Dissertations / Theses on the topic 'Neurorehabilitation'

Introduction: Brain computer interface (BCI) is a promising new technology with possible application in neurorehabilitation after spinal cord injury. Movement imagination or attempted movement-based BCI coupled with functional electrical stimulation (FES) enables the simultaneous activation of the motor cortices and the muscles they control. When using the BCI- coupled with FES (known as BCI-FES), the subject activates the motor cortex using attempted movement or movement imagination of a limb. The BCI system detects the motor cortex activation and activates the FES attached to the muscles of the limb the subject is attempting or imaging to move. In this way the afferent and the efferent pathways of the nervous system are simultaneously activated. This simultaneous activation encourages Hebbian type learning which could be beneficial in functional rehabilitation after spinal cord injury (SCI). The FES is already in use in several SCI rehabilitation units but there is currently not enough clinical evidence to support the use of BCI-FES for rehabilitation. Aims: The main aim of this thesis is to assess outcomes in sub-acute tetraplegic patients using BCI-FES for functional hand rehabilitation. In addition, the thesis explores different methods for assessing neurological rehabilitation especially after BCI-FES therapy. The thesis also investigated mental rotation as a possible rehabilitation method in SCI. Methods: Following investigation into applicable methods that can be used to implement rehabilitative BCI, a BCI based on attempted movement was built. Further, the BCI was used to build a BCI-FES system. The BCI-FES system was used to deliver therapy to seven sub-acute tetraplegic patients who were scheduled to receive the therapy over a total period of 20 working days. These seven patients are in a 'BCI-FES' group. Five more patients were also recruited and offered equivalent FES quantity without the BCI. These further five patients are in a 'FES-only' group. Neurological and functional measures were investigated and used to assess both patient groups before and after therapy. Results: The results of the two groups of patients were compared. The patients in the BCI-FES group had better improvements. These improvements were found with outcome measures assessing neurological changes. The neurological changes following the use of the BCI-FES showed that during movement attempt, the activation of the motor cortex areas of the SCI patients became closer to the activation found in healthy individuals. The intensity of the activation and its spatial localisation both improved suggesting desirable cortical reorganisation. Furthermore, the responses of the somatosensory cortex during sensory stimulation were of clear evidence of better improvement in patients who used the BCI-FES. Missing somatosensory evoked potential peaks returned more for the BCI-FES group while there was no overall change in the FES-only group. Although the BCI-FES group had better neurological improvement, they did not show better functional improvement than the FES-only group. This was attributed mainly to the short duration of the study where therapies were only delivered for 20 working days. Conclusions: The results obtained from this study have shown that BCI-FES may induce cortical changes in the desired direction at least faster than FES alone. The observation of better improvement in the patients who used the BCI-FES is a good result in neurorehabilitation and it shows the potential of thought-controlled FES as a neurorehabilitation tool. These results back other studies that have shown the potential of BCI-FES in rehabilitation following neurological injuries that lead to movement impairment. Although the results are promising, further studies are necessary given the small number of subjects in the current study.

The research fieldof this dissertation are noninvasive, electroencephalography (EEG)-based, Brain-Computer Interfaces (BCIs), and their use for neurorehabilitation and control purposes.Brain-Computer Interfaces are systems enabling a straightforwardcommunication between the brain and the outside, by recording the neural activity and directly translating it into control signals for a particulardevice(likea robotic arm, a machine, or a computer).Given their independence from thenaturalneuromuscularpathways, BCIs are envisioned as tools to restore communication and control in patients with severe motor impairments. Also, BCIshave recently emerged inneurorehabilitation, where they are employed to objectify thedesiredmodulations of the neural features, toguidethe practiceand boost rehabilitation.This dissertation includes several research activities fromthe two above-mentioned contexts. Each studybuilds up on the advancementsof the previous researchand introducesa furtherstep, either by investigatingnew configurationsof theavailabletechnology(chapter 2), introducing some novel design elements(chapter 3), contributing into the practical implementation of new approaches(chapter 4), or improving the efficiency of available algorithms (chapter 5).The work is organized into five chapters. Chapter 1serves as introduction toEEG-based BCIsand their use inneurorehabilitation and control. In chapter 2, a novel combination of two neurorehabilitation tools is investigated,namelyi) BCI-guided motor imagery training and ii) transcranial direct current stimulation (tDCS). The work in chapter 3falls within the context of co-adaptive BCIs based on the modulationof sensorimotor rhythms, suggestingsome novel elements to improve the flexibility and tailoring of user training. In chapter 4real-time, continuous control of a robotic arm by means of continuously EEG-decoded movements is enabled for the first time. Chapter 5finally closes the thesis, with proposing two simple but effective ways to significantly improve SSVEP recognition based on Canonical Correlation Analysis (CCA).

About this work This doctoral project aims to improve the overall knowledge on the effects of neurorehabilitation in People with Multiple Sclerosis (PwMS), by providing more insights on fatigue and the relationship between fatigue and motor functional aspects. The general introduction provides background information on the main topics of this doctoral project. In the first part, the specific disease characteristics of Multiple Sclerosis are described. In the second part, the current status of fatigue and motor impairment and a focus on the management are presented. Finally, the aims and outline thesis are reported. Four studies were conducted and reported in 4 different chapters. The first study provides information about the cardiac autonomic function during rest, postural changes and exercise and the relationship between autonomic modulation of heart rate and the perceived fatigue. The second study investigates the effect of an experimental rehabilitation protocol which combines aerobic training and task oriented exercises aimed to reduce fatigue and improve upper limb impairments and function. The third study provides information about preliminary effects of a high-intensity rehabilitative multimodal training protocol carried out on a treadmill aimed at improving mobility and balance. The fourth study shows the effectiveness of functional electrical stimulation on reducing falls, improving gait kinematics and promoting energy recovery. Lastly, general conclusions, including main findings and clinical implications, are provided at the end of the doctoral thesis.

Accumulating research evidence recognises the interaction between people and place, and demonstrates the potential for the built environment to provide a supportive influence on a person’s health status and recovery journey following illness or injury. However, the nature of the supportive influence of the healthcare built environment is not well understood, particularly within inpatient neurorehabilitation settings, where people experience prolonged admissions and due to the functional, cognitive and social challenges often resulting from serious injury, may be particularly dependent on the environment to support rehabilitation and recovery. Despite the relevance of the built environment during this critical stage in the rehabilitation process, there are no clear guidelines for the design of supportive neurorehabilitation settings. Design of these settings has often focused on functional and safety requirements as dictated by building codes and industry standards. This is not commensurate with the current healthcare focus on patient-centred approaches to practice, which has broadened the focus from safety, clinical efficiencies and cost-effectiveness, toward supporting user activity and experiences of care (Bate & Robert, 2007a; Gesler, Bell, Curtis, Hubbard & Francis, 2004). Further, the lack of research specific to neurorehabilitation populations and in-depth examination of user experiences limits the development of supportive settings that contribute positively to recovery and rehabilitation experiences following serious spinal cord and brain injury. The current study employed a multi-method, multiple-case study approach to explore how patients and staff interact with and experience the neurorehabilitation built environment at two sites, a spinal injury unit (SIU) and a brain injury unit (BIU). It aimed to address the central research question, how does the built environment support the inpatient neurorehabilitation experience? Each case (neurorehabilitation unit) included four embedded units of analysis to explore the potential supportive function of the built environment. This included 1) analysis of available archival data on the original building purpose and design, 2) independent surveys of physical features of the setting and the likely experiences they afford, 3) observations of user activity and 4) interviews and focus groups with patients and staff to understand user experiences. In accordance with the multiple-case study approach outlined by Yin (2009), results for each of the four types of data collected were first analysed independently for the SIU and BIU (within-case analyses). A cross-case thematic analysis of user experiences was then conducted to provide deeper insight into patterns and underlying themes in user experiences and further investigate similarities and differences across the two sites. Results from the within-case analyses identified a built environment focus on safety and processes, with limited inclusion of features to support positive user experiences. This environmental focus was in contrast with current patient-centred approaches to rehabilitation and was detrimental to positive user experiences of the setting. Patients and staff at both units described the settings as no longer supportive of current rehabilitation practice, describing a number of key challenges impacting activity and experiences within the current settings including a lack of space, issues with accessibility and functionality, a lack of privacy, poor aesthetics and sensory environment, and outdated buildings. In the absence of built environment support for day-to-day activities, users were able to adapt to operate within the limitations of the current settings. However, this adaptation was limited in scope and was often experienced as stressful and as placing unnecessary pressure on users, who suggested that a more supportive setting would be required for improved rehabilitation practice and experiences. The potential for more supportive, adaptive rehabilitation environments was identified in the cross-case thematic analysis of user experiences, which identified a number of important environmental considerations for neurorehabilitation settings. An adaptive environment was one that could better support rehabilitation by facilitating a balance between change and certainty. The process of change described the dynamic nature of rehabilitation and the need for a built environment to facilitate this development at two levels, namely, changes to rehabilitation practice and changes at an individual level. The process of certainty described the need for a predictable, reliable environment, which would allow users to understand the environment, facilitate users to retain control over the immediate environment, and support patients to regain or maintain their sense of self. The current study extends the current evidence-based design literature, highlighting the importance of environmental support that extends beyond safety and functionality and providing a model for holistic, patient-centred design of more supportive neurorehabilitation environments. Although the buildings for the sites studied were designed and constructed over 30 years ago, they were representative of buildings of this age designed for people with complex conditions. Findings can inform the development of future neurorehabilitation settings that actively contribute to rehabilitation, recovery and wellbeing following life-changing spinal cord or brain injury.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Human Service & Social Work
Griffith Health
Full Text

New evidence in neuroscience has led to substantial innovations in the provision of rehabilitation therapy, which includes new therapeutic possibilities for patients suffering from central nervous system lesions. The goal of my dissertation is to understand the role of Robot- assisted Gait Training (RAGT) within a multidisciplinary rehabilitation program for patients suffering from outcomes of central nervous system lesions. In this dissertation, I studied participants with traumatic brain Injury (TBI) to determine how cognitive function at admission can interfere in functional improvement after RAGT training in a rehabilitation program and the impact of gender, age and RAGT dose (sessions) on functional improvement in subacute stroke patients. In my first experiment, I studied a cohort of patients with severe traumatic brain injury (n=80 ) to investigate the impact of the cognitive level at admission on recovery after RAGT within a multidisciplinary rehabilitation setting. I found evidence that patients with a low cognitive level at admission were mainly in the subacute phase of rehabilitation. Cognitive impairment did not preclude recovery so that irrespective of the level of cognition, patients might benefit from RAGT during a multidisciplinary program. Also, although other heterogeneous factors (age, rehabilitation phase, severity) may have influenced recovery, the cognitive level at admission influence the rehabilitation length of stay (LOS) and the time needed to receive RAGT during the multidisciplinary rehabilitation programme. In the second set of study in this dissertation, I analyzed a cohort of subacute stroke patients (n= 236) who underwent RAGT in rehabilitation programs to determine the gender-related response. This approach allowed me to highlight that both genders can be subject to the same standards of treatment beyond the differences in anatomical morphology. While I expected to have a difference in recovery, instead, I found a significant positive correlation in clinical outcome. Among subacute stroke patients, equal adherence and benefits were observed following RAGT training in both genders. A conventional rehabilitation treatment empowered by RAGT ensured good results in terms of gait recovery, without any gender differences for all parameters considered. In the third set of this thesis, I studied a subacute stroke population who were undergoing RAGT training during multidisciplinary rehabilitation (n= 236). The principal aim was to investigate the intensity of RAGT (dose) needed to reach the minimal clinical important difference (MCID), measured with the Functional Independence Measure (FIM) and the Functional Ambulatory Category (FAC). Also evaluate the clinical, demographic and functional characteristics that can predict a good functional recovery. I found, with a regression model, that a significant number of patients achieved MCID with more than 14 sessions. Also, the independence of walking on discharge was influenced by the patient's age and the severity of the damage on admission.
Nuove evidenze nel campo delle neuroscienze hanno portato innovazioni sostanziali in neuroriabilitazione che includono nuove possibilità terapeutiche per i pazienti che soffrono di esiti di lesioni del sistema nervoso centrale. L'obiettivo della mia ricerca è stato di comprendere il ruolo della rieducazione robot-assistita del cammino(RAGT) all'interno di un programma di riabilitazione multidisciplinare per pazienti affetti da esiti di lesioni del sistema nervoso centrale. In questa dissertazione, ho studiato partecipanti con lesioni cerebrali traumatiche (TBI) per determinare in che modo la funzione cognitiva al momento del ricovero può interferire nel miglioramento funzionale dopo RAGT in un programma di riabilitazione. Ho valutato inoltre l'impatto del RAGT su sesso, età e come la dose (sessioni) potrebbe contribuire nel miglioramento funzionale per i pazienti in fase subacuta dell'ictus. Nella mia prima serie di analisi, ho studiato una coorte di pazienti con grave trauma cranico (TBI) per indagare l'impatto del RAGT a secondo del livello cognitivo al momento del ricovero sul recupero, all'interno di un contesto riabilitativo multidisciplinare. Ho concluso e che i pazienti con un basso livello cognitivo al momento del ricovero erano per lo più nella fase subacuta della riabilitazione e che il deterioramento cognitivo non precludeva il recupero in modo che, indipendentemente dal livello di cognizione, i pazienti potessero beneficiare di RAGT durante un programma multidisciplinare ed ottenere risultati soddisfacenti. Inoltre, sebbene altri fattori eterogenei (età, fase di riabilitazione) possano avere influenzato il recupero; il livello cognitivo ha influenzato la durata della riabilitazione (LOS) e il tempo necessario per ricevere RAGT durante il programma di riabilitazione multidisciplinare. Nella seconda serie di analisi in questa dissertazione, ho utilizzato il set di dati di una coorte di pazienti con ictus subacuto sottoposti a RAGT nel programma di riabilitazione per determinare la risposta correlata al genere. Questo approccio mi ha permesso di evidenziare che al di là delle differenze di morfologia anatomica, entrambi i sessi possono essere soggetti agli stessi criteri di trattamento. Mentre mi aspettavo di avere differenze nel recupero, invece ho trovato una significativa correlazione positiva nel risultato clinico. Tra i pazienti con ictus subacuto sono stati osservati uguale aderenza e benefici dopo RAGT in entrambi i sessi. Un trattamento riabilitativo convenzionale potenziato da RAGT ha assicurato buoni risultati in termini di recupero dell'andatura, senza differenze di genere per tutti i parametri considerati. Nella terza serie di questo studio, ho utilizzato una popolazione di ictus subacuto che ha ricevuto RAGT durante la riabilitazione multidisciplinare. Lo scopo principale è stato quello di indagare l'intensità di RAGT (dose) necessaria per il raggiungimento della minima differenza clinica importante (MCID), misurata con la Functional Independence Measure (FIM) e la Functional Ambulatory Category (FAC). Inoltre valutare quali sono le caratteristiche cliniche, demografiche e funzionali che possono predire un buon recupero funzionale. Ho scoperto che un numero significativo di pazienti ha raggiunto la MCID con almeno 14 sessioni. Inoltre, l'indipendenza nel cammino alla dimissione è influenzata dall'età del paziente e dalla gravità del danno al momento del ricovero.

