Characterizing Heart Rate Response During Upper Extremity Repetitive Task Practice in Chronic Stroke

IMPORTANCE

Although the cardiopulmonary benefits of aerobic exercise poststroke are well-established, typical stroke rehabilitation does not elicit an aerobic response.

OBJECTIVE

To characterize heart rate response during upper extremity repetitive task practice (RTP) and determine factors that predict a higher aerobic intensity during RTP.

DESIGN

Secondary analysis of a subset of data from a randomized clinical trial.

SETTING

Research laboratory in a large academic medical center.

PARTICIPANTS

Patients with chronic stroke (N = 19).

INTERVENTION

Participants received 90 min of RTP for 24 sessions across 8 wk.

OUTCOMES AND MEASURES

Aerobic intensity as measured by heart rate reserve (HRR) during RTP.

RESULTS

A total of 2,968 tasks were included in the analysis. Of the tasks performed, approximately 79.5% elicited a very light aerobic response (<30% HRR), 10.2% elicited a light aerobic response (30%-39% HRR), and 10.3% elicited a moderate to vigorous intensity aerobic response (≥40% HRR). Of the tasks that elicited a moderate to vigorous intensity aerobic response, 54.1% were performed in standing, 79.7% were gross motor in nature, and 27.9% had targets at or above shoulder height. Standing position, targets at or above shoulder height, and gross motor tasks predicted higher HRR (all ps < .001).

CONCLUSIONS AND RELEVANCE

To maximize aerobic intensity during poststroke RTP, therapists should include gross motor tasks trained in standing with targets at or above shoulder height. Plain-Language Summary: The study characterizes heart rate response in stroke rehabilitation and identifies factors that predict a higher aerobic intensity during upper extremity repetitive task practice. Certain task characteristics were more likely to produce an aerobic response, including gross motor, targets at or above the shoulder, and a standing position. Occupational therapists should include gross motor tasks trained in standing with targets at or above shoulder height to maximize aerobic intensity during poststroke repetitive task practice. Monitoring heart rate may improve awareness of aerobic response to training.

Older adults are impaired in the release of grip force during a force tracking task

Age-related changes in force generation have been implicated in declines in older adult manual dexterity. While force generation is a critical aspect of the successful manipulation of objects, the controlled release of force represents the final component of dexterous activities. The impact of advancing age on the release of grip force has received relatively little investigation despite its importance in dexterity. The primary aim of this project was to determine the effects of age on the control of force release during a precision grip tracking task. Young adults (N = 10, 18-28 years) and older adults (N = 10, 57-77 years) completed a ramp-hold-release (0-35% of maximum grip force) force tracking task with their dominant hand. Compared to young adults, older adults were disproportionately less accurate (i.e., less time within target range) and had more error (i.e., greater relative root mean squared error) in the release of force, compared to generation of grip force. There was a significant difference between groups in two-point discrimination of the thumb, which was moderately correlated to force control across all phases of the task. The decline in force release performance associated with advanced age may be a result of sensory deficits and changes in central nervous system circuitry.

An Augmented Reality Rifle Qualification Test for Return-to-Duty Assessment in Service Members

INTRODUCTION

Variability in return-to-duty (RTD) decision-making following mild traumatic brain injury (mTBI) is a threat to troop readiness. Current RTD assessments lack military-specific tasks and quantitative outcomes to inform stakeholders of a service member's (SM) capacity to successfully perform military duties. Augmented reality (AR), which places digital assets in a user's physical environment, provides a technological vehicle to deliver military-relevant tasks to a SM to be used in the RTD decision-making process. In addition to delivering digital content, AR headsets provide biomechanical data that can be used to assess the integrity of the central nervous system in movement control following mTBI. The objective of this study was to quantify cognitive and motor performance on an AR rifle qualification test (RQT) in a group of neurologically healthy military SMs.

MATERIALS AND METHODS

Data were collected from 111 healthy SMs who completed a basic (single-task) and complex (dual-task) RQT with a simulated M4 rifle. The complex scenario required the SM to perform the RQT while simultaneously answering arithmetic problems. Position data from the AR headset were used to capture postural sway, and the built-in microphone gathered responses to the arithmetic problems.

RESULTS

There were no differences in the number of targets hit, trigger pull reaction time, and transition time from kneeling to standing between the basic and complex scenarios. A significant worsening in postural sway following kneel-to-stand transition was observed in the complex scenario. The average reaction time to answer the arithmetic problems was nearly 2 times slower than the average reaction time to pull the trigger to a displayed target in the complex scenario.

CONCLUSION

The complex scenario provoked dual-task interference in SMs as evidenced by worsening postural sway and reaction time differences between the cognitive and motor tasks. An AR RQT provides objective and quantitative outcomes during a military-specific task. Greater precision in evaluating cognitive and motor performance during a military-relevant task has the potential to aid in the detection and management of SMs and their RTD following MTBI.

Gait patterns during overground and virtual omnidirectional treadmill walking

BACKGROUND

Omnidirectional treadmills (ODTs) offer a promising solution to the virtual reality (VR) locomotion problem, which describes the mismatch between visual and somatosensory information and contributes to VR sickness. However, little is known about how walking on ODTs impacts the biomechanics of gait. This project aimed to compare overground and ODT walking and turning in healthy young adults.

METHODS

Fifteen young adults completed forward walk, 180° turn, and 360° turn tasks under three conditions: (1) overground, (2) on the Infinadeck ODT in a virtual environment without a handrail, and (3) on the ODT with a handrail. Kinematic data for all walking trials were gathered using 3D optical motion capture.

RESULTS

Overall, gait speed was slower during ODT walking than overground. When controlling for gait speed, ODT walking resulted in shorter steps and greater variability in step length. There were no significant differences in other spatiotemporal metrics between ODT and overground walking. Turning on the ODT required more steps and slower rotational speeds than overground turns. The addition of the stability handrail to the ODT resulted in decreased gait variability relative to the ODT gait without the handrail.

