A Female-Specific Treatment Group for ADHD-Description of the Programme and Qualitative Analysis of First Experiences

Background: The diagnostics and treatment of attention-deficit/hyperactivity disorder (ADHD) in women remain insufficient. Fluctuations of reproductive hormones during the premenstrual period, postpartum period, and (peri)menopause are neglected, even though they impact ADHD symptoms and associated mood disorders. Therefore, we created a female-specific treatment group for women with ADHD and premenstrual worsening of ADHD and/or mood symptoms. Methods: We describe the group programme and underlying rationale, offering a qualitative analysis of the participants' evaluation. Results: The seven bi-weekly sessions foreground the menstrual cycle and address several ADHD-specific topics in relation to this cyclical pattern. Concurrently, women track their menstrual cycle and (fluctuating) ADHD and mood symptoms with an adjusted premenstrual calendar. In total, 18 women (25-47 years) participated in three consecutive groups. We analysed the evaluation of the last group. Participants experienced the group as a safe and welcoming space. Recognition was valued by all. The topics discussed were deemed valuable, and the structure suited them well. Completing the premenstrual calendar augmented the awareness and recognition of individual cyclical symptoms. A lifespan approach increased self-understanding. Participants took their menstrual cycle more seriously, prioritising self-acceptance and self-care. Conclusions: Exploring a cyclical approach in a group setting seems to be a positive addition to treatment for female ADHD.

Personalized remotely guided preventive exercise therapy for a healthy heart: protocol and design of the PRIORITY study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation – Flanders (FWO)

Introduction

Approximately half of the heart failure population has heart failure with preserved ejection fraction (HFpEF), a chronic disease starting with cardiovascular risk factors such as hypertension, diabetes and obesity (stage A) which can further emerge in a structural heart disease without (stage B) or with (stage C) signs or symptoms. Structured exercise therapy is recommended as a Class IA intervention in national and international guidelines and, as such, should be offered to all patients. Yet, in current practice, exercise therapy is often only offered within a secondary prevention program. At present, there exists no comprehensive preventive care program that includes structured exercise for patients in the early stages of heart failure, when cardiovascular risk factors are present, but cardiac remodeling and dysfunction might still be reversible or even preventable.

Purpose

PRIORITY aims to investigate the use of remotely guided exercise therapy as a preventive clinical and cost-effective treatment in the HFpEF continuum. This includes both prevention of progression of asymptomatic diastolic dysfunction towards symptomatic HFpEF (= primary prevention) and delaying progression of symptomatic HFpEF (= secondary prevention).

Methods

A randomized controlled multicenter trial will be conducted in 450 patients (men and women, aged 35-80 years) with heart failure (n = 180 stage A, 180 stage B, 90 stage C). Participants are being recruited from 3 different hospitals and the general population during a 16-month period which started in September 2021. Patients will be randomized (1:1) to usual care or to the PRIORITY exercise intervention (i.e. a combination of supervised with remotely guided home-based training sessions). Training prescription is based on the EXPERT tool and includes person-tailored endurance and dynamic strength training. During one year, participants will receive 18 supervised exercise sessions supplemented with a structured progressive home-based exercise program. Outcomes will be assessed at baseline, 4 months, one and two-years. Primary outcome is the proportion of patients with a clinically relevant improvement in peak oxygen uptake at one-year. Secondary outcomes include vascular health, muscle metabolism, change in electrocardiographic parameters and physical fitness parameters (muscle strength, body composition). Further, big data of physical activity collected during the trial will be used to develop models using machine-learning algorithms which can predict physical activity uptake and changes in fitness to facilitate the creation of more personalized interventions and better tailored exercise prescription.

Conclusion

We anticipate that the PRIORITY study will contribute to better prevention of heart failure thanks to an early easily accessible person-tailored exercise intervention.

Prevention of heart failure in type 2 diabetes by exercise intervention: protocol and design of the PROTECTION study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): research Foundation - Flanders (FWO)

Introduction

Cardiac dysfunction is highly prevalent in patients with type 2 diabetes mellitus (T2DM), leading to increased risk of cardiac morbidity and premature death. Previous research underscored the high prevalence of a disturbed global longitudinal strain (GLS), a marker to predict this cardiac dysfunction, in both symptomatic and asymptomatic T2DM patients. Exercise-based therapy is recommended in the management of patients with type 2 diabetes. However, it remains unclear i) which type of exercise therapy to have the biggest effect on GLS and ii) which factors modify the effect of exercise therapy on GLS.

Purpose

The PROTECTION study will i) investigate the impact of exercise volume and intensity on GLS to optimize exercise prescription in T2DM and will ii) assess which patient-specific factors influence the change in GLS and physical fitness as a result of exercise intervention in T2DM.