The increase in stroke survivors poses a global challenge for the current health care system. The way that standard therapy is provided today impacts long-term disability and dependency in ADL insufficiently. The associated need for long-term care and the increase in health-care costs hence demand for novel therapeutic approaches. For this reason, we need to obtain gain a better understanding of the manifold consequences and the recovery process after stroke. In this dissertation we will advance the idea that besides increasing the intensity other factors need to be considered. Rehabilitation must incorporate learning strategies that induce recovery by changing the impaired behaviour. The principles of learning can be obtained from animal and human learning neuroscientific literature. As symptoms are neurologically and behaviourally interrelated, they can be addressed by common learning methods. We argue that technology is an aptly medium to implement and test these methods. Technology-based rehabilitation systems are not only cost-efficient, scalable and accessible, but also allow us to induce virtual manipulations which enhances learning in a way that is not possible in reality. The main goal of this dissertation is to design, test and deliver advanced neuroscience-based therapies in virtual reality that exploit principles of learning. We first offer a synthesis of known principles of learning obtained from human and animal behaviour and show that VR-based systems that incorporate these principles can have a significant impact on recovery. We then explore in three studies how augmented sensorimotor performance, individualized challenges and goal-oriented embodied training in a VR-based rehabilitation system can modify behaviour to address physical, cognitive and social post-stroke consequences. Lastly, we offer two possibilities how the information gained through the VR-based training can help to understand deficits better and therefore complement diagnostics. The contribution of the scientific work presented in this dissertation is that a systematic principle-based approach that augments learning with the advantages of technology can address a variety of post-stroke deficits and advance the understanding of recovery.

This thesis aimed to critique the research on person centred care (PCC) in neurorehabilitation, and consider how PCC in this setting can be further developed. Paper One reviews the extant literature on PCC in neurorehabilitation. The literature search returned 27 papers, which were critiqued for quality, how they conceptualised PCC, how they practiced PCC and the feasibility of PCC. Conceptualisations of PCC used varied from narrow conceptualisations of PCC as participation in goal setting, to broader ones which also incorporated issues such as shared decision making, outcomes, respect and emotional support. Similarly, methods of practicing PCC primarily used goal setting, with a minority of papers addressing outcomes and communication aspects of PCC. The review found that PCC is feasible for neurorehabilitation, with important benefits for clients and professionals. Providing PCC in neurological rehabilitation can be challenging and the literature review discusses ways to overcome barriers to PCC. The literature review highlights the need for methods to assess and develop PCC which are suitable for people with and without cognitive impairments. Paper Two addresses this need, by presenting research investigating the feasibility of using Dementia Care Mapping (DCM) on a neurorehabilitation ward. DCM is an observational method aims to document the quality of care from the perspective of the patient. DCM was found to be feasible for use on a neurorehabilitation ward, as shown by the suitability of the coding system. Q-methodology was used to assess staff perceptions of DCM. This further supported DCM feasibility, with staff reporting that DCM provided useful information for staff that they could use to improve the care they provided. DCM required some minor amendments in order to be used in a hospital rehabilitation environment and further amendments could improve its suitability for use in neurorehabilitation settings. Paper Three is a critical appraisal of both the literature review and research paper. The strengths and weaknesses of the use of both DCM and Q-methodology are critiqued, and consideration given to the limitations of the research.

Donat el nivell d'incidència i impacte de l'ictus, hi ha la necessitat de trobar mètodes de rehabilitació més automatitzats que els actuals. Un candidat prometedor és la Realitat Virtual, on múltiples sistemes ja han estat proposats. Malauradament, encara no és coneixen exactament quins són els beneficis d'aquests sistemes en comparació amb mètodes de rehabilitació convencionals. Aquí presentem el raonament, disseny, desenvolupament i resultats en l'impacte clínic d'un d'aquests sistemes, el Rehabilitation Gaming System (RGS). El RGS combina conceptes d'execució i observació d'accions amb una avaluació psicomètrica per proporcionar un entrenament personalitzat i automatitzat al pacient d'ictus. El RGS s'adapta al usuari d'una manera efectiva, i així permet l'aplicació de protocols de rehabilitació personalitzats amb una supervisió mínima. Els nostres resultats mostren que la rehabilitació amb el RGS facilita la recuperació funcional de les extremitats superiors en les fases aguda i crònica de l'ictus, i que per aquest motiu, el RGS és una eina valuosa per a la rehabilitació.

Given the high incidence and impact of stroke, the need has arisen to find more automated and self-managed rehabilitation approaches. A promising candidate is the use of Virtual Reality, and a number of systems have been proposed. Thus far, however, it is not clear what the benefits of these systems are when compared to conventional methods. Here we present the rationale, development and results on the clinical impact of one such system, the Rehabilitation Gaming System (RGS). RGS combines concepts of action execution and observation with a psychometric evaluation to provide a personalized and automated training. The RGS effectively adjusts to the individual features of the user, allowing for a minimally supervised deployment of individualized rehabilitation protocols. Our results show that rehabilitation with the RGS facilitates the functional recovery of the upper extremities in the acute and chronic stages of stroke, and that this system is therefore a valuable tool for rehabilitation.

This thesis aim to test the effectiveness of an immersive virtual reality set-up by using an embodied virtual body in neurorehabilitation, specifically for motor and chronic pain disorders. More specifically, my first study entitled: Motor-cognitive training through Immersive Virtual Reality during the immobilization period in distal radius fracture patients, aims to investigate whether an upper limb immersive virtual reality (IVR) training program, may improve the motor and functional ability of a fractured arm in 54 distal radius fracture (DRF) patients during the immobilization period. With this intention, we compared 6 weeks of our IVR training group (n=20), with 6 weeks of a non-IVR training group (n=20), and with another conventional rehabilitation group (n=14), during the immobilization period. We observed that through our training program patients in the IVR training group reached a better motor-functional ability of the fractured arm after cast removal, compared to the patients in the control groups: non-immersive virtual reality group and conventional rehabilitation group. Finally, patients in the IVR training group presented better results in the follow-up (6 weeks later) compared to the control groups, especially in the wrist range of motion. Secondly, we wanted to investigate the effects of the upper limb IVR training program in chronic stroke patients without arm mobility with a case study: Using immersive virtual reality to rehabilitate the paretic upper limb in chronic stroke patients. In that case study, we tested the IVR program in three chronic stroke patients. To this aim all three chronic stroke patients, underwent two IVR training periods during 5 weeks every day, with a 3 weeks period of pause between the two training periods. After the first training period we found improvements in motor recovery of the paretic arm, as well as in the cognitive capability and quality of life of all three chronic stroke patients. Further, we observe that the motor-cognitive improvements obtained after the first IVR training period remained over time, during the period of pause. However, the second IVR training period was not effective to further enhance motor and cognitive improvements. Further, a pre-post brain imaging analysis by using resting state and diffusor tension imaging (DTI) techniques, allowed us to identify the underpinning neuroplastic changes following the first IVR training, that were mainly found at the cerebellum from a functional connectivity point of view, and in the primary motor cortex from an structural point of view, in all three chronic stroke patients. Finally, the last study of this thesis entitled: Immersive virtual reality reliefs pain in patients with complex regional pain syndrome type I but not with peripheral nerve injury, aimed to investigate whether varying properties of a virtual arm co-located with the real arm modulated pain ratings in patients with chronic arm/hand pain due to complex regional pain syndrome (CRPS) type I (without nerve injury) or peripheral nerve injury (PNI). CRPS (n=9) and PNI (n=10) patients were immersed in VR and the virtual arm was shown at four transparency levels (transparency test) and three sizes (size test). We evaluated pain ratings throughout the conditions and assessed the virtual experience, finding that patients with chronic pain can achieve levels of ownership and agency over a virtual arm similar to healthy participants. All seven conditions globally decreased pain ratings to half. Increasing transparency decreased pain in CRPS but did the opposite in PNI, while increasing size slightly increased pain ratings only in CRPS. In overall my doctoral thesis pave the way to the use of embodiment through an IVR set-up in neurorehabilitation following the principles of body illusions for rehabilitation.
La presente tesis pretende hacer una breve revisión de las diferentes técnicas de integración multisensorial en rehabilitación utilizando principalmente el feedback visual y que han llevado a la implementación de la realidad virtual como herramienta terapéutica. Actualmente, la realidad virtual está adquiriendo un papel importante en el campo de la rehabilitación, y en específico en el campo de la neurorehabilitación para el tratamiento de alteraciones motoras, cognitivas y síndromes dolorosos. Sin embargo, todavía es una incógnita cuál es la manera más efectiva de aplicarla y que pacientes se pueden beneficiar en mayor grado de ella. Por esta razón, en esta tesis doctoral se presentan tres diferentes estudios en los cuales se aplica el uso de un sistema de realidad virtual immersiva, generando la ilusión de posesión de un cuerpo virtual. Específicamente, el primer estudio está realizado con pacientes ortopédicos. El segundo estudio es un caso estudio realizado con tres pacientes neurológicos, y el tercer estudio está realizado con un grupo de pacientes que sufren dolor crónico neuropático. En los tres estudios, se demuestra que el hecho de generar la ilusión de posesión de un cuerpo virtual mediante el uso de un sistema de realidad virtual immersiva, permite mejorar déficits motores, cognitivos y dolorosos en diferentes patologías. Esta tesis doctoral abre el camino a la introducción de nuevas técnicas de tratamiento en el campo de la neurorehablitación mediante el uso de técnicas de integración multisensorial, como los sistemas de realidad virtual immersiva.

Strokes affect thousands of people worldwide leaving sufferers with severe disabilities affecting their daily activities. Lesions to one part of the sensory or motor cortex produces symptoms in the opposite half of the body. Lesions might also impair speech, cognition and movement. Evidence supports the use of robot-mediated therapy to reduce functional upper limb impairment but current technologies only target proximal or distal upper limb segments independently. This study developed and evaluated whole-arm robot-aided rehabilitation, using a purpose designed robotic system for upper limb rehabilitation facilitating selective functional reaching and grasping movements in a reach-grasp-transport-release sequence with a task orientated paradigm incorporating visual, audio, haptic and performance feedback. A clinical trial with a total duration of twelve weeks was conducted with four stroke impaired subjects at the sub-acute phase of recovery and with four unimpaired volunteers. Impaired subjects were exposed to sixteen hours of robotic intervention whereas the unimpaired participants experienced one hour of robotic therapy. Clinical outcome measures were used to assess therapy effectiveness on the recovery of the stroke participants prior to the study, during the study and on study completion. Electromyography techniques were used to quantify functional gains obtained with the clinical outcome measures and features from two muscles on the hand involved in grasp and release movements. The results obtained from the clinical outcome measures showed substantial gains in favour of the robot-aided intervention. The clinical outcome results are consistent with the results reported in the literature, and show higher gains when compared to other sub-acute studies targeting only proximal arm segments. Specific muscle features were indentified with the unimpaired participants reproduced with the stroke subjects at the end of the robot-aided intervention.

Aim: This review aimed to evaluate the effects of self-management interventions on self-efficacy in patients with acquired neurological conditions. Method: Four electronic databases (MEDLINE, PsychINFO, CINAHL Plus and PubMed) were systematically searched and papers were assessed against inclusion and exclusion criteria producing 20 eligible articles. Results: Thirteen randomised controlled trials, 2 quasi-experimental controlled design studies, 4 pre-post design studies and 1 multiple participant, two-phase single subject design study were included in the review. There was a variety of neurological diagnoses covered including Multiple Sclerosis (N=8), stroke (N=6), epilepsy (N=5) and acquired brain injury (N=1). The sample sizes varied from 10 to 216 participants. Mean age varied from 29.87 to 67.38 years. Twelve out of 20 studies found some support for the effectiveness of self-management programmes in increasing self-efficacy, although the studies were prone to biases, such as small sample sizes, lack of blinding and low power to detect effects. All but one of the studies involved some incorporation of social cognitive theory or self-efficacy enhancing strategies in their programmes. Conclusion: The review found some evidence for the effectiveness of selfmanagement programmes in increasing levels of self-efficacy in patients with neurological conditions. However, more rigorous studies are needed in order to draw firm conclusions regarding the effectiveness of the programmes and their application in clinical practice.

This thesis aim to test the effectiveness of an immersive virtual reality set-up by using an embodied virtual body in neurorehabilitation, specifically for motor and chronic pain disorders. More specifically, my first study entitled: Motor-cognitive training through Immersive Virtual Reality during the immobilization period in distal radius fracture patients, aims to investigate whether an upper limb immersive virtual reality (IVR) training program, may improve the motor and functional ability of a fractured arm in 54 distal radius fracture (DRF) patients during the immobilization period. With this intention, we compared 6 weeks of our IVR training group (n=20), with 6 weeks of a non-IVR training group (n=20), and with another conventional rehabilitation group (n=14), during the immobilization period. We observed that through our training program patients in the IVR training group reached a better motor-functional ability of the fractured arm after cast removal, compared to the patients in the control groups: non-immersive virtual reality group and conventional rehabilitation group. Finally, patients in the IVR training group presented better results in the follow-up (6 weeks later) compared to the control groups, especially in the wrist range of motion. Secondly, we wanted to investigate the effects of the upper limb IVR training program in chronic stroke patients without arm mobility with a case study: Using immersive virtual reality to rehabilitate the paretic upper limb in chronic stroke patients. In that case study, we tested the IVR program in three chronic stroke patients. To this aim all three chronic stroke patients, underwent two IVR training periods during 5 weeks every day, with a 3 weeks period of pause between the two training periods. After the first training period we found improvements in motor recovery of the paretic arm, as well as in the cognitive capability and quality of life of all three chronic stroke patients. Further, we observe that the motor-cognitive improvements obtained after the first IVR training period remained over time, during the period of pause. However, the second IVR training period was not effective to further enhance motor and cognitive improvements. Further, a pre-post brain imaging analysis by using resting state and diffusor tension imaging (DTI) techniques, allowed us to identify the underpinning neuroplastic changes following the first IVR training, that were mainly found at the cerebellum from a functional connectivity point of view, and in the primary motor cortex from an structural point of view, in all three chronic stroke patients. Finally, the last study of this thesis entitled: Immersive virtual reality reliefs pain in patients with complex regional pain syndrome type I but not with peripheral nerve injury, aimed to investigate whether varying properties of a virtual arm co-located with the real arm modulated pain ratings in patients with chronic arm/hand pain due to complex regional pain syndrome (CRPS) type I (without nerve injury) or peripheral nerve injury (PNI). CRPS (n=9) and PNI (n=10) patients were immersed in VR and the virtual arm was shown at four transparency levels (transparency test) and three sizes (size test). We evaluated pain ratings throughout the conditions and assessed the virtual experience, finding that patients with chronic pain can achieve levels of ownership and agency over a virtual arm similar to healthy participants. All seven conditions globally decreased pain ratings to half. Increasing transparency decreased pain in CRPS but did the opposite in PNI, while increasing size slightly increased pain ratings only in CRPS. In overall my doctoral thesis pave the way to the use of embodiment through an IVR set-up in neurorehabilitation following the principles of body illusions for rehabilitation.

