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In stroke rehabilitation, simple robotic devices hold the potential to increase the training dosage in group therapies and to enable continued therapy at home after hospital discharge. However, we identified a lack of portable and cost-effective devices that not only focus on improving motor functions but also address sensory deficits. Thus, we designed a minimally-actuated hand training device that incorporates active grasping movements and passive pronosupination, complemented by a rehabilitative game with meaningful haptic feedback. Following a human-centered design approach, we conducted a usability study with 13 healthy participants, including three therapists. In a simulated unsupervised environment, the naive participants had to set up and use the device based on written instructions. Our mixed-methods approach included quantitative data from performance metrics, standardized questionnaires, and eye tracking, alongside qualitative feedback from semi-structured interviews. The study results highlighted the device's overall ease of setup and use, as well as its realistic haptic feedback. The eye-tracking analysis further suggested that participants felt safe during usage. Moreover, the study provided crucial insights for future improvements such as a more intuitive and comfortable wrist fixation, more natural pronosupination movements, and easier-to-follow instructions. Our research underscores the importance of continuous testing in the development process and offers significant contributions to the design of user-friendly, unsupervised neurorehabilitation technologies to improve sensorimotor stroke rehabilitation., Human-Robot Interaction, Cognitive Robotics

Falling is a major cause of morbidity, and is often caused by a decrease in postural stability. A key component of postural stability is whole-body centroidal angular momentum, which can be influenced by control moment gyroscopes. In this proof-of-concept study, we explore the influence of our wearable robotic gyroscopic actuator “GyroPack” on the balance performance and gait characteristics of non-impaired individuals (seven female/eight male, 30 ± 7 years, 68.8 ± 8.4 kg). Participants performed a series of balance and walking tasks with and without wearing the GyroPack. The device displayed various control modes, which were hypothesised to positively, negatively, or neutrally impact postural control. When configured as a damper, the GyroPack increased mediolateral standing time and walking distance, on a balance beam, and decreased trunk angular velocity variability, while walking on a treadmill. When configured as a negative damper, both peak trunk angular rate and trunk angular velocity variability increased during treadmill walking. This exploratory study shows that gyroscopic actuators can influence balance and gait kinematics. Our results mirror the findings of our earlier studies; though, with more than 50% mass reduction of the device, practical and clinical applicability now appears within reach., Biomechatronics & Human-Machine Control, Human-Robot Interaction

Background: Upper limb impairments in a hemiparetic arm are clinically quantified by well-established clinical scales, known to suffer poor validity, reliability, and sensitivity. Alternatively, robotics can assess motor impairments by characterizing joint dynamics through system identification. In this study, we establish the merits of quantifying abnormal synergy, spasticity, and changes in joint viscoelasticity using system identification, evaluating (1) feasibility and quality of parametric estimates, (2) test–retest reliability, (3) differences between healthy controls and patients with upper limb impairments, and (4) construct validity. Methods: Forty-five healthy controls, twenty-nine stroke patients, and twenty cerebral palsy patients participated. Participants were seated with the affected arm immobilized in the Shoulder-Elbow-Perturbator (SEP). The SEP is a one-degree-of-freedom perturbator that enables applying torque perturbations to the elbow while providing varying amounts of weight support to the human arm. Participants performed either a ‘do not intervene’ or a resist task. Elbow joint admittance was quantified and used to extract elbow viscosity and stiffness. Fifty-four of the participants performed two sessions to establish the test–retest reliability of the parameters. Construct validity was assessed by correlating system identification parameters to parameters extracted using a SEP protocol that objectifies current clinical scales (Re-Arm protocol). Results: Feasibility was confirmed by all participants successfully completing the study protocol within ~ 25 min without reporting pain or burden. The parametric estimates were good with a variance-accounted-for of ~ 80%. A fair to excellent test–retest reliability was found (ICC= 0.46 - 0.98) for patients, except for elbow stiffness with full weight support (ICC= 0.35). Compared to healthy controls, patients had a higher elbow viscosity and stiffness during the ‘do not intervene’ task and lower, Biomechatronics & Human-Machine Control

Transcranial direct current stimulation (tDCS) over the contralateral primary motor cortex of the target muscle (conventional tDCS) has been described to enhance corticospinal excitability, as measured with transcranial magnetic stimulation. Recently, tDCS targeting the brain regions functionally connected to the contralateral primary motor cortex (motor network tDCS) was reported to enhance corticospinal excitability more than conventional tDCS. We compared the effects of motor network tDCS, 2 mA conventional tDCS, and sham tDCS on corticospinal excitability in 21 healthy participants in a randomized, single-blind within-subject study design. We applied tDCS for 12 min and measured corticospinal excitability with TMS before tDCS and at 0, 15, 30, 45, and 60 min after tDCS. Statistical analysis showed that neither motor network tDCS nor conventional tDCS significantly increased corticospinal excitability relative to sham stimulation. Furthermore, the results did not provide evidence for superiority of motor network tDCS over conventional tDCS. Motor network tDCS seems equally susceptible to the sources of intersubject and intrasubject variability previously observed in response to conventional tDCS., Biomechatronics & Human-Machine Control