CONCLUSION

Walking on an ODT resembles natural gait patterns apart from slower gait speed and shorter step length. Slower walking and shorter step length are likely due to the novelty of physically navigating a virtual environment which may result in a more conservative approach to gait. Future work will evaluate how older adults and those with neurological disease respond to ODT walking.

Use of a Home-Based, Commercial Exercise Platform to Remotely Monitor Aerobic Exercise Adherence and Intensity in People With Parkinson Disease

OBJECTIVE

Physical therapists are well-positioned to prescribe exercise outside of a clinical setting to promote positive health behaviors in people with Parkinson disease (PD). Traditionally, a barrier to precise exercise prescription has been reliance on participant self-reported exercise adherence and intensity. Home-based, commercially available exercise platforms offer an opportunity to remotely monitor exercise behavior and facilitate adherence based on objective performance metrics. The primary aim of this project was to characterize the feasibility and processes of remote aerobic exercise data monitoring from a home-based, commercially available platform in individuals participating in the 12-month Cyclical Lower Extremity Exercise for PD II (CYCLE-II) randomized clinical trial. Secondary aims focused on using exercise behavior to classify the cohort into exercise archetypes and describing a shared decision-making process to facilitate exercise adherence.

METHODS

Data from each exercise session were extracted, visualized, and filtered to ensure ride integrity. Weekly exercise frequency was used to determine exercise archetypes: Adherent (2-4 exercise sessions per week), Over-adherent (>4 exercise sessions per week), and Under-adherent (<2 exercise sessions per week).

RESULTS

A total of 123 people with PD completed 22,000+ exercise sessions. Analysis of exercise frequency indicated that 79% of participants were adherent; 8% were over-adherent; and 13% were under-adherent. Three case reports illustrate how shared decision-making with the use of exercise performance data points guided exercise prescription.

CONCLUSIONS

The number of exercise sessions and completeness of the data indicate that people with PD were able to utilize a commercial, home-based exercise platform to successfully engage in long-term aerobic exercise. Physical therapists can use objective data as a part of a shared decision-making process to facilitate exercise adherence.

IMPACT

Commercially available exercise platforms offer a unique approach for physical therapists to monitor exercise behavior outside of a clinical setting. The methods used in this project can serve as a roadmap to utilizing data from consumer-based platforms.

The Microsoft HoloLens 2 Provides Accurate Biomechanical Measures of Performance During Military-Relevant Activities in Healthy Adults

INTRODUCTION

Augmented reality systems, like the HoloLens 2 (HL2), have the potential to provide accurate assessments of mild traumatic brain injury (mTBI) symptoms in military personnel by simulating complex military scenarios while objectively measuring the user's movements with embedded motion sensors. The aim of this project was to determine if biomechanical measures of marching and squatting, derived from the HL2 motion sensors, were statistically equivalent, within 5%, to metrics derived from the gold-standard three-dimensional motion capture (MoCap) system.

MATERIALS AND METHODS

Sixty-four adults (18-45 years; 34 males) completed a squatting and a marching task under single- (motor) and dual-task (motor + cognitive) conditions. Positional data from the HL2 and MoCap were simultaneously collected during the tasks and used to calculate and compare biomechanical outcomes. The HL2's augmented reality capabilities were utilized to deliver the cognitive component of the marching dual task.

RESULTS

Equivalence testing indicated the HL2 and MoCap measures were within 5% in all squatting metrics-trial time, squat duration, squat velocity, squat depth, and dwell time. Marching metrics, including trial time, step count, stepping rate, and step interval, were also equivalent between the two systems. The mean reaction time for responses during the Stroop test was 810 (125) milliseconds per response.

CONCLUSIONS

Biomechanical outcomes characterizing performance during two common military movements, squatting and marching, were equivalent between the HL2 and MoCap systems in healthy adults. Squatting and marching are two military-relevant tasks that require strength, motor coordination, and balance to perform, all of which are known to be affected by mTBI. Taken together, the data provide support for using the HL2 platform to deliver military-specific assessment scenarios and accurately measure performance during these activities. Utilizing objective and quantitative measures of motor function may enhance the management of military mTBI and reduce unnecessary risk to service members.

Development of the Troop Readiness Evaluation With Augmented Reality Return-to-Duty (Troop READY) Platform to Aid in the Detection and Treatment of Military Mild Traumatic Brain Injury

INTRODUCTION

Mild traumatic brain injury (mTBI) is prevalent in service members (SMs); however, there is a lack of consensus on the appropriate approach to return to duty (RTD). Head-mounted augmented reality technology, such as the HoloLens 2, can create immersive, salient environments to more effectively evaluate relevant military task performance. The Troop Readiness Evaluation with Augmented Reality Return-to-Duty (READY) platform was developed to objectively quantify cognitive and motor performance during military-specific activities to create a comprehensive approach to aid in mTBI detection and facilitate appropriate RTD. The aim of this project was to detail the technical development of the Troop READY platform, the outcomes, and its potential role in the aiding detection and RTD decision-making post mTBI. The secondary aim included evaluating the safety, feasibility, and SM usability of the Troop READY platform.

MATERIALS AND METHODS

The Troop READY platform comprises three assessment modules of progressing complexity: (1) Static and Dynamic Mobility, (2) Rifle Qualification Test, and (3) Small Unit Operations Capacity-Room Breach/Clearing Exercise. The modules were completed by 137 active duty SMs. Safety was assessed through monitoring of adverse events. Feasibility was assessed using the self-directed module completion rate. Usability was measured using the Systems Usability Scale.