Traumatic brain injury (TBI) increases risk of depression which is distressing and can be a barrier to recovery. This program of research examined non-pharmacological interventions for people with depression following TBI. A Cochrane systematic review was conducted in order to identify studies of interventions (Gertler, Tate, & Cameron, 2015; Chapter 2, section 1). Cochrane reviews are the most stringent form of systematic review of evidence relating to treatment outcomes. The review identified six studies, three studies relating to cognitive-behavioural therapy (CBT) which were combined in a meta-analysis that showed a very small effect in favour of treatment versus control, with a wide confidence interval. Other treatment studies were evaluated but either did not favour any treatment or were low quality studies. Recent studies have reported positive findings for CBT extended by booster sessions or for acceptance and commitment therapy (Chapter 2, section 2). Chapter 3 (Gertler & Cameron, 2018) is a published journal article explaining data analytic techniques used in a Cochrane review. Chapter 4 describes a psychometric evaluation of single-item mood scales (SIMS; Gertler & Tate, 2020) that can be used to demonstrate progress in treatment. SIMS are frequently used in clinical practice but had not yet been shown to be valid when used with people with brain impairment. SIMS were demonstrated to have construct and criterion validity when applied to TBI. Chapter 5 (Gertler and Tate, 2019) is a published journal article describing a single case experimental design (SCED) trial of behavioural activation (BA) to improve participation and mood. BA was chosen because it had not been evaluated for people with TBI and was thought to be more suitable than treatments such as CBT that require abstract thinking. The authors did not find evidence in favour of BA and this was discussed in the context of recent research findings that suggested that new technologies could improve the quality of measurement and interventions. In conclusion, there is more research to do in order to improve the effectiveness of interventions for depression after TBI however, using SIMS as a measure and SCED methodology, the thesis demonstrates a model for investigating untested interventions and their active components.

Stroke is the leading cause of adult disability, with upper limb hemiparesis being one of the most common consequences. Regaining voluntary arm movement is one of the major goals of rehabilitation. However, even with intensive rehabilitation, approximately 30% of patients remain permanently disabled and only 5 to 20% of them recover full independence. Hence, there is an increasing interest in incorporating the latest advances in neuroscience, medicine and engineering to improve the efficacy of conventional therapies. In the last years, a variety of promising targets have been identified to improve rehabilitation. However, there is no consensus on which measure should be applied as a gold standard to study functional recovery. This fact dramatically hinders the development of new interventions since it turns difficult to compare different clinical trials and draw consistent conclusions about therapeutic efficiency. In addition, available scales are subjective, qualitative and often lead to incongruent outcomes. Indeed, there is increasing suspicion that the lack of optimal assessment measures hampers the detection of benefits of new therapies. Moreover, existing scales totally ignore the neuromuscular state of the patient masking the ongoing recovery processes. In consequence, making appropriate clinical decisions in such environment is almost impossible. In light of all these facts, the need for new objective biomarkers to develop effective therapies is undeniable. To give response to these demands we have organized this thesis into two main branches. On the one hand, we have developed an innovative physiological scale that reveals the neuromuscular state of the patient and is able to discriminate between motor impairment levels. The innovation here resides in the concept of interlimb similarity (ILS). Based on the latest findings about the modular organization of the motor system and taking into account that stroke provokes unilateral motor damage, we propose comparing the control structure of the unaffected arm with the control structure of the paretic arm to quantify motor impairment. We have defined the control structure as the set of muscle synergies and activation coefficients needed to complete a task. The advantage of this approach is not only its capacity to provide neuromuscular information about the patient, but also that the ILS is personalized to each patient and can purposely guide rehabilitation based on the patient¿s own physiological patterns. This supposes a huge advance taking into account the heterogeneity of stroke pathogenesis. On other hand, we have characterized the therapeutic potential of Visual Feedback (VF) as a tool to purposely induce neuroplastic changes. We have chosen VF among the various interventions proven to improve motor performance, because VF is a cheap strategy that can be implemented in almost any rehabilitation center. We demonstrate that VF is able to modulate the human control structure. In healthy subjects, it seems that VF makes accessible the refined dominant motor programs for the nondominant hemisphere giving rise to an increased interlimb similarity of the control structure. Interestingly, in stroke patients VF is able to manipulate the ILS of upper-limb kinematics in favor of finer motor control but a single training session seems not to be enough to fix those changes in the neuromuscular system of a damaged brain. Overall, these findings offer a new promising framework to develop and assess an effective intervention to guide the restoration of the original neuromuscular patterns and avoid unwanted maladaptive neuroplasticity. In conclusion, this thesis seeks moving forward in the understanding of human motor recovery processes and their relationship with neuroplasticity. In this sense, it provides important advances in the design of a new biomarker of motor impairment and tests the power of VF to modulate the neuromuscular control of patients with stroke.
L'ictus és la principal causa de discapacitat en adults, essent l'hemiparèsia del membre superior una de les conseqüències més comunes. Els programes de rehabilitació tenen com a objectiu fonamental restituir la mobilitat del braç afectat. No obstant això, es calcula que només entre el 5 i el 20% dels pacients aconsegueixen recuperar la seva independència mentre que el 30% queden incapacitats permanentment. En front d'aquest escenari es fa necessari incorporar els últims avenços de la neurociència, la medicina i l'enginyeria en aquesta àrea. En els darrers anys s'han identificat diversos aspectes clau per intentar millorar la rehabilitació. El problema, però, és que no hi ha consens per definir una mesura com a "gold estàndard" per avaluar la recuperació funcional, motiu pel qual, el desenvolupament de noves teràpies queda profundament afectat, ja que esdevé impossible poder comparar diferents assajos clínics i extreure conclusions consistents sobre la seva eficiència terapèutica. A més, les diverses mesures que s'utilitzen són subjectives, qualitatives i sovint donen resultats incongruents. De fet, se sospita que la manca de mesures d'avaluació òptimes dificulta la detecció dels beneficis de noves teràpies. A tot això se li ha d'afegir que les mesures actuals no consideren l'estat neuromuscular del pacient, emmascarant els processos reparadors subjacents. Així doncs, prendre les decisions clíniques adequades sota aquestes condicions esdevé pràcticament impossible. En aquestes circumstàncies, no es pot ignorar el requeriment de nous biomarcadors que proporcionin dades objectives per catalitzar el disseny de teràpies efectives. Per donar resposta a aquesta situació, la tesi s'ha estructurat en dues parts. Per una banda, s'ha desenvolupat una innovadora escala fisiològica que revela l'estat neuromuscular del pacient i és capaç de discriminar entre diferents nivells d'incapacitat motora. La innovació rau en el concepte de similitud entre membres (ILS, en anglès). Així, basant-nos en els darrers descobriments sobre l'organització modular del sistema motor, i en el fet que l'ictus provoca dany unilateral, proposem comparar l'estructura de control del braç no-afectat amb l'estructura de control del braç parètic per quantificar la incapacitat motora. L'estructura de control l'hem definida com el conjunt de sinergies musculars i coeficients d'activació que es necessiten per a dur a terme una tasca. L'avantatge d'aquesta proposta és doble, ja que proporciona informació sobre l'estat neuromuscular del pacient i en ser personalitzable, pot guiar la rehabilitació d'acord amb els patrons fisiològics propis de cada pacient. Això suposa un enorme avenç en aquesta àrea, donada la immensa heterogeneïtat de la patogènesi d'aquest trastorn. D'altra banda, s'ha caracteritzat el potencial terapèutic del feedback visual (VF) per induir canvis neuroplàstics. Aquesta és una eina molt interessant perquè a més de millorar el control motor, és assequible per gairebé qualsevol centre de rehabilitació. S'ha demostrat que el VF és capaç de modular l'estructura de control. Concretament, el VF sembla transferir els programes motors de l'hemisferi dominant al costat no dominant augmentant així el ILS dels subjectes sans. En pacients amb ictus, el VF és capaç d'augmentar el ILS cinemàtic afavorint patrons de control més fins. En conclusió, l'objectiu d'aquesta tesi és aprofundir en la comprensió dels processos de recuperació motora i la seva relació amb la neuroplasticitat. La tesi ofereix un nou i prometedor marc per desenvolupar i avaluar procediments efectius per guiar la restauració dels patrons neuromusculars originals i evitar que el cervell pateixi canvis neuroplàstics indesitjables. Així, la tesi proporciona avanços importants en el disseny d'un biomarcador per quantificar la incapacitat motora i avaluar el potencial del VF per modular el control neuromuscular de pacients amb ictus.

The purpose of this research was to develop a new test, the Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN). The SCCAN is intended to be used in the hospital setting to make appropriate treatment and discharge recommendations, and to guide more in depth assessment in other contexts. The test was designed to: (1) provide an overview of cognitive and communicative abilities in adult patients diagnosed with a variety of neurological disorders; (2) provide a measure of both impairment and functional ability; and (3) be administered in approximately 30 minutes. 20 neurologically healthy young controls and 20 neurologically healthy older controls were administered the SCCAN to ensure that these groups could complete the test successfully. The SCCAN and six standardized measures of cognition and communication were administered to 51 patients diagnosed with either left hemisphere stroke, right hemisphere pathology, or probable Alzheimer's disease. The SCCAN was re-administered to the patient group after a delay of 7 days. Data was analyzed using methods from both classical test theory and item response theory (IRT). The SCCAN demonstrated sufficient reliability across test administrations (r = .96), items (r = .99), and raters (percent agreement = .97). Findings also support the conclusion that this test provides an overview of cognition and communication that is appropriate for a broad range of patients. First, the test adequately distinguished the performance of separate subject groups (sensitivity = 98%, specificity = 95%). In addition, test scores correlated significantly with external measures of the same constructs (r = .41 to .91). Furthermore, a wide range of difficulty was observed among test items (item p-values ranged from 0 to 1). The fact that the SCCAN correlated significantly with a measure of impairment (r = .90) and functional ability (r = .94) suggests that this test provides a valid measure of both impairment and function. Lastly, results support the claim that the test can be administered in approximately 30 minutes. This test differs from similar instruments in terms of its comprehensiveness, providing a measure of both impairment and function, and incorporating a psychometrically validated decision tree to reduce test administration time.

L’osservazione delle azioni è in grado di evocare nel sistema motorio dell’osservatore un’attività comparabile a quella associata all’esecuzione della stessa azione. Tale capacità d trasformare la rappresentazione sensoriale delle azioni altrui nella propria rappresentazione motoria concernente la medesima azione – i.e. meccanismo specchio – gioca un ruolo fondamentale nella comprensione delle azioni e nell’apprendimento motorio tramite imitazione. L’osservazione delle azioni è in grado di favorire l’accesso al sistema motorio anche quando sussistono deficit motori agli arti, favorendo i processi di riorganizzazione corticale motoria e migliorando le abilità d’esecuzione del movimento. Sulla base di questo principio, un approccio riabilitativo basato sull’osservazione delle azioni (Action Observation Treatment – AOT) si è dimostrato efficace nel migliorare le funzioni motorie in diverse patologie neurologiche. Lo scopo di questa tesi è quello di discutere il ruolo dell’osservazione delle azioni nel favorire il recupero e il perfezionamento delle abilità motorie. La prima parte della tesi riporta uno studio clinico pilota che ha dimostrato l’efficacia della AOT nel miglioramento delle funzioni motorie dell’arto superiore nei bambini affetti da paralisi cerebrale infantile. Questo studio presenta due principali elementi innovativi. Il primo consiste nella somministrazione e nel monitoraggio da remoto del trattamento, in modo da permettere l’implementazione delle sessioni riabilitative direttamente a casa del bambino. Il secondo è l’introduzione dell’interazione remota fra bambini partecipanti come fattore attivo di trattamento. La differenza di abilità manuali fra pari è risultata essere associata all’efficacia del trattamento, indicando che è preferibile per il bambino osservare un compagno con abilità superiori alle proprie al fine di incrementare le probabilità di miglioramento. Questo studio apre l’AOT tradizionale a nuovi scenari, in cui i bambini possono simultaneamente essere beneficiari ed erogatori all’interno del processo di apprendimento motorio. La seconda parte della tesi ha lo scopo di esplorare i substrati neurofisiologici dell’apprendimento motorio delle azioni tramite la loro osservazione attraverso uno studio di Stimolazione Magnetica Transcranica (TMS). In relazione alla recente interruzione delle attività sperimentali conseguente alla pandemia, questa parte della tesi richiederà un tempo aggiuntivo per essere ultimata. Pertanto, è stata richiesta una proroga semestrale per la consegna finale della tesi.
The observation of an action is able to trigger in the observer’s motor system an activity similar to that evoked by the correspondent action execution. Such a capacity to transform the sensory representations of other’s actions into one’s own motor representation concerning the same action – i.e. mirror mechanism – plays a key role in action understanding and imitation-driven motor learning. Action observation is able to access the cortical motor system even when limb motor function is impaired, favoring cortical reorganization and ultimately affecting motor abilities in action execution. On this basis, a rehabilitative approach grounded on action observation (i.e. Action Observation Treatment – AOT) have proven effective in improving motor function in several neurological disorders. The aim of the thesis is to discuss the role of action observation in driving the recovery and the perfectioning of motor abilities. The first part of the thesis reports a clinical pilot study demonstrating the effectiveness of AOT for the improvement of upper limb motor function in children with cerebral palsy. This study presents two main elements of novelty. The first is the remote treatment delivery and monitoring, allowing the implementation of rehabilitative sessions at patient’s own home. The second is the introduction of child-to-child remote interaction as driving-factor of motor improvement. In particular, child-to-child difference in hand motor ability is linked to improvement, suggesting that it is preferable for a child to observe a leading peer with superior motor skills to his own. This study extends traditional AOT approaches to novel social-enriched scenarios by which children could simultaneously be both recipient and leader within the motor learning process. The second part of the thesis aim to investigate the neurophysiological substrates of observational learning in healthy subjects, by means of a Transcranial Magnetic Stimulation study (TMS). Since the recent interruption of the experimental activities due to the pandemic, this part needs additional time to be completed. Thus, a six-months extension for the completion of the thesis has been requested.

