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Training of specific muscles causes plastic changes in corticomotor pathways which may underlie the effect of various clinical rehabilitation procedures. The paired pulse transcranial magnetic stimulation (ppTMS) technique can be used to assess short interval intra-cortical inhibitory (SICI) and intra-cortical facilitatory (ICF) networks. This study examined changes in SICI and ICF in tongue motor cortex after tongue training in 11 healthy volunteers using ppTMS. Paired pulse TMS was applied to the 'hot-spot' for the tongue motor cortex and motor-evoked potentials (MEPs) were recorded from tongue muscles. In tongue motor cortex, bilateral SICI (P < 0.019) and ICF (P < 0.001) was detected before and after training. There were no significant effects of training on single MEPs or SICI/ICF (P > 0.063). The success rate improved during training (P < 0.001) and changes in success were correlated to changes in single MEP amplitude (P < 0.006) but not to SICI/ICF (P > 0.113). This first study of SICI/ICF after tongue training showed no training-related changes in intra-cortical inhibitory or facilitatory networks. However, there was an association between task performance and changes in corticomotor excitability. Further studies are required to determine the clinical utility of muscle specific training for oral rehabilitation purposes.

Background. Recent studies have proposed a role for robotic gait training in participants with acquired brain injury, but the effects on the excitability of cortical and spinal neurons even in healthy participants are uncertain. Objective. To investigate changes in corticospinal excitability in healthy participants after active and passive robotic gait training in a driven gait orthosis (DGO), the Lokomat. Methods. Thirteen healthy participants took part in 2 experiments. Each participant performed 20 minutes of active and passive gait training in a DGO. Motor evoked potentials (MEP), short-interval intracortical inhibition (SICI), intracortical facilitation (ICF), F-wave frequency, and Mmax were measured in the right tibialis anterior muscle before and after training. Results. Active training led to a decline in MEP amplitude and F-wave frequency. The MEP decline was associated with subjective muscle fatigue. Passive training induced a decrease in SICI lasting for 20 minutes after training. Conclusions. The decline in MEP after active training is most likely because of central fatigue, whereas the decreased F-wave frequency might represent short-term plastic changes in the spinal cord. The decrease in SICI after passive training probably reflects a decrease in intracortical GABA activity, which could benefit the acquisition of new motor skills.

To identify predictors of outcome, epilepsy, spasticity and depression one year after severe acquired brain injury.Retrospective cohort study. A consecutive sample of 165 patients with severe acquired brain injury admitted for inpatient rehabilitation during a 18-month time period, was contacted and offered home visits one-year after brain injury. Of the 165 patients 12 did not participate. The cohort included patients with different etiologies primarily traumatic brain injury (65), stroke (25) and subarachnoid hemorrhage (34). Functional independent measure (FIM) was measured at admission at rehabilitation unit and at follow-up. At follow-up the presence of epilepsy, spasticity, and depression was evaluated.Using multiple logistic regression a short length of stay at acute hospital (LOS1) (P=0.004), a high FIM score at admission (P0.001), and low age (P=0.003), were all predictors of good outcome. No difference was found between etiologies (P=0.077). The presence of spasticity was predicted by low FIM score (P0.001), longer LOS1 (P0.036), etiology (P0.001), and lower age (P=0.001). Depression was predicted by higher age (P=0.035).Age, functional status, and length of acute hospital stay are associated with outcome one year after brain injury. The functional outcome was not correlated to etiology.

Introduction. The contribution of hyperreflexia to impairment after stroke is debated. Spinal motoneuron excitability in healthy subjects and stroke patients with and without spasticity was compared. Methods. Twenty-four patients with single stroke more than 6 months ago and 18 gender-matched healthy volunteers were included. Spasticity was assessed according to the Modified Ashworth Scale. Mmax amplitude and F wave frequency in the abductor pollicis brevis muscle were measured by electrical stimulation of the median nerve. Results . Mmax values were comparable between the groups. However, patients with (n = 7) and without (n = 17) clinically evident spasticity had a significant increase in F wave frequency when compared with healthy subjects. F wave frequency did not differ between spastic and nonspastic patients. Discussion. Increase in spinal motoneuron excitability after stroke is present in stroke patients with minor or no motor deficiencies and does not necessarily lead to spasticity.

