Multilevel upper body movement control during gait in children with cerebral palsy

Upper body movements during walking provide information about balance control and gait stability. Typically developing (TD) children normally present a progressive decrease of accelerations from the pelvis to the head, whereas children with cerebral palsy (CP) exhibit a general increase of upper body accelerations. However, the literature describing how they are transmitted from the pelvis to the head is lacking. This study proposes a multilevel motion sensor approach to characterize upper body accelerations and how they propagate from pelvis to head in children with CP, comparing with their TD peers. Two age-and gender-matched groups of 20 children performed a 10m walking test at self-selected speed while wearing three magneto-inertial sensors located at pelvis, sternum, and head levels. The root mean square value of the accelerations at each level was computed in a local anatomical frame and its variation from lower to upper levels was described using attenuation coefficients. Between-group differences were assessed performing an ANCOVA, while the mutual dependence between acceleration components and the relationship between biomechanical parameters and typical clinical scores were investigated using Regression Analysis and Spearman's Correlation, respectively (alpha = 0.05). New insights were obtained on how the CP group managed the transmission of accelerations through the upper body. Despite a significant reduction of the acceleration from pelvis to sternum, children with CP do not compensate for large accelerations, which are greater than in TD children. Furthermore, those with CP showed negative sternum-to-head attenuations, in agreement with the documented rigidity of the head-trunk system observed in this population. In addition, the estimated parameters proved to correlate with the scores used in daily clinical practice. The proposed multilevel approach was fruitful in highlighting CP-TD gait differences, supported the in-field quantitative gait assessment in children with CP and might prove beneficial to designing innovative intervention protocols based on pelvis stabilization

Usefulness of magnetoinertial wearable devices in neurorehabilitation of children with cerebral palsy

Background. Despite the increasing use of wearable magnetoinertial measurement units (MIMUs) for gait analysis, the efficacy of MIMU-based assessment for planning rehabilitation has not been adequately documented yet. Methods. The usefulness of a MIMU-based assessment was evaluated comparing the data acquired by three MIMUs located at the pelvis, sternum, and head levels in 12 children with cerebral palsy (CP, age: 2-9 years) and 12 age-matched children with typical development (TD). Gait stability was quantified in terms of acceleration attenuation coefficients from pelvis to head, pelvis to sternum, and sternum to head. Children with CP were randomly divided in two groups: in the first group (CPI), MIMU-based parameters were used by therapists for planning patient-tailored rehabilitation programs, whereas in the second group (CPB), therapists were blind to the MIMU-based assessment results. Both CPI and CPB were tested before and after the relevant neurorehabilitation program. Ad hoc questionnaires were also administered to therapists of the CPI group to assess the degree of usefulness perceived about the information provided by the MIMU-based assessment. Results. Significant differences were found between children with CP and those with TD for the acceleration attenuation coefficient from pelvis to head (p = 0 048) and from pelvis to sternum (p = 0 021). After neurorehabilitation, this last parameter increased more in CPI (35%) than in CPB (6%, p = 0 017 for the interaction group per time). The results of the questionnaires showed that therapists agreed with the usability (100% judged it as "easy to use") and usefulness of the MIMU-based assessment in defining patient-oriented interventions (87%). Conclusions. There is a large debate in literature about the efficacy of classical gait analysis that should be enlarged to new technological approaches, such as that based on MIMUs. This study is a first proof of concept about the efficacy of this approach for neurorehabilitation of children with CP

The effect of vestibular stimulation on motor functions of children with cerebral palsy

Background: Cerebral palsy (CP) has been defined as a nonprogressive disease of movement and posture development. Physical therapy techniques use different forms of sensory stimulation to improve neuromotor development. Aim: The aim of this study was to assess the efficacy of a vestibular stimulation training in improving motor functions in cerebral palsy. Population: Fourteen children with CP were randomly separated into two different groups in a cross-over trial. Methods: Over a period of 10 weeks, each group performed 10 sessions of 50 min of neurodevelopmental treatment (NDT) and 10 sessions of vestibular training (VR). Children were evaluated with the Gross Motor Function Measurement-88 scale, the Goal Attainment Scale and the root mean square of head accelerations. Results: A significant improvement in the GAS-score (p =.003) was noted after NDT+VR. Conclusions: Vestibular stimulation integrated with NDT proved to be an effective complementary strategy for facilitating motor functioning

Post-stroke depression increases disability more than 15% in ischemic stroke survivors: a case-control study