RESULTS

No adverse events occurred. Completion rates of the three modules ranged from 98 to 100%. In terms of usability, the mean Systems Usability Scale score of all participants was 83.92 (13.95), placing the Troop READY platform in the good-to-excellent category. Objective motor and cognitive outcomes were generated for each module.

CONCLUSION

The Troop READY platform delivers self-directed, salient assessment modules to quantify single-task, dual-task, and unit-based performance in SMs. The resultant data provide insight into SM performance through objective outcomes and identify specific areas of executive or motor function that may be slow to recover following mTBI.

Cerebellar deep brain stimulation for chronic post-stroke motor rehabilitation: a phase I trial

Upper-extremity impairment after stroke remains a major therapeutic challenge and a target of neuromodulation treatment efforts. In this open-label, non-randomized phase I trial, we applied deep brain stimulation to the cerebellar dentate nucleus combined with renewed physical rehabilitation to promote functional reorganization of ipsilesional cortex in 12 individuals with persistent (1-3 years), moderate-to-severe upper-extremity impairment. No serious perioperative or stimulation-related adverse events were encountered, with participants demonstrating a seven-point median improvement on the Upper-Extremity Fugl-Meyer Assessment. All individuals who enrolled with partial preservation of distal motor function exceeded minimal clinically important difference regardless of time since stroke, with a median improvement of 15 Upper-Extremity Fugl-Meyer Assessment points. These robust functional gains were directly correlated with cortical reorganization evidenced by increased ipsilesional metabolism. Our findings support the safety and feasibility of deep brain stimulation to the cerebellar dentate nucleus as a promising tool for modulation of late-stage neuroplasticity for functional recovery and the need for larger clinical trials. ClinicalTrials.gov registration: NCT02835443 .

A Randomized Clinical Trial to Evaluate a Digital Therapeutic to Enhance Gait Function in Individuals With Parkinson's Disease

BACKGROUND

Postural instability and gait dysfunction (PIGD) is a cardinal symptom of Parkinson's disease (PD) and is exacerbated under dual-task conditions. Dual-task training (DTT), enhances gait performance, however it is time and cost intensive. Digitizing DTT via the Dual-task Augmented Reality Treatment (DART) platform can expand the availability of an effective intervention to address PIGD.

OBJECTIVE

The aim of this project was to evaluate DART in the treatment of PIGD in people with PD compared to a Traditional DTT intervention. It was hypothesized that both groups would exhibit significant improvements in gait, and the improvements for the DART group would be non-inferior to Traditional DTT.

METHODS

A single-blind randomized controlled trial was conducted with 47 PD participants with PIGD. Both groups completed 16 therapeutic sessions over 8 weeks; the DART platform delivered DTT via the Microsoft HoloLens2. Primary outcomes included clinical ratings and single- and dual-task gait biomechanical outcomes.

RESULTS

Clinical measures of PD symptoms remained stable for DART and Traditional DTT groups. However, both groups exhibited a significant increase in gait velocity, cadence, and step length during single- and multiple dual-task conditions following the interventions. Improvements in gait velocity in the DART group were non-inferior to Traditional DTT under the majority of conditions.

CONCLUSION

Non-inferior improvements in gait parameters across groups provides evidence of the DART platform being an effective digital therapeutic capable of improving PIGD. Effective digital delivery of DTT has the potential to increase use and accessibility to a promising, yet underutilized and difficult to administer, intervention for PIGD.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Dual-task Augmented Reality Treatment for Parkinson's Disease (DART) NCT04634331; posted November 18, 2020.

The Parkinson's disease waiting room of the future: measurements, not magazines

Utilizing technology to precisely quantify Parkinson's disease motor symptoms has evolved over the past 50 years from single point in time assessments using traditional biomechanical approaches to continuous monitoring of performance with wearables. Despite advances in the precision, usability, availability and affordability of technology, the "gold standard" for assessing Parkinson's motor symptoms continues to be a subjective clinical assessment as none of these technologies have been fully integrated into routine clinical care of Parkinson's disease patients. To facilitate the integration of technology into routine clinical care, the Develop with Clinical Intent (DCI) model was created. The DCI model takes a unique approach to the development and integration of technology into clinical practice by focusing on the clinical problem to be solved by technology rather than focusing on the technology and then contemplating how it could be integrated into clinical care. The DCI model was successfully used to develop the Parkinson's disease Waiting Room of the Future (WROTF) within the Center for Neurological Restoration at the Cleveland Clinic. Within the WROTF, Parkinson's disease patients complete the self-directed PD-Optimize application on an iPad. The PD-Optimize platform contains cognitive and motor assessments to quantify PD symptoms that are difficult and time-consuming to evaluate clinically. PD-Optimize is completed by the patient prior to their medical appointment and the results are immediately integrated into the electronic health record for discussion with the movement disorder neurologist. Insights from the clinical use of PD-Optimize has spurred the development of a virtual reality technology to evaluate instrumental activities of daily living in PD patients. This new technology will undergo rigorous assessment and validation as dictated by the DCI model. The DCI model is intended to serve as a health enablement roadmap to formalize and accelerate the process of bringing the advantages of cutting-edge technology to those who could benefit the most: the patient.