We investigated the contribution of afferent feedback to the soleus (SOL) muscle activity during the stance phase of walking in patients with spastic stroke. A total of 24 patients with hemiparetic spastic stroke and age-matched healthy volunteers participated in the study. A robotic actuator attached to the foot and leg was used to apply 3 types of ankle perturbations during treadmill walking. First, fast dorsiflexion perturbations were applied to elicit stretch reflexes in the SOL muscle. The SOL short-latency stretch reflex was facilitated in the patients (1.4 +/- 0.3) compared with the healthy volunteers (1.0 +/- 0.3, P = .05). Second, fast plantar flexion perturbations were applied during the stance phase to unload the plantar flexor muscles, thus, removing the afferent input from these muscles to the SOL motoneurons. These perturbations produced a distinct decrease in SOL activity that was significantly smaller in the patients (-30 +/- 3%) compared with the control subjects (-43 +/- 4%, P = .03). Third, slow-velocity, small-amplitude ankle trajectory modifications mimicking small deviations in the walking surface were applied to evaluate the afferent-mediated amplitude modulation of the locomotor SOL electromyogram (EMG). In the healthy volunteers these perturbations generated gradual increments and decrements on the SOL EMG; however, in the patients the SOL EMG modulation was significantly depressed (P = .04). Moreover, this depression was related to the spasticity level measured by the Ashworth score. These results indicate that although the stretch reflex response is facilitated during spastic gait, the contribution of afferent feedback to the ongoing locomotor SOL activity is depressed in patients with spastic stroke.

Lene Odgaard,1 Ingrid Poulsen,2 Lars Peter Kammersgaard,2 Søren Paaske Johnsen,3 Jørgen Feldbæk Nielsen,1 1Hammel Neurorehabilitation Center and University Research Clinic, Aarhus University, Aarhus, Denmark; 2Department of Neurorehabilitation, TBI and Research Unit on Brain injury rehabilitation (RUBRIC), Glostrup Hospital, Copenhagen University, Copenhagen, Denmark; 3Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark Purpose: To identify all hospitalized patients surviving severe traumatic brain injury (TBI) in Denmark and to compare these patients to TBI patients admitted to highly specialized rehabilitation (HS-rehabilitation). Patients and methods: Patients surviving severe TBI were identified from The Danish National Patient Registry and The Danish Head Trauma Database. Overall incidence rates of surviving severe TBI and incidence rates of admission to HS-rehabilitation after severe TBI were estimated and compared. Patient-related predictors of no admission to HS-rehabilitation among patients surviving severe TBI were identified using multivariable logistic regression. Results: The average incidence rate of surviving severe TBI was 2.3 per 100,000 person years. Incidence rates of HS-rehabilitation were generally stable around 2.0 per 100,000 person years. Overall, 84% of all patients surviving severe TBI were admitted to HS-rehabilitation. Female sex, older age, and non-working status pre-injury were independent predictors of no HS-rehabilitation among patients surviving severe TBI. Conclusion: The incidence rate of hospitalized patients surviving severe TBI was stable in Denmark and the majority of the patients were admitted to HS-rehabilitation. However, potential inequity in access to HS-rehabilitation may still be present despite a health care system based on equal access for all citizens. Keywords: database, health care disparities, registries, validity&nbsp

We tested the hypothesis that changes in soleus stretch reflex was correlated to changes in intrathecal baclofen dose in 12 multiple sclerosis patients with moderate-severe spasticity treated with intrathecal baclofen pump. Twice patients were evaluated clinically and biomechanically. The short-latency soleus stretch reflex was elicited by rotating the ankle joint 48 with a velocity from 3.1 to 1808/s. There was a strong correlation between changes in intrathecal baclofen dose and amplitude of the short-latency stretch reflex (r=- 0.88, PB < 0.001), which means that with an increase in baclofen dose there is a decrease in the amplitude. In contrast, no correlation exists between changes in intrathecal baclofen dose and clinical assessment of spasticity by using the Ashworth scale. The amplitude of the stretch reflex was very small (5 mV) compared with previous findings (> 50 μV), which indicates an effective antispastic effect of intrathecal baclofen. We suggest that clinical evaluation of spasticity using Ashworth scale is insensitive to detect minor changes in moderate-severe spasticity and consequently might not be very useful in evaluating spasticity in relation to ambulatory filling of baclofen pumps. The soleus stretch reflex might be useful in situations when there is doubt about the effect of intrathecally administered baclofen.

The study of subliminal perception in normal and brain lesioned subjects has long been of interest to scholars studying the neural mechanisms behind conscious vision. Using brief durations and a developed methodology of introspective reporting, we present an experiment with visual stimuli that gives rise to little or no subliminal perception under normal viewing conditions. Coupled with transcranial magnetic stimulation, however, we find a dissociation between correctness and conscious awareness. Furthermore, we find support for the hypothesis that the ventral projection streams from V1 are necessary for visual consciousness.