Item does not contain fulltext, PURPOSE: Elucidating the complex interactions between physical activity (PA), a multidimensional concept, and physical capacity (PC) may reveal ways to improve rehabilitation interventions. This cross-sectional study aimed to explore which PA dimensions are related to PC in people after minor stroke. MATERIALS AND METHODS: Community dwelling individuals >6 months after minor stroke were evaluated with a 10-Meter-Walking-Test (10MWT), Timed-Up & Go, and the Mini Balance Evaluation System Test. The following PA outcomes were measured with an Activ8 accelerometer: counts per minute during walking (CPM(walking); a measure of intensity), number of active bouts (frequency), mean length of active bouts (distribution), and percentage of waking hours in upright positions (duration). Multivariable linear regression models, adjusted for age, sex and BMI, were used to assess the relationships between PC and PA outcomes. RESULTS: Sixty-nine participants [62.2 ± 9.8 years, 61% male, 20 months post onset (IQR 13.0-53.5)] were included in the analysis. CPM(walking) was significantly associated to PC in the 10MWT (std. ß = 0.409, p = 0.002), whereas other associations between PA and PC were not significant. CONCLUSIONS: The PA dimension intensity of walking is significantly associated with PC, and appears to be an important tool for future interventions in rehabilitation after minor stroke.Implications for rehabilitationIt is recommended to express physical activity after minor stroke in multiple dimensions such as intensity, frequency, duration and distribution.In particular, intensity of physical activity measured with accelerometer counts is most closely related to physical capacity.The findings of this study underline the importance of being physically active beyond a certain intensity.In future development of interventions and guidelines that aim to promote daily physical activity, intensity should be taken into account.

Item does not contain fulltext, BACKGROUND: Despite being well established, acute surgery in traumatic acute subdural haematoma is based on low-grade evidence. We aimed to compare the effectiveness of a strategy preferring acute surgical evacuation with one preferring initial conservative treatment in acute subdural haematoma. METHODS: We did a prospective, observational, comparative effectiveness study using data from participants enrolled in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) cohort. We included patients with no pre-existing severe neurological disorders who presented with acute subdural haematoma within 24 h of traumatic brain injury. Using an instrumental variable analysis, we compared outcomes between centres according to treatment preference for acute subdural haematoma (acute surgical evacuation or initial conservative treatment), measured by the case-mix-adjusted percentage of acute surgery per centre. The primary endpoint was functional outcome at 6 months as rated with the Glasgow Outcome Scale Extended, which was estimated with ordinal regression as a common odds ratio (OR) and adjusted for prespecified confounders. Variation in centre preference was quantified with the median OR (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). FINDINGS: Between Dec 19, 2014 and Dec 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI, of whom 1407 (31%) presented with acute subdural haematoma and were included in our study. Acute surgical evacuation was done in 336 (24%) patients, by craniotomy in 245 (73%) of those patients and by decompressive craniectomy in 91 (27%). Delayed decompressive craniectomy or craniotomy after initial conservative treatment (n=982) occurred in 107 (11%) patients. The percentage of patients who underwent acute surgery ranged from 5·6% to 51·5% (IQR 12·3-35·9) between centres

Transcranial direct current stimulation (tDCS) is a promising tool to improve and speed up motor rehabilitation after stroke, but inconsistent clinical effects refrain tDCS from clinical implementation. Therefore, this study aimed to assess the need for individualized tDCS configurations in stroke, considering interindividual variability in brain anatomy and motor function representation. We simulated tDCS in individualized MRI-based finite element head models of 21 chronic stroke subjects and 10 healthy age-matched controls. An anatomy-based stimulation target, i.e. the motor hand knob, was identified with MRI, whereas a motor function-based stimulation target was identified with EEG. For each subject, we simulated conventional anodal tDCS electrode configurations and optimized electrode configurations to maximize stimulation strength within the anatomical and functional target. The normal component of the electric field was extracted and compared between subjects with stroke and healthy, age-matched controls, for both targets, during conventional and optimized tDCS. Electrical field strength was significantly lower, more variable and more frequently in opposite polarity for subjects with stroke compared to healthy age-matched subjects, both for the anatomical and functional target with conventional, i.e. non-individualized, electrode configurations. Optimized, i.e. individualized, electrode configurations increased the electrical field strength in the anatomical and functional target for subjects with stroke but did not reach the same levels as in healthy subjects. Considering individual brain structure and motor function is crucial for applying tDCS in subjects with stroke. Lack of individualized tDCS configurations in subjects with stroke results in lower electric fields in stimulation targets, which may partially explain the inconsistent clinical effects of tDCS in stroke trials., Biomechatronics & Human-Machine Control, Precision and Microsystems Engineering, Biomechanical Engineering

