Motor skill changes and neurophysiologic adaptation to recovery-oriented virtual rehabilitation of hand function in a person with subacute stroke: a case study

Purpose: The complexity of upper extremity (UE) behavior requires recovery of near normal neuromuscular function to minimize residual disability following a stroke. This requirement places a premium on spontaneous recovery and neuroplastic adaptation to rehabilitation by the lesioned hemisphere. Motor skill learning is frequently cited as a requirement for neuroplasticity. Studies examining the links between training, motor learning, neuroplasticity, and improvements in hand motor function are indicated.

Methods: This case study describes a patient with slow recovering hand and finger movement (Total Upper Extremity Fugl–Meyer examination score?=?25/66, Wrist and Hand items?=?2/24 on poststroke day 37) following a stroke. The patient received an intensive eight-session intervention utilizing simulated activities that focused on the recovery of finger extension, finger individuation, and pinch-grasp force modulation.

Results: Over the eight sessions, the patient demonstrated improvements on untrained transfer tasks, which suggest that motor learning had occurred, as well a dramatic increase in hand function and corresponding expansion of the cortical motor map area representing several key muscles of the paretic hand. Recovery of hand function and motor map expansion continued after discharge through the three-month retention testing.

Conclusion: This case study describes a neuroplasticity based intervention for UE hemiparesis and a model for examining the relationship between training, motor skill acquisition, neuroplasticity, and motor function changes.

• Implications for rehabilitation

• Intensive hand and finger rehabilitation activities can be added to an in-patient rehabilitation program for persons with subacute stroke.

• Targeted training of the thumb may have an impact on activity level function in persons with upper extremity hemiparesis.

• Untrained transfer tasks can be utilized to confirm that training tasks have elicited motor learning.

• Changes in cortical motor maps can be used to document changes in brain function which can be used to evaluate changes in motor behavior persons with subacute stroke.

     

Evaluation of hand orthoses in Duchenne muscular dystrophy

Abstract

Purpose: The purpose of this study was to evaluate whether treatment of boys with Duchenne muscular dystrophy using hand orthoses could benefit joint mobility, grip strength, or fine motor function.

Method: Eight boys with Duchenne muscular dystrophy were provided with individually customised rest orthoses. The results were analysed using single-subject design. The study included a baseline and an intervention phase. A follow-up examination was also performed.

Results: Boys with less than 50° passive wrist extension mobility were included. Wrist extension of the dominant hand increased in four and was maintained in four. Wrist extension in the non-dominant hand increased in five, was maintained in two and decreased in one. Thumb abduction in the dominant hand increased in six and two remained stable. In the non-dominant hand five increased and three remained stable. Grip strength and fine motor function showed also positive results.

Conclusions: This study indicates that the use of hand orthoses in Duchenne muscular dystrophy can delay development of contractures and improve passive wrist extension and thumb abduction. Hand orthoses can therefore be recommended for boys who start to develop contractures in the long finger flexors. Due to small sample size further studies are needed to confirm this result.

• Implications for rehabilitation

• Evaluation of hand orthoses in Duchenne muscular dystrophy.

• Preserved hand function is of uttermost importance for performance of activities in the late stages of Duchenne muscular dystrophy.

• Contractures of long finger flexors affect hand function and limit performance of daily activities.

• Hand orthoses can delay development of contractures and preserve hand function and give prerequisites for independence.

• The occupational therapists should measure wrist joint mobility regularly to be able to find the right time for intervention with hand orthoses in this progressive disorder.

     

Development and evaluation of a hand tracker using depth images captured from an overhead perspective

Purpose: We present the development and evaluation of a robust hand tracker based on single overhead depth images for use in the COACH, an assistive technology for people with dementia. The new hand tracker was designed to overcome limitations experienced by the COACH in previous clinical trials. Methods: We train a random decision forest classifier using ～5000 manually labeled, unbalanced, training images. Hand positions from the classifier are translated into task actions based on proximity to environmental objects. Tracker performance is evaluated using a large set of ～24?000 manually labeled images captured from 41 participants in a fully-functional washroom, and compared to the system’s previous colour-based hand tracker. Results: Precision and recall were 0.994 and 0.938 for the depth tracker compared to 0.981 and 0.822 for the colour tracker with the current data, and 0.989 and 0.466 in the previous study. Conclusions: The improved tracking performance supports integration of the depth-based tracker into the COACH toward unsupervised, real-world trials.

