This study evaluates the usability of Holoreach, a mixed reality (MR) system combined with a mobile therapy chair to improve trunk control and arm function in post-stroke rehabilitation. The device integrates smart glasses and gamified exercises for upper extremity reaching tasks requiring trunk engagement. Ten therapists and 15 stroke patients participated in a user-centered trial involving supervised therapy sessions. Data collection employed questionnaires, diaries, and focus group interviews to assess preparation, usability, motivation, and safety. Overall, therapists and 80

Background: Virtual reality (VR) therapy is increasingly used and has shown encouraging effects. Yet, it is unknown which patients respond best to VR-based balance therapy as part of neurorehabilitation. Methods: Data from 30 persons with stroke and 51 persons with multiple sclerosis who performed three to four weeks of VR-based balance therapy during in-patient rehabilitation were analysed. Participants were divided into responders and nonresponders based on achievement of the minimal clinically important difference in functional balance post intervention. Measures of balance, trunk function, mobility, gait, motivation, and exergame parameters were compared between groups. Results: Post intervention, all clinical measurements significantly improved (p < 0.05; effect size: 0.45–0.59). Participants that achieved the minimal clinically important difference in functional balance (n = 49; 60%) had significantly lower preintervention functional and dynamic balance (median(IQR): 39(27–46) versus 45(37–50); p = 0.02 and 11(6–15) versus 16(11–18); p = 0.03). They spent less time on higher difficulty exercises (11(8–17) versus 14.5(10–12); p = 0.03) and demonstrated increased motivation over time compared with nonresponders (1(−1–5) versus −2(−7–3); p = 0.03). Conclusion: Lower baseline balance ability, spending more time on adequately challenging exercises, and increased motivation potentially influence response to therapy. These factors can support the personalisation of VR-based balance therapy.

BackgroundPhysical activity (PA) represents a low-cost and readily available means of mitigating multiple sclerosis (MS) symptoms and alleviating the disease course. Nevertheless, persons with MS engage in lower levels of PA than the general population. ObjectiveThis study aims to enhance the understanding of the barriers to PA engagement in persons with MS and to evaluate the applicability of the Barriers to Health Promoting Activities for Disabled Persons (BHADP) scale for assessing barriers to PA in persons with MS, by comparing the BHADP score with self-reported outcomes of fatigue, depression, self-efficacy, and health-related quality of life, as well as sensor-measured PA. MethodsStudy participants (n=45; median age 46, IQR 40-51 years; median Expanded Disability Status Scale score 4.5, IQR 3.5-6) were recruited among persons with MS attending inpatient neurorehabilitation. They wore a Fitbit Inspire HR (Fitbit Inc) throughout their stay at the rehabilitation clinic (phase 1; 2-4 wk) and for the 4 following weeks at home (phase 2; 4 wk). Sensor-based step counts and cumulative minutes in moderate to vigorous PA were computed for the last 7 days at the clinic and at home. On the basis of PA during the last 7 end-of-study days, we grouped the study participants as active (≥10,000 steps/d) and less active (<10,000 steps/d) to explore PA barriers compared with PA level. PA barriers were repeatedly assessed through the BHADP scale. We described the relevance of the 18 barriers of the BHADP scale assessed at the end of the study and quantified their correlations with the Spearman correlation test. We evaluated the associations of the BHADP score with end-of-study reported outcomes of fatigue, depression, self-efficacy, and health-related quality of life with multivariable regression models. We performed separate regression analyses to examine the association of the BHADP score with different sensor-measured outcomes of PA. ResultsThe less active group reported higher scores for the BHADP items Feeling what I do doesn’t help, No one to help me, and Lack of support from family/friends. The BHADP items Not interested in PA and Impairment were positively correlated. The BHADP score was positively associated with measures of fatigue and depression and negatively associated with self-efficacy and health-related quality of life. The BHADP score showed an inverse relationship with the level of PA measured but not when dichotomized according to the recommended PA level thresholds. ConclusionsThe BHADP scale is a valid and well-adapted tool for persons with MS because it reflects common MS symptoms such as fatigue and depression, as well as self-efficacy and health-related quality of life. Moreover, decreases in PA levels are often related to increases in specific barriers in the lives of persons with MS and should hence be addressed jointly in health care management.