Objectives : To study post-exercise facilitation following a non-fatigue exercise in a homogenous group of multiple sclerosis (MS) patients with complaints of muscle fatigue. Methods : In 15 MS patients and matched controls motor evoked potentials (MEP) were recorded from the biceps brachii muscle at time delays of 0.5–30s after an isometric contraction with a torque of 50% of maximal voluntary contraction (MVC) maintained for 2–6s. In addition, MEP was recorded after isometric torque of 25, 50, and 100% of MVC maintained for 6s. Results : Isometric non-fatigue contraction induced significant post-exercise increase in MEP amplitude in MS patients compared with controls being most pronounced after a contraction for 6s. The post-exercise increase in MEP lasted for longer than 30s in MS patients. Conclusions : Post-exercise increase of MEP amplitude following a non-fatigue exercise was significant in MS patients with complaints of muscle fatigue compared with healthy subjects.

Objectives : To characterize so-called central fatigue, the effect of various levels of exercise on central and peripheral motor potentials were compared. Methods : Thirteen healthy subjects performed 4 levels of exercise following isometric dorsiflexion of the foot. Post-exercise recordings from the anterior tibial muscle of motor evoked potentials (MEP) evoked by transcranial magnetic stimulation (TMS) and M wave evoked by electrical stimulation of the peroneal nerve were performed. Results : After 5 s the post-exercise MEP amplitude increased. The increase was related to the degree of work performed. Subsequently, there was a gradually decrease of amplitude reaching statistical significance after 15 min. The area of the M wave increased significantly after 10 s and returned to baseline after 2–3 min. Conclusions : Facilitation and depression of MEP after fatiguing exercise is at least partly a peripheral phenomenon dependent on the level of exercise performed.

The input-output properties of the soleus stretch reflex during walking and sitting were examined in 11 spastic stroke patients and 10 healthy subjects. In the early swing phase, the threshold of the input-output relation was significantly lower in the patient group - on average 108°/s compared to 309°/s in the control group (P=0.02). The slope of the input-output properties was unchanged in patients and in control subjects (P=0.39). In stroke patients we found a minor, but significant, difference in threshold with 108°/s in the early swing phase compared to 74°/s in sitting position at matched TA EMG activity (P=0.01). Furthermore, we found an unchanged slope of 0.25μVs/° during walking and 0.28μVs/° in the sitting position (P=0.21). In contrast, control subjects showed a large difference in the threshold in the early swing phase during walking (309°/s) compared with findings in the sitting position at a matched TA EMG activity (71°/s, P=0.004). The slope was unchanged during walking and when the subject was sitting (P=0.22). There was a significant correlation between clinical spasticity score and stretch reflex threshold in the early swing phase (P=-0.61, P=0.04) and between clinical spasticity score and the slope in the early swing phase (P=0.72, P=0.009). It is concluded that in the early swing phase, the markedly reduced soleus stretch reflex threshold was preventing the stroke patients from making fast dorsiflexion of the foot at the ankle joint and thereby impairing the walking speed.

The effect of repetitive magnetic stimulation at the spinal level on the soleus H-reflex amplitude was evaluated in II MS patients with lower limb spasticity and in nine healthy subjects. In MS patients stimulation with a train of 16 stimuli at 25 Hz induced a decrease in amplitude to 61.2 ± 25.7% of the unconditioned H-reflex amplitude at interstimulus interval (ISI) of 10 - 1000 ms (P < 0.0 1). The amount of decrease in H-reflex amplitude was highly dependent on the stimulation intensity and the placement of the coil, and to a lesser extent influenced by the stimulation frequency. No decrease in motor evoked potentials (MEPs) evoked by transcranial magnetic stimulation was seen following trains of 16 stimuli at mid-thoracic in contrast to the post-stimulation depression in H-reflex amplitude which could imply that mechanisms acting at presynaptic level were involved. In response to repetitive magnetic stimuli for 5 min, a long-lasting decrease in H-reflex amplitude to a level of about 70% of the pre-stimulation H-reflex amplitude occurred in MS patients (P< 0.01 ). A similar although not significant decrease was observed in healthy subjects. We propose that long-lasting depression of the soleus H-reflex amplitude after repetitive magnetic stimuli is due to long-term depression of the synaptic transmission.

Motor evoked potentials were recorded from the first dorsal interosseous muscle on the dominant side evoked by transcranial magnetic stimulation in 20 healthy volunteers. Amplitude data revealed skewness of distribution and variance heterogeneity. Natural logarithmic transformation of amplitude data results in normal distribution and ensures variance homogeneity. There was a negative first-order autocorrelation between consecutive recordings, which indicates that a stimulus-free interval of 5 s in consecutive stimulations is insufficient to ensure independent events. In a variability study, no systematic changes in latency and amplitude during day-to-day examinations or in consecutive examinations were found. There was a significant change in latency data (p = 0.02) during a gradual increase of constant elements in the stimulation procedure, whereas the amplitude data were unchanged. Estimation of random contributors to the total variability in the magnetic stimulation technique was performed. Intersubject differences were the major contributor to the variability of latency data but not to variability of logarithmic amplitude data. The variance estimates of different examiners' contribution to the variability was 0.02 for latency data and 0 for amplitude data. This indicates that staff members familiar with the principles in magnetic stimulation and following a thorough verbal and written instruction in the standardized examination procedure can perform the stimulation procedure without increasing the data variability.

