THERAPY-Magazin
Annual Science Review
Explore key neurorehabilitation research from 2021: From stroke recovery timing and robotic gait therapy to core training and motor imagery in Parkinson’s. A month-by-month science recap.
Jakob Tiebel
Business Owner, N+ Digital Health Agency
This is what drove science in the field of neurorehabilitation in 2021
What exciting news has the past year brought from the field of research and development in terms of evidence-based therapies for walking rehabilitation? To kick off the new year, we have compiled some studies that we found interesting here. This, and of course much more, was the driving force behind the researchers in 2021. Here’s a brief overview by month.
January
Impact of rehabilitation start time on functional outcomes after stroke.
When should rehabilitation be started after having an acute stroke? Right at the beginning of the year, Otokita et al. published an interesting paper with findings on how the start time of rehabilitation influences the outcome. In a retrospective database study, they analysed the courses of 140,655 patients who had had a stroke. In general, they found no significant difference in the outcome between starting rehabilitation immediately on day 1 or day 2 after the event. That being said, in a subgroup of patients who had had a haemorrhagic stroke, starting rehabilitation on day 2 resulted in a better outcome than starting on day 1.
However, for haemorrhagic strokes, starting rehabilitation on the second day of hospitalisation may be more effective than on the day of admission.
Impact of rehabilitation start time on functional outcomes after stroke.
When should rehabilitation be started after having an acute stroke? Right at the beginning of the year, Otokita et al. published an interesting paper with findings on how the start time of rehabilitation influences the outcome. In a retrospective database study, they analysed the courses of 140,655 patients who had had a stroke. In general, they found no significant difference in the outcome between starting rehabilitation immediately on day 1 or day 2 after the event. That being said, in a subgroup of patients who had had a haemorrhagic stroke, starting rehabilitation on day 2 resulted in a better outcome than starting on day 1.
However, for haemorrhagic strokes, starting rehabilitation on the second day of hospitalisation may be more effective than on the day of admission.
Starting rehabilitation after a stroke on the day of admission or the second day of hospitalisation could be the optimal time for functional outcomes.
February
Effects on walking performance and lower body strength by short message service guided training after stroke or transient ischemic attack (Results of the STROKEWALK Study)
In February, Vahlberg et al. published their results on the STROKEWALK study. The researchers investigated the extent to which daily mobile phone messages with exercise instructions over a period of three months increase physical activity and general mobility in patients shortly after having a stroke or a transient ischaemic attack. The intervention group received standard care and daily text message instructions via mobile phone to encourage them to go on regular outdoor walks and do functional leg exercises. The control group received standard care, i.e. follow-up by their general practitioner. The results: Three months of daily mobile phone text messages and guided exercise instructions improved combined mobility measures, i.e. walking performance and lower body strength.
Effects on walking performance and lower body strength by short message service guided training after stroke or transient ischemic attack (Results of the STROKEWALK Study)
In February, Vahlberg et al. published their results on the STROKEWALK study. The researchers investigated the extent to which daily mobile phone messages with exercise instructions over a period of three months increase physical activity and general mobility in patients shortly after having a stroke or a transient ischaemic attack. The intervention group received standard care and daily text message instructions via mobile phone to encourage them to go on regular outdoor walks and do functional leg exercises. The control group received standard care, i.e. follow-up by their general practitioner. The results: Three months of daily mobile phone text messages and guided exercise instructions improved combined mobility measures, i.e. walking performance and lower body strength.
March
Understanding the therapeutic alliance in stroke rehabilitation.
The quality of the therapeutic alliance between a patient and the therapist is considered to play an important role in health care, but there is little research on this concept when it comes to stroke rehabilitation.
The study by Bishop et al., published in March, showed that a therapeutic alliance in stroke care consists of three overlapping core components: a personal connection, a professional collaboration and a family collaboration. The researchers found that building and maintaining a therapeutic alliance appears to be an individual and complex process. The ability of a clinician to use their own personal qualities therapeutically and to use their professional skills flexibly seems to be an essential part of the quality of the relationship.