Background: Prolonged disorders of consciousness (PDOC) may occur after severe brain injury. Two diagnostic entities are distinguished within PDOC: unresponsive wakefulness syndrome (UWS, previously known as vegetative state) and minimally conscious state (MCS). Patients with PDOC may benefit from early intensive neurorehabilitation (EIN). In the Netherlands, the EIN programme is provided by one designated expert rehabilitation centre and forms the starting point of a dedicated chain of specialised rehabilitation and care for this group. This study project, called DOCTOR: Disorders of Consciousness; Treatment and Outcomes Registry, sets up a registry and systematically investigates multiple short- and long-term outcomes of patients with PDOC who receive EIN. Methods: Single-centre prospective cohort study with a 2-year follow-up period. Patients with PDOC due to acute brain injury who receive EIN, aged 16 years and older are included. Measurements will take place at start EIN, in week 5, 10, and at discharge from the EIN programme (duration = max 14 weeks) and at week 28, 40, 52, and 104 after admission to the EIN programme, following patients through the health-care chain. Outcome measures are the changes over time in level of consciousness, using the Coma Recovery Scale-Revised; the frequency and type of medical complications; the mortality rate; level of disability, including the level of motor, cognitive, behavioural and emotional functioning; participation; and quality of life. Secondary outcomes include self-efficacy of caregivers, caregivers’ strain and cost-effectiveness of the programme. Discussion: The DOCTOR study will provide insight in the recovery patterns and predictors of recovery for multiple outcomes in PDOC patients after following EIN. The results of the study will enable us to benchmark and improve EIN and the organisation of the health-care chain, both for patients with PDOC and for their families. Trial registration: Netherlands Trial Register

Background: Transcranial direct current stimulation (tDCS) has emerged as a non-invasive brain stimulation technique. Most studies show that anodal tDCS increases cortical excitability. However, this effect has been found to be highly variable. Objective: To test the effect of anodal tDCS on cortical excitability and the interaction effect of two participant-specific factors that may explain individual differences in sensitivity to anodal tDCS: the Brain Derived Neurotrophic Factor Val66Met polymorphism (BDNF genotype) and the latency difference between anterior-posterior and lateromedial TMS pulses (APLM latency). Methods: In 62 healthy participants, cortical excitability over the left motor cortex was measured before and after anodal tDCS at 2 mA for 20 min in a pre-registered, double-blind, randomized, placebo-controlled trial with repeated measures. Results: We did not find a main effect of anodal tDCS, nor an interaction effect of the participant-specific predictors. Moreover, further analyses did not provide evidence for the existence of responders and non-responders. Conclusion: This study indicates that anodal tDCS at 2 mA for 20 min may not reliably affect cortical excitability.

Neurophysiologic correlates of motor learning that can be monitored during neurorehabilitation interventions can facilitate the development of more effective learning methods. Previous studies have focused on the role of the beta band (14–30 Hz) because of its clear response during motor activity. However, it is difficult to discriminate between beta activity related to learning a movement and performing the movement. In this study, we analysed differences in the electroencephalography (EEG) power spectra of complex and simple explicit sequential motor tasks in healthy young subjects. The complex motor task (CMT) allowed EEG measurement related to motor learning. In contrast, the simple motor task (SMT) made it possible to control for EEG activity associated with performing the movement without significant motor learning. Source reconstruction of the EEG revealed task-related activity from 5 clusters covering both primary motor cortices (M1) and 3 clusters localised to different parts of the cingulate cortex (CC). We found no association between M1 beta power and learning, but the CMT produced stronger bilateral beta suppression compared to the SMT. However, there was a positive association between contralateral M1 theta (5–8 Hz) and alpha (8–12 Hz) power and motor learning, and theta and alpha power in the posterior mid-CC and posterior CC were positively associated with greater motor learning. These findings suggest that the theta and alpha bands are more related to motor learning than the beta band, which might merely relate to the level of perceived difficulty during learning., Biomechatronics & Human-Machine Control, Biomechanical Engineering

Introduction: Predicting upper limb capacity recovery is important to set treatment goals, select therapies and plan discharge. We introduce a prediction model of the patient-specific profile of upper limb capacity recovery up to 6 months poststroke by incorporating all serially assessed clinical information from patients. Methods: Model input was recovery profile of 450 patients with a first-ever ischaemic hemispheric stroke measured using the Action Research Arm Test (ARAT). Subjects received at least three assessment sessions, starting within the first week until 6 months poststroke. We developed mixed-effects models that are able to deal with one or multiple measurements per subject, measured at non-fixed time points. The prediction accuracy of the different models was established by a fivefold cross-validation procedure. Results: A model with only ARAT time course, finger extension and shoulder abduction performed as good as models with more covariates. For the final model, cross-validation prediction errors at 6 months poststroke decreased as the number of measurements per subject increased, from a median error of 8.4 points on the ARAT (Q1-Q3:1.7-28.1) when one measurement early poststroke was used, to 2.3 (Q1-Q3:1-7.2) for seven measurements. An online version of the recovery model was developed that can be linked to data acquisition environments. Conclusion