• Implications for Rehabilitation

• The COACH is an intelligent assistive technology that can enable people with cognitive disabilities to stay at home longer, supporting the concept of aging-in-place.

• Automated prompting systems, a type of intelligent assistive technology, can help to support the independent completion of activities of daily living, increasing the independence of people with cognitive disabilities while reducing the burden of care experienced by caregivers.

• Robust motion tracking using depth imaging supports the development of intelligent assistive technologies like the COACH.

• Robust motion tracking also has application to other forms of assistive technologies including gaming, human–computer interaction and automated assessments.

     

Musculoskeletal complaints in individuals with finger or partial hand amputations in the Netherlands: a cross-sectional study

Purpose: To compare the prevalence of musculoskeletal complaints (MSCs) in individuals with finger or partial hand amputations (FPHAs) with a control group and to explore the effect and predictors of MSCs in individuals with FPHAs.

Method: A questionnaire-based cross-sectional study was conducted. The primary outcome measures were: prevalence of MSCs, health status, pain-related disability, physical work demands, work productivity, and hand function.

Results: The response rate was 61%. A comparable proportion of individuals with FPHAs (n?=?99) and controls (n?=?102) reported MSCs in the preceding 4 weeks (33% vs. 28%, respectively) or in the preceding year (37% vs. 33%, respectively). Individuals with FPHAs with MSCs experienced more pain than controls with MSCs. Regular occurrence of stump sensations and self-reported limited range of motion (ROM) of the wrist of the affected limb were predictors for MSCs in individuals with FPHAs.

Conclusions: The prevalence of MSCs was comparable in individuals with FPHAs and controls. However, clinicians should pay special attention to the risk of developing MSCs in patients with stump sensations and limited ROM of the wrist of the affected limb. Future research should focus on the role of wrist movements and compensatory movements in the development of MSCs in individuals with FPHAs.

• Implications for Rehabilitation

• The prevalence of musculoskeletal complaints (MSCs) in individuals with finger or partial hand amputations (FPHAs) and control subjects was similar.

• Regular occurrence of stump sensations and limited range of motion of the wrist of the affected limb were predictors of developing MSCs in individuals with FPHAs.

• Clinicians should pay special attention to individuals with FPHAs with the presence of these predictors of developing MSCs.

• For a better understanding of the development of and treatment options for MSCs, future research focusing on the role of wrist function in the development of MSCs in individuals with FPHAs is necessary.

     

Robot-assisted assessment of vibration perception and localization on the hand

Sensory perception is crucial for motor learning and the control of fine manipulations. However, therapy after stroke still strongly focuses on the training of motor skills. Sensory assessments are often left out or provide only very subjective data from poorly controlled stimuli. This paper presents a vibration detection/localization test with the Robotic Sensory Trainer, a device that focuses entirely on the assessment and training of sensory function of the hand, with the aim of gaining insights into the prevalence and severity of sensory deficits after stroke, and to provide semiobjective data on absolute and difference perception thresholds in patients. An initial feasibility study investigated localization performance and reaction time during the discrimination of vibration stimuli presented in four locations on the dominant and nondominant hands of 13 healthy volunteers. High correct detection rates were observed (mean ± SD of 99.6% ± 0.6%), touch screen PC Robotic Sensory Trainer which were found to be significantly different between stimulus locations on the dominant hand. Average correct detection rates were not statistically different between dominant and nondominant hand. These data will serve as baseline for future measurements on elderly and stroke subjects, and suggest that data from the nonimpaired hand could be used to identify and assess sensory deficits in the affected hand of stroke patients.

