Postural behaviour in people with multiple sclerosis: A complexity paradox

BACKGROUND

Balance deficits are a major concern for people with multiple sclerosis (pwMS). Measuring complexity of motor behaviour can offer an insight into MS-related changes in adaptability of the balance control system when dealing with increasingly complex tasks.

QUESTION

Does postural behaviour complexity differ between pwMS at early stages of the disease and healthy controls (HC)? Does postural behaviour complexity change across increasingly complex tasks?

METHODS

Forty-eight pwMS and 24 HC performed four increasingly complex postural tasks with eyes open (EO), eyes closed (EC), on firm (FS) and compliant surface (CS). Lumbar and sternum sensors recorded 3D acceleration, from which complexity index (CI) was calculated using multiscale sample entropy (MSE) in the frontal and sagittal planes.

RESULTS

We found that only the complexity index in both planes during the eyes closed on compliant surface (EC-CS) task was significantly lower in pwMS compared to HC. We also found that complexity in pwMS was significantly lower during EC-CS compared to the other three tasks when using both lumbar and sternum sensors.

SIGNIFICANCE

Increasing the complexity of postural tasks reduces the complexity of postural behaviour in pwMS. This paradox may reflect reduced adaptability of the sensorimotor integration processes at early stages of MS. CI can provide a different perspective on balance deficits and could potentially be a more sensitive biomarker of MS progression and an early indicator of balance deficit.

Sample Entropy Improves Assessment of Postural Control in Early-Stage Multiple Sclerosis

Postural impairment in people with multiple sclerosis (pwMS) is an early indicator of disease progression. Common measures of disease assessment are not sensitive to early-stage MS. Sample entropy (SE) may better identify early impairments. We compared the sensitivity and specificity of SE with linear measurements, differentiating pwMS (EDSS 0-4) from healthy controls (HC). 58 pwMS (EDSS ≤ 4) and 23 HC performed quiet standing tasks, combining a hard or foam surface with eyes open or eyes closed as a condition. Sway was recorded at the sternum and lumbar spine. Linear measures, mediolateral acceleration range with eyes open, mediolateral jerk with eyes closed, and SE in the anteroposterior and mediolateral directions were calculated. A multivariate ANOVA and AUC-ROC were used to determine between-groups differences and discriminative ability, respectively. Mild MS (EDSS ≤ 2.0) discriminability was secondarily assessed. Significantly lower SE was observed under most conditions in pwMS compared to HC, except for lumbar and sternum SE when on a hard surface with eyes closed and in the anteroposterior direction, which also offered the strongest discriminability (AUC = 0.747), even for mild MS. Overall, between-groups differences were task-dependent, and SE (anteroposterior, hard surface, eyes closed) was the best pwMS classifier. SE may prove a useful tool to detect subtle MS progression and intervention effectiveness.

Application of the extended technology acceptance model to explore clinician likelihood to use robotics in rehabilitation

PURPOSE

Evidence suggests that patients with upper limb impairment following a stroke do not receive recommended amounts of motor practice. Robotics provide a potential solution to address this gap, but clinical adoption is low. The aim of this study was to utilize the technology acceptance model as a framework to identify factors influencing clinician adoption of robotic devices into practice.

MATERIALS AND METHOD

Mixed methods including survey data and focus group discussions with allied health clinicians whose primary caseload was rehabilitation of the neurologically impaired upper limb. Surveys based on the technology acceptance measure were completed pre/post exposure to and use of a robotic device. Focus groups discussions based on the theory of planned behaviour were conducted at the conclusion of the study.

RESULTS

A total of 34 rehabilitation clinicians completed the surveys with pre-implementation data indicating that rehabilitation clinicians perceive robotic devices as complex to use, which influenced intention to use such devices in practice. The focus groups found that lack of experience and time to learn influenced confidence to implement robotic devices into practice.

CONCLUSION

This study found that perceived usefulness and perceived ease of use of a robotic device in clinical rehabilitation can be improved through experience, training and embedded technological support. However, training and embedded support are not routinely offered, suggesting there is a discordance between current implementation and the learning needs of rehabilitation clinicians.IMPLICATIONS FOR REHABILITATIONPatients do not receive adequate amounts of upper limb motor practice following a stroke, and although robotic devices have the potential to address this gap, clinical adoption is low.The technology acceptance model identified that clinicians perceive robotic devices to be complex to use with current implementation efforts failing to consider their training needs.Implementation adoption of robotic devices in rehabilitation should be supported with adequate training and technological support if sustainable practice change is to be achieved.

The effect of COVID-19 lockdowns on exercise and the role of online exercise in Australians with multiple sclerosis

INTRODUCTION

Regular exercise is beneficial for people with Multiple Sclerosis (MS), regardless of disability level. The previously reported differential effect of COVID-19-related lockdowns on exercise levels in this population remains unexplained. We examined effects of lockdowns on exercise in Australians with MS according to disability levels, lockdown severity and health technology use.

METHODS

A cross-sectional survey of people with MS in Australia (22 April-23 September 2021) collected demographic and clinical information as well as exercise patterns before and during lockdowns. Mann-Whitney was used to compare ordinal data and Likelihood Ratio to compare dichotomous data.

RESULTS

151 people completed the survey. 72.2% had mild disability and 25.2% moderate disability. Extended lockdowns were associated with significantly decreased sedentary behaviour (31.5% to 25.9%) but also with decreased exercise frequency in frequent exercisers (≥3 times/week; 53.7% to 22.2%). The latter occurred significantly more in those with mild disability (-22.7%) than with moderate disability (-3.5%). More people with mild disability walked for exercise pre-pandemic (LR 8.6, p=.004) and during lockdowns (LR 6.6, p=.010). Walking during lockdowns was positively associated with working from home. People with moderate disability were more likely to engage in home exercise both pre-pandemic (LR 5.5, p=.019) and during lockdown (LR 5.2, p=.023). Engagement in home exercise rose for both groups during lockdowns and was facilitated by on-line exercise classes.

CONCLUSION

Lockdowns differentially affected exercise patterns according to disability level. The proportion of people achieving exercise recommendations decreased more in those with mild but not moderate disability. Incidental physical activity was disproportionately impacted in people with moderate disability.

Optimal sensor location and direction to accurately classify people with early-stage multiple sclerosis using gait stability

BACKGROUND

The local divergence exponent (LDE) has been used to assess gait stability in people with multiple sclerosis (pwMS). Although previous studies have consistently found that stability is lower in pwMS, inconsistent methodologies have been used to assess patients with a broad range of disability levels.

QUESTIONS

What sensor location and movement direction(s) are better able to classify pwMS at early stages of the disease?

METHODS

49 pwMS with EDSS ≤ 2.5 and 24 healthy controls walked overground for 5 min while 3D acceleration data was obtained from sensors placed at the sternum (STR) and lumbar (LUM) areas. Unidirectional (vertical [VT], mediolateral [ML], and anteroposterior [AP]) and 3-dimensional (3D) LDEs were calculated using STR and LUM data over 150 strides. ROC analyses were performed to assess classification models using single and combined LDEs, with and without velocity per lap (VEL_LAP) as a covariate.

RESULTS

Four models performed equally well by using combinations of VEL_LAP, LUM_3D, LUM_VT, LUM_ML, LUM_AP, STR_ML, and STR_AP (AUC = 0.879). The best model using single sensor LDEs included VEL_LAP, STR_3D, STR_ML, and STR_AP (AUC = 0.878), whereas using VEL_LAP + STR_VT (AUC = 0.869) or VEL_LAP + STR_3D (AUC=0.858) performed best using a single LDE.

SIGNIFICANCE

The LDE offers an alternative to currently insensitive tests of gait impairment in pwMS at early stages, when deterioration is not clinically evident. For clinical purposes, the implementation of this measure can be simplified using a single sensor at the sternum and a single LDE measure, but speed should be considered. Longitudinal studies to determine the predictive power and responsiveness of the LDE to MS progression are still needed.

Predicting strength outcomes for upper limb nerve transfer surgery in tetraplegia

We report a retrospective study of 112 nerve transfers in 39 participants to investigate predictors of strength outcomes after nerve transfer surgery for upper limb reanimation in tetraplegia. We measured clinical and pre- and intraoperative neurophysiological assessment variables and compared them with strength outcomes 2 years after nerve transfer surgery. We found statistically significant improvement in Medical Research Council strength grades after nerve transfer surgery with lower cervical spine injuries (between one and two grades), lower donor nerve stimulation thresholds (half of a grade), greater motor evoked potential activity in recipient nerves (half of a grade) and greater muscle responses to intraoperative stimulation of donor (half of a grade) and recipient nerves (half of a grade).Level of evidence: III.