Background. Despite progress made in understanding functional reorganization patterns underlying recovery in subacute aphasia, the relation between recovery and changes in white matter structure remains unclear. Objective. To investigate changes in dorsal and ventral language white matter tract integrity in relation to naming recovery in subacute poststroke aphasia. Methods. Ten participants with aphasia after left-hemisphere stroke underwent language testing and diffusion tensor imaging twice within 3 months post onset, with a 1-month interval between sessions. Deterministic tractography was used to bilaterally reconstruct the superior longitudinal fasciculus (SLF), inferior fronto-occipital fasciculus (IFOF), inferior longitudinal fasciculus (ILF), middle longitudinal fasciculus (MdLF), and uncinate fasciculus (UF). Per tract, the mean fractional anisotropy (FA) was extracted as a measure of microstructural integrity. Naming accuracy was assessed with the Boston Naming Test (BNT). Correlational analyses were performed to investigate the relationship between changes in FA values and change in BNT score. Results. A strong positive correlation was found between FA change in the right ILF within the ventral stream and change on the BNT (r = 0.91, P <.001). An increase in FA in the right ILF was associated with considerable improvement of naming accuracy (range BNT change score: 12-14), a reduction with limited improvement or slight deterioration. No significant correlations were found between change in naming accuracy and FA change in any of the other right or left ventral and dorsal language tracts. Conclusions. Naming recovery in subacute aphasia is associated with change in the integrity of the right ILF.

Item does not contain fulltext, PURPOSE OF REVIEW: There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies. RECENT FINDINGS: Clinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome. SUMMARY: Recent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable.

INTRODUCTION: Controversy exists about the optimal treatment for patients with a traumatic acute subdural haematoma (ASDH) and an intracerebral haematoma/contusion (t-ICH). Treatment varies largely between different regions. The effect of this practice variation on patient outcome is unknown. Here, we present the protocol for a prospective multicentre observational study aimed at comparing the effectiveness of different treatment strategies in patients with ASDH and/or t-ICH. Specifically, the aims are to compare (1) an acute surgical approach to an expectant approach and (2) craniotomy to decompressive craniectomy when evacuating the haematoma. METHODS AND ANALYSIS: Patients presenting to the emergency room with an ASDH and/or an t-ICH are eligible for inclusion. Standardised prospective data on patient and injury characteristics, treatment and outcome will be collected on 1000 ASDH and 750 t-ICH patients in 60-70 centres within two multicentre prospective observational cohort studies: the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and Neurotraumatology Quality Registry (Net-QuRe). The interventions of interest are acute surgery, defined as surgery directly after the first CT at presentation versus late or no surgery and craniotomy versus decompressive craniectomy. The primary outcome measure is the Glasgow Outcome Score-Extended at 6 months. Secondary outcome measures include in-hospital mortality, quality of life and neuropsychological tests. In the primary analysis, the effect of treatment preference (eg, proportion of patients in which the intervention under study is preferred) per hospital will be analysed with random effects ordinal regression models, adjusted for casemix and stratified by study. Such a hospital-level approach reduces confounding by the indication. Sensitivity analyses will include

Background: Changes in transcranial magnetic stimulation motor map parameters can be used to quantify plasticity in the human motor cortex. The golden standard uses a counting analysis of motor evoked potentials (MEPs) acquired with a predefined grid. Recently, digital reconstruction methods have been proposed, allowing MEPs to be acquired with a faster pseudorandom procedure. However, the reliability of these reconstruction methods has never been compared to the golden standard. Objective: To compare the absolute reliability of the reconstruction methods with the golden standard. Methods: In 21 healthy subjects, both grid and pseudorandom acquisition were performed twice on the first day and once on the second day. The standard error of measurement was calculated for the counting analysis and the digital reconstructions. Results: The standard error of measurement was at least equal using digital reconstructions. Conclusion: Pseudorandom acquisition and digital reconstruction can be used in intervention studies without sacrificing reliability.

Objective: To compare 2 configurations of transcranial direct current stimulation (tDCS) for treatment of aphasia. Design: Randomized cross-over study. Subjects: Patients with chronic post-stroke aphasia (n = 13). Methods: TDCS was combined with word-finding therapy in 3 single sessions. In session 1, sham-tDCS/ pseudo-stimulation was applied. In sessions 2 and 3, 2 active configurations were provided in random order: Anodal tDCS over the left inferior frontal gyrus (l-IFG) and anodal tDCS over the left posterior superior temporal gyrus (l-STG). The optimal configuration was determined per individual based on a pre-set improvement in naming trained (> 20%) and untrained picture items (> 10%). Results: Overall, participants improved on trained items (median = 50%; interquartile range = 20-85) and post-treatment performance was highest in the active l-IFG condition (p = 0.040). Of the 13 participants, 6 (46%) showed relevant improvement during active tDCS; either in the l-IFG condition (n = 4; 31%) or in both the l-IFG and l-STG conditions (n = 2; 15%). On the untrained items there was no improvement (median = 0%; interquartile range = 0-0). Conclusion: This randomized cross-over single-session protocol to determine an optimal tDCS configuration for treatment of aphasia suggests that only performance on trained items can be used as guidance for configuration, and that it is relevant for half of the patients. For this subgroup, the l-IFG configuration is the optimal choice.