A prototype system aimed at improving arm function and trunk control after stroke has been developed that combines mixed-reality (MR) feedback with a mobile seat system (Holoreach). The purpose of this study was to assess the usability of Holoreach in a rehabilitation setting from both the patient and therapist perspective. Ten therapists (eight physiotherapists and two occupational therapists) used the device in their regular therapy programs for fifteen stroke patients with trunk control issues. Each patient received four individual therapy sessions with the device performed under the supervision of the therapist. Therapists and patients kept therapy diaries and used customized questionnaires. At the end of the study two focus groups were conducted to further assess usability. Generally, the prototype system is suitable for training trunk and arm control. The therapists expressed overall positive views on the impact of Holoreach. They characterized it as new, motivating, fresh, joyful, interesting, and exciting. All therapists and 80% of the patients agreed with the statement that training with Holoreach is beneficial for rehabilitation. Nonetheless, improvements are required in the hardware and software, and design. The prototype system contributes at various levels to the rapidly evolving advances in neurorehabilitation, particularly regarding the practical aspect of exercise delivery.

Background Consumer-grade fitness trackers offer exciting opportunities to study persons with chronic diseases in greater detail and in their daily-life environment. However, attempts to bring fitness tracker measurement campaigns from tightly controlled clinical environments to home settings are often challenged by deteriorating study compliance or by organizational and resource limitations. Objectives By revisiting the study design and patient-reported experiences of a partly remote study with fitness trackers (BarKA-MS study), we aimed to qualitatively explore the relationship between overall study compliance and scalability. On that account, we aimed to derive lessons learned on strengths, weaknesses, and technical challenges for the conduct of future studies. Methods The two-phased BarKA-MS study employed Fitbit Inspire HR and electronic surveys to monitor physical activity in 45 people with multiple sclerosis in a rehabilitation setting and in their natural surroundings at home for up to 8 weeks. We examined and quantified the recruitment and compliance in terms of questionnaire completion and device wear time. Furthermore, we qualitatively evaluated experiences with devices according to participants' survey-collected reports. Finally, we reviewed the BarKA-MS study conduct characteristics for its scalability according to the Intervention Scalability Assessment Tool checklist. Results Weekly electronic surveys completion reached 96%. On average, the Fitbit data revealed 99% and 97% valid wear days at the rehabilitation clinic and in the home setting, respectively. Positive experiences with the device were predominant: only 17% of the feedbacks had a negative connotation, mostly pertaining to perceived measurement inaccuracies. Twenty-five major topics and study characteristics relating to compliance were identified. They broadly fell into the three categories: “effectiveness of support measures”, “recruitment and compliance barriers”, and “technical challenges”. The scalability assessment revealed that the highly individualized support measures, which contributed greatly to the high study compliance, may face substantial scalability challenges due to the strong human involvement and limited potential for standardization. Conclusion The personal interactions and highly individualized participant support positively influenced study compliance and retention. But the major human involvement in these support actions will pose scalability challenges due to resource limitations. Study conductors should anticipate this potential compliance-scalability trade-off already in the design phase.

Objective: To compare the duration of exercise therapy needed to achieve a minimal clinically important difference in mobility, walking endurance and patient-reported global physical health in patients referred for inpatient rehabilitation after knee surgery, hip surgery, or with multiple sclerosis or Parkinson’s disease. Design: Retrospective pre-post intervention observational cohort study. Subjects: A total of 388 patients (57% women, mean age 65.6 years (standard deviation 9.5)) with a minimum length of stay 10 days were included between 1 January 2020 and 30 April 2021. Methods: Outcomes were assessed at the start of, and discharge from, rehabilitation, using the following measures: mobility (Timed Up and Go test), walking endurance (6-minute walk test), patient-reported global physical health (Global Physical Health subscale of the 10-item Patient-Reported Outcomes Measurement Information System). The duration of exercise therapy needed to achieve a minimal clinically important difference was determined using anchor-based and distribution-based methods. Results: The duration of therapy needed to achieve a minimal clinically important difference was longer in patients with multiple sclerosis or Parkinson’s disease (18–88 h) than in patients after knee or hip surgery (8–25 h). In all patient groups, the duration of exercise therapy needed, determined using the distribution-based method, was shortest for patient-reported global physical health (knee surgery 9.6 h, hip surgery 6.8 h, multiple sclerosis 38.7 h, Parkinson’s disease 18.4 h). Conclusion: The duration of active therapies required to achieve a minimal clinically important difference in physical outcomes varies widely (range 8–88 h) among different patient groups and outcomes.