Establishing an Australian pediatric spinal cord disorder register using consumer, health professional, and researcher perspectives

CONTEXT/OBJECTIVE

Pediatric spinal cord disorders (SCD) are rare, and epidemiological data available to support treatment are lacking. The implementation of a national data register tailored to this population would greatly assist clinicians and therapists in guiding clinical practice. This study gathered perspectives surrounding a prospective national pediatric spinal cord disorder register.

DESIGN

Survey and modified Delphi technique.

SETTING

Australia.

PARTICIPANTS

SCD consumers, health professionals, and researchers.

INTERVENTIONS

None.

OUTCOME MEASURES

None.

RESULTS

Purposive sampling recruited 6 consumers and 52 health professionals and researchers working in the field of SCD to participate. The consumer survey contained items including demographic information, general and pediatric-specific SCD health issues, and questions regarding activity and participation. The modified Delphi survey required health professionals and researchers to identify which "collection items" and "administrative features" should be included in a national SCD register for both clinical and research purposes. Seventeen essential and nine optional items, two outcome measures, data collection methods, consumer access, definition of "pediatric," and use of International Data Standards were included in the consensus for a minimum dataset.

CONCLUSION

This study developed a minimum dataset that could inform an Australian register for pediatric SCD. A register linking to an adult database is recommended to ensure coverage across the lifespan. While items for a minimum dataset have been recommended, this dataset is large. Review and refinement of this list are recommended to ensure the register is not overly time-consuming for practical use.

A Practical Post-Stroke Elbow Spasticity Assessment Using an Upper Limb Rehabilitation Robot: A Validation Study

Spasticity is a motor disorder characterised by a velocity-dependent increase in muscle tone, which is critical in neurorehabilitation given its high prevalence and potential negative influence among the post-stroke population. Accurate measurement of spasticity is important as it guides the strategy of spasticity treatment and evaluates the effectiveness of spasticity management. However, spasticity is commonly measured using clinical scales which may lack objectivity and reliability. Although many technology-assisted measures have been developed, showing their potential as accurate and reliable alternatives to standard clinical scales, they have not been widely adopted in clinical practice due to their low usability and feasibility. This paper thus introduces an easy-to-use robotic based measure of elbow spasticity and its evaluation protocol. Preliminary results collected with one post-stroke patient and one healthy control subject are presented and demonstrate the feasibility of the approach.

Factors influencing thigh muscle volume change with cycling exercises in acute spinal cord injury - a secondary analysis of a randomized controlled trial

Objective: To conduct a per-protocol analysis on thigh muscle volume outcomes from the Spinal Cord Injury and Physical Activity (SCIPA) Switch-On Trial.Design: Secondary analysis from an assessor-blind randomized, controlled trial.Setting: Four acute/sub-acute hospitals in Australia and New Zealand.Participants: 24 adults (1 female) within four weeks of motor complete or incomplete spinal cord injury (SCI)Intervention: Functional electrical stimulation-assisted cycling (FESC) or passive cycling (PC) 4x/week for 12 weeks.Outcome Measures: Whole thigh and muscle group volumes calculated from manually segmented MR images.Results: 19/24 participants completed ≥ twelve weeks of the intervention. Five participants experienced hypertrophy (4 FESC; 1 PC) and eight attenuation of atrophy (<20% volume loss) (3 FESC; 5 PC) in thigh muscle volume. Six participants were non-responders, exhibiting atrophy >20% (3 FESC; 3 PC). Mean (SD) change for FESC was -2.3% (25.3%) and PC was -14.0% (12.3%). After controlling for baseline muscle volumes, a strong significant correlation was found between mean weekly exercise frequency and quadriceps and hamstring volumes (r=6.25, P=0.006), regardless of mode. Average watts was highly correlated to quadriceps volumes only (r=5.92, P=0.01), while total number of sessions was strongly correlated with hamstring volumes only (r=5.91, P=0.01).Conclusion: This per-protocol analysis of FESC and PC early after SCI reports a partial response in 42% and a beneficial response in 25% of patients who completed 12 weeks intervention, regardless of mode. Strong correlations show a dose-response according to exercise frequency. Characteristics of non-responders are discussed to inform clinical decision-making.

Implementing education: Personal communication with a healthcare professional is a critical step to address vaccine hesitancy for people with multiple sclerosis

Background

People with Multiple Sclerosis (PwMS) were first able to access COVID-19 vaccines in Australia from March 2021, when vaccine hesitancy in the general population was high (14–43%). High uptake of vaccination is important globally and critical to protect this vulnerable population. We conducted an on-line survey to examine factors influencing COVID-19 vaccination willingness among PwMS in Australia.

Methods

149 PwMS living in Australia completed the on-line survey (April-September 2021) examining demographic, environmental and clinical factors with respect to vaccine willingness, including attitudes towards COVID-19 illness and vaccines. Additional items explored the influence of different information sources on vaccination decisions. Continuous and ordinal data were compared using the Mann-Whitney U test. All tests were two-tailed, with alpha set at 0.5.

Results

A majority of the respondents were female (87.2%) with relapsing-remitting MS (77.5%) treated by a neurologist (94.0%). A majority were on high efficacy disease-modifying therapies (DMTs) (64.9%), while 19.9% were on no DMTs. About one third of respondents (32.9%) had had two doses, 20.8% had received their first dose, and 22.1% were unvaccinated, while 24.2% of responses were missing. When asked about vaccine intentions, 60.6% of the unvaccinated indicated they were likely to extremely likely to get vaccinated, while 15.2% were very unlikely or extremely unlikely to do so and 24.2% were undecided. Unvaccinated people were significantly more concerned about vaccine side effects (mean 5.3 versus 3.1/10; p < .001). Only 53.3% of people on DMTs were vaccinated, compared to 75% of those who were not. People on ocrelizumab therapy (n = 35) had a lower vaccination rate (39%) than those on other medications (n = 86, 59%). Vaccine willingness in the unvaccinated was most highly correlated with knowledge regarding the vaccine (r_s²=.709), agreement with the statement that COVID-19 vaccination is “too new for me to be confident about getting vaccinated” (r_s²= -.709), anticipation of regret due to side effects of vaccination (r_s²= -.642), and lack of knowledge regarding interactions between COVID-19 vaccines and DMTs (r_s²= -.570).

Almost two thirds had read MS-specific information about COVID-19 vaccinations and found it easy to understand (67.6%) and applicable to their situation (53.6%). However, less than half (47.8%) reported the information helped them make a personal vaccination decision. Over two-thirds (64.9%) had discussed vaccinations with their healthcare professional and 31.1% had not. Those who had not, were significantly more uninformed about the interactions of the vaccine with MS medications (mean 3.9 versus 2.9/10; p = .044) and significantly lower intention of vaccine uptake than those who had (mean 5.8 versus 7.9/10; p = .009).

Conclusion

Our study highlights that vaccination efforts should be delivered by healthcare professionals, focus on educating those who are managed with DMTs, and include individual recommendations related to specific DMTs, how the vaccines work, expectations regarding potential side-effects, potential exacerbation of MS symptoms, likelihood of recovery from any exacerbation, and the relative risks of side effects versus COVID-19 infection. Specific recommendations are provided.

Gait stability reflects motor tracts damage at early stages of multiple sclerosis

Background:

Gait in people with multiple sclerosis (PwMS) is affected even when no changes can be observed on clinical examination. A sensitive measure of gait deterioration is stability; however, its correlation with motor tract damage has not yet been established.

Objective:

To compare stability between PwMS and healthy controls (HCs) and determine associations between stability and diffusion magnetic resonance image (MRI) measures of axonal damage in selected sensorimotor tracts.

Methods:

Twenty-five PwMS (Expanded Disability Status Scale (EDSS) < 2.5) and 15 HCs walked on a treadmill. Stability from sacrum (LDESAC), shoulder (LDESHO) and cervical (LDECER) was calculated using the local divergence exponent (LDE). Participants underwent a 7T-MRI brain scan to obtain fibre-specific measures of axonal loss within the corticospinal tract (CST), interhemispheric sensorimotor tract (IHST) and cerebellothalamic tract (CTT). Correlation analyses between LDE and fibre density (FD) within tracts, fibre cross-section (FC) and FD modulated by FC (FDC) were conducted. Between-groups LDE differences were analysed using analysis of variance (ANOVA).

Results:

Correlations between all stability measures with CSTFD, between CSTFDC with LDESAC and LDECER, and LDECER with IHSTFD and IHSTFDC were significant yet moderate ( R < −0.4). Stability was significantly different between groups.

Conclusions:

Poorer gait stability is associated with corticospinal tract (CST) axonal loss in PwMS with no-to-low disability and is a sensitive indicator of neurodegeneration.

