Background and Purpose Neurophysiological models of rehabilitation and recovery suggest that a large volume of specific practice is required to induce the neuroplastic changes that underlie behavioral recovery. The primary objective of this meta-analysis was to explore the relationship between time scheduled for therapy and improvement in motor therapy for adults post-stroke by (1) comparing high-doses to low-doses and (2) using meta-regression to further quantify the dose-response relationship. Methods Databases were searched to find randomized controlled trials that were not dosage matched for total time scheduled for therapy. Regression models were used to predict improvement during therapy as a function of total time scheduled for therapy and years post-stroke. Results Overall, treatment groups receiving more therapy improved beyond control groups that received less, g = 0.35, 95% CI = [0.26, 0.45]. Furthermore, increased time scheduled for therapy was a significant predictor of increased improvement by itself and when controlling for linear and quadratic effects of time post-stroke. Conclusions There is a positive relationship between the time scheduled for therapy and therapy outcomes. These data suggest that large doses of therapy lead to clinically meaningful improvements, controlling for time post-stroke. Currently, trials report time scheduled for therapy as a measure of therapy dose. Preferable measures of dose would be active time in therapy or repetitions of an exercise.

BackgroundThe objective of this analysis was to systematically review the evidence for virtual reality (VR) therapy in an adult post-stroke population in both custom built virtual environments (VE) and commercially available gaming systems (CG).MethodsMEDLINE, CINAHL, EMBASE, ERIC, PSYCInfo, DARE, PEDro, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were systematically searched from the earliest available date until April 4, 2013. Controlled trials that compared VR to conventional therapy were included. Population criteria included adults (>18) post-stroke, excluding children, cerebral palsy, and other neurological disorders. Included studies were reported in English. Quality of studies was assessed with the Physiotherapy Evidence Database Scale (PEDro).ResultsTwenty-six studies met the inclusion criteria. For body function outcomes, there was a significant benefit of VR therapy compared to conventional therapy controls, G = 0.48, 95% CI = [0.27, 0.70], and no significant difference between VE and CG interventions (P = 0.38). For activity outcomes, there was a significant benefit of VR therapy, G = 0.58, 95% CI = [0.32, 0.85], and no significant difference between VE and CG interventions (P = 0.66). For participation outcomes, the overall effect size was G = 0.56, 95% CI = [0.02, 1.10]. All participation outcomes came from VE studies.DiscussionVR rehabilitation moderately improves outcomes compared to conventional therapy in adults post-stroke. Current CG interventions have been too few and too small to assess potential benefits of CG. Future research in this area should aim to clearly define conventional therapy, report on participation measures, consider motivational components of therapy, and investigate commercially available systems in larger RCTs.Trial RegistrationProspero CRD42013004338

No abstract

Research on the focus of attention has begun exploring the physiological changes that underlie the difference between internal and external foci of attention. However, previous electromyography studies have used dynamic tasks, making it difficult to interpret electrophysiological data. The authors analyzed how the focus of attention affects a subject's ability to perform an isometric force production task (focus was directed either at the force platform or the muscles responsible for force production). Subjects received practice without attentional focus instructions and then completed blocks of trials with an external and internal attentional focus separately. An external focus led to significantly less error overall and reduced surface electromyography activity with lower median power frequencies in the antagonist muscle, but attentional focus had no effects on the agonist muscle. Thus, an external focus of attention led to more efficient motor unit recruitment patterns (reduced cocontraction) and improved performance. Posttest surveys revealed subjects were aware of their improved performance with an external focus.

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low-or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI).Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression.

Purpose of the review Prescribing the most appropriate dose of motor therapy for individual patients is a challenge because minimal data are available and a large number of factors are unknown. This review explores the concept of dose and reviews the most recent findings in the field of neurorehabilitation, with a focus on relearning motor skills post stroke. Recent findings Appropriate dosing involves the prescription of a specific amount of an active ingredient, at a specific frequency and duration. Dosing parameters, particularly amount, are not well-defined or quantified in most studies. Compiling data across studies indicates a positive, moderate dose-response relationship, indicating that more movement practice results in better outcomes. This relationship is confounded by time post stroke however, where longer durations of scheduled therapy may not be beneficial in the first few hours, days, and/or weeks. Summary These findings suggest that substantially more movement practice may be necessary to achieve better outcomes for people living with the disabling consequences of stroke. Preclinical investigations are needed to elucidate many of the unknowns and allow for a more biologically-driven rehabilitation prescription process. Likewise, clinical investigations are needed to determine the dose-response relationships and examine the potential dose-timing interaction in humans.

Patient nonadherence with therapy is a major barrier to rehabilitation. Recovery is often limited and requires prolonged, intensive rehabilitation that is time-consuming, expensive, and difficult. We review evidence for the potential use of video games in rehabilitation with respect to the behavioral, physiological, and motivational effects of gameplay. In this Special Interest article, we offer a method to evaluate effects of video game play on motor learning and their potential to increase patient engagement with therapy, particularly commercial games that can be interfaced with adapted control systems. We take the novel approach of integrating research across game design, motor learning, neurophysiology changes, and rehabilitation science to provide criteria by which therapists can assist patients in choosing games appropriate for rehabilitation. Research suggests that video games are beneficial for cognitive and motor skill learning in both rehabilitation science and experimental studies with healthy subjects. Physiological data suggest that gameplay can induce neuroplastic reorganization that leads to long-term retention and transfer of skill; however, more clinical research in this area is needed. There is interdisciplinary evidence suggesting that key factors in game design, including choice, reward, and goals, lead to increased motivation and engagement. We maintain that video game play could be an effective supplement to traditional therapy. Motion controllers can be used to practice rehabilitation-relevant movements, and well-designed game mechanics can augment patient engagement and motivation in rehabilitation. We recommend future research and development exploring rehabilitation-relevant motions to control games and increase time in therapy through gameplay.Video Abstract available (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A61) for more insights from the authors.

No abstract