Neurological Disorders

Feasibility and effects of the StepIt approach for cognitive-motor step training in people with Parkinson`s disease

Mareike Eschweiler
mareike.eschweiler@go.johanniter-kliniken.de

Precision medicine in the rehabilitation of locomotor function: individual gait profiles for deficit-specific training strategies in spinal cord injury

Sabrina Imhof
sabrina.imhof@maastrichtuniversity.nl

Locomotor function in humans with spinal cord damage can be improved through training. However, the best form of physical therapy remains undetermined, with the application of deficit- vs. task-oriented training of particular importance. In addition, the exceptional diversity of gait dysfunctions in patients with spinal cord lesions, regardless of whether the result of inflammation, ischemia or trauma, makes it difficult to identify the main factors leading to gait dysfunction and to apply the most adequate form of training, particularly in good to moderately-good walkers. A lack of evidence-based guidance and standardisation prevents the development of optimal training programs for patients with spinal cord damage and rather broad and subjective clinical judgement is applied to determine patient care.

The objective of this PhD project is to further advance current clinical locomotor training strategies by applying a deficit-oriented gait training approach based on subject-specific, objective gait profiles gleaned from 3D gait analysis in chronic, mildly to moderately gait-impaired individuals with spinal cord damage due to inflammation (MS) or with traumatic or ischemic spinal cord injury (SCI; motor incomplete). Within a parallel-group clinical trial, gait impaired subjects (MS: n=22; SCI: n=30) will be characterised by detailed kinematic 3D gait analysis and either trained according to their individual deficits or treated with non-specific, standard walking therapy for six weeks. Normalised improvement in the six minute walk test, one of the most responsive clinical measures to changes in good to moderately-good walkers, will serve as the primary outcome in this study. Secondary outcome measures include short distance walking tests, kinematic, kinetic and electromyographic measures during treadmill walking, and a patient-based questionnaire on walking function as well as quantitative readouts describing performance in an untrained motor task, i.e., in this case swimming, to assess transfer of improvements.

This project may pave the way to more efficient training approaches in subjects with spinal cord damage by transferring and implementing modern gait assessment techniques into clinical neurorehabilitation and to move towards individual, patient-tailored locomotor training programs. 

Body weight supported overground gait training to promote recovery of walking function in chronic spinal cord injury: a randomized clinical trial

Romina Willi
romina.willi@balgrist.ch

Contextual interference: the challenging way towards evidence in paediatric neurorehabilitation - Judith Graser 2021

This research aimed to assess whether children with brain lesions would profit more from practicing different motor tasks in blocked order (i.e. repeating one task several times before switching to the next task) or in random order (practicing the different tasks randomly). In literature, 27 studies were found assessing typically developing children and one assessing children with cerebral palsy. All the studies were of low quality. The researcher planned and conducted a pilot study aiming to evaluate blocked versus random order practice by using a robotic device (an exoskeleton) that can be used to train and measure upper limb function in children. Testing the robotic assessments for their reliability resulted in one parameter measuring movement fluency that was reliable enough for using it in our study. In the pilot study ten predefined criteria were assessed and showed that conducting a future main trial with this procedure would not be feasible.

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Measuring and training of walking abilities in pediatric neurorehabilitation - Corinne Amman 2018

Walking ability is often a primary focus in pediatric neurorehabilitation. The dissertation presents a detailed overview of commonly used measurement instruments for the evaluation of gait function in children with neuromotor disorders. The dissertation further demonstrates that with the Functional Mobility Scale and the Gillette Functional Assessment Questionnaire Walking Scale, children’s everyday life mobility – an underrepresented perspective in clinical practice and in research - can be evaluated in inpatient settings. Finally, the dissertation addresses the rehabilitation of walking ability by investigating the effectiveness of robot-assisted gait training, a treatment approach that has been introduced ten years ago in pediatric neurorehabilitation.

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Treatment and assessment tools for stroke patients with and without visuo-spatial neglect - Bernadette Tobler-Amman 2018

This thesis examined two virtual reality (VR) tools, which had been developed to assess and treat motor and cognitive impairment in sub-acute and chronic stroke patients with and without visuo-spatial neglect (VSN) symptoms. The two tools are (i) a series of nine exergames – computer games based on therapeutic principles – aimed at improving exploration of the neglected space, and (ii) the Virtual Peg Insertion Test (VPIT)). It further tested a novel cognitive tool, the Zürich maxi mental status inventory (ZüMAX), and assessed the users’ perspectives on these exergames, together with patients’ experiences on how it is to live with a stroke during inpatient rehabilitation.  