Changes of excitability in the neuraxis were studied in 11 healthy subjects with repetitive transcranial magnetic stimuli of the motor cortex at frequencies of 1-10 Hz. Following trains of four stimuli, compound muscle action potentials (CMAPs) were obtained from the flexor carpi radialis muscle. At an interstimulation interval (ISI) of 100-180 ms. the amplitudes of the CMAPs evoked by stimuli II and IV were inhibited as compared with the amplitude of the CMAPs evoked by the first stimulus. In contrast, the amplitude of the CMAPs evoked by stimulus III was almost unchanged. Changes in excitability depended on the stimulation intensity. Thus, it was demonstrated that the amplitude of the CMAPs evoked by stimulus III was reduced at low stimulation intensities (100 and 110% of threshold intensity) but normalized at higher stimulation intensities (120 and 130% of threshold intensity). Results of H-reflex studies indicated that excitability changes at the segmental level are not necessarily involved in the inhibition of the CMAPs evoked by stimuli II and IV at an ISI of 100 ms. It is proposed that long acting neurotransmitter modulation can explain part of the inhibition during repetitive magnetic stimulation, and that recruitment of different neurons, due to electric field differences, explains the dependence of excitability on stimulation intensity.

In the clinical, neurological examination, the presence of spasticity is evaluated when the patient is asked to relax. Often the clinical examination does not relate to the subjective description of spasticity that the patient experiences during his/her daily motor activities. Several investigations have shown that the input-output properties of spinal neural reflex circuits are a function of the motor task. One reason for the discrepancies between the clinical and subjective description of spasticity could be that the level of spasticity depends on the motor task. In developing methods to quantitate changes in reflex control in persons with spasticity, it might therefore be of importance that such methods are capable of investigating the motor system during different and relevant motor tasks. Here we present a method by which it is possible to quantitate the input-output properties of the stretch reflex during walking in healthy as well as motor impaired subjects.

Central motor pathways were studied in 17 normoalbuminuric insulin-dependent diabetic (IDDM) patients who had been diabetic for more than 20 years, and compared with findings in 17 age-, sex-, and height-matched control subjects. The central motor conduction time was calculated from recordings of the compound muscle action potentials of the abductor pollicis brevis muscle after single transcranial and spinal root magnetic stimulation. The central motor conduction time from motor cortex to cervical spinal roots was 9.8 +/- 1.65 ms in diabetic patients and 10.1 +/- 1.48 ms in control subjects. In diabetic patients with neuropathy the central motor conduction time was 9.5 +/- 1.76 ms vs 10.1 +/- 1.56 ms in patients without neuropathy. The excitability of the motor pathways was studied by paired transcranial magnetic stimulation at interstimulation intervals of 30-1000 ms. In normal control subjects, an early facilitation of the amplitude of the compound muscle action potential at an interstimulation interval of 30 ms was found, while no facilitation was present in diabetic patients. In addition the compound muscle action potential latencies were prolonged at interstimulation intervals of 30-50 ms in diabetic patients. The changes of excitability did not correlate with the presence of peripheral neuropathy, metabolic control or diabetes duration. It is concluded that long-term normoalbuminuric IDDM patients have imparied excitability but normal central conduction time of the motor pathways.

The effect of repetitive magnetic stimulation on spasticity was evaluated in 38 patients with multiple sclerosis in a double-blind placebo-controlled study. One group was treated with repetitive magnetic stimulation (n = 21) and the other group with sham stimulation (n = 17). Both groups were treated twice daily for 7 consecutive days. Primary end-points of the study were changes in the patients self-score, in clinical spasticity score, and in the stretch reflex threshold. The self-score of ease of daily day activities improved by 22% (P = 0.007) after treatment and by 29% (P = 0.004) after sham stimulation. The clinical spasticity score improved -3.3 +/- 4.7 arbitrary unit (AU) in treated patients and 0.7 +/- 2.5 AU in sham stimulation (P = 0.003). The stretch reflex threshold increased 4.3 +/- 7.5 deg/s in treated patients and -3.8 +/- 9.7 deg/s in sham stimulation (P = 0.001). The data presented in this study supports the idea that repetitive magnetic stimulation has an antispastic effect in multiple sclerosis. Future studies should clarify the optimal treatment regimen.