Objective: This pilot study compared muscle activity during lateral reaching tasks between mobile and stable sitting using a novel therapy chair in people after stroke and healthy controls. Design: Observational pilot study. Setting: This study was conducted in a rehabilitation center for people after stroke and at the university's movement laboratory for healthy participants. Participants: A total of eleven people after stroke and fifteen healthy people (N=26) took part. Interventions: Lateral reaching exercises to the ipsilateral and contralateral sides were performed on a mobile and a stable seat. Main Outcome Measure: Muscular activity of the multifidus, erector spinae and external oblique was measured bilaterally. A within-subject linear mixed model was applied to analyze the effects of seat condition, task, muscle side, and group. Results: A seat condition effect was found for the multifidus and external oblique that was dependent on the muscle side and task. During ipsilateral reaching, the activity of the multifidi decreased for people after stroke on the mobile seat, while increasing for healthy participants. The erector spinae showed no condition effect. Decreased activity of the external oblique was found for both groups on the mobile seat. Conclusions: Mobile sitting influences muscular activity. However, these preliminary results should be further investigated in order to generate recommendations for rehabilitation.

Tools for monitoring daily physical activity (PA) are desired by persons with multiple sclerosis (MS). However, current research-grade options are not suitable for longitudinal, independent use due to their cost and user experience. Our objective was to assess the validity of step counts and PA intensity metrics derived from the Fitbit Inspire HR, a consumer-grade PA tracker, in 45 persons with MS (Median age: 46, IQR: 40-51) undergoing inpatient rehabilitation. The population had moderate mobility impairment (Median EDSS 4.0, Range 2.0-6.5). We assessed the validity of Fitbit-derived PA metrics (Step count, total time in PA, time in moderate to vigorous PA (MVPA)) during scripted tasks and free-living activity at three levels of data aggregation (minute, daily, and average PA). Criterion validity was assessed though agreement with manual counts and multiple methods for deriving PA metrics via the Actigraph GT3X. Convergent and known-groups validity were assessed via relationships with reference standards and related clinical measures. Fitbit-derived step count and time in PA, but not time in MVPA, exhibited excellent agreement with reference measures during scripted tasks. During free-living activity, step count and time in PA correlated moderately to strongly with reference measures, but agreement varied across metrics, data aggregation levels, and disease severity strata. Time in MVPA weakly agreed with reference measures. However, Fitbit-derived metrics were often as different from reference measures as reference measures were from each other. Fitbit-derived metrics consistently exhibited similar or stronger evidence of construct validity than reference standards. Fitbit-derived PA metrics are not equivalent to existing reference standards. However, they exhibit evidence of construct validity. Consumer-grade fitness trackers such as the Fitbit Inspire HR may therefore be suitable as a PA tracking tool for persons with mild or moderate MS.

Objectives: To determine the effect of 1-h education session, compared with no education, on physiotherapists' (PTs) inter-rater reliability in two lumbar spine motor control tests (MCTs): waiter's bow (WB) and sitting knee extension (SKE). To determine whether reliability at baseline and the effect of education are affected by PT's clinical experience, knowledge and experience of MCTs, and post-graduate education in manual therapy.Design: Randomized controlled trial.Participants: 54 PTs. Intervention: The experimental group (EG) took part in a 1-h group education session. Control group (CG) had no intervention.Measurements: At baseline and after EG had completed the education session, therapists rated 40 SKE and 40 WB video recordings.Analysis: Changes in Fleiss' kappa were compared between groups. Differences >0.1 in kappa values were considered meaningful. Regression analysis was used to evaluate the effect of therapist's characteristics on inter -rater reliability at baseline and changes in inter-rater reliability.Results: Education had significant and meaningful effect on reliability compared with no education. WB kappa values improved from 0.36 to 0.63 in the experimental group and from .39 to .46 in the control group. SKE kappa values improved from .50 to .71 in the EG and from 0.49 to 0.57 in the CG. None of PTs' characteristics affected reliability at baseline or education effects.Conclusion: The effect of 1-h group education session for physiotherapists on inter-rater reliability in MCTs is significant and meaningful. Provision of education for PTs in performing observational tests would improve inter-rater reliability, resulting in improved treatment planning and outcome evaluation.