Implications for Rehabilitation

• Sensory deficits may limit functional recovery after stroke, are poorly documented and often neglected in current therapeutic programs.

• Clinical sensory assessments are not well standardized, lack sensitivity and suffer from high variability.

• We present a novel device for the semiobjective assessment of hand sensory function, capable of providing vibration, proprioception and pressure stimuli.

• Vibration perception and localization on the hand were tested on 13 healthy subjects to serve as baseline data for future measurements with stroke patients.

     

Walking with robot assistance: the influence of body weight support on the trunk and pelvis kinematics

Purpose: The goal was to assess in healthy participants the three-dimensional kinematics of the pelvis and the trunk during robot-assisted treadmill walking (RATW) at 0%, 30% and 50% body weight support (BWS), compared with treadmill walking (TW). Methods: 18 healthy participants walked (2?kmph) on a treadmill with and without robot assistance (Lokomat; 60% guidance force; 0%, 30% and 50% BWS). After an acclimatisation period (four minutes), trunk and pelvis kinematics were registered in each condition (Polhemus Liberty? [240?Hz]). The results were analysed using a repeated measures analysis of variance with Bonferroni correction, with the level of suspension as within-subject factor. Results: During RATW with BWS, there were significantly (1) smaller antero-posterior and lateral translations of the trunk and the pelvis; (2) smaller antero-posterior flexion and axial rotation of the trunk; (3) larger lateral flexion of the trunk; and (4) larger antero-posterior tilting of the pelvis compared with TW. Conclusions: There are significant differences in trunk and pelvis kinematics in healthy persons during TW with and without robot assistance. These data are relevant in gait rehabilitation, relating to normal balance regulation. Additional research is recommended to further assess the influence of robot assistance on human gait.

• Implications for Rehabilitation

• The trunk and pelvis moves in a different way during walking with robot assistance.

• The data suggest that the change in movement is due to the robot device and the harness of the suspension system more than due to the level of suspension itself.

     

Body weight supported treadmill training versus traditional training in patients dependent on walking assistance after stroke: a randomized controlled trial

Purpose: Treadmill training with body weight support (TTBWS) for relearning walking ability after brain damage is an approach under current investigation. Efficiency of this method beyond traditional training is lacking evidence, especially in patients needing walking assistance after stroke. The objective of this study was to investigate change in walking and transfer abilities, comparing TTBWS with traditional walking training. Methods: A single-blinded, randomized controlled trial was conducted. Sixty patients referred for multi-disciplinary primary rehabilitation were assigned into one of two intervention groups, one received 30 sessions of TTBWS plus traditional training, the other traditional training alone. Daily training was 1?hr. Outcome measures were Functional Ambulation Categories (FAC), Walking, Functional Independence Measure (FIM); shorter transfer and stairs, 10 m and 6-min walk tests. Results: Substantial improvements in walking and transfer were shown within both groups after 5 and 11 weeks of intervention. Overall no statistical significant differences were found between the groups, but 12 of 17 physical measures tended to show improvements in favour of the treadmill approach. Conclusions: Both training strategies provided significant improvements in the tested activities, suggesting that similar outcomes can be obtained in the two modalities by systematic, intensive and goal directed training.

Implications for Rehabilitation

• Treadmill training with body weight support (TTBWS) and traditional gait training were found to be equally effective in improving walking and transfer in patients dependent on walking assistance after stroke.

• However, most outcome measures showed a tendency of improvement in favour of the treadmill group.

• Both training modalities were systematic, goal-directed and intensive, and the time used for training was the same.

• The choice between the two equally effective training alternatives should be based on the patients’ preference, and availability of equipment and resources.