Prevention of work-related musculoskeletal disorders among dental professionals: A scoping review

BACKGROUND: Musculoskeletal disorders (MSDs) are highly prevalent among dental professionals. Studies examining the prevention of dental work-related MSDs have been completed globally. OBJECTIVE: To identify and evaluate the available evidence regarding MSD prevention in dental practice, and to identify knowledge gaps. METHODS: An electronic search was conducted across multiple scientific databases. Identified articles were assessed according to inclusion/exclusion criteria. Systematic reviews, interventions and published expert opinion were included. RESULTS: Five systematic reviews, 27 intervention studies and 21 expert opinion articles were included. There was overall consensus that use of ergonomic equipment is beneficial in MSD prevention. Knowledge gaps identified included: a lack of systematic reviews on the role of exercise and therapy in MSD prevention; a lack of high-quality intervention studies; a lack of research in general outside of ergonomic equipment use. Expert opinion articles have been published despite a lack of dental-specific research. CONCLUSIONS: Whilst more robust research is required, current evidence supports the use of optical enhancement, saddle chairs, and wide-diameter silicone-handled instruments in MSD prevention. Knowledge gaps were identified relating to the use of exercise, therapy, and education in the prevention of dental work-related MSDs. Further research is required, specifically high-quality intervention studies.

Transfer of the supinator nerve to the posterior interosseous nerve for hand opening in tetraplegia through an anterior approach

We report a retrospective series of 44 transfers in 26 patients in whom a functioning supinator nerve was transferred to a paralyzed posterior interosseous nerve through a single, anterior approach to re-animate hand opening in mid-cervical tetraplegia. Eighteen patients underwent concurrent nerve or tendon transfers to re-animate grasp and/or pinch through the same anterior incision. We evaluated the strength of the innervated muscle at mean follow-up of 24 months (range 12-27). The strength attained in our patients was equivalent to the strength after the transfer through a posterior approach reported in the literature. Nineteen of our patients were satisfied with the hand opening procedure. First webspace opening was the only variable to correlate with patient satisfaction. We conclude that the anterior approach yields similar results to the posterior approach and has the advantage of allowing easier access for simultaneously performing nerve or tendon transfers to reconstruct grasp and pinch.Level of evidence: IV.

The Effect of Transcranial Direct Current Stimulation on Chronic Neuropathic Pain in Patients with Multiple Sclerosis: Randomized Controlled Trial

OBJECTIVE

Chronic neuropathic pain is a common symptom in multiple sclerosis (MS). This randomized controlled single-blinded study investigated whether a new protocol involving five days of transcranial direct current stimulation (tDCS) with an interval period would be effective to reduce pain using the visual analog scale (VAS). Other secondary outcomes included the Neuropathic Pain Scale (NPS), Depression Anxiety Stress Score (DASS), Short Form McGill Pain Questionnaire (SFMPQ), and Multiple Sclerosis Quality of Life 54 (MSQOL54).

DESIGN

A total of 30 participants were recruited for the study, with 15 participants randomized to a sham group or and 15 randomized to an active group. After a five-day course of a-tDCS, VAS and NPS scores were measured daily and then weekly after treatment up to four weeks after treatment. Secondary outcomes were measured pretreatment and then weekly up to four weeks.

RESULTS

After a five-day course of a-tDCS, VAS scores were significantly reduced compared with sham tDCS and remained significantly low up to week 2 post-treatment. There were no statistically significant mean changes in MSQOL54, SFMPQ, NPS, or DASS for the sham or treatment group before treatment or at four-week follow-up.

CONCLUSIONS

This study shows that repeated stimulation with a-tDCS for five days can reduce pain intensity for a prolonged period in patients with MS who have chronic neuropathic pain.

Does respiratory muscle training improve respiratory function compared to sham training, no training, standard treatment or breathing exercises in children and adults with neuromuscular disease? A Cochrane Review summary with commentary

BACKGROUND

Progressive muscle weakness is a feature of neuromuscular diseases (NMDs), a heterogeneous group of conditions with variable onset, presentation and prognosis that affect both children and adults. Respiratory muscle weakness compromises respiratory function and may lead to respiratory failure.

OBJECTIVE

To assess the effects of respiratory muscle training (RMT) in adults and children with NMD.

METHODS

A Cochrane Review by Silva et al. was summarized with comments.

RESULTS

Eleven studies involving 250 randomized participants with NMD were included. While the studies showed that RMT may lead to improvements in lung function and respiratory muscle strength in people with ALS and DMD, this was not a consistent finding. The evidence from all the included trials was of low or very low certainty.

CONCLUSIONS

There may be some improvement in lung capacity and respiratory muscle strength following RMT in some NMD. There appears to be no clinically meaningful effect of RMT on physical functioning and quality of life in ALS. The low certainty of the evidence means that the results need to be interpreted with caution.

Axonal loss in major sensorimotor tracts is associated with impaired motor performance in minimally disabled multiple sclerosis patients

Multiple sclerosis is a neuroinflammatory disease of the CNS that is associated with significant irreversible neuro-axonal loss, leading to permanent disability. There is thus an urgent need for in vivo markers of axonal loss for use in patient monitoring or as end-points for trials of neuroprotective agents. Advanced diffusion MRI can provide markers of diffuse loss of axonal fibre density or atrophy within specific white matter pathways. These markers can be interrogated in specific white matter tracts that underpin important functional domains such as sensorimotor function. This study aimed to evaluate advanced diffusion MRI markers of axonal loss within the major sensorimotor tracts of the brain, and to correlate the degree of axonal loss in these tracts to precise kinematic measures of hand and foot motor control and gait in minimally disabled people with multiple sclerosis. Twenty-eight patients (Expanded Disability Status Scale < 4, and Kurtzke Functional System Scores for pyramidal and cerebellar function ≤ 2) and 18 healthy subjects underwent ultra-high field 7 Tesla diffusion MRI for calculation of fibre-specific measures of axonal loss (fibre density, reflecting diffuse axonal loss and fibre cross-section reflecting tract atrophy) within three tracts: cortico-spinal tract, interhemispheric sensorimotor tract and cerebello-thalamic tracts. A visually guided force-matching task involving either the hand or foot was used to assess visuomotor control, and three-dimensional marker-based video tracking was used to assess gait. Fibre-specific axonal markers for each tract were compared between groups and correlated with visuomotor task performance (force error and lag) and gait parameters (stance, stride length, step width, single and double support) in patients. Patients displayed significant regional loss of fibre cross-section with minimal loss of fibre density in all tracts of interest compared to healthy subjects (family-wise error corrected p-value < 0.05), despite relatively few focal lesions within these tracts. In patients, reduced axonal fibre density and cross-section within the corticospinal tracts and interhemispheric sensorimotor tracts were associated with larger force tracking error and gait impairments (shorter stance, smaller step width and longer double support) (family-wise error corrected p-value < 0.05). In conclusion, significant gait and motor control impairments can be detected in minimally disabled people with multiple sclerosis that correlated with axonal loss in major sensorimotor pathways of the brain. Given that axonal loss is irreversible, the combined use of advanced imaging and kinematic markers could be used to identify patients at risk of more severe motor impairments as they emerge for more aggressive therapeutic interventions.

Functional correlates of motor control impairments in multiple sclerosis: A 7 Tesla task functional MRI study

Upper and lower limb impairments are common in people with multiple sclerosis (pwMS), yet difficult to clinically identify in early stages of disease progression. Tasks involving complex motor control can potentially reveal more subtle deficits in early stages, and can be performed during functional MRI (fMRI) acquisition, to investigate underlying neural mechanisms, providing markers for early motor progression. We investigated brain activation during visually guided force matching of hand or foot in 28 minimally disabled pwMS (Expanded Disability Status Scale (EDSS) < 4 and pyramidal and cerebellar Kurtzke Functional Systems Scores ≤ 2) and 17 healthy controls (HC) using ultra‐high field 7‐Tesla fMRI, allowing us to visualise sensorimotor network activity in high detail. Task activations and performance (tracking lag and error) were compared between groups, and correlations were performed. PwMS showed delayed (+124 s, p = .002) and more erroneous (+0.15 N, p = .001) lower limb tracking, together with lower cerebellar, occipital and superior parietal cortical activation compared to HC. Lower activity within these regions correlated with worse EDSS (p = .034), lower force error (p = .006) and higher lesion load (p < .05). Despite no differences in upper limb task performance, pwMS displayed lower inferior occipital cortical activation. These results demonstrate that ultra‐high field fMRI during complex hand and foot tracking can identify subtle impairments in lower limb movements and upper and lower limb brain activity, and differentiates upper and lower limb impairments in minimally disabled pwMS.

Heterogeneity in microstructural deterioration following spinal cord injury

BACKGROUND

Modelling and remodelling adapt bone morphology to accommodate strains commonly encountered during loading. If strains exceed a threshold threatening fracture, modelling-based bone formation increases bone volume reducing these strains. If unloading reduces strains below a threshold that inhibits resorption, increased remodelling-based bone resorption reduces bone volume restoring strains, but at the price of compromised bone volume and microstructure. As weight-bearing regions are adapted to greater strains, we hypothesized that microstructural deterioration will be more severe than at regions commonly adapted to low strains following spinal cord injury.

