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Introduction: In recent years, the rehabilitation of children with neurological disorders has taken into account the possibility of using videogaming consoles and virtual reality systems to make children's therapy more enjoyable, motivating, participated and effective. This study aims at conducting a systematic review about the use and the efficacy of digital games in pediatric neurorehabilitation., Evidence Acquisition: In accordance with the PRISMA approach, a rather wide-ranging search was conducted on PubMed, Scopus, and Web of Science databases by using different combinations of keywords based on MeSH terms., Evidence Synthesis: Fifty-five papers have been included into this review, namely, 38 original studies and 17 reviews. The total number of children and adolescents is 573, with 58% of them being affected by cerebral palsy. Despite a wide variability in the adopted protocols, devices, assessment tools, and a more frequent focus on motor aspects than on cognitive ones, the results of the majority of the analyzed studies support the safety (i.e., absence of severe adverse effects) and efficacy of the videogame-based therapy., Conclusions: Videogames, when administered by means of commercial consoles or ad-hoc digital systems, seem to be a valid support for physical therapy. Further researchers are needed to deeply investigate the role of this approach in cognitive therapy and cognitive outcomes.

Active wearable devices such as protective smart belts have been proposed to reduce hip impact in the event of a fall. This study primarily evaluated the feasibility and acceptance of a specific protective belt among selected patients identified as being at risk of falling who were admitted to an ICS Maugeri Neurorehabilitation Unit from September 2022 to April 2023. According to previous institutional observations, the device was worn between the 6th and 21st days of recovery. Out of 435 admitted patients, 118 were considered eligible, but 101 declined to participate (about 50% refused to wear the belt without first trying it on; the other 50% found it too heavy or difficult to manage). Among the 17 patients who accepted (users), 9 used the belt correctly. The remaining eight patients refused to wear it after 24 h, due to discomfort. Out of 435 patients admitted, we observed at least one fall in 49 patients, of whom 5 were eligible patients; 1 was a user who had quickly refused to use the belt and fell with mild damage. Two non-eligible patients and one eligible non-user patient experienced falls resulting in hip fractures; only in the latter case could the use of the belt have limited the damage to the hip. Difficulties in recruiting patients and low acceptance of the proposed intervention present further challenges., Competing Interests: The authors declare no conflicts of interest.

Neurological disorders, such as Parkinson's disease (PD), multiple sclerosis (MS), cerebral palsy (CP) and stroke are well-known causes of gait and balance alterations. Innovative devices (i.e., robotics) are often used to promote motor recovery. As an alternative, anti-gravity treadmills, which were developed by NASA, allow early mobilization, walking with less effort to reduce gait energy costs and fatigue. A systematic search, according to PRISMA guidelines, was conducted for all peer-reviewed articles published from January 2010 through September 2023, using the following databases: PubMed, Scopus, PEDro and IEEE Xplore. After an accurate screening, we selected only 16 articles (e.g., 5 RCTs, 2 clinical trials, 7 pilot studies, 1 prospective study and 1 exploratory study). The evidence collected in this systematic review reported promising results in the field of anti-gravity technology for neurological patients, in terms of improvement in gait and balance outcomes. However, we are not able to provide any clinical recommendation about the dose and parameters of anti-gravity treadmill training, because of the lack of robust high-quality RCT studies and large samples. Registration number CRD42023459665., (© 2024. The Author(s).)

Purpose of Review: While wearable robotics is expanding within clinical settings, particularly for neurological rehabilitation, there is still a lack of consensus on how to effectively assess the performance of these devices. This review focuses on the most common metrics, whose selection and design are crucial for optimizing treatment outcomes and potentially improve the standard care., Recent Findings: The literature reveals that while wearable robots are equipped with various embedded sensors, most studies still rely on traditional, nontechnological methods for assessment. Recent studies have shown that, although quantitative data from embedded sensors are available (e.g., kinematics), these are underutilized in favor of qualitative assessments. A trend toward integrating automatic assessments from the devices themselves is emerging, with a few notable studies pioneering this approach., Summary: Our analysis suggests a critical need for developing standardized metrics that leverage the data from embedded sensors in wearable robots. This shift could enhance the accuracy of patient assessments and the effectiveness of rehabilitation strategies, ultimately leading to better patient outcomes in neurological rehabilitation., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Given the conference's focus on innovative healthcare solutions, our investigation into robotic assistance systems highlights crucial advancements in early motor rehabilitation, aligning closely with emerging healthcare priorities. In combination with conventional therapy, the assistance systems offer new possible therapy programs. They can be used to mobilize and move patients as early as possible. The paper discusses the possibilities that arise from their use and considers the obstacles that arise. As part of a qualitative survey, nine expert interviews from different fields were conducted to guide them on robotic assisted living systems. The results obtained were summarized by coding into categories and evaluated. Our analysis of 148 coding points from nine expert interviews reveals significant insights into the strengths and weaknesses of robotic systems in neurorehabilitation. Each point was meticulously categorized to reflect its impact on both practice and patient outcomes, highlighting the practical implications of our findings. The results of the survey and the literature indicate a positive effect of robotic assistance systems in early rehabilitation. Their use requires intensive monitoring and studies on the long-term application of the systems.

Objective. In recent years, the robot assisted (RA) rehabilitation training has been widely used to counteract defects of the manual one provided by physiotherapists. However, since the proprioception feedback provided by the robotic assistance or the manual methods is relatively weak for the paralyzed patients, their rehabilitation efficiency is still limited. In this study, a dynamic electrical stimulation (DES) based proprioception enhancement and the associated quantitative analysis methods have been proposed to overcome the limitation mentioned above. Approach. Firstly, the DES based proprioception enhancement method was proposed for the RA neural rehabilitation. In the method, the relationship between the surface electromyogram (sEMG) envelope of the specified muscle and the associated joint angles was constructed, and the electrical stimulation (ES) pulses for the certain joint angles were designed by consideration of the corresponding sEMG envelope, based on which the ES can be dynamically regulated during the rehabilitation training. Secondly, power spectral density, source estimation, and event-related desynchronization of electroencephalogram, were combinedly used to quantitatively analyze the proprioception from multiple perspectives, based on which more comprehensive and reliable analysis results can be obtained. Thirdly, four modes of rehabilitation training tasks, namely active, RA, DES-RA, and ES-only training, were designed for the comparison experiment and validation of the proposed DES based proprioception enhancement method. Main results. The results indicated that the activation of the sensorimotor cortex was significantly enhanced when the DES was added, and the cortex activation for the DES-RA training was similar to that for the active training. Meanwhile, relatively consistent results from the multiple perspectives were obtained, which validates the effectiveness and robustness of the proposed proprioception analysis method. Significance. The proposed methods have the potential to be applied in the practical rehabilitation training to improve the rehabilitation efficiency., (© 2024 IOP Publishing Ltd.)

