T.W.J. Janssen

4th International State-of-the-art-congress ‘Rehabilitation: Mobility, Exercise & Sports’

Rehabilitation medicine is a young medical discipline and field of multidisciplinary care, finding its roots in the USA in the very first years of the twentieth century, and receiving a strong boost during and after World War II [1]. In the Netherlands, rehabilitation medicine has been officially founded as a self-standing medical profession in 1955 [2]. Being a young multidisciplinary area of clinical practice and health care, rehabilitation medicine evolved from an initially clinically founded discipline towards a more academic-based discipline at the start of this millennium. Todate clinical rehabilitation care is often offered in specialised rehabilitation centres (24 in the Netherlands), in university hospitals and in many of the larger general hospitals. Rehabilitation medicine and care is internationally often based upon the conceptual framework of the International Classification of Functioning, Disability and Health (ICF [3]), and on an integral, structured and multidisciplinary team approach. In the Netherlands, the rehabilitation medical doctor is trained (in a 4-year specialisation programme after medical training) largely towards the concepts and aims stated in the ‘White book on Physical and Rehabilitation Medicine in Europe’ [4], which has been published by the governing bodies of European specialists in physical and rehabilitation medicine. The rehabilitation medical specialist is a clinical specialist, yet part of the training programme is directed towards research, methodological content and skills [5,6]. Human Movement Sciences has been intimately linked to rehabilitation from its inception as an academic discipline, which was for the Netherlands in the early seventies in Amsterdam. Different from many other Western countries, in the Netherlands the professional training of paramedical and nursing staff is beyond the university teaching programme and part of a separate system of higher education that primarily offers professional bachelor and master programmes. This is where physio, occupational, vocational therapists, physical education and sports teachers are educated and trained, also for the rehabilitation practice. Human movement scientists follow a research-oriented university-based training programme, focussed on the study of human movement, both with a fundamental and an applied connotation. ‘Human movement sciences’ (HMS) is an interdisciplinary study, encompassing a wide range of disciplines such as (exercise) physiology, psychology, anatomy, biomechanics, and motor control and learning, etc. It is offered in many universities all over the world and has a wellestablished scientific journal by this name for 29 years (Human Movement Science, Elsevier) as well as many others addressing the field of human movement sciences. In the Netherlands, the study of human movement sciences is offered as a selfstanding scientific bachelor-master programme at two universities (Amsterdam and Groningen) and as a Master specialisation in two other universities (Nijmegen, Maastricht) today. Among the most important applied contexts are the fields of sports, health care and labour. Within the context of health, rehabilitation has been an important field of research and study among both staff and students from the beginning of HMS and has – in the Netherlands – let to active collaborations between rehabilitation professionals and human movement scientists, almost from the early years onwards. It has generated two professors in human movement sciences and rehabilitation, in Amsterdam and Groningen. As such HMS – together with the technical and social sciences – have almost by nature contributed to the continued metamorphosis of rehabilitation from a clinical field of (para-)medical care and practice, towards a much more evidence-based academic and clinical-research (multi-) disciplinary environment [7]. Today – and not only in the Netherlands – human movement scientists are in many cases the linking pin between their schools’ and research institutes’ programmes on the one hand and the rehabilitation centres/departments on the other. Disability and Rehabilitation, 2010; 32(26): 2149–2154