An extensive body of literature supports the clinical utility and feasibility of client-centric goal-setting techniques in neurorehabilitation. However, such techniques are seldom used and difficult to adopt in mainstream clinical practice. Two primary barriers that limit uptake and adoption of individualized goal-setting techniques into routine practice include: (1) lack of an operationalized framework susceptible to variations in the characteristics of the user and constraints of a medical setting and (2) limited knowledge on the part of clinicians and clients to confidently engage in goal-setting conversations. The eGAS app was designed to address the need for a semi-structured client-centric goal-setting framework for clinicians engaged in neurorehabilitation. This study used a single-subject design to investigate the effects of using eGAS in an outpatient hospital setting on clinician behavior and client responsiveness. A nonconcurrent, multiple-baseline design was used across three clinicians to determine if use of eGAS would result in functional changes in collaborative interviewing behaviors, validity of generated goal scales, and reliability of the process. Results revealed that using eGAS had strong functional effects on collaborative interviewing behaviors and validity of goal scales, and a weak effect on reliability. Another noteworthy finding was that eGAS could be implemented with relatively high fidelity within the constraints of a clinical context despite variations in the characteristics of the end-user, i.e. clients and clinicians. I discuss support for ecological validity of eGAS in terms of implementation barriers and facilitators that affected outcomes, methodological limitations, and future steps to improve design validity and implementation integrity.

Alors que de nombreux exosquelettes destinés à la rééducation neuromotrice ont été développés ces dernières années, ces dispositifs n'ont pas encore permis de vrai progrès dans la prise en charge des patients cérébrolésés. Une des clés pour améliorer les faibles résultats thérapeutiques obtenus serait de constamment adapter la thérapie robotisée en fonction de l'évolution du patient et de sa récupération, en adaptant l'assistance fournie par le robot pour maximiser l'engagement du patient. L'objectif de cette thèse est donc de comprendre les processus d'adaptations réciproques dans un contexte d'interaction physique Homme-Exosquelette. Dans un premier temps nous avons donc développé un nouveau type de contrôleur adaptatif qui assiste le sujet "au besoin", en modulant l'assistance fournie; et évalué différent signaux pour piloter cette adaptation afin de suivre au mieux la récupération du patient. Dans un deuxième temps, nous avons étudié l'adaptation de sujets sains à l'application de champs de forces distribués par un exosquelette sur leur bras durant la réalisation de mouvements dans l'espace. En effet, lors d'une interaction physique homme-robot, le sujet adapte aussi son comportement aux contraintes exercées par le robot. D'importantes différences inter-individuelles ont été observées, avec une adaptation à la contrainte imposée chez seulement 21% des sujets, mais avec des effets à-posteriori persistants mesurés chez 85% d'entre eux; ainsi qu'une généralisation dans l'espace de ces effets et un transfert à des contextes différents (hors du robot). Ces premiers résultats devraient permettre à terme d'améliorer la rééducation neuromotrice robotisée
While many robotic exoskeletons have been developed for stroke rehabilitation in recent years, there were not yet improvements to the traditional therapy. A key to unleash the potentiality of robotics is to adapt the assistance provided by the robot in order to maximize the subject engagement and effort, by having the robotic therapy evolving with the patient recovery. For this reason, we aim at better understanding the process of reciprocal adaptation in a context of physical Human-Robot Interaction (pHRI). We first developed a new adaptive controller, which assists the subject "as-needed", by regulating its interaction to maximize the human involvement. We further compared different signals driving this adaptation, to better following the functional recovery level of the patients. While the control is performed by the robot, the subject is also adapting his movements, and this adaptation has not yet been studied when dealing with 3D movements and exoskeletons. Therefore, we exposed human motions to distributed force fields, generated by the exoskeleton at the joint level, to produce specific inter-joint coordination and to analyse the effects of this exposition. With healthy participants, we observed important inter-individual difference, with adaptation to the fields in 21% of the participants, but post-effects and persisting retention of these in time in 85% of the subjects, together with spatial generalization, and, preliminarily, transfer of the effects outside of the exoskeleton context. This work towards understanding pHRI could provide insights on innovative ways to develop new controllers for improving stroke motor recovery with exoskeletons

Older adults often show declines in subjective and objective memory performance relative to younger adults. One potential path for helping older adults with memory may be compensatory memory training programs. Compensatory memory training programs teach strategies to manage memory impairment. Traditional compensatory memory training programs tend to be highly specific to a task and often do not generalize to other memory tasks. Ecologically Oriented Neurorehabilitation of Memory (EON-Mem) is a method for teaching memory strategies that may generalize for efficient use in everyday contexts. We performed a feasibility study to determine the value of pursuing a group-based version of EON-Mem with older adults in a future larger-scale randomized controlled trial. The current feasibility study took place in two phases with two separate samples. The first sample consisted of five separate groups of healthy young adults (n=39). The second sample consisted of three separate groups of older adults (n=26). We collected data on recruitment, treatment adherence, memory improvement, drop-out rate, cost, time spent, and participant-report data on barriers to successful implementation of EON-Mem treatment. We also collected data on memory performance and overall cognitive functioning. In order to assess improvement before and after treatment within our sample, reliable change indices were calculated using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) delayed memory index score. Participants first performed a baseline assessment (traditional and ecological memory tasks, general cognition tasks, emotional functioning, demographics). After the baseline assessment, participants attended one treatment session (90 minutes) per week for a total of seven group-based EON-Mem treatment sessions. Thirty-nine young adults and 26 older adults enrolled in the study; 20 young adults and 10 older adults completed the treatment sessions. We prematurely ended older adult group treatment sessions due to the COVID-19 pandemic. All participants performed a post-intervention assessment using alternate versions when available. Attendance rates were low for the young adult sample (51% completed the treatment) and as expected for the older adult sample when accounting for COVID-related changes (77% eligible for completer status prior to cancelling sessions). Twenty percent of each sample reliably improved on the RBANS delayed memory index score before and after treatment. Costs were higher than expected ($345 and 18.6 research hours for each young adult participant; $319 and 16.9 research hours for each older adult participant). Subjectively, both samples reported enjoying the interactions with others and the presentation of the treatment, but disliked peg words. Overall, although a randomized controlled trial of group-format EON-Mem in older adults is feasible, such a study may or may not be cost-effective depending on the resources and goals of the researcher.

Background. Paper I: Published guidelines and policies continually promote the importance of increasing service-user involvement in health care services. Q-methodology has become a popular method for revealing the subjective perspectives of patients who use health services, yet there is currently no review considering the potential issues of using Q-methodology with clinical populations. Paper II: Measuring the quality of care for people using neurorehabilitation services is a complex area requiring reliable methods. Dementia Care Mapping (DCM) is used widely in dementia care settings to help improve person-centred care and with appropriate evaluation may be usefully applied to neurorehabilitation settings. Aims. Paper I [literature review] examined studies which used Q-methodology with clinical populations, with a particular emphasis on the potential adaptations required to ensure its reliable use. Paper II [research study] explored the acceptability views of staff and patients for the pilot use of DCM in a neurorehabilitation setting. Paper III attempted to critically appraise these papers, as well as the research process overall. Methods. Paper I reviewed 29 studies, published over a 20-year period, using a narrative synthesis. Paper II conducted DCM on an acute neurorehabilitation ward, and evaluated the acceptability of DCM using Q-methodology with 23 staff and 10 patients on the ward. Results. Paper I identified a number of considerations for the effective application of Q-methodology with clinical populations. Paper II, reporting on the factor analysis, indicated a 'consensus' viewpoint, where all participants indicated positive acceptability for the use of DCM in a neurorehabilitation setting, with additional factors indicating some potential changes to the tool for increasing acceptability in the future. Paper II also indicated the potential for Q-methodology to be useful with a neurorehabilitation in-patient population. Conclusion. Paper I indicated the potential worth of Q-methodology for use with clinical populations. It also indicated guidelines which researchers might consider when using this method with clinical populations in the future. Paper II revealed promising results for the acceptability of DCM in a neurorehabilitation setting, though further research is required to explore this further. It also confirmed the value of Q-methodology with patients within a neurorehabilitation setting, similarly to those in Paper I. Paper III explored the relevance of Papers I and II in adding to the literature independently, but also the unequivocal link regarding the use of Q-methodology with clinical populations.

Background: Pisa Syndrome (PS) is a lateral trunk flexion frequently associated to Parkinson’s disease (PD). The management of PS is still a challenge for the physicians, because it poorly responds to the anti-parkinsonian drugs, and the improvement achieved with neurorehabilitation or botulinum toxin injections tends to fade in 6 months or less. Transcranial direct current stimulation (t-DCS) is a non-invasive neuromodulation technique, which showed promising results in movement disorders. The aim of our study is to evaluate the role of bi-hemispheric t-DCS as add-on to neurorehabilitation in PS. Methods: Twenty-eight patients with PD and PS (21 male, age 72.9±5.1 years, PD duration 9.3±7.4 years, PS duration 3.0±1.9 years) received a 4-week intensive neurorehabilitation treatment and were randomized to receive t-DCS (t-DCS group, n=13), 5 daily sessions (20 minutes - 2 mA) with cathode over the primary motor cortex (M1) contralateral to PS, and anode over the M1 cortex ipsilateral to PS, or sham group (sham group, n=15). At baseline (T0), end of rehabilitation (T1) and 6 months later, patients were evaluated with trunk kinematic analysis in static and dynamic conditions, UPDRS-III, FIM, and VAS for lumbar pain rating. At T0, the evaluations were completed by an EMG study of trunk muscles. Results: The study groups were comparable for clinical/demographic features and EMG phenotypes. When compared to sham group, t-DCS group achieved better results in several variables: overall posture (p=0.014), lateral inclination (p=0.013) of trunk during upright standing position, total range of motion (ROM) of the trunk (p=0.012), ROM of bending ipsilateral to PS (p=0.037), and ROM of anterior trunk flexion (p=0.014). The improvement in the overall trunk posture in upright standing position was persistent in t-DCS group at 6 months (T2 vs. T0: p<0.05). UPDRS-III scores decreased after rehabilitation (p=0.001), without significant differences between t-DCS and sham groups (p=0.942). In contrast, FIM score and lumbar pain intensity improved the most in t-DCS group when compared to sham group (p=0.048, and p=0.017 respectively). The EMG pattern was not a predictor of the efficacy of the t-DCS treatment. Conclusions: Our data supports the use of neuromodulation with t-DCS as add-on to neurorehabilitation for the treatment of patients affected by PS in PD. t-DCS is a non-invasive and repeatable approach that proved effective even in those patients with an EMG pattern not amenable to botulinum toxin injections.

This thesis considers the provision of person-centred care (PCC) in acute healthcare. In recent years it has been increasingly recognised that healthcare should be delivered in a person-centred manner and that staff should receive training and support in relation to this. There is a growing body of literature investigating the potential benefits of PCC in relation to both patient and service level outcomes. Paper one of this thesis is a systematic review of the literature examining staff training interventions for improving PCC in acute healthcare settings. The findings offer preliminary support for the positive impact of such training interventions on patient and service level outcomes in hospital environments. The research in this area is not of a uniformly high standard and this paper concludes that further research in this area is required. Paper two is an examination of a modified version of Dementia Care Mapping (Care Mapping – Neurorehabilitation: DCM-NR), an observational tool for measuring and improving PCC. Results provide evidence of the feasibility and validity of DCM-NR in a range of Clinical Neuroscience settings. Future research should examine the impact of DCM-NR on person-centred practices over time.The critical reflection paper considers both the systematic review and the empirical study. It aims to consider both the strengths and limitations of the research, challenges encountered, clinical implications and highlights areas for future research.

Anodal transcranial direct current stimulation (tDCS) is an intervention which is thought to enhance motor learning in healthy and stroke-injured states, when applied adjunctively during skill learning. We set out to investigate whether anodal tDCS might enhance functional rehabilitation from incomplete tetraplegic SCI. To address current limitations in the measurement of task-dependent skill, a novel integrated skill training and measurement task, the Motor Skill Rehabilitation Task (MSRT) was designed and developed. Measures of performance from this task delivered the functional measure of spatial motor skill learning, Task Productivity Rate (TPR). TPR was analysed and validated as a univariate dependent outcome, which is of potential importance to the future development of clinical measures measuring goal-directed motor skills. The MSRT was included alongside conventional behavioural measures in a repeated-measures RCT pilot study, the first to investigate the effect of anodal tDCS on rehabilitation of motor skill from chronic spinal cord injury. Adjunctive application of anodal tDCS had a statistically significant benefit upon retention of skill in the incomplete spinal cord injured population, but only when the independent factor of sensory acuity was included in the analysis. Differences between the development of task-dependent skill and generic dexterity over time suggested that spatial skill development was subject to an interaction of short-term and lasting effects. A larger study in healthy persons further investigated these phenomena, also applying Transcranial Magnetic Stimulation (TMS)–evoked measurements to investigate intervention-dependent effects upon the excitability of projections between the primary motor cortex and muscles involved in the prehension task. The findings revealed that active tDCS did not enhance skill learning at 7 days beyond the training period, but did significantly alter the development of motor skill following a period of learning and subsequent skill consolidation which was associated with underlying perturbation of motor control strategy. Significant and divergent patterns of cortical plasticity were evoked in projections to muscles necessary for reaching and grasping. The main findings of this thesis do not support anodal tDCS as an effective adjunctive means of enhancing spatial motor skill in rehabilitation from incomplete tetraplegic SCI. If applied in patient populations, the clinical benefits of anodal tDCS may be contingent both on the nature of the sensorimotor deficit affecting upper limb function and the spatial demands of the behavioural task. The findings of this project serve to inform further research in relation to the effect of anodal tDCS on the brain and behavioural outcomes, the potential for efficacy in target patient groups and the sensitivity of outcome measures to spatial and temporal dimensions of practical motor skills.