This study evaluates the R3THA™ assessment protocol (R3THA-AP™), a technology-supported testing module for personalized rehabilitation in children with cerebral palsy (CP). It focuses on the reliability and validity of the R3THA-AP in assessing hand and arm function, by comparing kinematic assessments with standard clinical assessments. Conducted during a 4-week summer camp, the study assessed the functional and impairment levels of children with CP aged 3-18. The findings suggest that R3THA is more reliable for children aged 8 and older, indicating that age significantly influences the protocol's effectiveness. The results also showed that the R3THA-AP's kinematic measurements of hand and wrist movements are positively correlated with the Box and Blocks Test Index (BBTI), reflecting hand function and dexterity. Additionally, the R3THA-AP's accuracy metrics for hand and wrist activities align with the Melbourne Assessment 2's Range of Motion (MA2-ROM) scores, suggesting a meaningful relationship between R3THA-AP data and clinical assessments of motor skills. However, no significant correlations were observed between the R3THA-AP and MA2's accuracy and dexterity measurements, indicating areas for further research. These findings validate the R3THA-AP's utility in assessing motor abilities in CP patients, supporting its integration into clinical practice.

Background: Restoring hand functionality is critical for fostering independence in individuals with neurological disorders. Various therapeutic approaches have emerged to address motor function restoration, with music-based therapies demonstrating notable advantages in enhancing neuroplasticity, an integral component of neurorehabilitation. Despite the positive effects observed, there remains a gap in the literature regarding implementing music treatments in neurorehabilitation, such as Neurologic Music Therapy (NMT), especially in conjunction with emerging fields like wearable devices and game-based therapies., Methods: A literature search was conducted in various databases, including PubMed, Scopus, IEEE Xplore, and ACM Digital Library. The search was performed using a literature search methodology based on keywords. Information collected from the studies pertained to the approach used in music therapy, the design of the video games, and the types of wearable devices utilized., Results: A total of 158 articles were found, including 39 from PubMed, 34 from IEEE Xplore, 48 from Scopus, 37 from ACM Digital Library, and 35 from other sources. Duplicate entries, of which there were 41, were eliminated. In the first screening phase, 152 papers were screened for title and abstract. Subsequently, 89 articles were removed if they contained at least one exclusion criterion. Sixteen studies were considered after 63 papers had their full texts verified., Conclusions: The convergence of NMT with emerging fields, such as gamification and wearable devices designed for hand functionality, not only expands therapeutic horizons but also lays the groundwork for innovative, personalized approaches to neurorehabilitation. However, challenges persist in effectively incorporating NMT into rehabilitation programs, potentially hindering its effectiveness., (© 2024. The Author(s).)

Background: Neurological disorders, such as stroke and chronic pain syndromes, profoundly impact independence and quality of life, especially when affecting upper extremity (UE) function. While conventional physical therapy has shown effectiveness in providing some neural recovery in affected individuals, there remains a need for improved interventions. Virtual reality (VR) has emerged as a promising technology-based approach for neurorehabilitation to make the patient's experience more enjoyable. Among VR-based rehabilitation paradigms, those based on fully immersive systems with headsets have gained significant attention due to their potential to enhance patient's engagement., Methods: This scoping review aims to investigate the current state of research on the use of immersive VR for UE rehabilitation in individuals with neurological diseases, highlighting benefits and limitations. We identified thirteen relevant studies through comprehensive searches in Scopus, PubMed, and IEEE Xplore databases. Eligible studies incorporated immersive VR for UE rehabilitation in patients with neurological disorders and evaluated participants' neurological and motor functions before and after the intervention using clinical assessments., Results: Most of the included studies reported improvements in the participants rehabilitation outcomes, suggesting that immersive VR represents a valuable tool for UE rehabilitation in individuals with neurological disorders. In addition, immersive VR-based interventions hold the potential for personalized and intensive training within a telerehabilitation framework. However, further studies with better design are needed for true comparison with traditional therapy. Also, the potential side effects associated with VR head-mounted displays, such as dizziness and nausea, warrant careful consideration in the development and implementation of VR-based rehabilitation programs., Conclusion: This review provides valuable insights into the application of immersive VR in UE rehabilitation, offering the foundation for future research and clinical practice. By leveraging immersive VR's potential, researchers and rehabilitation specialists can design more tailored and patient-centric rehabilitation strategies, ultimately improving the functional outcome and enhancing the quality of life of individuals with neurological diseases., (© 2024. The Author(s).)

Study Design: Prospective Comparative Study., Objective: This study aims to compare the functional outcomes of Robotic-assisted rehabilitation by Lokomat system Vs. Conventional rehabilitation in participants with Dorsolumbar complete spinal cord injury (SCI)., Setting: University level teaching hospital in a hilly state of northern India., Methods: 15 participants with Dorsolumbar SCI with ASIA A neurology were allocated to robotic rehabilitation and 15 participants to conventional rehabilitation after an operative procedure. Pre-and Post-rehabilitation parameters were noted in terms of ASIA Neurology, Motor and sensory function scores, WISCI II score (Walking Index in SCI score), LEMS (Lower Extremity Motor Score), SCI M III score (Spinal Cord Independence Measure III score), AO Spine PROST (AO Patient Reported Outcome Spine Trauma), McGill QOL score (Mc Gill Quality of Life score), VAS score (Visual Analogue Scale) for pain and Modified Ashworth scale for spasticity in lower limbs., Results: On comparing robotic group with conventional group there was a statistically significant improvement in Robotic-assisted rehabilitation group in terms of Motor score (p = 0.034), WISCI II score (p = 0.0001), SCIM III score (p = 0.0001), AO PROST score (p = 0.0001), Mc GILL QOL score (p = 0.0001), Max velocity (p = 0.0001) and Step length (p = 0.0001). Whereas LEMS score (p = 0.052), ASIA neurology (p = 0.264 (ASIA A); 1.000 (ASIA B); 0.053 (ASIA C)), VAS score (p = 0.099), Sensory score (p = 0.422) and Modified Ashworth scale for spasticity (p = 0.136) were not statically significant when comparing between two groups., Conclusion: Robot-assisted rehabilitation is superior than conventional rehabilitation in people living with SCI with AIS A neurology. Differences in the patient group, type of a lesion its and severity, duration from onset to initiation of rehabilitation, devices employed, administration of the therapies and regulation of interventions are likely the cause of variations in the findings seen in the literature for robotic assisted training., Level of Evidence: III., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Objective: To systematically review the effects of robotic rehabilitation with the Erigo ® device on patients with neurological injury on safety, spasticity, muscle strength, functionality, gait/balance, and changes in the level of consciousness., Methods: MEDLINE, SciELO, EMBASE, The Cochrane Library - CENTRAL and PEDro databases were consulted without the restriction of date and language. Randomized controlled trials that evaluated the robotic rehabilitation and compared it to conventional or placebo therapy, isolated or in association with other therapy, were selected. Studies in which the treatment time was less than 10 sessions were excluded. The risk of bias was assessed with the use of the RoB 2.0 tool., Results: Nine studies were included, totaling 347 patients. The robotic rehabilitation performed by the Erigo ® device proved to be safe for neurological patients. The meta-analysis showed an improvement for spasticity (MD = 0.29; 95% CI = -0.49 to -0.08; I 2 = 0%), but there was no significant increase in muscle strength in patients with stroke (MD = 0.25; CI 95% = -0.22 to -0,71; I 2 = 0%). Erigo ® showed inconclusive effects on functionality, gait/balance and level of consciousness in patients with severe acquired brain injury and vegetative or minimally conscious state. All studies present some concerns for the risk of bias., Conclusion: Erigo ® as a robotic rehabilitation strategy is safe for patients with acquired brain injury and appears to reduce spasticity in patients with stroke. The effects on muscle strength, functionality, gait and balance and level of consciousness remain uncertain and the methodological quality of the clinical trials included in this review is limited.