     

The use of augmented auditory feedback to improve arm reaching in stroke: a case series

Purpose: After practice, augmented feedback is the most important factor that facilitates motor learning. We assess the potential effectiveness of two types of augmented auditory feedback on the re-learning of arm reaching in individuals with stroke: (a) real-time knowledge of performance (KP) feedback and (b) rhythmic cueing in the form of knowledge of results (KR) feedback. Method: Five participants with stroke underwent short-term practice, reaching with their affected arm with KP, KR and no feedback, on separate days. We assessed range of motion of the upper extremity (shoulder, elbow) and trunk, mean error and variability of the performed trajectory, and movement time, before and after training. Results: All participants benefitted from practice with feedback, though the effects varied across participants and feedback type. In three participants, KP feedback increased elbow extension and reduced compensatory trunk flexion. In four participants, KR feedback reduced movement time taken to perform the reach. Of note, one participant benefitted mostly from KP feedback, which increased shoulder flexion and elbow extension, and decreased compensatory trunk flexion and mean error. Conclusions: Within day practice with augmented auditory feedback improves reaching in individuals with stroke. This warrants further investigation with longer practice periods in a larger sample size.

• Implications for Rehabilitation

• After practice, augmented feedback is the second most important factor that facilitates motor learning.

• Music-based augmented auditory feedback has potential to enhance reaching abilities in individuals with stroke.

• Future studies are warranted to evaluate the long-term effectiveness of this feedback over a longer training period in a larger sample size.

     

Performance evaluation of 3D vision-based semi-autonomous control method for assistive robotic manipulator

We developed a 3D vision-based semi-autonomous control interface for assistive robotic manipulators. It was implemented based on one of the most popular commercially available assistive robotic manipulator combined with a low-cost depth-sensing camera mounted on the robot base. To perform a manipulation task with the 3D vision-based semi-autonomous control interface, a user starts operating with a manual control method available to him/her. When detecting objects within a set range, the control interface automatically stops the robot, and provides the user with possible manipulation options through audible text output, based on the detected object characteristics. Then, the system waits until the user states a voice command. Once the user command is given, the control interface drives the robot autonomously until the given command is completed. In the empirical evaluations conducted with human subjects from two different groups, it was shown that the semi-autonomous control can be used as an alternative control method to enable individuals with impaired motor control to more efficiently operate the robot arms by facilitating their fine motion control. The advantage of semi-autonomous control was not so obvious for the simple tasks. But, for the relatively complex real-life tasks, the 3D vision-based semi-autonomous control showed significantly faster performance.

• Implications for Rehabilitation

• A 3D vision-based semi-autonomous control interface will improve clinical practice by providing an alternative control method that is less demanding physically as well cognitively.

• A 3D vision-based semi-autonomous control provides the user with task specific intelligent semiautonomous manipulation assistances.

• A 3D vision-based semi-autonomous control gives the user the feeling that he or she is still in control at any moment.

• A 3D vision-based semi-autonomous control is compatible with different types of new and existing manual control methods for ARMs.

     

The first step in using a robot in brain injury rehabilitation: patients’ and health-care professionals’ perspective

Purpose: To evaluate the usability of a mobile telepresence robot (MTR) in a hospital training apartment (HTA). The MTR was manoeuvred remotely and was used for communication when assessing independent living skills, and for security monitoring of cognitively impaired patients. Method: Occupational therapists (OTs) and nurses received training in how to use the MTR. The nurses completed a questionnaire regarding their expectations of using the MTR. OTs and patients staying in the HTA were interviewed about their experiences of the MTR. Interviews and questionnaires were analysed qualitatively. Results: The HTA patients were very satisfied with the MTR. The OTs and nurses reported generally positive experiences. The OT’s found that assessment via the MTR was more neutral than being physically present. However, the use of the MTR implied considerable difficulties for health-care professionals. The main obstacle for the nurses was the need for fast and easy access in emergency situations while protecting the patients’ integrity. Conclusions: The results indicate that the MTR could be a useful tool to support daily living skills and safety monitoring of HTA patients. However, when designing technology for multiple users, such as health-care professionals, the needs of all users, their routines and support services involved, should also be considered.

