The purpose of the present study was to investigate the effects of transcranial direct current stimulation (tDCS) on motor recovery in adult patients with stroke, taking into account the parameters that could influence the motor recovery responses. The second aim was to identify the best tDCS parameters and recommendations available based on the enhanced motor recovery demonstrated by the analyzed studies. Our systematic review was performed by searching full-text articles published before February 18, 2019 in the PubMed database. Different methods of applying tDCS in association with several complementary therapies were identified. Studies investigating the motor recovery effects of tDCS in adult patients with stroke were considered. Studies investigating different neurologic conditions and psychiatric disorders or those not meeting our methodologic criteria were excluded. The main parameters and outcomes of tDCS treatments are reported. There is not a robust concordance among the study outcomes with regard to the enhancement of motor recovery associated with the clinical application of tDCS. This is mainly due to the heterogeneity of clinical data, tDCS approaches, combined interventions, and outcome measurements. tDCS could be an effective approach to promote adaptive plasticity in the stroke population with significant positive premotor and postmotor rehabilitation effects. Future studies with larger sample sizes and high-quality studies with a better standardization of stimulation protocols are needed to improve the study quality, further corroborate our results, and identify the optimal tDCS protocols.
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via Motor stroke recovery after tDCS: a systematic review : Reviews in the Neurosciences
Background: A 2015 systematic review evaluated the efficacy of utilizing virtual reality in vestibular rehabilitation programs. However, the biggest limitation with most of the included virtual reality systems was the associated cost of the equipment. In addition, home-based exercises are the preferred method of vestibular rehabilitation treatments.
Objectives: The purpose of this systematic review was to examine the effectiveness of home-based virtual reality systems on vestibular rehabilitation outcomes.
Methods: The following databases were examined: CINAHL Complete, ProQuest Medical Database, and PubMed. The following search terms were utilized: ‘video OR computer’ AND ‘vestibular’ AND ‘home’. The evidence level for all of the included articles was evaluated using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and the methodological rigor for all of the included articles was evaluated using a 10-item tool created by Medlicott and Harris.
Results: Based on the inclusion and exclusion criteria, seven articles were selected for inclusion in this systematic review. This systematic review found that home-based virtual reality interventions were able to effectively achieve the primary objectives of vestibular rehabilitation and that the use of these interventions was equally as effective as the use of a traditional vestibular rehabilitation program. In addition, it may be most beneficial to combine virtual reality with traditional vestibular rehabilitation.
Conclusions: Clinicians should consider using a combination of virtual reality and traditional vestibular rehabilitation when treating individuals who have been diagnosed with a vestibular dysfunction.
via Effectiveness of home-based virtual reality on vestibular rehabilitation outcomes: a systematic review: Physical Therapy Reviews: Vol 0, No 0
Background: Upper limb impairment is a common problem for people with neurological disabilities, affecting activity, performance, quality of life, and independence. Accurate, timely assessments are required for effective rehabilitation, and development of novel interventions. International consensus on upper limb assessment is needed to make research findings more meaningful, provide a benchmark for quality in clinical practice, more cost-effective neurorehabilitation and improved outcomes for neurological patients undergoing rehabilitation.
Aim: To conduct a systematic review, as part of the output of a European COST Action, to identify what recommendations are made for upper limb assessment.
Methods: We systematically reviewed published guidance on measures and protocols for assessment of upper limb function in neurological rehabilitation via electronic databases from January 2007–December 2017. Additional records were then identified through other sources. Records were selected for inclusion based on scanning of titles, abstracts and full text by two authors working independently, and a third author if there was disagreement. Records were included if they referred to “rehabilitation” and “assessment” or “measurement”. Reasons for exclusion were documented.
Results: From the initial 552 records identified (after duplicates were removed), 34 satisfied our criteria for inclusion, and only six recommended specific outcome measures and /or protocols. Records were divided into National Guidelines and other practice guidelines published in peer reviewed Journals. There was agreement that assessment is critical, should be conducted early and at regular intervals and that there is a need for standardized measures. Assessments should be conducted by a healthcare professional trained in using the measure and should encompass body function and structure, activity and participation.