Spinal cord injury (SCI) results in neurological deficits below the level of injury, causing motor dysfunction and various severe multisystem complications. Rehabilitative training plays a crucial role in the recovery of individuals with SCI, and exoskeleton serves as an emerging and promising tool for rehabilitation, especially in promoting neuroplasticity and alleviating SCI-related complications. This article reviews the classifications and research progresses of medical exoskeletons designed for SCI patients and describes their performances in practical application separately. Meanwhile, we discuss their mechanisms for enhancing neuroplasticity and functional remodeling, as well as their palliative impacts on secondary complications. The potential trends in exoskeleton design are raised according to current progress and requirements on SCI rehabilitation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

After a neurological injury, neurorehabilitation aims to restore sensorimotor function of patients. Technological assessments can provide high-quality data on a patient's performance and support clinical decision making towards the most appropriate therapy. In this study, the ArmeoPower, a robotic exoskeleton for the upper extremities, was used to assess 12 neurological patients and 31 non-disabled participants performing various standardized single joint and frontal plane game-like exercises. From the collected data, kinematic metrics (End-Point Error, Hand-Path Ratio, reaction time, stability, Number of Velocity Peaks, peak, and mean Velocity) and the game score, were calculated and analyzed according to three criteria: the reliability (a), the difference between patients and non-disabled participants (b), as well as the influence of robotic movement assistance (c). In total, 39 metrics were analyzed and the following five most promising assessment variables for different exercises could be identified based on the three above-mentioned criteria: smoothness (RainMug (wrist)), mean speed (RainMug (wrist)), reaction time (Goalkeeper), maximum speed (HighFlyer (elbow)) and accuracy (Connect the dots), with the former showing good validity (rho=0.82, p=0.02) when comparing to the patient's severity level. The results demonstrate feasibility to extract and analyze various kinematic metrics from the ArmeoPower, which can provide quantitative information about human performance during training and therapy. The generated data increases the understanding of the patient's movement and can be used in the future in clinical research for better performance evaluation and providing more feedback options, leading towards a more personalized and patient-centric therapy.

Robotic rehabilitation has been shown to match the effects of conventional physical therapy on motor function for patients with neurological diseases. Rehabilitation robots have the potential to reduce therapists' workload in time-intensive training programs as well as perform actions that are not replicable by human therapists. We investigated the effects of one such modality that cannot be achieved by a human therapist: assistance and resistance within the electromechanical delay between muscle activation and muscle contraction during arm extension. We found increased muscle activation when providing robotic assistance within this electromechanical delay. Assistance provided within this delay moves the participant's arm quicker than their own muscle and increases the subsequent peak voluntary muscle activation compared to normal arm extension by 68.97 ± 80.05 % (SE = 0.021; p = 0.007 ). This is surprising since all previous literature shows that muscle activation either decreases or does not change when participants receive robotic assistance. As a consequence, traditional robotic rehabilitation incrementally reduces assistance as the patient improves to maintain levels of muscle activation which is suggested to be important for neuronal repair. The present result may enable therapists to no longer have to choose between providing assistance or increasing muscle activation. Instead, therapists may be able to provide assistance while also increasing muscle activation.

A spinal cord injury interrupts the communication between the brain and the region of the spinal cord that produces walking, leading to paralysis 1,2 . Here, we restored this communication with a digital bridge between the brain and spinal cord that enabled an individual with chronic tetraplegia to stand and walk naturally in community settings. This brain-spine interface (BSI) consists of fully implanted recording and stimulation systems that establish a direct link between cortical signals 3 and the analogue modulation of epidural electrical stimulation targeting the spinal cord regions involved in the production of walking 4-6 . A highly reliable BSI is calibrated within a few minutes. This reliability has remained stable over one year, including during independent use at home. The participant reports that the BSI enables natural control over the movements of his legs to stand, walk, climb stairs and even traverse complex terrains. Moreover, neurorehabilitation supported by the BSI improved neurological recovery. The participant regained the ability to walk with crutches overground even when the BSI was switched off. This digital bridge establishes a framework to restore natural control of movement after paralysis., (© 2023. The Author(s).)

The body weight support rehabilitation training system has now become an important treatment method for the rehabilitation of lower limb motor dysfunction. In this paper, a pelvic brace body weight support rehabilitation system is proposed, which follows the center of mass height (CoMH) of the human body. It aims to address the problems that the existing pelvic brace body weight support rehabilitation system with constant impedance provides a fixed motion trajectory for the pelvic mechanism during the rehabilitation training and that the patients have low participation in rehabilitation training. The system collectes human lower limb motion information through inertial measurement unit and predicts CoMH through artificial neural network to realize the tracking control of pelvic brace height. The proposed CoMH model was tested through rehabilitation training of hemiplegic patients. The results showed that the range of motion of the hip and knee joints on the affected side of the patient was improved by 25.0% and 31.4%, respectively, and the ratio of swing phase to support phase on the affected side was closer to that of the gait phase on the healthy side, as opposed to the traditional body weight support rehabilitation training model with fixed motion trajectory of pelvic brace. The motion trajectory of the pelvic brace in CoMH mode depends on the current state of the trainer so as to realize the walking training guided by active movement on the healthy side of hemiplegia patients. The strategy of dynamically adjustment of body weight support is more helpful to improve the efficiency of walking rehabilitation training.

Motor neurons convey information about motor intent that can be extracted and interpreted to control assistive devices. However, most methods for measuring the firing activity of single neurons rely on implanted microelectrodes. Although intracortical brain-computer interfaces (BCIs) have been shown to be safe and effective, the requirement for surgery poses a barrier to widespread use that can be mitigated by instead using noninvasive interfaces. The objective of this study was to evaluate the feasibility of deriving motor control signals from a wearable sensor that can detect residual motor unit activity in paralyzed muscles after chronic cervical spinal cord injury (SCI). Despite generating no observable hand movement, volitional recruitment of motor units below the level of injury was observed across attempted movements of individual fingers and overt wrist and elbow movements. Subgroups of motor units were coactive during flexion or extension phases of the task. Single digit movement intentions were classified offline from the electromyogram (EMG) power [root-mean-square (RMS)] or motor unit firing rates with median classification accuracies >75% in both cases. Simulated online control of a virtual hand was performed with a binary classifier to test feasibility of real-time extraction and decoding of motor units. The online decomposition algorithm extracted motor units in 1.2 ms, and the firing rates predicted the correct digit motion 88 ± 24% of the time. This study provides the first demonstration of a wearable interface for recording and decoding firing rates of motor units below the level of injury in a person with motor complete SCI. NEW & NOTEWORTHY A wearable electrode array and machine learning methods were used to record and decode myoelectric signals and motor unit firing in paralyzed muscles of a person with motor complete tetraplegia. The myoelectric activity and motor unit firing rates were task specific, even in the absence of visible motion, enabling accurate classification of attempted single-digit movements. This wearable system has the potential to enable people with tetraplegia to control assistive devices through movement intent.