Intensive Language Action Therapy (ILAT) is a short-term aphasia therapy that emphasises massed-practise of language, where communication is framed through language action games that approximate everyday interactions. Despite increasing interest in ILAT, a comprehensive description of its methods has thus far been missing. Furthermore due to inconsistent results, further exploration of cortical reorganisation of language functions following ILAT is warranted. The underlying principles and practical features of ILAT methods and of language-action games are fully described, including the structure and materials for two specific games. 14 English speaking patients with chronic aphasia underwent two weeks of ILAT utilising the methods outlined. Pre and post measures of language performance were collected through standardised clinical assessments, along with functional Magnetic Resonance Imaging scans from a subset of 8 patients. Accuracy and response times for speech output and comprehension during language-action games were also recorded to measure success during the therapy interval. Data analysis showed significant improvements in clinical assessments of naming and comprehension, but not in auditory or syntactic processing tasks. Significant increases were also seen in patients’ self-ratings of quality of communication following therapy. Video and voice recordings during therapy sessions demonstrated significantly faster response times in production and comprehension of language, alongside an increase in the complexity of patients’ spoken output. Cortical activation was recorded whilst patients heard low-level noise, sentences containing ambiguous words and low-ambiguity sentences. Although the results showed no changes in cortical activation in the group of patients whilst processing low-level noise or low ambiguity sentences, increases in language-induced activation were seen in single-subject analyses in both the left and right hemispheres. Furthermore the group of patients recruited the right hemisphere significantly more than the left hemisphere following ILAT when processing complex sentences containing ambiguous words. iii Clinical assessments and measures of everyday communication showed undergoing two weeks of ILAT significantly improved speech output and comprehension in patients with chronic aphasia. Gains made in communicative performance during therapy highlight the importance of recording therapy sessions for additional assessment of therapy efficacy. Although conclusions regarding cortical reorganisation are not entirely clear, they indicate the important role of the right hemisphere in reorganisation of language after stroke.

Intensive Language Action Therapy (ILAT) is a short-term aphasia therapy that emphasises massed-practise of language, where communication is framed through language action games that approximate everyday interactions. Despite increasing interest in ILAT, a comprehensive description of its methods has thus far been missing. Furthermore due to inconsistent results, further exploration of cortical reorganisation of language functions following ILAT is warranted. The underlying principles and practical features of ILAT methods and of language-action games are fully described, including the structure and materials for two specific games. 14 English speaking patients with chronic aphasia underwent two weeks of ILAT utilising the methods outlined. Pre and post measures of language performance were collected through standardised clinical assessments, along with functional Magnetic Resonance Imaging scans from a subset of 8 patients. Accuracy and response times for speech output and comprehension during language-action games were also recorded to measure success during the therapy interval. Data analysis showed significant improvements in clinical assessments of naming and comprehension, but not in auditory or syntactic processing tasks. Significant increases were also seen in patients’ self-ratings of quality of communication following therapy. Video and voice recordings during therapy sessions demonstrated significantly faster response times in production and comprehension of language, alongside an increase in the complexity of patients’ spoken output. Cortical activation was recorded whilst patients heard low-level noise, sentences containing ambiguous words and low-ambiguity sentences. Although the results showed no changes in cortical activation in the group of patients whilst processing low-level noise or low ambiguity sentences, increases in language-induced activation were seen in single-subject analyses in both the left and right hemispheres. Furthermore the group of patients recruited the right hemisphere significantly more than the left hemisphere following ILAT when processing complex sentences containing ambiguous words. iii Clinical assessments and measures of everyday communication showed undergoing two weeks of ILAT significantly improved speech output and comprehension in patients with chronic aphasia. Gains made in communicative performance during therapy highlight the importance of recording therapy sessions for additional assessment of therapy efficacy. Although conclusions regarding cortical reorganisation are not entirely clear, they indicate the important role of the right hemisphere in reorganisation of language after stroke.

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Neurological disorders can let sequelae that make affected person to be unable to have independence in their daily activities, but rehabilitation can provide a partial or total recovery of lost skills. The Behavior Analysis provides useful basis for the application of procedures in a program of rehabilitation of neurological patients and has offered grants to effective interventions. This review intended to continue and expand other reviews about neurological rehabilitation, using the analysis of studies from 2011 to 2015, with single-subject design and procedures based on Behavior Analysis. This research was conducted in the databases: PsycINFO, PePSIC, Medline, LILACS, Science Direct, Wiley Online Library and SciELO BRAZIL. 20 articles were found and were defined 18 variables for analysis. The reliability index was 91%. The results indicated that there was a predominance of elderly participants diagnosed with dementia and sequelae related to cognitive difficulties and performing daily living activities. The most widely used design was a reversal and multiple baseline among participants. Few studies conducted functional analysis of behavior. Among the procedures that manipulated the background stimuli and consequences, are included: prompting, blocking and response redirection, verbal script, fading. Some studies manipulated only reinforcing consequence. Many of the procedures were classified as practice based on evidence of moderate level. Most authors reported effectiveness of the procedures applied, although few have been concerned with the implications of intervention in the daily lives of patients, failing to perform maintenance measures and social validity and to plan generalization. With the results of this review it was evident the need for future studies to deepen on the social impact of rehabilitation interventions
As patologias neurológicas podem deixar sequelas que impossibilitam a pessoa acometida de ter independência nas suas atividades cotidianas, porém um trabalho de reabilitação pode proporcionar uma recuperação parcial ou total de habilidades perdidas. A Análise do Comportamento apresenta fundamentação útil para a aplicação de procedimentos em um programa de reabilitação de pacientes neurológicos e tem oferecido subsídios para intervenções eficazes. A presente revisão pretendeu continuar e ampliar outras revisões sobre reabilitação neurológica, utilizando a análise de estudos de 2011 a 2015, com delineamento de sujeito único e com procedimentos embasados na Análise do Comportamento. A investigação foi realizada nos bancos de dados: PsycINFO, PePSIC, Medline, Lilacs, Science Direct, Wiley Online Library e SciELO Brasil. Foram encontrados vinte artigos, e definidas 18 variáveis para análise. O índice de fidedignidade foi de 91%. Os resultados indicaram que houve um predomínio de participantes idosos com diagnóstico de demência e com sequelas referentes a dificuldades cognitivas e de realização de atividades de vida diária. O delineamento mais utilizado foi de reversão e de linha de base múltipla entre participantes. Poucos artigos realizaram uma análise funcional do comportamento. Entre os procedimentos que manipularam os estímulos antecedentes e as consequências, destacaram-se: Prompting, Bloqueio e Redirecionamento de Resposta, Roteiro Verbal, Fading. Alguns estudos manipularam apenas a consequência reforçadora. Grande parte dos procedimentos foi classificada como uma prática baseada em evidência de nível moderado. A maioria dos autores relatou eficácia dos procedimentos aplicados, embora poucos tenham demonstrado preocupação com as implicações da intervenção na vida diária dos pacientes, deixando de realizar medidas de manutenção e de validade social e de planejar a generalização. Com os resultados desta revisão ficou evidente a necessidade de realizar estudos futuros que se aprofundem sobre o impacto social das intervenções de reabilitação

Plusieurs champs de recherche ont été combinés - mettant en évidence l'utilité de l'analyse cinématique, non seulement afin d'évaluer le comportement moteur, mais aussi afin de contribuer à la compréhension de la récupération motrice post-AVC. Au travers d'analyses cinématiques, les mouvements du membre supérieur hémiplégique ont été décomposés dans le temps et l'espace, afin d'en extraire l'échelle et les composantes structurelles. Cette décomposition systématique, d'abord connue pour son bien-fondé clinique, nous a permis d'identifier les marqueurs les plus pertinents du contrôle du membre supérieur parétique : i.e., la fluidité, la rectitude et la vitesse. Subséquemment, il a été démontré que i) les changements cinématiques se stabilisent au cours de la phase de rééducation, indiquant potentiellement la nécessité de modifier la stratégie thérapeutique; ii) les patient post-AVC sont capables de percevoir la fluidité du mouvement en réalité virtuelle, cette perception étant meilleure lorsque le feedback visuel ne concerne que le point du travail du membre; iii) l'espace de travail post-AVC n'est pas isotrope pour un patient hémiplégique; iv) chez les patients post-AVC, le niveau de ‘bruit neuromoteur' est augmenté; et v) la cinématique reflète la conséquence des stratégies d'adaptation à l'augmentation du bruit, ces stratégies étant basées sur un compromis entre des modes de contrôle d'erreur en feedforward et en feedback des actions motrices. Ainsi, il peut être conclut que la décomposition du mouvement dans le temps et l'espace est un moyen simple et efficace d'appréhender contrôle moteur chez l'Homme en situation normale et âpres AVC. L'enjeu est maintenant d'implémenter ces méthodes d'analyse cinématique dans les protocoles de rééducation post-AVC quotidienne afin de développer de larges bases de données permettant, à l'aide de méthodes de modélisation, de définir des profils de récupération et ainsi personnaliser de façon optimale la rééducation à chaque patient particulier
Multiple research fields were combined – highlighting the value of kinematic analysis, not only to evaluate motor behaviour, but also to contribute to the understanding of motor recovery post-stroke. By means of kinematics, hemiplegic upper-limb movements were unfolded in time and space, to extract the scaling and structural components of the movement. This systematic decomposition, first proven to have clinical relevance, allowed us to identify the most pertinent markers of paretic upper-limb control: i.e. smoothness, directness and velocity. Subsequently it was shown that i) change in kinematics levels off over rehabilitation, possibly indicating that treatment may profit from change; ii) people post-stroke are able to perceive movement fluency in virtual realities, whereby simple end-point displays facilitate perception; iii) the workspace post-stroke is heterogeneous; iv) stroke patients have increased levels of neuromotor noise; and v) kinematics reflect the outcome of adaptation strategies to the increased noise in relation to the automaticity of error-corrections on the trade-off between feedforward and feedback based motor control. It may thus be concluded that unfolding the movement in space and time, is a simple and powerful way to define human motor control. The challenge is to implement kinematic analysis in daily post-stroke practice to develop a large database enabling the definition of recovery profiles contributing to provide each individual patient with the right therapy at the right time

