Dr Johnny Collett

Background.
Symptom fluctuations within and between individuals with long COVID are widely reported, but the extent to which severity varies following different types of activity and levels of exertion, and the timing of symptoms and recovery, have not previously been quantified. We aimed to characterise timing, severity, and nature of symptom fluctuations in response to effortful physical, social and cognitive activities, using Ecological Momentary Assessments.

Methods.
We recorded activity, effort, and severity of 8 core symptoms every 3 h for up to 24 days, in cohorts from both clinic and community settings. Symptom severities were jointly modelled using autoregressive and moving average processes.

Findings.
Consent was received from 376 participants providing ≥1 week's measurements (273 clinic-based, 103 community-based). Severity of all symptoms was elevated 30 min after all categories of activity. Increased effort was associated with increased symptom severity. Fatigue severity scores increased by 1.8/10 (95% CI: 1.6–1.9) following the highest physical exertions and by 1.5 (1.4–1.7) following cognitive efforts. There was evidence of only mild delayed fatigue 3 h (0.3, 0.2–0.5) or one day later (0.2, 0.0– 0.5). Fatigue severity increased as the day progressed (1.4, 1.0–1.7), and cognitive dysfunction was 0.2 lower at weekends (0.1–0.3).

Interpretation. 
Cognitive, social, self-care and physical activities all triggered increased severity across every symptom, consistent with associated common pathways as potential therapeutic targets. Clear patterns of symptom fluctuations emerged that support more targeted self-management.

Funding. 
National Institute for Health and Care Research.

Introduction. 
People with Parkinson’s disease (PwPD) present motor alterations which can impact daily life tasks that require speed and/or accuracy of movement.

Objective. 
A sub analysis of NCT01439022, aiming to estimate the extent to which two different exercise training protocols (global and handwriting upper limb exercise training) impact reaction time, travel speed, and accuracy in PwPD.

Methods. 
Seventy PwPD, right-side dominant were randomised 1:1 into two six-month training protocol groups; 35 PwPD performed global exercise training and 35 performed specific training (handwriting upper limb exercise movements). Assessments of speed-accuracy and trade-off were carried out at baseline, after 3 and 6 months of training, and at a 12-month follow-up. The current study used data from a previous publication of a randomised controlled trial that included a 6-month self-managed community exercise programme for PwPD. For the present study we included only the participants who completed the Fitts’ task during the baseline assessment.

Results. 
In the upper limb assessments, no main effects were found for the number of touches, but the exercise group showed a marginal increase over time on the left side. Error averages on the left side decreased significantly for the exercise group from baseline to 6 and 12 months. The exercise group also presented a lower Error CoV and the Reaction Time CoV increased on the right side. Significant findings for Fitts r on the left side indicated lower values for the exercise group, with improvements continuing at 12 months.

Conclusion. 
We report the potential of global exercise interventions to facilitate improvements in reaction time and travel speed, as well as other motor control metrics, with lasting effects at 12 months, particularly on the non-dominant side.

Introduction:
Despite practice guidelines, professionals do not feel confident in implementing positive risk-taking. This may be due to the guidance provided.

Method:
A scoping review of current organisational guidance for the professional practice of positive risk-taking within Adult Social Care services for people with a physical disability. Guidelines were obtained from Local Authorities in England in October 2020. The data were extracted using TIDieR to describe positive risk-taking as an intervention. The quality of the guidelines was assessed using AGREE II.

Findings:
In all, 36 Local Authorities responded out of 106 contacted. A total of 21 documents were included for review. Substantial variability was found in terminology, definitions and risk grading between documents. The greatest consistency was found in how to implement a positive risk-taking intervention. Consistency was also found in the policy that documents cited. There was little reference to evidence to support intervention components. Overall, AGREE II quality scores were low and stakeholder involvement, specifically with regard to the views and preferences of service users, was largely absent.

Conclusion:
There is a need for a greater consensus to guide the professional practice of positive risk-taking. Determining the extent of current evidence and establishing an evidence base may facilitate more consistent guidelines and support professionals’ confidence in implementing positive risk-taking.

Aim: To assess the feasibility of methods and estimate the potential effect of interrupting sedentary behaviour, with intermittent or continuous physical activity breaks, on cognitive performance in young people with Cerebral Palsy.

Methods: A randomised three-arm exposure response cross-over design with process evaluation. Participants were recruited throughout the Thames Valley, UK between 01/11/2018 to 31/03/2020. The three 2-hour activity exposure visits included: i) sitting only (controls), ii) sitting plus 20 minutes of moderate-to-vigorous activity burst, or iii) 4 x 5 minutes of moderate-to-vigorous activity bursts, during a 2.5-hour sedentary session. Measures of feasibility were sought. Cognitive performance outcomes (using the Eriksen Flanker task and Forward and Backward Digit Span) were delivered before and after the 2-hour testing period.

Results: 36 participants were randomised (age 13.2 ± 2.7, Gross-Motor Functional Classification System 1-3). Study retention was 83% across all three interventions and overall missing data for measures was 4%. A small intervention effect was found in reaction time in the 4 x 5-minute physical activity exposure session compared to the sedentary control condition (0.42; 95% CI 0.40 to 0.79). There were two research-related minor adverse effects, an allergic reaction to the FreeStyle Libre and feeling faint and vomiting after consumption of glucose solution. Both events were resolved and participants continued with the study.

Conclusion: The study design and intervention implementing short bursts of physical activity was feasible and indicated a potential effect on reaction time as a measure of cognitive performance in young people with cerebral palsy.

Purpose
This review synthesised the evidence for the effect of prehabilitation interventions on biopsychosocial and service outcomes.

Materials and Methods
A systematic review was conducted. 10 databases were searched to December 2023. Prospective experimental studies exploring prehabilitation interventions in adults undergoing upper gastrointestinal surgery were included. Prehabilitation was any preoperative intervention to improve physical or psychological outcomes. Included studies required a comparator group or alternative preoperative intervention as well as baseline, presurgical and postoperative assessment points. Study quality was assessed using the Cochrane risk of bias tool (v.2). Data synthesis was narrative (SWiM guidance).

Results
6028 studies were screened, with 25 studies included. Prehabilitation interventions were: inspiratory muscle training (five studies n = 450); exercise (nine studies n = 683); psychological (one study n = 400); and nutritional (ten studies n = 487). High quality studies showed preoperative improvements in impairments directly targeted by the interventions. Generally, these did not translate into functional or postoperative improvements, but multimodal interventions were more promising.

Conclusion
Current evidence supports prehabilitation as safe to preserve or improve preoperative function. Heterogeneity in outcomes and variable study quality means definitive conclusions regarding interventions are not yet possible, limiting implementation. Agreement of clinical outcomes and cost effectiveness evaluation is required.

Objective

Physical activity in people with stroke remains low despite considerable research. This overview aimed to provide high-level synthesis and aid clinical decision-making. The Capability, Opportunity, Motivation-Behaviour (COM-B) model was used to classify interventions to understand which components improve physical activity behaviour in people with stroke.

Data Sources

CINAHL, Cochrane Database, MEDLINE, PEDro, PsychINFO, SPORTDiscus

Review Methods

A systematic search was conducted (November 2023) to identify reviews of interventions to improve physical activity in people with stroke. Results were screened and assessed for eligibility. Participant characteristics, intervention classification using COM-B, and effect of intervention were extracted. Quality was assessed using AMSTAR2, and Corrected Cover Analysis for study overlap. Narrative synthesis was used to understand components of interventions to improve physical activity behaviour.

Results

1801 references were screened and 29 full-text references assessed for eligibility. Twenty reviews were included. Quality ranged from critically low (n = 3) to high (n = 10). Study overlap calculated using corrected cover area indicated slight overlap (0.028) and minimal reporting bias.

The majority of participants were mobile with mild stroke and community dwelling. Twenty-three interventions were classified using COM-B. Three of twelve interventions classified to one aspect of the COM-B were effective. Fourteen of sixteen effective interventions combined at least two COM-B elements, ten of these combined capability and motivation.

Conclusion

Interventions including at least two elements of the COM-B are most likely to improve physical activity in mobile stroke survivors. Further research is needed to understand physical activity behaviour in those with moderate to severe stroke.

Objective
A diagnosis of Parkinson's often leads to uncertainty about the future and loss of perceived control. Peer support may offer a means to address these concerns and promote self-management.