Background:Upper limb disability in persons with Multiple Sclerosis (pwMS) leads to increased dependence on caregivers. To better understand upper limb disability, observer-based or time-based clinical assessments have been applied. However, these only poorly capture the behavioural aspects underlying goal-directed task performance. Objective:We aimed to document alterations in goal-directed upper limb movement patterns and hand grip forces in a cohort of pwMS (n = 123) with mild to moderate upper limb impairments. Methods:We relied on the Virtual Peg Insertion Test (VPIT), a technology-aided assessment with a goal-directed pick-and-place task providing a set of validated digital health metrics. Results:All metrics indicated significant differences to an able-bodied reference sample (p < 0.001), with smoothness, speed, and grip force control during object manipulation being most affected in pwMS. Such abnormalities negatively influenced the time to complete the goal-directed task (p < 0.001, R2 = 0.77), thereby showing their functional relevance. Lastly, abnormalities in movement patterns and grip force control were consistently found even in pwMS with clinically normal gross dexterity and grip strength. Conclusion:This work provides a systematic documentation on goal-directed upper limb movement patterns and hand grip forces in pwMS, ultimately paving the way for an early detection of MS sign using digital health metrics.

Purpose To evaluate discriminative validity, relative reliability and absolute reliability of four tablet-based tests for the evaluation of upper limb motor function in healthy persons and patients with neurological disorders. Methods Cross-sectional study in 54 participants: 29 patients with upper limb movement impairment due to a neurological condition recruited from an inpatient rehabilitation centre and 25 healthy persons. Accuracy, speed and path length were analysed for four tablet-based tests: "Spiral drawings," "Tapping," "Follow the dot" and "Trace a star." The area under the receiver operating characteristic curve (AUC) was used to evaluate discriminative validity. Relative reliability was analysed with the intra-class correlation coefficient (ICC), and absolute reliability by limits of agreement (LoA) and minimal detectable difference (MDD). Results All four tests showed excellent discriminative validity for the parameter accuracy (AUC 0.93-0.98). Tapping was the best test for discriminating patients from healthy persons. Test-retest reliability was good for accuracy in all tests (ICC = 0.76-0.88), but poor to moderate for speed and path length (ICC = 0.20-0.69). The MDD varied between 14% and 38%. Performance on the four tablet-based tests was stable between sessions, indicating that there was no learning effect. Conclusion The parameter accuracy showed excellent discriminative validity and reliability in all four tablet-based tests. Discriminative validity was excellent for all three parameters in the Tapping test. In the other tasks speed showed good to poor reliability, while the reliability of path-length was poor in all tasks. Results were comparable for the dominant and non-dominant hand. Tablet-based tests have the advantage that patients can use them for self-monitoring of upper limb motor function.

Background Patients with multiple sclerosis have low levels of physical activity. This is of concern because low activity levels are related to cardiovascular disease, poor walking ability, and reduced quality of life. The aim of this study was to evaluate the impact of rehabilitation on daily physical activity and walking capacity in patients with multiple sclerosis who have moderate to severe walking disability. Methods This exploratory, observational study of 24 patients with multiple sclerosis examined daily physical activity, walking capacity and fatigue before and after 3 weeks of inpatient rehabilitation. Inpatient rehabilitation included physiotherapy (30–60 min, 5 times/week), strength and endurance training (30–45 min, 3–5 times/week), occupational therapy (30 min, 2–3 times/week), and neuropsychological training (30 min, 2 times/week). There were no specific interventions to target daily levels of physical activity. Results Daily physical activity did not change after rehabilitation (physical activity: effect size = –0.23, 95% confidence interval (95% CI) 0.02‒0.62). There were significant improvements in walking capacity (Two-Minute Walk Test: effect size = 0.74, 95% CI 0.31‒1.16, +17 m, 20.2%) and mobility (Timed Up and Go Test: effect size = 0.65, 95% CI 0.22‒1.07, ‒2.1 s, 14.9%). Motor and cognitive fatigue (Fatigue Scale for Motor: effect size = 0.56, 95% CI 0.14‒0.99 and Cognitive Functions: effect size = 0.44, 95% CI 0.01‒0.86) improved significantly after rehabilitation. Conclusion Three weeks of rehabilitation improved walking capacity, but not daily physical activity, in patients with multiple sclerosis with moderate to severe walking disability. To increase physical activity, it may be necessary to add specific behavioural interventions to the rehabilitation programme. The intervention plan should include strategies to overcome personal and environmental barriers.