The primary objectives of the thesis were  

• to determine the feasibility of usage of exergames, with minimal therapist supervision, in terms of implementation of the intervention, including adherence, attrition, and safety, and limited efficacy testing, also aiming to evaluate possible effects on VSN symptoms in patient users (feasibility study).
• to assess users’ perspectives (patients and therapists) when using the exergames for rehabilitation of VSN symptoms. Specifically, we wanted to evaluate perceived user-friendliness of the exergames, attitudes towards using them, plus intention to continue to use them in the future (usability study).

Secondary objectives of this thesis were

• to gain knowledge about the quality and level of reporting of exercise training principles used in the rehabilitation of the patient group, plus patient adherence to the prescribed intervention (systematic review).
• to test psychometric properties of a novel VR-based assessment to quantify upper extremity (UE) function in patients with chronic stroke (the VPIT) and of a novel cognitive paper-and-pencil tool to screen for disturbances in neuropsychological function (the ZüMAX) aiming to evaluate their clinical utility (methodological studies).
• to explore everyday life experiences of persons with right hemispheric stroke and spatial neglect symptoms near the end of inpatient rehabilitation (qualitative study). 

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The influence of walking aids on the recovery of gait function and balance following stroke - Clare Maguire 2016

In the general introduction, the prevalence of stroke, resulting disability and global burden of disease are discussed in order to highlight the need for effective and affordable treatment interventions. The requirement of a clear understanding of neurophysiological processes as a basis for the development of effective treatments is debated. These thoughts are considered both in the context of the International Classification of Function (ICF) and in relation to the historical development of many physiotherapeutic, rehabilitative interventions. Current research into walking aids is summarized, indicating that the majority of experimental studies are cross-sectional, testing the immediate, biomechanical effects of assistive devices. It is shown that prospective, experimental studies which consider the neurophysiological impact of walking-aids are lacking. Finally, the aims of the thesis are described. 

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Robotics-assisted treadmill exercise for cardiovascular rehabilitation early after stroke - Oliver Stoller 2015

This dissertation addresses the implementation of cardiovascular exercise early after severe stroke. The aims were: (1) to review the knowledge about the effects of cardiovascular exercise early after stroke, (2) to implement a robotic-based strategy to accomplish recent standards for exercise testing and prescription for severely motor impaired stroke survivors, and (3) to systematically evaluate the concept within a clinical setting.

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Ambulatory rehabilitation in patients with spinal cord injury: A clinical perspective - Markus Wirz 2013

This dissertation addresses ambulatory rehabilitation in patients with a spinal cord injury (SCI). Topics covered include neurophysiology, assessment of walking capacity and ambulatory training.

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Paratonia enlightened : definition, diagnosis, course, riskfactors, and treatment - Hans Hobbelen 2010

Gives an overview of the history behind this thesis. Paratonia is a distinctive muscletone disorder in late stage dementia that, although already noticed and described in 1910, never gained much scientific interest. Paratonia is noted to be of importance in the decline of the quality of life and results in an exponential increase of the carer’s burden in the final stages of dementia. The prevalence of paratonia is estimated on 10% in the early stages towards 90% in the final stages of dementia. In the international literature exists a wide variety of descriptions and limited hypotheses about the origin of paratonia. Passive movement therapy (PMT) is one of the main interventions administered by physiotherapists in Dutch nursing homes to reduce the muscle tone and sustain the range of motion. Although carers claim that this therapy is beneficial physiotherapists have some doubts about the efficacy and this was the main reason to increase the insight into Paratonia. For this we formulated four aims; (1) The realization of a valid description of paratonia. (2) To give the clinician a tool for diagnosing paratonia by which differentiation with other muscle tone disorders can be established. (3) To point out factors that influence the development and severity of paratonia. (4) To answer the question if PMT has any beneficial effect on the severity of paratonia in late stage dementia patients.

Link to dissertation