Design
A programme evaluation of the feasibility and potential effects of ‘First Steps’, utilising a pragmatic step wedge approach. Comparing First Steps (intervention) to (control) conditions.
Setting: In the community at four sites in southern England.
Participants: Newly diagnosed (≤ 12months) people with Parkinson's.
Intervention: First Steps was a 2-day peer-conceived, developed and led intervention to support self-management.
Main measures: At 0, 12 and 24 weeks anxiety and depression (Hospital, Anxiety and Depression Scale, HADS), daily functioning (World Health Organisation Disability Assessment Schedule, WHODAS), physical activity, quality of life (EQ5D), carer strain and service utilisation were assessed.

Results
Between February 2018 and July 2019, 36 participants were enrolled into intervention and 21 to control conditions, all were included in statistical analysis. Lost to follow up was n = 1 (intervention) and n = 1 adverse event was reported (control, unrelated). Of the 36 allocated to the intervention n = 22 participants completed both days of First Steps during the study period. Completion of outcome measures was >95% at 24 weeks. Small effects favouring the intervention were found for HADS (odds ratio (OR) = 2.06, 95% confidence interval (CI) 0.24:17.84), Carer Strain Index (OR = 2.22, 95% CI 0.5:9.76) and vigorous (d = 0.42, 95% CI −0.12:0.97) and total physical activity (d = 0.41, 95% CI −0.13:0.95). EQ5D, WHOSDAS and service utilisation, was similar between groups.

Conclusions
First Steps was feasible and safe and we found potential to benefit physical activity, mental health and carer strain. Further research with longer-term follow up is warranted.

Background:
Multiple sclerosis (MS) exercise terminology lacks consistency across disciplines, hindering research synthesis.
Objective:
The ‘Moving exercise research in MS forward initiative’ (MoXFo) aims to establish agreed definitions for key MS exercise terms.
Methods:
The Lexicon development methodology was employed. A three-step process identified key exercise terminology for people with multiple sclerosis (pwMS): (1) consensus and systematic review, (2) Delphi round 1 and consideration of existing definitions and (3) Delphi round 2 for consensus among MoXFo steering group and exercise experts. Final definitions and style harmonisation were agreed upon.
Results:
The two-stage Delphi process resulted in the selection and scoring of 30 terminology definitions. The agreement was 100% for resistance exercise, balance and physical activity. Most terms had agreement >75%, but ‘posture’ (60%) and ‘exercise’ (65%) had a lower agreement.
Conclusion:
This study identified key terms and obtained agreement on definitions for 30 terms. The variability in agreement for some terms supports the need for clearly referencing or defining terminology within publications to enable clear communication across disciplines and to support precise synthesis and accurate interpretation of research.

Purpose: This study set out to identify the extent of the relationships between subsections of the Movement Assessment Battery for Children 2nd Edition - MABC2 (manual dexterity, aiming and catching, and balance) to PA, CRF and BMI in adolescents.

Methods: Height, BMI, the MABC2, a 20m shuttle run test and wrist-worn accelerometery PA levels (mins) were measured. Multivariable linear regression models, adjusting for sex, height and BMI were used to assess the relationship of the three subsections of the MABC2 with PA, CRF and BMI.

Results: A total of 155 adolescents, aged 13-14 years, took part in this study (77 girls, 78 boys). Balance reported significant relationships with moderate to vigorous PA (unstandardised Beta B=0.15, 95%CI 0.02-0.28), vigorous PA (B=0.06, 95%CI 0.02-0.09) and BMI (B=-0.01, 95%CI -0.02-0.005). Balance in addition to aiming and catching skills were both significantly related to adolescent CRF (B=0.30, 95%CI 0.17-0.42 and B=0.29, 95%CI 0.14-0.45, respectively).

Conclusion: This study suggests that balance is the strongest correlate skill to achieving the highest intensities of PA and healthier BMI status in adolescents.

Background

Volunteering may have therapeutic benefits, but little is known about its requirements and potential for people with neurological conditions (pwNC).

Design

Two separate focus groups were conducted in Darmstadt, Germany: one group consisting of six pwNC and another group consisting of four health care professionals and three volunteering service providers. The focus groups were audio-recorded, transcribed and data were managed using NVivo12. The thematic analysis was applied.

Results

Four main themes were identified: (1) Impact of volunteering, (2) Individualisation, (3) Developmental space and (4) Funded supported volunteering.

Conclusion

According to the findings, volunteering can be used as a strategy to enhance physical, mental and social well-being in disease management for people with long-term neurological conditions.

Introduction
A substantial proportion of COVID-19 survivors continue to have symptoms more than 3 months after infection, especially of those who required medical intervention. Lasting symptoms are wide-ranging, and presentation varies between individuals and fluctuates within an individual. Improved understanding of undulation in symptoms and triggers may improve efficacy of healthcare providers and enable individuals to better self-manage their Long Covid. We present a protocol where we aim to develop and examine the feasibility and usability of digital home monitoring for capturing daily fluctuation of symptoms in individuals with Long Covid and provide data to facilitate a personalised approach to the classification and management of Long Covid symptoms.

Methods and analysis
This study is a longitudinal prospective cohort study of adults with Long Covid accessing 10 National Health Service (NHS) rehabilitation services in the UK. We aim to recruit 400 people from participating NHS sites. At referral to study, 6 weeks and 12 weeks, participants will complete demographic data (referral to study) and clinical outcome measures, including ecological momentary assessment (EMA) using personal mobile devices. EMA items are adapted from the COVID-19 Yorkshire Rehabilitation Scale items and include self-reported activities, symptoms and psychological factors. Passive activity data will be collected through wrist-worn sensors. We will use latent class growth models to identify trajectories of experience, potential phenotypes defined by co-occurrence of symptoms and inter-relationships between stressors, symptoms and participation in daily activities. We anticipate that n=300 participants provide 80% power to detect a 20% improvement in fatigue over 12 weeks in one class of patients relative to another

Background

Fatigue after acquired brain injury (ABI) leads to detrimental changes in ABI survivors’ daily activities and participation. There is a need to capture individual’s experience of fatigue as it happens, to better support self-management of fatigue.

Study aims

To investigate the usability of a real-time tracker of fatigue and activity (using ecological momentary assessment delivered by a smartphone application) and the feasibility of capturing activity and environmental factors using phone sensors.

Methods

Participants wore an activity monitor and completed up to eight surveys a day on a smartphone app, for 6 days, completed the system usability scale (SUS) and were interviewed on their views of using the app. Interview transcripts were analysed using qualitative content analysis. Agreement between data from the phone’s sensors and the activity monitor was analysed using Kappa statistics.

Results

Seven participants completed between 11 and 58 surveys. Mean score on the SUS indicated good perceived usability of the app. Phone sensors did not reliably capture physical activity or background noise. Participants found the app easy to use and perceived self-monitoring to help their understanding of fatigue. A fatigue-tracking app may be acceptable to ABI survivors and has potential to aid self-management of fatigue.

Developmental coordination disorder (DCD) is characterized by motor learning deficits that are poorly understood within whole-body activities context.  Here we present results of one of the largest nonrandomized interventional trials combining brain imaging and motion capture techniques to examine motor skill acquisition and its underpinning mechanisms in adolescents with and without DCD. A total of 86 adolescents with low fitness levels (including 48 with DCD) were trained on a novel stepping task for a duration of 7 weeks. Motor performance during the stepping task was assessed under single and dual-task conditions. Concurrent cortical activation in the prefrontal cortex (PFC) was measured using functional near-infrared spectroscopy (fNIRS). Additionally, structural and functional magnetic resonance imaging (MRI) was conducted during a similar stepping task at the beginning of the trial.

The results indicate that adolescents with DCD performed similarly to their peers with lower levels of fitness in the novel stepping task and demonstrated the ability to learn and improve motor performance. Both groups showed significant improvements in both tasks and under single- and dual-task conditions at post-intervention and follow-up compared to baseline. While both groups initially made more errors in the Stroop task under dual-task conditions, at follow-up, a significant difference between single- and dual-task conditions was observed only in the DCD group. Notably, differences in prefrontal activation patterns between the groups emerged at different time points and task conditions. Adolescents with DCD exhibited distinct prefrontal activation responses during the learning and performance of a motor task, particularly when complexity was increased by concurrent cognitive tasks. Furthermore, a relationship was observed between MRI brain structure and function measures and initial performance in the novel stepping task. Overall, these findings suggest that strategies that address task and environmental complexities, while simultaneously enhancing brain activity through a range of tasks, offer opportunities to increase the participation of adolescents with low fitness in physical activity and sports.

Purpose.
To explore, in a European cohort of people living with Parkinson’s (PD), issues affecting employment and economic consequences, considering age at diagnosis.