Background: In stroke rehabilitation not only are the levels of physical activity important, but body postures and movements performed during one’s daily-life are also important. This information is provided by a new one-sensor accelerometer that is commercially available, low-cost, and user-friendly. The present study examines the accuracy of this activity monitor (Activ8) in detecting several classes of body postures and movements in people after a stroke. Methods: Twenty-five people after a stroke participated in an activity protocol with either basic activities or daily-life activities performed in a laboratory and/or at home. Participants wore an Activ8 on their less-affected thigh. The primary outcome was the difference in registered time for the merged class “upright position” (standing/walking/running) between the Activ8 and the video recording (the reference method). Secondary

Background: Cerebellar transcranial direct current stimulation has been reported to enhance motor associative learning and motor adaptation, holding promise for clinical application in patients with movement disorders. However, behavioral benefits from cerebellar tDCS have been inconsistent. Objective: Identifying determinants of treatment success is necessary. BDNF Val66Met is a candidate determinant, because the polymorphism is associated with motor skill learning and BDNF is thought to mediate tDCS effects. Methods: We undertook two cerebellar tDCS studies in subjects genotyped for BDNF Val66Met. Subjects performed an eyeblink conditioning task and received sham, anodal or cathodal tDCS (N = 117, between-subjects design) or a vestibulo-ocular reflex adaptation task and received sham and anodal tDCS (N = 51 subjects, within-subjects design). Performance was quantified as a learning parameter from 0 to 100%. We investigated (1) the distribution of the learning parameter with mixture modeling presented as the mean (M), standard deviation (S) and proportion (P) of the groups, and (2) the role of BDNF Val66Met and cerebellar tDCS using linear regression presented as the regression coefficients (B) and odds ratios (OR) with equally-tailed intervals (ETIs). Results: For the eyeblink conditioning task, we found distinct groups of learners (MLearner = 67.2%; SLearner = 14.7%; PLearner = 61.6%) and non-learners (MNon-learner = 14.2%; SNon-learner = 8.0%; PNon-learner = 38.4%). Carriers of the BDNF Val66Met polymorphism were more likely to be learners (OR = 2.7 [1.2 6.2]). Within the group of learners, anodal tDCS supported eyeblink conditioning in BDNF Val66Met non-carriers (B = 11.9% 95%ETI = [0.8 23.0]%), but not in carriers (B = 1.0% 95%ETI = [-10.2 12.1]%). For the vestibulo-ocular reflex adaptation task, we found no effect of BDNF Val66Met (B = −2.0% 95%ETI = [-8.7 4.7]%) or anodal tDCS in either carriers (B = 3.4% 95%ETI = [-3.2 9.5]%) or non-carriers (B = 0.6% 95%ET

The role of the cerebellum in cognitive processing is increasingly recognized but still poorly understood. A recent study in this field applied cerebellar Transcranial Direct Current Stimulation (c-tDCS) to the right cerebellum to investigate the role of prefrontal-cerebellar loops in language aspects of cognition. Results showed that the improvement in participants' verbal response times on a verb generation task was facilitated immediately after cathodal c-tDCS, compared to anodal or sham c-tDCS. The primary aim of the present study is to replicate these findings and additionally to investigate possible longer term effects. A crossover within-subject design was used, comparing cathodal and sham c-tDCS. The experiment consisted of two visits with an interval of one week. Our results show no direct contribution of cathodal c-tDCS over the cerebellum to language task performance. However, one week later, the group receiving cathodal c-tDCS in the first visit show less improvement and increased variability in their verbal response times during the second visit, compared to the group receiving sham c-tDCS in the first visit. These findings suggest a potential negative effect of c-tDCS and warrant further investigation into long term effects of c-tDCS before undertaking clinical studies with poststroke patients with aphasia.

Background: Peak oxygen uptake (VO2peak) established during progressive cardiopulmonary exercise testing (CPET) is the “gold-standard” for cardiorespiratory fitness. However, CPET measurements may be limited in patients with aneurysmal subarachnoid hemorrhage (a-SAH) by disease-related complaints, such as cardiovascular health-risks or anxiety. Furthermore, CPET with gas-exchange analyses require specialized knowledge and infrastructure with limited availability in most rehabilitation facilities. Objectives: To determine whether an easy-to-administer six-minute walk test (6MWT) is a valid clinical alternative to progressive CPET in order to predict VO2peak in individuals with a-SAH. Methods: Twenty-seven patients performed the 6MWT and CPET with gas-exchange analyses on a cycle ergometer. Univariate and multivariate regression models were made to investigate the predictability of VO2peak from the six-minute walk distance (6MWD). R

Objective: To describe variation in structural and process characteristics of acute in-hospital rehabilitation and referral to post-acute care for patients with traumatic brain injury across Europe. Design: Survey study, of neurotrauma centres. Methods: A 14-item survey about in-hospital rehabilitation and referral to post-acute care was sent to 71 neurotrauma centres participating in a European multicentre study (CENTER-TBI). The questionnaire was developed based on literature and expert opinion and was pilot-tested before sending out to the centres. Results: Seventy (99%) centres in 20 countries completed the survey. The included centres were predominately academic level I trauma centres. Among the 70 centres, a multidisciplinary rehabilitation team can be consulted at 41% (n = 29) of the intensive care units and 49% (n = 34) of the wards. Only 13 (19%) centres used rehabilitation guidelines in patients with traumatic brain injury. Age was reported as a major determinant of referral decisions in 32 (46%) centres, with younger patients usually referred to specialized rehabilitation centres, and patients ≥ 65 years also referred to nursing homes or local hospitals. Conclusion: Substantial variation exists in structural and process characteristics of in-hospital acute rehabilitation and referral to post-acute rehabilitation facilities among neurotrauma centres across Europe.

