Susan Linder

It is not about the bike, it is about the pedaling: forced exercise and Parkinson's disease.

Forced exercise has resulted in neuroprotective effects and improved motor function in animal studies. These promising results have not yet been translated fully to humans with Parkinsons disease (PD), as traditional exercise interventions have not yielded global improvements in function. A novel forced exercise intervention is described that has resulted in improved motor function and central nervous system function in PD patients.

Improving Quality of Life and Depression After Stroke Through Telerehabilitation

OBJECTIVE The aim of this study was to determine the effects of home-based robot-assisted rehabilitation coupled with a home exercise program compared with a home exercise program alone on depression and quality of life in people after stroke. METHOD A multisite randomized controlled clinical trial was completed with 99 people<6 mo after stroke who had limited access to formal therapy. Participants were randomized into one of two groups, (1) a home exercise program or (2) a robot-assisted therapy+home exercise program, and participated in an 8-wk home intervention. RESULTS We observed statistically significant changes in all but one domain on the Stroke Impact Scale and the Center for Epidemiologic Studies Depression Scale for both groups. CONCLUSION A robot-assisted intervention coupled with a home exercise program and a home exercise program alone administered using a telerehabilitation model may be valuable approaches to improving quality of life and depression in people after stroke.

A Scoping Review of Exergaming for Adults with Systemic Disabling Conditions

Background: Exergaming, or playing a game on a television, computer or projector screen with a motion-monitoring system to enable control of on-screen action by bodily movements that result in a substantially greater expenditure of energy compared to resting levels, may be particularly relevant for adults with systemic disabling conditions because of its potential to increase health and function and improve adherence to rehabilitation/exercise programs. Thus, we conducted a scoping review of the literature on examining the usability and utility of low-cost exergaming technology in adults with systemic disabling conditions. Methods: Comprehensive strategies were used to search for studies published or in-press between 1980 and July, 2011. Main inclusion-exclusion criteria were studies that examined the usability or utility of affordable exergaming technology (e.g., excluding fully immersive virtual reality platforms) in adults with systemic disabling conditions. We used the User-Orientation Evaluation Framework, GameFlow model, and Dobkin’s framework on the progressive staging of pilot studies to determine the scope and quality of the existing literature. Results: We identified 25 studies, which reported on 346 adults with disabling conditions. Most participants were male and stroke survivors. Only four studies employed a randomized controlled trial design and most studies were classified in the consideration-of-concept stage, according to Dobkin’s framework. Few studies were comprehensive in their usability assessment. Common exergaming technology platforms examined were Sony PlayStation EyeToy, Nintendo Wii, and technology developed by the researchers of the study. Eight adverse events were reported across the 25 studies. Conclusions: Research on exergaming using affordable exergaming technology platforms is still in its infancy. We recommend that randomized controlled trials be conducted with a long-term follow-up that employs a mixedmethods approach to collecting data. Multidisciplinary collaborations among exercise physiologist, behavioral scientist, rehabilitation scientist and neuromotor control experts are needed to advance the field and identify possible mechanisms of action.

The HAAPI (Home Arm Assistance Progression Initiative) Trial: A Novel Robotics Delivery Approach in Stroke Rehabilitation.

Background. Geographical location, socioeconomic status, and logistics surrounding transportation impede access of poststroke individuals to comprehensive rehabilitative services. Robotic therapy may enhance telerehabilitation by delivering consistent and state-of-the art therapy while allowing remote monitoring and adjusting therapy for underserved populations. The Hand Mentor Pro (HMP) was incorporated within a home exercise program (HEP) to improve upper-extremity (UE) functional capabilities poststroke. Objective. To determine the efficacy of a home-based telemonitored robotic-assisted therapy as part of a HEP compared with a dose-matched HEP-only intervention among individuals less than 6 months poststroke and characterized as underserved. Methods. In this prospective, single-blinded, multisite, randomized controlled trial, 99 hemiparetic participants with limited access to UE rehabilitation were randomized to either (1) the experimental group, which received combined HEP and HMP for 3 h/d ×5 days ×8 weeks, or (2) the control group, which received HEP only at an identical dosage. Weekly communication between the supervising therapist and participant promoted compliance and progression of the HEP and HMP prescription. The Action Research Arm Test and Wolf Motor Function Test along with the Fugl-Meyer Assessment (UE) were primary and secondary outcome measures, respectively, undertaken before and after the interventions. Results. Both groups demonstrated improvement across all UE outcomes. Conclusions. Robotic + HEP and HEP only were both effectively delivered remotely. There was no difference between groups in change in motor function over time. Additional research is necessary to determine the appropriate dosage of HMP and HEP.