Materials and methods.
A cross-sectional survey (European convenience sample). Inclusion criteria were ≥18 years, a PD diagnosis and in work when diagnosed. Data were collected online on demographics, employment status, occupation, and perceived health. For those no longer in paid work, time from diagnosis until loss of employment, reasons for leaving and enablers to stay in work were ascertained.

Results.
Between April and November 2019, n = 692 enrolled and n = 560 were eligible. Those who had lost paid work (n = 190, 34%) reported worse fatigue, sleep, and general health than those still in work (p

Conclusions.
This study confirms lost productivity after a PD diagnosis, especially in those with many years of potential employment ahead. The study also identified potential targets for interventions. Clinical trial registration: Clincaltrials.gov (NCT03905954).

Implications for rehabilitation.

* People with Parkinson’s diagnosed at career establishment or at mid working age risk losing many years of potential employment.

* Most people with Parkinson’s do not receive early intervention to support self-management of problems identified with leaving work early, such as fatigue.

* Adaptations to the work environment and more flexible working patterns were identified factors that may help people remain in work.

Flavonoids, plant compounds found in certain foods, may have the ability to improve fatigue and fatigability.  However, to date, no well-designed intervention studies assessing the role of flavonoid consumption for fatigue management in people with Parkinson’s (pwP) have been performed. 

Objectives: To determine the feasibility and estimate potential effect of flavonoid-rich cocoa on fatigue and fatigability in pwP.

Methods: This was a randomised (1:1) double-blind placebo controlled feasibility study in which 30 pwP were recruited from the European Parkinson Therapy Centre, Italy (trial registration: NCT03288155). During a six day intervention participants consumed a high (10.79mg/g) or low flavonoid cocoa (1.02mg/g) beverage (18 grams Cocoa with 200ml Rice milk) once daily. Potential effect on fatigue and fatigability was measured (baseline to day 6). Feasibility and fidelity were assessed through recruitment and retention, adherence and a process evaluation.

Results: From July 2017 to May 2018, 30 pwP were recruited and randomised and allocated to high (n=15) or low (n=15) flavonoid groups and included in analysis. Missing data was less than 5% and adherence to intervention of all allocated individuals was 97%. There was a small effect on fatigability (six minute walk test: ES 0.11 (95%CI=-0.11-0.26); Z=0.81).There were 2 adverse events (one in the control and one in the intervention group).

Conclusion: The consumption of cocoa is feasible and well received in pwP, and further investigation on the effect on fatigability is warranted.

Objectives The objective was to determine recent cross-sectional trends in health-related fitness (HRF) in secondary school students by studying the 13–14 years old age group repeatedly over 6 years, considering parallel national trends in physical education (PE).

Methods Height, weight, broad jump, grip strength, 20 m shuttle run and throwing and catching skills were measured by the same research team using standardised techniques from 2014 to 2019. Trends in these HRF measures were assessed by linear regression, adjusting for school, sex and height. Interactions with fitness and body mass index (BMI) were tested. The number of PE lessons reported in the UK Annual School Workforce Census between 2010 and 2019 for all state-funded secondary schools was analysed.

Results Grip strength (B=−0.60, 95% CI −0.78 to –0.41), broad jump (B=−1.16, 95% CI −1.99 to –0.34), 20 m shuttle run (B=−1.85, 95% CI −2.58 to –1.12) and throwing and catching skills (B=−0.12, 95% CI −0.15 to –0.08) declined significantly over the study period. There was a greater reduction in broad jump and grip strength in adolescents with low fitness and a greater reduction in fitness and motor competence in adolescents with normal BMI. These declines coincided with a 16% reduction nationally in secondary school PE between 2010 (333 800 hours) and 2019 (280 725 hours).

Conclusion Adolescent HRF has declined in recent years, in parallel with PE lessons. Declines were observed across all young people and particularly those of low fitness and normal BMI. To reach the majority of young people, policy makers could increase PE in schools to increase activity and prevent worsening fitness and health in future generations.

Fatigue is a common and pervasive symptom reducing physical activity in people with multiple sclerosis (pwMS). Exercise may reduce fatigue, although evidence to guide optimal prescription is limited. Specifically, supportive evidence for the timing of exercise for fatigue management or the impact of dietary supplements is unavailable. We performed intensive phenotyping of the interrelation of time of day, physical activity levels, and fatigue to evidence exercise prescription in 40 pwMS participating in a six week randomized controlled trial of morning flavonoid intake (n=19) or a control (n=21). Physical activity was measured over seven days by using an accelerometer at baseline, week three and week six. Participants self-reported their fatigue on a 1–10 rating scale at 10 am, 3 pm, and 8 pm daily. Physical activity levels were calculated for 2.5 h before and after fatigue was reported. Generalized estimating equations were used to explore the time of day fatigue profiles, the relationship of physical activity to fatigue, and the effect of morning flavonoids on this relationship. Participants experienced higher fatigue at 8 pm (4.64±2.29) than at 3 pm (4.39±2.28) and 10 am (3.90±2.10) (P0.05). Morning flavonoid cocoa consumption reduced the relationship of fatigue to physical activity (P=0.049) and fatigue to time of the day (P

Objective:
To test the extent to which initial walking speed influences dual-task performance after walking intervention, hypothesising that slow walking speed affects automatic gait control, limiting executive resource availability.

Design:
A secondary analysis of a trial of dual-task (DT) and single-task (ST) walking interventions comparing those with good (walking speed ⩾0.8 m s−1, n = 21) and limited (walking speed

Setting:
Community.

Subjects:
Adults six-months post stroke with walking impairment.

Interventions:
Twenty sessions of 30 minutes treadmill walking over 10 weeks with (DT) or without (ST) cognitive distraction. Good and limited groups were formed regardless of intervention received.

Main measures:
A two-minute walk with (DT) and without (ST) a cognitive distraction assessed walking. fNIRS measured prefrontal cortex activation during treadmill walking with (DT) and without (ST) Stroop and planning tasks and an fMRI sub-study used ankle-dorsiflexion to simulate walking.

Results:
ST walking improved in both groups (∆baseline: Good = 8.9 ± 13.4 m, limited = 5.3±8.9 m, Group × time = P

Conclusion:
In individual who walk slowly it may be difficult to improve dual-task walking ability.

The purpose of this study was to determine how dual-task (DT) effect on gait differs among adolescents with different fitness and health profiles. The gait performances of 365 adolescents aged 13-14 years were assessed at single and DT walking. The proportional changes in gait parameters from single to dual were regressed against gender, body mass index (BMIz), three components of MABC-2 (balance, aiming &catching and manual dexterity), group (high vs low motor competence), body strength, physical fitness level using multiple regression analyses; and gender and four items of balance subtest of MABC-2 in the secondary analysis. The analyses showed that being female was associated with greater reduction in gait speed and stride length and an increase in double support time and step time; and having lower score in balance was related to greater reduction in gait speed, and cadence, and an increase in step time. Only zig-zag hopping item of the balance subtest was associated with DT effect on gait speed and stride length. No significant relationships were found between DT effect on gait and the rest of the predictors. Females and adolescents with lower level of balance function may be at higher risk of having DT deficit during walking.

To assess the intake of nutrients in people with multiple sclerosis (pwMS) compared to a control population, and to assess the pro/ anti-inflammatory properties of nutrients/ foods and their relationships with fatigue and quality of life. This was a cross sectional study in which 2410 pwMS (686 men; 1721 women, 3 n/a, mean age 53 (11 years)) provided dietary data using a food frequency questionnaire that was hosted on the MS Register for a period of 3 months and this was compared to a cohort of 24,852 controls (11,250 male, 13,602 female, mean age 59 years). Consent was implied by anonymously filling out the questionnaire. A Wilcoxon test was used to compare intake between pwMS and controls, and a bivariate analyses followed by chi2 test were undertaken to identify significance and the strength of the relationship between pro/anti-inflammatory dietary factors and fatigue and EQ-5D. Compared to controls, all nutrients were significantly lower in the MS group (P

Background: Transcranial direct current stimulation (tDCS) and therapy-based virtual reality (VR) have been investigated separately. They have shown promise as efficient and engaging new tools in the neurological rehabilitation of individuals with cerebral palsy (CP). However, the recent literature encourages investigation of the combination of therapy tools in order to potentiate clinic effects and its mechanisms.