• Implications for Rehabilitation

• A mobile telepresence robot (MTR) can be a useful tool for assessments and communication in rehabilitation.

• The design of the robot has to allow easy use by remote users, particularly in emergency situations.

• When designing MTRs the needs of ALL users have to be taken into consideration.

     

The effects of practicing sitting Tai Chi on balance control and eye-hand coordination in the older adults: a randomized controlled trial

Abstract

Purpose: The purpose of this study was to examine the effects of 3 months of sitting Tai Chi training on the sitting balance control and eye-hand coordination of older adults subjects. Methods: We randomly assigned 59 older adults from four residential care facilities to either sitting Tai Chi group or mobilizing exercises group as control. The sitting Tai Chi group underwent 3 months of training with a total of 36 sessions (1 hour/session, 3 sessions/week). The outcome measures included sitting balance tests (testing sequential weight shifting and forward reaching in a sitting position) and eye-hand coordination tests (reaction time, movement time and accuracy in finger pointing task). Results: The Tai Chi practitioners showed significant improvement in their sequential weight shifting while sitting (improved by 29.0%, p?≤?0.05) and in their maximum reaching distance from a sitting position (improved by 21.2%, p?≤?0.05). No such improvements were found in the control group. In the eye-hand coordination test, the sitting Tai Chi practitioners had significant improvements in accuracy (improved by 17.3%, p?≤?0.05). Also, no improvement was found in the control group. Conclusions: The results demonstrate 3-months of sitting Tai Chi training can improve sitting balance and accuracy in finger pointing task in the older adults.

• Implications for Rehabilitation

• Traditional Tai Chi poses difficulties for older adults with poor standing balance.

• This pilot study showed that a 3 months sitting Tai Chi training can improve sitting balance and accuracy in the finger pointing task in the older adults.

• Sitting Tai Chi can be a therapy option for older adults with poor standing balance.

     

Improving fine motor function after brain injury using gesture recognition biofeedback

Purpose: We developed a gesture recognition biofeedback (GRB) device for improving fine motor function in persons with brain injury using surface muscle pressures of the forearm to provide real-time visual biofeedback. The GRB apparatus is easy to don by moderately impaired users and does not require precise placement of sensors. Method: The efficacy of GRB training with each subject was assessed by comparing its effectiveness against standard repetitive training without feedback. The outcome was measured using a nine-hole peg test (HPT) administered before and after each condition, in a cross-over study design. Results: GRB was shown to be effective for short-term improvement of fine motor function of 12 impaired participants, reducing their average time to completion of the HPT by 15.5% (S.D. 7.14%). In a subset of impaired subjects, this effect was significant in comparison to similar training without biofeedback (p < 0.05). Control subjects experienced negligible change in HPT time. Conclusions: This pilot study of a heterogeneous group shows that GRB may offer a simple means to help impaired users re-learn specified manual tasks.

Implications for Rehabilitation

• Grasp Recognition Biofeedback (GRB) is a novel technology for biofeedback in fine motor function.

• Surface Muscle Pressure in the forearm is used to record hand activity and give simple, real-time feedback.

• In a relatively small sample, training with GRB yields short-term improvements in brain-injured subjects.

     

Combining strength training and botulinum neurotoxin intervention in children with cerebral palsy: the impact on muscle morphology and strength