Objective: Technology is being increasingly used for physical assessment and interventions in health care settings. However, clinical adoption is relatively slow, and the factors affecting use remain underexplored. This study aimed to investigate factors influencing technology use by clinicians working in neurorehabilitation., Methods: In this qualitative study, 9 physical therapists and 9 occupational therapists (N = 18) were recruited from urban and regional locations in Australia and in Singapore. Three 60-minute focus groups were conducted via video conferencing. Each group comprised 3 physical therapists and 3 occupational therapists working across different neurorehabilitation settings. Participants were asked to discuss which technologies they used in their workplace for physical assessment and treatment and barriers, motivators, and future desires for technology use. Transcripts were analyzed independently using an inductive approach to generate codes and themes., Results: Our results comprised 3 themes and 7 categories. These were encompassed by a single overarching theme, namely "Technology use is influenced by the benefits and challenges of the technology itself, users, and organizational context." Themes showed that technology should promote effective interventions, is preferred if easy to use, and should be dependable. Furthermore, clinical reasoning is important, and users have varying levels of receptivity and confidence in technology use. Also, organizational resources are required, along with supportive cultures and processes, to facilitate technology use., Conclusions: The themes identified multiple and interlinking factors influencing clinicians' use of technology in neurorehabilitation settings. Clinicians often consider context-specific benefits and challenges when deciding whether to use technology. Although our study found that clinicians generally perceived technology as having a beneficial role in improving health outcomes, there were several challenges raised. Therefore, the characteristics of the technology itself, individual users, and organizational context should be considered., Impact: These findings will guide successful technology implementation and future developments., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Aim: This study was aimed to investigate the acute effects of kinesiology taping (KT) on physical performance, gait characteristics, and balance in early-stage Duchenne Muscular Dystrophy (DMD)., Method: Forty-five children at early functional level of DMD were included. 6-minute walk test (6MWT), and timed performance tests were performed; gait characteristics, and balance were assessed before and one hour after taping. KT was applied to bilateral quadriceps and tibialis anterior muscles. The comparison of assessments was performed by using Wilcoxon Signed Ranks test., Results: Significant increase in the distance of 6MWT, decrease in the duration of descending 4 steps, and 10 m walk timed performance tests, improvements in all of the gait characteristics, and balance were determined after taping ( p < .05)., Conclusions: KT has positive acute effects on performance and gait of children with DMD at early functional level which encourages therapists to use KT as a complementary approach in rehabilitation programs.

A method for EEG-based distraction detection during motor-rehabilitation tasks is proposed. A wireless cap guarantees very high wearability with dry electrodes and a low number of channels. Experimental validation is performed on a dataset from 17 volunteers. Different feature extractions from spatial, temporal, and frequency domain and classification strategies were evaluated. The performances of five supervised classifiers in discriminating between attention on pure movement and with distractors were compared. A k-Nearest Neighbors classifier achieved an accuracy of 92.8 ± 1.6%. In this last case, the feature extraction is based on a custom 12 pass-band Filter-Bank (FB) and the Common Spatial Pattern (CSP) algorithm. In particular, the mean Recall of classification (percentage of true positive in distraction detection) is higher than 92% and allows the therapist or an automated system to know when to stimulate the patient's attention for enhancing the therapy effectiveness.

Background: The Andago is a rehabilitation robot that allows training walking over-ground while providing bodyweight unloading (BWU). We investigated the practicability, acceptability, and appropriateness of the device in children with gait impairments undergoing neurorehabilitation. Concerning appropriateness, we investigated whether (i) stride-to-stride variability of the stride time and inter-joint coordination was higher when walking over-ground in Andago versus treadmill walking, and (ii) activation of antigravity leg muscles decreased with higher levels of BWU., Methods: Eighteen children and adolescents with gait impairments participated in three sessions. Practicability was assessed by determining the time needed to get a patient in and out of Andago, the accuracy of the BWU system, and other aspects. Acceptability was assessed by patients responding to questions, while six therapists filled out the System Usability Scale. To determine appropriateness, the participants were equipped with surface electromyography (sEMG) electrodes, electrogoniometers and accelerometers. Various parameters were compared between walking over-ground and on a treadmill, and between walking with three different levels of BWU (median: 20%, 35% and 50% of the bodyweight) over-ground., Results: Practicability: the average time needed to get in and out of Andago amounted to 60 s and 16 s, respectively. The BWU system seemed accurate, especially at higher levels. We experienced no technical difficulties and Andago prevented 12 falls. However, participants had difficulties walking through a door without bumping into it. Acceptability: after the second session, nine participants felt safer walking in Andago compared to normal walking, 15 preferred walking in Andago compared to treadmill walking, and all wanted to train again with Andago. Therapists rated the usability of the Andago as excellent. Appropriateness: stride-to-stride variability of stride duration and inter-joint coordination was higher in Andago compared to treadmill walking. sEMG activity was not largely influenced by the levels of BWU investigated in this study, except for a reduced M. Gluteus Medius activity at the highest level of BWU tested., Conclusions: The Andago is a practical and well-accepted device to train walking over-ground with BWU in children and adolescents with gait impairments safely. The system allows individual stride-to-stride variability of temporospatial gait parameters without affecting antigravity muscle activity strongly., Trial Registration: ClinicalTrials.gov Identifier: NCT03787199.

Neural prostheses are designed to counter the effects of neurotrauma and restore the fundamental building blocks of human experience including motor action, sensation, and meaningful communication with other individuals. Here, we present an overview of active avenues, open questions, and debated topics in neuroprosthetics, such as targeting the mechanisms of sensorimotor recovery and designing brain interfaces for scalability. We review leading opinions in this thriving field, aiming to inform translational practice toward clinical adoption.

Functional electrical stimulation (FES) has been widely adopted to elicit muscle contraction in rehabilitation training after spinal cord injury (SCI). Conventional FES modalities include stimulations coupled with rowing, cycling, assisted walking and other derivatives. In this review, we studied thirteen clinical reports from the past 5 years and evaluated the effects of various FES aided rehabilitation plans on the functional recovery after SCI, highlighting upper and lower extremity strength, cardiopulmonary function, and balder control. We further explored potential mechanisms of FES using the Hebbian theory and lumbar locomotor central pattern generators. Overall, FES can be used to improve respiration, circulation, hand strength, mobility, and metabolism after SCI.

Objective : The study evaluated a smartphone-aided program to support independent access to leisure events and performance of daily activities in seven participants with moderate intellectual disability, four of whom also had severe hearing loss. Method : The program relied on the use of a Samsung Galaxy J4 Plus smartphone with Android 9.0 operating system. The smartphone's functioning was automated via the MacroDroid application. The program was to allow the participants to alternate access to leisure events (delivered via the smartphone) with performance of vocational activities (guided through smartphone-delivered pictorial or pictorial and verbal instructions) over sessions of about 30 min. Results : During the baseline, the participants failed to access leisure events and perform scheduled activities independently. When the program was used, however, all participants succeeded in both accessing leisure events and performing activities independently. Conclusions : The smartphone-aided program can be a useful tool for people like the participants of this study.

Clinicians and researchers have become increasingly interested in the potential of technology in assisting persons with dementia (PwD). However, several issues have emerged in relation to how studies have conceptualized who the main technology user is (PwD/carer), how technology is used (as compensatory, environment modification, monitoring or retraining tool), why it is used (i.e., what impairments and/or disabilities are supported) and what variables have been considered as relevant to support engagement with technology. In this review we adopted a Neuropsychological Rehabilitation perspective to analyse 253 studies reporting on technological solutions for PwD. We analysed purposes/uses, supported impairments and disabilities and how engagement was considered. Findings showed that the most frequent purposes of technology use were compensation and monitoring, supporting orientation, sequencing complex actions and memory impairments in a wide range of activities. The few studies that addressed the issue of engagement with technology considered how the ease of use, social appropriateness, level of personalization, dynamic adaptation and carers' mediation allowed technology to adapt to PWD's and carers' preferences and performance. Conceptual and methodological tools emerged as outcomes of the analytical process, representing an important contribution to understanding the role of technologies to increase PwD's wellbeing and orient future research.