Dissertação de Mestrado Integrado em Medicina Veterinária
A mielomalácia progressiva (MMP) corresponde a necrose hemorrágica ou isquémica que pode ascender e/ou descender ao longo da medula espinhal (ME). Atualmente acredita-se que, aproximadamente, 10% dos cães com hérnia de extrusão toracolombar aguda e ausência da sensibilidade à dor profunda (SDP) possam desenvolver a MMP, sendo as raças condrodistróficas as mais suscetíveis. O presente estudo teve como objetivos: avaliar o papel da neuroreabilitação funcional intensiva (NRFI) com protocolo agregado de regeneração e despolarização dos feixes motores descendentes da ME na recuperação da funcionalidade dos cães com doença degenerativa do disco intervertebral (DIV), de pós-cirúrgico e em grau 0, segundo a Escala de Frankel Modificada (EFM); e avaliar o tempo médio de aplicabilidade destes protocolos multidisciplinares. A amostra populacional incluiu 17 cães, 11 pertencentes ao grupo de estudo (GE) e 6 ao grupo de controlo (GC), diagnosticada com hérnia de Hansen tipo I,em T10-L3, com classificação segundo a EFM em grau 0, ausência ou diminuição de reflexos periféricos e hipotonicidade generalizada dos membros pélvicos (MP). Ambos os grupos realizaram protocolos de NRFI, mas apenas no GE se associaram modalidades de regeneração neural. Os resultados evidenciaram que no GC todos os doentes se mantiveram não funcionais, em grau neurológico 0 e sem recuperação da SDP. No GE três dos doentes evoluíram para grau neurológico 4 segundo a EFM, recuperando a SDP, e um atingiu locomoção de reflexos espinhais funcional, tornando-se estes quatro (36,4%) doentes funcionais em qualquer ambiente. Ainda no GE 36,4% (4 em 11) dos doentes atingiu locomoção de reflexos espinhais não funcional permitindo a sua funcionalidade em ambiente caseiro. Por fim neste grupo mantiveram se em grau 0 três doentes, correspondente a 27,2%. Perante a evolução do GE, verificou-se que o grau de funcionalidade obteve uma correlação de forte significância estatística, p value de 0,000, com a recuperação dos reflexos periféricos, do tónus do reto abdominal e do reflexo do tronco cutâneo. Assim, pode concluir-se que os protocolos de neuroreabilitação funcional e regenerativa intensiva permitem que 72,8% (8 em 11) dos cães recuperem a funcionalidade, sendo essencial a continuidade do estudo.
ABSTRACT - The role of neurorehabilitation in dogs with myelomalacia - Progressive myelomalacia (PMM) corresponds to a phenomenon of hemorrhagic or ischemic necrosis that may ascend and/or descend along the spinal cord. Currently, it is believed that approximately 10% of dogs with acute thoracolumbar disc extrusion and loss of deep pain perception (DPP) can develop PMM, being the chondrodystrophic dogs the most susceptible. That said, the main goals of this study are to evaluate the functional neurorehabilitation intensive protocols (FNRIP) with an aggregated protocol for regeneration and depolarization of the descending motor pathways from spinal cord in recovery of the functionality in dogs with intervertebral disc degenerative disease (IVDDD), of post-surgical and neurological grade 0 according to Modified Frankel Scale (MFS); and to evaluate is the average expected time of multidisciplinary protocols. For this study, were considered a population sample of 17 dogs, 11 belonging to the study group (SG) and 6 to the control group (CG), diagnosed with Hansen type I IVDDD in T10-L3, classification in neurological grade 0 according to MFS (paraplegic without DPP), absence or decrease of peripheral reflexes and generalized hypotonicity of the pelvic limbs. Both groups performed FNRIP protocols but only in the SG were neural regeneration modalities associated. The results revealed that 100% of CG patients remained non-functional, in neurological grade 0 and without recovery of DPP. In SG 3 patients evolved to neurologic grade 4 according to MFS (recovering DPP) and 1 achieved functional spinal reflex locomotion, making these 4 (36.4%) dogs functional in any environment. Additionally, 36.4% (4 in 11) of dogs in the SG achieved non-functional spinal reflex locomotion allowing functionality in a home environment. Finally, in these group three patients were kept in degree 0, corresponding to 27.2%. The evolution of the SG allowed us to verify that the degree of functionality obtained a strong correlation, p value of 0.000, with the recovery of the peripheral reflexes, the tone of the rectus abdominis and the cutaneous trunci muscle reflex. In conclusion, the current study reveals that FNRIP protocols associated with neural regeneration modalities allow 72.8% (8 in 11) of dogs to recover functionality, being essential the continuity of this study.
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Dissertação de Mestrado Integrado em Medicina Veterinária
A doença degenerativa do disco intervertebral (DDIV) é uma das causas mais comuns de disfunção neurológica em cães, podendo resultar em quadros clínicos de doentes em grau 0 segundo a Escala de Frankel modificada (EFM). A perda da sensibilidade à dor profunda (SDP) é um factor de prognóstico bastante desfavorável, traduzindo-se em incapacidade sensorial e motora e perda da qualidade de vida. A neuroreabilitação funcional (NRF) é uma área da medicina veterinária que pretende restabelecer a funcionalidade e independência do doente, através da reorganização neural por neuroplasticidade, neuromodulação e memorização. Nos doentes de grau 0, o objectivo da NRF é estimular a recuperação da SDP ou o desenvolvimento de locomoção fictícia funcional (LFF). O presente estudo tem como objectivos aferir o papel do treino de NRF intensivo (TNRFI) na recuperação da funcionalidade por locomoção voluntária ou por LFF, determinando a percentagem de recuperação da SDP e o tempo necessário para atingir a funcionalidade motora. Incluiram-se 28 cães diagnosticados com lesão medular (T3-L3) por DDIV, de grau 0, que foram integrados num TNRFI, ao qual foi associado a administração farmacológica de 4-aminopiridina. Em doentes de grau 0, o estudo permitiu concluir que o TNRFI é uma indicação terapêutica, uma vez que o retorno à funcionalidade foi de 60,7%, tendo 28,6% dos doentes recuperado a SDP e destes 10,7% num período temporal de 2 meses. No período temporal de 2 a 3 meses, 17,9% recuperaram a SDP e 32,1% obtiveram funcionalidade por LFF. Neste estudo verificouse ainda que a recuperação da funcionalidade por LFF dependeu do peso (p=0,036) e houve tendência para depender da idade do doente (p=0,098), pois todos os animais com LFF tiveram peso inferior a 7 kg e idade inferior a 7 anos. Verificou-se ainda que no grupo com locomoção fictícia não funcional, a plasticidade neural conferiu automaticidade não funcional compatível com capacidade de obter qualidade de vida.
ABSTRACT - EFFECT OF FUNCTIONAL REHABILITATION ON THE OBTENTION OF FICTIVE LOCOMOTION IN DOGS - Intervertebral disc disease is one of the most common causes of neurological dysfunction in dogs and can lead to clinical conditions of patients in grade 0, according to the modified Frankel scale (MFS). The loss of deep pain perception (DPP) is considered a bad prognostic factor, resulting in sensory and motor incapacity and poor life quality. Functional neurorehabilitation (FNR) is a field of veterinary medicine that aims to restore the patient’s independency and functionality, through neural reorganization by neuroplasticity, neuromodelation and memorization. In grade 0 patients, the objective of FNR is to recover DPP or to obtain functional fictive locomotion. The present study aims at assessing the role of intensive FNR training (IFNRT) in the recovery of functionality by voluntary locomotion or functional fictive locomotion, to determine the recovery of DPP and the time required to achieve motor function. In the study, 28 dogs were diagnosed with spinal cord injury (T3-L3) due to IVDD, classified in grade 0 that were integrated into an IFNRT, which was associated with the administration of 4-aminopyridine. In grade 0 patients, the study concluded that IFNRT should be a therapeutic indication, since it stimulated the return to functionality in 60.7%, with 28.6% of the patients recovering DPP and among these 10.7% in 2 months. In the period of 2 to 3 months, 17.9% recovered DPP and 32.1% obtained functionality by fictive locomotion. In this study it was verified that recovery of functionality by fictive locomotion depended on the weight (p=0,036) and there was a tendency to depend on the age of the patient (p=0,098), since all the patients with fictive locomotion had weight inferior to 7 kg and age inferior to 7 years. It was also concluded that in the group that didn’t achieve functional fictive locomotion, the neural plasticity conferred non functional automaticity, compatible with capacity to obtain quality of life.
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Numerose indagini neuroscientifiche degli ultimi trent'anni hanno ampliato la conoscenza del funzionamento del Sistema dei neuroni Specchio (SS), le cui rappresentazioni neuronali sono attive sia durante l'esecuzione che durante l'osservazione di un’azione. In particolare, la componente facciale del SS è stata proposta come uno dei network principali per i processi socio-emotivi, data la presenza di regioni coinvolte sia nelle rappresentazioni sensorimotorie delle espressioni facciali che nella modulazione delle risposte autonomiche legate alle emozioni. È stato inoltre suggerito come l'organizzazione del SS facciale sia probabilmente predisposta già prima della nascita e poi definita sulla base dell'esperienza durante periodi sensibili dello sviluppo cerebrale. A tal proposito, è stato dimostrato come bambini con paralisi facciale congenita, affetti da Sindrome di Moebius (SM), riportino difficoltà nel riconoscimento delle espressioni facciali e ridotta attività autonomica in risposta a stimoli emotivi, probabilmente a causa di un ipo-funzionamento del SS. Per verificare questa ipotesi, scopo di questa tesi di dottorato è valutare l'organizzazione anatomo-funzionale sensorimotoria del volto in relazione alla capacità di elaborare le emozioni in pazienti con SM. Un secondo obiettivo è studiare la plasticità corticale dei pazienti con SM a seguito di chirurgia facciale e interventi neuroriabilitativi basati sul SS. Il primo studio ha mostrato, tramite un’indagine elettrocardiografica, la presenza di una ridotta reattività autonomica in risposta ad espressioni facciali in termini di bassa modulazione dell'aritmia sinusale respiratoria (RSA) in bambini con SM. Ciò suggerisce come pazienti con SM possano avere difficoltà a rispondere adeguatamente ed adattivamente a stimoli emotivi e sociali. Il secondo studio consiste in un'indagine cinematica longitudinale sulla produzione del sorriso in pazienti affetti da SM che hanno seguito un protocollo di neuroriabilitazione FIT-SAT (Facial-Imitation and Synergistic hand-mouth Activity) dopo un intervento chirurgico facciale, tramite procedura di free muscle transfer. I risultati hanno mostrato che il protocollo FIT-SAT 1) facilita l'attivazione dei muscoli trapiantati sul viso e 2) promuove una migliore modulazione del sorriso rispetto ai trattamenti tradizionali, probabilmente favorendo un più efficace reclutamento delle strutture neurali responsabili dell'esecuzione del sorriso. Il terzo studio ha mostrato come pazienti con SM che hanno svolto un intervento chirurgico per aumentare la motilità del viso in età avanzata abbiano, rispetto ai soggetti di controllo, una minore consapevolezza sensoriale del volto durante la stimolazione simultanea faccia-mano. Al contrario, i pazienti operati durante l'infanzia non mostrano tale difficoltà, riportano prestazioni simili a soggetti di controllo. Questi risultati suggeriscono che 1) l'immobilità facciale congenita potrebbe causare un restringimento della rappresentazione somatotopica del volto a favore di un’aumentata estensione della regione della mano 2) che gli interventi in età precoce potrebbero essere più efficaci nell'indurre riorganizzazione sensorimotoria facciale. Nel complesso, questi risultati confermano come l'impossibilità congenita di produrre gesti facciali complessi possa influenzare l’organizzazione sensorimotoria facciale, supportando anche l'ipotesi che un’ipo-funzionamento del SS in pazienti con SM sia alla base delle difficoltà nell’elaborazione delle emozioni. Infine, questi risultati suggeriscono come interventi chirurgici e di riabilitazione possano indurre riorganizzazione cerebrale e comportamentale anche nel caso di malattie congenite, soprattutto se svolti durante l'infanzia, grazie a processi di plasticità attività-dipendenti più efficaci.
Several neuroscientific investigations over the last thirty years have extended our knowledge about the anatomo-functional organization of the sensorimotor “Mirror Neurons System” (MNS), whose neuronal representation are active during both action execution and observation. In particular, the facial component of the MNS has been proposed as a core network for socio-emotional processes, with regions involved both in sensorimotor representations of facial expressions and in the modulation of autonomic responses related to emotion. Moreover, the organization of the facial MNS is thought as already predisposed even before birth and then refined based on the actual experience of an individual, especially during highly sensitive periods of brain development. To this regard, some studies have reported emotion processing difficulties in children with congenital facial paralysis, such as Moebius Syndrome (MBS). In particular, it has been demonstrated that MBS children reported difficulties in facial expressions recognition and reduced autonomic activity in response to emotional stimuli, probably because of an abnormal functioning of their facial MNS. To test this hypothesis, the aim of this doctoral thesis is to evaluate MBS patient facial sensorimotor anatomo-functional organization in relation to the capacity to process emotion. A second objective is to investigate MBS patients cortical plasticity following facial surgery and MNS based neurorehabilitative interventions. The first study investigated MBS children autonomic response to facial expressions, by means of Electrocardiographic measurements. Results showed significant lower autonomic modulation in MBS children in terms of Respiratory Sinus Arrythmia (RSA) reactivity in response to faces. This confirm already demonstrated MBS children difficulties in emotion processing, probably even in terms of lower predisposition to adaptively react to social stimuli. The second study consisted in a post-surgery longitudinal kinematics investigation of smile production in MBS patients who followed a Facial-Imitation and Synergistic hand-mouth Activity (FIT-SAT) neurorehabilitation protocol after facial surgery, namely a free muscle transfer procedure. Results showed that the FIT-SAT protocol 1) facilitate the activation of the transplanted muscles on the face and 2) promote better modulation of the smile compared to traditional treatments, probably fostering a more effective recruitment of neural structures responsible for smile execution. The third study showed that MBS patients who underwent surgery to increase face motility late in life reported lower sensory facial awareness during simultaneous face-hand stimulation, compared to age-matched control subjects. In contrast, patients operated during childhood reported control-like performances. These results suggest that 1) congenital facial immobility could cause a shrinkage of the facial somatotopic field in favour of an over-represented hand region and 2) interventions in early age could be more effective in inducing facial sensorimotor reorganization. As a whole, these findings confirm that the impossibility to produce complex facial gesture since gestational development could affect the actual facial sensorimotor organization, supporting also the hypothesis of a hypo functioning facial MNS in patients with congenital facial palsy. This supports the idea that emotion processing difficulties in MBS patients could be linked to deficits in motor simulation. Finally, these results suggest that brain and behavioral reorganization following interventions could occur also in congenital disease, especially if performed during childhood, probably because of more effective activity-dependent plasticity process.

Doutoramento em Ciências e Tecnologias da Saúde
Nervous system disorders are associated with cognitive and motor deficits, and are responsible for the highest disability rates and global burden of disease. Their recovery paths are vulnerable and dependent on the effective combination of plastic brain tissue properties, with complex, lengthy and expensive neurorehabilitation programs. This work explores two lines of research, envisioning sustainable solutions to improve treatment of cognitive and motor deficits. Both projects were developed in parallel and shared a new sensible approach, where low-cost technologies were integrated with common clinical operative procedures. The aim was to achieve more intensive treatments under specialized monitoring, improve clinical decision-making and increase access to healthcare. The first project (articles I – III) concerned the development and evaluation of a web-based cognitive training platform (COGWEB), suitable for intensive use, either at home or at institutions, and across a wide spectrum of ages and diseases that impair cognitive functioning. It was tested for usability in a memory clinic setting and implemented in a collaborative network, comprising 41 centers and 60 professionals. An adherence and intensity study revealed a compliance of 82.8% at six months and an average of six hours/week of continued online cognitive training activities. The second project (articles IV – VI) was designed to create and validate an intelligent rehabilitation device to administer proprioceptive stimuli on the hemiparetic side of stroke patients while performing ambulatory movement characterization (SWORD). Targeted vibratory stimulation was found to be well tolerated and an automatic motor characterization system retrieved results comparable to the first items of the Wolf Motor Function Test. The global system was tested in a randomized placebo controlled trial to assess its impact on a common motor rehabilitation task in a relevant clinical environment (early post-stroke). The number of correct movements on a hand-to-mouth task was increased by an average of 7.2/minute while the probability to perform an error decreased from 1:3 to 1:9. Neurorehabilitation and neuroplasticity are shifting to more neuroscience driven approaches. Simultaneously, their final utility for patients and society is largely dependent on the development of more effective technologies that facilitate the dissemination of knowledge produced during the process. The results attained through this work represent a step forward in that direction. Their impact on the quality of rehabilitation services and public health is discussed according to clinical, technological and organizational perspectives. Such a process of thinking and oriented speculation has led to the debate of subsequent hypotheses, already being explored in novel research paths.
As doenças do sistema nervoso estão associadas a défices cognitivos e motores, sendo responsáveis pelas maiores taxas de incapacidade e impacto global. A sua recuperação é difícil e depende em simultâneo da plasticidade cerebral e de programas de neurorreabilitação complexos, longos e dispendiosos. Este trabalho explora duas linhas de investigação, que visam soluções sustentáveis para melhoria do tratamento de défices cognitivos e motores. Ambos os projetos foram desenvolvidos em paralelo, partilhando uma abordagem assisada onde se combinam tecnologias de baixo custo com processos clínicos comuns. O objetivo era obter tratamentos mais intensivos e supervisionados, melhorar o processo de decisão clínica e eliminar barreiras no acesso aos cuidados de saúde. O primeiro projeto (artigos I – III) permitiu o desenvolvimento e avaliação de uma plataforma online para treino cognitivo (COGWEB), adequada para uso intensivo, em casa ou instituições, e num largo espectro de idades e doenças com envolvimento das funções cognitivas. A sua usabilidade foi testada numa consulta de memória, sendo de seguida implementada numa rede colaborativa que envolveu 41 centros e 60 profissionais. A taxa de adesão aos planos de treino cognitivo online foi 82,8% aos 6 meses, verificando-se uma intensidade média de 6 horas/semana. O segundo projeto (artigos IV – VI) originou a construção e validação de um dispositivo de reabilitação inteligente para doentes com acidente vascular cerebral (AVC). Permite estímulos proprioceptivos no lado hemiparético, enquanto caracteriza o movimento tridimensional em ambulatório (SWORD). A estimulação vibratória foi bem tolerada pelos doentes e um sistema automático de caracterização motora revelou resultados comparáveis aos de uma escala utilizada frequentemente na prática clínica. O sistema integrado foi testado num ensaio clínico randomizado e controlado com placebo para avaliação do impacto numa tarefa de reabilitação motora na fase subaguda após AVC. O número de movimentos correctos numa tarefa mão-boca aumentou em média 7,2/minuto, enquanto a probabilidade de ocorrência de erro se reduziu de 1:3 para 1:9. A neurorreabilitação e a neuroplasticidade têm incorporado abordagens de múltiplos domínios das neurociências. Em simultâneo, a sua utilidade para os doentes e sociedade está dependente do desenvolvimento de tecnologias mais eficazes que facilitem também a disseminação do conhecimento entretanto produzido. Os resultados obtidos através do presente trabalho representam um passo adicional nessa direcção. O seu impacto na qualidade dos serviços de reabilitação e saúde pública são discutidos segundo perspectivas clínica, tecnológica e organizacional. Este processo de reflexão foi gerador de novas hipóteses, algumas já em exploração através de linhas de investigação específicas.