Using Accelerometer and Gyroscopic Measures to Quantify Postural Stability

CONTEXT Force platforms and 3-dimensional motion-capture systems provide an accurate method of quantifying postural stability. Substantial cost, space, time to administer, and need for trained personnel limit widespread use of biomechanical techniques in the assessment of postural stability in clinical or field environments. OBJECTIVE To determine whether accelerometer and gyroscope data sampled from a consumer electronics device (iPad2) provide sufficient resolution of center-of-gravity (COG) movements to accurately quantify postural stability in healthy young people. DESIGN Controlled laboratory study. SETTING Research laboratory in an academic medical center. PATIENTS OR OTHER PARTICIPANTS A total of 49 healthy individuals (age = 19.5 ± 3.1 years, height = 167.7 ± 13.2 cm, mass = 68.5 ± 17.5 kg). INTERVENTION(S) Participants completed the NeuroCom Sensory Organization Test (SOT) with an iPad2 affixed at the sacral level. MAIN OUTCOME MEASURE(S) Primary outcomes were equilibrium scores from both systems and the time series of the angular displacement of the anteroposterior COG sway during each trial. A Bland-Altman assessment for agreement was used to compare equilibrium scores produced by the NeuroCom and iPad2 devices. Limits of agreement was defined as the mean bias (NeuroCom - iPad) ± 2 standard deviations. Mean absolute percentage error and median difference between the NeuroCom and iPad2 measurements were used to evaluate how closely the real-time COG sway measured by the 2 systems tracked each other. RESULTS The limits between the 2 devices ranged from -0.5° to 0.5° in SOT condition 1 to -2.9° to 1.3° in SOT condition 5. The largest absolute value of the measurement error within the 95% confidence intervals for all conditions was 2.9°. The mean absolute percentage error analysis indicated that the iPad2 tracked NeuroCom COG with an average error ranging from 5.87% to 10.42% of the NeuroCom measurement across SOT conditions. CONCLUSIONS The iPad2 hardware provided data of sufficient precision and accuracy to quantify postural stability. Accuracy, portability, and affordability make using the iPad2 a reasonable approach for assessing postural stability in clinical and field environments.

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

Rationale Because many individuals poststroke lack access to the quality and intensity of rehabilitation to improve upper extremity motor function, a home-based robotic-assisted upper extremity rehabilitation device is being paired with an individualized home exercise program. Aims/Hypothesis The primary aim of this project is to determine the effectiveness of robotic-assisted home therapy compared with a home exercise program on upper extremity motor recovery and health-related quality of life for stroke survivors in rural and underserved locations. The secondary aim is to explore whether initial degree of motor function of the upper limb may be a factor in predicting the extent to which patients with stroke may be responsive to a home therapy approach. We hypothesize that the home exercise program intervention, when enhanced with robotic-assisted therapy, will result in significantly better outcomes in motor function and quality of life. Design A total of 96 participants within six-months of a single, unilateral ischemic, or hemorrhagic stroke will be recruited in this prospective, single-blind, multisite randomized clinical trial. Study Outcomes The primary outcome is the change in upper extremity function using the Action Research Arm Test. Secondary outcomes include changes in: upper extremity function (Wolf Motor Function Test), upper extremity impairment (upper extremity portion of the Fugl-Meyer Test), self-reported quality of life (Stroke Impact Scale), and affect (Centers for Epidemiologic Studies Depression Scale). Discussion Similar or greater improvements in upper extremity function using the combined robotic home exercise program intervention compared with home exercise program alone will be interpreted as evidence that supports the introduction of in-home technology to augment the recovery of function poststroke.

Quantification of the Balance Error Scoring System with Mobile Technology.

PURPOSE The aim of this project was to develop a biomechanically based quantification of the Balance Error Scoring System (BESS) using data derived from the accelerometer and gyroscope of a mobile tablet device. METHODS Thirty-two healthy young adults completed the BESS while an iPad was positioned at the sacrum. Data from the iPad were compared to position data gathered from a three-dimensional motion capture system. Peak-to-peak (P2P), normalized path length (NPL), and root mean squared (RMS) were calculated for each system and compared. Additionally, a 95% ellipsoid volume, iBESS volume, was calculated using center of mass (CoM) movements in the anteroposterior (AP), mediolateral (ML), and trunk rotation planes of movement to provide a comprehensive, 3D metric of postural stability. RESULTS Across all kinematic outcomes, data from the iPad were significantly correlated with the same outcomes derived from the motion capture system (rho range, 0.37-0.94; P < 0.05). The iBESS volume metric was able to detect a difference in postural stability across stance and surface, showing a significant increase in volume in increasingly difficult conditions, whereas traditional error scoring was not as sensitive to these factors. CONCLUSIONS The kinematic data provided by the iPad are of sufficient quality relative to motion capture data to accurately quantify postural stability in healthy young adults. The iBESS volume provides a more sensitive measure of postural stability than error scoring alone, particularly in conditions 1 and 4, which often suffer from floor effects, and condition 5, which can experience ceiling effects. The iBESS metric is ideally suited for clinical and in the field applications in which characterizing postural stability is of interest.