METHODS

We quantified distal tibial, fibula and radius volumetric bone mineral density (vBMD) using high-resolution peripheral quantitative computed tomography in 31 men, mean age 43.5 years (range 23.5-75.0), 12 with tetraplegia and 19 with paraplegia of 0.7 to 18.6 years duration, and 102 healthy age- and sex-matched controls. Differences in morphology relative to controls were expressed as standardized deviation (SD) scores (mean ± SD). Standardized between-region differences in vBMD were expressed as SDs (95% confidence intervals, CI).

RESULTS

Relative to controls, men with tetraplegia had deficits in total vBMD of -1.72 ± 1.38 SD at the distal tibia (p < 0.001) and - 0.68 ± 0.69 SD at distal fibula (p = 0.041), but not at the distal radius, despite paralysis. Deficits in men with paraplegia were -2.14 ± 1.50 SD (p < 0.001) at the distal tibia and -0.83 ± 0.98 SD (p = 0.005) at the distal fibula while distal radial total vBMD was 0.23 ± 1.02 (p = 0.371), not significantly increased, despite upper limb mobility. Comparing regions, in men with tetraplegia, distal tibial total vBMD was 1.04 SD (95%CI 0.07, 2.01) lower than at the distal fibula (p = 0.037) and 1.51 SD (95%CI 0.45, 2.57) lower than at the distal radius (p = 0.007); the latter two sites did not differ from each other. Results were similar in men with paraplegia, but total vBMD at the distal fibula was 1.06 SD (95%CI 0.35, 1.77) lower than at the distal radius (p = 0.004).

CONCLUSION

Microarchitectural deterioration following spinal cord injury is heterogeneous, perhaps partly because strain thresholds regulating the cellular activity of mechano-transduction are region specific.

Using the Technology Acceptance Model to Identify Factors That Predict Likelihood to Adopt Tele-Neurorehabilitation

Tele-neurorehabilitation has the potential to reduce accessibility barriers and enhance patient outcomes through a more seamless continuum of care. A growing number of studies have found that tele-neurorehabilitation produces equivalent results to usual care for a variety of outcomes including activities of daily living and health related quality of life. Despite the potential of tele-neurorehabilitation, this model of care has failed to achieve mainstream adoption. Little is known about feasibility and acceptability of tele-neurorehabilitation and most published studies do not use a validated model to guide and evaluate implementation. The technology acceptance model (TAM) was developed 20 years ago and is one of the most widely used theoretical frameworks for predicting an individual's likelihood to adopt and use new technology. The TAM3 further built on the original model by incorporating additional elements from human decision making such as computer anxiety. In this perspective, we utilize the TAM3 to systematically map the findings from existing published studies, in order to explore the determinants of adoption of tele-neurorehabilitation by both stroke survivors and prescribing clinicians. We present evidence suggesting that computer self-efficacy and computer anxiety are significant predictors of an individual's likelihood to use tele-neurorehabilitation. Understanding what factors support or hinder uptake of tele-neurorehabilitation can assist in translatability and sustainable adoption of this technology. If we are to shift tele-neurorehabilitation from the research domain to become a mainstream health sector activity, key stakeholders must address the barriers that have consistently hindered adoption.

Evaluating Rehabilitation Progress Using Motion Features Identified by Machine Learning

Evaluating progress throughout a patient's rehabilitation episode is critical for determining the effectiveness of the selected treatments and is an essential ingredient in personalised and evidence-based rehabilitation practice. The evaluation process is complex due to the inherently large human variations in motor recovery and the limitations of commonly used clinical measurement tools. Information recorded during a robot-assisted rehabilitation process can provide an effective means to continuously quantitatively assess movement performance and rehabilitation progress. However, selecting appropriate motion features for rehabilitation evaluation has always been challenging. This paper exploits unsupervised feature learning techniques to reduce the complexity of building the evaluation model of patients' progress. A new feature learning technique is developed to select the most significant features from a large amount of kinematic features measured from robotics, providing clinically useful information to health practitioners with reduction of modeling complexity. A novel indicator that uses monotonicity and trendability is proposed to evaluate kinematic features. The data used to develop the feature selection technique consist of kinematic data from robot-aided rehabilitation for a population of stroke patients. The selected kinematic features allow for human variations across a population of patients as well as over the sequence of rehabilitation sessions. The study is based on data records pertaining to 41 stroke patients using three different robot assisted exercises for upper limb rehabilitation. Consistent with the literature, the results indicate that features based on movement smoothness are the best measures among 17 kinematic features suitable to evaluate rehabilitation progress.

Speech metrics, general disability, brain imaging and quality of life in multiple sclerosis

BACKGROUND AND PURPOSE

Objective measurement of speech has shown promising results to monitor disease state in multiple sclerosis. In this study, we characterize the relationship between disease severity and speech metrics through perceptual (listener based) and objective acoustic analysis. We further look at deviations of acoustic metrics in people with no perceivable dysarthria.

METHODS

Correlations and regression were calculated between speech measurements and disability scores, brain volume, lesion load and quality of life. Speech measurements were further compared between three subgroups of increasing overall neurological disability: mild (as rated by the Expanded Disability Status Scale ≤2.5), moderate (≥3 and ≤5.5) and severe (≥6).

RESULTS

Clinical speech impairment occurred majorly in people with severe disability. An experimental acoustic composite score differentiated mild from moderate (P < 0.001) and moderate from severe subgroups (P = 0.003), and correlated with overall neurological disability (r = 0.6, P < 0.001), quality of life (r = 0.5, P < 0.001), white matter volume (r = 0.3, P = 0.007) and lesion load (r = 0.3, P = 0.008). Acoustic metrics also correlated with disability scores in people with no perceivable dysarthria.

CONCLUSIONS

Acoustic analysis offers a valuable insight into the development of speech impairment in multiple sclerosis. These results highlight the potential of automated analysis of speech to assist in monitoring disease progression and treatment response.

Comparison of segmental lean tissue mass in individuals with spinal cord injury measured by dual energy X-ray absorptiometry and predicted by bioimpedance spectroscopy

STUDY DESIGN

Observational.

OBJECTIVES

To compare two methods for predicting segmental (arms, legs, trunk) lean tissue mass (LTM: non-bone fat-free mass) from bioimpedance spectroscopy (BIS) against LTM measured from dual energy X-ray absorptiometry (DXA) in individuals with acute spinal cord injury (SCI).

SETTING

Austin Health Victorian Spinal Cord Service, Victoria, Australia.

METHODS

Fourteen participants (two female), within 8 weeks of traumatic SCI had BIS measured following an overnight fast and within 24 h of DXA scanning. Total body fat-free mass (FFM, body weight minus fat mass) and segmental LTM were predicted from BIS using manufacturer's proprietary software and a previously established SCI-specific prediction method. Appendicular LTM (ALM) was calculated from the sum of the LTM of the arms and legs. Agreement and strength of relationships with DXA for predicted LTM measures using both approaches were assessed using Lin's concordance coefficient and limits of agreement analysis (LOA).

RESULTS

The BIS proprietary method performed better than the SCI-specific prediction method in predicting DXA LTM, demonstrating substantial concordance for total body FFM (rc = 0.80), ALM (rc = 0.78), arm (rc = 0.76) and leg LTM (rc = 0.65) and a smaller bias and LOA for ALM (+0.8 vs. -3.4 kg; LOA -4.9-6.4 vs. -11.9-5.1 kg), arm (+0.02 vs. -0.3 kg; LOA -1.1-1.1 kg vs. -2.2-1.6 kg) and leg (+0.4 vs. -1.4 kg; LOA -2.0-2.8 vs. -5.6-2.8) LTM.

CONCLUSIONS

BIS can be used to accurately predict total body FFM, segmental LTM and ALM in individuals with acute SCI.

Multidisciplinary rehabilitation in persons with multiple trauma: A systematic review

OBJECTIVE

To determine the effectiveness of multidisciplinary rehabilitation in improving functional and psychological outcomes in person with multiple trauma.

DATE SOURCES

A comprehensive literature review was conducted using medical and health science electronic databases up to February 2019.

DATA EXTRACTION

Two independent reviewers selected studies, extracted data and assessed study quality using the Critical Appraisal Skills Programme (CASP) checklists and Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

DATA SYNTHESIS

One randomized controlled trial, 1 clinical controlled trial and 4 observational studies (1 with 2 reports) were included. Qualitative analysis was used to synthesize the evidence due to the heterogeneity of included trials. The quality of the studies varied (CASP approach); the majority were of "low quality". The findings suggest "very low to moderate" evidence (GRADE) for the effectiveness of multidisciplinary rehabilitation in improving functional ability and participation. The majority of studies (n = 6) reported functional improvements after multidisciplinary rehabilitation in the short-term.