Conclusions: We present a comprehensive, critical, and original summary of current recommendations. Defining a core set of measures and agreed protocols requires international consensus between experts representing the diverse and multi-disciplinary field of neurorehabilitation including clinical researchers and practitioners, rehabilitation technology researchers, and commercial developers. Current lack of guidance may hold-back progress in understanding function and recovery. Together with a Delphi consensus study and an overview of systematic reviews of outcome measures it will contribute to the development of international guidelines for upper limb assessment in neurological conditions.
Worldwide prevalence of stroke in 2010 was 33 million, with 16.9 million people having a first stroke, of which 795,000 were American and 1.1 million European (1). It has been estimated that approximately one third of people fail to regain upper limb capacity, despite receiving therapy (2). This has important implications for both individuals and the wider society as reduced upper limb function is associated with dependence and poor quality of life for both patients and carers (3–5) and impacts on national economies (6).
While stroke has the highest prevalence, other neurological conditions such as Multiple Sclerosis (MS), Spinal Cord Injury (SCI), and Traumatic Brian Injury, have a significant incidence and there are often similarities in presentation, and treatment and therefore assessment. The worldwide incidence of SCI is 40–80 cases per million population and the estimated European mean annual rate of MS incidence is 4.3 cases per 100,000 (7). Recently, Kister et al. (8) reported that 60% of people with MS have impaired hand function. The impact of upper limb dysfunction on ADL is higher than in stroke, as both sides are often affected (9). Although dysfunction after SCI depends on level of injury, upper limb function is consistently cited as a health priority. The incidence rate of TBI in Europe is about 235 per 100,000 population (10). Outcome data among European countries are very heterogeneous. From the US however, it is known that about 1.1% of the population suffer a TBI resulting in long term disability (11).
Continue —> Frontiers | A Systematic Review of International Clinical Guidelines for Rehabilitation of People With Neurological Conditions: What Recommendations Are Made for Upper Limb Assessment? | Neurology
Background: Upper limb impairment is a common problem for people with neurological disabilities, affecting activity, performance, quality of life and independence. Accurate, timely assessments are required for effective rehabilitation, and development of novel interventions. International consensus on upper limb assessment is needed to make research findings be more meaningful, provide a benchmark for quality in clinical practice, more cost-effective neurorehabilitation and improved outcomes for neurological patients undergoing rehabilitation.
Aim: To conduct a systematic review, as part of the output of a European COST Action, to identify what recommendations are made for upper limb assessment.
Methods: We systematically reviewed published guidance on measures and protocols for assessing upper limb function in neurological rehabilitation via electronic databases from January 2007 – December 2017. Additional records were then identified through other sources. Records were selected for inclusion based on scanning of titles, abstracts and full text by two authors working independently, and a third author if there was disagreement. Records were included if they referred to ‘rehabilitation’ and ‘assessment’ or ‘measurement’. Reasons for exclusion were documented.
Results: From the initial 552 records identified (after duplicates were removed), 34 satisfied our criteria for inclusion and only six recommended specific outcome measures and /or protocols. Records were divided into National Guidelines and other practice guidelines published in peer reviewed Journals. There was agreement that assessment is critical, should be conducted early and at regular intervals and that there is a need for standardised measures. Assessments should be conducted by a healthcare professional trained in using the measure and should encompass body function and structure, activity and participation.