Aims : This study aims to compare the total heart beat index (THBI) in evaluating energy efficiency between using a manual wheelchair and walking for children with cerebral palsy (CP). Methods : The energy efficiency was measured in 21 participants with CP (mean age, 13.6 ± 3.4 years) who walk or drive a manual wheelchair using a square course. THBI was calculated as total number of heart beats during the exercise period/total distance traveled. Results : Significant differences in the THBI were observed between Gross Motor Function Classification System (GMFCS) levels III and IV ( p = .049, effect size = 1.60). No significant differences in THBI were observed between GMFCS levels II and III or between GMFCS levels II and IV ( p > .05). Conclusions : The energy efficiency of children with CP who use a manual wheelchair in this study was equal to or better than that for walking.

Background: In recent years, a remarkable trend in neurorehabilitation is the combination of conventional methods and emerging technologies, such as robotic platforms with virtual reality (VR), Serious Games (SG) and other types of sophisticated graphic interfaces. The aim of the present study is to evaluate the influence on the user's mental workload of the degree of graphic detail present in this kind of environments, comparing the experience of subjects working with two graphical environments with the same physical load but radically different graphic detail levels., Methods: The same therapy is performed by 52 healthy subjects in two totally different graphic environments, one rich in details and visual stimuli, and its schematic version focusing just in the target graphic elements. Autonomic Nervous System (ANS) activity, related to emotional state, is analyzed through the capture and processing of associated physiological signals. The SAM test is used to assess the subjective perception of the participants in order to establish a relationship with the calculated physiological parameters., Results: Indexes calculated from the ANS physiological signals show significant differences between the basal state and those corresponding to the performance of the therapies but do not allow discriminating between the effects of performing a therapy based on an environment rich in stimuli and an austere one. In the case of subjective perceptions, based on the results of the SAM test, the subjects perceive significant differences between the basal stage and the therapies, and also between each of the two graphic environments., Conclusions: Users reflected that a graphic environment rich in detail was more pleasant and attractive than a schematic one. However, this is not reflected in values obtained from their physiological activity, which suggests that more research is needed about the online inference of the emotional state of the subject from the record of his physiological activity., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier B.V.)

Study Design: A pre-post observational study., Objectives: To evaluate the safety and feasibility of a new rehabilitation robotic device for assisting individuals with lower extremity motor complete lesions following spinal cord injury (SCI)., Setting: Three hospitals in Sichuan Province, China., Methods: Individuals aged 15-75 years with an SCI between vertebrae six (T6) and lumbar 1 (L1) and complete motor paralysis participated in an exoskeletal-assisted walking (EAW) programme (2 weeks, 5 days/week, 30 min/day). Data were collected pre-, mid- (week 1) and post-intervention (week 2)., Results: Twenty-eight individuals (mean age = 41.3, 71% males) participated in the EAW programme. The distance walked during the 6-min walking test (6MWT) increased relative to that at baseline, during week 1 (13.0 ± 5.3 m) and week 2 (16.2 ± 5.3 m) when wearing the exoskeleton. The walking speed during the 10-m walking test (10MWT) increased from 0.039 ± 0.016 to 0.045 ± 0.016 m/s. The Hoffer walking ability grade, the Spinal Cord Independence Measure (SCIM), and the Walking Index for SCI II (WISCI II) changed after 2 weeks of EAW. No improvement in lower extremity motor score (LEMS) was observed. The rates of adverse events and serious adverse events were 21% and 4%, respectively., Conclusions: The EAW programme with the new robotic exoskeleton provided potential meaningful improvements in mobility for individuals with SCI and had few adverse events.

Background . People with Parkinson's disease and freezing of gait (FOG+) have more falls, postural instability and cognitive impairment compared with FOG-. Objective . To conduct a secondary analysis of the V-TIME study, a randomized, controlled investigation showing a greater reduction of falls after virtual reality treadmill training (TT + VR) compared with usual treadmill walking (TT) in a mixed population of fallers. We addressed whether these treadmill interventions led to similar gains in FOG+ as in FOG-. Methods . A total of 77 FOG+ and 44 FOG- were assigned randomly to TT + VR or TT. Participants were assessed pre- and posttraining and at 6 months' follow-up. Main outcome was postural stability assessed by the Mini Balance Evaluation System Test (Mini-BEST) test. Falls were documented using diaries. Other outcomes included the New Freezing of Gait Questionnaire (NFOG-Q) and the Trail Making Test (TMT-B). Results . Mini-BEST scores and the TMT-B improved in both groups after training ( P = .001), irrespective of study arm and FOG subgroup. However, gains were not retained at 6 months. Both FOG+ and FOG- had a greater reduction of falls after TT + VR compared with TT ( P = .008). NFOG-Q scores did not change after both training modes in the FOG+ group. Conclusions . Treadmill walking (with or without VR) improved postural instability in both FOG+ and FOG-, while controlling for disease severity differences. As found previously, TT + VR reduced falls more than TT alone, even among those with FOG. Interestingly, FOG itself was not helped by training, suggesting that although postural instability, falls and FOG are related, they may be controlled by different mechanisms.

Background and Purpose . The use of virtual reality (VR) therapy among individuals with spinal cord injury (SCI) is a relatively new rehabilitation approach replicating real-life scenarios. The aim of this study was to evaluate the effectiveness of VR therapy for improving gait and balance in individuals with SCI. Methods . Databases of PubMed, Web of Science, Scopus, SportDiscuss, and CINHAL were searched from inception until September 2019. Two independent reviewers screened articles for inclusion, extracted data, and evaluated methodological quality of the trials. Results . Ten trials, including 3 randomized clinical trials (RCTs) and 7 pre-post trials, with a total of 149 participants were analyzed. Meta-analysis of RCTs demonstrated significant improvement in sitting balance (standardized mean difference [SMD] = 1.65; 95% CI 1.21-2.09; P < .01) after VR therapy with conventional rehabilitation compared with only conventional rehabilitation. Also, pre-post studies using VR therapy without a control group showed improvement in standing balance (Berg Balance Scale, MD = 4.22; 95% CI 1.78-6.66; P < .01 and Activities-specific Balance Confidence scale, MD = 8.53; 95% CI 2.52-14.53; P = .01) and a trend for improvement in gait (SMD = 0.34; 95% CI 0.02-0.66; P = .04). Conclusion . This study demonstrated the beneficial effects of VR therapy to enhance sitting and standing balance and showed a trend of gait improvement in individuals with SCI. This conclusion is based on mainly preliminary data and therefore, more RCTs are needed to confirm the effects of the use of VR in individuals with SCI.