CONCLUSION

The lack of "high-quality" evidence for multidisciplinary rehabilitation in improving outcomes following trauma highlights gaps in the available evidence, signifying the need for more robust studies.

Promoting clinical best practice in a user-centred design study of an upper limb rehabilitation robot

Purpose: Despite their promise to increase therapy intensity in neurorehabilitation, robotic devices have not yet seen mainstream adoption. Whilst there are a number of contributing factors, it is obvious that the treating clinician should have a clear understanding of the objectives and limitations of robotic device use. This study sought to explore how devices can be developed to support a clinician in providing clinical best practice.Methods and Materials: A user-centred design study of a robotic device was conducted, involving build-then-use iterations, where successive iterations are built based on feedback from the use cycle. This work reports results of an analysis of qualitative and quantitative data describing the use of the robotic device in the clinical sessions, and from a focus group with the treating clinicians.Results and Conclusions: The data indicated that use of the device did not result in patient goal-setting and may have resulted in poor movement quality. Therapists expected a higher level of autonomy from the robotic device, and this may have contributed to the above problems. These problems can and should be addressed through modification of both the study design and device to provide more explicit instructions to promote clinical best practice.IMPLICATIONS FOR REHABILITATIONEncouraging clinical best practice when using evaluating prototype devices within a clinical setting is important to ensure that best practice is maintained - and can be achieved through both study and device designSupport from device developers can significantly improve the confidence of therapists during the use of that device in rehabilitation, particularly with new or prototype devicesEnd effector-based robotic devices for rehabilitation show potential for a wide variety of patient presentations and capabilities.

Gait stability at early stages of multiple sclerosis using different data sources

BACKGROUND

People at early stages of multiple sclerosis have subtle balance problems that may affect gait stability. However, differences in methods of determining stability such as sensor type and placements, may lead to different results and affect their interpretation when comparing to controls and other studies.

QUESTIONS

Do people with multiple sclerosis (PwMS) exhibit lower gait stability? Do location and type of data used to calculate stability metrics affect comparisons?

METHODS

30 PwMS with no walking impairments as clinically measured and 15 healthy controls walked on a treadmill at 1.2 ms^-1 while 3D acceleration data was obtained from sacrum, shoulder and cervical markers and from an accelerometer placed at the sacrum. The local divergence exponent was calculated for the four data sources. An ANOVA with group (multiple sclerosis and control) and data source as main factors was used to determine the effect of disease, data source and their interaction on stability metrics.

RESULTS

PwMS walked with significantly less stability according to all sensors (no interaction). A significant effect of data source on stability was also found, indicating that the local divergence exponent derived from sacrum accelerometer was lower than that derived from the other 3 sensor locations.

SIGNIFICANCE

PwMS with no evident gait impairments are less stable than healthy controls when walking on a treadmill. Although different data sources can be used to determine MS-related stability deterioration, a consensus about location and data source is needed. The local divergence exponent can be a useful measure of progression of gait instability at early stages of MS.

Increased ankle muscle coactivation in the early stages of multiple sclerosis

Background

Neural damage at early stages of multiple sclerosis (MS) can subtly affect gait muscle activation patterns. Detecting these changes using current clinical tools, however, is not possible. We propose using muscle coactivation measures to detect these subtle gait changes. This may also help in identifying people with MS (PwMS) that may benefit from strategies aimed at preventing further mobility impairments.

Objective

We aimed to determine if coactivation of ankle muscles during gait is greater in PwMS with Expanded Disability Status Scale (EDSS) score <3.5. A secondary aim is to determine whether coactivation increases are speed dependent.

Methods

For this study 30 PwMS and 15 healthy controls (HC) walked on a treadmill at 1.0 m/s, 1.2 m/s and 1.4 m/s. Electromyography was recorded from the tibialis anterior (TA), soleus (SO) and lateral gastrocnemius (LG). The coactivation index was calculated between SO/TA and LG/TA. Ankle kinematics data were also collected.

Results

Compared with HC, PwMS exhibited significantly greater SO/TA and LG/TA coactivation, which was greater during early stance and swing phases (p < .01). Speed did not affect coactivation except during early stance. Ankle kinematic changes were also observed.

Conclusion

PwMS exhibited greater ankle muscles coactivation than controls regardless of the speed of walking. These changes in muscle activation may serve as a biomarker of neurodegeneration occurring at early stages of the disease.

High-Level Mobility Assessment Tool Normative Values for Children

BACKGROUND

Physical therapists need to be able to evaluate high-level gross motor skills of children to determine their capacity to engage in activities such as running, jumping, hopping, and stair climbing. The High-Level Mobility Assessment Tool (HiMAT) has excellent interrater and retest reliability and is less susceptible to a ceiling effect than existing mobility scales in children who are 6 to 17 years old and have traumatic brain injury.

OBJECTIVE

The purposes of this study were to develop normative HiMAT score ranges for Australian children and to investigate the relationship between children's HiMAT scores and their age, height, weight, and body mass index (BMI).

DESIGN

This study used a cross-sectional design.

METHODS

Children included in this study were 5 to 12 years old, had no condition affecting their mobility, could follow 2-stage instructions, and had written informed consent from their parent or guardian. A total 1091 children were assessed at their local school, where their height, weight, and HiMAT score were recorded. The relationships between children's age, height, weight, and BMI were summarized using Spearman rank correlations. Truncated regression models were used to determine the most appropriate predictor variable for developing sex-specific normative ranges.

RESULTS

There was a positive correlation between children's HiMAT scores and their age, height, weight, and BMI. Age explained the most variability in HiMAT scores for both boys and girls.

LIMITATIONS

The reliability, validity, and responsiveness of the HiMAT have not been tested across a broad range of children with mobility limitations. Normative data reported in this study are for Australian children only.

CONCLUSIONS

HiMAT scores for children in this study increased with age, height, weight, and BMI. Age was the most appropriate variable for developing a normative dataset of HiMAT scores for children of primary school age.

Interdisciplinary management for chronic pain in central neurological disorders: a retrospective study

Background/aims

Chronic pain in central neurological disorders is common and the current management of chronic pain is through an interdisciplinary approach. The aim of this study was to compare outpatient interdisciplinary-based treatment for chronic pain in patients with central neurological disorders to those without central neurological disorders.

Methods

This was a retrospective study and pain-related outcome measures were collected from a clinical outcomes registry (electronic Persistent Pain Outcomes Collaboration). This registry contained data on people who attended a pain management service who, for the purpose of this study, were categorised into those with a central neurological disorder and those without a central neurological disorder. The two sample t-test was used to determine the significance of the difference between the groups and statistical significance was defined as P<0.05. Outcome measures compared included the Brief Pain Inventory, Depression, Anxiety and Stress Scale 21, Patient Self-efficacy Questionnaire and Patient Catastrophisation Scale.

Results

There was a total of 1924 participants with a central neurological disorder. The electronic Persistent Pain Outcomes Collaboration registry shows that after engagement with an interdisciplinary pain management service, there was a reduction in pain severity scores, interference, mean depression, anxiety and stress in both groups at end of an episode of care compared to referral. There was a significant difference in mean changes for pain catastrophising between those with a central neurological disorder (−10.3) and those without (−7.8).

Conclusions

This study shows that people with central neurological disorders can also benefit from interdisciplinary management and have similar results to those without these conditions.

Evaluation of a technology-assisted enriched environmental activities programme for upper limb function: A randomized controlled trial

OBJECTIVE

To evaluate the effectiveness and feasibility of an intensive technology-assisted inpatient enriched environmental programme for upper limb function.

METHODS

Patients consecutively admitted to the rehabilitation unit randomly allocated to an intervention (enriched environmental programme, n = 46)) or a control group (usual ward activity, n = 46). Assessments were performed at baseline (T0), discharge (T1) and 3 months (T2) using validated measures.

RESULTS

At T1, the enriched environmental group showed significant improvement in upper limb func-tion, compared with the control group: Action Research Arm Test (ARAT) "Total" (p = 0.002), and "Grip", "Pinch" and "Gross" subscales (p < 0.05 for all), with small effect size = 0.04-0.16. Most participants in the enriched environmental group had clinically significant improvement > 5.7 points on the ARAT "Total" compared with the control group (83% vs 44%, p < 0.001). Participants in the enriched environmental group were more involved in various forms of activities during waking hours. At T2, despite no significant between-group difference in ARAT scores, the majority of participants in the enriched environmental group maintained the improvement (> 5.7 points) on ARAT "Total" compared with the control group (91% vs 61%, p = 0.001). Both groups improved in other measures at both T1 and T2.