This means the development of therapeutic relationships requires a person-centred and sometimes family or relative-centred approach. The prudent use of self-
disclosure can achieve emotional closeness while still maintaining professional boundaries.
Understanding the therapeutic alliance in stroke rehabilitation.
The quality of the therapeutic alliance between a patient and the therapist is considered to play an important role in health care, but there is little research on this concept when it comes to stroke rehabilitation.
The study by Bishop et al., published in March, showed that a therapeutic alliance in stroke care consists of three overlapping core components: a personal connection, a professional collaboration and a family collaboration. The researchers found that building and maintaining a therapeutic alliance appears to be an individual and complex process. The ability of a clinician to use their own personal qualities therapeutically and to use their professional skills flexibly seems to be an essential part of the quality of the relationship.
This means the development of therapeutic relationships requires a person-centred and sometimes family or relative-centred approach. The prudent use of self-
disclosure can achieve emotional closeness while still maintaining professional boundaries.
April
What is the impact of robotic rehabilitation on balance and gait outcomes in people with multiple sclerosis? A systematic review of randomized control trials
In April, Bowman et al. published their findings on the use of equipment-based gait training in patients with multiple sclerosis. For this purpose, they conducted a systematic literature review and evaluated randomised control trials. Searching through databases resulted in 336 entries and in the end 12 studies were included. The researchers found moderate evidence that robotics-assisted gait training has positive effects on the ability to walk in people with multiple sclerosis. In the available RCTs, balance and gait outcomes improved in a way that was clinically meaningful. After considering the multiple advantages in terms of safety, motor support and intensity of training, the researchers recommended device-assisted gait training be used to improve motor skills, especially in patients with severe disabilities in a multimodal rehabilitation context.
What is the impact of robotic rehabilitation on balance and gait outcomes in people with multiple sclerosis? A systematic review of randomized control trials
In April, Bowman et al. published their findings on the use of equipment-based gait training in patients with multiple sclerosis. For this purpose, they conducted a systematic literature review and evaluated randomised control trials. Searching through databases resulted in 336 entries and in the end 12 studies were included. The researchers found moderate evidence that robotics-assisted gait training has positive effects on the ability to walk in people with multiple sclerosis. In the available RCTs, balance and gait outcomes improved in a way that was clinically meaningful. After considering the multiple advantages in terms of safety, motor support and intensity of training, the researchers recommended device-assisted gait training be used to improve motor skills, especially in patients with severe disabilities in a multimodal rehabilitation context.
May
Core Stability Exercises in Addition to Usual Care Physiotherapy Improve Stability and Balance After Stroke: A Systematic Review and Meta-analysis
In May, Gamble et al. presented their findings on balance training. They had carried out a review using meta-analysis. This included eleven randomised controlled trials comparing usual physiotherapy with usual physiotherapy alongside additional core stability exercises in people who had had a stroke. They found that adding core stability exercises to the usual physiotherapy after a stroke lead to an improvement in core control and dynamic balance. This means that additional core stability exercises should definitely be included in rehabilitation if improvements in these areas help patients to achieve their goals. The researchers report that future studies should consider body kinematics outcomes in functional tasks to assess movement quality and participation outcomes.
Core Stability Exercises in Addition to Usual Care Physiotherapy Improve Stability and Balance After Stroke: A Systematic Review and Meta-analysis
In May, Gamble et al. presented their findings on balance training. They had carried out a review using meta-analysis. This included eleven randomised controlled trials comparing usual physiotherapy with usual physiotherapy alongside additional core stability exercises in people who had had a stroke. They found that adding core stability exercises to the usual physiotherapy after a stroke lead to an improvement in core control and dynamic balance. This means that additional core stability exercises should definitely be included in rehabilitation if improvements in these areas help patients to achieve their goals. The researchers report that future studies should consider body kinematics outcomes in functional tasks to assess movement quality and participation outcomes.