Digitizing a Therapeutic: Development of an Augmented Reality Dual-Task Training Platform for Parkinson's Disease

Augmented reality (AR) may be a useful tool for the delivery of dual-task training. This manuscript details the development of the Dual-task Augmented Reality Treatment (DART) platform for individuals with Parkinson's disease (PD) and reports initial feasibility, usability, and efficacy of the DART platform in provoking dual-task interference in individuals with PD. The DART platform utilizes the head-mounted Microsoft HoloLens2 AR device to deliver concurrent motor and cognitive tasks. Biomechanical metrics of gait and cognitive responses are automatically computed and provided to the supervising clinician. To assess feasibility, individuals with PD (N = 48) completed a bout of single-task and dual-task walking using the DART platform. Usability was assessed by the System Usability Scale (SUS). Dual-task interference was assessed by comparing single-task walking and walking during an obstacle course while performing a cognitive task. Average gait velocity decreased from 1.06 to 0.82 m/s from single- to dual-task conditions. Mean SUS scores were 81.3 (11.3), which placed the DART in the "good" to "excellent" category. To our knowledge, the DART platform is the first to use a head-mounted AR system to deliver a dual-task paradigm and simultaneously provide biomechanical data that characterize cognitive and motor performance. Individuals with PD were able to successfully use the DART platform with satisfaction, and dual-task interference was provoked. The DART platform should be investigated as a platform to treat dual-task declines associated with PD.

Community-based high-intensity cycling improves disease symptoms in individuals with Parkinson's disease: A six-month pragmatic observational study

Participation in supervised, laboratory-based aerobic exercise protocols holds promise in slowing the progression of Parkinson's disease (PD). Gaps remain regarding exercise adherence and effectiveness of laboratory protocols translated to community-based programs. The aim of the project was to monitor exercise behaviour and evaluate its effect on disease progression over a 6 month period in people with PD participating in a community-based Pedalling for Parkinson's (PFP) cycling program. A pragmatic, observational study design was utilised to monitor exercise behaviour at five community sites. The Movement Disorders Society-Unified Parkinson's disease Rating Scale Motor III (MDS-UPDRS-III) and other motor and non-motor outcomes were gathered at enrollment and following 6 months of exercise. Attendance, heart rate, and cadence data were collected for each exercise session. On average, people with PD (N = 41) attended nearly 65% of the offered PFP classes. Average percent of age-estimated maximum heart rate was 69.3 ± 11.9%; average cadence was 74.9 ± 9.0 rpms. The MDS-UPDRS III significantly decreased over the 6-month exercise period (37.2 ± 11.7 to 33.8 ± 11.7, p = 0.001) and immediate recall significantly improved (42.3 ± 12.4 to 47.1 ± 12.7, p = 0.02). Other motor and non-motor metrics did not exhibit significant improvement. Participants who attended ~74% or more of available PFP classes experienced the greatest improvement in MDS-UPDRS III scores; of those who attended less than 74% of classes, cycling greater than or equal to 76 rpms lead to  improvement. Attendance and exercise intensity data indicated that a laboratory-based exercise protocol can be successfully translated to a community setting. Consistent attendance and pedalling at a relatively high cadence may be key variables to PD symptom mitigation. Improvement in clinical ratings coupled with lack of motor and non-motor symptom progression over 6 months provides rationale for further investigation of the real-world, disease-modifying potential of aerobic exercise for people with PD.

Effectiveness of a Long-Term, Home-Based Aerobic Exercise Intervention on Slowing the Progression of Parkinson Disease: Design of the Cyclical Lower Extremity Exercise for Parkinson Disease II (CYCLE-II) Study

OBJECTIVE

Previous short duration studies have demonstrated that high-intensity aerobic exercise improves aspects of motor and non-motor function in people with Parkinson disease (PwPD); however, the effectiveness of a long-term exercise intervention on slowing disease progression is unknown. The primary aim of this study is to determine the disease-altering effects of high-intensity aerobic exercise, administered on an upright stationary cycle, on the progression of PD. A secondary aim is to develop a prognostic model for 12-month changes in the Movement Disorder Society Unified Parkinson's Disease Rating Scale III (MDS-UPDRS III) of PwPD undergoing an aerobic exercise intervention.

METHODS

This pragmatic, multisite, single-rater blinded, randomized controlled trial will recruit PwPD from 2 large, urban, academic medical centers. Participants (N = 250 PwPD) will be randomized to (1) home-based aerobic exercise or (2) usual and customary care. Those in the aerobic exercise arm will be asked to complete in-home aerobic exercise sessions at 60% to 80% of heart rate reserve 3 times per week for 12 months utilizing a commercially available upright exercise cycle. The usual and customary care group will continue normal activity levels. Daily activity will be monitored for both groups throughout the 12-month study period. The primary outcome, both to assess disease-modifying response to aerobic exercise and for prognostic modeling in the aerobic exercise arm, is 12-month rate of change in the MDS-UPDRS III. Clinical and biomechanical measures will also be used to assess upper and lower extremity motor function as well as non-motor functions.

IMPACT

Should long-term aerobic exercise demonstrate disease-modifying capability, this study will provide evidence that "Exercise is Medicine" for PwPD. Further, the derived prognostic model will inform a patient-specific exercise prescription for PwPD and expected effects on PD progression.

High intensity aerobic exercise improves bimanual coordination of grasping forces in Parkinson's disease

INTRODUCTION

Parkinson's disease (PD) disrupts the control and coordination of grasping forces, likely due to a disruption in basal ganglia circuitry and diminished activity within the supplementary motor area (SMA). High intensity aerobic exercise has been shown to enhance connectivity between basal ganglia nuclei and cortical areas, including the SMA. The aim of this project was to determine the effects of high intensity lower extremity exercise on motor control patterns underlying a manual dexterity task.

METHODS

PD participants completed eight weeks of high intensity aerobic exercise under forced or voluntary exercise (FE or VE) modalities. Grasping forces for each limb were quantified during a functional bimanual dexterity task. Data were collected while OFF antiparkinsonian medication at baseline, end of treatment (EOT), and eight weeks after exercise cessation (EOT+8).

RESULTS

Eight weeks of high intensity exercise improved MDS-UPDRS Motor III clinical ratings by more than 4 points (~15%) for the FE and VE groups. Time to complete the task decreased nearly 30% across both groups as well. The control and coordination of grasping forces, simultaneity of force initiation, and rate of grip and load force exhibited significant improvements following exercise. In general, improvements in biomechanical outcomes were sustained following exercise cessation.