Durant les últimes quatre dècades, la rehabilitació de la lesió medul·lar ha canviat el focus del tractament mèdic cap als problemes que afecten a la qualitat de vida i a la participació. Les persones amb lesió medul·lar tendeixen a presentar una percepció del benestar més baix, de mitjana, en comparació de la població que no té una discapacitat, i la puntuen més baix pel que fa a la salut física, mental i social i en altres àmbits de la vida que es consideren importants per a tenir una bona qualitat de vida. La participació pot ser considerada com un component clau o com un factor determinant de la qualitat de vida, depenent de com es conceptualitza el constructe qualitat de vida. En les persones amb lesió medul·lar, la participació està més fortament associada amb la qualitat de vida subjectiva que no pas amb les deficències o les limitacions de les activitats. Els objectius d’aquesta tesi doctoral són els següents: Identificar, avaluar i sintetitzar l'evidència sobre la participació com un resultat dels tractaments de rehabilitació funcional per a persones amb lesió medul·lar. Identificar, avaluar i sintetitzar l'evidència sobre el benestar subjectiu com a resultat dels tractaments de rehabilitació funcional per a persones amb lesió medul·lar. Descriure les associacions entre el nivell de funcionament, la percepció del benestar subjectiu i el nivell de participació en les persones amb lesió medul·lar durant el procés de neurorehabilitació hospitalària que practiquen activitat física. Per tal d’abordar aquesta situació, aquesta tesi doctoral ha estat estructurada en tres treballs: 1. La rehabilitació funcional després de la lesió medul·lar: una revisió sistemàtica dels tractament focalitzats en la participació. 2. El benestar subjectiu com a resultat de les intervencions en rehabilitació funcional després de la lesió medul·lar: una revisió sistemàtica. 3. L’activitat física en la neurorehabilitació de la lesió medul·lar: un estudi pilot, obert, transversal de la relació amb el funcionament, el benestar subjectiu i la participació.
Durante las últimas cuatro décadas, la rehabilitación de la lesión medular ha cambiado el foco del tratamiento médico hacia los problemas que afectan a la calidad de vida y a la participación. Las personas con lesión medular tienden a presentar una percepción del bienestar más baja, en promedio, en comparación con la población que no tiene una discapacidad, y la puntúan más bajo en cuanto a la salud física, mental y social y en otros ámbitos de la vida que se consideran importantes para tener una buena calidad de vida. La participación puede ser considerada como un componente clave o como un factor determinante de la calidad de vida, dependiendo de cómo se conceptualiza el constructo calidad de vida. En las personas con lesión medular, la participación está más fuertemente asociada con la calidad de vida subjetiva que con las deficiencias o las limitaciones de las actividades. Los objetivos de esta tesis doctoral son los siguientes: 1. Identificar, evaluar y sintetizar la evidencia sobre la participación como un resultado de los tratamientos de rehabilitación funcional para personas con lesión medular. 2. Identificar, evaluar y sintetizar la evidencia sobre el bienestar subjetivo como resultado de los tratamientos de rehabilitación funcional para personas con lesión medular. 3. Describir las asociaciones entre el nivel de funcionamiento, la percepción del bienestar subjetivo y el nivel de participación en las personas con lesión medular durante el proceso de neurorrehabilitación hospitalaria que practican actividad física. Para abordar esta situación, esta tesis doctoral ha sido estructurada en tres trabajos: 1) La rehabilitación funcional tras la lesión medular: una revisión sistemática de los tratamientos focalizados en la participación. 2) El bienestar subjetivo como resultado de las intervenciones en rehabilitación funcional tras una lesión medular: una revisión sistemática. 3) La actividad física en la neurorrehabilitación de la lesión medular: un estudio piloto, abierto, transversal de la relación con el funcionamiento, el bienestar subjetivo y la participación.
Over the past four decades, the rehabilitation of spinal cord injury has shifted the focus from medical treatment to the problems that affect the quality of life and participation. People with SCI tend to have a perception of quality of life lower on average compared to people without a disability, and scored lowest in terms of physical, mental and social health and other areas of life that are considered important to have a good quality of life. Participation can be seen as a key component or as a determinant of quality of life, depending on how the quality of life construct is conceptualized. In people with spinal cord injury, participation is more strongly associated with subjective quality of life than with deficiencies or limitations of activities. The objectives of this thesis are: 1. Identify, assess and synthesize the evidence on participation as an outcome of functional rehabilitation treatments for people with spinal cord injury. 2. Identify, assess and synthesize the evidence on subjective well-being as an outcome of functional rehabilitation treatments for people with spinal cord injury. 3. Describe the associations between the functioning, the perception of subjective well-being and participation in people with spinal cord injury during neurorehabilitation inpatient hospital. To address this situation, this dissertation has been structured in three works: 1) Functional rehabilitation after spinal cord injury: a systematic review of treatments focused on participation. 2) The subjective well-being as an outcome of interventions on functional rehabilitation after spinal cord injury: a systematic review. 3) The effect of physical activity on subjective well-being and participation in individuals with spinal cord injury during inpatient neurorehabilitation: A cross-sectional pilot study.

Thesis (Ph.D.)--University of Alberta, 2009.
A thesis submitted to the Faculty of Graduate Studies and Research in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Neuroscience, Centre for Neuroscience. Title from pdf file main screen (viewed on October 18, 2009). Includes bibliographical references.

ABSTRACT: Coordinated walking behavior in vertebrates and multi-legged invertebrates is controlled by evolutionarily conserved neuronal networks capable of generating movement in a fast, stable, and energy-efficient way. At the same time, it provides the flexibility to adapt to changes in the terrain, load, and under extreme conditions, to changes in internal motor representations resulting from adaptation to injury or disease. Our aim is to understand and characterize the neuronal mechanisms of plasticity that mediate motor adaptation to injury. To do so, we use Drosophila melanogaster, an easily manipulatable animal model with a powerful genetic toolkit, and the FlyWalker System that allows quantification of locomotor behavior of freely-walking Drosophila with high spatial and temporal resolution. In order to study motor recovery, we submit flies to a middle-leg amputation and quantify locomotor behavior over the course of time. We found that, although highly uncoordinated, Drosophila melanogaster can walk immediately after amputation. Over time, we observe a gradual improvement in coordination and increasingly controlled gate choice, with several parameters returning to control values. Moreover, we found that this behavior is phenocopied in D. repleta and D. pseudoobscura, two distant Drosophila species, hence showing that the phenotype of locomotor recovery after limb injury is evolutionarily conserved in the Drosophilidae phylogenetic tree. We then tested several classic Learning and Memory mutants pertaining to the cAMP signaling pathway for Long Term Memory (amnesiac, rutabaga, dunce and radish); these mutants displayed little signs of locomotor recovery – reflected in the absence of gait adaptation, inability to stabilize the body during walking bursts and decreased footprint precision and accuracy; over time these add up, resulting in a locomotor behavior phenotype in which the flies are inaccurate and random in each step taken, and hence walk in an increasingly uncoordinated fashion. Additionally, we tested inhibition of de novo protein synthesis using the translation inhibitor Cycloheximide, which yielded no palpable results. These results indicate that flies can readjust their neuronal-motor circuitry to an injured state, observable through a time-dependent recovery in locomotor performance, and that this behavioral phenotype is evolutionarily conserved throughout the Drosophilidae phylogenetic tree. Moreover, general genetically encoded mechanisms relevant for memory and learning (described by classical olfactory learning paradigms) may be involved in this process of locomotor adaptation and recovery – possibly by promoting neuronal plasticity events. By identifying specific genes and their expression patterns in the nervous system occurring during motor adaptation, we will be able to genetically dissect and target mechanisms of neuronal plasticity involved in locomotor recovery.

Tese de mestrado integrado, Engenharia Biomédica e Biofísica (Engenharia Clínica e Instrumentação Médica) Universidade de Lisboa, Faculdade de Ciências, 2017
Apesar de não serem a principal causa de morte no Mundo, as lesões cerebrais são talvez a principal razão de existirem tantos casos de pessoas que veem a sua vida quotidiana afetada. Tal acontece devido a grandes dificuldades cognitivas que podem ser derivadas de um acidente de automóvel, de uma queda, da presença de um tumor, de um acidente vascular cerebral, da exposição a substâncias tóxicas ou de uma outra qualquer situação que tenha envolvido uma lesão do cérebro. De entre este tipo de lesões podem considerar-se aquelas que são provenientes de traumas por forças externas, ou seja, as chamadas lesões cerebrais traumáticas ou traumatismos crânio-encefálicos. É precisamente em pessoas que sofreram uma lesão desse tipo que se foca este estudo. Em pessoas que, depois dessas lesões, foram sujeitas a um tratamento de neuro reabilitação. Este tratamento, baseado na realização de tarefas especialmente desenhadas para estimular a reorganização das ligações neuronais, permite que os doentes tenham a possibilidade de voltar a conseguir realizar tarefas do dia-a-dia com a menor dificuldade possível. O objetivo da realização destas tarefas é a estimulação da capacidade de plasticidade cerebral, responsável pelo desenvolvimento das conexões sinápticas desde o nascimento e que permite ao cérebro voltar a estabelecer o seu funcionamento normal depois de uma lesão. Naturalmente, o grau de afetação de uma pessoa depende do tipo de lesão e tem uma grande influência não só no tempo de recuperação física e mental, como também no seu estado final. O estudo documentado neste relatório de estágio constitui um meio para atingir um objetivo comum a outros trabalhos de investigação nesta área; pretende-se que os tratamentos de neuro reabilitação possam vir a ser personalizados para cada paciente, para que a sua recuperação seja otimizada. A ideia é que, conhecendo alguns dos dados pessoais de um doente, considerando informação sobre o seu estado inicial e através dos resultados de testes realizados, seja possível associá-lo a um determinado perfil disfuncional, de características bastante específicas, para o terapeuta poder adaptar o seu tratamento. O Institut Guttmann, em Barcelona, foi o primeiro hospital espanhol a prestar cuidados a doentes de lesões medulares. Hoje em dia, um dos seus muitos projetos chama-se GNPT Guttmann NeuroPersonalTrainer e leva a casa dos seus doentes uma plataforma que lhes permite realizar as tarefas definidas pelos terapeutas, no âmbito dos seus tratamentos de neuro reabilitação. Dados desses doentes, incluindo informação démica e resultados de testes realizados antes e depois dos tratamentos, foram cedidos pelo Institut Guttmann ao Grupo de Biomédica e Telemedicina (GBT) sob a forma de bases de dados. Através da sua análise e utilizando ferramentas de Data Mining foi possível obter perfis gerais de disfunção cognitiva e descrever a evolução desses perfis, o principal objetivo desta dissertação. Encontrar padrões em grandes volumes de dados é a principal função de um processo de Data Mining, tratando o assunto de forma muito genérica. Na verdade, é este o conceito utilizado quando são abordados temas de extração de conhecimento a partir de grandes quantidades de dados. Há diversas técnicas que o permitem fazer, que utilizam algoritmos baseados em funções estatísticas e redes neuronais e que têm vindo a ser melhoradas ao longo dos últimos anos, desde que surgiu a primeira necessidade de lidar com grandes conjuntos de elementos. O propósito é sempre o mesmo: que a análise feita a partir destas técnicas permita converter a informação oculta dos dados em informação que pode ser depois utilizada para caracterizar populações, tomar decisões ou para validar resultados. Neste caso, foram utilizados algoritmos de Clustering, um método de Data Mining que permite obter grupos de elementos semelhantes entre si, os clusters, considerando as características de cada um destes elementos. Dados de 698 doentes que sofreram um traumatismo craniano e cuja informação disponível nas bases de dados fornecidas pelo Institut Guttmann satisfazia todas as condições necessárias para serem considerados no estudo, foram integrados num Data Warehouse - um depósito de armazenamento de dados - e depois estruturados. A partir de funções criadas em SQL - a principal linguagem de consultas e organização de bases de dados relacionais - foram obtidas as pontuações correspondentes aos testes realizados pelos doentes, antes do início do tratamento e depois de este ser terminado. Estes testes visaram avaliar, utilizando cinco diferentes níveis de pontuação correspondentes a cada grau de afetação (0 para sem afetação, 1 para afetação suave, 2 para afetação moderada, 3 para afetação severa e 4 para afetação aguda), três funções estritamente relacionadas com o nível cognitivo, a atenção, a memória e algumas funções executivas. As pontuações obtidas para cada uma das funções constituem uma média ponderada da pontuação cada uma das subfunções (atenção dividida, atenção seletiva, memória de trabalho, entre outras), calculadas por pelo menos um dos 24 itens de avaliação a que cada pessoa foi sujeita. De seguida, foram determinados os grupos iniciais e finais, recorrendo a uma ferramenta muito útil para encontrar correlações em grandes conjuntos de dados, o software SPSS. Para determinar a constituição dos clusters iniciais foi aplicado um algoritmo de Clustering designado K-means e, para os finais, um outro denominado TwoStep. A principal característica desta técnica descritiva de Data Mining é a utilização da distância como medida de verificação da proximidade entre dois elementos de um cluster. Os seus algoritmos diferem no tipo de dados a que se aplicam e também na forma como calculam os agrupamentos de elementos. Para cada um dos clusters, e de acordo com cada uma das funções, foi observada a distribuição das pontuações, através de gráficos de barras. Foram também confrontados ambos os conjuntos de clusters para se poder interpretar a relação entre eles. Os clusters, que neste contexto correspondem a perfis de afetação cognitiva, foram validados, e concluiu-se que permitem descrever bem a população em estudo. Por um lado, os seis clusters iniciais determinados representam de uma forma fiel, e com muito sentido do ponto de vista clínico, os conjuntos de pessoas com características suficientemente definidas que os distinguem entre si. Já os três clusters finais, usados para retratar a população no final do tratamento e analisar as evoluções dos pacientes, retratam perfis bastante opostos, o que permitiu, de certa forma interpretar com maior facilidade para que pacientes o efeito da neuro-reabilitação foi mais ou menos positivo. Alguns estudos citados no estado de arte revelaram que algumas variáveis são suscetíveis de influenciar o estado final de um doente. Aproveitando a existência de dados suficientes para tal, foi observado se, tendo em conta os clusters finais, se poderia fazer alguma inferência sobre o efeito de algumas das variáveis – incluindo a idade, o nível de estudos, o intervalo de tempo entre a lesão e o início do tratamento e a sua duração – em cada um destes. No final, considerando apenas as pontuações dos testes em cada função, antes e depois dos tratamentos, foram analisados e interpretados, recorrendo a gráficos, os desenvolvimentos e a evolução global de cada doente. Como desenvolvimentos possíveis, foram tidos em conta os casos em que houve melhorias, agravamentos e também os casos em que os doentes mantiveram o seu estado. Fazendo uso da informação sobre a forma como evoluíram os pacientes, foi possível verificar se, de facto, utilizando apenas os valores das pontuações obtidas nos testes, se poderia ou não confirmar que outras variáveis poderiam ter efeitos na determinação do estado final de um paciente. Os gráficos obtidos demonstraram que há diferenças muito subtis considerando algumas das variáveis, principalmente entre os dos doentes que melhoraram e os dos doentes que viram a sua condição agravada. Concluiu-se que o facto de os clusters agruparem pessoas com tipos de evolução diferentes levou a que o efeito de outras variáveis se mostrasse muito disperso. O tipo de investigação sugerido para futuros desenvolvimentos inclui: (i) o estudo das outras hipóteses de perfis apresentados pelo software usado (SPSS); (ii) considerar os diferentes aspetos das funções avaliadas a um nível mais detalhado; (iii) ter em conta outras variáveis com possíveis efeitos no estado final de um doente.
Although they are not the leading cause of death in the world, brain injuries are perhaps the main reason why there are so many cases of people who see their daily lives affected. This is due to the major cognitive difficulties that appear after brain lesion. Brain injuries include those that are derived from traumas due to external forces – the traumatic brain injuries. This study is focused in people who, after these injuries, were subjected to a neuro rehabilitation treatment. The treatment, based on tasks specially designed to stimulate the reorganization of neural connections, allows patients to regain their abilities to perform their everyday tasks with the least possible difficulty. These tasks aim to stimulate the brain plasticity capacity, responsible for the development of synaptic connections which allows the brain to re-establish its normal functioning after an injury. The study documented in this internship report constitutes another step for a major goal, common to other studies in this area: that neuro rehabilitation treatments can be personalized for each patient, so that their recovery is optimized. Knowing some of the personal data of a patient, considering information about their initial state and through the results of tests performed, it is possible to assign a person to a certain dysfunctional profile, with specific characteristics and for the therapist to adapt treatment. One of his many projects of the Institut Guttmann (IG) is called GNPT Guttmann NeuroPersonalTrainer and brings into its patients’ home a platform that allows them to perform the tasks set by the therapists in the context of their neurorehabilitation treatments. Data from these patients, including clinical information and test results performed before and after the treatment, were provided by the IG to the Biomedical and Telemedicine Group (GBT) as databases. Through its analysis and using Data Mining techniques it was possible to obtain general profiles of cognitive dysfunction and to characterize the evolution of these profiles, the objective of this work. Finding patterns and extracting knowledge from large volumes of data are the main functions of a Data Mining process. An analysis performed using these techniques enables the conversion of information hidden in data into information that can later be used to make decisions or to validate results. In this case, Clustering algorithms, which build groups of elements with the similar characteristics called clusters, were used. Also, data from 698 patients who suffered brain trauma and whose information available in the databases provided by the IG satisfied all the conditions considered necessary were integrated into a Data Warehouse and then structured. The scores corresponding to the tests performed before and after the treatment were calculated, for each patient. These tests aimed to evaluate, using five different punctuation levels corresponding to each degree of affectation, three functions strictly related to cognitive level: attention, memory and some executive functions (cognitive processes necessary for the cognitive control of behavior). The initial and final clusters, representing patients’ profiles, were determined, using the SPSS software. The distribution of the scores over the clusters was observed through bar graphs. Both groups of clusters were also confronted to interpret the relationship between them. The clusters, which in this context correspond to profiles of cognitive affectation, were validated, and it was concluded that, at this moment, they represent well the state of patients under study. As some variables, like age and study level, are likely to influence the final state of a patient, it was observed if, given the final clusters, some inference could be made about the effect of those variables. No valuable conclusions were taken from this part. Also, considering the tests scores, patients’ evolution was identified as improvements, aggravations and cases where the conditions is maintained. Using that information, conclusions were extracted, regarding the population and the variables effect. The plots obtained allowed us to correctly describe the patients’ evolution and also to see if the variables considered were good descriptors of that evolution. A simple interpretation from of the facts allows to conclude that the calculated are good general, but not perfect descriptors of the population. The type of research suggested for future developments includes: (i) the study of the other hypothesis of profiles presented by the Data Mining software; (ii) consider the different aspects of the functions evaluated at a more detailed level; (iii) take into account other variables with possible effects on describing the final state of a patient.