Fatigue is the most prevalent and disabling symptom in cancer patients. Yet, scientific literature on this topic is scarce and reports disparate results. This study systematically reviews how fatigue is assessed in patients with low-grade glioma and evaluates its prevalence in LGG patients. A systematic literature search was performed in PubMed, Embase and PsychINFO for articles reporting on fatigue in patients with LGG. Two reviewers independently extracted data from selected articles. Inclusion criteria were: (1) patients with suspected or confirmed LGG; (2) fatigue was assessed as primary or secondary outcome measure; (3) agee"18 years; (4) full-length article written in English or Dutch. In total, 19 articles were selected, including 971 patients. Seven self-assessment instruments were identified. Prevalence rates ranged from 39 to 77%. Fatigue was found to be a common side effect of treatment. The prevalence rates ranged from 20 to 76% when fatigue was reported as a mild or moderate side effect and fatigue was prevalent in 4% when reported as a severe side effect. Fatigue is a common problem in LGG patients that warrants more therapeutic and scientific attention. Gaining deeper insight in the underlying mechanisms of fatigue is essential in targeting therapy to individual patients

Background: Transcranial direct current stimulation (tDCS) is a promising new technique to optimize the effect of regular Speech and Language Therapy (SLT) in the context of aphasia rehabilitation. The present study focuses on the effect of tDCS provided during SLT in the sub-acute stage after stroke. The primary aim is to evaluate the potential effect of tDCS on language functioning, specifically on word-finding, as well as generalization effects to verbal communication. The secondary aim is to evaluate its effect on social participation and quality of life, and its cost-effectiveness. Methods: We strive to include 58 stroke patients with aphasia, enrolled in an inpatient or outpatient stroke rehabilitation program, in a multicenter, double-blind, randomized controlled trial with two parallel groups and 6 months' follow-up. Patients will participate in two separate intervention weeks, with a pause of 2 weeks in between, in the context of their regular aphasia rehabilitation program. The two intervention weeks comprise daily 45-minute sessions of word-finding therapy, combined with either anodal tDCS over the left inferior frontal gyrus (1 mA, 20 minutes; experimental condition) or sham-tDCS over the same region (control condition). The primary outcome measure is word-finding. Secondary outcome measures are verbal communication, social participation, quality of life, and cost-effectiveness of the intervention. Discussion: Our results will contribute to the discussion on whether tDCS should be implemented in regular aphasia rehabilitation programs for the sub-acute post-stroke population in terms of (cost-)effectiveness. Trial registration: Nederlands Trail Register: NTR4364. Registered on 21 February 2014.

Background and Purpose - Value-based health care aims to bring together patients and health systems to maximize the ratio of quality over cost. To enable assessment of healthcare value in stroke management, an international standard set of patient-centered stroke outcome measures was defined for use in a variety of healthcare settings. Methods - A modified Delphi process was implemented with an international expert panel representing patients, advocates, and clinical specialists in stroke outcomes, stroke registers, global health, epidemiology, and rehabilitation to reach consensus on the preferred outcome measures, included populations, and baseline risk adjustment variables. Results - Patients presenting to a hospital with ischemic stroke or intracerebral hemorrhage were selected as the target population for these recommendations, with the inclusion of transient ischemic attacks optional. Outcome categories recommended for assessment were s

Objective We describe the occurrence and course of anterior pituitary dysfunction (PD) after aneurysmal subarachnoid haemorrhage (SAH), and identify clinical determinants for PD in patients with recent SAH. Methods We prospectively collected demographic and clinical parameters of consecutive survivors of SAH and measured fasting state endocrine function at baseline, 6 and 14 months. We included dynamic tests for growth-hormone function. We used logistic regression analysis to compare demographic and clinical characteristics of patients with SAH with and without PD. Results 84 patients with a mean age of 55.8 (±11.9) were included. Thirty-three patients (39%) had PD in one or more axes at baseline, 22 (26%) after 6 months and 6 (7%) after 14 months. Gonadotropin deficiency in 29 (34%) patients and growth hormone deficiency (GHD) in 26 (31%) patients were the most common deficiencies. PD persisted until 14 months in 6 (8%) patients: GH