Methods and analyses

The PROTECTION study is composed of two work packages (WP). In WP 1, 100 T2DM adults (50% male, aged 30-75 years) will be randomized to a usual care group or one of the three supervised exercise intervention groups (see Table 1) for a duration of 26 weeks. Outcome measures will be performed at baseline, 13, 26 and 52 weeks of follow-up. The primary outcomes are GLS and cardiac dimensions. Secondary outcomes include health-related physical fitness, blood biomarkers and physical activity behavior. Data will be analyzed by two-way ANOVA repeated measures. A two-tailed P-value <0.05 will be considered statistically significant.

Parallel with the randomized controlled trial, a longitudinal intervention study (WP2) involving 107 adults (50% male, aged 30-75 years) with T2DM will be conducted. All participants will engage in a supervised intervention for 26 weeks, including a high volume of moderate intense physical activity (see Table 1). The main objective of this work package is to define determinants of change in GLS during an exercise intervention. Moreover, the interaction between diet-exercise, habitual physical activity-exercise and phenotype-exercise on change in GLS will be studied in great detail. Patient-specific data will be analyzed by multivariate regression analysis. A two-tailed P-value <0.05 will be considered statistically significant.

Conclusion

It is anticipated that the PROTECTION study will contribute to a better understanding on i) which exercise characteristics are preferred to maximally improve GLS in T2DM and on ii) the determinants of the responsiveness of GLS and physical fitness to exercise in T2DM.

Evolution and prediction of mismatch between observed and perceived upper limb function after stroke: a prospective, longitudinal, observational cohort study

BACKGROUND

A previously shown 'mismatch' group of patients with good observed upper limb (UL) motor function but low perceived UL activity at six months post stroke tends to use the affected UL less in daily life than would be expected based on clinical tests, and this mismatch may also be present at 12 months. We aimed to confirm this group in another cohort, to investigate the evolution of this group from six to 12 months, and to determine factors on admission to inpatient rehabilitation and at 6 months that can discriminate between mismatch and good match groups at 12 months.

METHODS

Persons after stroke were recruited on rehabilitation admission and re-assessed at six and 12 months. Observed UL function was measured with the upper extremity subscale of the Fugl-Meyer Assessment (FMA-UE) and perceived UL activity by the hand subscale of the Stroke Impact Scale 3.0 (SIS-Hand). We defined mismatch as good observed UL function (FMA-UE > 50/66) but low perceived activity (SIS-Hand≤75/100). Potential discriminators at admission and 6 months (demographic characteristics, stroke characteristics, UL somatosensory function, cognitive deficits, mental function and activity) were statistically compared for match and mismatch groups at 12 months.

RESULTS

We included 60 participants (female: 42%) with mean (SD) age of 65 (12) years. We confirmed a mismatch group of 11 (18%) patients at 6 months, which increased to 14 (23%) patients at 12 months. In the mismatch group compared to the good match group at 12 months, patients had a higher stroke severity and more somatosensory impairments on admission and at 6 months.

CONCLUSIONS

We confirmed a group of patients with good observed UL function but low perceived activity both at six and at 12 months post stroke. Assessment of stroke severity and somatosensory impairments on admission into rehabilitation could determine mismatch at 12 months and might warrant intervention. However, large differences in clinical outcomes between patients in the mismatch group indicate the importance of tailoring training to the individual needs.

Arm-Hand Boost Therapy During Inpatient Stroke Rehabilitation: A Pilot Randomized Controlled Trial

Objective: It was the aim to assess feasibility, safety, and potential efficacy of a new intensive, focused arm-hand BOOST program and to investigate whether there is a difference between early vs. late delivery of the program in the sub-acute phase post stroke. Methods: In this pilot RCT, patients with stroke were randomized to the immediate group (IG): 4 weeks (4 w) BOOST +4 w CONTROL or the delayed group (DG): 4 w CONTROL +4 w BOOST, on top of their usual inpatient care program. The focused arm-hand BOOST program (1 h/day, 5x/week, 4 weeks) consisted of group exercises with focus on scapula-setting, core-stability, manipulation and complex ADL tasks. Additionally, 1 h per week the Armeo®Power (Hocoma AG, Switzerland) was used. The CONTROL intervention comprised a dose-matched program (24 one-hour sessions in 4 w) of lower limb strengthening exercises and general reconditioning. At baseline, after 4 and 8 weeks of training, the Fugl-Meyer assessment upper extremity (FMA-UE), action research arm test (ARAT), and stroke upper limb capacity scale (SULCS) were administered. Results: Eighteen participants (IG: n = 10, DG: n = 8) were included, with a median (IQR) time post stroke of 8.6 weeks (5-12). No adverse events were experienced. After 4 weeks of training, significant between-group differences were found for FMA-UE (p = 0.003) and SULCS (p = 0.033) and a trend for ARAT (p = 0.075) with median (IQR) change scores for the IG of 9 (7-16), 2 (1-3), and 12.5 (1-18), respectively, and for the DG of 0.5 (-3 to 3), 1 (0-1), and 1.5 (-1 to 9), respectively. In the IG, 80% of patients improved beyond the minimal clinical important difference of FMA-UE after 4 weeks, compared to none of the DG patients. Between 4 and 8 weeks of training, patients in the DG tend to show larger improvements when compared to the IG, however, between-group comparisons did not reach significance. Conclusions: Results of this pilot RCT showed that an intensive, specific arm-hand BOOST program, on top of usual care, is feasible and safe in the sub-acute phase post stroke and suggests positive, clinical meaningful effects on upper limb function, especially when delivered in the early sub-acute phase post stroke. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04584177.