The burden of strokes on the healthcare system is tremendous. Strokes are one of the leading causes of long-term morbidity and mortality in the United States. In addition, strokes have a huge economic burden that lasts long after the actual stroke has occurred and has been medically stabilized. Thus, there is a desire to prevent strokes, as well as treat those who have experienced stroke. As technology has and continues to advance, there is the potential for the inclusion of new technologies to become integrated into the healthcare system. One such example is the inclusion of virtual reality in the rehabilitation of patients who have experienced a stroke. The current process of stroke rehabilitation focuses upon returning a patient as close as possible to their baseline level of function. This is generally through the use of repetitive activity to help the brain reroute neuro signaling pathways around damaged areas of the brain. With the inclusion of virtual reality into the process of rehab, it may be possible to better control the environment around a patient and create activities to help better simulate activities of daily life. Through the inclusion of current generation virtual reality into modern rehabilitation regiments it may be possible to better the outcomes of patients who have undergone a stroke with physical deficits. With the current burden of stroke on the medical system it is important to find ways to treat patients as efficiently as possible. By incorporating virtual reality into stroke rehabilitation, there may be better outcomes for patients which will allow them to live better and more capable lives. Much of the research that has been conducted on the matter has shown promise but has lacked large sample sizes and often uses outdated technology. More research must be conducted using more modern technologies and larger sample sizes to show a true benefit in its utilization. The proposed study in this thesis will be a two-armed randomized control trial to assess the efficacy of virtual reality in stroke rehabilitation. The Fugl-Meyer assessment of motor recovery after stroke will be used to evaluate the physical motor benefits of implementation of virtual reality in stroke rehab. The potential benefit of virtual reality into stroke rehab could profoundly impact how we take care of patients who have experienced a stroke. It can create an effective new means to help patients regain their pre-stroke level of function, thus better helping return individuals to their normal lives. This in turn can help decrease costs on the healthcare system by decreasing the number of people living with long term disability.

Ein Schlaganfall ist für die betroffenen Patienten häufig mit motorischen Einschränkungen der oberen Extremitäten verbunden. Neue Therapieverfahren können bestehende Verfahren ergänzen. Im Rahmen dieser kumulativ angefertigten Forschungsarbeit wurde der Roboterball „Sphero 2.0“ als potenziell geeignetes Therapiemittel im Rahmen der Neurorehabilitation nach Schlaganfall identifiziert. Auf dieser Basis wurde ein innovatives, spielerisch- motivierendes Therapiekonzept entwickelt und im Rahmen der Rehabilitation bei Schlaganfallpatienten erprobt. Die Arbeit begann mit einer umfassenden Literaturrecherche zum Effekt neuer Technik-gestützter Rehabilitationskonzepte in der Schlaganfallrehabilitation. In der Folge wurden der Roboterball und Elemente des Therapiekonzepts erstmalig bei Schlaganfallpatienten erprobt. Nach erfolgreicher Machbarkeitsstudie zur technischen und therapeutischen Eignung folgte die langfristige Anwendung des Therapiekonzepts in einer randomisierten, kontrollierten Crossover Studie. Im Mittelpunkt der Untersuchungen standen die Überprüfung eines motorischen und alltagsrelevanten Benefit sowie Fragen zur Usability, Eignung und zu möglichen Limitierungen bei einer Anwendung des neuen Therapiekonzepts im Rahmen der Neurorehabilitation nach Schlaganfall.

Dissertation of the Integrated Master in Veterinary Medicine
Canine degenerative myelopathy is a progressive and fatal neurodegenerative disease with an adult-onset, is described in several breeds and currently doesn’t have an effective treatment. Some forms of amyotrophic lateral sclerosis in humans have homology to degenerative myelopathy, sharing a mutation in the superoxide dismutase 1 (SOD1), which is considered a risk factor to the development of the disease. Functional neurorehabilitation is a modality of restorative neurology and has a fundamental role in neurologic patients. Furthermore, mesenchymal stem cells, due to its differentiation, immunomodulation and regeneration capacity, are an interesting therapeutic option for diverse neurodegenerative conditions. The present study was carried out in Hospital Veterinário da Arrábida, Centro de Reabilitação Animal da Arrábida and Veterinary Medicine School of Lisbon University. The main aim was to evaluate the therapeutic potential of adipose-derived mesenchymal stem cells (MSC) associated with an intensive protocol of functional neurorehabilitation (FNR) in degenerative myelopathy affected dogs. For such, a sample of ten dogs with a diagnosis of exclusion of degenerative myelopathy was selected, four constituted the control group and performed a physical therapy protocol and the other six comprised the study group and were submitted to a stem cell based protocol (MSC and FNR). The results revealed an increase in survival time of the study group’s animals comparing to the ones in the control group. The average survival time since the beginning of physical therapy protocol for the control group was 15 weeks, in contrast with the study group, in which a dog survived 36 weeks and another 88 weeks (death from clinical occurrence) since the initiation of stem cell based protocol. Additionally, two animals in the study group had follow-ups for 88 and 91 weeks, still with acquired motor functionality. It was also possible to verify that 67% of study group’s animals improved according to a functional scoring system (FSS), after the stem cells transplantation. In conclusion, the current study reveals a synergetic effect of the stem cell based protocol in canine degenerative myelopathy.
A mielopatia degenerativa é uma doença neurodegenerativa de caracter progressivo e fatal, que afeta cães adultos descrita em diversas raças, não tendo atualmente um tratamento eficaz. Algumas formas de esclerose lateral amiotrófica em humanos apresentam características homólogas com a mielopatia degenerativa, partilhando uma mutação no gene superóxido dismutase 1 (SOD1), sendo este um fator de risco para o desenvolvimento da doença. A neurorreabilitação funcional é uma medida de neurologia restaurativa com um papel fundamental nos doentes neurológicos. Por outro lado, as células estaminais mesenquimatosas, devido às suas capacidades de diferenciação, de imunomodulação e regeneração, são consideradas uma fascinante opção terapêutica para diversas doenças neurodegenerativas. O presente trabalho foi realizado no Hospital Veterinário da Arrábida, no Centro de Reabilitação Animal da Arrábida e na Faculdade de Medicina Veterinária da Universidade de Lisboa. Teve como objetivo avaliar o potencial terapêutico das células estaminais mesenquimatosas (MSC) derivadas de tecido adiposo juntamente com protocolos intensivos de neurorreabilitação funcional (PINRF) no tratamento de cães com mielopatia degenerativa. Foram incluídos dez cães com diagnóstico de exclusão de mielopatia degenerativa, quatro representaram o grupo de controlo e realizaram um protocolo de fisioterapia e os restantes seis constituíram o grupo de estudo, tendo estes sido sujeitos a um protocolo baseado em células estaminais (MSC e PINRF). Os resultados obtidos revelaram um aumento do tempo de sobrevivência dos animais do grupo de estudo em relação aos do grupo de controlo. O tempo médio de vida desde o início do protocolo de fisioterapia no grupo de controlo foi de 15 semanas, contrastando com um animal do grupo de estudo que sobreviveu 36 semanas e outro que sobreviveu 88 semanas (morte por ocorrência clínica) após o início do protocolo baseado em células estaminais. Para além disso, dois animais do grupo de estudo têm um seguimento de 88 e 91 semanas, continuando com funcionalidade motora adquirida. Foi ainda possível verificar que 67% dos animais do grupo de estudo tiveram uma melhoria segundo uma escala de pontuação funcional (FSS) depois da transplantação das células estaminais. Em conclusão, o presente estudo evidencia o papel sinergético do protocolo baseado em células estaminais na mielopatia degenerativa.

Neurological disorders, in particular Stroke, have an impact on many individuals worldwide. These individuals are often left with residual motor control in their upper limbs. Although conventional therapy can aid in recovery, it is not always accessible, and the procedures are dull for the patient. Novel methods of therapy are being developed, including Brain-Computer Interfaces (BCIs). Although BCI research has been flourishing in the past few years, most rehabilitation applications are not yet suitable for clinical practice.This is due to the fact that BCI reliability and validation has not yet been achieved, and few clinical trials have been done with BCIs. Another crucial factor, is that modern BCIs are often comprised of inconvenient hardware and software. This is a major factor of aversion from both patients and clinicians. This Master Dissertation introduces the EmotivBCI: an easy to use platform for Electroencephalogram acquisition, processing and classification of sensorimotor rhythms with respect to motor action and motor imagery. The acquisition of EEG is done through 8 channels of the Emotiv Epoc wireless headset. Signals are pre-processed, and the 2 best combinations of channel/frequency pairs that exhibit the greatest spectral variation between the rest and action conditions are extracted for different time frames. These features are then used to build a feature matrix with 2 sets of attributes and 2 class labels. Finally the resulting feature matrix is used to train 3 different classifiers, in which the best is selected. The EmotivBCI enables users to keep record of their performances, and provides additional features to further examine training sessions. To assess the performance of the EmotivBCI, two studies were conducted with healthy individuals. The first study compares classification accuracies between two different training paradigms. The second study evaluates the progress in performance of a group of individuals after several training sessions.