The aim of this study was to explore differences in trunk muscle activity on a stable and mobile seat for people after stroke and healthy participants. Trunk control exercises are known to have a beneficial effect on trunk control, balance, and mobility after stroke. The effect of such exercises could be enhanced by the use of a mobile seat to provide further training stimuli. However, little research on the musculoskeletal effects of trunk training on mobile seats has been carried out. On a stable and a mobile seat, thirteen people after stroke and fifteen healthy participants performed two selective trunk control exercises, which were lateral flexion initiated by the pelvis and the thorax. The maximal surface electromyography relative to static sitting of the muscles multifidus, erector spinae, and obliquus externus was recorded bilaterally. The effects of group, seat condition, trunk control exercise, and muscle side were investigated employing within-subject linear-mixed-models. Compared to the stable seat, the maximal muscle activity of people after stroke on the mobile seat was higher during the thorax-initiated exercise and lower during the pelvis-initiated exercise. Healthy participants showed opposite results with higher muscle activity on the mobile seat during the pelvis-initiated exercise. For trunk control training on a mobile seat with high muscle activation people after stroke should perform trunk control exercises initiated by the thorax, for training with lower muscle activity people after stroke should initiate selective trunk movements by the pelvis. The results can support the planning of progressive trunk control rehabilitation programs.

BackgroundPhysical activity (PA) is reduced in persons with multiple sclerosis (MS), though it is known to aid in symptom and fatigue management. Methods for measuring PA are diverse and the impact of this heterogeneity on study outcomes is unclear. We aimed to clarify this impact by comparing common methods for deriving PA metrics in MS populations.MethodsFirst, a rapid review of existing literature identified methods for calculating PA in studies which used the Actigraph GT3X in populations with MS. We then compared methods in a prospective study on 42 persons with MS [EDSS 4.5 (3.5–6)] during a voluntary course of inpatient neurorehabilitation. Mixed-effects linear regression identified methodological factors which influenced PA measurements. Non-parametric hypothesis tests, correlations, and agreement statistics assessed overall and pairwise differences between methods.ResultsIn the rapid review, searches identified 421 unique records. Sixty-nine records representing 51 eligible studies exhibited substantial heterogeneity in methodology and reporting practices. In a subsequent comparative study, multiple methods for deriving six PA metrics (step count, activity counts, total time in PA, sedentary time, time in light PA, time in moderate to vigorous PA), were identified and directly compared. All metrics were sensitive to methodological factors such as the selected preprocessing filter, data source (vertical vs. vector magnitude counts), and cutpoint. Additionally, sedentary time was sensitive to wear time definitions. Pairwise correlation and agreement between methods varied from weak (minimum correlation: 0.15, minimum agreement: 0.03) to perfect (maximum correlation: 1.00, maximum agreement: 1.00). Methodological factors biased both point estimates of PA and correlations between PA and clinical assessments.ConclusionsMethodological heterogeneity of existing literature is high, and this heterogeneity may confound studies which use the Actigraph GT3X. Step counts were highly sensitive to the filter used to process raw accelerometer data. Sedentary time was particularly sensitive to methodology, and we recommend using total time in PA instead. Several, though not all, methods for deriving light PA and moderate to vigorous PA yielded nearly identical results. PA metrics based on vertical axis counts tended to outperform those based on vector magnitude counts. Additional research is needed to establish the relative validity of existing methods.

