Review (Ken Chance-Larsen) – Ten guiding principles for movement training in neurorehabilitation.

Thank you for the opportunity to review this interesting article.

I’d like to commend James McLoughlin for developing this article, it is well written and addresses important issues with high clinical relevance.

I have offered some opinions below that I hope can be useful in developing the article and numbered these for ease of reference.

Introduction

  1. You provide a comprehensive list labels for ‘treatments’ or ‘movement training interventions’ and make the point that there is potential for inconsistencies when describing these interventions, making ‘information dissemination incredibly challenging’. I wonder if you would consider developing this to clarify that any inconsistent labelling might also be due to journal publication guidelines and restrictions. Is this to do with a lack of treatment fidelity or is it a reporting issue? Or could it be a bit of both?
    A minor point: the word ‘incredibly’ is perhaps better replaced by a less emotive adverb?

Actual and Predicted Bodily State.

  1. I suggest avoiding the use of exclamation marks to make a point (‘…why we cannot tickle ourselves!’).
  2. This sentence needs rewriting to make more sense: ‘Whiplash and concussion patients show deficits in cervical joint position error of the head in space’.

Cognitive Selection and Planning

  1. The second sentence (‘These motor chunks…’) needs supporting with a citation.

Practice and Variability

  1. The Birkenmeier et al (2010) study included 15 patients (humans) and I am therefore not certain how your statement regarding dose of practice having shown promise in animal studies can be supported by this source. Please clarify.
  2. Regarding this sentence: ‘For some movements, very high movement repetition numbers will be needed to drive neuroplasticity and functional change, however the benefits of high repetitions for stroke upper limb rehabilitation still reach a plateau in terms of functional effectiveness (Lang et al., 2016).’
    These authors interpreted their findings in a way that does not seem to quite support the sentiment of your sentence. They found overall small treatment effects with no evidence of a a dose-response effect. They did see plateau effect but only for one of the four groups. I suggest reviewing this section to reflect the apparent paucity of research supporting any correlation between high movement repetition number and positive change.

Biomechanics.

  1. The last sentence in this section includes the word ‘enormous’ and I suggest using less emotive language to reduce any perceptions – rightly or wrongly – of bias.

Physical Capacity.

  1. Regarding this sentence: ‘Tendinopathy, osteoporosis and osteoarthritis exercises all need individualized management of load, in addition to those recovering from ligament sprains, stress fractures and muscle strains (Drew & Finch, 2016).’
    When I look at this review I can’t see any mention of any of the conditions listed. Please clarify (and apologies if I’ve missed something obvious).

Beliefs and Self-efficacy.

  1. Regarding this sentence: ‘Fear of movement in pain states and beliefs around certain ‘safe’ or ‘correct’ postures result in kinesiophobia (Vaegter et al., 2018).’
    Firstly, this was a relatively small study and it would therefore be problematic to use this study to support this absolute causative claim. Further, the authors do not seem to present empirical data to support this link. I have only looked at the abstract of the study so realise that I might have missed relevant information.

Other.

  1. There are some apparent inconsistencies in citation style, some author first names and/or initials are included whilst most citations do not include these.

Thank you for the opportunity to review this interesting paper. I agree with James McLoughlin that MTPs have relevance across many domains and I congratulate the author on his achievement.

One thought on “Review (Ken Chance-Larsen) – Ten guiding principles for movement training in neurorehabilitation.

  1. I thank Kenneth Chance-Larsen for the constructive feedback. My responses are below and I have made changes within the paper accordingly.
    Introduction
    You provide a comprehensive list labels for ‘treatments’ or ‘movement training interventions’ and make the point that there is potential for inconsistencies when describing these interventions, making ‘information dissemination incredibly challenging’. I wonder if you would consider developing this to clarify that any inconsistent labelling might also be due to journal publication guidelines and restrictions. Is this to do with a lack of treatment fidelity or is it a reporting issue? Or could it be a bit of both?
    A minor point: the word ‘incredibly’ is perhaps better replaced by a less emotive adverb? – changed to ‘very’
    Thank you for this feedback. In Neurorehabilitation, the main issues stem from diverse terminology from different disciplines and origins. I have updated this section to reflect this idea more clearly and I have added a reference from another paper form Levin, 2009 who has mentioned that this is a ‘growing pain’ within neurorehab.
    In addition, intervention reporting in research historically has been very poor. I have also provided reference to a landmark framework paper (Bernhardt, 2019) in stroke research that has called for improved reporting within future trials.
    In the current climate of evidenced based learning, inconsistent labels such as these can make information dissemination very challenging. These problems with interdisciplinary rehabilitation terminology have been described as inevitable ‘growing pains’ which can lead to misinterpretation and conflict (Levin et al., 2009). Clinicians rarely use isolated interventions (Hayward et al., 2014; Kleynen et al., 2017), which creates an immediate divide between clinical practice and many singular or simple research design protocols. Poor intervention reporting is a common theme that limits the interpretation and implementation of research findings. For example, improved standards in the reporting and design of future stroke rehabilitation research has been recognised as a high priority (Bernhardt et al., 2019). As various clinical disciplines and research fields combine, a common language of movement training principles could help facilitate clinical reasoning, guide research toward specific problems encountered in practice (Esculier et al., 2018) and improve communication and coordination across disciplines (Hart et al., 2014).