We performed a retrospective, case-control study in consecutive ischemic stroke patients admitted to our stroke rehabilitation unit. Patients were matched for severity of neurological impairment (evaluated with the Canadian Neurological Scale, CNS), age (difference within 1 year), and onset admission interval (difference within 3 days). Participants were divided into two subgroups according to the presence or absence of PSD. Aim was to assess the specific influence of post-stroke depression (PSD) and antidepressant treatment on both basal functional status and rehabilitation outcomes. All PSD patients were treated primarily with serotoninergic antidepressants (AD). The final sample included 280 patients with depression (out of 320 found in a whole case series of 993 ischemic patients, i.e., 32.25%) and 280 without depression. Forty patients with depression were excluded because they had a history of severe psychiatric illness or aphasia, with a severe comprehension deficit. On one hand, PSD patients obtained lower Barthel Index (BI) and Rivermead Mobility Index (RMI) scores at both admission and discharge, with minor effectiveness of rehabilitative treatment and longer length of stay; on the other hand, this group had a lower percentage of dropouts. Lastly, PSD patients showed a different functional outcome, based on their response to antidepressant therapy, that was significantly better in responders than in non-responders (13.13%). Our results confirm the unfavorable influence of PSD on functional outcome, despite pharmacological treatment

Te.M.P.O., an app for using temporal musical mismatch in post-stroke neurorehabilitation: a preliminary randomized controlled study

BACKGROUND: Recently, the potential rehabilitation value of music has been examined and music-based interventions and techniques such as the Negative Mismatch (MMN) have been increasingly investigated in the neurological rehabilitation context. OBJECTIVE: The aim of this study was to investigate the effectiveness of a negative mismatch-based therapy on the disability and quality of life in patients with stroke in sub-acute phase. METHODS: Thirty patients with a stroke diagnosis in sub-acute phase were randomly assigned to one of two groups: Mismatch (Mg) or Control (CTRLg) group. Both groups used an innovative Android application: Temporal Musical Patterns Organisation (Te.M.P.O). The Disability Rating Scale (DRS), the Modified Barthel Index (MBI) and the Stroke Specific Quality of Life scale (SSQoL) were used at the baseline (T0) and after four weeks of training (T1), in order to assess changes over time. RESULTS: Statistical analysis was performed using the data of 24 (Mg = 12, CTRLg = 12) subjects. The results show a major improvement of the Mg with respect to the CTRLg in all clinical scales score. CONCLUSION: The temporal negative mismatch-based therapy performed with the Te.M.P.O. application could be useful in improving the disability and the quality of life in stroke survivors in a sub-acute phase

A water-based sequential preparatory approach vs. conventional aquatic training in stroke patients: a randomized controlled trial with a 1-month follow-up

Background: Many studies hypothesize that people who have suffered stroke could benefit from water-based exercises to improve their strength and ability to perform the activities of daily living. Objective: The study aim was to compare the effects of a water-based sequential preparatory approach (SPA) and conventional aquatic therapy in improving motor functions and quality of life in patients with chronic stroke. Methods: Thirty-three chronic stroke outpatients diagnosed with hemiplegia were recruited and randomly assigned to the experimental or control group. Subjects in the experimental group underwent a trial water-based SPA balance training, and patients in the control group were given traditional water balance training. Both groups of participants underwent 45 min of therapy twice a week for 4 weeks. All patients were evaluated before treatment (T0), after 4 weeks of training (T1), and 4 weeks after the end of training (T2) using the Berg balance scale (BBS), the modified Barthel index (MBI), the Tinetti balance and gait scale (TBG), the Stroke Specific Quality Of Life Scale (SS-QOL), and the modified Ashworth scale (MAS). Results: After the training, statistically significant differences (p < 0.05) were found between the groups in their score averages on the BBS (p = 0.01) and the SS-QOL scale (p = 0.03). Furthermore, the SPAg showed a significantly greater percentage of improvement on the BBS (p = 0.02) and the SS-QOL (p = 0.03). Both groups obtained a significantly improved MAS score (p < 0.01). Conclusion: Results indicate that water training based on an SPA is more effective than traditional aquatic training for balance rehabilitation of chronic poststroke patients

Effects of Walking Endurance Reduction on Gait Stability in Patients with Stroke

Control of gait is usually altered following stroke, and it may be further compromised by overexertion and fatigue. This study aims to quantitatively assess patients' gait stability during six-minute walking, measuring upper body accelerations of twenty patients with stroke (64 ± 13 years old) and ten age-matched healthy subjects (63 ± 10 years old). Healthy subjects showed a steady gait in terms of speed and accelerations over the six minutes. Conversely, the patients unable to complete the test (n = 8) progressively reduced their walking speed (−22 ± 11%, confidence interval CI95%: −13, −29%, P = 0.046). Patients able to complete the test (n = 12) did not vary their walking speed over time (P = 0.493). However, this ability was not supported by an adequate capacity to maintain their gait stability, as shown by a progressive increase of their upper body accelerations (+5 ± 11%, CI95%: −1; +12%, P = 0.010). Walking endurance and gait stability should be both quantitatively assessed and carefully improved during the rehabilitation of patients with stroke