Sensorimotor vs. Motor Upper Limb Therapy for Patients With Motor and Somatosensory Deficits: A Randomized Controlled Trial in the Early Rehabilitation Phase After Stroke

Background: Somatosensory function plays an important role in motor learning. More than half of the stroke patients have somatosensory impairments in the upper limb, which could hamper recovery. Question: Is sensorimotor upper limb (UL) therapy of more benefit for motor and somatosensory outcome than motor therapy? Design: Randomized assessor- blinded multicenter controlled trial with block randomization stratified for neglect, severity of motor impairment, and type of stroke. Participants: 40 first-ever stroke patients with UL sensorimotor impairments admitted to the rehabilitation center. Intervention: Both groups received 16 h of additional therapy over 4 weeks consisting of sensorimotor (N = 22) or motor (N = 18) UL therapy. Outcome measures: Action Research Arm test (ARAT) as primary outcome, and other motor and somatosensory measures were assessed at baseline, post-intervention and after 4 weeks follow-up. Results: No significant between-group differences were found for change scores in ARAT or any somatosensory measure between the three time points. For UL impairment (Fugl-Meyer assessment), a significant greater improvement was found for the motor group compared to the sensorimotor group from baseline to post-intervention [mean (SD) improvement 14.65 (2.19) vs. 5.99 (2.06); p = 0.01] and from baseline to follow-up [17.38 (2.37) vs. 6.75 (2.29); p = 0.003]. Conclusion: UL motor therapy may improve motor impairment more than UL sensorimotor therapy in patients with sensorimotor impairments in the early rehabilitation phase post stroke. For these patients, integrated sensorimotor therapy may not improve somatosensory function and may be less effective for motor recovery. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03236376.

Developing a revised definition of the Bobath concept: Phase three

OBJECTIVE

To develop a revised definition of the Bobath concept that incorporates the perspectives of members of the International Bobath Instructors Training Association (IBITA).

METHODS

A three-phase consensus building design utilizing (i) focus groups; (ii) survey methods; and, (iii) real-time Delphi. This paper presents the findings from the real-time Delphi, an iterative process to collect and synthesize expert opinions anonymously, provide controlled feedback, with the overall goal of achieving consensus.

RESULTS

One hundred and twenty-one IBITA members participated in the real-time Delphi. Over three Delphi Rounds, consensus was reached on six overarching conceptual statements and 11 statements representing unique aspects of Bobath clinical practice. One statement that aimed to describe the Bobath clinical term of "placing" was eliminated in Round One due to participant reservations that a text description was insufficient for this term. Seven statements underwent minor wording revisions in Round Two and Three to improve sentence clarity.

CONCLUSION

Using the real-time Delphi, we were successful in gaining consensus in an expert group on a series of statements on which a revised definition of the Bobath concept could be based.

Physiological responses and perceived exertion during robot-assisted treadmill walking in non-ambulatory stroke survivors

PURPOSE

To examine physiological responses and perceived exertion during robot-assisted treadmill walking in non-ambulatory stroke survivors; compare these outcomes with aerobic exercise recommendations; and investigate the effect of robotic assistance.

MATERIALS AND METHODS

Twelve non-ambulatory stroke survivors (67 ± 11 years-old, 84 ± 38 d post-stroke) participated. Subjects walked three times 20 min (1 session/day) in the Lokomat: once with conventional exercise parameters, once with 60% robotic assistance and once with 100% robotic assistance. Gas exchange and heart rate were monitored continuously. Perceived exertion was assessed every 3 min during walking.

RESULTS

During conventional robot-assisted treadmill walking, net perceived exertion (0-14 scale) significantly increased between minute 6 (median = 2, interquartile range = 4) and 18 (median = 5, interquartile range = 4). Net physiological responses did not significantly change over time. Throughout exercise, percentage of predicted heart rate reserve was significantly below the 40% threshold (medians: 11-14%) and percentage of predicted maximum heart rate reached the 55% threshold (medians: 59-60%). Perceived exertion reached the 11-point threshold halfway. Net physiological responses and perceived exertion did not significantly differ between 60% and 100% robotic assistance.

CONCLUSIONS

The assistance level that non-ambulatory stroke survivors require at their highest tolerable walking speed seems too high to sufficiently stress the cardiorespiratory system during robot-assisted treadmill walking.Implications for rehabilitationThe exercise intensity of 20-minute conventional robot-assisted treadmill walking can be low, and might be too low to challenge the cardiorespiratory system of non-ambulatory stroke survivors.Lowering the level of robotic assistance from 100% to 60% does not seem to increase the exercise intensity of 20-minute robot-assisted treadmill walking.