[Background] It is hypothesized that locomotion is achieved by means of rhythm generating networks (central pattern generators) and muscle activation generating networks. This modular organization can be partly identified from the analysis of the muscular activity by means of factorization algorithms. The activity of rhythm generating networks is described by activation signals whilst the muscle intervention generating network is represented by motor modules (muscle synergies). In this study, we extend the analysis of modular organization of walking to the case of robot-aided locomotion, at varying speed and body weight support level., [Methods] Non Negative Matrix Factorization was applied on surface electromyographic signals of 8 lower limb muscles of healthy subjects walking in gait robotic trainer at different walking velocities (1 to 3km/h) and levels of body weight support (0 to 30%)., [Results] The muscular activity of volunteers could be described by low dimensionality (4 modules), as for overground walking. Moreover, the activation signals during robot-aided walking were bursts of activation timed at specific phases of the gait cycle, underlying an impulsive controller, as also observed in overground walking. This modular organization was consistent across the investigated speeds, body weight support level, and subjects. [Conclusions] These results indicate that walking in a Lokomat robotic trainer is achieved by similar motor modules and activation signals as overground walking and thus supports the use of robotic training for re-establishing natural walking patterns., [Results] The muscular activity of volunteers could be described by low dimensionality (4 modules), as for overground walking. Moreover, the activation signals during robot-aided walking were bursts of activation timed at specific phases of the gait cycle, underlying an impulsive controller, as also observed in overground walking. This modular organization was consistent across the investigated speeds, body weight support level, and subjects., [Conclusions] These results indicate that walking in a Lokomat robotic trainer is achieved by similar motor modules and activation signals as overground walking and thus supports the use of robotic training for re-establishing natural walking patterns., This project is funded by Università Degli Studi di Roma “Foro Italico”, research project “Dynamic sensorimotor interaction during locomotion: influences of perturbations and/or body unloading” and by the European Commission, project " BETTER” (contract number 247935).

In healthy subjects, decreasing GABA facilitates motor learning[1]. Recent studies, using PET[2], TMS[3-5], and pharmacological challenges[6], have pointed indirectly to a decrease in neuronal inhibitory activity after stroke. Therefore, we hypothesize that a suppression of GABA levels post stroke might be beneficial to motor recovery during Constraint-Induced Movement Therapy (CIMT).

The primary aim of this study was to investigate the effect of different training types and secondary to test gender differences on the training-related cortical plasticity induced by three different tongue training paradigms: 1. Therapeutic tongue exercises (TTE), 2. Playing computer games with the tongue using Tongue Drive System (TDS) and 3. Tongue-protrusion task (TPT). Forty-eight participants were randomized into 3 groups with 1 h of TTE, TDS, or TPT. Stimulus–response curves of motor evoked potentials (MEPs) and motor cortex mapping for tongue muscles and first dorsal interosseous (FDI) (control) were established using transcranial magnetic stimulation (TMS) at three time-points: (1) before tongue training, (2) immediately after training, (3) 1 h after training. Subject-based reports of motivation, fun, pain and fatigue were evaluated on 0-10 numerical rating scales (NRS) after training. The resting motor thresholds of tongue MEPs were lowered by training with TDS and TPT (P0.335). The tongue cortical motor map areas were not significantly increased by training (P>0.142). Training with TDS was most motivating and fun (P0.071). These findings suggest a differential effect of tongue training paradigms on training-induced cortical plasticity and subject-based scores of fun, motivation and pain in healthy subjects.

Purpose: To identify predictors of outcome, epilepsy, spasticity and depression one year after severe acquired brain injury. Method: Retrospective cohort study. A consecutive sample of 165 patients with severe acquired brain injury admitted for inpatient rehabilitation during a 18-month time period, was contacted and offered home visits one-year after brain injury. Of the 165 patients 12 did not participate. The cohort included patients with different etiologies primarily traumatic brain injury (65), stroke (25) and subarachnoid hemorrhage (34). Functional independent measure (FIM) was measured at admission at rehabilitation unit and at follow-up. At follow-up the presence of epilepsy, spasticity, and depression was evaluated. Results: Using multiple logistic regression a short length of stay at acute hospital (LOS1) (P = 0.004), a high FIM score at admission ( P< 0.001), and low age (P = 0.003), were all predictors of good outcome. No difference was found between etiologies (P = 0.077). The presence of spasticity was predicted by low FIM score ( P< 0.001), longer LOS1 ( P< 0.036), etiology ( P< 0.001), and lower age (P = 0.001). Depression was predicted by higher age (P = 0.035). Conclusions: Age, functional status, and length of acute hospital stay are associated with outcome one year after brain injury. The functional outcome was not correlated to etiology.