Swallowing and cough are crucial components of airway protection. In patients with neurogenic dysphagia (ND), there is a high prevalence of dystussia (impaired cough) and atussia (absence of cough). As a result, the ability to detect and remove aspirated material from the airway decreases, exacerbating the sequelae associated with ND, including aspiration pneumonia, a leading cause of mortality in ND. This controlled intervention study aimed to quantify the cough response to aerosolized capsaicin (AC) in patients with ND and assess the potential of AC as a therapeutic tool in treating ND-related dystussia and atussia. Furthermore, we propose a novel application method that enables AC treatment to be performed at home. Spirometry was used to measure peak cough flow (PCF) of voluntary cough (cough on command) and reflexive cough (cough secondary to pharyngeal exposure to AC) in 30 subjects with and 30 without ND. The capsaicin aerosol was generated by adding 1–10 drops of liquid cayenne extract (1.5–2% capsaicin) to 100 mL carbonated water (0.00075–0.001% to 0.0075–0.01% capsaicin). Voluntary PCF in the ND group was significantly lower than in the control group ( p < 0.001), while there was no significant difference in reflexive PCF ( p = 0.225). Within the ND group, reflexive PCF was significantly higher than voluntary PCF ( p = 0.001), while in healthy controls, reflexive PCF was significantly lower ( p < 0.001). The data show that AC increased the tracheobronchial clearance efficacy in ND patients with dystussia and atussia, as it enabled subjects to access their individual cough potential, which is present, but inaccessible, due to neurological disorder.

Abstract Background There is a need to provide highly repetitive and intensive therapy programs for patients after stroke to improve sensorimotor impairment. The employment of technology-assisted training may facilitate access to individualized rehabilitation of high intensity. The purpose of this study was to evaluate the safety and acceptance of a high-intensity technology-assisted training for patients after stroke in the subacute or chronic phase and to establish its feasibility for a subsequent randomized controlled trial. Methods A longitudinal, multi-center, single-group study was conducted in four rehabilitation clinics. Patients participated in a high-intensity 4-week technology-assisted trainings consisting of 3 to 5 training days per week and at least 5 training sessions per day with a duration of 45 min each. Feasibility was evaluated by examining recruitment, intervention-related outcomes (adherence, subjectively perceived effort and effectiveness, adverse events), patient-related outcomes, and efficiency gains. Secondary outcomes focused on all three domains of the International Classification of Functioning Disability and Health. Data were analyzed and presented in a descriptive manner. Results In total, 14 patients after stroke were included. Participants exercised between 12 and 21 days and received between 28 and 82 (mean 46 ± 15) technology-assisted trainings during the study period, which corresponded to 2 to 7 daily interventions. Treatment was safe. No serious adverse events were reported. Minor adverse events were related to tiredness and exertion. From baseline to the end of the intervention, patients improved in several functional performance assessments of the upper and lower extremities. The efficiency gains of the trainings amounted to 10% to 58%, in particular for training of the whole body and for walking training in severely impaired patients. Conclusions Highly intensive technology-assisted training appears to be feasible for in- and outpatients in the subacute or chronic phase after stroke. Further clinical trials are warranted in order to define the most comprehensive approach to highly intensive technology-assisted training and to investigate its efficacy in patients with neurological disorders. Trial registration ClinicalTrials.gov Identifier: NCT03641651 at August 31st 2018