Developing a revised definition of the Bobath concept

OBJECTIVE

This study was developed as a consensus-building exercise within the International Bobath Instructors Training Association (IBITA) to develop a revised definition of the Bobath concept.

METHODS

A three-phase design utilizing (a) focus groups, (b) survey methods, and, (c) real-time Delphi. This paper details Phase 1 and 2.

RESULTS

Forty IBITA members participated in five focus groups. Eight broad themes were developed from the focus groups from which the survey statements were developed. There was a high level of agreement on all nine survey statements identifying overarching constructs and on 12 of the 13 statements identifying unique aspects of Bobath clinical practice. Lower scores were attributed to lack of understanding of the term humanistic, Bobath clinical practice addressing multiple domains such as impairments, activities, and participation and limited agreement on the description of the term "placing."

CONCLUSION

Focus groups and a web-based survey were successful in soliciting the opinions of IBITA members on themes and statements of importance for the development of a revised Bobath definition. The results of Phase 1 and 2 will inform Phase 3, a real-time Delphi, to gain consensus within IBITA on statements on which a revised Bobath definition is to be based.

Physiological Responses and Perceived Exertion During Robot-Assisted and Body Weight-Supported Gait After Stroke

INTRODUCTION

Physiological responses are rarely considered during walking after stroke and if considered, only during a short period (3-6 minutes). The aims of this study were to examine physiological responses during 30-minute robot-assisted and body weight-supported treadmill and overground walking and compare intensities with exercise guidelines.

METHODS

A total of 14 ambulatory stroke survivors (age: 61 ± 9 years; time after stroke: 2.8 ± 2.8 months) participated in 3 separate randomized walking trials. Patients walked overground, on a treadmill, and in the Lokomat (60% robotic guidance) for 30 minutes at matched speeds (2.0 ± 0.5 km/h) and matched levels of body weight support (BWS; 41% ± 16%). Breath-by-breath gas analysis, heart rate, and perceived exertion were assessed continuously.

RESULTS

Net oxygen consumption, net carbon dioxide production, net heart rate, and net minute ventilation were about half as high during robot-assisted gait as during body weight-supported treadmill and overground walking ( P < .05). Net minute ventilation, net breathing frequency, and net perceived exertion significantly increased between 6 and 30 minutes (respectively, 1.8 L/min, 2 breaths/min, and 3.8 units). During Lokomat walking, exercise intensity was significantly below exercise recommendations; during body weight-supported overground and treadmill walking, minimum thresholds were reached (except for percentage of heart rate reserve during treadmill walking).

CONCLUSION

In ambulatory stroke survivors, the oxygen and cardiorespiratory demand during robot-assisted gait at constant workload are considerably lower than during overground and treadmill walking at matched speeds and levels of body weight support. Future studies should examine how robotic devices can be Future studies should examine how robotic devices can be exploited to induce aerobic exercise.

Male and female opinions about orthotic devices of the lower limb: A multicentre, observational study in patients with central neurological movement disorders

BACKGROUND AND OBJECTIVE

Because user-satisfaction and acceptance may partly determine the grade of compliance to an orthotic device (OD), the aim of this multicentre observational study was to inquire the reasons for acceptance and the user-satisfaction of an OD of the lower limb in male and female central neurological movement disorders (CNMD) patients.

METHODS

Persons with CNMD having at least one prescribed OD of the lower limb were included. Two questionnaires were used: the MIRAD-ACCORT-II (reasons for acceptance) and a modified version of the D-QUEST 2.0 (user-satisfaction). Descriptive analyses were performed and to analyse the differences between the males' and females' answers Chi2- and Mann-Whitney U tests were used.

RESULTS

Twenty-six stroke and 23 multiple sclerosis patients participated (53% males). "Comfort", "safety", "effectiveness" and "ease of use" were reported as most important aspects. 86% of the patients were (very) satisfied about their OD. Only for the aspect safety, compared to males, significant more females reported that if the OD is not safe enough they will not use it.

CONCLUSION

For both, males and females, aspects related to comfort and functionality were reported as much more important than the esthetical aspects, and in general they are quite satisfied with the OD and the process of providing the OD. Orthopaedic technicians and health care providers can take these aspects into account when developing, constructing and providing OD's.

The Burden of ADHD in Older Adults: A Qualitative Study

OBJECTIVE

To explore how ADHD may have affected the lives of older adults who meet the diagnostic criteria of ADHD, but are unaware of their diagnosis. Our second aim was to examine whether the reported symptoms change over the life span.

METHOD

A qualitative study was conducted. Seventeen Dutch older people (>65 years) diagnosed in this study with ADHD participated in in-depth interviews. Data were analyzed according to techniques of thematic approach.