Conclusions: We present a comprehensive, critical and original summary of current recommendations. Defining a core set of measures and agreed protocols requires international consensus between experts representing the diverse and multi-disciplinary field of neurorehabilitation including clinical researchers and practitioners, rehabilitation technology researchers and commercial developers. Current lack of guidance may hold-back progress in understanding function and recovery. Together with a Delphi consensus study and an overview of systematic reviews of outcome measures it will contribute to the development of international guidelines for upper limb assessment in neurological conditions.
via Frontiers | A review of international clinical guidelines for rehabilitation of people with neurological conditions: what recommendations are made for upper limb assessment? | Neurology
The Full Outline of UnResponsiveness (FOUR) score assessment of consciousness replaces the Glasgow Coma Scale (GCS) verbal component with assessment of brainstem reflexes. A comprehensive overview studying the relationship between a patient’s FOUR score and outcome is lacking. We aim to systematically review published literature reporting the relationship of FOUR score to outcome in adult patients with impaired consciousness. We systematically searched for records of relevant studies: CENTRAL, MEDLINE, EMBASE, Scopus, Web of Science, ClinicalTrials.gov, and OpenGrey. Prospective, observational studies of patients with impaired consciousness were included where consciousness was assessed using FOUR score, and where the outcome in mortality or validated functional outcome scores was reported. Consensus-based screening and quality appraisal were performed. Outcome prognostication was synthesized narratively. Forty records (37 studies) were identified, with overall low (n = 2), moderate (n = 25), or high (n = 13) risk of bias. There was significant heterogeneity in patient characteristics. FOUR score showed good to excellent prognostication of in-hospital mortality in most studies (area under curve [AUC], >0.80). It was good at predicting poor functional outcome (AUC, 0.80–0.90). There was some evidence that motor and eye components (also GCS components) had better prognostic ability than brainstem components. Overall, FOUR score relates closely to in-hospital mortality and poor functional outcome. More studies with standardized design are needed to better characterize it in different patient groups, confirm the differences between its four components, and compare it with the performance of GCS and its recently described derivative, the GCS-Pupils, which includes pupil response as a fourth component.
Clinicians’ management decisions about acute traumatic brain injury (TBI) patients are guided by assessments of the person’s current state and may also be influenced by their perceptions of its relation to the patient’s likely outcome.1 Internationally, the Glasgow Coma Scale (GCS) is the most widely used tool for assessing and communicating about a patient’s responsiveness.2 All the three components—eye, motor, and verbal responses—relate to outcome,3 as does the derived summation into the GCS score, albeit with some loss of information. Moreover, the GCS is combined with other features, such as pupil response, age, and injury characteristics, in numerous multi-variate prognostic models for predicting functional outcome and mortality.4–6 The difficulty in assigning a verbal response in an intubated patient and the separation of assessment of brain stem features, such as pupil response, in multi-variate modeling stimulated specialists in neurological intensive care to propose an alternative approach.
The Full Outline of UnResponsiveness (FOUR) score was described by Wijdicks and colleagues. It is based on the eye and motor components of the Glasgow system, but the verbal component was removed and two new components added, namely brainstem reflexes and respiratory pattern. The FOUR score was developed for the assessment of level of consciousness in patients admitted to a neurointensive care unit.7 This was with the purpose of improving the standardized assessment of level of consciousness for patients who are intubated or have focal neurological deficits. Each component is a 5-point scale, ranging from 0 to 4, with combined FOUR score ranging from 0 to 16, with 16 indicating the highest level of consciousness. Unlike the GCS, the eyes must be able to track or blink to command in order to obtain the maximum score of 4 points for eye component in FOUR score. Table 1 shows the scoring criteria for all components of FOUR score and GCS. The FOUR score approach emphasizes description of a patient by the combined score and the validity of the latter as an index of acute severity through its relationship to outcome. In order to provide a comprehensive assessment of the latter, we have performed a systematic review of the reported evidence, with focus on prognostic performance in groups of patients particularly targeted by FOUR score, namely those with a neurological diagnosis, intubated patients, and those admitted to dedicated neuroscience centers.