Purpose: Investigate the combination effects of strength training and Botulinum Toxin Type-A (BoNT-A) on muscle strength and morphology in children with Cerebral Palsy (CP). Methods: Fifteen children receiving BoNT-A, classified as Spastic Diplegic CP, GMFCS I-II, and aged 5–12 years were recruited for this study. Randomly allocated to 10 weeks of strength training either before or after BoNT-A, children were assessed over 6 months. Eight of the 15 children also completed a control period. The Modified Ashworth Scale measured spasticity. The Goal Attainment Scale (GAS) assessed achievement of functional goals. Magnetic Resonance Imaging assessed muscle volume (MV). Instrumented dynamometry assessed strength. Results: Spasticity was significantly reduced following BoNT-A injection (p = 0.033). Children made significant isokinetic strength gains (mean p = 0.022, ES = 0.57) in the intervention period compared to the control period (mean p = 0.15, ES = 0.56). Irrespective of timing, significant strength improvements were seen immediately (10 weeks) and over 6 months for all children. This was also the case for improvements in the GAS (immediately: mean p = 0.007, ES = 4.17, 6 months: mean p = 0.029, ES = 0.99), and improvements in MV in all assessed muscles. Conclusion: The simultaneous use of BoNT-A and strength training was successful in spasticity reduction, improving strength and achieving functional goals, over and above treatment with BoNT-A alone. Muscles targeted for BoNT-A injection should be included in strength training.

Implications for Rehabilitation

Cerebral Palsy

• Botulinum toxin type-A (BoNT-A) and strength training are available interventions that, on their own have found success in managing spasticity and muscle weakness (both significant motor impairments), respectively in children with Cerebral Palsy (CP).

• This study has demonstrated that the concurrent treatment of BoNT-A and strength training can achieve positive outcomes in terms of strength, spasticity and for the achievement of set functional goals.

• The results of this study show that the improved muscle strength can be associated with hypertrophy, which could indicate the potential role of strength training in altering the rate of muscle growth, in an aim to improve the failure of muscle growth associated with CP.

• Home based strength training, based on a child’s individual goals is shown to be successful in improving strength and goal attainment for children with CP.

     

The applicability of four clinical methods to evaluate arm and hand function in all stages of spinal muscular atrophy type II

Abstract

Aim: To evaluate the ability of four clinical methods to reflect arm and hand function at impairment and activity level and to determine their ability to discriminate among SMA II patients of all ages and in all stages of the disease. Methods: Fifty-two patients with SMA II (age range: 8–73 years) were assessed by means of the Egen Klassifikation 2 (EK2 scale), the Motor Function Measure Scale (MFM D3), the Manual Muscle Test (MMT) and Hand-Held Dynamometry (HHD) in full fist grip and lateral pinch grip. Patients were classified into six levels of upper limb function by means of the Brooke Upper Limb Scale, and the four methods’ ability to differentiate among patients within these levels was calculated. Modified versions of the EK2 scale (EK Upper Limb) and the MFM D3 (MFM D3 Upper Limb) were assessed in the same manner. Results: The patients’ physical abilities were best described by the MMT and EK2 while the “EK Upper Limb”, MFM D3 and MMT were best at discriminating among patients across the range of upper limb function. Quantitative muscle tests as measured by Citec? HHD were less applicable to weak patients; full fist grip could discriminate among patients at Brooke levels 3–5, and lateral pinch grip among the strongest patients. Conclusion: At the impairment level, MMT is the superior measure of muscle function in very weak patients in whom HHD cannot reflect capacity. At the activity level, the EK 2 represents daily activities whereas the MFM D3 measures motor functions. In differentiating among SMA II patients of all ages and in all stages of the disease, the ability of abbreviated versions of scales targeting upper limb function is superior to unabridged versions of these scales.

• Implications for Rehabilitation

• Evaluation of upper limb function in spinal muscular atrophy II

• Even very weak patients with SMA II have some residual upper limb function that is measurable if the right method is chosen.

• The Manual muscle test is applicable to all patients with SMA II and is useful to determine possible interventions – such as methods to drive a wheelchair or operate a computer.

• Abbreviated versions of the EK2 scale and the MFM are useful as methods to evaluate subtle changes in upper limb function resulting from disease progression or interventions.