    Actual and Predicted Bodily State.
    I suggest avoiding the use of exclamation marks to make a point (‘…why we cannot tickle ourselves!’).
    Removed.
    This sentence needs rewriting to make more sense: ‘Whiplash and concussion patients show deficits in cervical joint position error of the head in space’.
    Rewritten
    Whiplash and concussion patients show deficits in cervical position awareness of the head in space when vision is removed (Cheever et al., 2016; Chen & Treleaven, 2013; Treleaven et al., 2006) which may drive ongoing symptoms, while many stroke patients with ‘Pusher Syndrome’ show altered perceptions of verticality and/or graviception that may contribute to the action of pushing toward the hemiplegic side (Karnath, 2007).

    Cognitive Selection and Planning
    The second sentence (‘These motor chunks…’) needs supporting with a citation.
    Rewritten. The Diedrichsen & Kornysheva paper is the most relevant paper that discusses both motor chunking and the functional neuroanatomy linked to retrieval.
    Movements include many sequential parts that are grouped together in a process called ‘motor chunking’ . These motor chunks are probably distributed throughout the cortex as motor plans and retrieved via memory processes involving basal ganglia and cerebellar networks (Diedrichsen & Kornysheva, 2015).

    Practice and Variability
    The Birkenmeier et al (2010) study included 15 patients (humans) and I am therefore not certain how your statement regarding dose of practice having shown promise in animal studies can be supported by this source. Please clarify.
    Thank you for picking this up. I have added the 3 most relevant animal study references and included the Birkenmeier in the human trial references.
    ‘Dose’ of practice has been gaining increasing attention, particular in populations such as stroke where interventions with higher doses of practice have shown promise in animal studies (Kleim et al., 1998; Nudo et al., 1996; Nudo & Milliken, 1996) and early human trials (Birkenmeier et al., 2010; Hsu et al., 2010; Lang et al., 2015; Lohse Keith R. et al., 2014; Moore Jennifer L. et al., 2010).

    Regarding this sentence: ‘For some movements, very high movement repetition numbers will be needed to drive neuroplasticity and functional change, however the benefits of high repetitions for stroke upper limb rehabilitation still reach a plateau in terms of functional effectiveness (Lang et al., 2016).’
    These authors interpreted their findings in a way that does not seem to quite support the sentiment of your sentence. They found overall small treatment effects with no evidence of a a dose-response effect. They did see plateau effect but only for one of the four groups. I suggest reviewing this section to reflect the apparent paucity of research supporting any correlation between high movement repetition number and positive change.
    Thanks. I agree this needs more clarification. A new editorial paper from Dorsch and Elkins has just been published that supports the push for more dose in inpatient stroke rehab so I have included this. I have also rewritten the section on dose-response to more accurately reflect the upper limb results with chronic stroke.
    Dose in this context refers to the number of movement repetitions, or time spent actively engaged in practice. For some movements, very high movement repetition numbers may be needed to drive neuroplasticity, improve strength, activity levels and functional change. In populations such a stroke, there is a growing consensus that dose of practice needs to increase in inpatient rehabilitation (Dorsch & Elkins, 2020), however there is no evidence for a dose-response effect of high repetition upper limb task-specific practice leading to increased functional capacity in chronic stroke (Lang et al., 2016).

    Biomechanics.
    The last sentence in this section includes the word ‘enormous’ and I suggest using less emotive language to reduce any perceptions – rightly or wrongly – of bias.
    The word ‘enormous’ has been removed.

    Physical Capacity.
    Regarding this sentence: ‘Tendinopathy, osteoporosis and osteoarthritis exercises all need individualized management of load, in addition to those recovering from ligament sprains, stress fractures and muscle strains (Drew & Finch, 2016).’
    When I look at this review I can’t see any mention of any of the conditions listed. Please clarify (and apologies if I’ve missed something obvious).
    Thank you for picking this up. I have rewritten to separate load management in injury/pathology which is more self-explanatory. I have also included the idea of training load and injury risk from the Drew and Finch review in athletes.
    Load on musculoskeletal structures is also very relevant. Tendinopathy, osteoporosis and osteoarthritis exercises all need individualized management of load, in addition to those recovering from ligament sprains, stress fractures and muscle strains. An increase in training load is related to injury in athletes (Drew & Finch, 2016) and could also be measured and monitored in neurological populations.The amount of practice may need slow incremental progression to minimize risk of injury and subsequent setbacks in rehabilitation.

    Beliefs and Self-efficacy.
    Regarding this sentence: ‘Fear of movement in pain states and beliefs around certain ‘safe’ or ‘correct’ postures result in kinesiophobia (Vaegter et al., 2018).’
    Firstly, this was a relatively small study and it would therefore be problematic to use this study to support this absolute causative claim. Further, the authors do not seem to present empirical data to support this link. I have only looked at the abstract of the study so realise that I might have missed relevant information.
    Thanks, I have found a more suitable reference for the early documented use of the term ‘kinesiophobia’ for pain and movement avoidance (Kori, 1990), rather than research into this area.
    Fear of movement in pain states and beliefs around certain ‘safe’ or ‘correct’ postures can result in movement avoidance in what has been termed kinesiophobia (Kori,1990), which may limit opportunity to train and explore all movement options.
    Other.
    There are some apparent inconsistencies in citation style, some author first names and/or initials are included whilst most citations do not include these.
    Thanks. The citations have been edited.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.