Table 1. Components of the FOUR Score and Glasgow Coma Scale
|Full Outline of UnResponsiveness Score
||Glasgow Coma Scale
4 = eyelids open or opened, tracking, or blinking to command
3 = eyelids open but not tracking
2 = eyelids closed, but open to loud voice
1 = eyelids closed, but open to pain
0 = eyelids remain closed with pain
4 = spontaneous
3 = to speech
2 = to pain
1 = none
4 = thumbs-up, fist, or peace sign
3 = localizing to pain
2 = flexion response to pain
1 = extension response to pain
0 = no response to pain or generalized myoclonus status
|Best motor response
6 = obeying commands
5 = localizing to pain
4 = withdrawal from pain
3 = abnormal flexion response to pain
2 = extension response to pain
1 = none
4 = pupil and corneal reflexes present
3 = one pupil wide and fixed
2 = pupil or corneal reflexes absent
1 = pupil and corneal reflexes absent
0 = absent pupil, corneal and cough reflex
5 = orientated
4 = confused
3 = inappropriate words
2 = incomprehensible sounds
1 = none
4 = not intubated, regular breathing pattern
3 = not intubated, Cheyne-Stokes breathing pattern
2 = not intubated, irregular breathing
1 = breathes above ventilator rate
0 = breathes at ventilator rate or apnea
Continue —> The Relationship of the FOUR Score to Patient Outcome: A Systematic Review | Journal of Neurotrauma
Introduction. Cognitive impairment after stroke has been associated with lower quality of life and independence in the long run, stressing the need for methods that target impairment for cognitive rehabilitation. The use of noninvasive brain stimulation (NIBS) on recovery of language functions is well documented, yet the effects of NIBS on other cognitive domains remain largely unknown. Therefore, we conducted a systematic review that evaluates the effects of different stimulation techniques on domain-specific (long-term) cognitive recovery after stroke.
Methods. Three databases (PubMed, EMBASE, and PsycINFO) were searched for articles (in English) on the effects of NIBS on cognitive domains, published up to January 2018.
Results. A total of 40 articles were included: randomized controlled trials (n = 21), studies with a crossover design (n = 9), case studies (n = 6), and studies with a mixed design (n = 4). Most studies tested effects on neglect (n = 25). The majority of the studies revealed treatment effects on at least 1 time point poststroke, in at least 1 cognitive domain. Studies varied highly on the factors time poststroke, number of treatment sessions, and stimulation protocols. Outcome measures were generally limited to a few cognitive tests.
Conclusion. Our review suggests that NIBS is able to alleviate neglect after stroke. However, the results are still inconclusive and preliminary for the effect of NIBS on other cognitive domains. A standardized core set of outcome measures of cognition, also at the level of daily life activities and participation, and international agreement on treatment protocols, could lead to better evaluation of the efficacy of NIBS and comparisons between studies.
Purpose: To evaluate the effectiveness of the Bobath concept in sensorimotor rehabilitation after stroke.
Materials and methods: A systematic literature review was conducted on the Bobath concept from the first publication available to January 2018, consulting PUBMED, CENTRAL, CINAHL and PEDro databases. Fifteen clinical trials were selected in two consecutive screenings. Two independent researchers rated the studies according to the PEDro scale from which a best evidence synthesis was derived to determine the strength of the evidence.
Results: The Bobath concept is not more effective than other approaches used in post-stroke rehabilitation. There is moderate evidence for the superiority of other therapeutic approaches such as forced use of the affected upper limb and constraint-induced movement therapy for motor control of the upper limb.
Conclusions: The Bobath concept is not superior to other approaches for regaining mobility, motor control of the lower limb and gait, balance and activities of daily living of patients after stroke. There is moderate evidence regarding the superior results of other approaches in terms of the motor control and dexterity of the upper limb. Due to the limitations concerning the methodological quality of the studies, further well-designed studies are needed.
- Implications for rehabilitation
- The Bobath concept is not superior to other approaches for patients after stroke.
- The treatments that incorporate overuse of the affected upper limb via intensive treatments with high-repetitions with or without robotic aids present greater effectiveness in the motor control of the upper limb and dexterity.