Methods: A triple-blinded randomised sham-controlled crossover trial will be performed. Thirty-six individuals with gross motor function of levels I to IV (aged 4–14 years old) will be recruited. Individuals will be randomly assigned to Group A (active first) or S (sham first): Group A will start with ten sessions of active tDSC combined with VR tasks. After a 1-month washout, this group will be reallocated to another ten sessions with sham tDCS combined with VR tasks. In contrast, Group S will carry out the opposite protocol, starting with sham tDCS. For the active tDCS the protocol will use low frequency tDCS [intensity of 1 milliampere (mA)] over the primary cortex (M1) area on the dominant side of the brain. Clinical evaluations (reaction times and coincident timing through VR, functional scales: Abilhand-Kids, ACTIVLIM-CP, Paediatric Evaluation of Disability Inventory-PEDI- and heart rate variability-HRV) will be performed at baseline, during, and after active and sham tDCS.

Conclusion: tDCS has produced positive results in treating individuals with CP; thus, its combination with new technologies shows promise as a potential mechanism for improving neurological functioning. The results of this study may provide new insights into motor rehabilitation, thereby contributing to the better use of combined tDCS and VR in people with CP.

Purpose. To develop an in-depth understanding of how survivors of acquired brain injury (ABI) experience fatigue and how fatigue affects everyday life.
Materials and methods. We conducted semi-structured in-depth interviews with 16 adults with ABI fatigue, recruited from support groups in south east UK. Interviews were analysed using the frameworks method. 
Results. We developed four themes: experiencing fatigue in the context of everyday activities, struggling to make sense of fatigue, coping with fatigue, adjusting social participation in the context of fatigue. Fatigue was comprised of mental, physical, generalised and motivational fatigue. Balancing fatigue against participation in daily activities was influenced by coping strategies and social support. Opportunities to socialize or participate in meaningful activities provided incentives for participants to push through their fatigue.
Conclusions. This study highlights complex interactions that potentially mitigate the impact of fatigue on everyday life.  Educational and self-management approaches to fatigue need to account for different types of fatigue in the contexts of an individual’s daily activity. Assessment of fatigue should capture in- the- moment experiences of different types of fatigue and activity. Social support and participation in meaningful activities may help individuals to break the negative cycle of fatigue and inactivity. 

Introduction: Individuals with Duchenne Muscular Dystrophy (DMD) present with progressive loss of motor function which can impair both control of speed and accuracy of movement. Aim: to evaluate movement time during a task at various levels of difficulty and to verify whether the level of difficulty affects the speed and/ or accuracy during the task. Methods: the DMD group comprised of 17 individuals age matched with 17 individuals with typical development (TD group). The task evaluates the relationship between speed and accuracy, consisting of the execution of manual movements (using the mouse of the computer) aimed at a target at three different levels of difficulty (ID). Results: A MANOVA demonstrated statistically significant differences in dispersion data and intercept values between the groups with greater movement time in the DMD group. An ANOVA indicated differences between groups for ID, except for when there was a higher accuracy demand (higher ID). In the other IDs that required lower accuracy demand, individuals in the DMD group had significantly longer movement time when compared to the TD group. Conclusion: These results show that the TD and DMD did not differ in the higher ID, therefore it can be concluded that for those with DMD, motor performance is more affected by speed than accuracy of movement. 

What this paper adds?
It is known that individuals with DMD have considerable motor deficits, however this paper shows that when the task involves higher accuracy compared with speed, people with DMD have performance similar to typically developed peers. This insight is a novel finding and can inform the rehabilitation team, to focus on training of speed, whilst maintaining accuracy for better execution of daily life tasks. 

Aim. The dual aim of this research is to consider the impact of providing the First Steps program on the stories of people with Parkinson’s Disease (PD)  and investigate the psychosocial and emotional mechanisms which may explain this impact. 
Methods. A qualitative study using a subtle realist paradigm and hermeneutic phenomenological methodology was undertaken. A single semi-structured interview was used to consider the impact and experiences of people with PD who completed either the intervention (2-day peer-led behavior intervention using storytelling 6-8 weeks apart) or received telephone support calls as part of the active control group. Descriptive statistics and narrative analysis were undertaken on the results. 
Results. Forty-two participants were invited to participate of whom forty completed the interview. This included 18 from the intervention group and 22 from the active control group. The intervention group identified the value of the program as worth-while, demonstrating improved exercise behavior and coping mechanisms following the intervention. Three major stories (the affirmed, the validated and the transformed story) identified the impact of the intervention. Three internal mechanisms (perceived control, hope and action, and the individual’s mind set) alongside three social mechanisms (social comparison, social control and the first opportunity to share with peers) appeared to explain the impact. 
Conclusion. This study provides exciting and novel evidence for the impact of a peer led psycho-educational intervention for people newly diagnosed with PD. Further research is needed to consider the impact of stories-based approaches on participants and consider a critical evaluation of the mechanisms which may explain changes in stories and self-reported behaviour.

Study design. Retrospective chart audit. Objectives. The National Early Warning Score (NEWS) is based on seven physiological parameters which can be altered in some individuals with spinal cord injuries (SCI). The aim was to start the development of adapted NEWS suitable for SCI population. The objective was to determine the SBP NEWS specificity based on neurological level of injury (NLI) and completeness of injury. Setting. Tertiary centre in the UK. Methods. Adult patients admitted for the first time to the National Spinal Injuries Centre between 1 January 2015 and 31 December 2016 were included if they were >6 months post injury. Data were extracted retrospectively including the last ten consecutive BP and heart rate readings before discharge. Data were analysed based on different AIS grades, completeness of injury and NLI. Results. One hundred and ninety one patients were admitted in 2015 and 2016 and 142 patients were included in the primary analysis. The mean SBP ranged between 92 and 151 mmHg. Patients with the NLI of T6 and above (≥T6) motor complete lesions had a significantly lower SBP than motor incomplete lesions. The specificity of the SBP NEWS was 35.3% in ≥T6 motor complete individuals versus 80.3% in ≥T6 motor incomplete individuals. Conclusion. The baseline BP is significantly lower in the ≥T6 motor complete SCI individuals (>6 months post injury) resulting in a very low specificity of 35.3% to SBP NEWS, which could lead to mismatch between clinical deterioration and NEWS resulting in lack of timely clinical response.

The impact of flavonoids on fatigue has not been investigated in Relapsing and Remitting Multiple Sclerosis (RRMS). Objective. To determine the feasibility and estimate the potential effect of flavonoid-rich cocoa on fatigue and fatigability in RRMS.  Methods. A randomised double-blind placebo-controlled feasibility study in people recently diagnosed with RRMS and fatigue, throughout the Thames Valley (ISRCTN: 69897291). During a six week intervention participants consumed a high or low flavonoid cocoa beverage daily. Fatigue and fatigability were measured at three visits (weeks 0, 3 and 6). Feasibility and fidelity were assessed through recruitment and retention, adherence and a process evaluation. Results. 40 pwMS (10 men, 30 women, age 44 ± 10 yrs) were randomised and allocated to high (n=19) or low (n=21) flavonoid groups and included in analysis. Missing data was 75%. There was a small effect on fatigue (Neuro-QoL: effect size {ES} 0.04; confidence interval {CI} -0.40-0.48) and a moderate effect on fatigability (six-minute walk test: ES 0.45; CI -0.18 - 1.07). There were seven adverse events (four control, three intervention), only one of which was possibly related and it was resolved.   Conclusion. A flavonoid beverage demonstrates the potential to improve fatigue and fatigability in RRMS. 

The names of the members of the IOPS MS study Group was inverted in the original paper and is now corrected in this article.

Background. We aimed to investigate the extent of the agreement on practices around brain death and postmortem organ donation. Methods. Investigators from 67 Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study centers completed several questionnaires (response rate: 99%). Results. Regarding practices around brain death, we found agreement on the clinical evaluation (prerequisites and neurological assessment) for brain death determination (BDD) in 100% of the centers. However, ancillary tests were required for BDD in 64% of the centers. BDD for nondonor patients was deemed mandatory in 18% of the centers before withdrawing life-sustaining measures (LSM). Also, practices around postmortem organ donation varied. Organ donation after circulatory arrest was forbidden in 45% of the centers. When withdrawal of LSM was contemplated, in 67% of centers the patients with a ventricular drain in situ had this removed, either sometimes or all of the time. Conclusions. This study showed both agreement and some regional differences regarding practices around brain death and postmortem organ donation. We hope our results help quantify and understand potential differences, and provide impetus for current dialogs toward further harmonization of practices around brain death and postmortem organ donation.