RESULTS

Seven themes emerged from the analyses. Four themes correspond to ADHD symptoms: "being active," "being impulsive," "attention problems," and "mental restlessness." In addition, the themes "low self-esteem," "overstepping boundaries," and "feeling misunderstood" emerged. The impact of ADHD symptoms seems to have declined with age.

CONCLUSION

ADHD has a negative impact on late life, and older adults with the disorder may benefit from treatment. Moreover, this study's findings call for early detection and treatment of ADHD in children and adults.

The Bobath concept - a model to illustrate clinical practice

Background and purpose: The model of Bobath clinical practice provides a framework identifying the unique aspects of the Bobath concept in terms of contemporary neurological rehabilitation. The utilisation of a framework to illustrate the clinical application of the Bobath concept provides the basis for a common understanding with respect to Bobath clinical practice, education, and research. The development process culminating in the model of Bobath clinical practice is described. Case description: The use of the model in clinical practice is illustrated using two cases: a client with a chronic incomplete spinal cord injury and a client with a stroke. Discussion: This article describes the clinical application of the Bobath concept in terms of the integration of posture and movement with respect to the quality of task performance, applying the Model of Bobath Clinical Practice. Facilitation, a key aspect of Bobath clinical practice, was utilised to positively affect motor control and perception in two clients with impairment-related movement problems due to neurological pathology and associated activity limitations and participation restrictions - the outcome measures used to reflect the individual clinical presentation. Implications for Rehabilitation The model of Bobath clinical practice provides a framework identifying the unique aspects of the Bobath-concept. The model of Bobath clinical practice provides the basis for a common understanding with respect to Bobath clinical practice, education, and research. The clinical application of the Bobath-concept highlights the integration of posture and movement with respect to the quality of task performance. Facilitation, a key aspect of Bobath clinical practice, positively affects motor control, and perception.

Virtual Reality Training for Upper Extremity in Subacute Stroke (VIRTUES)

Objective:

To compare the effectiveness of upper extremity virtual reality rehabilitation training (VR) to time-matched conventional training (CT) in the subacute phase after stroke.

Methods:

In this randomized, controlled, single-blind phase III multicenter trial, 120 participants with upper extremity motor impairment within 12 weeks after stroke were consecutively included at 5 rehabilitation institutions. Participants were randomized to either VR or CT as an adjunct to standard rehabilitation and stratified according to mild to moderate or severe hand paresis, defined as ≥20 degrees wrist and 10 degrees finger extension or less, respectively. The training comprised a minimum of sixteen 60-minute sessions over 4 weeks. The primary outcome measure was the Action Research Arm Test (ARAT); secondary outcome measures were the Box and Blocks Test and Functional Independence Measure. Patients were assessed at baseline, after intervention, and at the 3-month follow-up.

Results:

Mean time from stroke onset for the VR group was 35 (SD 21) days and for the CT group was 34 (SD 19) days. There were no between-group differences for any of the outcome measures. Improvement of upper extremity motor function assessed with ARAT was similar at the postintervention (p = 0.714) and follow-up (p = 0.777) assessments. Patients in VR improved 12 (SD 11) points from baseline to the postintervention assessment and 17 (SD 13) points from baseline to follow-up, while patients in CT improved 13 (SD 10) and 17 (SD 13) points, respectively. Improvement was also similar for our subgroup analysis with mild to moderate and severe upper extremity paresis.

Conclusions:

Additional upper extremity VR training was not superior but equally as effective as additional CT in the subacute phase after stroke. VR may constitute a motivating training alternative as a supplement to standard rehabilitation.

ClinicalTrials.gov identifier:

NCT02079103.

Classification of evidence:

This study provides Class I evidence that for patients with upper extremity motor impairment after stroke, compared to conventional training, VR training did not lead to significant differences in upper extremity function improvement.

Efficacy and safety of collagenase treatment for Dupuytren's disease: 2-year follow-up results

Dupuytren's contracture is a common hand problem that affects the palmar fascia. Several treatment options exist, but none are curative and recurrence is common. Bacterial collagenase has recently been proven beneficial for treating Dupuytren's disease, cleaving the collagen fibers at different sites, with weakening and eventually rupture of the fibrous cords after manipulation. An independent prospective follow-up study was organized on 87 patients, treated with one or more collagenase injections. Inclusion criteria were a contracture of at least 20° at the metacarpophalangeal (MCP) or the proximal interphalangeal (PIP) joint. The most diseased joint was taken into consideration for follow-up evaluation. The resulting extension deficit was measured at 1 month, 1 year and 2 years and was graded as "clinical success", "clinical improvement" or "clinical failure". The mean contracture improved from 45° (39° for MCP and 54° for PIP joints) before treatment to 5° (2° for MCP and 9° for PIP joints) 4 weeks after treatment. No serious complications occurred. After 2 years, 68 joints were evaluated; 61.5% of the MCP joints and 34.5% of the PIP joints had a contracture of ≤20°. When compared with the 4-week evaluation, 28.2% of MCP joints and 62.1% of PIP joints had a recurrence (20° or greater worsening) or had received additional treatment. Collagenase injection is a safe and effective treatment option for Dupuytren disease, but recurrence is common especially for the PIP joint.