CONCLUSION

High intensity aerobic exercise, achieved via a forced or voluntary mode, improved PD symptoms and bimanual dexterity. Sustained improvement of upper extremity motor control following exercise cessation indicates high intensity exercise enhances CNS functioning and suggests exercise may be a candidate for altering PD progression.

The Universal Prescription for Parkinson's Disease: Exercise

Over the past two decades, aerobic exercise has emerged as a mainstream recommendation to aid in treating Parkinson's disease (PD). Despite the acknowledgement of the benefits of exercise for people with PD (PwPD), frequently, exercise recommendations lack specificity in terms of frequency, intensity and duration. Additionally, conflating physical activity with exercise has contributed to providing vague exercise recommendations to PwPD. Therefore, the beneficial effects of exercise may not be fully realized in PwPD. Data provided by animal studies and select human trials indicate aerobic exercise may facilitate structural and functional changes in the brain. Recently, several large human clinical trials have been completed and collectively support the use of aerobic exercise, specifically high-intensity aerobic exercise, in improving PD motor symptoms. Data from these and other studies provide the basis to include aerobic exercise as an integral component in treating PD. Based on positive clinical findings and trials, it is advised that PwPD perform aerobic exercise in the following dose: 3x/week, 30-40-minute main exercise set, 60-80% of heart rate reserve or 70-85% of heart rate max. In lieu of heart rate, individuals can achieve an intensity of 14-17 on a 20-point RPE scale. Ongoing clinical trials, SPARX3 and CYCLE-II, have potential to further develop patient-specific exercise recommendations through prognostic modeling.

Parkinson's gait kinematics deteriorates across multiple cognitive domains under dual-task paradigms

OBJECTIVE

The symptoms of Parkinson's disease (PD) in many circumstances lead to gait dysfunction which contribute to decreased mobility, reduced quality of life, and increased risk of falling. Dual-task conditions have been shown to amplify gait dysfunction from a spatiotemporal parameter standpoint; however, less is known regarding gait joint kinematics under dual-task conditions in PD, specifically across multiple cognitive domains. The purpose of this project was to systematically characterize lower extremity joint kinematics in individuals with mild-moderate PD under dual-task paradigms across multiple cognitive domains.

PATIENTS AND METHODS

Twenty-three individuals with idiopathic Parkinson's disease participated in this observational study evaluating hip, knee, and ankle joint kinematics while walking on a self-paced treadmill under dual-task conditions that taxed memory, attention, verbal fluency, and information processing.

RESULTS

Gait velocity and range of motion at the ankle, knee, and hip decreased (p < 0.05) under all of the dual-task conditions. Hip kinematics were affected to a greater extent than the ankle and knee, with reduction in flexion and extension during all timestamps of the gait cycle (p < 0.05) under all dual-task conditions.

CONCLUSION

The worsening of gait kinematics under dual-task conditions regardless of the aspect of cognition being challenged suggest that information processing and motor output are unable to withstand dual-task loads without consequence. These study results provide insight for target areas to focus on during therapeutic interventions in order to help minimize gait kinematic decrements observed under dual-task conditions.

Computer-Assisted Immersive Visual Rehabilitation in Argus II Retinal Prosthesis Recipients

PURPOSE

The field of retinal prostheses is expanding. However, the best approach to training and assessing the functional benefit of postoperative vision has not been established. The purpose of this single-center prospective interventional case series was to evaluate the feasibility and effectiveness of using the Computer Assisted Rehabilitation Environment (CAREN) system as a visual rehabilitation tool in Argus II patients.

DESIGN

Single-center prospective interventional case series (clinicaltrials.gov identifier, NCT03444961).

PARTICIPANTS

Four Argus II recipients (3 men and 1 woman).

METHODS

Eight visual rehabilitation sessions using the CAREN system (twice weekly for 4 weeks).

MAIN OUTCOME MEASURES

Baseline and postintervention assessments consisted of visual function, mobility, and balance tests.

RESULTS

All patients successfully completed training on the CAREN system. While the Argus II device was active, walking speed increased from baseline to immediately after the intervention on flat and undulating surfaces and while localizing objects by 20%, 10%, and 18%, respectively. An improved ability to complete the timed up and go test successfully was observed.

CONCLUSIONS

Novel methods of visual rehabilitation for retinal prostheses recipients, such the CAREN system, are feasible and may result in improved ability to use the Argus II while performing functional tasks. Immersive technology may provide a solution for the standardization of effective rehabilitation approaches to augment retinal prosthesis performance. Heterogeneity of results indicates that a larger sample size would be beneficial.

Forced, Not Voluntary, Aerobic Exercise Enhances Motor Recovery in Persons With Chronic Stroke

Background. The recovery of motor function following stroke is largely dependent on motor learning-related neuroplasticity. It has been hypothesized that intensive aerobic exercise (AE) training as an antecedent to motor task practice may prime the central nervous system to optimize motor recovery poststroke. Objective. The objective of this study was to determine the differential effects of forced or voluntary AE combined with upper-extremity repetitive task practice (RTP) on the recovery of motor function in adults with stroke. Methods. A combined analysis of 2 preliminary randomized clinical trials was conducted in which participants (n = 40) were randomized into 1 of 3 groups: (1) forced exercise and RTP (FE+RTP), (2) voluntary exercise and RTP (VE+RTP), or (3) time-matched stroke-related education and RTP (Edu+RTP). Participants completed 24 training sessions over 8 weeks. Results. A significant interaction effect was found indicating that improvements in the Fugl-Meyer Assessment (FMA) were greatest for the FE+RTP group (P = .001). All 3 groups improved significantly on the FMA by a mean of 11, 6, and 9 points for the FE+RTP, VE+RTP, and Edu+RTP groups, respectively. No evidence of a treatment-by-time interaction was observed for Wolf Motor Function Test outcomes; however, those in the FE+RTP group did exhibit significant improvement on the total, gross motor, and fine-motor performance times (P ≤ .01 for all observations). Conclusions. Results indicate that FE administered prior to RTP enhanced motor skill acquisition greater than VE or stroke-related education. AE, FE in particular, should be considered as an effective antecedent to enhance motor recovery poststroke.