Objective. To evaluate the tolerability of, adherence to and efficacy of a community walking training  programme with simultaneous cognitive demand (dual‐task) compared to a control walking training programme without cognitive distraction. Methods. Adult stroke survivors, at least 6 months after stroke with a visibly obvious gait abnormality or reduced two‐minute walk distance were included into a 2‐arm parallel randomized controlled trial of complex intervention with blinded assessments. Participants received a 10 week, bi‐weekly, 30 minutes treadmill program at an aerobic training intensity (55‐85% heart rate maximum), either with, or without simultaneous cognitive demands. Outcome measured at 0, 11 and 22 weeks. Primary: two‐minute‐walk tests with and without cognitive distraction, dual task effect on walking and cognition; secondary: SF‐36, EuroQol‐5D‐5L, Physical Activity Scale for Elderly (PASE), and step activity. Results. Fifty stroke patients were included, 43 received allocated training and 45 completed all assessments. The experimental group (n = 26) increased mean (SD) two‐minute walking distance from 90.7 (8.2) to 103.5 (8.2) metres, compared with 86.7 (8.5) to 92.8 (8.6) in the control group, and their PASE score from 74.3 (9.1) to 89.9 (9.4), compared with 94.7 (9.4) to 77.3 (9.9) in the control group. Statistically, only the change in the PASE differed between the groups (p = 0.029), with the dual‐task group improving more. There were no differences in other measures. Conclusions. Walking with specific additional cognitive distraction (dual‐task training) might increase activity more over 12 weeks, but the data are not conclusive.

Symptoms of Parkinson’s can result in low physical activity and poor sleep patterns which can have a detrimental effect on a person’s quality of life. To date, studies looking into exercise interventions for people with Parkinson’s (PwP) for symptom management are promising but inconclusive. The aim of this study is to estimate the effect of a clearly defined exercise prescription on general physical activity levels, fatigue, sleep, and quality of life in PwP. Method. PwP randomised into either an exercise group (29; 16 males, 13 females; mean age 67 years (7.12)) or a control handwriting group (36; 19 males; 17 females; mean age 67 years (5.88)) as part of a larger trial were included in this substudy if they had completed a 6-month weekly exercise programme (intervention group) and had complete objective physical activity data (intervention and control group). Sleep and fatigue were recorded from self-reported measures, and physical activity levels measured through the use of accelerometers worn 24 hours/day over a seven-day testing period at baseline and following the 24-week intervention. A Wilcoxon’s test followed by a Mann–Whitney post hoc analysis was used, and effect sizes were calculated. Results. Participants showed a significant increase in time spent in sedentary and light activities during the overnight period postintervention in both exercise and handwriting groups (p

The development of fatigue during single-joint isolated muscle contractions is accompanied by an increase in long-interval intracortical inhibition (LICI). However, the effect of whole-body locomotor endurance exercise on LICI is unknown. Eighteen healthy men completed three exercise trials on a cycle ergometer. The first trial was completed to determine the lactate threshold (LT) and maximal oxygen uptake (V˙O2max). The remaining two trials (familiarisation and experimental) involved cycling to volitional exhaustion at an intensity equivalent to halfway between the LT and V˙O2max (50%Δ). Responses to stimulation of the femoral nerve [motor nerve stimulation (MNS)] and motor cortex [transcranial magnetic stimulation (TMS)] were determined pre- and post-exercise to determine the level of peripheral fatigue [potentiated quadriceps twitch (Qtw,pot)] and central fatigue [voluntary activation measured by MNS and TMS (VAMNS and VATMS, respectively)]. Corticospinal excitability (motor evoked potentials) and intracortical inhibition [LICI and corticospinal silent period (SP)] were also measured from electromyography recordings on the vastus lateralis. There were exercise-induced reductions in maximal voluntary contraction torque (− 21 ± 10%), Qtw,pot (− 37 ± 18%), VAMNS (− 7 ± 7%) and VATMS (− 8 ± 10) (all P

Background.

Limited data suggests that an altered metabolic and cardiorespiratory exercise response may affect exercise performance in individuals with Huntington's disease (HD). There is no clear exploration of the response in individuals at different stages of the disease or in relation to genetic markers. This study aimed to examine the exercise response and recovery of HD participants, and the relationship to genetic and clinical markers.

Method.

HD gene-positive participants (n = 31; 9 pre-manifest; 22 manifest HD) and a healthy control group (n = 29) performed an incremental exercise test until exhaustion. Performance, cardiorespiratory, metabolic and perceptual responses to exercise were determined from a maximal cycle ergometer test throughout the exercise test and during a recovery period.

Results.

During sub-maximal exercise, metabolic (lactate levels, oxygen uptake) and cardiorespiratory markers (heart rate) were elevated in HD participants compared to controls. Lactate elevation was specific to pre-manifest HD participants. Work capacity was reduced in both pre-manifest and manifest HD participants with tests terminated with no difference in metabolic, perceptual or cardiorespiratory markers. Submaximal oxygen uptake was correlated with motor score, whilst peak measures were unrelated to genetic or clinical markers. Heart rate recovery was attenuated in pre-manifest and manifest HD participants.

Conclusions.

Our findings confirm metabolic and cardiorespiratory deficits reduce exercise performance and affect recovery from an early stage in HD, with submaximal deficits related to phenotypic expression. Exercise capacity appears to be limited by an altered movement economy, thus clinicians should consider an altered exercise response and recovery may affect prescription in HD.

Context. Current research suggests that dark cocoa may reduce fatigue; however, the effect on fatigue in people with MS (pwMS) has never been established. The objective of this feasibility study was to explore the acute effect of high flavonoid cocoa on measures of fatigue and glycaemic response. Methods. This was a randomised crossover participant blind exploratory study in 12 participants (2 male and 10 female) with MS-related fatigue (>4 on the Fatigue Severity Scale; FSS). After fasting overnight, participants consumed the high flavonoid cocoa drink (350 mg gallic acid equivalents {GAE}/g) or a low flavonoid cocoa control (120 mg GAE/g), consuming the alternative drink on the next visit. Fatigue was self-reported on a 100 mm visual analogue scale at 30-min time intervals for 2 h post cocoa consumption and every 2 h for the rest of the day. Fatigability was monitored using a 6 min walk test (6MWT) at the end of the visit (2 h), and activity monitors worn for 24 h commencing at 12 noon on the day of testing. The feasibility of performing the trial including outcome measures was documented. Results. A moderate effect was found in self-reported fatigue throughout the day in favour of the high flavonoid group (Cohen's d 0.32, 95% non-central t CI −0.57 to 1.20). Fatigability measures did not change. Participants consumed and enjoyed the cocoa, all participants completed the study and outcome measures were accepted. Conclusion. The results of this study support further trials to investigate the feasibility and efficacy of pure cocoa as a dietary supplement for fatigue in pwMS.

Objective: To report on the control group of a trial primarily designed to investigate exercise for improving mobility in people with Parkinson’s Disease (pwP). The control group undertook a handwriting intervention to control for attention and time spent practising a specific activity.

Design: Secondary analysis of a two arm parallel phase II randomised controlled trial with blind assessment.

Setting: Community

Participants: PwP able to walk ≥100meters and with no contraindication to exercise recruited from the Thames valley, UK and randomised (1:1) to exercise or handwriting, via a concealed computer-generated list.

Intervention: Handwriting was undertaken at home and exercise in community facilities, both were delivered through workbooks with monthly support visits and involved practice for one hour, twice weekly, over six months.

Main measures:  Handwriting was assessed, at baseline, 3, 6 and 12months, using a pangram giving writing speed, amplitude (area) and progressive reduction in amplitude (ratio). The MSD-UPDRS item 2.7 (UPDRS-2.7) measured self-reported handwriting deficits.

Results:  105 pwP were recruited (analysed: n=51 handwriting, n=54 exercise).  Forty pwP adhered to the handwriting program most completing ≥1 session/week. Moderate effects were found for amplitude (total area: d=0.32 95%CI -0.11:0.7, p=0.13) in favour of handwriting over 12months, effects for writing speed and ratio parameters were small ≤0.11. Self-reported handwriting difficulties also favoured handwriting (UPDRS-2.7: OR= 0.55 95%CI 0.34:0.91, p=0.02).  No adverse effects were reported 

Conclusion: PwP generally adhere to self-directed home handwriting which may provide benefit with minimal risk. Encouraging effects were found in writing amplitude and, moreover, perceived ability. (ClinicalTrials.Gov:NCT01439022).

Materials and Methods. Two-hundred adults with intellectual disabilities from a local authority lists in UK were invited to participate. Participants were administered an accelerometer for seven days and the IPAQ-s (self and carer-reported).

Results. Twenty participants with mild to profound intellectual disabilities (20–70 years) were recruited. The response rate was significantly different between home (16%) and residential homes (4%): χ2(1) = 7.7, p

Conclusions. Recruitment demonstrated a need for better engagement with residential homes. While both the IPAQ-s and accelerometers can be used to evaluate PA levels, the IPAQ-s was more acceptable and carer report was accurate, but it underestimated absolute moderate-vigorous PA levels. These findings indicate that IPAQ-s can be used to measure PA levels, including in those with profound intellectual disabilities.