Upper limb motor improvement in chronic stroke after combining botulinum toxin A injection and multi-joints robot-assisted therapy: A case report

Spasticity is one of the major complications after stroke. Botulinum toxin type A (BoNT-A) injection is commonly used to manage focal spasticity. However, it is uncertain whether BoNT-A can improve activities of daily living function of paretic arm. The recovery of functions of the affected arm is also the aim of robotic upper limb (UL) therapy. The motorized exoskeleton assists the patient in a large 3D work environment by promoting movement for the UL (shoulder, elbow, wrist, hand). The combination of the BoNT-A injection and the robotic therapy might enhance functional recovery after stroke.We reported the case of a chronic stroke patient in which the injection of BoNT-A was combined with multi-joint exoskeleton training. The patient showed improvement in the motor control of the UL, supporting the feasibility of this approach

Italian version of the pittsburgh rehabilitation participation scale: Psychometric analysis of validity and reliability

Patient’s active participation in therapy is a key component of successful rehabilitation. In fact, low participation has been shown to be a prognostic factor of poor outcome; however, participation is rarely assessed in clinical settings. The Pittsburgh Rehabilitation Participation Scale (PRPS) is a validated, quick, and accurate measure of participation, relying on clinicians’ observation, and not requiring any self-report by patients. The aim of this study was to validate an Italian version of the PRPS. Following forward and back-translation of PRPS into Italian, the translated version was validated in a total of 640 therapy sessions, related to a cohort of 32 patients admitted to an Italian hospital. It was tested for concurrent validity, finding significant correlations with Barthel Index (R > 0.58, p < 0.001) and SF-36 Physical and Mental Health (R > 0.4, p < 0.02), for predictive validity, finding significant correlation with the effectiveness of rehabilitation (R = 0.358, p = 0.045), and for inter-rater and intra-rater reliability, computing an Intra-class correlation coefficient (ICC = 0.926 and 0.756, respectively). These psychometric properties results were similar to those of the original version of this scale. The proposed PRPS can be helpful for Italian clinicians in the assessment of patient’s participation during rehabilitation

The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke

Objective: To test the hypothesis that the size of a juxtaluminal black (hypoechoic) area (JBA) in ultrasound images of asymptomatic carotid artery plaques predicts future ipsilateral ischemic stroke. Methods: A JBA was defined as an area of pixels with a grayscale value <25 adjacent to the lumen without a visible echogenic cap after image normalization. The size of a JBA was measured in the carotid plaque images of 1121 patients with asymptomatic carotid stenosis 50% to 99% in relation to the bulb (Asymptomatic Carotid Stenosis and Risk of Stroke study); the patients were followed for up to 8 years. Results: The JBA had a linear association with future stroke rate. The area under the receiver-operating characteristic curve was 0.816. Using Kaplan-Meier curves, the mean annual stroke rate was 0.4% in 706 patients with a JBA <4 mm 2, 1.4% in 171 patients with a JBA 4 to 8 mm2, 3.2% in 46 patients with a JBA 8 to 10 mm2, and 5% in 198 patients with a JBA >10 mm2 (P <.001). In a Cox model with ipsilateral ischemic events (amaurosis fugax, transient ischemic attack [TIA], or stroke) as the dependent variable, the JBA (<4 mm2, 4-8 mm2, >8 mm2) was still significant after adjusting for other plaque features known to be associated with increased risk, including stenosis, grayscale median, presence of discrete white areas without acoustic shadowing indicating neovascularization, plaque area, and history of contralateral TIA or stroke. Plaque area and grayscale median were not significant. Using the significant variables (stenosis, discrete white areas without acoustic shadowing, JBA, and history of contralateral TIA or stroke), this model predicted the annual risk of stroke for each patient (range, 0.1%-10.0%). The average annual stroke risk was <1% in 734 patients, 1% to 1.9% in 94 patients, 2% to 3.9% in 134 patients, 4% to 5.9% in 125 patients, and 6% to 10% in 34 patients. Conclusions: The size of a JBA is linearly related to the risk of stroke and can be used in risk stratification models. These findings need to be confirmed in future prospective studies or in the medical arm of randomized controlled studies in the presence of optimal medical therapy. In the meantime, the JBA may be used to select asymptomatic patients at high stroke risk for carotid endarterectomy and spare patients at low risk from an unnecessary operation