Muscle properties and functional recovery until one year after stroke

Purpose: to investigate functional performance in relation to muscle function during first year after stroke. Methods: Maximal voluntary isometric torques of knee extensors (MVTe) and flexors (MVTf) were obtained in 14 patients with subacute stroke (bilaterally) 3.5±2 months after stroke and 3 (n=8), 6 (n=5) and 12 months (n=3) thereafter and in 12 age-matched able-bodied subjects. Maximal triplet response (intrinsic muscle strength), maximal rate of torque development (MRTD) and degree of voluntary activation of knee extensors were estimated. Patients performed 7 tests of functional performance. Results: In the paretic lower limb (PL), all parameters significantly (0.494<|r|<0.909) improved during all follow-ups. In the non-paretic lower limb (NL) most improvement occurred within the first 3 months. For NL and PL, MVTe improved 5 and 16%, respectively MVTf 3 and 20%, triplet 0 and 13%, activation 8 and 9%, MRTD 16 and 61%. Significant correlations (0.460<|r|<0.906) were found between all tests of functional performance and all muscle parameters of PL and all parameters (0.454<|r|<0.873) but triplet and MRTD of NL. Conclusion: All strength parameters correlated significantly with functional performance. Therefore, it is recommended to investigate the role of strength training of both legs during at least the first year of stroke.

Relation between shoulder proprioception, kinematics and pain after stroke

Purpose: To identify a possible relationship between chronic Post-Stroke Shoulder Pain (PSSP), scapular resting pose and shoulder proprioception. Methods: A total of 21 inpatients with stroke and 10 healthy control subjects were included and kinematics and proprioception of both shoulders were measured. Results: The contralateral (i.e. paretic) shoulder of patients with PSSP showed more scapular lateral rotation and larger errors on proprioception tests compared to both patients without PSSP and control subjects. Additionally, the contralateral shoulder of patients with deteriorated proprioception showed more scapular lateral rotation compared to control subjects whereas their ipsilateral (i.e. unaffected) shoulder showed more scapular lateral rotation when compared to both control subjects and patients with good proprioception. Conclusions: A clear relation between affected shoulder kinematics, affected proprioception and PSSP was found. In determining the risk of developing PSSP, attention should be paid to a patients shoulder proprioception and kinematics. If both are altered after stroke, this could worsen the initial pathology or cause secondary pathologies and thus initiate a vicious circle of repetitive soft tissue damage leading to chronic PSSP. Additionally, more attention should be paid to the ipsilateralshoulder since it could be used in determining the risk of developing PSSP in the contralateral shoulder.

Muscle activity patterns during robotic walking and overground walking in patients with stroke

The aim of the present study was to examine the muscle activity of patients with stroke during robotic walking. In the robotic walking condition (RWC), subjects (n=10) walked in a robotic walking device with minimal support and a walking speed of 2.2 km/h. In the overground walking condition (OWC), subjects walked without any assistance on their preferred walking speed. The results showed significant differences between conditions in individual phases of the gait cycle. Thereby, a significant lower EMG amplitude was found in the RWC compared to the OWC. Furthermore, significant interaction effects were found indicating a higher activity of the paretic semitendinosus and gastrocnemius muscle during the RWC compared to the OWC, supporting the use of robot treadmill training after stroke.

Development of a hybrid strength training technique for paretic lower-limb muscles

A hybrid resistance exercise technique for strength training of patients with lower-limb paresis was developed. It consists of electrical stimulation-induced contractions (ESIC) superimposed on voluntary contractions to increase recruitment of motor units and the functional load capability of paretic quadriceps and hamstring muscle groups. The feasibility of this hybrid exercise technique was demonstrated in 10 able-bodied subjects during submaximal isometric contractions by eliciting greater forces than the voluntary contractions at given efforts. Mean (/spl plusmn/SE) submaximal voluntary contraction forces (46.4% maximum voluntary contraction forces) for the quadriceps and hamstrings, respectively, were 206.0/spl plusmn/18.0 N and 115.9/spl plusmn/12.7 N, whereas the hybrid forces were 282.7/spl plusmn/30.3 N and 126.1/spl plusmn/12.9 N at ES current levels of 55.6/spl plusmn/7.9 mA and 51.5/spl plusmn/5.7 mA. This represented a 37.2% and an 8.8% increase over the voluntary effort for these muscle groups. Since this hybrid technique recruits additional muscle fibers for stronger contractions, the greater force overload may be more effective for the strength training of patients with lower-limb paresis.