June
Effects of robot-assisted gait training on postural instability in Parkinson’s disease: a systematic review
The systematic review that was published by Picelli in June provides the reader with a complete overview of the current literature and evidence base on the effects of robotic gait training on problems with postural instability (static and dynamic balance, freezing of gait, falls, confidence in activities that are part of daily life and gait parameters related to balance ability) in patients with Parkinson’s disease. A total of 18 articles (2 systematic reviews, 9 randomised controlled trials, 4 uncontrolled trials and 3 case series/case reports) were included.
Effects of robot-assisted gait training on postural instability in Parkinson’s disease: a systematic review
The systematic review that was published by Picelli in June provides the reader with a complete overview of the current literature and evidence base on the effects of robotic gait training on problems with postural instability (static and dynamic balance, freezing of gait, falls, confidence in activities that are part of daily life and gait parameters related to balance ability) in patients with Parkinson’s disease. A total of 18 articles (2 systematic reviews, 9 randomised controlled trials, 4 uncontrolled trials and 3 case series/case reports) were included.
“We found a high level of evidence on the effects of robotic gait training on balance and freezing of gait in patients with Parkinson’s disease”, the researchers explain.
On the one hand, they found that robot-assisted gait training both after treatment and during the course of treatment (up to one month after the end of treatment) can lead to significant improvements in postural control and gait parameters related to balance ability compared to baseline assessment or non-specific conventional low-intensity training methods. On the other hand, there is evidence that robotic gait training is not necessarily superior to conventional balance training and treadmill training of the same intensity when it comes to improving postural instability and gait parameters related to balance control in patients with Parkinson’s. For this reason, it’s necessary to evaluate when the intervention makes sense and what advantages it has over comparable training methods.
July
Factors associated with time to independent walking recovery post-stroke
So far, studies have inconsistently identified factors associated with independent walking after having a stroke. In July, Kennedy et al. published new results from their study in which they examined the relationship between pre-stroke factors and factors collected acutely after stroke, and related these to the number of days to independent walking of 50 m using data from “A Very Early Rehabilitation Trial” (AVERT). A total of 2,100 participants who had has a stroke were included. It took an average of 6 days for them to walk 50 m unassisted, 75% achieved independent walking after 3 months. Therefore, the analysis provides robust evidence of important factors associated with regaining independent walking. The researchers highlight the need for customised mobilisation programmes targeting subgroups, as all patients are individual and respond differently to interventions. This is especially true for people with haemorrhagic and severe strokes (cf. results from January by Otokita et al.).
Factors associated with time to independent walking recovery post-stroke
So far, studies have inconsistently identified factors associated with independent walking after having a stroke. In July, Kennedy et al. published new results from their study in which they examined the relationship between pre-stroke factors and factors collected acutely after stroke, and related these to the number of days to independent walking of 50 m using data from “A Very Early Rehabilitation Trial” (AVERT). A total of 2,100 participants who had has a stroke were included. It took an average of 6 days for them to walk 50 m unassisted, 75% achieved independent walking after 3 months. Therefore, the analysis provides robust evidence of important factors associated with regaining independent walking. The researchers highlight the need for customised mobilisation programmes targeting subgroups, as all patients are individual and respond differently to interventions. This is especially true for people with haemorrhagic and severe strokes (cf. results from January by Otokita et al.).
August
SWEAT2 Study: Effectiveness of Core Training on Muscle Activity after Stroke. A randomized controlled trial
n August, there was news on core training for stroke patients, published by Criekinge et al. Whether the core holds the key is debatable. However, it is undisputed that core training after a stroke is an effective way to improve core control, balance while standing and mobility. Core training primarily improves selective control and endurance of the core muscles after a subacute stroke. The SWEAT2 study sought to explore the underlying mechanisms that lead to these observable mobility transfer effects after core training. What the field of clinical rehabilitation has recently discovered is that core training does not alter muscle activation patterns and the amount of muscle synergies over time, and a decrease in fast-twitch motor recruitment in the erector spinae muscle during walking can be detected after core training. In this way, core training seems to primarily increase the fatigue resistance of the back muscles and allows greater isolated activation, which is important for dynamic movement in high starting positions and mobility.