     

Effect of mirror therapy on hand function in patients with hand orthopaedic injuries: a randomized controlled trial

Abstract

Purpose: To investigate the effects of mirror therapy (MT) in restoring hand function in patients with active range of motion (AROM) impairments following orthopaedic injuries. Method: In a randomized controlled trial (RCT), 30 patients with active ROM impairment (8 men and 22 women; mean age: 38 years) were measured. Intervention group received MT, 30?min a day, five days a week for three weeks, as well, half an hour conventional rehabilitation after each MT session. Patients in the control group received the same treatment programme, but instead of mirror, they observed directly the affected hand. In addition, both groups performed a 15?min home programme, including MT for intervention group and AROM with direct observation of the affected hand for control group, twice daily. Outcome measures, including total active motion (TAM) and Disabilities of Arm, Shoulder and Hand (DASH) questionnaire, were administered pre- and post-treatment and three weeks later. This study was registered as an RCT, no. NCT01503762 in http://clinicaltrials.gov/. Results: Final analysis was performed on 23 patients. The mean (SD) changes at post-test from baseline TAM was 154 (32) in the MT (N?=?12) and 61 (24) in the control group (N?=?11); mean difference (95% CI) 93 (68–118), p?=?0.001. The mean (SD) change at post-test from baseline DASH was ?34 (7) in the MT (N?=?12) and ?15 (11) in the control group (N?=?11); mean difference (95% CI) 19 (?27 to ?11), p?=?0.001. Conclusions: Despite significant improvement at post-test in both groups and maintenance of improvement during the follow-up period, MT combined with conventional rehabilitation produced more improvement in hand function than control group.

• Implications for Rehabilitation

• Hand orthopaedic injuries can result in disabilities in activities of daily living.

• Mirror therapy (MT) provides perception of two healthy limbs through reflection of the healthy limb as the injured limb.

• In a randomized controlled trial, our study shows positive effects of MT combined with a classical rehabilitation programme to improve hand function in patients with orthopaedic injuries.

     

A kinematic and electromyographic study of grip in extension in a clinical setting

Aim: Grip, including grip in extension, is an essential element in human beings. The functional evaluation scales of the hand require a greater number of objective variables in order to offer an overall perspective. Devices such as surface electromyography and inertial sensors can be used in evaluation and tasks. Such equipment can lead to new variables for analysis and offer different approaches for treatment. Methods: Six participants were selected randomly from a sample of healthy population. Each participant made the grip in extension, which was parameterized in real time. This movement was analyzed and recorded in a synchronized manner with surface electromyography and accelerometer-type inertial sensors in the hand. Results: After analyzing and processing the data, it was possible to detect five phases within the movement thanks to in-depth analysis of the module vector of the index finger along with electromyography of the musculature of the first dorsal interosseous. Conclusions: Parameterization is possible in real time for the grip in extension based on surface electromyography and accelerometer, offering new analysis variables on hand operation while providing a suitable complement to standardized assessments.

• Implications for Rehabilitation

• The use of surface electromyography and accelerometry in the arm synchronously, allows clinicians to identify new intervention and treatment variables.

• The protocol developed can be used in clinical practice because it is non-invasive, the enabled devices do not cause damage on the subject.

• According to the results, the muscles of the hypothenar region and the first dorsal interosseous have greater activation in the hand during grip extension.

• The wrist extensor muscles and flexor carpi ulnaris have more activation during the approach phase to grip. These are the muscles that should be prioritized for rehabilitation.

• The variation of the acceleration allows you to differentiate between the phases of rest and movement of the hand. If the variation of the acceleration at rest is higher than 0.3g, this could indicate the presence of abnormal movements or tremor.

     

Assisted normality – a grounded theory of adolescent’s experiences of living with personal assistance

Purpose: The purpose of the study was to explore how adolescents with disabilities experience everyday life with personal assistants. Method: In this qualitative study, individual interviews were conducted at 35 occasions with 16 Swedish adolescents with disabilities, in the ages 16–21. Data were analyzed using grounded theory methodology. Results: The adolescents' main concern was to achieve normality, which is about doing rather than being normal. They try to resolve this by assisted normality utilizing personal assistance. Assisted normality can be obtained by the existing relationship, the cooperation between the assistant and the adolescent and the situational placement of the assistant. Normality is obstructed by physical, social and psychological barriers. Conclusion: This study is from the adolescents’ perspective and has implications for understanding the value of having access to personal assistance in order to achieve assisted normality and enable social interaction in everyday life.