Effectiveness of Active Cycling in Subacute Stroke Rehabilitation: A Randomized Controlled Trial

OBJECTIVE

To examine the effects of 3 months of aerobic training (AT) followed by coaching on aerobic capacity, strength, and gait speed after subacute stroke.

DESIGN

Randomized controlled trial.

SETTING

Inpatient rehabilitation center.

PARTICIPANTS

Patients (N=59; mean age ± SD, 65.4±10.3y; 21 women (36%); Barthel Index ≤50 in 64% of patients) with first stroke and able to cycle at 50 revolutions/min were enrolled in the study 3 to 10 weeks after stroke onset.

INTERVENTIONS

Patients were randomly allocated to a 3-month active cycling group (ACG, n=33) and education, or to a control group (CG, n=26). Afterward, patients in the ACG were randomly assigned either to a coaching (n=15) or to a noncoaching group (n=16) for 9 months.

MAIN OUTCOME MEASURES

Aerobic capacity, isometric knee extension strength, and gait ability and speed were measured before and after intervention and during follow-up at 6 and 12 months.

RESULTS

A nonsignificant difference was found in workload (Watt_peak) (P=.078) between ACG and CG after 3 months. Furthermore, after 3 months of cycling and after 9 months of coaching, all groups showed significant changes over time (P≤.027) in peak oxygen consumption, Watt_peak, leg strength, and gait speed. Also, significant changes over time (P<.001) were found in the ACG and the CG in patients with walking inability at baseline.

CONCLUSIONS

No significant differences between training groups were found over time. Although our study did not have objective exercise data from the training device during follow-up, the 3-month active cycling (AC) program combined with education sessions seemed an applicable method in subacute stroke rehabilitation. New long-term AT interventions should focus on coaching approaches to facilitate training after a supervised AC program.

Motivation, expectations, and usability of a driven gait orthosis in stroke patients and their therapists

BACKGROUND

In the development of efficacious driven gait orthoses (DGO), it is an added value to consider patients' and therapists' perspectives concerning robot-assisted gait training (RAGT). A better understanding of these issues may improve the process of care and outcome.

OBJECTIVES

This study aimed to examine stroke patients' motivation and expectations of RAGT, and therapists' expectations and perspectives on the usability of RAGT. Additionally, the differences in expectations between stroke patients and their therapists were analyzed.

METHODS

A cross sectional, multi-center, three-group trial was conducted. Included were (1) stroke patients who have experience with RAGT (i.e. the stroke user group), (2) stroke patients who have no experience with RAGT (i.e. the stroke non-user group), and (3) therapists who have experience with RAGT (i.e. the therapist user group). The Intrinsic Motivation Inventory (IMI), Credibility/Expectancy Questionnaire (CEQ), and Usefulness, Satisfaction and Ease of Use Questionnaire (USE) were used. Descriptive statistics and non-parametric Kruskal-Wallis tests were conducted.

RESULTS

In total, 46 subjects were assessed (stroke user group: n = 23, stroke non-user group: n = 14, therapist user group: n = 9). IMI subscale scores ranged from 42 to 88%. Mean credibility and expectancy ranged from 80 to 85% and 57 to 72%, respectively, with no significant differences between groups. USE subscale scores ranged from 61 to 72%.

CONCLUSIONS

Stroke user group patients seem quite motivated to train with the DGO and both patients and therapists reasonably believe that this training could improve gait functioning. Therapists are moderately satisfied with the usability of the DGO, but there is room for improvement with respect to usefulness and ease of use.

Physical activity in chronic home-living and sub-acute hospitalized stroke patients using objective and self-reported measures

BACKGROUND

Despite confirmed reduced physical activity (PA) after stroke in various stages of recovery, the type of activities stroke patients executed and the time spent at different activity levels have not been sufficiently verified with stroke-validated assessment tools.

DESIGN

Observational study.

OBJECTIVE

To determine PA of sub-acute stroke patients hospitalized in a rehabilitation centre (HOS) compared to chronic home-living stroke patients (HOM) using objective and self-reported measures during 2 weekdays and 1 weekend day.

METHODS

Fifteen HOS and 15 HOM patients wore a Sense Wear Pro 2 accelerometer (METs*minutes/24 h) and a knee-worn pedometer Yamax Digi Walker SW 200 (steps) and filled in a coded activity diary (kcal/24 h; METs*minutes/24 h) during three consecutive days.