SWEAT2 Study: Effectiveness of Core Training on Muscle Activity after Stroke. A randomized controlled trial
n August, there was news on core training for stroke patients, published by Criekinge et al. Whether the core holds the key is debatable. However, it is undisputed that core training after a stroke is an effective way to improve core control, balance while standing and mobility. Core training primarily improves selective control and endurance of the core muscles after a subacute stroke. The SWEAT2 study sought to explore the underlying mechanisms that lead to these observable mobility transfer effects after core training. What the field of clinical rehabilitation has recently discovered is that core training does not alter muscle activation patterns and the amount of muscle synergies over time, and a decrease in fast-twitch motor recruitment in the erector spinae muscle during walking can be detected after core training. In this way, core training seems to primarily increase the fatigue resistance of the back muscles and allows greater isolated activation, which is important for dynamic movement in high starting positions and mobility.
September
Ankle-foot orthoses improve walking but do not reduce dual-task costs after stroke
Cognitive-motor interference, as measured by dual-task walking (performing a mental task while walking), occurs in many clinical patient groups. Ankle-foot orthoses (AFOs) are lower leg splints prescribed to stabilise the foot and ankle and prevent drop foot – a gait deficit that often occurs after a stroke. In the study published by Drake in September, the use of AFOs is shown to improve gait parameters such as speed and step time, which are often negatively affected when walking with two tasks.
“Our aim was to determine whether AOFs can improve the cognitive-motor skills of patients with stroke-induced hemiplegia as measured by dual-task gait exercises”, explain the researchers. Their results support the use of AFOs to improve certain gait parameters in post-stroke hemiplegia. However, AFOs do not seem to protect against cognitive-motor dysfunction when walking with dual tasks (see also our main articles on cognitive-motor training).
Ankle-foot orthoses improve walking but do not reduce dual-task costs after stroke
Cognitive-motor interference, as measured by dual-task walking (performing a mental task while walking), occurs in many clinical patient groups. Ankle-foot orthoses (AFOs) are lower leg splints prescribed to stabilise the foot and ankle and prevent drop foot – a gait deficit that often occurs after a stroke. In the study published by Drake in September, the use of AFOs is shown to improve gait parameters such as speed and step time, which are often negatively affected when walking with two tasks.
“Our aim was to determine whether AOFs can improve the cognitive-motor skills of patients with stroke-induced hemiplegia as measured by dual-task gait exercises”, explain the researchers. Their results support the use of AFOs to improve certain gait parameters in post-stroke hemiplegia. However, AFOs do not seem to protect against cognitive-motor dysfunction when walking with dual tasks (see also our main articles on cognitive-motor training).
October
Prevalence of Walking Limitation after Acute Stroke and its Impact on Discharge to Home
While some are concerned with the question of when to start training after an acute stroke and what the time frames should be, depending on which predictors, improvements can be achieved, Louie and colleagues looked at the prevalence and impact of walking disability after stroke. The aim of their study, which was published in October, was to provide current estimates of the prevalence of lower limb motor impairment and walking disability following a first-time stroke and to characterise the predictive nature of early walking ability for discharge to home after an acute hospital stay. Around half of patients with a first-time stroke are found to have lower limb weakness and walking limitations. Early walking ability is, in their view, a significant predictor of returning home after an acute hospital stay, regardless of the severity of the stroke. Based on their findings, the researchers recommend early assessment of walking ability, in particular to also improve discharge planning for patients. “Early assessment of walking ability within a few days after suffering a stroke can help to optimise discharge management”, the researchers say.