Introduction: Neuropathic pain and spasticity after spinal cord injury (SCI) represent still a significant, unresolved problem causing suffering and re¬duced quality of life in patients with SCI. Treatment of neuropathic pain is a complex and difficult task, and many patients have incom¬plete relief from present available and recom¬mended treatment. Palmitoylethanolamide (PEA) is a fatty acid which is produced in many cells in the body. It suggested to potentiate the body’s own canna¬bis-like substances (endocannabinoids) and to reduce pain and inflammation. Clinical trials support the use of PEA on neuro¬pathic pain. So far no studies have been pub¬lished looking at the effect of PEA on neuro¬pathic pain in patients with SCI. Normast is a medical supplement, which con¬tains PEA and is approved for use in Denmark. Aims: The primary aim is to investigate the effect of Normast (PEA) on neuropathic pain, and sec¬ondary to study the effect of Normast on spas¬ticity and psychological functioning in patients with spinal cord injury. Population characteristics: Gender, male/female, n 43/15 Age since inclusion, years, mean (SD) 55.3 (9.5) Time since injury, years, mean (SD) 8.8 (8.9) Present status:Presently, 66 patients (74% male) are included of which 55 have completed the trial. Of those included, 5% have complete tetraplegia, 39% incomplete tetraplegia, 29% complete paraplegia and 27% incomplete paraplegia. Average age at inclusion is 55.3 (±9.5) years and average time since injury is 8.8 (±8.9) years.Causes of injury are 29% transport, 26% fall, 25% unspecified or unknown, 16% other traumatic causes and 4% sports injuries. No major side effects have been reported.The study was financially supported by Region Midtjyllands Sundhedsvidenskabelige Forskningsfond, Hospitalsenheden Midts forskningspulje and PTU. Epitech Group SLR supported by providing Normast and placebo.

Background and PurposeElderly people denote the majority of stroke cases worldwide. Post-stroke sequelae often leadto a more isolated and inactive life and a risk of close relatives being overburdened. The aim of this study was to investigate the effect of a novel self-management intervention targeting elderly people with stroke, on self-efficacy, quality of life and the burden on close relative.MethodsA randomized controlled trial including participants recruited two weeks before discharge from three subacute rehabilitation units was conducted. All participants received usual care. The participants randomized to the intervention group were offered eight self-management sessions of 45–60 min duration by a physiotherapist or an occupational therapist during a period of nine months after discharge as an add-on to usual care. All participants were assessed at baseline, 3 months and 9 months after discharge on the primary outcome measure. The primary outcome was the Stroke Self-Efficacy Questionnaire. Secondary outcomes included a short version of Stroke Specific Quality of Life Scale, the Impact on Participation and Autonomy scale and the Caregiver Burden Scale (only at 3 and 9 months). Data were analysed using mixed models and paired with-in and between analysis when relevant.ResultsSixty-nine individuals aged > 65 years with stroke were randomized. Sixty-six of these had primary outcome registered at baseline. Age participants (years), mean(sd): 76(6); Gender, m/f(%): 50/50; Age relatives (years), mean(sd): 68(11). There was no significant difference between the two groups at baseline. Six patients had loss to follow up at some point during the 9 months' project period but measurements were included when possible. The analysis showed an overall improvement in self-efficacy independent of randomization group. However, the improvement in the intervention group did not significantly differ as compared with the control group, neither in self-efficacy, quality of life nor in impact on participation and autonomy. Moreover, there was no significant difference in change between groups in regard of the caregiver burden scale. However, a significant different level at 3 and 9 months was found between the intervention group and the control group. ConclusionsThe novel self-management intervention did not improve the self-efficacy, quality of life, nor in impact on participation and autonomy compared to usual care for elderly people after stroke. The difference in caregivers' burden scale between the two groups at 3 and 9 months may suggest that the intervention had affected the caregivers already before 3 months. Further exploration is recommended.

Question: There is little knowledge on rest-activity cycles (RAC) in patients with severe acquired brain injury (sABI) during early in-hospital rehabilitation. Consolidated RACs have been linked to improvements in consciousness and function in TBI. This study aims to investigate if patients with sABI displayed unconsolidated RACs at the beginning of rehabilitation, and how these cycles changed over time. Methods: This study was an observational cohort study. All patients admitted to one ward at a rehabilitation hospital were screened consecutively. Patients with a consciousness level < Rancho Los Amigos Scale score III and reduced motor activity due to locked in syndrome or brain injury with comparable motor deficits were excluded. Motor activity were registered using an Actigraph wGTX3-BT device (ACC), starting as early after admission as possible and continuing for 20 days. From the raw vector magnitude, the ratio (Daytime Activity Ratio (DAR)) of activity between daytime (7-22), and the total 24hr activity were calculated per day. Previous research has defined a DAR of ≥ 80% as a consolidated RAC (Duclos, 2014). Prevalence of consolidated RAC in this study was based on the mean DAR of day 1 and 2. In order to describe development over time, the mean DAR of day 19 and 20 was calculated. Change in DAR over time was analyzed using paired t-test. Results: 55 patients were screened and 20 patients could be included for data acquisition. ACC recording started on average (SD) on day 5 (2). In 18 patients there was no missing data in day 1 one and 2 of ACC recording. 56% of 18 patients had a consolidated RAC at the beginning of rehabilitation. At follow up, complete data could be obtained from 15 patients, 80% of 15 patients displayed consolidation of RAC. 9 patients improved their DAR over time while 5 patients had deteriorated DAR. One patient showed no DAR change. When comparing first and last two days a significant mean 5.8% (0.52;11.01, 95% CI) increase in DAR was found p