CONCLUSION

An enriched environmental programme was feasible and effective in improving upper limb function and increasing the activity of patients during their inpatient subacute care.

Multidimensional evaluation of changes in limb function following botulinum toxin injection in persons with stroke

BACKGROUND

There are limited evidence of instrumented measures of gait and balance to determine the functional effects of botulinum toxin injections (BoNT-A) in spasticity after stroke.

OBJECTIVE

To evaluate the functional changes in gait and balance following upper limb and lower limb BoNT-A in persons with stroke.

METHODS

A pre-post prospective study of 35 stroke patients with upper and/or lower limb spasticity after focal treatment with BoNT-A. Assessments were at baseline (T0), 6-weeks (T1) and 12-weeks (T2), using validated subjective and objective physical activity measures.

RESULTS

After BoNT-A injections, significant improvements in most measures of impairments, activity and participation domains were found at T1 (p < 0.05, effect sizes (r) = 0.5-0.9). There was a significant increase in low intensity physical activity (at T1) and sedentary time reductions at both follow-up periods. Instrumented gait/balance measures showed a significant increase in cadence and turn velocity, but no changes in sway measures were found using posturography. Improvements in most outcome measures were maintained at 12-weeks.

CONCLUSION

BONT-A improved scores in most clinical measures but only in some of the objective gait/balance and physical activity measures. Further robust studies should utilize a larger sample size to better determine the benefits of BoNT-A for stroke-related spasticity.

Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series

BACKGROUND

Loss of upper extremity function after cervical spinal cord injury greatly affects independence, including social, vocational, and community engagement. Nerve transfer surgery offers an exciting new option for the reanimation of upper limb function in tetraplegia. The aim of this study was to evaluate the outcomes of nerve transfer surgery used for the reanimation of upper limb function in tetraplegia.

METHODS

In this prospective case series, we consecutively recruited people of any age with early (<18 months post-injury) cervical spinal cord injury of motor level C5 and below, who had been referred to a single centre for upper extremity reanimation and were deemed suitable for nerve transfer. All participants underwent single or multiple nerve transfers in one or both upper limbs, sometimes combined with tendon transfers, for restoration of elbow extension, grasp, pinch, and hand opening. Participants were assessed at 12 months and 24 months post-surgery. Primary outcome measures were the action research arm test (ARAT), grasp release test (GRT), and spinal cord independence measure (SCIM).

FINDINGS

Between April 14, 2014, and Nov 22, 2018, we recruited 16 participants (27 limbs) with traumatic spinal cord injury, among whom 59 nerve transfers were done. In ten participants (12 limbs), nerve transfers were combined with tendon transfers. 24-month follow-up data were unavailable for three patients (five limbs). At 24 months, significant improvements from baseline in median ARAT total score (34·0 [IQR 24·0-38·3] at 24 months vs 16·5 [12·0-22·0] at baseline, p<0·0001) and GRT total score (125·2 [65·1-154·4] vs 35·0 [21·0-52·3], p<0·0001) were observed. Mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference, and the mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months. Median Medical Research Council strength grades were 3 (IQR 2-3) for triceps and 4 (IQR 4-4) for digital extensor muscles after 24 months. Mean grasp strength at 24 months was 3·2 kg (SD 1·5) in participants who underwent distal nerve transfers (n=5), 2·8 kg (3·2) in those who had proximal nerve transfers (n=9), and 3·9 kg (2·4) in those who had tendon transfers (n=8). There were six adverse events related to the surgery, none of which had any ongoing functional consequences.

INTERPRETATION

Early nerve transfer surgery is a safe and effective addition to surgical techniques for upper limb reanimation in tetraplegia. Nerve transfers can lead to significant functional improvement and can be successfully combined with tendon transfers to maximise functional benefits.

FUNDING

Institute for Safety, Compensation, and Recovery Research (Australia).

Real-time foot clearance biofeedback to assist gait rehabilitation following stroke: a randomized controlled trial protocol

Background

The risk of falling is significantly higher in people with chronic stroke and it is, therefore, important to design interventions to improve mobility and decrease falls risk. Minimum toe clearance (MTC) is the key gait cycle event for predicting tripping-falls because it occurs mid-swing during the walking cycle where forward velocity of the foot is maximum.

High forward velocity coupled with low MTC increases the probability of unanticipated foot-ground contacts. Training procedures to increase toe-ground clearance (MTC) have potential, therefore, as a falls-prevention intervention. The aim of this project is to determine whether augmented sensory information via real-time visual biofeedback during gait training can increase MTC.

Methods

Participants will be aged > 18 years, have sustained a single stroke (ischemic or hemorrhagic) at least six months previously, able to walk 50 m independently, and capable of informed consent. Using a secure web-based application (REDCap), 150 participants will be randomly assigned to either no-feedback (Control) or feedback (Experimental) groups; all will receive 10 sessions of treadmill training for up to 10 min at a self-selected speed over 5–6 weeks. The intervention group will receive real-time, visual biofeedback of MTC during training and will be asked to modify their gait pattern to match a required “target” criterion. Biofeedback is continuous for the first six sessions then progressively reduced (faded) across the remaining four sessions. Control participants will walk on the treadmill without biofeedback. Gait assessments are conducted at baseline, immediately following the final training session and then during follow-up, at one, three, and six months. The primary outcome measure is MTC. Monthly falls calendars will also be collected for 12 months from enrolment.

Discussion

The project will contribute to understanding how stroke-related changes to sensory and motor processes influence gait biomechanics and associated tripping risk. The research findings will guide our work in gait rehabilitation following stroke and may reduce falls rates. Treadmill training procedures incorporating continuous real-time feedback may need to be modified to accommodate stroke patients who have greater difficulties with treadmill walking.

Trial registration

Australia New Zealand Clinical Trials Registry, ACTRN12617000250336. Registered on 17 February 2017.

A Human Sensory Pathway Connecting the Foot to Ipsilateral Face That Partially Bypasses the Spinal Cord

Human sensory transmission from limbs to brain crosses and ascends through the spinal cord. Yet, descriptions exist of ipsilateral sensory transmission as well as transmission after spinal cord transection. To elucidate a novel ipsilateral cutaneous pathway, we measured facial perfusion following painfully-cold water foot immersion in 10 complete spinal cord-injured patients, 10 healthy humans before and after lower thigh capsaicin C-fiber cutaneous conduction blockade, and 10 warm-immersed healthy participants. As in healthy volunteers, ipsilateral facial perfusion in spinal cord injured patients increased significantly. Capsaicin resulted in contralateral increase in perfusion, but only following cold immersion and not in 2 spinal cord-injured patients who underwent capsaicin administration. Supported by skin biopsy results from a healthy participant, we speculate that the pathway involves peripheral C-fiber cross-talk, partially bypassing the cord. This might also explain referred itch and jogger's migraine and it is possible that it may be amenable to training spinal-injured patients to recognize lower limb sensory stimuli.

Challenges and barriers for implementation of the World Health Organization Global Disability Action Plan in low- and middle- income countries

OBJECTIVE

To identify potential barriers and facilitators for implementation of the World Health Organization Global Disability Action Plan (GDAP) in Nigeria and compare these with other low- and middle-income countries.

METHODS

A rehabilitation team from the Royal Melbourne Hospital, Parkville, Australia, conducted intensive workshops at medical/academic institutions in Nigeria for healthcare professionals from various local Physical Medicine and Rehabilitation facilities. A modified Delphi method identified challenges for person with disability, using 3 GDAP objectives. Findings were compared with similar exercises in Madagascar, Pakistan and Mongolia.

RESULTS

Despite differences in the healthcare system and practice, the challenges reported in Nigeria were similar to those in other 3 low- and middle-income countries, at both macro (governmental/policymakers) and micro levels (community/social/individual). Common challenges identified were: limited knowledge of disability services, limited Physical Medicine and Rehabilitation workforce, guidelines and accreditation standards; coordination amongst healthcare sectors; social issues; data and research; legislation and political commitment. Common potential facilitators included: need for strong leadership; advocacy of disability-inclusive development; investment in infrastructure/human resources; coordination/partnerships in healthcare sector; and research.

CONCLUSION

Disability care is an emerging priority in low- and middle-income countries to address the needs of people with disability. The challenges identified in Nigeria are common to most low- and middle-income countries. The GDAP framework can facilitate access and strengthen Physical Medicine and Rehabilitation services.