The single-joint Hybrid Assistive Limb (HAL-SJ) robot is an exoskeleton-type suit developed for the neurorehabilitation of upper limb function. Several studies have addressed the usefulness of the robot; however, the appropriate patient selection remains unclear. In this study, we evaluated the effectiveness of the HAL-SJ exoskeleton in improving upper limb function in the subacute phase after a stroke, as a function of the severity of arm paralysis. Our analysis was based on a retrospective review of 35 patients, treated using the HAL-SJ exoskeleton in the subacute phase after their stroke, between October 2014 and December 2018. The severity of upper limb impairment was quantified using the Brunnstrom recovery stage (BRS) as follows: severe, BRS score 1-2, n = 10; moderate, BRS 3-4, n = 12; and mild, BRS 5-6, n = 13. The primary endpoint was the improvement in upper limb function, from baseline to post-intervention, measured using the Fugl-Meyer assessment upper limb motor score (ΔFMA-UE; range 0-66). The ΔFMA-UE score was significant for all three severity groups (P <0.05). The magnitude of improvement was greater in the moderate group than in the mild group (P <0.05). The greatest improvement was attained for patients with a moderate level of upper limb impairment at baseline. Our findings support the feasibility of the HAL-SJ to improve upper limb function in the subacute phase after a stroke with appropriate patient selection. This study is the first report showing the effect of robot-assisted rehabilitation using the HAL-SJ, according to the severity of paralysis in acute stroke patients with upper extremity motor deficits.

Background: Parkinson's disease (PD) is a neurodegenerative disorder characterized by various motor symptoms including balance and gait impairment. Several studies have shown that physiotherapy, cueing techniques, treadmill training, and cognitive movement strategies are useful in improving balance and gait in patients with PD. Devices employing virtual reality (VR) have been shown to be promising in neurorehabilitation as they can provide the patients with multisensory stimulation creating a realistic environment and improve the motivation and the adhesion of patients to the rehabilitation program. This preliminary study is aimed at testing the efficacy and feasibility of gait training based on the computer-assisted virtual reality environment (CAREN) in a sample of PD., Methods: In this preliminary study, 22 outpatients affected by PD who attended the Behavioral and Robotic Neurorehab Laboratory of the IRCCS Neurolesi between August 2017 and October 2018 were enrolled. All PD patients underwent 20 conventional physiotherapy sessions followed by 3-month of rest. Then, the patients were provided with 20 sessions of CAREN training. Gait and balance performances were rated before, after each training protocol, and 3 months later. Gait analysis was also performed before and after CAREN training., Results: All patients completed both of the rehabilitation trainings without any adverse event. All considered scales improved significantly at the end of both rehabilitation treatments. However, patients presented with a greater clinical improvement after the CAREN training, compared with conventional physiotherapy. In particular, patients walked faster and with more stability, with wider, longer steps., Conclusions: Even though further neurophysiological details are required to identify the patients who may benefit from CAREN training, our findings suggest that this innovative device is an effective and feasible tool to train balance and gait in patients with PD.

Children with complex disabilities sometimes have difficulty communicating with their parents, caregivers, and teachers. For these children, eye gaze assistive technology can be used to facilitate communication. Eye gaze assistive technology outcomes for children and youth were analyzed in this systematic review. Database and hand-searches yielded 4412 unduplicated results, of which 11 articles were eligible for this review. Outcome measures, as well as environmental and personal factors, were mapped to the World Health Organization's International Classification of Functioning, Disability and Health framework. Communication outcomes were most prevalent and co-occurred with outcomes in all reported activities and participation domains. Environmental and personal factors were classified as either facilitators or as barriers in relation to device uptake and success. Although comprehensive professional and caregiver support was the primary facilitator for success, barriers could lead to rejection of the technology even when children were successful using the system.

Background: Many studies showed that robot-assisted gait training might improve walking of patients after stroke. The question remains whether patients with other neurological diagnoses can improve their ability to walk by training in a gait center. Aim of the present study was therefore to investigate the effects of a gait center training in inpatient neurological rehabilitation on walking ability., Methods: We implemented a gait center training in addition to individual inpatient rehabilitation. Our primary outcome was walking ability based on the Functional Ambulation Categories (FAC). Our secondary outcomes were vital capacity and blood pressure. We predefined subgroups of patients with ischemic and hemorrhagic stroke and critical illness myopathy (CIM) and polyneuropathy (CIP)., Results: We included 780 patients from our inpatient rehabilitation center in our cohort study. We analyzed 329 patients with ischemic, 131 patients with hemorrhagic stroke and 74 patients with CIP/ CIM. A large number of patients were able to improve their ability to walk. At the end of rehabilitation, patients with ischemic stroke and FAC 3 = increased theirFAC scores by 5%, FAC 4 = 4% and FAC 5 = 7%. Patients with hemorrhagic stroke and FAC 3 = increased by 5%, FAC 4 = 11% and FAC 5 = 9% and patients with CIP/CIM increased by FAC 3 = 3%, FAC 4 = 22% and FAC 5 = 26%. The largest improvement in walking ability during rehabilitation had patients with a FAC = 1 at baseline who improved by a median of 1.4 FAC points (p < 0.001). After adjusting for the number of gait training sessions, the largest improvement in walking ability during rehabilitation had patients with a FAC = 0 at baseline who improved by 1.8 FAC points (p < 0.001)., Conclusions: Implementation of an additional gait center training may significantly improve walking ability in neurological rehabilitation.

Closed-loop control of functional electrical stimulation coupled with motorized assistance to induce cycling is a rehabilitative strategy that can improve the mobility of people with neurological conditions (NCs). However, robust control methods, which are currently pervasive in the cycling literature, have limited effectiveness due to the use of high stimulation intensity leading to accelerated fatigue during cycling protocols. This paper examines the design of a distributed repetitive learning controller (RLC) that commands an independent learning feedforward term to each of the six stimulated lower-limb muscle groups and an electric motor during the tracking of a periodic cadence trajectory. The switched controller activates lower limb muscles during kinematic efficient regions of the crank cycle and provides motorized assistance only when most needed (i.e., during the portions of the crank cycle where muscles evoke a low torque output). The controller exploits the periodicity of the desired cadence trajectory to learn from previous control inputs for each muscle group and electric motor. A Lyapunov-based stability analysis guarantees asymptotic tracking via an invariance-like corollary for nonsmooth systems. The switched distributed RLC was evaluated in experiments with seven able-bodied individuals and five participants with NCs. A mean root-mean-squared cadence error of 3.58 ± 0.43 revolutions per minute (RPM) (0.07 ± 7.35% average error) and 4.26 ± 0.84 RPM (0.1 ± 8.99% average error) was obtained for the healthy and neurologically impaired populations, respectively.

Advancements in the Neuro-rehabilitation across Pakistan is warranted to effectively and efficiently deal with the disease burden of neurological conditions. Being a developing country, an in-expensive treatment approach is required to culminate the rise in the disease occurrence in Pakistan. Brain-Computer Interfaces (BCIs) have come up as a new channel for communication and control, eliminating the need of physical input, opening doors to a wide array of applications in terms of assistive and rehabilitative devices for paralyzed patients and those with neuromuscular disorders. Even with a promising prospect, BCIs and electroencephalograms (EEG) can be very expensive and therefore, they are not practically applicable. For this reason, the purpose of the current study was to come up with a possibility of an inexpensive BCI for rehabilitation of patients with neuro-muscular disorders in Pakistan by using a low-cost and readily available equipment like Emotiv EPOC+ EEG headset and electrical muscle stimulator.