Prevalence of Walking Limitation after Acute Stroke and its Impact on Discharge to Home
While some are concerned with the question of when to start training after an acute stroke and what the time frames should be, depending on which predictors, improvements can be achieved, Louie and colleagues looked at the prevalence and impact of walking disability after stroke. The aim of their study, which was published in October, was to provide current estimates of the prevalence of lower limb motor impairment and walking disability following a first-time stroke and to characterise the predictive nature of early walking ability for discharge to home after an acute hospital stay. Around half of patients with a first-time stroke are found to have lower limb weakness and walking limitations. Early walking ability is, in their view, a significant predictor of returning home after an acute hospital stay, regardless of the severity of the stroke. Based on their findings, the researchers recommend early assessment of walking ability, in particular to also improve discharge planning for patients. “Early assessment of walking ability within a few days after suffering a stroke can help to optimise discharge management”, the researchers say.
November
Passive leg cycling increases activity of the cardiorespiratory system in people with tetraplegia
People with a spinal cord injury (SCI) are at increased risk of cardiovascular disease and exercise is known to be a proven way to prevent these conditions. However, there are few simple and safe training methods that can increase cardiorespiratory system activity after a cervical spine injury. The aim of the study, published in November by Soriano and et al., was therefore to investigate the cardiorespiratory response to passive leg cycling in people with cervical SCI. The results were exciting: Therefore, the researchers conclude that passive leg cycling is an effective, inexpensive and practical alternative exercise method for people with SCI of the cervical spine.
Passive leg cycling increases activity of the cardiorespiratory system in people with tetraplegia
People with a spinal cord injury (SCI) are at increased risk of cardiovascular disease and exercise is known to be a proven way to prevent these conditions. However, there are few simple and safe training methods that can increase cardiorespiratory system activity after a cervical spine injury. The aim of the study, published in November by Soriano and et al., was therefore to investigate the cardiorespiratory response to passive leg cycling in people with cervical SCI. The results were exciting: Therefore, the researchers conclude that passive leg cycling is an effective, inexpensive and practical alternative exercise method for people with SCI of the cervical spine.
Passive leg cycling increases cardiorespiratory system activity and improves markers of cardiovascular health in cervical SCI.
December
Motor imagery and gait control in Parkinson’s disease: techniques and new perspectives in neurorehabilitation
Motor imagery (MI), which is defined as the ability to mentally imagine an action without actual movement, has been used to improve motor function in athletes and more recently in neurological disorders such as Parkinson’s disease (PD). Several studies have investigated the neural correlates of motor imagination, which also change depending on the imagined action. Despite a manageable number of included studies, the end-of-year literature review by Coumo et al. supports the potential positive effects of motor imagination interventions in PD that focus on moving forward. The researchers discuss that the development of new technologies could improve the delivery of training based on motor imagery in the future, and the application could lead to new rehabilitation protocols aimed at improving the walking ability of patients with Parkinson’s disease. It will be exciting to see what further insights these and other working groups will provide this year!
Motor imagery and gait control in Parkinson’s disease: techniques and new perspectives in neurorehabilitation
Motor imagery (MI), which is defined as the ability to mentally imagine an action without actual movement, has been used to improve motor function in athletes and more recently in neurological disorders such as Parkinson’s disease (PD). Several studies have investigated the neural correlates of motor imagination, which also change depending on the imagined action. Despite a manageable number of included studies, the end-of-year literature review by Coumo et al. supports the potential positive effects of motor imagination interventions in PD that focus on moving forward. The researchers discuss that the development of new technologies could improve the delivery of training based on motor imagery in the future, and the application could lead to new rehabilitation protocols aimed at improving the walking ability of patients with Parkinson’s disease. It will be exciting to see what further insights these and other working groups will provide this year!
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Jakob Tiebel
Business Owner, N+ Digital Health Agency
Jakob Tiebel studied applied psychology with a focus on health economics. He has clinical expertise from his previous therapeutic work in neurorehabilitation. He conducts research and publishes on the theory-practice transfer in neurorehabilitation and is the owner of Native.Health, an agency for digital health marketing.