SCIPA Full-On: A Randomized Controlled Trial Comparing Intensive Whole-Body Exercise and Upper Body Exercise After Spinal Cord Injury

Background. While upper body training has been effective for improving aerobic fitness and muscle strength after spinal cord injury (SCI), activity-based therapies intended to activate the paralyzed extremities have been reported to promote neurological improvement. Objective. To compare the effectiveness of intensive whole-body exercise compared with upper body exercise for people with chronic SCI. Methods. A parallel-group randomized controlled trial was conducted. Participants with a range of SCI levels and severity were randomized to either full-body exercise (FBE) or upper body exercise (UBE) groups (3 sessions per week over 12 weeks). FBE participants underwent locomotor training, functional electrical stimulation-assisted leg cycling, and trunk and lower extremity exercises, while UBE participants undertook upper body strength and aerobic fitness training only. The primary outcome measure was the American Spinal Injury Association (ASIA) motor score for upper and lower extremities. Adverse events were systematically recorded. Results. A total of 116 participants were enrolled and included in the primary analysis. The adjusted mean between-group difference was −0.04 (95% CI −1.12 to 1.04) for upper extremity motor scores, and 0.90 (95% CI −0.48 to 2.27) for lower extremity motor scores. There were 15 serious adverse events in UBE and 16 in FBE, but only one of these was definitely related to the experimental intervention (bilateral femoral condyle and tibial plateau subchondral fractures). No significant between-group difference was found for adverse events, or functional or behavioral variables. Conclusions. Full-body training did not lead to improved ASIA motor scores compared with upper body training in people with chronic SCI.

World Health Organization Global Disability Action Plan: The Mongolian Perspective

OBJECTIVE

To provide an update on disability and rehabilitation in Mongolia, and to identify potential barriers and facilitators for implementation of the World Health Organization (WHO) Global Disability Action Plan (GDAP).

METHODS

A 4-member rehabilitation team from the Royal Melbourne Hospital conducted an intensive 6-day workshop at the Mongolian National University of Medical Sciences, for local healthcare professionals (n = 77) from medical rehabilitation facilities (urban/rural, public/private) and non-governmental organizations. A modified Delphi method (interactive sessions, consensus agreement) identified challenges for rehabilitation service provision and disability education and attitudes, using GDAP objectives.

RESULTS

The GDAP summary actions were considered useful for clinicians, policy-makers, government and persons with disabilities. The main challenges identified were: limited knowledge of disability services and rehabilitation within healthcare sectors; lack of coordination between sectors; geo-topographical issues; limited skilled workforces; lack of disability data, guidelines and accreditation standards; poor legislation and political commitment. The facilitators were: strong leadership; advocacy of disability-inclusive development; investment in local infrastructure/human resources; opportunities for coordination and partnerships between the healthcare sector and other stakeholders; research opportunities; and dissemination of information.

CONCLUSION

Disability and rehabilitation is an emerging priority in Mongolia to address the rights and needs of persons with disabilities. The GDAP provides guidance to facilitate access and strengthen rehabilitation services.

The combined effect of cranial-nerve non-invasive neuromodulation with high-intensity physiotherapy on gait and balance in a patient with cerebellar degeneration: a case report

Background

Cranial-nerve non-invasive neuromodulation (CN-NINM) using the portable neuromodulation stimulator (PoNS™⁾ device has been proposed as a novel adjuvant intervention to improve efficacy of gait and balance. This device modulates input and output signals during motor tasks which prompts neuroplastic changes. In this study, we investigated the efficacy of physiotherapy using the PoNS™ in a case with cerebellar degeneration.

Case presentation

The PoNS™ was used during a high-intensity physiotherapy programme delivered over 2 weeks (2 × 1.5 h sessions daily). Clinical and instrumented gait and balance tests were applied pre- and post-intervention.

Results

The patient improved in all tests without any adverse effects.

Conclusion

This study showed the efficacy and feasibility of combined high-intensity physiotherapy and CN-NINM for gait and balance rehabilitation. Further studies should explore CN-NINM effects in larger and more diverse samples of neurological patients.

Technologies for Advanced Gait and Balance Assessments in People with Multiple Sclerosis

Subtle gait and balance dysfunction is a precursor to loss of mobility in multiple sclerosis (MS). Biomechanical assessments using advanced gait and balance analysis technologies can identify these subtle changes and could be used to predict mobility loss early in the disease. This update critically evaluates advanced gait and balance analysis technologies and their applicability to identifying early lower limb dysfunction in people with MS. Non-wearable (motion capture systems, force platforms, and sensor-embedded walkways) and wearable (pressure and inertial sensors) biomechanical analysis systems have been developed to provide quantitative gait and balance assessments. Non-wearable systems are highly accurate, reliable and provide detailed outcomes, but require cumbersome and expensive equipment. Wearable systems provide less detail but can be used in community settings and can provide real-time feedback to patients and clinicians. Biomechanical analysis using advanced gait and balance analysis technologies can identify changes in gait and balance in early MS and consequently have the potential to significantly improve monitoring of mobility changes in MS.

EMG-triggered stimulation post spinal cord injury: A case report

BACKGROUND

Mechanical injury in patients with spinal cord injury (SCI) rarely transects the cord completely, even when the injury is classified as complete. These patients can show sub-clinical evidence of spared motor connections, which might be amenable to targeted rehabilitation. Neurophysiological evaluations can complement the clinical evaluation by providing objective data about conduction across the SCI site.

CASE DESCRIPTION

A twenty-four year old patient with SCI was admitted to a rehabilitation centre 49 days post traumatic SCI. His injury was categorized as motor and sensory complete (AIS A) with a neurological level of C4. The strength of his triceps bilaterally was recorded 0/5 repeatedly by his therapists during the five-month period post-injury. As a result, no training was provided for these muscles during the rehabilitation program. Neurophysiological Assessment: Motor evoked potentials (MEPs) were recorded from his left triceps with transcranial magnetic stimulation (TMS) which confirmed the existence of spared corticospinal connections to this muscle post-injury.

INTERVENTION

He completed a series of active-assisted exercises with an EMG-triggered neuromuscular stimulation (NMS) device for his left triceps comprising 20-minutes elbow extension (15 trials), three times per day for 4 weeks.

OUTCOME

The strength of his left triceps gradually improved to 2/5.

DISCUSSION

Neurophysiological evaluation can be useful in identifying residual function below the level of injury, which can, in turn, be enhanced through appropriate rehabilitation strategies.

Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury ('Hands On'): a randomised trial

QUESTION

What is the effect of adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy in people with sub-acute tetraplegia?

DESIGN

A parallel group, randomised, controlled trial. Participants were randomly assigned (1:1) via a computer-generated concealed block randomisation procedure to either a control or experimental intervention.

PARTICIPANTS

Seventy people with C2 to T1 motor complete or incomplete tetraplegia within 6 months of injury. Participants were recruited from seven spinal units in Australia and New Zealand.

INTERVENTION

Experimental participants received intensive training for one hand. Intensive training consisted of training with an instrumented exercise workstation in conjunction with functional electrical stimulation for 1hour per day, 5 days per week for 8 weeks. Both groups received usual care and 15minutes of one-to-one hand therapy three times per week without functional electrical stimulation.

OUTCOME MEASURES

The primary outcome was the modified Action Research Arm Test reflecting arm and hand function, which was assessed at the end of the intervention, that is, 11 weeks after randomisation. Secondary outcomes were measured at 11 and 26 weeks.

RESULTS

Sixty-six (94%) participants completed the post-intervention assessment and were included in the primary intention-to-treat analysis. The mean (SD) modified Action Research Arm Test score for experimental and control participants at the post-intervention assessment was 36.5 points (SD 16.0) and 33.2 points (SD 17.5), respectively, with an adjusted mean between-group difference of 0.9 points (95% CI -4.1 to 5.9).

CONCLUSION

Adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy does not improve hand function in people with sub-acute tetraplegia.

REGISTRATION

Australian and New Zealand Trial Registry ACTRN12609000695202 and ClinicalTrials.gov NCT01086930. [Harvey LA, Dunlop SA, Churilov L, Galea MP, Spinal Cord Injury Physical Activity (SCIPA) Hands On Trial Collaborators (2017) Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury ('Hands On'): a randomised trial. Journal of Physiotherapy 63: 197-204].

Optimizing post-acute care in breast cancer survivors: a rehabilitation perspective

Breast cancer (BC) is the most common malignancy and a leading cause of morbidity and mortality in women worldwide. Therapeutic advances and improved survival rates of women with BC have implications for long-term impact on disability, psychological function and quality of life (QoL), which may be amenable to rehabilitation. The focus of rehabilitation is on managing disability, reducing sequelae and symptoms, and enhancing participation and societal reintegration, to achieve the highest possible independence and the best QoL. Rehabilitation interventions should be considered early for maintaining functional capacity and reducing the risk of losing important abilities or independence and should be individualized depending on disease phase, functional deficits, personal requirements and specific goals. A number of interventions have been trialled to support rehabilitation input for women with BC, which include physical therapy, psychological interventions (psychotherapy, cognitive behavioral training) and others. Multidisciplinary rehabilitation and uni-disciplinary interventions such as physical therapy have been shown to be beneficial in reducing disability, and improving participation and QoL. There is a need for comprehensive assessment of health domains in BC patients using a standardized framework and a common language for describing the impact of disease at different levels, using the International Classification of Functioning, Disability and Health core sets. This will provide more detailed information on the needs of these patients, so more efficient and targeted rehabilitation interventions can be provided.