RESULTS

In HOM significantly more steps (stepstotal HOM = 18722.6 ± 10063.6; stepstotal HOS = 7097.8 ± 5850.5) and higher energy expenditure (EE) levels (EEtotal HOM = 7759.34 ± 2243.04; EEtotal HOS = 5860.15 ± 1412.78) were measured. In this group less moderate activity (≥3-6 ≤ METs) was performed on a weekday (pday1 = 0.006; pday2 = 0.027) and in total (p = 0.037). Few therapy hours (physical, occupational and speech therapy, and psychological support) were provided in HOM compared to HOS (p < 0.001). Vigorous activities were only seen in HOM. In both groups few patients executed sport activities.

CONCLUSIONS

In HOM significantly more steps were performed and higher EE values were measured. However, participation in moderate activities and time spent on therapy were less in HOM. Evaluating PA with quantitative measures is feasible in both chronic home-living and sub-acute hospitalized patients with stroke.

Somatosensory Impairments in the Upper Limb Poststroke: Distribution and Association With Motor Function and Visuospatial Neglect

BACKGROUND

A thorough understanding of the presence of different upper-limb somatosensory deficits poststroke and the relation with motor performance remains unclear. Additionally, knowledge about the relation between somatosensory deficits and visuospatial neglect is limited.

OBJECTIVE

To investigate the distribution of upper-limb somatosensory impairments and the association with unimanual and bimanual motor outcomes and visuospatial neglect.

METHODS

A cross-sectional observational study was conducted, including 122 patients within 6 months after stroke (median = 82 days; interquartile range = 57-133 days). Somatosensory measurement included the Erasmus MC modification of the (revised) Nottingham Sensory Assessment (Em-NSA), Perceptual Threshold of Touch (PTT), thumb finding test, 2-point discrimination, and stereognosis subscale of the NSA. Upper-limb motor assessment comprised the Fugl-Meyer assessment, motricity index, Action Research Arm Test, and Adult-Assisting Hand Assessment Stroke. Screening for visuospatial neglect was performed using the Star Cancellation Test.

RESULTS

Upper-limb somatosensory impairments were common, with prevalence rates ranging from 21% to 54%. Low to moderate Spearman ρ correlations were found between somatosensory and motor deficits (r = 0.22-0.61), with the strongest associations for PTT (r = 0.56-0.61) and stereognosis (r = 0.51-0.60). Visuospatial neglect was present in 27 patients (22%). Between-group analysis revealed somatosensory deficits that occurred significantly more often and more severely in patients with visuospatial neglect (P < .05). Results showed consistently stronger correlations between motor and somatosensory deficits in patients with visuospatial neglect (r = 0.44-0.78) compared with patients without neglect (r = 0.08-0.59).

CONCLUSIONS

Somatosensory impairments are common in subacute patients poststroke and are related to motor outcome. Visuospatial neglect was associated with more severe upper-limb somatosensory impairments.

Human-Robot Interaction: Does Robotic Guidance Force Affect Gait-Related Brain Dynamics during Robot-Assisted Treadmill Walking?

In order to determine optimal training parameters for robot-assisted treadmill walking, it is essential to understand how a robotic device interacts with its wearer, and thus, how parameter settings of the device affect locomotor control. The aim of this study was to assess the effect of different levels of guidance force during robot-assisted treadmill walking on cortical activity. Eighteen healthy subjects walked at 2 km.h-1 on a treadmill with and without assistance of the Lokomat robotic gait orthosis. Event-related spectral perturbations and changes in power spectral density were investigated during unassisted treadmill walking as well as during robot-assisted treadmill walking at 30%, 60% and 100% guidance force (with 0% body weight support). Clustering of independent components revealed three clusters of activity in the sensorimotor cortex during treadmill walking and robot-assisted treadmill walking in healthy subjects. These clusters demonstrated gait-related spectral modulations in the mu, beta and low gamma bands over the sensorimotor cortex related to specific phases of the gait cycle. Moreover, mu and beta rhythms were suppressed in the right primary sensory cortex during treadmill walking compared to robot-assisted treadmill walking with 100% guidance force, indicating significantly larger involvement of the sensorimotor area during treadmill walking compared to robot-assisted treadmill walking. Only marginal differences in the spectral power of the mu, beta and low gamma bands could be identified between robot-assisted treadmill walking with different levels of guidance force. From these results it can be concluded that a high level of guidance force (i.e., 100% guidance force) and thus a less active participation during locomotion should be avoided during robot-assisted treadmill walking. This will optimize the involvement of the sensorimotor cortex which is known to be crucial for motor learning.

Robot-assisted walking with the Lokomat: the influence of different levels of guidance force on thorax and pelvis kinematics

BACKGROUND

Little attention has been devoted to the thorax and pelvis movements during gait. The aim of this study is to compare differences in the thorax and pelvis kinematics during unassisted walking on a treadmill and during walking with robot assistance (Lokomat-system (Hocoma, Volketswil, Switzerland)).

METHODS

18 healthy persons walked on a treadmill with and without the Lokomat system at 2kmph. Three different conditions of guidance force (30%, 60% and 100%) were used during robot-assisted treadmill walking (30% body weight support). The maximal movement amplitudes of the thorax and pelvis were measured (Polhemus Liberty™ (Polhemus, Colchester, Vermont, USA) (240/16)). A repeated measurement ANOVA was conducted.