Background: Fatigue is one of the most frequent symptoms of persons with Multiple Sclerosis (pwMS) but has limited treatment options. Aerobic capacity and endurance training have been discussed as relevant factors to improve fatigue. However, over the last decades, results have been equivocal. This secondary analysis of two pooled parallel group RCTs of three weeks of endurance training (high intensity interval training (HIIT) and moderate continuous training (MCT)) for pwMS aimed to (I) reproduce reported associations between aerobic capacity and fatigue on a cross-sectional and interventional level. The analysis further aimed to (II) investigate intervention effects on fatigue in a severely fatigued subgroup and (III) analyze differences in changes of fatigue between peak oxygen uptake (VO2peak) responders and non-responders. Methods: Both RCTs were conducted in the same inpatient rehabilitation clinic in Valens, Switzerland. Original primary outcomes were cognitive function (RCT1) and change in proportion of circulating regulatory T-cells (RCT2). PwMS (n = 131) with a relapsing-remitting or secondary progressive MS phenotype and Expanded Disability Status Scale score between 1 6.5 were eligible. Over the two studies participants exercised 3 5 times per week on cycle ergometers at intensities of 65 70% of maximum heart rate (HRmax) for 30 min (MCT groups) or three times per week with five 90 - 180 s intervals at intensities of 85% - 100% of HRmax and 90 s rest intervals (HIIT groups). Main outcome measures for the present secondary analysis were VO2peak measured during a cardiopulmonary exercise test and the Fatigue Scale for Motor and Cognitive Functions (FSMC), both assessed at the start and end of inpatient rehabilitation. Results: Baseline correlations did not reveal a significant association between VO2peak and FSMC. There were no significant improvements in fatigue after the HIIT and MCT in the overall sample or the subsample of severely fatigued pwMS and no significant differences in fatigue changes between VO2peak-responders and non responders. Conclusions: Our analysis did not confirm the aerobic capacity - fatigue relationship on a cross-sectional and experimental level, even when analyzing subgroups that should benefit the most according to proposed hypotheses.

Background Virtual reality (VR) exergames have gained popularity in the rehabilitation of persons with neurological disorders as an add-on therapy to increase intensity of training. Intensity is strongly dependent on the motivation of the patient. Motivation can be increased by delivering variation within training and challenging exercises. However, patients are often underchallenged, as exergame difficulty often does not match the patient’s ability. A Rasch analysis can establish hierarchy of exergame items in order to assist the delivery of patient-centered therapy. Objective The aim of this study was to apply the Rasch model to create a hierarchical order of existing VR balance exergames and to relate these exergames to the abilities of persons with neurological disorders, in order to deliver challenge and variation. Methods A total of 30 persons with stroke and 51 persons with multiple sclerosis (MS) were included in the study. All participants performed a training program, lasting 3 weeks for persons with MS and 4 weeks for persons with stroke, in which they performed VR balance exergames with a movement recognition–based system (MindMotion GO; MindMaze SA). VR exercise scores, Berg Balance Scale scores, and clinical descriptive data were collected. Berg Balance Scale and device scores were analyzed with the Rasch model using a repeated-measures approach to examine whether the distribution of exercise scores fitted the Rasch model. Secondly, a person-item map was created to show the hierarchy of exercise difficulty and person ability. Results Participants completed a selection of 56 balance exercises (ie, items), which consisted of a combination of various balance tasks and levels (ie, exercises). Using repeated measures, this resulted in a count of 785 observations. Analysis showed strong evidence for unidimensionality of the data. A total of 47 exercises (ie, items) had a sufficiently good fit to the Rasch model. Six items showed underfit, with outfit mean square values above 1.5. One item showed underfit but was kept in the analysis. Three items had negative point-biserial correlations. The final model consisted of 47 exercises, which were provided for persons with low to moderate balance ability. Conclusions The VR exercises sufficiently fitted the Rasch model and resulted in a hierarchical order of VR balance exercises for persons with stroke and MS with low to moderate balance ability. In combination with the Berg Balance Scale, the results can guide clinical decision-making in the selection of patient-focused VR balance exercises. Trial Registration ClinicalTrials.gov NCT03993275; https://clinicaltrials.gov/ct2/show/NCT03993275

A prototype assistive therapy chair (T-Chair) that induces exercise stimuli to improve trunk control and standing and walking early after stroke has been developed. The aim of this study was to assess its usability in a rehabilitation setting. Eleven physical therapists (PTs) integrated the T-Chair into the therapy programs of 15 patients post stroke. Each patient performed on average four individual therapy sessions on the T-Chair under the PTs' supervision. Usability was assessed using questionnaires, therapy diaries and focus group interviews with PTs'. Among PTs', 64% had generally a positive view on the T-Chair. Physical therapists recognized the potential for unsupervised therapy. Generally, patients reacted positively and enjoyed training. The T-Chair has the potential to become an adequate training tool for patients with an intermediate trunk control after stroke. Further development and usability testing are required to provide a therapeutic device allowing for an intensive therapy early post stroke.