Chronic pain in multiple sclerosis: A 10-year longitudinal study

BACKGROUND AND PURPOSE

Pain is a common symptom associated with multiple sclerosis (MS), and has lasting effects on an individual's functional capacity and quality of life. A wide range of prevalence rates of pain (between 23% and 90%)have been reported in MS and this is mainly due to the methodological differences amongst the studies such as variability in patient sources, method of sampling and the definition of pain used. Chronic pain in MS, defined as pain lasting for greater than 3-6 months, can have a significant impact on their biopsychosocial health, including negative impact on activities of daily living, relationships and social participation. The long-term course of MS-related pain and its impact in an Australian cohort over a 7-year period has been investigated earlier. The aim of this longitudinal study was to describe the impact of chronic pain, pain-related disability and carer burden in persons with MS over a 10-year period. The aim of this longitudinal study was to describe the impact of chronic pain, pain-related disability and carer burden in persons with MS over a 10-year period.

METHODS

This was a prospective longitudinal study conducted at the Rehabilitation Department of Royal Melbourne Hospital (RMH), a tertiary referral hospital in Victoria and Australia. The source of participants was from the RMH MS database and contains detailed MS patient information including demographic data, diagnosis details (using McDonald's criteria), pain characteristics. Structured face-face interviews and validated measures were used, which include the visual analogue scale (VAS); chronic pain grade (CPG); the assessment of quality of life (AQoL) and the carer strain index (CSI). The mean age of the participants (n=70) was 55.3 years and majority (70%) were female.

RESULTS

The mean age of the participants (n=70) was 55.3 years and majority (70%) were female. The findings show that over time (10 years), participants report having greater bilateral bodily pain and greater description of pain as 'worse as it could be'. Pain types were similar to 7-years follow-up but remained higher than baseline. There was a significant deterioration in quality of life in those with more severe CPG over time. Almost half of the participants 31 (44%) required care either from a private carer, institution or from a family member. Although fear of taking medications and side effects were common barriers to treatment for pain, there was an increase in the use of pharmacological treatment over time and an increase in the use of healthcare services, mainly neurologists and general practitioners.

CONCLUSIONS

The pain measures reported by the participants were similar to those at the 7-year follow-up except there was a greater representation of bilateral pain locations (limb, trunk and facial pain) compared to baseline and 7-year follow-up. At 10-year follow-up, more participants used medications compared to 7-year follow-up and there was an increase in the use of health professionals at the 10-year follow-up. At the 10-year follow up QoL of the participants deteriorated significantly and more participants had progressed to higher CPG III and CPG IV. This study demonstrates that chronic pain is a significant issue over time in MS, with clinical and health implications, impact on quality of life, disability and healthcare utilization.

IMPLICATIONS

Greater awareness of chronic pain in pwMS, cognitive classifications and an interdisciplinary approach is required to improve long-term patient outcomes and well-being.

Gait and balance deterioration over a 12-month period in multiple sclerosis patients with EDSS scores ≤ 3.0

BACKGROUND AND PURPOSE

It is not currently known whether gait and balance measures are responsive to deterioration of motor function in multiple sclerosis (MS) patients with low EDSS scores (≤3.0). The aim of this study was to quantify MS-related gait and balance deterioration over a 12-month period.

METHODS

Thirty-eight participants with MS (33 female, mean age: 41.1 ± 8.3 years), mean time since diagnosis 2.2 ± 4.1 years, EDSS score ≤3.0 and without clinical evidence of gait deterioration, were recruited. Participants performed walking trials and Functional and Lateral Reach Tests. Kinematics of the ankle and knee, and electromyography of the tibialis anterior and medial gastrocnemius muscles were also measured.

RESULTS

Three participants reported relapses with worsening EDSS scores and 4 non-relapsing participants had worse EDSS scores at 12 months. There were significant decreases in mean gait speed, stride length and balance scores, and a significant increase in double support. Marked changes in ankle kinematics, with decreased medial gastrocnemius activity were observed.

CONCLUSION

Gait and balance performance of non-disabled RRMS participants may progressively decline, even in the absence of both acute clinical relapse and change in clinical status measured by the EDSS.

A preliminary investigation on the effect of extracorporeal shock wave therapy as a treatment for neurogenic heterotopic ossification following traumatic brain injury. Part I: Effects on pain

INTRODUCTION

Neurogenic heterotopic ossification (NHO) is a complication of a neurological injury following traumatic brain injury (TBI) and may be present around major synovial joints. It is often accompanied by severe pain, which may lead to limitation in activities of daily living. Currently, a common intervention for NHO is surgery, which has been reported to carry many additional risks. This study was designed to assess the effect of extracorporeal shock wave therapy (ESWT) on pain in patients with TBI with chronic NHO.

METHODS

A series of single-case studies (n = 11) was undertaken with patients who had TBI and chronic NHO at the hip or knee. Each patient received four applications of high-energy EWST delivered to the affected joint over 8 weeks. Two-weekly follow-up assessments were carried out, and final assessments were made 3 and 6 months post-intervention. Pain was measured using the Faces Rating Scale, and X-rays were taken at baseline and 6-months post-intervention to physiologically measure the size of the NHO.

RESULTS

The application of high-energy ESWT was associated with significant overall reduction of pain in patients with TBI and NHO (Tau-0.412, 95% confidence interval -0.672 to -0.159, p = 0.002).

CONCLUSIONS

ESWT is a novel non-invasive intervention for reducing pain resulting from NHO in patients with TBI.

A preliminary investigation on the effect of extracorporeal shock wave therapy as a treatment for neurogenic heterotopic ossification following traumatic brain injury. Part II: Effects on function

INTRODUCTION

Neurogenic heterotopic ossification (NHO) occurs as a complication of traumatic brain injury (TBI). Management of clinically significant NHO remains variable. Complications of mature NHO include limitation of mobility. The effect of the extracorporeal shock wave therapy (ESWT) on range of motion at hip and knee, and function in patients with TBI with chronic NHO was investigated.

METHODS

A series of single-case studies applying ESWT to chronic NHO at the hip or knee of 11 patients with TBI were undertaken at a rehabilitation hospital. Participants received four applications of high-energy EWST delivered to the affected hip or knee over a period of 8 weeks. Two-weekly follow- up assessments were carried out; final assessments were made 3 and 6 months post-intervention. Range of motion (ROM) and Functional Reach (FR) or Modified Functional Reach (MFR) were measured.

RESULTS

Application of high-energy ESWT was associated with significant improvement in ROM (flexion) of the NHO-affected knee (Tau = 0.833, 95% CI 0.391-1.276, p = 0.002) and significant improvement of FR (Overall Tau 0.486, 95% CI 0.141-0.832, p = 0.006); no significant improvement in hip ROM or MFR.

CONCLUSIONS

ESWT may improve mobility and balance of patients with TBI who have chronic NHO.

SCIPA Switch-On: A Randomized Controlled Trial Investigating the Efficacy and Safety of Functional Electrical Stimulation–Assisted Cycling and Passive Cycling Initiated Early After Traumatic Spinal Cord Injury

Background. Substantial skeletal muscle atrophy after spinal cord injury (SCI) carries significant repercussions for functional recovery and longer-term health. Objective. To compare the efficacy, safety, and feasibility of functional electrical stimulation–assisted cycling (FESC) and passive cycling (PC) to attenuate muscle atrophy after acute SCI. Methods. This multicenter, assessor-blinded phase I/II trial randomized participants at 4 weeks post-SCI to FESC or PC (4 sessions per week, 1 hour maximum per session, over 12 weeks). The primary outcome measure was mean maximum cross-sectional area (CSA) of thigh and calf muscles (magnetic resonance imaging), and secondary outcome measures comprised body composition (dual energy X-ray absorptiometry), anthropometry, quality of life, and adverse events (AEs). Results. Of 24 participants, 19 completed the 12-week trial (10 FESC, 9 PC, 18 male). Those participants completed >80% of training sessions (FESC, 83.5%; PC, 85.9%). No significant between-group difference in postintervention muscle CSA was found. No significant between-group difference was found for any other tissue, anthropometric parameter, or behavioral variable or AEs. Six participants experienced thigh hypertrophy (FESC = 3; PC = 3). Atrophy was attenuated (<30%) in 15 cases (FESC = 7; PC = 8). Conclusions. Both cycle ergometry regimens examined were safe, feasible, and well tolerated early after SCI. No conclusions regarding efficacy can be drawn from our data. Further investigation of both modalities early after SCI is required.