Background: Fatigue, slowness, apathy and decrease in level of activity are common long-term complaints after a subarachnoid haemorrhage (SAH). They resemble the symptoms frequently found in patients with endocrine dysfunction. Pituitary dysfunction may be the result of SAH or its complications. We therefore hypothesized that it may explain some of the long-term complaints after SAH. We reviewed the literature to clarify the occurrence, pattern and severity of endocrine abnormalities and we attempted to identify risk factors for hypopituitarism after SAH. We also assessed the effect of hypopituitarism on long-term functional recovery after SAH. Methods: In a MEDLINE search for studies published between 1995 and 2014, we used the term subarachnoid haemorrhage in combination with pituitary, hypopituitarism, growth hormone, gonadotropin, testosterone, cortisol function, thyroid function and diabetes insipidus. We selected all case-series and cohort studies reporting endocrine function at least 3 months after SAH and studied their reported prevalence, pathogenesis, risk factors, clinical course and outcome. Results: We identified 16 studies describing pituitary function in the long term after SAH. The reported prevalence of endocrine dysfunction varied from 0 to 55% and the affected pituitary axes differed between studies. Due to methodological issues no inferences on risk factors, course and outcome could be made. Conclusions: Neuroendocrine dysfunction may be an important and modifiable determinant of poor functional outcome after SAH. There is an urgent need for well-designed prospective studies to more precisely assess its incidence, clinical course and effect on mood, behaviour and quality of life.

Objectives: To compare cognitive and emotional outcomes between patients with aneurysmal and perimesencephalic subarachnoid haemorrhage and norm scores. Design: First measurement in prospective cohort study. Patients: Sixty-seven patients with subarachnoid haemorrhage, were divided into perimesencephalic (n = 8) and aneurysmal (n = 59) subarachnoid haemorrhage groups. Methods: Patients completed several questionnaires within the first year after haemorrhage. Depression was measured with the Center for Epidemiologic Studies Depression scale, fatigue with the Fatigue Severity Scale, and objective cognitive functioning with the Trail Making Test. Glasgow Coma Scale scores were collected at hospital admission. Results: Perimesencephalic patients had lower depression (p = 0.006) and lower fatigue scores (p = 0.029) and were faster on the Trail Making Test A (p = 0.002) than aneurysmal patients. No differences between the groups were found on Trail Making Test B (p = 0.112) and presence of fatigue (p = 0.105). Compared with norm scores, aneurysmal patients scored significantly worse on all outcomes, whereas perimesencephalic patients scored worse on Trail Making Test B (p < 0.008), fatigue (p = 0.073) and presence of fatigue (p = 0.058). Conclusion: Perimesencephalic patients may experience problems in complex cognitive functioning and fatigue. In this respect, they have similar sequelae as aneurysmal patients, which may interfere with daily activities and social participation. These findings are of clinical relevance, as perimesencephalic patients often are discharged from hospital without long-term follow-up.

Background: Coping style is one of the determinants of health-related quality of life after stroke. Stroke patients make less use of active problem-oriented coping styles than other brain damaged patients. Coping styles can be influenced by means of intervention. The primary aim of this study is to investigate if Problem Solving Therapy is an effective group intervention for improving coping style and health-related quality of life in stroke patients. The secondary aim is to determine the effect of Problem Solving Therapy on depression, social participation, health care consumption, and to determine the cost-effectiveness of the intervention.Methods/design: We strive to include 200 stroke patients in the outpatient phase of rehabilitation treatment, using a multicenter pragmatic randomized controlled trial with one year follow-up. Patients in the intervention group will receive Problem Solving Therapy in addition to the standard rehabilitation program. The intervention will be provided in an open group design, with a continuous flow of patients. Primary outcome measures are coping style and health-related quality of life. Secondary outcome measures are depression, social participation, health care consumption, and the cost-effectiveness of the intervention.Discussion: We designed our study as close to the implementation in practice as possible, using a pragmatic randomized trial and open group design, to represent a realistic estimate of the effectiveness of the intervention. If effective, Problem Solving Therapy is an inexpensive, deliverable and sustainable group intervention for stroke rehabilitation programs.Trial registration: Nederlands Trial Register, NTR2509.

Rede, In verkorte vorm uitgesproken ter aanvaarding van de bijzondere leerstoel Neurorevalidatie aan het Erasmus MC, faculteit der Geneeskunde van de Erasmus Universiteit Rotterdam op 11 oktober 2013 Bewijs van effectiviteit en bewijs van efficiëntie. Dat wordt meer en meer het motto in de gezondheidszorg. Wat werkt voor wie, voor wie niet en hoe kan het sneller en vooral goedkoper? En, zoals Robert Dijkgraaf dat ironisch formuleert: “Wie kan die bewijzen beter leveren dan de wetenschap, de hofleverancier van zekerheden in onzekere tijden?” Dit geldt ook voor de neurorevalidatie, dat deel van de revalidatiegeneeskunde dat zich richt op het behandelen en voorkomen van de gevolgen van niet-aangeboren hersenaandoeningen (NAH). Een NAH legt grote druk op het individu, op zijn mantelzorgers en op de maatschappij. Het verbeteren van de effectiviteit en efficiëntie van de neurorevalidatie is een continue noodzaak en vormt het centrale thema van mijn leerstoel. De gevolgen van NAH worden echter bepaald door een kluwen van mechanismen die op elkaar ingrijpen en specifiek zijn voor het letsel, die de patiënt typeren of zijn fysieke en sociale leefomgeving. Wetenschap en maatschappij treffen elkaar in de neurorevalidatie. Interventies worden, soms serieel in de tijd soms parallel, gericht op medische, sensomotorische, psychische, linguïstische en sociale problematiek. De omgeving van de patiënt zoals mantelzorgers en werkgevers, wordt betrokken in de behandeling en schotten in het Nederlandse zorgstelsel moeten worden geslecht om tot een optimaal resultaat te komen. De vragen die ontstaan wanneer gezondheidszorg en maatschappij elkaar treffen kunnen niet altijd opgelost worden door wetenschappelijk onderzoek.