• Implications for Rehabilitation

• Access to personal assistance is important to enable social interaction in everyday life.

• A good and functional relationship is enabled through the existing relation, co-operation and situational placement of the assistant.

• If the assistant is not properly sensitized, young people risk turning into objects of care.

• Access to personal assistants cannot compensate for disabling barriers in the society as for example lack of acceptance.

     

Effects of hand-training in persons with myotonic dystrophy type 1 – a randomised controlled cross-over pilot study

Abstract

Purpose: To investigate the effects of a hand-training programme on grip, pinch and wrist force, manual dexterity and activities of daily living, in adults with myotonic dystrophy type 1 (DM1). Method: In this randomised controlled trial with a crossover design, 35 adults with DM1 were, after stratification for grip force, assigned by lot to two groups. Group A started with 12 weeks of hand training, while group B had no intervention. After a wash-out period of 12 weeks, where none received training, the order was reversed. The Grippit® was used as primary outcome measure and the hand-held Microfet2? myometer, the Purdue Pegboard, the Canadian Occupational Performance Measure (COPM) and the Assessment of Motor and Process Skills (AMPS) were secondary outcome measures. Assessments were performed before and after training and control periods, i.e. four times altogether. Results: Ten persons dropped out and 13 had acceptable adherence. Intention-to-treat analyses revealed significant intervention effects for isometric wrist flexor force (p?=?0.048), and for COPM performance (p?=?0.047) and satisfaction (p?=?0.027). On an individual level, improvements were in general showed after a training period. Conclusion: The hand-training programme had positive effects on wrist flexor force and self-perception of occupational performance, and of satisfaction with performance. No evident detrimental effects were shown.

• Implications for Rehabilitation

• Myotonic dystrophy type 1 (DM1) is a slowly progressive neuromuscular disease characterised by myotonia and muscle weakness and wasting.

• People with DM1 are often concerned about their ability to carry out ADL and to participate in, e.g. work, sports and hobbies when they gradually become weaker.

• This pilot study showed that a hand-training programme improved wrist flexor force and self-perception and satisfaction of occupational performance.

• Resistance training of hand muscles with a silicon-based putty can be a therapy option for people with DM1 in clinical practise.

     

Muscle function and body composition profile in adolescents with restrictive anorexia nervosa: does resistance training help?

Purpose: The aim of this study was to analyze the effects of short-term resistance training on the body composition profile and muscle function in a group of Anorexia Nervosa restricting type (AN-R) patients. Methods: The sample consisted of AN-R female adolescents (12.8?±?0.6 years) allocated into the control and intervention groups (n?=?18 each). Body composition and relative strength were assessed at baseline, after 8 weeks and 4 weeks following the intervention. Results: Body mass index (BMI) increased throughout the study (p?=?0.011). Significant skeletal muscle mass (SMM) gains were found in the intervention group (p?=?0.045, d?=?0.6) that correlated to the change in BMI (r?=?0.51, p?p?=?0.047, d?=?0.6) and correlated (r?>?0.60) with change in BMI in both the groups. Significant relative strength increases (p?Conclusions: SMM gain is linked to an increased relative strength when resistance training is prescribed. Although FM, relative body fat (%BF), BMI and body weight (BW) are used to monitor nutritional progress. Based on our results, we suggest to monitor SMM and relative strength ratios for a better estimation of body composition profile and muscle function recovery.

• Implications for Rehabilitation

• Anorexia Nervosa Restricting Type (AN-R)

• AN-R is a psychiatric disorder that has a major impact on muscle mass content and function. However, little or no attention has been paid to muscle recovery.

• High intensity resistance training is safe for AN-R after hospitalization and enhances the force generating capacity as well as muscle mass gains.

• Skeletal muscle mass content and muscular function improvements are partially maintained for a short period of time when the exercise program ceases.