FINDINGS

Robot-assisted treadmill walking with different levels of guidance force showed significantly smaller maximal movement amplitudes for thorax and pelvis, compared to treadmill walking. Only the antero-posterior tilting of the pelvis was significantly increased during robot-assisted treadmill walking compared to treadmill walking. No significant changes of kinematic parameters were found between the different levels of guidance force.

INTERPRETATION

With regard to the thorax and pelvis movements, robot-assisted treadmill walking is significantly different compared to treadmill walking. It can be concluded that when using robot assistance, the thorax is stimulated in a different way than during walking without robot assistance, influencing the balance training during gait.

Body weight support during robot-assisted walking: influence on the trunk and pelvis kinematics

BACKGROUND

Efficacy studies concerning robot assisted gait rehabilitation showed limited clinical benefits. A changed kinematic pattern might be responsible for this. Little is known about the kinematics of the trunk and pelvis during robot assisted treadmill walking (RATW).

OBJECTIVE

The aim of this study was to assess the trunk and pelvis kinematics of healthy subjects during RATW, with different amounts of body weight support (BWS) compared to regular treadmill walking (TW).

METHOD

Eighteen healthy participants walked on a treadmill, while kinematics were registered by an electromagnetic tracking device. Hereafter, the kinematics of pelvis and trunk were registered during RATW (guidance force 30%) with 0%, 30% and 50% BWS.

RESULTS

Compared to TW, RATW showed a decrease in the following trunk movements: axial rotation, anteroposterior flexion, lateral and anteroposterior translation. Besides, a decrease in lateral tilting and all translation of the pelvis was found when comparing RATW with TW. Furthermore, the anteroposterior tilting of the pelvis increased during RATW.

CONCLUSION

In general, there was a decrease in trunk and pelvis movement amplitude during RATW compared with regular TW. Though, it is not known if these changes are responsible for the limited efficacy of robot assisted gait rehabilitation. Further research is indicated.

Is a coded physical activity diary valid for assessing physical activity level and energy expenditure in stroke patients?

Objectives

to determine the concurrent validity of a physical activity diary for measuring physical activity level and total energy expenditure in hospitalized stroke patients.

Method

Sixteen stroke patients kept coded activity diaries and wore SenseWear Pro2 multi-sensor activity monitors during daytime hours for one day. A researcher observed the patients and completed a diary. Data from the patients' diaries were compared with observed and measured data to determine total activity (METs*minutes), activity level and total energy expenditure.

Results

Spearman correlations between the patients' and researchers' diaries revealed a high correlation for total METs*minutes (r_s = 0.75, p<0.01) for sedentary (r_s = 0.74,p<0.01) and moderate activities (r_s = 0.71,p<0.01) and a very high correlation (r_s = 0.92, p<0.01) for the total energy expenditure. Comparisons between the patients' diaries and activity monitor data revealed a low correlation (r_s 0.29) for total METs*minutes and energy expenditure.

Conclusion

Coded self-monitoring activity diaries appear feasible as a low-tech alternative to labor-intensive observational diaries for determining sedentary, moderate, and total physical activity and for quantifying energy expenditure in hospitalized stroke patients. Given the poor correlation with objective measurements of physical activity, however, further research is needed to validate its use against a gold-standard measure of physical activity intensity and energy expenditure.

Walking with robot assistance: the influence of body weight support on the trunk and pelvis kinematics

PURPOSE

The goal was to assess in healthy participants the three-dimensional kinematics of the pelvis and the trunk during robot-assisted treadmill walking (RATW) at 0%, 30% and 50% body weight support (BWS), compared with treadmill walking (TW).

METHODS

18 healthy participants walked (2 kmph) on a treadmill with and without robot assistance (Lokomat; 60% guidance force; 0%, 30% and 50% BWS). After an acclimatisation period (four minutes), trunk and pelvis kinematics were registered in each condition (Polhemus Liberty [240 Hz]). The results were analysed using a repeated measures analysis of variance with Bonferroni correction, with the level of suspension as within-subject factor.

RESULTS

During RATW with BWS, there were significantly (1) smaller antero-posterior and lateral translations of the trunk and the pelvis; (2) smaller antero-posterior flexion and axial rotation of the trunk; (3) larger lateral flexion of the trunk; and (4) larger antero-posterior tilting of the pelvis compared with TW.

CONCLUSIONS

There are significant differences in trunk and pelvis kinematics in healthy persons during TW with and without robot assistance. These data are relevant in gait rehabilitation, relating to normal balance regulation. Additional research is recommended to further assess the influence of robot assistance on human gait.

IMPLICATIONS FOR REHABILITATION

The trunk and pelvis moves in a different way during walking with robot assistance. The data suggest that the change in movement is due to the robot device and the harness of the suspension system more than due to the level of suspension itself.