Introduction: Parkinson's disease (PD) is managed primarily by dopamine agonists and physiotherapy while virtual reality (VR) has emerged recently as a complementary method. The present study reviewed the effectiveness of VR in rehabilitation of patients with PD., Methods: Literature search up to June 2019 identified ten studies (n = 343 participants) suitable for meta-analysis and 27 studies (n = 688 participants) for systematic review. Standard mean difference (SMD) and 95% confidence intervals (CI) were calculated using a random effects model., Results: In meta-analysis, compared with active rehabilitation intervention, VR training led to greater improvement of stride length, SMD = 0.70 (95%CI = 0.32-1.08, p = 0.0003), and was as effective for gait speed, balance and co-ordination, cognitive function and mental health, quality of life and activities of daily living. Compared with passive rehabilitation intervention, VR had greater effects on balance: SMD = 1.02 (95%CI = 0.38-1.65, p = 0.002). Results from single randomised controlled trials showed that VR training was better than passive rehabilitation intervention for improving gait speed SMD = 1.43 (95%CI = 0.51-2.34, p = 0.002), stride length SMD = 1.27 (95%CI = 0.38-2.16, p = 0.005) and activities of daily living SMD = 0.96 (95%CI = 0.02-1.89). Systematic review showed that VR training significantly (p < 0.05) improved motor function, balance and co-ordination, cognitive function and mental health, and quality of life and activities of daily living., Conclusion: VR used in rehabilitation for patients with PD improves a number of outcomes and may be considered for routine use in rehabilitation.

Stroke is one of the leading causes of long-term disability. Advanced technological solutions ("neurotechnologies") exploiting robotic systems and electrodes that stimulate the nervous system can increase the efficacy of stroke rehabilitation. Recent studies on these approaches have shown promising results. However, a paradigm shift in the development of new approaches must be made to significantly improve the clinical outcomes of neurotechnologies compared with those of traditional therapies. An "evolutionary" change can occur only by understanding in great detail the basic mechanisms of natural stroke recovery and technology-assisted neurorehabilitation. In this review, we first describe the results achieved by existing neurotechnologies and highlight their current limitations. In parallel, we summarize the data available on the mechanisms of recovery from electrophysiological, behavioral, and anatomical studies in humans and rodent models. Finally, we propose new approaches for the effective use of neurotechnologies in stroke survivors, as well as in people with other neurological disorders., Competing Interests: Declaration of Interests S.M. holds shares of the companies IUVO, GTX, Sensars Neurotechnologies, and AGO Neurotechnologies, which are all developing neurotechnologies to restore the sensory-motor functions of disabled people. All the other authors have no conflicts of interest to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Traumatic brain injury (TBI) is a clinical condition characterized by damage due to a mechanical physical event, which has a devastating impact on both the patient and his/her family. The purpose of this study is to evaluate the effects of robotic neurorehabilitation using Lokomat with virtual reality (VR) on attention process es and executive functions in patients with TBI. Materials and Methods: This is a retrospective case-control study. Fifty-six TBI patients have been included in the analysis, using an electronic recovery data system. The enrolled patients were divided into two groups: the experimental group (LPG) underwent rehabilitation training with Lokomat Pro, equipped with a VR screen, whereas the control group (LNG) performed rehabilitation training using Lokomat Nanos, without VR. The two groups matched for age, sex, education, brain lesions, interval from TBI. The rehabilitation protocol consisted of a total of 40 training sessions. Results: LPG and LNG had a significant improvement in mood and in the perception of physical well-being. However, only the LPG had a significant improvement in global cognitive, executive and attention functions. Furthermore, LPG presented a significant enhancement of the quality of life, with regard to the perception of the mental and physical state. Conclusion: Our study supports the idea that Lokomat is a useful tool in the rehabilitation of patients with TBI; in particular, the integration of the VR device can implement the cognitive and behavioral functions of TBI patients, enhancing also their physical and mental well-being.

Purpose: Early intervention is effective for developing motor ability and preventing contractures and deformities in patients with cerebral palsy (CP). Gait training using the newly developed Hybrid Assistive Limb (HAL) shows promise as an intervention to prevent deterioration in walking ability and deformities in pediatric CP patients. The purpose of this pilot study was to examine the safety and immediate effects on walking ability after gait training using the HAL in pediatric CP patients., Methods: Nineteen patients (six females, 13 males; mean age 8.5 years; mean height 120.5 cm; mean weight 23.2 kg) were enrolled. The Gross Motor Functional Classification Scale level was I in two patients, II in two, III in eight, and IV in seven. The HAL was used for a single session of gait training. The primary outcome was safety of the HAL for use in pediatric CP patients. The secondary outcome was the immediate effect after gait training with HAL, evaluated by passive range of motion (ROM) and gait parameters, including gait speed (m/s), step length (cm), and cadence (step/min)., Results: All 19 patients were able to carry out the gait training without any severe adverse events. Significant improvements were observed for mean internal/external rotation and abduction angles of the hip joint, and ankle dorsiflexion angles (n = 19). Significant improvements were observed for mean gait speed and step length based on expansion of the hip flexion-extension range (n = 11)., Conclusion: Gait training using the HAL is safe and can produce immediate improvements in ROM and walking ability in pediatric patients with CP., (Copyright © 2019. Published by Elsevier B.V.)

Background: We know little about the budget impact of integrating robotic exoskeleton over-ground training into therapy services for locomotor training. The purpose of this study was to estimate the budget impact of adding robotic exoskeleton over-ground training to existing locomotor training strategies in the rehabilitation of people with spinal cord injury., Methods: A Budget Impact Analysis (BIA) was conducted using data provided by four Spinal Cord Injury (SCI) Model Systems rehabilitation hospitals. Hospitals provided estimates of therapy utilization and costs about people with spinal cord injury who participated in locomotor training in the calendar year 2017. Interventions were standard of care walking training including body-weight supported treadmill training, overground training, stationary robotic systems (i.e., treadmill-based robotic gait orthoses), and overground robotic exoskeleton training. The main outcome measures included device costs, training costs for personnel to use the device, human capital costs of locomotor training, device demand, and the number of training sessions per person with SCI., Results: Robotic exoskeletons for over-ground training decreased hospital costs associated with delivering locomotor training in the base case analysis. This analysis assumed no difference in intervention effectiveness across locomotor training strategies. Providing robotic exoskeleton overground training for 10% of locomotor training sessions over the course of the year (range 226-397 sessions) results in decreased annual locomotor training costs (i.e., net savings) between $1114 to $4784 per annum. The base case shows small savings that are sensitive to parameters of the BIA model which were tested in one-way sensitivity analyses, scenarios analyses, and probability sensitivity analyses. The base case scenario was more sensitive to clinical utilization parameters (e.g., how often devices sit idle and the substitution of high cost training) than device-specific parameters (e.g., robotic exoskeleton device cost or device life). Probabilistic sensitivity analysis simultaneously considered human capital cost, device cost, and locomotor device substitution. With probabilistic sensitivity analysis, the introduction of a robotic exoskeleton only remained cost saving for one facility., Conclusions: Providing robotic exoskeleton for over-ground training was associated with lower costs for the locomotor training of people with SCI in the base case analyses. The analysis was sensitive to parameter assumptions.