Mobility improves after high intensity aerobic exercise in individuals with Parkinson's disease

Emerging literature indicates aerobic exercise improves the motor symptoms associated with Parkinson's disease (PD). However, the impact of aerobic exercise on functional locomotor performance has not been evaluated systematically. The aim of this project was to determine the impact of an 8-week high intensity aerobic exercise intervention on Timed Up and Go (TUG) performance in PD. Fifty-nine participants with idiopathic PD completed 24 aerobic exercise sessions over 8 weeks. Two modes of exercise were utilized: forced (FE) and voluntary (VE). A mobile application was used to gather biomechanical data for the characterization of the TUG subtasks: Sit-Stand, Gait, Turning, and Stand-Sit. Participants were assessed in an off medication state at: 1) baseline, prior to any exercise intervention, and 2) after completion of exercise treatment. At baseline, the VE group completed the TUG in 9.41 s, while the FE group completed the TUG significantly faster in 8.0 s. Following the exercise intervention, the VE group decreased TUG time to 8.9 s (p < .01). Both exercise groups demonstrated significant improvements in Turning Velocity, time of Gait phase and Stand-Sit duration. Overall mobility in participants with PD was significantly improved after high intensity aerobic exercise training. Improvements in turning and gait speed, and in Stand-Sit times indicate exercise is effective in improving functional aspects of mobility that are often associated with falls and quality of life measures. These results support the use of high intensity aerobic exercise for improvements in functional lower extremity performance in a PD population.

Combined Aerobic Exercise and Task Practice Improve Health-Related Quality of Life Poststroke: A Preliminary Analysis

OBJECTIVE

The aim of this project was to determine the effects of lower extremity aerobic exercise coupled with upper extremity repetitive task practice (RTP) on health-related quality of life (HRQOL) and depressive symptomology in individuals with chronic stroke.

DESIGN

Secondary analysis of data from 2 randomized controlled trials.

SETTING

Research laboratory.

PARTICIPANTS

Individuals (N=40) with chronic stroke.

INTERVENTIONS

Participants received one of the following interventions: forced exercise+RTP (FE+RTP, n=16), voluntary exercise+RTP (VE+RTP, n=16), or stroke education+RTP (EDU+RTP, n=8). All groups completed 24 sessions, each session lasting 90 minutes.

MAIN OUTCOME MEASURES

The Center for Epidemiological Studies-Depression Scale (CES-D) and Stroke Impact Scale (SIS) were used to assess depressive symptomology and HRQOL.

RESULTS

There were no significant group-by-time interactions for any of the SIS domains or composite scores. Examining the individual groups following the intervention, those in the FE+RTP and VE+RTP groups demonstrated significant improvements in the following SIS domains: strength, mobility, hand function, activities of daily living, and the physical composite. In addition, the FE+RTP group demonstrated significant improvements in memory, cognitive composite, and percent recovery from stroke. The HRQOL did not change in the EDU+RTP group. Although CES-D scores improved predominantly for those in the FE+RTP group, these improvements were not statistically significant. Overall, results were maintained at the 4-week follow-up.

CONCLUSION

Aerobic exercise, regardless of mode, preceding motor task practice may improve HRQOL in patients with stroke. The potential of aerobic exercise to improve cardiorespiratory endurance, motor outcomes, and HRQOL poststroke justifies its use to augment traditional task practice.

Quantifying turning behavior and gait in Parkinson's disease using mobile technology

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Improvements in mobility were detected from meds using a mobile device IMU in PD.

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Algorithms using mobile device IMU data can segment the TUG into subtasks.

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The Cleveland Clinic Mobility App can provide an objective assessment of mobility.

Gait and balance impairments associated with Parkinson’s disease (PD) are often refractory to traditional treatments. Objective, quantitative analysis of gait patterns is crucial in successful management of these symptoms. This project aimed to 1) determine if biomechanical metrics from a mobile device inertial measurement unit were sensitive enough to characterize the effects of anti-parkinsonian medication during the Timed Up and Go (TUG) Test, and 2) develop the Cleveland Clinic Mobility and Balance application (CC-MB) to provide clinicians with objective report following completion of the TUG. The CC-MB captured 3-dimensional acceleration and rotational data from people with PD (pwPD) to characterize center of mass movement while performing the TUG. Trials were segmented into four components: Sit-to-Walk, Gait, Turning, and Stand-to-Sit. Thirty pwPD were tested On and Off (12 h) anti-PD medication. Significant improvements (p < 0.05) between On versus Off conditions included: reduction in MDS-UPDRS III motor scores (10.7%), faster trial times (9.3%), more dynamic walking as evident by increased normalized jerk scores (vertical: 17.3%, medial-lateral: 12.3%), shorter turn durations (10.4%), and faster turn velocities (8%). Measures in Sit-to-Walk and Stand-to-Sit did not show significant changes. Trial time and turn velocity showed excellent test-retest reliability (ICC range: 0.83-0.96) across both medication states. A mobile device platform provided quantitative measures of gait and turning during the TUG that detected significant improvements from anti-parkinsonian medications. This platform is a low-cost, easy-to-use tool that can provide objective reports immediately following the clinical assessments, making it ideal for use in and outside the clinical setting.