Background: Assessment of swallowing musculature using motor evoked potentials (MEPs) can be used to evaluate neural pathways. However, recording of the swallowing musculature is often invasive, uncomfortable and unrealistic in normal clinical practise. Suprahyoid muscle complex (SMC) might be a non-invasive reliable neural assessment tool for patients with dysphagia.Objective: To investigate the possibility of using the suprahyoid muscle complex (SMC) using surface electromyography (sEMG) to assess changes to neural pathways by determining the reliability of measurements in healthy participants over days.Methods: Seventeen healthy participants were recruited. Measurements were performed twice with one week between sessions. Single pulse (at 120% and 140% of the resting motor threshold (rMT)) and paired pulse (2 ms and 15 ms paired pulse) transcranial magnetic stimulation (TMS) were used to elicit MEPs in the SMC which were recorded using sEMG.Results: ≈50% of participants (range: 42%-58%; depending on stimulus type/intensity) had significantly different MEP values between day 1 and day 2 for single pulse and paired pulse TMS. A large stimulus artefact resulted in MEP responses that could not be assessed in four participants.Conclusions: The assessment of the SMC using sEMG following TMS was poorly reliable for ≈50% of participants. Although using sEMG to assess swallowing musculature function is easier to perform clinically and more comfortable to patients than invasive measures, as the measurement of muscle activity using TMS is unreliable, the use of sEMG for this muscle group is not recommended and requires further research and development.

Background: Assessment of swallowing musculature using motor evoked potentials (MEPs) can be used to evaluate neural pathways. However, recording of the swallowing musculature is often invasive, uncomfortable and unrealistic in normal clinical practise. Objective: To investigate the possibility of using the suprahyoid muscle complex (SMC) using surface electromyography (sEMG) to assess changes to neural pathways by determining the reliability of measurements in healthy participants over days. Methods: Seventeen healthy participants were recruited. Measurements were performed twice with one week between sessions. Single pulse (at 120% and 140% of the resting motor threshold (rMT)) and paired pulse (2 ms and 15 ms paired pulse) transcranial magnetic stimulation (TMS) were used to elicit MEPs in the SMC which were recorded using sEMG. Results: ≈50% of participants (range: 42%-58%; depending on stimulus type/intensity) had significantly different MEP values between day 1 and day 2 for single pulse and paired pulse TMS. A large stimulus artefact resulted in MEP responses that could not be assessed in four participants. Conclusions: The assessment of the SMC using sEMG following TMS was poorly reliable for ≈50% of participants. Although using sEMG to assess swallowing musculature function is easier to perform clinically and more comfortable to patients than invasive measures, as the measurement of muscle activity using TMS is unreliable, the use of sEMG for this muscle group is not recommended and requires further research and development.

INTRODUCTION: The aim of this study was to examine the use of standardised instruments to describe functioning in stroke patients in the transition from hospital to home-based rehabilitation.METHODS: Questionnaires were sent to 26 hospitals discharging patients with stroke and 52 primary care health services treating stroke patients at home, within an area with a population of three million. Questionnaires were targeted at healthcare professionals who typically take part in home-based stroke rehabilitation asking: "Which instruments, outcome measures or tests are commonly used to describe functioning in persons with stroke?" Instruments routinely used to assess functioning were reported.RESULTS: 85% of the hospitals and 90% of the primary care services returned the questionnaire. 95% of the hospitals and 96% of the primary care services used standardised instruments. Hospitals reported 61 standardised instruments and primary care services reported 60 standardised instruments. A total of 89 standardised instruments were reported. No instrument was used in every hospital or primary care service.CONCLUSIONS: The vast majority of services use standardised instruments, but there is absolutely no consensus on which instruments to use. There is a strong need for recommendations on which instruments should be used in stroke rehabilitation in the transition from hospital-based to home-based rehabilitation.FUNDING: This study was supported by a grant from the Management Forum for Collaboration between Aarhus University and the Central Denmark Region, Denmark. None of the authors have any personal financial interests in the work undertaken or the findings reported.TRIAL REGISTRATION: not relevant.