Aim Evaluate safety and adherence to a minimally supported community exercise intervention and estimate effect sizes (ES).
 

Methods Two arm parallel phase II randomised controlled trial with blind assessment. PwP able to walk ≥100meters and with no contraindication to exercise were recruited from the Thames valley, UK and randomised (1:1) to intervention (exercise) or control (handwriting) groups, via a concealed computer-generated list. Groups received a six month, twice weekly program. Exercise was undertaken in community facilities (30minutes aerobic and 30minutes resistance) and handwriting at home, both were delivered through workbooks with monthly support visits. Primary outcome was a 2minute walk, with motor symptoms (MDS-UPDRS III), fitness, health and wellbeing measured.
 

 Results  Between December 2011 and August 2013,  n=53  (n=54 analysed) were allocated to exercise and n=52 (n=51 analysed) to handwriting. n=37 adhered to the exercise, most attending ≥1 session/week. Aerobic exercise was performed in 99% of attended sessions and resistance in 95%. Attrition and adverse events (AE) were similar between groups, no Serious AEs (n=2 exercise, n=3 handwriting) were related, exercise group related AEs (n=2) did not discontinue intervention. Largest effects were for motor symptoms (2minute walk ES= 0.20 (95%CI=-0.44:0.45) and MDS-UPDRS III ES=-0.30 (95%CI=0.07:0.54)) in favour of exercise over the 12month follow-up period. Some small effects were observed in fitness and wellbeing measures (ES >0.1).
 

Conclusion pwP exercised safely and the possible long-term benefits observed support a substantive evaluation of this community program.(ClinicalTrials.Gov:NCT01439022).

This study aimed to evaluate the feasibility and benefit of a structured exercise intervention in people with Huntington’s Disease (HD).

Methods

This study was conducted at 6 sites, and participants were randomized into either exercise or control (usual care) groups, and were assessed at baseline, 13 and 26 weeks. The intervention was a 12 week, three times per week progressive exercise program, including aerobic (stationary cycling) and upper and lower body strengthening exercise with tapered 1:1 support for 20 of 36 sessions.

Results

314 adults were assessed for eligibility: 248 did not meet inclusion criteria, 34 declined, and 32 were recruited and randomized. Three individuals in the intervention group were withdrawn within the first month due to concomitant medical conditions, resulting in 14 participants in intervention and 15 in control groups. There were two AEs in the intervention group, both related to previous medical conditions, and there were two SAEs, both in the control group. The intervention group had better fitness (predicted VO2 max difference: 492.3 ml min−1, 95% CI: [97.1, 887.6]), lower UHDRS mMS (difference 2.9 points, 95% [−5.42, −0.32]) and lower weight at Week 13 (difference 2.25 kg, 95% CI: [−4.47, −0.03]).

Conclusion

This study demonstrates that a short-term exercise intervention is safe and feasible. Individuals with HD may benefit from structured exercise, and intensity, monitoring and support may be key factors in optimizing response. Larger scale trials are now required to fully elucidate the extended clinical potential of exercise in HD.

Fifteen studies were included consisting of 3159 awID, aged 16–81 years, 54% male and 46% female. Only 9% of participants achieved minimum PA guidelines. PA levels were measured using objective and subjective methods. ID severity, living in care, gender, and age were independently significantly correlated with the number of participants achieving PA guidelines with the strongest predictor being ID severity (Beta 0.631, p < 0.001). Findings should be in the context that most of the participants were in the mild/moderate range of ID severity and none of the studies objectively measured PA in people with profound ID. To inform measurement and intervention design for improved PA, we recommend that there is an urgent need for future PA studies in awID population to include all disability severity levels. PROSPERO registration number CRD42015016675.

Purpose. A better understanding of how people with Multiple Sclerosis (pwMS) recover from exercise may help inform interventions. Methods. We explored physiological and perceptual responses following exercise of different intensities, using a crossover exposure-response design, in 14 adults with MS and nine controls. A cycling exercise test determined maximum capacity (Wpeak). Participants then performed 20minute exercise sessions relative to Wpeak (random order separated by 7days): 1) 45% and 2) 60% continuous cycling, and 3) 90% intermittent cycling (30seconds cycling, 30seconds rest). During a 45minute recovery period, tympanic temperature (Temp°C), exertion in breathing (RPEbr) and legs (RPEleg), and cortical excitability (MEParea) were measured. Results. Eleven pwMS and eight controls completed the study. Controls performed better on the exercise test (p<0.05), thus more absolute work during subsequent sessions. PwMS took longer to recover RPEleg with recovery time increasing with intensity (45%-6mins; 60%-15mins; 90%-35mins) and correlating with Temp°C.  MEParea was significantly depressed in both groups at 45% and 60% (p<0.001), in the MS group; this also correlated with RPEleg. Conclusion. Feelings of leg exertion may persist after exercise in some pwMS, especially at high intensities. This may relate to body temperature and, after continuous exercise, cortical excitability. These results support considering the recovery period post exercise and provide insight into potential correlates of post exercise fatigue .

The development of fatigue after non-exhaustive and exhaustive exercise eliciting differing metabolic demands is poorly understood. Sixteen active males completed five cycling trials. The first trial established the lactate threshold (LT) and maximal oxygen uptake (VO2max). Two of the remaining trials were completed at a severe intensity (halfway between LT and VO2max, SI) and two at a moderate intensity (90% LT, MI). Each trial involved two non-exhaustive bouts matched for work between intensities before cycling to exhaustion. Responses to stimulation of the femoral nerve and motor cortex were determined after each bout to determine peripheral and central fatigue. Corticospinal excitability, cortical silent period (cSP), short-interval intracortical inhibition (SICI), and intracortical facilitation (ICF) were also assessed. Non-exhaustive cycling induced greater peripheral and central fatigue in the SI compared with the MI (P < 0.05). At exhaustion, there was no difference between intensities; however, peripheral fatigue tended to be greater in the SI vs MI (−31% vs −17%, respectively, P = 0.051). Exhaustive cycling increased SICI (24%, P < 0.001) and reduced the cSP (−14%, P < 0.001) in the SI, whereas ICF was reduced in the MI (−16%, P < 0.001). These findings demonstrate exercise-induced metabolic stress accelerates the development of peripheral and central fatigue, and differentially influences intracortical excitability.

Objective: To explore exercise response in people with Huntington’s disease (HD).

Design: Experimental observational study with a randomly allocated subgroup before/after interventional study.

Setting: Community.

Subjects: People with HD (n=30) and a healthy comparator group (n=20). Thirteen people from the HD group were randomly allocated to an exercise training program.

Main measures: Heart rate (HR) and perceived exertion on the Borg-CR10 scale (RPE) during a submaximal cycle ergometer exercise test (three minute unloaded and nine minute 65%-75%HRmaximum phase). Expired air and lactate measures were available for 8 people with HD during the exercise.

Intervention: A 12 week gym and home walking exercise programme (n=13).

Results: People with HD achieved a lower work rate at nine minutes (82±42(0-195) v 107±35(50 -185) Watts (p

Conclusions: There was a large variability in the observed metabolic and physiological responses to exercise in people with HD. The observed exercise responses suggest that altered exercise prescription parameters may be required for people with HD and that exercise response and factors’ affecting this requires further investigation.

Introduction: Transcranial magnetic stimulation (TMS) is an important tool to examine neurological pathologies, movement disorders, and central nervous system responses to exercise, fatigue, and training. The reliability has not been examined in a functional locomotor knee extensor muscle.

Methods: Within- (n = 10) and between-day (n = 16) reliability of single and paired-paired pulse TMS was examined from the active vastus lateralis.

Results: Motor evoked potential amplitude and cortical silent period duration showed good within- and between-day reliability (intraclass correlation coefficient [ICC] ≥ 0.82). Short- and long-interval intracortical inhibition (SICI and LICI, respectively) demonstrated good within-day reliability (ICC ≥ 0.84). SICI had moderate to good between-day reliability (ICC ≥ 0.67), but LICI was not repeatable (ICC = 0.47). Intracortical facilitation showed moderate to good within-day reliability (ICC ≥ 0.73) but poor to moderate reliability between days (ICC ≥ 0.51).

Conclusions: TMS can reliably assess cortical function in a knee extensor muscle. This may be useful to examine neurological disorders that affect locomotion. 

Background

Integrating rehabilitation services through wearable systems has the potential to accurately assess the type, intensity, duration, and quality of movement necessary for procuring key outcome measures.