Improved lower extremity pedaling mechanics in individuals with stroke under maximal workloads

Background Individuals with stroke present with motor control deficits resulting in the abnormal activation and timing of agonist and antagonist muscles and inefficient movement patterns. The analysis of pedaling biomechanics provides a window into understanding motor control deficits, which vary as a function of workload. Understanding the relationship between workload and motor control is critical when considering exercise prescription during stroke rehabilitation. Objectives To characterize pedaling kinematics and motor control processes under conditions in which workload was systematically increased to an eventual patient-specific maximum. Methods A cohort study was conducted in which 18 individuals with chronic stroke underwent a maximal exertion cardiopulmonary exercise test on a stationary cycle ergometer, during which pedaling torque was continuously recorded. Measures of force production, pedaling symmetry, and pedaling smoothness were obtained. Results Mean Torque increased significantly (p < 0.05) for both legs from initial to terminal workloads. Mean torque Symmetry Index, calculated for down and upstroke portions of the pedaling action, improved from 0.37(0.29) to 0.29(0.35) during downstroke (p = 0.007), and worsened during the upstroke: -0.37(0.38) to -0.62(0.46) (p < 0.001) from initial to terminal workloads. Low Torque Duration improved from initial to terminal workloads, decreasing from 121.1(52.9) to 58.1(39.6) degrees (p < 0.001), respectively. Smoothness of pedaling improved significantly from initial to terminal workloads (p < 0.001). Conclusions Improved pedaling kinematics at terminal workloads indicate that individuals with stroke demonstrate improved motor control with respect to the timing, sequencing, and activation of hemiparetic lower extremity musculature compared to lower workloads. Therapeutic prescription involving higher resistance may be necessary to sufficiently engage and activate the paretic lower extremity.

Dual-task Interference Disrupts Parkinson's Gait Across Multiple Cognitive Domains

Gait dysfunction, a hallmark of Parkinson's disease, contributes to a relatively high incidence of falling. Gait function is further diminished during the performance of a motor-cognitive task (i.e., dual-task). It is unclear if Parkinson's disease-related dual-task deficits are related to a specific area of cognitive function or are the result of a more global decline in executive function. The aim of this project was to systematically evaluate gait performance to determine if gait dysfunction is restricted to certain types of executive function or a global phenomenon in individuals with Parkinson's disease. Twenty-three individuals with mild-moderate Parkinson's disease completed a series of dual-task conditions in which gait was paired with cognitive tasks requiring: working memory (0, 1, and 2-back), attention and problem solving (serial-7 subtraction), verbal memory (digit recall), semantic memory (Controlled Oral Word Association) and information processing speed (visual Stroop test). The results demonstrate that individuals with mild-moderate Parkinson's disease have a generalized worsening of spatial-temporal gait parameters regardless of the specific cognitive demand being performed concurrently. Overall, gait velocity decreased (p < 0.01) and stride and stance time both increased (p < 0.01) across all cognitive conditions. The attention and problem solving task resulted in the greatest number of gait parameter decrements. Results indicated that performance on cognitive tasks remained unchanged from single-task to dual-task conditions. Diminished gait performance under dual-task conditions across different cognitive function domains suggests a global Parkinson's disease-related deficit in information processing and regulation of gait.

Forced Aerobic Exercise Preceding Task Practice Improves Motor Recovery Poststroke

OBJECTIVE

To understand how two types of aerobic exercise affect upper-extremity motor recovery post-stroke. Our aims were to (1) evaluate the feasibility of having people who had a stroke complete an aerobic exercise intervention and (2) determine whether forced or voluntary exercise differentially facilitates upper-extremity recovery when paired with task practice.

METHOD

Seventeen participants with chronic stroke completed twenty-four 90-min sessions over 8 wk. Aerobic exercise was immediately followed by task practice. Participants were randomized to forced or voluntary aerobic exercise groups or to task practice only.

RESULTS

Improvement on the Fugl-Meyer Assessment exceeded the minimal clinically important difference: 12.3, 4.8, and 4.4 for the forced exercise, voluntary exercise, and repetitive task practice-only groups, respectively. Only the forced exercise group exhibited a statistically significant improvement.

CONCLUSION

People with chronic stroke can safely complete intensive aerobic exercise. Forced aerobic exercise may be optimal in facilitating motor recovery associated with task practice.

Forced Aerobic Exercise Enhances Motor Recovery After Stroke: A Case Report

OBJECTIVE

Previously, we demonstrated that forced aerobic exercise (FE) increases the pattern of neural activation in Parkinson's disease. We sought to evaluate whether FE, when coupled with repetitive task practice, could promote motor recovery poststroke.

METHOD

A 46-yr-old man with ischemic stroke exhibited chronic residual upper-extremity deficits, scoring 35/66 on the Fugl-Meyer Assessment (FMA) at baseline. He completed 24 training sessions comprising 45 min of FE on a motorized stationary bicycle followed by 45 min of upper-extremity repetitive task practice.

RESULTS

From baseline to end of treatment, the FMA score improved by 20 points, perceived level of recovery on the Stroke Impact Scale increased by 20 percentage points, and cardiovascular function measured by peak oxygen uptake improved 30%. These improvements persisted 4 wk after the intervention ceased.

CONCLUSION

FE may be a safe and feasible rehabilitation approach to augment recovery of motor and nonmotor function while improving aerobic fitness in people with chronic stroke.

Improving Quality of Life and Depression After Stroke Through Telerehabilitation

OBJECTIVE

The aim of this study was to determine the effects of home-based robot-assisted rehabilitation coupled with a home exercise program compared with a home exercise program alone on depression and quality of life in people after stroke.

METHOD

A multisite randomized controlled clinical trial was completed with 99 people<6 mo after stroke who had limited access to formal therapy. Participants were randomized into one of two groups, (1) a home exercise program or (2) a robot-assisted therapy+home exercise program, and participated in an 8-wk home intervention.