References:
- Otokita S, Uematsu H, Kunisawa S, et al. Impact of rehabilitation start time on functional outcomes after stroke. J Rehabil Med. 2021 Jan 13;53(1):jrm00145. doi: 10.2340/16501977-2775. PMID: 33284355.
- Vahlberg B, Lundström E, Eriksson S, et al. Effects on walking performance and lower body strength by short message service guided training after stroke or transient ischemic attack (The STROKEWALK Study): a randomized controlled trial. Clin Rehabil. 2021 Feb;35(2):276-287. doi: 10.1177/0269215520954346. Epub 2020 Sep 18. PMID: 32942914; PMCID: PMC7874373.
- Bishop M, Kayes N, McPherson K. Understanding the therapeutic alliance in stroke rehabilitation. Disabil Rehabil. 2021 Apr;43(8):1074-1083. doi: 10.1080/09638288.2019.1651909. Epub 2019 Aug 21. PMID: 31433673.
- Bowman T, Gervasoni E, Amico AP, et al. What is the impact of robotic rehabilitation on balance and gait outcomes in people with multiple sclerosis? A systematic review of randomized control trials. Eur J Phys Rehabil Med. 2021 Apr;57(2):246-253. doi: 10.23736/S1973-9087.21.06692-2. Epub 2021 Feb 4. PMID: 33541044.
- Gamble K, Chiu A, Peiris C. Core Stability Exercises in Addition to Usual Care Physiotherapy Improve Stability and Balance After Stroke: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2021 Apr;102(4):762-775. doi: 10.1016/j.apmr.2020.09.388. Epub 2020 Oct 22. PMID: 33239203.
- Picelli A, Capecci M, Filippetti M, et al. Effects of robot-assisted gait training on postural instability in Parkinson’s disease: a systematic review. Eur J Phys Rehabil Med. 2021 Jun;57(3):472-477. doi: 10.23736/S1973-9087.21.06939-2. Epub 2021 Apr 7. PMID: 33826278.
- Kennedy C, Bernhardt J, Churilov L, et al. Factors associated with time to independent walking recovery post-stroke. J Neurol Neurosurg Psychiatry. 2021 Jul;92(7):702-708. doi: 10.1136/jnnp-2020-325125. Epub 2021 Mar 17. PMID: 33737383.
- Van Criekinge T, Saeys W, Hallemans A, et al. SWEAT2 study: effectiveness of trunk training on muscle activity after stroke. A randomized controlled trial. Eur J Phys Rehabil Med. 2021 Aug;57(4):485-494. doi: 10.23736/S1973-9087.20.06409-6. Epub 2020 Nov 9. PMID: 33165310.
- Drake R, Parker K, Clifton KL, et al. Ankle-foot orthoses improve walking but do not reduce dual-task costs after stroke. Top Stroke Rehabil. 2021 Sep;28(6):463-473. doi: 10.1080/10749357.2020.1834271. Epub 2020 Oct 16. PMID: 33063635.
- Louie DR, Simpson LA, Mortenson WB, et al. Prevalence of Walking Limitation after Acute Stroke and its Impact on Discharge to Home. Phys Ther. 2021 Oct 23:pzab246. doi: 10.1093/ptj/pzab246. Epub ahead of print. PMID: 34718796.
- Soriano JE, Romac R, Squair JW, et al. Passive leg cycling increases activity of the cardiorespiratory system in people with tetraplegia. Appl Physiol Nutr Metab. 2021 Nov 5. doi: 10.1139/apnm-2021-0523. Epub ahead of print. PMID: 34739759.
- Cuomo G, Maglianella V, Ghanbari Ghooshchy S, et al. Motor imagery and gait control in Parkinson’s disease: techniques and new perspectives in neurorehabilitation. Expert Rev Neurother. 2021 Dec 28:1-9. doi: 10.1080/14737175.2022.2018301. Epub ahead of print. PMID: 34906019.
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