Objectives

This review aims to explore wearable accelerometry-based technology (ABT) capable of assessing mobility-related functional activities intended for rehabilitation purposes in community settings for neurological populations. In this review, we focus on the accuracy of ABT-based methods, types of outcome measures, and the implementation of ABT in non-clinical settings for rehabilitation purposes.

Data sources

Cochrane, PubMed, Web of Knowledge, EMBASE, and IEEE Xplore. The search strategy covered three main areas, namely wearable technology, rehabilitation, and setting.

Study selection

Potentially relevant studies were categorized as systems either evaluating methods or outcome parameters.

Methods

Methodological qualities of studies were assessed by two customized checklists, depending on their categorization and rated independently by three blinded reviewers.

Results

Twelve studies involving ABT met the eligibility criteria, of which three studies were identified as having implemented ABT for rehabilitation purposes in non-clinical settings. From the twelve studies, seven studies achieved high methodological quality scores. These studies were not only capable of assessing the type, quantity, and quality measures of functional activities, but could also distinguish healthy from non-healthy subjects and/or address disease severity levels.

Conclusion

While many studies support ABT’s potential for telerehabilitation, few actually utilized it to assess mobility-related functional activities outside laboratory settings. To generate more appropriate outcome measures, there is a clear need to translate research findings and novel methods into practice.

The purpose of this study was to establish and cross-validate a method for analyzing gait patterns determined by the center of mass (COM) through inertial sensors embedded in smart devices. The method employed an extended Kalman filter in conjunction with a quaternion rotation matrix approach to transform accelerations from the object onto the global frame. Derived by double integration, peak-to-trough changes in vertical COM position captured by a motion capture system, inertial measurement unit, and smart device were compared in terms of averaged and individual steps. The inter-rater reliability and levels of agreement for systems were discerned through intraclass correlation coefficients (ICC) and Bland–Altman plots. ICCs corresponding to inter-rater reliability were good-to-excellent for position data (ICCs,.80–.95) and acceleration data (ICCs,.54–.81). Levels of agreements were moderate for position data (LOA, 3.1–19.3%) and poor for acceleration data (LOA, 6.8%–17.8%). The Bland–Altman plots, however, revealed a small systematic error, in which peak-to-trough changes in vertical COM position were underestimated by 2.2 mm; the Kalman filter׳s accuracy requires further investigation to minimize this oversight. More importantly, however, the study׳s preliminary results indicate that the smart device allows for reliable COM measurements, opening up a cost-effective, user-friendly, and popular solution for remotely monitoring movement. The long-term impact of the smart device method on patient rehabilitation and therapy cannot be underestimated: not only could healthcare expenditures be curbed (smart devices being more affordable than today‘s motion sensors), but a more refined grasp of individual functioning, activity, and participation within everyday life could be attained.

Methods: Thirty-one participants (16 men; mean [SD] age = 50.4 [11.4] years) were randomly allocated to intervention (n = 16) or control group (usual care; n = 15). The intervention entailed a weekly supervised gym session of stationary cycling and resistance exercises, and a twice weekly independent home-based walking program. Retention and adherence rates and adverse events were recorded. Acceptability was determined from subjective reports of tolerability and physiological measures recorded during the gym sessions. Assessment of benefit included measures of physical abilities, disease severity, and quality of life (36-Item Short Form Health Survey). Analysis of covariance was used to test outcomes of interest.

Results: The retention rate was 81% (9 of the 11 individuals who started the intervention completed it) and of the 9 who completed the program, 7 attended more than 75% (9/12) of the gym sessions. There were no related adverse events and the intervention was well tolerated by most participants. The between-group effect estimate for the Mental Component Summary score of the 36-Item Short Form Health Survey (n = 9; intervention, n = 13; control) was 7 (95% CI: 0.4–13.7) Moderate effect sizes for cognitive outcomes and measures of walking were also observed.

Discussion and Conclusions: Observed effect sizes for clinical outcomes suggest the structured exercise program has benefit for persons with HD; larger scale trials are warranted.

Video Abstract available (see Video, Supplemental Digital Content 1, https://links.lww.com/JNPT/A60) for more insights from the authors.

BACKGROUND:

Guidelines for optimal exercise doses in people with multiple sclerosis (MS) have to be established. We need to ascertain the basic physiological and perceptual response and adaptation to different exercise doses in this clinical population.

AIM:

The aim of this paper was to explore the response during maximal and sub-maximal exercise in people with MS prior to and following two different twelve week exercise programmes.

DESIGN:

Sub-analysis of per protocol exercise data of a two group, single blinded, randomised control trial.

SETTING:

Multicentre (community leisure and rehabilitation centres).

POPULATION:

Participants with MS assigned to a continuous (N.=12; mean±SE age=52.3±2.08; Barthel index median & range=19&13-20) or interval (N.=9; mean±SE age=49.3±3.5; Barthel index median & range=19&18-20) exercise programme.

METHODS:

Cardiovascular, respiratory and perceptual exercise response and adaption was measured at maximal and sub-maximal levels of physical exercise prior to and following a twelve week exercise programme, delivered at different intensities.

RESULTS:

Irrespective of the type of exercise programme followed, there was a significant increase in peak power (z=-1.98; P=0.05) and normalised oxygen uptake during unloaded cycling (z =-2.00; P=0.05). At discharge from the exercise programmes, the cardiovascular response to sub-maximal exercise had significantly changed (t(360) =-4.62; p<0.01).

CONCLUSION:

The response in people with MS at maximal and sub-maximal levels of physical exercise following a twelve week programme is analogous to non-diseased adults.

CLINICAL REHABILITATION IMPACT:

Cardiovascular adaptation in people with MS following a twelve week exercise programme suggests deconditioning rather than autonomic dysfunction caused by the disease.

Background. Fatigue is a chronic symptom for people with multiple sclerosis (PwMS).Objective. Symptoms of fatigue were investigated during and following a single exercise session. Methods. In all, 58 PwMS and 15 healthy, low-active controls performed a cycle ergometer incremental exercise test to voluntary exhaustion. Physiological intensity (expired air and heart rate), perceived breathlessness, and leg fatigue (Rating of Perceived Exertion [RPE] CR-10 Scale) were measured during and for 10 minutes following exercise. Measures of baseline disability (Barthel Index), activity (Physical Activity Scale for the Elderly), vitality (Subjective Vitality Scale), and general fatigue (Fatigue Severity Scale [FSS]) were recorded. Results. PwMS had reduced exercise capacity (P = .00 to .01), but sensations of breathlessness and leg fatigue were the same at voluntary exercise termination in both groups (P = .09). PwMS with fatigue (FSS ≥ 4) exhibited reduced exercise capacity (P = .03 to .05) but reached the same physiological intensity, breathlessness, and leg fatigue symptoms at test termination as nonfatigued peers (P = .16 to .59). During recovery, there was no difference in observed means between groups, except for leg RPE, which was higher in the MS group (P = .047) and higher at 3 and 5 minutes after exercise in the fatigued MS group (P = .02). Physiological markers and breathlessness recovered at the same rate in both groups (P = .33 to .67). Conclusion. Monitoring leg fatigue symptoms during and through recovery from physical activities may help guide participation in physical activities for PwMS, particularly in people managing high levels of fatigue.

OBJECTIVES:

To understand how patients with Multiple Sclerosis experience and express hope within a rehabilitation setting and use this information to help therapists in a clinical setting.

DESIGN:

One guided interview was undertaken.

SETTING:

Two locations were used for interviews: (1) a rehabilitation centre in Oxfordshire. (2) A meeting location for the MS society in London.

PARTICIPANTS:

Eleven patients with Multiple Sclerosis were selected (54.5±8.8 years). Six patients were classified as being in the secondary progressive stage and 5 were classified as relapsing remitting phase.

METHOD:

The patients selected were part of a 12-week Multiple Sclerosis rehabilitation program. One interview took place mid way through the rehabilitation program and immediately following the end of the rehabilitation program. The semi-structured interview comprised of 5 sub-sections. Categorical content analysis was used to analyse the results.

RESULTS:

Three main themes were identified that related to the paradox of chronic illness: (1) defiance and the patient (2) accepting the diagnosis and prognosis and (3) accepting deterioration. These themes provide a basis for the different types of hopes expressed by patients.

CONCLUSION:

It is vital to understand the paradox of chronic illness as an expression common among patients with Multiple Sclerosis. This research illustrates the importance of listening to a patient's narrative during rehabilitation.