Objective: To determine the diagnostic value of a ghrelin test in the diagnosis of GH deficiency (GHD) shortly after aneurysmal subarachnoid hemorrhage (SAH). Design: Prospective single-center observational cohort study. Methods: A ghrelin test was assessed after the acute phase of SAH and a GH-releasing hormone (GHRH)-arginine test 6 months post SAH. Primary outcome was the diagnostic value of a ghrelin test compared with the GHRH-arginine test in the diagnosis of GHD. The secondary outcome was to assess the safety of the ghrelin test, including patients' comfort, adverse events, and idiosyncratic reactions. Results: Forty-three survivors of SAH were included (15 males, 35%, mean age 56.6G11.7). Six out of 43 (14%) SAH survivors were diagnosed with GHD by GHRH-arginine test. In GHD subjects, median GH peak during ghrelin test was significantly lower than that of non-GHD subjects (5.4 vs 16.6, PZ0.002). Receiver operating characteristics analysis showed an area under the curve of 0.869. A cutoff limit of a GH peak of 15 mg/l corresponded with a sensitivity of 100% and a false-positive rate of 40%. No adverse events or idiosyncratic reactions were observed in subjects undergoing a ghrelin test, except for one subject who reported flushing shortly after ghrelin infusion. Conclusion: Owing to its convenience, validity, and safety, the ghrelin test might be a valuable GH provocative test, especially in the early phase of SAH.

Akathisia is reported to be one of the most common and disabling side effects of antipsychotics and other drugs. Akathisia is also a rare cause of psychomotor agitation in patients with traumatic brain injury (TBI). In this clinical note, we describe a case report of akathisia in a 34-year-old woman with TBI; review earlier case studies on akathisia in TBI; and discuss the differential diagnosis and its pathophysiology, treatment, and prognosis.

Background: Stroke is one of the leading causes of long-term disability in modern western countries. Stroke survivors often have functional limitations which might lead to a vicious circle of reduced physical activity, deconditioning and further physical deterioration. Current evidence suggests that routine moderate- or vigorous-intensity physical activity is essential for maintenance and improvement of health among stroke survivors. Nevertheless, long-term participation in physical activities is low among people with disabilities. Active video games, such as Nintendo Wii Sports, might maintain interest and improve long-term participation in physical activities; however, the intensity of physical activity among chronic stroke patients while playing Wii Sports is unknown. We investigated the energy expenditure of chronic stroke patients while playing Wii Sports tennis and boxing. Methods: Ten chronic ([greater than or equal to] 6 months) stroke patients comprising a convenience sample, who were able to walk independently on level ground, were recruited from a rehabilitation centre. They were instructed to play Wii Sports tennis and boxing in random order for 15 minutes each, with a 10-minute break between games. A portable gas analyzer was used to measure oxygen uptake (VO2) during sitting and during Wii Sports game play. Energy expenditure was expressed in metabolic equivalents (METs), calculated as VO2 during Wii Sports divided by VO2 during sitting. We classified physical activity as moderate (3-6 METs) or vigorous (>6 METs) according to the American College of Sports Medicine and the American Heart Association Guidelines. Results: Among the 10 chronic stroke patients, 3 were unable to play tennis because they had problems with timing of hitting the ball, and 2 were excluded from the boxing group because of a technical problem with the portable gas analyzer. The mean ([plus/minus]SD) energy expenditure during Wii Sports game play was 3.7 ([plus/minus]0.6) METs for

Contains fulltext : 77498.pdf (publisher's version ) (Closed access), Memory Self-Efficacy (MSE) has been shown to be related to memory performance and social participation in a healthy elderly population. This relation is unclear in stroke. As about 30% of all stroke survivors report memory complaints, there is an urgent need for effective treatment strategies. Before implementing MSE as a potential target in memory training, it should be examined whether the association between MSE and memory performance demonstrated in healthy elderly people also applies in stroke patients. This study therefore explored the predictive value of MSE on two kinds of memory tests in stroke patients; adjusted and unadjusted for age, gender, education and location of stroke. In 57 stroke patients, the Metamemory in Adulthood Questionnaire (MIA), an everyday memory test (RBMT) and a more traditional memory test (AVLT) were completed. The results show that MSE significantly predicts memory test performance on both memory tests (RBMT: β = .34; p = .01 AVLT: β = .28; p = .04). When adjusted for gender, age, education and location of stroke, the predictive value of MSE remained significant for the AVLT (RBMT: β = .23; p = .07; AVLT: β = .23; p = .05). The results support the hypothesis that MSE predicts test performance in stroke patients and, by consequence, enables improving memory performance in post-acute memory rehabilitation after stroke.