RESULTS

We observed statistically significant changes in all but one domain on the Stroke Impact Scale and the Center for Epidemiologic Studies Depression Scale for both groups.

CONCLUSION

A robot-assisted intervention coupled with a home exercise program and a home exercise program alone administered using a telerehabilitation model may be valuable approaches to improving quality of life and depression in people after stroke.

Home Arm Assistance Progression Initiative (HAAPI) Trial: Robotic-Assisted Telerehabilitation for Stroke

Date Presented 4/18/2015

Stroke survivors in rural areas lack access to the specialized occupational therapy needed for functional gains in the upper extremity (UE). The Home Arm Assistance Progression Initiative (HAAPI) trial demonstrates robotic-assisted telerehabilitation as a viable means to deliver occupational therapy remotely, maintain a client-centered relationship, improve quality of life (QoL), and promote UE neuromotor recovery.

The cyclical lower extremity exercise for Parkinson's trial (CYCLE): methodology for a randomized controlled trial

Background

Motor and non-motor impairments affect quality of life in individuals with Parkinson’s disease. Our preliminary research indicates that forced exercise cycling, a mode of exercise in which a participant’s voluntary rate of exercise is augmented on a stationary cycle, results in global improvements in the cardinal symptoms of Parkinson’s disease. The objective of the Cyclical Lower Extremity Exercise (CYCLE) trial for Parkinson’s disease is to determine the effects of forced exercise cycling on motor and non-motor performance when compared to voluntary rate cycling and a non-exercise control group. Additionally, we plan to identify any associated changes in neural activity determined by functional magnetic resonance imaging.

Methods/Design

A total of 100 individuals with mild to moderate idiopathic Parkinson’s disease will participate in a single-center, parallel-group, rater-blind study. Participants will be randomized 2:2:1 into a forced exercise, voluntary exercise, or no-exercise control group, respectively. Both exercise groups will cycle 3 times per week for 8 weeks at identical aerobic intensities for 40 minutes, but participants in the forced exercise group will cycle 30% faster than their voluntary rate by means of an augmented motorized bicycle. Neuroimaging, clinical, and biomechanical assessments of motor and non-motor performance will be made at baseline both ‘on’ and ‘off’ medication, after four weeks of exercise (midpoint), end of treatment, 4 weeks after end of treatment, and 8 weeks after end of treatment.

Discussion

CYCLE trial will play a critical role in determining the effectiveness of two different types of aerobic exercise, forced and voluntary, on motor and non-motor performance in individuals with Parkinson’s disease. Additionally, the coupling of clinical, biomechanical, and neuroimaging outcomes has the potential to provide insight into mechanisms underlying change in function as a result of exercise.

Trial registration

Clinicaltrials.gov registration number NCT01636297.

Objective assessment of postural stability in Parkinson's disease using mobile technology

BACKGROUND

A significant gap remains in the ability to effectively characterize postural instability in individuals with Parkinson's disease. Clinical evaluation of postural declines is largely subjective, whereas objective biomechanical approaches are expensive and time consuming, thus limiting clinical adoption. Recent advances in mobile devices present an opportunity to address the gap in the quantification of postural stability. The aim of this project was to determine whether kinematic data measured by hardware within a tablet device, a 3rd generation iPad, was of sufficient quantity and quality to characterize postural stability.

METHODS

Seventeen patients and 17 age-matched controls completed six balance conditions under altered surface, stance, and vision. Simultaneous kinematic measurements were gathered from a three-dimensional motion capture system and tablet.

RESULTS

The motion capture system and tablet provided similar measures of stability across groups. In particular, within the patient population, correlation between the two systems for peak-to-peak, normalized path length, root mean square, 95% volume, and total power values ranged from 0.66 to 1.00. Kinematic data from five balance conditions--double-leg stance with eyes open on a foam surface, double-leg stance with eyes closed on firm and foam surfaces, and tandem stance on firm and foam surfaces--were capable of discriminating patients from controls.

CONCLUSIONS

The hardware within the tablet provides data of sufficient accuracy for the quantification of postural stability in patients with Parkinson's disease. The objectivity, portability, and ease of use of this device make it ideal for use in clinical environments lacking sophisticated biomechanical systems.

The home stroke rehabilitation and monitoring system trial: a randomized controlled trial

RATIONALE

Because many individuals poststroke lack access to the quality and intensity of rehabilitation to improve upper extremity motor function, a home-based robotic-assisted upper extremity rehabilitation device is being paired with an individualized home exercise program.

AIMS/HYPOTHESIS

The primary aim of this project is to determine the effectiveness of robotic-assisted home therapy compared with a home exercise program on upper extremity motor recovery and health-related quality of life for stroke survivors in rural and underserved locations. The secondary aim is to explore whether initial degree of motor function of the upper limb may be a factor in predicting the extent to which patients with stroke may be responsive to a home therapy approach. We hypothesize that the home exercise program intervention, when enhanced with robotic-assisted therapy, will result in significantly better outcomes in motor function and quality of life.

DESIGN

A total of 96 participants within six-months of a single, unilateral ischemic, or hemorrhagic stroke will be recruited in this prospective, single-blind, multisite randomized clinical trial.

STUDY OUTCOMES

The primary outcome is the change in upper extremity function using the Action Research Arm Test. Secondary outcomes include changes in: upper extremity function (Wolf Motor Function Test), upper extremity impairment (upper extremity portion of the Fugl-Meyer Test), self-reported quality of life (Stroke Impact Scale), and affect (Centers for Epidemiologic Studies Depression Scale).

DISCUSSION

Similar or greater improvements in upper extremity function using the combined robotic home exercise program intervention compared with home exercise program alone will be interpreted as evidence that supports the introduction of in-home technology to augment the recovery of function poststroke.