Objective: To assess safety and feasibility for persons with acute spinal cord injury (SCI) using the robotic exoskeleton., Design: Case series observational study., Setting: A level-1 trauma center in Canada with both acute and tertiary inpatient SCI rehabilitation units., Participants: Eight male and 3 female (N=11) participants were recruited with a mean age of 41 years and with neurologic level of injury (C6-L2) and severity (American Spinal Injury Association Impairment Scale [AIS] A-D). The time since injury is a range of 3-15 weeks at the onset of training., Interventions: Up to 25 one-hour sessions of exoskeletal-assisted walking gait training, with participants less than 6 months from initial SCI., Main Outcome Measures: Cardiopulmonary outcomes including blood pressure, heart rate, and peripheral oxygen saturation; and perceived physical exertion using the Borg CR10 Scale were recorded. Gait parameters were measured by 6-minute walk test (6MWT) and 10-meter walk test (10MWT). Up Time, walk time, and number of steps were detailed longitudinally. Safety was assessed with regard to pain, falls, and skin integrity., Results: No serious adverse events occurred. Blood pressure decreased following initial sit to stand and increased during walking. Symptoms of hypotension were rare and improved with increased number of sessions. Perceived exertion was reported on average to be moderate (mean of 3.1). There was no significant increase in pain scores by Visual Analog Scale. On 6MWT, participants covered more distance (mean [m] ± SD, 117.1±11.7) in session 25 compared to session 2 (mean [m] ± SD, 47.6±6.6). On the 10MWT, all participants showed consistently improved gait speed; with participants traveling an average of 3.2 times faster during their last training session (mean [m/s] ± SD, 0.40±0.04) in comparison to session 2 (mean [m/s] ± SD, 0.12±0.01)., Conclusions: Exoskeletal-assisted walking in acute rehabilitation (<6mo) following SCI appears to be both safe and feasible., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Contemporary goals of rehabilitation after traumatic brain injury (TBI) aim to improve cognitive and motor function by applying concepts of neuroplasticity. This can be challenging to carry out in TBI patients with motor, balance, and cognitive impairments., Objective: To determine whether use of dynamic body-weight support (DBWS) would allow safe administration of intensive motor therapy during inpatient rehabilitation and whether its use would yield greater improvement in functional recovery than standard-of-care (SOC) therapy in adults with TBI., Methods: Data in this retrospective cohort study was collected from patients with TBI who receive inpatient rehabilitation incorporating DBWS (n = 6) and who received inpatient rehabilitation without DBWS (SOC, n = 6). The primary outcome measure was the change in Functional Independence Measures (FIM) scores from admission to discharge., Results: There was significant improvement in total FIM scores at discharge compared to admission for both the DBWS (p = 0.001) and SOC (p = 0.005) groups. Overall, the DBWS group had greater improvement in total FIM score and FIM subscales compared to the SOC group., Conclusions: Our results suggest DBWS has the potential to allow a greater intensity of therapy during inpatient rehabilitation and yield better outcomes compared to SOC in patients with TBI.

Proprioception is critical for movement control. After a spinal cord injury (SCI), individuals not only experience paralysis but may also experience proprioceptive deficits, further confounding motor recovery. The objective of this study was to test the effects of a robotic-based proprioception training protocol on lower limb proprioceptive sense in people with incomplete SCI. A secondary objective was to assess whether the effects of training transferred to a precision stepping task in people with motor-incomplete SCI. Participants with chronic incomplete SCI and able-bodied controls underwent a 2-day proprioceptive training protocol using the Lokomat robotic exoskeleton. The training involved positioning the test leg to various positions and participants were asked to report whether they felt their heel position (end-point position) was higher or lower compared with a reference position. Feedback was provided after each trial to help participants learn strategies that could help them discern different positions of their foot. Changes in end-point position as well as knee joint position sense were assessed pre- and posttraining. We also assessed the effects of proprioception training on the performance of a precision stepping task in people with motor-incomplete SCI. Following training, there were significant improvements in end-point and knee joint position sense in both groups. The magnitude of improvement was related to pretraining (baseline) proprioceptive sense, indicating that those who initially had better lower limb position sense showed greater changes. Participants also showed improvements in performance of a precision stepping task. NEW & NOTEWORTHY We show that it is possible to alter proprioceptive sense in people with incomplete SCI using a passive proprioception training protocol combined with feedback. Improvements in proprioceptive sense transferred from end-point to joint position sense and also to an untrained precision stepping task.

Background : The use of assistive technology, specifically microswitches, with children with RTT has been shown to effectively moderate the impact of their disability on their quality of life - by facilitating access to meaningful leisure and other activities. Objectives : This study aimed to evaluate the effectiveness of a microswitch intervention on increased choice making, engagement in a targeted sorting activity, and indices of happiness, and decreased stereotypic behaviors for six girls with Rett syndrome. Targeted dependent variables were also assessed at six months post-intervention. Following the intervention study, 90 external raters completed a social validation procedure. Method : An ABABAB experimental sequence was implemented for each participant with a cross-over effect. A social validation assessment involving 90 external raters was carried out. Results : Data emphasized an improved performance for each participants involved (i.e., adaptive responses). Five participants showed a capacity of independent choice. One participant seemed to be closely linked to the position of the container. Social raters favorably endorsed the use of the program since they positively evaluated the use of the technology on all the dimensions investigated. Conclusion : A microswitch intervention may improve choice making and activity engagement for children with Rett syndrome. Further research is needed on the development of more sophisticated forms of individualized technological options to improve opportunities for enhanced engagement and choice-making for individuals with RTT.

Aim: The present study describes the training effects of a novel motorized bicycle-like device for individuals with incomplete spinal cord injury. Methods: Participants were five individuals with motor incomplete spinal cord injury (56 ± 7 years). Four of five participants received two 30-min sessions of training: one with, and one without, mechanical stimulation on the plantar surface of the foot; soleus paired H-reflex depression was examined before and after each session. Three of five participants received 24 sessions of 30-min of training (long-training). Following the long-training, balance, walking and spasticity improvements were assessed using validated clinical outcome measures, in addition to the H-reflex assessment. Results: One cycling session with mechanical stimulation yielded 14% and 32% more reflex depression in participants with moderate spasticity ( n  = 2/4). The same trend was not observed in non-spastic participants ( n  = 2/4). All participants who participated in the long-training had spasticity and showed reduced spasticity, improved walking speed, endurance and balance. Conclusions: Overall, participants with spasticity showed increased soleus H-reflex suppression after one training session with mechanical stimulation and reduced spasticity scores after long training. We interpret this as evidence that the training influenced both presynaptic and postsynaptic inhibitory mechanisms acting on soleus motoneurons. Therefore, this training has the potential to be a non-invasive complementary therapy to reduce spasticity after incomplete spinal cord injury.

Social competence is often impaired in children with acquired brain injury (ABI), but evidence-based rehabilitation has remained undeveloped. This pilot-study aimed to create a structured model for sociocognitive rehabilitation for children with ABI. A total of 32 children aged 8-13 years participated: 22 with ABI -epilepsy, traumatic brain injury, or tic disorder and 10 healthy controls. Interactive computer-based applications were implemented into rehabilitation design using multitouch-multiuser tabletop (MMT) devices: Snowflake MultiTeach (MT) and Diamond Touch Table (DTT), plus MediqVR virtual reality (VR) platform. At baseline, patients demonstrated social incompetence compared to healthy controls. Post-training evaluations showed that rehabilitation on Snowflake MT improved children's executive and cooperation skills. DTT developed new communication and language skills, metacognitive skills, and coping with difficult social situations. This structured model for social competence rehabilitation helps therapists to understand the objectives and tools for improving social and cooperation skills in children with ABI. We provide practical recommendations using next-generation devices, which are effective and motivating for children.