To enable the evaluation of spasticity during a more functional situation and to determine the degree of which the nervous system regulates muscular mechanical properties the authors have developed a method to investigate the electromyographic and mechanical stretch reflex components during treadmill walking. Here, they report on how the stretch reflex is modulated during walking in spastic patients.

Introduction Patients undergoing rehabilitation after severe acquired brain injuries (sABI) are offered several daytime resting periods (DRPs) each day. DRPs are supposed to consolidate the patient’s motor and cognitive learning processes and to counteract fatigue. These potential effects depend on the quality of the rest achieved during DRPs. Therefore, it is of interest to assess whether quality of rest is measureable in patients who cannot express themselves. To date, no clinically feasible systematic measure of quality of rest has been documented for use in patients with sABI. To evaluate quality of rest, this study explores the possibilities of using staff assessments and objective measures, such as heartrate (HR), measured by electrocardiography (ECG), and motor activity, measured by accelerometer (ACC). Objectives Our aim is to develop a statistical model based on ECG and ACC measures to predict quality of rest as assessed through staff observations. Patients & methods This is an observational study. Patients are recruited from a subacute rehabilitation ward and screened for eligibility according to set criteria: 1st admission to the rehabilitation hospital, referred due to sABI, ≥18 years old, ≤ 7 on the levels of cognitive function scale, closest relative noted in record, not terminal ill, no spinal lesions and absence of paroxysmal sympathetic hyperactivity. Subjects are monitored for 20 days during DRPs. We have implemented a simple staff-administered clinical assessment (CA) for assessing quality of rest. The CA is an ordinal scale containing the categories of quality "Very good" "Good", "Bad", "Very bad" and "Insufficient information to assess quality of DRP". The staff document the CA's after each DRP. The predictive value of the independent variables is analysed. The independent variables are patient characteristics and objective measures of ACC and ECG recorded during the DRPs. From ACC, the motor rest ratio is derived as the percentage of time resting during a DRP. From ECG, the mean HR, HR/Resting HR and selected HR variability estimates from the time domain and the power spectrum are calculated. Results Results are pending. Status per April 15th 2019 is that 21 subjects have been included. Discussion Models that allow evaluating the quality of rest in patients with sABI could be an important contribution to document overall improvement and furthermore guide rehabilitation staff in regards of timing of the DRPs.

It has been hypothesized that the coordinated activation of muscles is controlled by the central nervous system by means of a small alphabet of control signals (also referred to as activation signals) and motor modules (synergies). We analyzed the locomotion of 10 patients recently affected by stroke (maximum of 20 wk) and compared it with that of healthy controls. The aim was to assess whether the walking of subacute stroke patients is based on the same motor modules and/or activation signals as healthy subjects. The activity of muscles of the lower and upper limb and the trunk was measured and used for extracting motor modules. Four modules were sufficient to explain the majority of variance in muscle activation in both controls and patients. Modules from the affected side of stroke patients were different from those of healthy controls and from the unaffected side of stroke patients. However, the activation signals were similar between groups and between the affected and unaffected side of stroke patients, and were characterized by impulses at specific time instants within the gait cycle, underlying an impulsive controller of gait. In conclusion, motor modules observed in healthy subjects during locomotion are different from those used by subacute stroke patients, despite similar impulsive activation signals. We suggest that this pattern is consistent with a neuronal network in which the timing of activity generated by central pattern generators is directed to the motoneurons via a premotor network that distributes the activity in a task-dependent manner determined by sensory and descending control information.

Background Brief measures of health-related quality of life (HRQOL) that assess both patient-reported functioning and well-being after stroke are scarce. The objective of this study was to examine reliability and validity of one of these measures, the patient-reported Quality of Life after Brain Injury–Overall Scale (QOLIBRI-OS), in patients after stroke. Methods Stroke survivors were examined prospectively using survey methods. Core survey data (n = 125) and retest data (n = 36) were obtained at 3 and 12 months, respectively. Item properties (distribution, floor and ceiling effects), psychometric properties (reliability and model fit), and validity (correlations with established measures of anxiety, depression and HRQOL) of the QOLIBRI-OS were examined. Results Missing responses on the questionnaire were low (0.5%). All items were positively skewed. No floor effects were present, whereas five out of six items showed ceiling effects. The summary QOLIBRI-OS score exhibited no floor or ceiling effects, and had excellent internal consistency (Cronbach’s α =0.93). All item-total correlations were high (0.73–0.88). The test-retest reliability of single items varied from 0.74 to 0.91 and was 0.93 for the overall score. The confirmatory factor analysis yielded an excellent fit for a five-item version and provided tentative support for the original six-item version. The convergent validity correlations were in the hypothesized directions, thus supporting the construct validity. Conclusions The brief QOLIBRI-OS is a valid and reliable brief health-related outcome measure that is appropriate for screening HRQOL in patients after stroke.