Walking models driven by centre of mass (CoM) data obtained from inertial measurement units (IMU) or optical motion capture systems (OMCS) can be used to objectively measure gait. However current models have only been validated within typical developed adults (TDA). The purpose of this study was to compare the projected CoM movement within Parkinson's disease (PD) measured by an IMU with data collected from an OMCS after which spatio-temporal gait measures were derived using an inverted pendulum model. The inter-rater reliability of spatio-temporal parameters was explored between expert researchers and clinicians using the IMU processed data. Participants walked 10 m with an IMU attached over their centre of mass which was simultaneously recorded by an OMCS. Data was collected on two occasions, each by an expert researcher and clinician. Ten people with PD showed no difference (p = 0.13) for vertical, translatory acceleration, velocity and relative position of the projected centre of mass between IMU and OMCS data. Furthermore no difference (p = 0.18) was found for the derived step time, stride length and walking speed for people with PD. Measurements of step time (p = 0.299), stride length (p = 0.883) and walking speed (p = 0.751) did not differ between experts and clinicians. There was good inter-rater reliability for these parameters (ICC3.1 = 0.979. ICC3.1 = 0.958 and ICC3.1 = 0.978, respectively). The findings are encouraging and support the use of IMUs by clinicians to measure CoM movement in people with PD.

Laboratory based gait analysis techniques are expensive, time consuming and require technical expertise. Inertial measurement units can directly measure temporal parameters and in combination with gait models may provide a solution to obtain spatial gait measurements within daily clinical assessments. However it is not known if a model and standard correction factor determined by Zijlstra and Hof [8] to estimate step and stride length parameters in typically developed adults (TDA) can be accurately used in neurologically impaired gaits.This research estimated the stride length over two 10 m walks at self selected walking speed in people with neurological conditions, using a previously established model and correction factor for TDA. The relation of the correction factor to walking speed was explored. We recruited TDA (n = 10) and participants with Parkinson's disease (PD; n = 24), muscular dystrophy (MD; n = 13), motor neuron disease (MND; n = 7) and stroke survivors (n = 18) for the study who twice walked 10 m at a self-selected pace. Stride length correction factors, for TDA (1.25 +/- 0.01), PD (1.25 +/- 0.03), and MD (1.21 +/- 0.08) (p = 0.833 and p = 0.242) were the same as previously reported in TDA (Zijlstra and Hof [8]). Correction factors for stroke (1.17 +/- 0.42) and MND (1.10 +/- 0.08) were different (p < 0.01 and p = 0.028 respectively). However there was a high level of variability for correction factors within groups, which did not relate to walking speed. Our findings support that correction factors should be determined for each individual to estimate average step/stride length in patients suffering from a neurological condition.

Background: The most effective exercise dose has yet to be established for multiple sclerosis (MS). Objective: The aim of this study was to investigate the effect of different exercise intensities in people with MS. Methods: We completed a randomized comparator study of three cycling exercise intensities, with blinded assessment, wascarried out inOxford. Sixty-one adults with MS who fulfilled inclusion criteriawere randomized at entry into the study, using a computer-generated list held by an exercise professional, into either: continuous (at 45% peak power, n¼20), intermittent (30 sec on, 30 sec off at 90% peak power, n¼21) or combined (10 min intermittent at 90% peak power then 10min continuous at 45% peak power, n¼20) exercise for 20min twice a week for 12weeks in a leisure facility. Groups were assessed at: baseline, halfway (6weeks), end intervention (12weeks) and follow-up (24weeks). Primary outcome measure was 2min walk. Results: Fifty-five participants were included in the analysis (n¼continuous 20, intermittent 18, combined 17). No differences were found between groups. After 6 weeks, considering all participants, 2 min walk distance increased by 6.962.56m (95% CI: 1.81 to 12.10, effect size (es): 0.25, p<0.01). The continuous group increased by 4.714.24m (95% CI: 3.80 to 13.22, es: 0.06), intermittent by 12.944.71m (95% CI: 3.97 to 21.92, es: 0.28) and combined by 3.224.60m (95% CI: 6.01 to 12.46, es: 0.04). Two minute walk did not significantly change between further assessments. Between 6 and 12 weeks there was a drop in attendance that seemed to be associated with the intermittent and combined groups; these groups also had a greater number of adverse events (leg pain during cycling most common) and dropouts (n¼continuous 1, intermittent 5, combined 10). Considering all participants, 6 weeks of cycling exercise produced benefits in mobility that were maintained with further sessions. Conclusion: While no differences were found between groups, greater benefit may be associated with higher-intensityexercise, but this may be less well tolerated.

Background and Purpose-The mechanisms underlying motor recovery after stroke are not fully understood. Several studies used functional MRI longitudinally to relate brain activity changes with performance gains of the upper limb after therapy, but research into training-induced recovery of lower limb function has been relatively neglected thus far. Methods-We investigated functional reorganization after 4 weeks of treadmill training with partial body weight support in 18 chronic patients (mean age, 59.9 +/- 13.5 years) with mild to moderate paresis (Motricity Index affected leg: 77.7 +/- 10.5; range, 9 to 99) and gait impairment (Functional Ambulation Category: 4.4 +/- 0.6; range, 3 to 5) due to a single subcortical ischemic stroke using repeated 3.0-T functional MRI and an ankle-dorsiflexion paradigm. Results-Walking endurance improved after training (2-minute timed walking distance: 121.5 +/- 39.0 versus pre: 105.1 +/- 38.1 m; P = 0.0001). For active movement of the paretic foot versus rest, greater walking endurance correlated with increased brain activity in the bilateral primary sensorimotor cortices, the cingulate motor areas, and the caudate nuclei bilaterally and in the thalamus of the affected hemisphere. Conclusions-Despite the strong subcortical contributions to gait control, rehabilitation-associated walking improvements are associated with cortical activation changes. This is similar to findings in upper limb rehabilitation with some differences in the involved cortical areas. We observed bihemispheric activation increases with greater recovery both in cortical and subcortical regions with movement of the paretic foot. However, although the dorsal premotor cortex appears to play an important role in recovery of hand movements, evidence for the involvement of this region in lower extremity recovery was not found. (Stroke. 2009; 40: 2460-2467.)

Previous studies have shown that walking is not a purely automatic motor task but places demands on sensory and cognitive systems. We set out to investigate whether complex walking tasks, as when walking down a steeper gradient while performing a concurrent cognitive task, would demand gait adaptation beyond those required for walking under low-challenge conditions. Thirteen healthy young individuals walked at their self-selected speed on a treadmill at different inclinations (0, 5 and 10%). Gait spatio-temporal measures, pelvis angular excursion, and sacral centre of mass (CoM) motion were acquired while walking or while walking and performing a mental tracking task. Repeated-measures ANOVAs revealed that decreasing treadmill inclination from 0 to 10% resulted in significant decreased walking speed (P < 0.001), decreased stride length (P < 0.001), increased pelvis tilt (P = 0.006) and obliquity variability (P = 0.05), decreased pelvis rotation (P = 0.02), and increased anterio-posterior (A-P) CoM displacement (P = 0.015). Compared to walking alone, walking under dual-task condition resulted in increased step width (P < 0.001), and increased medio-lateral (M-L) CoM displacement (P = 0.039) regardless of inclination grade, while sagittal plane dynamics did not change. Findings suggest that gait adapts differently to cognitive and mechanical constraints; the cognitive system is more actively involved in controlling frontal than sagittal plane gait dynamics, while the reverse is true for the mechanical system. Finally, these findings suggest that gait adaptations maintain the ability to perform concurrent tasks while treadmill walking in healthy young adults.

The purpose of this study was to use a quaternion rotation matrix in combination with an integration approach to transform translatory accelerations of the centre of mass (CoM) from an inertial measurement unit (IMU) during walking, from the object system onto the global frame. Second, this paper utilises double integration to determine the relative change in position of the CoM from the vertical acceleration data. Five participants were tested in which an IMU, consisting of accelerometers, gyroscopes and magnetometers was attached on the lower spine estimated centre of mass. Participants were asked to walk three timed through a calibrated volume at their self-selected walking speed. Synchronized data were collected by an IMU and an optical motion capture system (OMCS); both measured at 100 Hz. Accelerations of the IMU were transposed onto the global frame using a quaternion rotation matrix. Translatory acceleration, speed and relative change in position from the IMU were compared with the derived data from the OMCS. Peak acceleration in vertical axis showed no significant difference (p >= 0.05). Difference between peak and trough speed showed significant difference (p < 0.05) but relative peak-trough position between the IMU and OMCS did not show any significant difference (p >= 0.05). These results indicate that quaternions, in combination with Simpsons rule integration, can be used in transforming translatory acceleration from the object frame to the global frame and therefore obtain relative change in position, thus offering a solution for using accelerometers in accurate global frame kinematic gait analyses.