Individuals with mild cognitive impairment (MCI) are at heightened risk of developing dementia. Rapid advances in computing technology have enabled researchers to conduct cognitive training and rehabilitation interventions with the assistance of technology. This systematic review aims to evaluate the effects of technology-based cognitive training or rehabilitation interventions to improve cognitive function among individuals with MCI.
We conducted a systematic review using the following criteria: individuals with MCI, empirical studies, and evaluated a technology-based cognitive training or rehabilitation intervention. Twenty-six articles met the criteria.
Studies were characterized by considerable variation in study design, intervention content, and technologies applied. The major types of technologies applied included computerized software, tablets, gaming consoles, and virtual reality. Use of technology to adjust the difficulties of tasks based on participants’ performance was an important feature. Technology-based cognitive training and rehabilitation interventions had significant effect on global cognitive function in 8 out of 22 studies; 8 out of 18 studies found positive effects on attention, 9 out of 16 studies on executive function, and 16 out of 19 studies on memory. Some cognitive interventions improved non-cognitive symptoms such as anxiety, depression, and ADLs.
Technology-based cognitive training and rehabilitation interventions show promise, but the findings were inconsistent due to the variations in study design. Future studies should consider using more consistent methodologies. Appropriate control groups should be designed to understand the additional benefits of cognitive training and rehabilitation delivered with the assistance of technology.
Due to the aging of the world’s population, the number of people who live with dementia is projected to triple to 131 million by the year 2050 [1, 2]. Development of preventative strategies for individuals at higher risk of developing dementia is an international priority [3, 4]. Mild cognitive impairment (MCI) is regarded as an intermediate stage between normal cognition and dementia [5, 6]. Individuals with MCI usually suffer with significant cognitive complaints, yet do not exhibit the functional impairments required for a diagnosis of dementia. These people typically have a faster rate of progression to dementia than those without MCI , but the cognitive decline among MCI subjects has the potential of being improved [7, 8]. Previous systematic reviews of cognitive intervention studies, both cognitive training and cognitive rehabilitation, have demonstrated promising effects on improving cognitive function among subjects with MCI [3, 7, 9, 10].
Recently, rapid advances in computing technology have enabled researchers to conduct cognitive training and rehabilitation interventions with the assistance of technology. A variety of technologies, including virtual reality (VR), interactive video gaming, and mobile technology, have been used to implement cognitive training and rehabilitation programs. Potential advantages to using technology-based interventions include enhanced accessibility and cost-effectiveness, providing a user experience that is immersive and comprehensive, as well as providing adaptive responses based on individual performance. Many computerized cognitive intervention programs are easily accessed through a computer or tablet, and the technology can objectively collect data during the intervention to provide real-time feedback to participants or therapists. Importantly, interventions delivered using technology have shown better effects compared to traditional cognitive training and rehabilitation programs in improving cognitive function and quality of life [11–13]. The reasons for this superiority are not well-understood but could be related to the usability and motivational factors related to the real-time interaction and feedback received from the training system .
Three recent reviews of cognitive training and rehabilitation for use with individuals with MCI and dementia suggest that technology holds promise to improve both cognitive and non-cognitive outcomes [14–16]. The reviews conducted by Coyle, et al.  and Chandler, et al.  were limited by accessing articles from only two databases, and did not comprehensively cover available technologies. Hill, et al.  limited their review to papers published until July 2016 and included only older adults aged 60 and above. More technology-based intervention studies have been conducted since then, and only including studies with older adults 60 and above could limit the scope of the review given that adults can develop early-onset MCI in their 40s . Therefore, the purpose of this review is to 1) capture more studies using technology-based cognitive interventions by conducting a more comprehensive search using additional databases 2) understand the effect of technology-based cognitive interventions on improving abilities among individuals with MCI; and 3) examine the effects of multimodal technology-based interventions and their potential superiority compared to single component interventions.[…]
Continue —-> Technology-based cognitive training and rehabilitation interventions for individuals with mild cognitive impairment: a systematic review