ENGAGE: Guided Activity-Based Gaming in Neurorehabilitation after Stroke: A Pilot Study

Introduction. Stroke is a leading cause of disability in healthy adults. The purpose of this pilot study was to assess the feasibility and outcomes of a novel video gaming repetitive practice paradigm, (ENGAGE) enhanced neurorehabilitation: guided activity-based gaming exercise. Methods. Sixteen individuals at least three months after stroke served as participants. All participants received concurrent outpatient therapy or took part in a stroke exercise class and completed at least 500 minutes of gaming. Primary baseline and posttest outcome measures included the Wolf motor function test (WMFT) and the Fugl-Meyer assessment (FMA). ENGAGE uses a game selection algorithm providing focused, graded activity-based repetitive practice that is highly individualized and directed. The Wilcoxon signed ranks test was used to determine statistical significance. Results. There were improvements in the WMFT (P = 0.003) and the FMA (P = 0.002) that exceeded established values of minimal clinically important difference. Conclusions. ENGAGE was feasible and an effective adjunct to concurrent therapy after stroke.

Incorporating robotic-assisted telerehabilitation in a home program to improve arm function following stroke

BACKGROUND AND PURPOSE After stroke, many individuals lack resources to receive the intensive rehabilitation that is thought to improve upper extremity motor function. This case study describes the application of a telerehabilitation intervention using a portable robotic device combined with a home exercise program (HEP) designed to improve upper extremity function. CASE DESCRIPTION The participant was a 54-year-old man, 22 weeks following right medullary pyramidal ischemic infarct. At baseline, he exhibited residual paresis of the left upper extremity, resulting in impaired motor control consistent with a flexion synergistic pattern, scoring 22 of 66 on the Fugl-Meyer Assessment. INTERVENTION The participant completed 85 total hours of training (38 hours of robotic device and 47 hours of HEP) over the 8-week intervention period. OUTCOMES The participant demonstrated an improvement of 26 points on the Action Research Arm Test, 5 points on the Functional Ability Scale portion of the Wolf Motor Function Test, and 20 points on the Fugl-Meyer Assessment, all of which surpassed the minimal clinically important difference. Of the 17 tasks of the Wolf Motor Function Test, he demonstrated improvement on 11 of the 15 time-based tasks and both strength measures. The participant reported an overall improvement in his recovery from stroke on the Stroke Impact Scale quality-of-life questionnaire from 40 of 100 to 65 of 100. His score on the Center for Epidemiologic Studies Depression Scale improved by 19 points. DISCUSSION This case demonstrates that robotic-assisted therapy paired with an HEP can be successfully delivered within a home environment to a person with stroke. Robotic-assisted therapy may be a feasible and efficacious adjunct to an HEP program to elicit substantial improvements in upper extremity motor function, especially in those persons with stroke who lack access to stroke rehabilitation centers.

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

OBJECTIVE Previously, we demonstrated that forced aerobic exercise (FE) increases the pattern of neural activation in Parkinsons disease. We sought to evaluate whether FE, when coupled with repetitive task practice, could promote motor recovery poststroke. METHOD A 46-yr-old man with ischemic stroke exhibited chronic residual upper-extremity deficits, scoring 35/66 on the Fugl-Meyer Assessment (FMA) at baseline. He completed 24 training sessions comprising 45 min of FE on a motorized stationary bicycle followed by 45 min of upper-extremity repetitive task practice. RESULTS From baseline to end of treatment, the FMA score improved by 20 points, perceived level of recovery on the Stroke Impact Scale increased by 20 percentage points, and cardiovascular function measured by peak oxygen uptake improved 30%. These improvements persisted 4 wk after the intervention ceased. CONCLUSION FE may be a safe and feasible rehabilitation approach to augment recovery of motor and nonmotor function while improving aerobic fitness in people with chronic stroke.