance disorder in stroke may be caused by decreased central integration of sensory cues, including somatosensory, visual and vestibular input.Case Presentation: This case describes a 23-year-old male with bilateral thalamic stroke following surgical resection of a recurring optic nerve meningioma. He had a complex medical history and is legally blind. He presented to outpatient neurorehabilitation 5 months following his stroke. He demonstrated absent light touch sensation and absent proprioception and kinesthetic awareness in his upper extremities, lower extremities, and trunk. Secondary to absent proprioception and vision and significant impairments related to shunt malfunction, he required total assistance for all mobility at initial examination.Discussion: After 8 months of intensive rehabilitation, he demonstrated substantial improvements in all functional mobility and recovery of sensation. Rehabilitation included interventions such as electrical stimulation, fluidotherapy, repetitive task training, and most significantly, external augmented feedback. This feedback included sensory cues, auditory and tactile cues, and maximizing the use of vestibular input. This case demonstrates that neurorehabilitation can benefit patients with impaired use of sensory cues and central integration.

Wristband Accelerometers to motiVate arm Exercises after Stroke (WAVES): a pilot randomized controlled trial

OBJECTIVE

To evaluate the feasibility of a multicentre, observer-blind, pilot randomized controlled trial (RCT) of a wristband accelerometer with activity-dependent vibration alerts to prompt impaired arm use after stroke.

DESIGN

Parallel-group pilot RCT.

SETTING

Four English stroke services.

PARTICIPANTS

Patients 0-3 months post stroke with a new arm deficit.

INTERVENTION

Participants were randomized to wear a prompting or 'sham' wristband during a four-week self-directed therapy programme with twice-weekly therapy review.

MAIN OUTCOMES

Recruitment, retention and adherence rates, safety and completion of assessments were reported. Arm recovery was measured by Action Research Arm Test (ARAT) and Motor Activity Log (MAL) without statistical comparison.

RESULTS

In total, 33 patients were recruited (0.6 per month/site; median time post stroke: 26 days (interquartile range (IQR):15.5-45)). Baseline, four-week and eight-week median (IQR) ARAT for the control group (n = 19) were 15 (2-35), 35 (15-26) and 31 (21-55) and those for the intervention group (n = 14) were 37 (16-45), 57 (29-57) and 57 (37-57), respectively; for MAL Amount of Use, the corresponding values in the control group were 0.2 (0.0-1.2), 1.1 (0.3-2.9) and 1.2 (0.7-2.9) and in the intervention group were 1.4 (0.5-2.6), 3.8 (1.9-4.5) and 3.7 (2.1-4.3). Four participants withdrew from the study. Wristbands were worn for 79% of the recommended time. The intervention and control group participants received a median of 6.0 (IQR: 4.3-8.0) and 7.5 (IQR: 6.8-8.0) therapy reviews. A median of 8 (IQR: 6-10) prompts were delivered per intervention participant/day. Research assessments were completed for 28/29 and 25/28 patients at four and eight weeks. Eight serious adverse events were reported, all unrelated to the intervention.

CONCLUSION

A multicentre RCT of wristband accelerometers to prompt arm activity early after stroke is feasible. A total sample of 108 participants would be required.